Contact isolation in surgical patients: a barrier to care?

BACKGROUND: Contact isolation is commonly used to prevent transmission of resistant organisms. We hypothesized that contact isolation negatively impacts the amount of direct patient care. METHODS: For 2 hours per day over a 5-week period, a single observer recorded provider/patient contact in adjacent isolated and nonisolated patient rooms on both the surgical intensive care unit (ICU) and surgical wards of a university hospital. Number of visits, contact time, and compliance with isolation were recorded, as was illness severity as assessed by APACHE II score. RESULTS: Isolated patients were visited fewer times than nonisolated patients (5.3 vs 10.9 visits/h, P <.0001) and had less contact time overall (29 +/- 5 vs 37 +/- 3 min/h, P =.008), in the ICU (41 +/- 10 vs 47 +/- 5 min/h, P =.03), and on the floor (17 +/- 3 vs 28 +/- 4 min/h, P =.039), in spite of higher mean APACHE II scores in the isolated (10.1 +/- 1.0 vs 7.6 +/- 0.8, P =.05). Among floor patients with APACHE II scores greater than 10, patients in the isolated group had nearly 40% less contact time per hour than patients in the nonisolated group (19 +/- 4 vs 34 +/- 7 min/h, P =.05). CONCLUSIONS: Because of the significantly lower contact time observed, particularly among the most severely ill of floor patients, we propose a reexamination of the risk-benefit ratio of this infection control method.     

Orbital apex syndrome due to trauma in a 3-year-old boy

Orbital apex syndrome is a disastrous ophthalmic disease which usually leads to visual loss and immobility in the injured eyes. Up to now, no effective treatment has been achieved. So as much as possible attention should be paid to prevent such tragedies.     

Misattributed paternity in a living related donor: to disclose or not to disclose?

Many ethical considerations surround living kidney donation, some of which are not anticipated. We present a case in which misattributed paternity was inadvertently discovered during the workup of a father and son and present arguments for and against disclosure of this information. We recommend that transplant programs advise patients participating in living organ donor programs that misattributed paternity might be discovered during routine preoperative testing and that protocols for dealing with complex ethical issues be in place.     

Are there variations in timing to tracheostomy in a tertiary academic medical center?

BackgroundIt is unclear what drives variation in timing to tracheostomy among different patients.MethodsAge, ethnicity, admission service, and income were retrospectively collected for patients undergoing tracheostomy in a Level 1 trauma center from 2007 to 2017. The primary outcome was time to tracheostomy with early tracheostomy (ET) or late tracheotomy (LT) defined as 3–7 or ≥ 10 days post-intubation, respectively. Secondary outcomes included length of stay (LOS), ventilator associated pneumonia, and mortality.ResultsAmong 1,640 patients, more men had ET compared to women (30% vs 28%; p = 0.05). The mean time to tracheostomy was 11.2 ± 7.7 days. Neurology and trauma patients had significantly shorter time to tracheostomy compared to other services. Age, ethnicity, and income showed no differences in timing to tracheostomy. Patients who underwent LT had a longer LOS (46 vs 32 days, p < 0.01) and higher mortality (19% vs 13% p < 0.01). Conclusions: There were no disparities in timing to tracheostomy based on age, ethnicity, or income. We detected a hesitation in performing tracheostomies by certain providers with shorter LOS and improved mortality in ET.     

Glucocorticoid metabolism in testicular tissue： a key to fertility？

Glucocorticoids are well-known as mediators of the systemic stress response. Increased glucocorticoid release and synthesis in response to endogenous or exogenous stressors have been shown to impair testicular hormone production in a variety of species and therefore may affect fertility. However, the physiological involvement of glucocorticoid hormones in tissue maturation and differentiation during both fetal and postnatal life is at least of similar importance as their role in the stress response. A well-regulated balance between beneficial and detrimental glucocorticoid hormone levels is therefore of utmost importance for tissue development as well as maintenance of tissue function. In the issue of the Asian Journal of Andrology,     

Does a nephron deficit in rats predispose to salt-sensitive hypertension?

AIM: This study tested the hypothesis that a nephron deficit predisposes rats to salt-sensitive hypertension in adulthood. METHODS: Female Wistar-Kyoto rats were fed a low (9%) or a normal (20%) protein diet during pregnancy and lactation. Male, birth-weight-matched offspring were paired. One rat from each pair was perfusion fixed at 4 weeks of age and the other rat at 40 weeks of age. Kidneys were removed and nephron number and total renal filtration surface area (FSA) determined using unbiased stereological techniques. The rats that were allowed to grow to adulthood had tail-cuff systolic blood pressure and body weight determined twice weekly. Between 30 and 40 weeks of age, a normal or a high-salt diet was fed to the rats. RESULTS: The offspring of rats fed the low-protein diet were significantly smaller at birth, and at 4 weeks of age they had a significant reduction in kidney volume, nephron number, and total renal FSA when compared to controls. Tail-cuff systolic blood pressure in the offspring from 4 to 29 weeks of age did not significantly differ between the two groups. Administration of a high-salt diet from 30 to 40 weeks of age led to a significant increase in blood pressure in both dietary treatment groups; however, it was not exacerbated in the rats exposed to the low-protein diet in utero. CONCLUSIONS: Maternal protein restriction in rats did not lead to salt-sensitive hypertension. Nephron endowment and FSA did not correlate with blood pressure in adulthood.     

Pediatric surgical capacity building – a pathway to improving access to pediatric surgical care in Haiti

Purpose

Lack of human resources is a major barrier to accessing pediatric surgical care globally. Our aim was to establish a model for pediatric surgical training of general surgery residents in a resource constrained region.

Does open surgery continue to have a role in elective splenectomy?

Background Since it was first reported in 1991, laparoscopic splenectomy has become the procedure of choice for elective splenectomy. However, doubts have been raised regarding the suitability of patients with splenomegaly (>1 kg) for laparoscopic resection because there have been reports of greater morbidity and higher conversion rates in this group of patients. Since 2000, patients referred to the authors’ center for splenectomy with an estimated spleen weight exceeding 1 kg have undergone splenectomy by the open approach. Methods Between September 1995 and April 2005, 95 elective splenectomies were performed by a single surgeon. Operative data were collected prospectively. Results A comparison between the operations that took place before 2001 (n = 47) and those performed after 2000 (n = 48) for all sizes of spleen showed significant reductions in conversion rate, operative time, and hospital stay in the later group. As compared with laparoscopic splenectomy (n = 11), open splenectomy (n = 18) for cases of splenomegaly resulted in a significantly shorter operative time, less operative blood loss, and no significant difference in hospital stay. Conclusion Although laparoscopic splenectomy is the treatment of choice for the majority of patients requiring elective splenectomy, the procedure for patients with significant splenomegaly requires caution and common sense. This study shows that an open splenectomy for these patients significantly reduces operative time and blood loss without increasing morbidity or hospital stay.     

When and how to start sedation in a neuro-intensive care patient?

Sedatives drugs are part of the everyday care in the neuro-ICU. Reasons to sedate patients in neuro-ICU are as usual to ensure the comfort and to secure the patients, to permit nursing as well as to permit adaptation to the ventilator. But some objectives are specific in neuro-ICU as optimisation of cerebral haemodynamics and oxygenation, and to avoid a convulsive state or a dysautonomic syndrome. Starting the sedation usually necessitate a tracheal intubation and mechanical ventilation. Patients presenting with intracranial hypertension are at risk of developing cerebral ischaemia in case of cerebral haemodynamics alteration associated with anaesthetic drugs injection. Morphinomimetics increase intracranial pressure (ICP), but cerebral perfusion pressure and oxygenation (CPP) remain usually unaltered. Injection of an intravenous bolus of thiopental or propofol lowers ICP and CPP, but also the cerebral tissular oxygen consumption: the cerebral oxygenation seems therefore protected. The succinylcholine used for emergency tracheal intubation has no effect on the cerebral haemodynamic. Some more studies are needed to better understand the cerebral oxygenation at the local level when sedative drugs are injected or perfused in patients with intracranial hypertension.     

Discordant Hirschsprung's disease in monozygotic twins: a clue to pathogenesis?

Presented is a case of discordant aganglionosis in monozygous twins that supports the "post migration" destruction mechanism in Hirschsprung's disease.