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1.
Paull DE Mazzia LM Wood SD Theis MS Robinson LD Carney B Neily J Mills PD Bagian JP 《American journal of surgery》2010,200(5):620-623
Background
The purpose of this study was to examine the outcomes of checklist-driven preoperative briefings and postoperative debriefings during the Veterans Health Administration (VHA) medical team training program.Methods
A briefing score (1, never started; 2, started then discontinued; 3, maintained on original targeted cases; 4, expanded to other services; 5, briefing all cases, all services) was established at 10.1 ± .3 months after introduction of the checklist. Outcomes included antibiotic and deep venous thrombosis prophylaxis compliance rates before and after use of the checklist.Results
Antibiotic (97.0% ± .1% vs 92.1% ± 1.5%; P = .01) and deep venous thrombosis (95.7% ± .8% vs 85.1% ± 4.6%; P = .05) prophylaxis compliance rates were higher after initiation of a surgical checklist.Conclusions
Checklist-driven preoperative briefings and postoperative debriefings are associated with improvements in patient safety for surgical patients. 相似文献2.
Tammy R. Kopelman M.D. Patrick J. O'Neill Paola G. Pieri Jeffrey P. Salomone Scott T. Hall Asia Quan Jordan R. WellsMelissa S. Pressman Ph.D. 《American journal of surgery》2013
Background
Inadequate anti–factor Xa levels and increased venous thromboembolic events occur in trauma patients receiving standard prophylactic enoxaparin dosing. The aim of this study was to test the hypothesis that higher dosing (40 mg twice daily) would improve peak anti-Xa levels and decrease venous thromboembolism.Methods
A retrospective review was performed of trauma patients who received prophylactic enoxaparin and peak anti-Xa levels over 27 months. Patients were divided on the basis of dose: group A received 30 mg twice daily, and group B received 40 mg twice daily. Demographics and rates of venous thromboembolism were compared between dose groups and patients with inadequate or adequate anti-Xa levels.Results
One hundred twenty-four patients were included, 90 in group A and 34 in group B. Demographics were similar, except that patients in group B had a higher mean body weight. Despite this, only 9% of group B patients had inadequate anti-Xa levels, compared with 33% of those in group A (P = .01). Imaging studies were available in 69 patients and revealed 8 venous thromboembolic events (P = NS, group A vs group B) with significantly more venous thromboembolic events occurring in patients with low anti-Xa levels (P = .02).Conclusions
Although higher dosing of enoxaparin led to improved anti-Xa levels, this did not equate to a statistical decrease in venous thromboembolism. 相似文献3.
Madhukar S. Patel M.D. M.B.A. Sc.M. Tyler Ewing David NguyenCristobal Barrios M.D. Marianne Cinat Matthew Dolich Michael Lekawa Darren Malinoski 《American journal of surgery》2013
Background
We sought to identify independent predictors of venous thromboembolism in critically ill general surgery patients who cannot receive chemical prophylaxis in order to identify those who may benefit from aggressive screening and/or prophylactic inferior vena cava filter placement.Methods
Nontrauma patients in the surgical intensive care unit were prospectively followed for 2 years. Patients who had contraindications to prophylactic anticoagulation and received routine screening duplex examinations were included. Data regarding lower-extremity deep venous thrombosis or pulmonary embolism (PE) rates, past medical history (PMH), surgeries, and transfusions were collected. Logistic regression was used to identify independent predictors of lower-extremity deep venous thrombosis or PE (venous thromboembolism) with a P < .05.Results
Data were complete for 204 patients. Twenty (9.8%) patients developed venous thromboembolism. Independent predictors of venous thromboembolism included postoperative blood product requirements (odds ratio = 1.04 per unit), a PMH of PE (OR = 10.1), and a PMH of renal insufficiency (odds ratio = 5.1).Conclusions
Aggressive screening and/or prophylactic inferior vena cava filter may be considered when prophylactic anticoagulation is prohibited in patients with increased postoperative transfusion requirements or a PMH of either PE or renal insufficiency. 相似文献4.
Hilary C. McCrary Jonida Krate Christine E. Savilo Melissa H. Tran Hang T. Ho William J. Adamas-Rappaport Rebecca K. Viscusi 《American journal of surgery》2016,212(5):1020-1025
Background
The aim of our study was to determine if a fresh cadaver model is a viable method for teaching ultrasound (US)-guided breast biopsy of palpable breast lesions.Methods
Third-year medical students were assessed both preinstruction and postinstruction on their ability to perform US-guided needle aspiration or biopsy of artificially created masses using a 10-item checklist.Results
Forty-one third-year medical students completed the cadaver laboratory as part of the surgery clerkship. Eight items on the checklist were found to be significantly different between pre-testing and post-testing. The mean preinstruction score was 2.4, whereas the mean postinstruction score was 7.10 (P < .001).Conclusions
Fresh cadaver models have been widely used in medical education. However, there are few fresh cadaver models that provide instruction on procedures done in the outpatient setting. Our model was found to be an effective method for the instruction of US-guided breast biopsy among medical students. 相似文献5.
Stephen B. Williams Mehrdad Alemozaffar Yin Lei Nathanael Hevelone Stuart R. Lipsitz Blakely A. Plaster Jim C. Hu 《European urology》2010
Background
Transperitoneal robot-assisted laparoscopic prostatectomy (RALP) urethrovesical anastomosis is a critical step. Although the prevalence of urine leaks ranges from 4.5% to 7.5% at high-volume RALP centers, urine leaks prolong catheterization and may lead to ileus, peritonitis, and require intervention. Barbed polyglyconate sutures maintain running suture line tension and may be advantageous in RALP anastomosis for reducing this complication.Objective
To compare barbed polyglyconate and polyglactin 910 (Vicryl, Ethicon, Somerville, NJ, USA) running sutures for RALP anastomosis.Design, setting, and participants
This was a prospective, randomized, controlled, single-surgeon study comparing RALP anastomosis using either barbed polyglyconate (n = 45) or polyglactin 910 (n = 36) sutures.Surgical procedure
RALP anastomosis using either barbed polyglyconate or polyglactin 910 sutures was studied.Measurements
Operative time, cost differential, perioperative complications, and cystogram contrast extravasation by anastomosis suture type were measured.Results and limitations
Although baseline characteristics and overall operative times were similar, barbed polyglyconate sutures were associated with shorter mean anastomosis times of 9.7 min versus 9.8 min (p = 0.014). In addition, anastomosis with barbed polyglyconate rather than polyglactin 910 sutures was associated with more frequent cystogram extravasation 8 d postoperatively (20.0% vs 2.8%; p = 0.019), longer mean catheterization times (11.1 d vs 8.3 d; p = 0.048), and greater suture costs per case ($51.52 vs $8.44; p < 0.001). After 8 of 29 (27.6%) barbed polyglyconate anastomosis sites demonstrated postoperative day 8 cystogram extravasation, we modified our technique to avoid overtightening, reducing cystogram extravasation to 1 (6.3%) of 16 subsequent barbed polyglyconate anastomosis sites. Potential limitations include small sample size and the single-surgeon study design.Conclusions
Compared to traditional sutures, barbed polyglyconate is more costly and requires technical modification to avoid overtightening, delayed healing, and longer catheterization time following RALP. 相似文献6.
David E. Leshikar Jonathan L. PierceEdgardo S. Salcedo M.D. Gurpreet BolaJoseph M. Galante M.D. 《American journal of surgery》2014
Background
Simulation training can improve proficiency in central line placement, but it is expensive and resource intensive. The authors developed a 3-phase approach to central venous catheter placement training, including an online module, mannequin-based simulation using a single faculty member, followed by department directed clinical observation. The hypothesis was that standardizing institutional central venous catheter placement training would maintain training efficiency and reduce faculty and resource demands.Methods
Preintervention and postintervention assessments of the trainees' performance were collected to evaluate program effectiveness. Program surveys were collected to evaluate residents' satisfaction and comfort with the procedure. Resource utilization was compared between the period before program implementation and the 2 following years.Results
Mean pretest to posttest scores for the online module improved significantly from 7.0 to 8.4 in 2010 and from 7.1 to 8.4 in 2011. Video evaluation demonstrated significant improvement across all postgraduate year levels. Surveys revealed high resident satisfaction and increased procedural confidence. Overall resource costs and faculty requirements decreased.Conclusions
A standardized training program for an entire institution can maintain quality while being more cost effective than traditional central venous catheter placement training. 相似文献7.
Brandon C. ChapmanErnest E. Moore M.D. Carlton BarnettRobert T. Stovall M.D. Walter L. BifflClay C. Burlew M.D. Denis D. BensardGregory J. Jurkovich M.D. Fredric M. Pieracci 《American journal of surgery》2013
Background
The optimal time to initiate venous thromboembolism pharmacoprophylaxis after blunt abdominal solid organ injury is unknown.Methods
Postinjury coagulation status was characterized using thromboelastography (TEG) in trauma patients with blunt abdominal solid organ injuries; TEG was divided into 12-hour intervals up to 72 hours.Results
Forty-two of 304 patients (13.8%) identified underwent multiple postinjury thromboelastographic studies. Age (P = .45), gender (P = .45), and solid organ injury grade (P = .71) were similar between TEG and non-TEG patients. TEG patients had higher Injury Severity Scores compared with non-TEG patients (33.2 vs 18.3, respectively, P < .01). Among the TEG patients, the shear elastic modulus strength and maximum amplitude values began in the normal range within the first 12-hour interval after injury, increased linearly, and crossed into the hypercoagulable range at 48 hours (15.1 ± 1.9 Kd/cs and 57.6 ± 1.6 mm, respectively; P < .01, analysis of variance).Conclusions
Patients sustaining blunt abdominal solid organ injuries transition to a hypercoagulable state approximately 48 hours after injury. In the absence of contraindications, pharmacoprophylaxis should be considered before this time for effective venous thromboembolism prevention. 相似文献8.
Cathryn A. DoughtieErin E. Priddy M.D. Prejesh PhilipsRobert C.G. Martin M.D. Ph.D. Kelly M. McMastersCharles R. Scoggins M.D. M.B.A. 《American journal of surgery》2014,208(6):1009-1015
Background
Venous thromboembolism is a common cause of morbidity. Guidelines recommend perioperative thromboprophylaxis, but clinicians remain cautious of bleeding after major oncologic resections.Methods
Retrospective analysis of a single institution's prospective hepatopancreatobiliary database was performed for patients undergoing surgery between January 2010 and February 2013. A total of 223 patients received postoperative thromboprophylaxis and 93 patients were dosed with low-molecular-weight heparin (LMWH) preoperatively.Results
Two hundred twenty-three patients were analyzed; 50.6% underwent pancreatic and 49.3% underwent liver resection. There were no differences in previous venous thromboembolism (3.8% vs 3.3%; P = .56) or preoperative venous thromboembolism scores (5.74 vs 5.67; P = .82). Estimated blood loss (537 mL vs 592 mL; P = .54), transfusions (25.4% vs 30.4%; P = .25), and complications (52.3% vs 43.5%; P = .12) were equivalent. Incidence of thromboembolic events was lower (6.1% vs 1.1%; P = .05); however, bleeding requiring intervention was increased in the preoperative LMWH group (10.9% vs 3.1%; P = .026).Conclusions
Caution must be exercised when using LMWH, as bleeding remains a concern for oncologic hepatopancreatobiliary surgery. 相似文献9.
Introduction
Carotid cavernous sinus fistulas are a potentially severe pathology. Their basic standard treatment is an occlusion of the CCF performed by retrograde venous catheterization via the inferior petrous sinus. When the inferior petrous sinuses are occluded, other alternative venous routes are possible with various subsequent difficulties and risks. We report an original and safe method for endovascular treatment using submandibular puncture of the facial vein.Clinical cases
We report 4 cases of patients with severe unilateral carotid cavernous sinus fistula associated with the occlusion of both inferior petrous sinuses. A submandibular surgical puncture of the ipsilateral inferior facial vein permitted the catheterization of the fistula. Complete occlusion of carotid cavernous sinus fistula was obtained by using a combination of microcoils and Onyx™.Discussion
When inferior petrous sinuses are occluded, endovascular treatment of carotid cavernous sinus fistulas is more difficult. After reviewing the other treatment options reported in the literature and their respective advantages and adverse effects, we describe an original technique based on the surgical puncture of the ipsilateral facial vein. The occlusion of the fistula is then obtained by using a combination of microcoils and Onyx™.Conclusion
When the inferior petrous sinuses are occluded, an endovascular treatment for a carotid cavernous sinus fistula can be performed using an original and secure method. This method relies on a simple surgical puncture of the facial vein in the submandibular region, which then permits a retrograde catheterization of the carotid cavernous sinus fistula with no significant risk. 相似文献10.
Arianna Bertocchini Pierluigi Falappa Chiara Grimaldi Giuseppe Bolla Lidia Monti Jean de Ville de Goyet 《Journal of pediatric surgery》2014
Background
Children with extrahepatic portal hypertension typically present with cavernomatous transformation of the portal vein and a poorly defined intrahepatic portal vein system on conventional imaging. With the Meso-Rex Bypass becoming the gold-standard intervention for a cure, a precise assessment of the intrahepatic portal vein system provides helpful data for deciding whether a Meso-Rex Bypass is feasible or not.Methods
All children with extrahepatic portal hypertension were prospectively assessed by wedged hepatic venous portography. Venous anatomy was categorized into five subtypes (A to E), depending on the presence of thrombosis in the Rex recessus, or not, and its extension within the intrahepatic portal venous system.Results
Eighty-nine children entered the study. Previous umbilical vein catheterization is usually associated with Rex thrombosis, while the Rex recessus and the intrahepatic portal venous system are patent in idiopathic cases, thus allowing for the performance of a Meso-Rex Bypass with a good outcome.Conclusions
Wedged hepatic venous portography is a very effective tool for detailed preoperative assessment and identification of children being considered for Meso-Rex Bypass surgery. An anatomic–radiological classification is useful in selecting patients for Meso-Rex Bypass with anticipation of a high rate of success. 相似文献11.
Mustafa N. Sulemanji Humberto Azpurua Matthew Suh Kristina Potanos Ryan Cauley Shaun M. Kunisaki Biren Modi David Zurakowski Steven J. Fishman Heung Bae Kim 《Journal of pediatric surgery》2013
Introduction
The etiology of necrotizing enterocolitis (NEC) remains elusive and no definite trigger has been identified. There are no studies to date examining the potential role of closure of the ductus venosus (DV), its effect on increasing portal venous pressure (PVP) and its association to mesenteric venous ischemia in the development of NEC. Our aim was to develop an animal model to examine this physiology.Methods
Fifteen near-term lambs were used. The DV was occluded in experimental animals by a balloon tip catheter, while the sham controls underwent catheterization without DV occlusion. Vital signs and PVP were monitored for 4 h, followed by intestinal biopsy.Results
The experimental group (n = 5) demonstrated a significant increase in PVP following DV occlusion (11.87 mm Hg [95% CI: 11.40–12.34]), compared to controls (8.95 mm Hg [95% CI: 8.34–9.56]) (F = 12.16, p = 0.001). Histology of the terminal ileum showed vacuolar degeneration, indicative of reversible cellular damage in the experimental group.Conclusions
We demonstrate that DV closure in the neonatal lamb leads to transient portal hypertension which is associated with cellular damage and inflammatory changes of the intestinal mucosa. Additional studies will be necessary to determine if the transient portal hypertension following DV closure leads to clinically apparent intestinal ischemia and NEC. 相似文献12.
Brian A. Boone Katherine A. Kirk Nikia Tucker Scott Gunn Raquel Forsythe 《The Journal of surgical research》2014
Background
Central venous pressure (CVP) is traditionally obtained through subclavian or internal jugular central catheters; however, many patients who could benefit from CVP monitoring have only femoral lines. The accuracy of illiac venous pressure (IVP) as a measure of CVP is unknown, particularly following laparotomy.Methods
This was a prospective, observational study. Patients who had both internal jugular or subclavian lines and femoral lines already in place were eligible for the study. Pressure measurements were taken from both lines in addition to measurement of bladder pressure, mean arterial pressure, and peak airway pressure. Data were evaluated using paired t-test, Bland-Altman analysis, and linear regression.Results
Measurements were obtained from 40 patients, 26 of which had laparotomy. The mean difference between measurements was 2.2 mm Hg. There were no significant differences between patients who had laparotomy and nonsurgical patients (P = 0.93). Bland-Altman analysis revealed a bias of 1.63 ± 2.44 mm Hg. There was no correlation between IVP accuracy and bladder pressure, mean arterial pressure, or peak airway pressure.Conclusions
IVP is an adequate measure of CVP, even in surgical patients who have had recent laparotomy. Measurement of IVP to guide resuscitation is encouraged in patients who have only femoral venous catheter access. 相似文献13.
Background
The well-being of residents in general surgery is an important factor in their success within training programs. Consequently, it is important to identify individuals at risk for burnout and low levels of well-being as early as possible. The aim of this study was to test the hypothesis that resident well-being may be related to grit, a psychological factor defined as perseverance and passion for long-term goals.Methods
One hundred forty-one residents across 9 surgical specialties at 1 academic medical center were surveyed; the response rate was 84%. Perseverance was measured using the Short Grit Scale. Resident well-being was measured with (1) burnout using the Maslach Burnout Inventory and (2) psychological well-being using the Dupuy Psychological General Well-Being Scale.Results
Grit was predictive of later psychological well-being both as measured by the Maslach Burnout Inventory (B = −.20, P = .05) and as measured by the Psychological General Well-Being Scale (B = .27, P < .01).Conclusions
Measuring grit may identify those who are at greatest risk for poor psychological well-being in the future. These residents may benefit from counseling to provide support and improve coping skills. 相似文献14.
Background
With the increasing use of simulation in surgical training there is an increasing need for low cost methods of objective assessment.Methods
Hand-motion data (3 degrees of freedom) were acquired using microelectromechanical gyroscope tracking devices worn on both hands during an intracorporeal suture/knot-tying laparoscopic task performed by FLS-certified and non-FLS-certified surgeons. Each data sample was processed into a symbolic time series, and the Lempel-Ziv complexity metric was calculated for each hand for the whole task and the first 60 seconds of the task from the dominant hand.Results
FLS-certified surgeons had more complex hand-motion patterns. This was statistically significant only for the dominant hand (P = .02) but was still statistically significant when calculated from the first 60 seconds of the task (P = .04) and therefore independent of the total time taken to complete the task.Conclusions
Hand-motion patterns were quantified and shown to be different between FLS-certified and non-FLS-certified surgeons using low-cost microelectromechanical technology and the Lempel-Ziv complexity metric. 相似文献15.
Joseph D. Valentino Piotr G. Rychahou W. Conan Mustain Victoria A. Elliott B. Mark Evers 《The Journal of surgical research》2013
Background
Small interfering RNA (siRNA) provides a highly selective method to target mutated pathways; however, its use is complicated by specific delivery to tumor cells. The aims of the present study were to develop a novel murine model of portal vein catheterization for the chronic delivery of therapeutic agents to liver metastases, determine the benefits of local delivery of siRNA to liver metastases, and determine the utility of epithelial cell adhesion molecule (EpCAM) as a selective target for siRNA delivery to colorectal cancer (CRC) metastases.Materials and methods
First, portal vein catheterization was performed through a midline laparotomy in 2 mo-old Balb/C mice. Second, the portal venous flow distribution and catheter patency were evaluated using fluorescent-labeled microspheres. Metastatic studies were performed by splenic injection of CT26 murine colon cancer cells. Uptake of DY-547-labeled siRNA was assessed by IVIS imaging, with delivery to the metastases confirmed using fluorescent microscopy. Finally, EpCAM expression was evaluated using immunohistochemical staining of human tissue microarrays.Results
Successful portal vein catheterization was confirmed by saline injection and ultrasound. Fluorescent imaging of microspheres confirmed excellent distribution and catheter patency. Portal venous injection of DY547-labeled siRNA demonstrated a high level of fluorescence throughout the liver, with siRNA also identified within the liver metastases. Also, all primary CRCs and liver metastases stained strongly for EpCAM, with no expression in normal hepatocytes.Conclusions
Liver-directed therapy can provide the selective delivery of siRNA to CRC metastases. EpCAM expression in CRC, but not normal liver, could further selectively target hepatic metastases of epithelial origin. 相似文献16.
Background
The purpose of this study was to determine if laterality of internal jugular vein (IJV) sampling affects the accuracy of intraoperative parathyroid hormone (PTH) monitoring during parathyroidectomy for primary hyperparathyroidism.Methods
In this study, 109 patients underwent parathyroidectomy (82 with unilateral disease, 27 with multigland disease). PTH samples were taken from both the left and the right IJV at these time points: preincision (baseline) and then at 5, 10, and, in selected patients, 20 minutes after excision. The Miami criterion was used to determine operative success.Results
In all 109 patients combined, the mean decreases in intraoperative PTH levels were 73.8 ± 22.2% for the left IJV and 71.9 ± 23.0% for the right IJV (P = .22). The Miami criterion was met in 105 patients: in 100 (95%) left IJV samples and 99 (94%) right IJV samples (P = 1.00).Conclusions
No difference was found in the accuracy of intraoperative PTH monitoring between patients' left and right IJV samples. Central venous laterality did not affect fulfillment of the Miami criterion. 相似文献17.
Mihara K Shindo H Mihara H Ohtani M Nagasaki K Katoh N 《Burns : journal of the International Society for Burn Injuries》2012,38(3):371-377
Purpose
Videomicroscopy is very useful for burn depth assessment in an early phase; however, there is no practical classification that includes complicated anatomic, pathologic, and morphologic findings of burn wounds.The aim of this study was to propose a novel classification to assess burn depth in its early phase easily and reliably by videomicroscopy.Methods
Forty-four patients with 56 intermediate-depth burn wounds were included. Burn depth was divided into each grade according to our proposed classification, which is composed of five categories based on dermal capillary integrity patterns. The intrarater and interrater reliabilities of the assessment by the second and third authors were evaluated by Cohen's unweighted κ-value.Results
The results of the measurements according to the proposed classification showed an accuracy of 92.9%, sensitivity of 81.8%, and specificity of 100.0%.The intrarater reliability of the second and third authors showed substantial agreement (κ = 0.719 and 0.729, respectively). The interrater reliability of the sum of each observer's variable also showed substantial agreement (κ = 0.636).Conclusion
This pattern analysis system is easy to use even for inexperienced personnel, and is reliable with high accuracy and specificity. Intrarater and interrater statistics also support its reliability and reproducibility. 相似文献18.
19.
Iliana Harrysson Louise HullNick Sevdalis Ph.D. Ara DarziRajesh Aggarwal M.D. Ph.D. M.A. F.R.C.S. 《American journal of surgery》2014
Background
The implementation of duty-hour restrictions and a heightened awareness of patient safety has changed resident education and training. A new focus has been placed on high-yield training programs and simulation training has naturally grown to fill this need.Methods
This article discusses the development of a training framework, knowledge, skills, and attitudes, and the design of a surgical simulation curriculum. Five residents were recruited for a pilot study of the curriculum.Results
A successful framework for curriculum development was implemented using laparoscopic cholecystectomy as the example. The curriculum consisted of classroom and virtual reality simulation training and was completed in 3.1 to 4.8 hours.Conclusions
The current curricula that have been developed for surgical education cover the breadth of a surgical residency well. This curriculum went beyond these curricula and developed a structured framework for surgical training, a method that can be applied to any procedure. 相似文献20.
Aissaoui Y Chouaib N Chouikh C Rafai M Azendour H Balkhi H Haimeur C Drissi Kamili N 《Annales fran?aises d'anesthèsie et de rèanimation》2010,29(12):897-901