Hemolysis falsely decreases intraoperative parathyroid hormone levels

Background

Intraoperative parathyroid hormone (IOPTH) measurement is used to confirm biochemical cure during parathyroidectomy. Falsely decreased IOPTH measurements could result in false-negative or false-positive results and lead to failed parathyroidectomy or unnecessary additional exploration.

Study design

The records of all patients who underwent parathyroidectomy with IOPTH between May and August 2007 were retrospectively reviewed, and the frequency of hemolysis of IOPTH samples was determined. Separately, 10 split-samples were hemolyzed using the freeze-thaw technique.

Results

Forty-seven patients underwent parathyroidectomy, and 226 IOPTH samples were sent. Seventeen (7.5%) specimens from 9 (18.8%) patients were hemolyzed. In 8 split-samples, the range of decrease caused by hemolysis was 24.5% to 53.8% compared with nonhemolyzed controls.

Conclusions

Hemolysis of IOPTH samples occurs commonly and falsely decreases IOPTH levels. Unrecognized hemolysis in pre-excision specimens could result in false-negative IOPTH results and lead to unnecessary continued exploration. Unrecognized hemolysis in postexcision specimens could lead to false-positive IOPTH results and lead to failed parathyroidectomy and the need for reoperation. Thus, hemolysis may be an easily preventable cause of erroneous IOPTH measurements.     

Can parturients identify the midline during neuraxial block placement?

Study Objective

To determine whether parturients can reliably identify their midline during epidural or spinal needle insertion, and to determine whether parturient feedback helps the anesthesiologist successfully identify the midline.

Design

Survey instrument completed by anesthesiologists.

Setting

Labor and delivery unit of a university-based, tertiary-care hospital.

Measurements

Completed questionnaires were obtained for 554 of 904 (61.3%) neuraxial blocks. Data were collected on the type of neuraxial block, number of needle redirections required to identify the midline, the patient's height and weight, the patient's position during block placement, whether the patient was questioned for assistance identifying the midline, and if so, how helpful the patient was in redirecting the needle to locate the epidural or subarachnoid space.

Main Results

The anesthesiologist requested the assistance of 194 patients (35.0%) for needle location. Of those questioned, the anesthesiologist reported 128 instances (66.0%) when the patient's response was helpful in identification of the midline. Morbidly obese parturients (BMI > 35 kg/m²) were questioned more often than their non-morbidly obese counterparts (48.9% vs. 30.5%; P < 0.0005). Of those morbidly obese parturients who were questioned (n = 64), 76.6% were reported by the anesthesiologist to be helpful.

Conclusions

Most patients, including morbidly obese patients, are helpful in identifying the midline during neuraxial anesthesia.     

The relationship between weight loss and psychosocial functioning among bariatric surgery patients

Background

Success after bariatric surgery should also reflect improvement in psychosocial functioning. The objective of this study was to assess the relationships between both mental health and eating disorders and weight loss in morbidly obese patients 2 years after gastric bypass.

Methods

Forty-three obese women (mean age, 39.3 ± 1.4 years; mean body mass index, 44.7 ± 0.4 kg/m²) were evaluated before and 1 and 2 years after gastric bypass. The Beck Depression Inventory and the Hospital Anxiety and Depression Scale were used for depression and anxiety evaluation and the Eating Disorder Inventory for eating disorder assessment.

Results

Decreases in depression (P <.01), anxiety (P <.05), and eating disorder (P <.01) scores were measured 2 years after surgery. Both excess weight loss and change in body mass index were associated with improvements in all measured psychologic outcomes 2 years after surgery.

Conclusions

The importance of weight loss is in relation to mental health 2 years after bariatric surgery. Psychologic outcomes and eating disorders did not predict weight loss 2 years after gastric bypass. However, these factors improved significantly after weight loss.     

Comparison of safety and efficacy of foam-based versus solution-based ciprofloxacin for acute otitis externa

Objective

To compare and evaluate the efficacy and safety of a foam-based antibiotic formulation in the treatment of acute otitis externa (AOE) with the more conventional solution-based formulation.

Study Design

Phase 2, open-label, randomized controlled trial.

Setting

Multicenter.

Subjects and Methods

Sixty-three eligible adult patients with unilateral AOE were randomly assigned to one of two treatment groups: an experimental 0.3 percent foam-based ciprofloxacin, (FoamOtic Cipro) or 0.3 percent solution-based ciprofloxacin (Ciloxan). All patients received the same dose regime (twice daily for 7 days). The primary efficacy variable was response to therapy (cure) in the test-of-cure visit. Secondary variables included improvement of the disease symptoms otalgia, tenderness, edema, and otorrhea.

Results

Sixty-four patients were enrolled in the study. Seven patients were excluded from the per-protocol analysis due to major deviations from the protocol. Per-protocol analysis (n = 57) showed that cure was achieved in all the patients (P = 1.000). No significant differences were found between groups for symptomatic relief, resolution of otic discharge, or onset of pain reduction. Both treatments were found to be highly efficacious and safe, demonstrating the noninferiority of the experimental drug.

Conclusion

Foam-based ciprofloxacin is a safe and an effective new treatment for AOE.     

A simple method to predict pretracheal tissue thickness to prevent accidental decannulation in the obese

Objective

Accidental decannulation is the most common and serious complication associated with tracheostomy in obese patients. We lack a simple way to choose appropriate-size tracheostomy tubes in this patient subset. Our purpose was to 1) establish the range of trachea-to-skin soft tissue thickness (TTSSTT) in obese patients and 2) determine which easily obtained anthropometric measurements are most predictive of TTSSTT.

Study Design

Case series with planned data collection.

Setting

Tertiary care center.

Subjects and Methods

Forty consenting patients with body mass index ranging from 30 to 70 were evaluated. These patients, from a bariatric clinic, underwent ultrasound (US) of the neck in predetermined sitting, supine, and neck-extended positions (as for tracheostomy). US was performed by a qualified radiologist. Standard anthropometric measurements of weight, height, arm, hip, waist, and neck sizes were performed. Multiple regression analysis was used to determine which anthropometric measurements best correlated with TTSSTT.

Results

The TTSSTT, as measured by US in the supine position, ranged from 0.65 to 3.53 cm. Although the anthropometric measurement most predictive of TTSSTT was waist circumference, a combination of the more practical arm and neck circumferences resulted in an equivalent correlation (r = 0.82). The average root mean squared error was 0.4 cm. From the fitted regression equation, a table predicting TTSSTT from neck and arm circumference was prepared.

Conclusion

TTSSTT can be closely predicted using simple anthropometric tape measures. The predicted TTSSTT can be used to select appropriate tracheostomy tube size in obese patients. Use of this simple tool is expected to significantly reduce the incidence of accidental decannulation in obese patients.     

Clinical manifestations of hypercalcemia and hypophosphatemia after kidney transplantation

Introduction

Abnormalities of calcium and phosphorus metabolism in end-stage renal disease patients can persist after transplantation. We investigated their natural courses after transplantation, their risk factors for posttransplantation hypercalcemia and hypophosphatemia, and their impacts on allograft outcomes.

Methods

We retrospectively analyzed a total of 490 adult patients who underwent kidney transplantations between 2000 and 2009.

Results

The serum calcium continued to increase, and reaching a plateau at around 3 months after transplantation. Thereafter it decreased, reaching a stable level by 2 years. Forty-four patients (9.0%) displayed hypercalcemia within 1 year; it persisted longer than that in 23 subjects (4.7%). Both longer dialysis duration (odds ratio [OR] 1.423; 95% confidence interval [CI], 1.192-1.699) and high intact serum parathyroid hormone (iPTH) level before transplantation (OR 1.002; 95% CI, 1.000-1.003) increased the risk for posttransplantation hypercalcemia. After a significant decrease during the first week, the serum phosphorus level increased, becoming stable between 1 and 6 months after transplantation. Hypophsphatemia occurred in 379 patients (77.3%) with 336 patients displaying hypophosphatemia without hypercalcemia. However, neither hypercalcemia nor hypophosphatemia influenced graft outcomes. Eight patients underwent pretransplantation parathyroidectomy, whereas 4 patients underwent posttransplantation parathyroidectomy. Neither group of patients experienced posttransplantation hypercalcemia.

Conclusions

Both hypercalcemia and hypophosphatemia are common after renal transplantation, especially among patients with a long history of dialysis before transplantation. Strict control of hyperparathyroidism including parathyroidectomy before transplantation may be the appropriate approach to these abnormalities.     

Comparison of otologic complications between intensity-modulated and two-dimensional radiotherapies in nasopharyngeal carcinoma patients

Objective

To investigate the otologic complications in patients with nasopharyngeal carcinoma (NPC) who were treated by intensity-modulated radiotherapy (IMRT) and compared with those who were treated by two-dimensional radiotherapy (2DRT).

Study Design

A historical cohort study was performed comprising NPC patients who underwent IMRT or 2DRT at Chung Shan Medical University Hospital.

Setting

Chung Shan Medical University Hospital.

Subjects and Methods

Twenty-six NPC patients treated by IMRT (group A) and 18 NPC patients treated by 2DRT (group B) were enrolled. All patients underwent otoscopy, audiometry, and a vestibular-evoked myogenic potential (VEMP) test at a mean interval of three years after irradiation.

Results

Although groups A and B did not significantly differ in the occurrence rate of otitis media with effusion (OME), group B had a significantly greater occurrence rate of chronic otitis media than group A (P < 0.05, χ² test). The incidences of high-frequency sensorineural hearing loss were 46 percent in group A and 67 percent in group B, with no significant difference between the two. In terms of VEMPs, group A had a significantly lower abnormal rate (31%) than group B (61%; P < 0.05, χ² test). In addition, a significant relationship existed between T stages and OME in NPC patients treated by IMRT (P < 0.01, Fisher-Freeman-Halton test) but not by 2DRT.

Conclusion

The incidence of chronic otitis media and abnormal VEMPs in NPC patients treated by IMRT were significantly lower when compared with those treated by 2DRT, demonstrating the superiority of IMRT in decreasing unwanted otologic complications. However, occurrence of OME, which was related with advanced T stage, cannot be reduced by IMRT.     

Factores de riesgo de mortalidad de los pacientes quirúrgicos en un hospital terciario: estudio del registro de pacientes en el periodo 2004-2006

Objective

To determine mortality risk factors in surgical patients.

Material and method

A cross-sectional study was carried out on all surgical patients who died while in hospital, over a period of three years (2004-2006). Pre, intra and postoperative variables were analysed. Comparisons were made between patients operated on as emergencies and elective surgery patients. Multivariate analysis was performed on the pre, intra and postoperative variables, using χ² of Pearson correlation with a confidence interval of 95%.

Results

Surgery was performed on a total of 38 815 patients, of which 6 326 were emergency procedures and 32 489 as elective. There were 479 deaths registered: 36 occurred in the operating theatre and 443 died after the operation. Arterial hypertension, diabetes mellitus and cancer were significant causes of death. Intraoperative complications were associated with mortality during the surgical procedure. Emergency surgery was an independent risk factor (mortality, 5.5% vs. 0.4% for elective surgery). Sepsis, cardiac and respiratory related deaths were the main risk factors for postoperative death.

Conclusions

Prevention and adequate treatment of perioperative risk factors should significantly reduce morbidity and mortality rates, mainly in those patient operated as emergencies.     

The risk of upstaged disease increases with body mass index in low-risk prostate cancer patients eligible for active surveillance

Background

Obese patients have a greater risk of adverse pathologic features and biochemical recurrence after radical prostatectomy (RP). The impact of body mass index (BMI) on the risk of reclassification and deferred treatment in active surveillance (AS) programs has not been thoroughly assessed.

Objective

To evaluate the impact of BMI on the risk of reclassification for AS eligibility.

Design, setting, and participants

We assessed 230 men who underwent an immediate RP and were eligible for AS according to the following criteria: prostate-specific antigen (PSA) ≤10 ng/ml, clinical stage T1c, Gleason score ≤6, fewer than three positive cores, extent of cancer in any core <50%, and life expectancy >10 yr.

Intervention

All patients underwent a standardised 21-core biopsy and RP at our department between January 2001 and December 2010.

Measurements

Reclassification was defined as upstaged disease (pathologic stage >pT2) and/or upgraded disease (Gleason score ≥7; primary Gleason pattern 4) in RP specimens. PSA outcomes were also recorded.

Results and limitations

Mean BMI was 26.4 kg/m², and 13% of patients were obese (BMI >30). Mean BMI was the only preoperative factor significantly associated with the risk of upstaged disease. In multivariate analysis, BMI >30 remained an independent predictive factor for upstaged disease (p = 0.003; odds ratio: 4.2). The risk of upgraded disease (primary Gleason pattern 4) was significantly decreased 4.5-fold in large prostate glands (>50 ml; p = 0.008). The biochemical recurrence-free survival curves were not significantly different between men who were or were not overweight (p = 0.950).

Conclusions

Obese men are at higher risk of upstaged disease, with a proportion of 30% of pT3 disease in RP specimens. BMI should be taken into account for inclusion of low-risk prostate cancer patients in AS programs, and our results may help urologists better inform their obese patients eligible for AS about this risk of reclassification and improve treatment decision making.     

The impact of age, vitamin D3 level, and incidental parathyroidectomy on postoperative hypocalcemia after total or near total thyroidectomy

Background

Hypocalcemia caused by transient or definitive hypoparathyroidism is the most frequent complication after thyroidectomy. We aimed to compare the impact of incidental parathyroidectomy and serum vitamin D₃ level on postoperative hypocalcemia after total thyroidectomy (TT) or near total thyroidectomy (NTT).

Patients

Two hundred consecutive patients with nontoxic multinodular goiter treated by TT and NTT were included prospectively in the present study. Group 1 (n = 49) consisted of patients with a postoperative serum calcium level ≤8 mg/dL, and group 2 (n = 151) had a postoperative serum calcium level greater than 8 mg/dL. Patients were evaluated according to age, preoperative serum 25-hydroxy vitamin D (25-OHD) levels, postoperative serum calcium levels, incidental parathyroidectomy, and the type of thyroidectomy.

Results

Patients in group 1 (n = 49) were hypocalcemic, whereas patients in group 2 (n = 151) were normocalcemic. Preoperative serum 25-OHD levels in group 1 were significantly lower than in group 2 (P < .001). The incidence of hypoparathyroidism was significantly higher following TT (13.5%) than following NTT (2.5%) (P < .05). The risk for postoperative hypocalcemia was increased 25-fold for patients older than 50 years, 28-fold for patients with a preoperative serum 25-OHD level less than 15 ng/mL, and 71-fold for patients who underwent TT. Incidental parathyroidectomy did not have an impact on postoperative hypocalcemia. The highest risk of postoperative hypocalcemia was found in the patients with all of the above variables.

Conclusions

Age, preoperative low serum 25-OHD, and TT are significantly associated with postoperative hypocalcemia. Patients with advanced age and low preoperative serum 25-OHD levels should be placed on calcium or vitamin D supplementation after TT to avoid postoperative hypocalcemia and decrease hospital stay.     

Post-appendectomy visits to the emergency department within the global period: a target for cost containment

Background

Postoperative visits to the emergency department (ED) instead of the surgeon's office consume enormous cost.

Hypothesis

Postoperative ED visits can be avoided.

Setting

Fully accredited, single-institution, 617-bed hospital affiliated with the University of Connecticut School of Medicine.

Patients

Retrospective analysis of 597 consecutive patients with appendectomies over a 4-year period.

Methods

Demographic and medical data, at initial presentation, surgery, and ED visit were recorded as categorical variables and statistically analyzed (Pearson χ² test, Fisher exact test, and linear-by-linear). Costs were calculated from the hospital's billing department.

Results

Forty-six patients returned to the ED within the global period with pain (n = 22, 48%), wound-related issues (n = 6, 13%), weakness (n = 4, 9%), fever (13%), and nausea and vomiting (n = 3, 6%). Thirteen patients (28%) required readmission. Predictive factors for ED visit postoperatively were perforated appendicitis (2-fold increase over uncomplicated appendicitis) and comorbidities (cardiovascular or diabetes). The cost of investigations during ED visits was $55,000 plus physician services.

Conclusions

ED visits during the postoperative global period are avoidable by identifying patients who may need additional care; improving patient education, optimizing pain control, and improving patient office access.     

Calcimimetics and Bone Mineral Density in Renal Transplant Patients With Persistent Secondary Hyperparathyroidism

Background

The persistence of secondary hyperparathyroidism plays an important role in posttransplant bone loss. Calcimimetics are efficient to control metabolic alterations associated with this problem, but there are few publications that assess their effects on bone density.

Patients and Methods

This prospective study assessed the effects of a single daily dose of cinacalcet on calcemia, phosphatemia, parathyroid hormone (PTH), and bone densitometry (femur and spine) values of 27 renal transplant patients with stable kidney function, calcium > 10.5 mg/dL, and PTH > 65 pg/mL.

Results

A preliminary study after 6 months showed decreased calcemia (11.05 ± 0.5 to 10.18 ± 0.6 mg/dL; P < .0001), reduced levels of intact PTH (iPTH; 258 ± 104 to 209.61 ± 127 pg/mL; P < .05), and increased phosphatemia (2.38 ± 0.45 to 2.54 ± 0.3 mg/dL; P < .05). We also observed an increase in femoral neck bone mass with improved T score (−1.36 ± 1.19 to −1.05 ± 0.84 g/cm²; P < .05).

Conclusions

Cinacalcet was effective in the management of posttransplant persistent secondary hyperparathyroidism, resulting in decreased calcemia and iPTH, while also improving femoral neck bone loss. Longer-term studies with control groups are needed to determine the drug's influence on overall bone mineral density.     

Cyclosporine A-protection against microvascular hyperpermeability is calcineurin independent

Background

Mitochondria-mediated apoptotic signaling contributes to microvascular hyperpermeability. We hypothesized that cyclosporine A (CsA), which protects mitochondrial transition pores, would attenuate hyperpermeability independent of its calcineurin inhibitory property.

Methods

Hyperpermeability was induced in microvascular endothelial cell monolayers using proapoptotic BAK or active caspase-3 after CsA or a specific calcineurin inhibitor, calcineurin autoinhibitory peptide (CIP), treatment. Permeability was measured based on fluorescein isothiocyanate-albumin flux across the monolayers. Mitochondrial transmembrane potential (MTP) was determined using 5,5′,6,6′-tetrachoro-1,1′,3,3′-tetraethylbenzimidazolyl carbocyanine iodide. Mitochondrial release of cytochrome c was measured using an enzyme-linked immunosorbent assay and caspase-3 activity fluorometrically.

Results

CsA-attenuated (10 nmol/L) but not CIP-attenuated (100 μmol/L) BAK induced hyperpermeability (P < .05), CsA- but not CIP-attenuated BAK induced a decrease in MTP and an increase in cytochrome c levels and caspase-3 activity (P < .05). CsA and CIP were ineffective against caspase-3-induced hyperpermeability.

Conclusions

CsA attenuated hyperpermeability by protecting MTP, thus preventing mitochondria-mediated apoptotic signaling. The protective effect of CsA is independent of calcineurin inhibition.     

Intact parathyroid hormone measurement 1 hour after thyroid surgery identifies individuals at high risk for the development of symptomatic hypocalcemia

Background

There is currently no consensus regarding the utilization of intact parathyroid hormone (iPTH) for predicting postthyroid surgery hypocalcemia. The objective of this study was to determine a threshold value for the 1-hour postoperative iPTH level that can identify those patients at significantly increased risk for the development of symptomatic hypocalcemia.

Methods

A prospective study of 21 individuals undergoing either total or completion thyroid operations was performed. One-hour postoperative iPTH levels were drawn along with ionized calcium at 6 hours postoperatively and at 7 am the following morning. Symptoms of hypocalcemia were recorded.

Results

Of the 21 patients recruited into the study cohort, there were 18 individuals that developed hypocalcemia (4 symptomatic and 14 asymptomatic) and 3 that remained normocalcemic. The mean iPTH level 1 hour postoperatively was significantly different when comparing the normocalcemic, asymptomatic hypocalcemic, and symptomatic hypocalcemic patient groups (6.50 pmol/L versus 3.76 pmol/L versus 0.7 pmol/L, respectively; P = .007). An iPTH level ≤2.5 pmol/L was 100% sensitive for predicting which individuals would go on to develop symptomatic hypocalcemia.

Conclusions

This study suggests that a 1-hour postoperative iPTH level ≤2.5 pmol/L can identify those individuals at risk for developing symptomatic hypocalcemia. Therefore, we recommend early calcium supplementation for these patients to decrease their postoperative morbidity from symptomatic hypocalcemia.     

Detecting cholesteatoma with non-echo planar (HASTE) diffusion-weighted magnetic resonance imaging

Objective

The purpose of this study was to evaluate the diagnostic performance of half-Fourier-acquisition single-shot turbo-spin-echo (HASTE) diffusion-weighted magnetic resonance imaging (DWMRI) in the detection of cholesteatoma.

Study Design

Prospective blinded comparative study.

Setting

London teaching hospital.

Subjects and Methods

Subjects comprised 32 consecutive patients with suspected primary or residual cholesteatoma. HASTE DWMRI was performed on all patients an average of three months before mastoid surgery and evaluated for the presence of cholesteatoma. Radiological findings were correlated with intraoperative findings.

Results

HASTE DWMRI accurately predicted the presence or absence of cholesteatoma in 30 of 32 patients. Residual cholesteatoma was correctly diagnosed by DWMRI in 12 of 14 cases and correctly excluded in six, with two false-negative results caused by movement artifact and keratin pearls less than 2 mm. All primary cholesteatomas were correctly identified. Sensitivity and specificity were 0.93 (95% confidence interval [CI] 0.75-0.99) and 1.00 (95% CI 0.54-1.0), respectively, whereas positive and negative predictive values were 1.00 (95% CI 0.86-1.00) and 0.75 (95% CI 0.35-0.97), respectively.

Conclusion

Our study supports the increasing but small body of evidence that non-echo-planar imaging (i.e., HASTE) DWMRI performs well in the detection of cholesteatoma. We propose that HASTE DWMRI should be performed on all patients before their second-look surgery to provide valuable information to the operating surgeon.     

Postoperative sternal dehiscence in obese patients: incidence and prevention

Background

Obesity has been identified as the single most important risk factor for postoperative sternal infection in coronary bypass surgery patients. It is also a major risk factor for sternal dehiscence, with or without infection, for any type of cardiac operation. We assessed whether prophylactic measures could prevent this complication.

Methods

Two studies were conducted. In study A, 3,158 heart surgery patients were analyzed at 3 cardiac units. Obesity was defined as body mass index (BMI) more than 30. Group I (1,253 obese [39.7%]) was compared with group II (1,905 nonobese [60.3%]). Sternal closure was done at the surgeon's preference: (a) plain wires through and through the bone; (b) peristernal figure-of-eight wires; or (c) peristernal method, using stainless-steel cables. In study B, 123 obese patients were prospectively divided into 2 subgroups. Group B-1 (54 patients) underwent lateral prophylactic sternal reinforcement before placement of peristernal wires. Group B-2 (69 patients) had standard sternal closure, as in study A.

Results

In study A, group I had 81 dehiscences (6.46%); 78 also suffered deep sternal infection and mediastinitis (96%). Despite treatment, dehiscence recurred in 13, and mortality was 38.4%. In group II nonobese patients, 31 dehisced (1.6%, p = 0.000), with no mortality. In study B, group B-1 (54) had 0% dehiscence versus group B-2 (69) with 6 dehiscences (8.7%).

Conclusions

In our study, the rate of obesity is high (∼ 40%). Sternal dehiscence is real when the BMI is more than 30 (6.46%), and has high morbidity and mortality. Prophylactic sternal reinforcement seems to prevent this complication.     

Endovascular aneurysm repair is associated with less malnutrition than open abdominal aortic aneurysm repair

Background

Patients undergoing abdominal aortic aneurysm (AAA) repair have high rates of postoperative malnutrition. We examined whether endovascular aneurysm repair (EVAR) is associated with reduced postoperative malnutrition compared with open AAA repair.

Methods

The records of patients undergoing AAA repair in the Veterans Affairs (VA) Connecticut Healthcare System were reviewed. Primary outcomes were 30-day morbidity, lengths of hospitalization and intensive care unit stay, duration of intubation, and nutritional risk index scores.

Results

Sixty-two patients were included (open repair, 37; EVAR, 25). Nutritional parameters were comparable between groups before surgery. Patients treated with EVAR had improved postoperative nutritional profiles as determined by albumin level (3.7 ± .08 vs 3.2 ± .12; P = .003), and nutritional risk index (97.9 ± 1.3 vs 88.9 ± 1.8; P = .0006), compared with patients treated with open repair.

Conclusions

Patients undergoing EVAR developed significantly less postoperative malnutrition compared with those having open repair. EVAR may be a strategy to avoid malnutrition and improve outcomes in patients at risk for malnutrition after undergoing AAA repair.     

Initial experiences and outcomes of telepresence in the management of trauma and emergency surgical patients

Background

Teletrauma programs allow rural patients access to advanced trauma and emergency medical services that are often limited to urban areas.

Methods

A retrospective analysis of 59 teleconsults between 5 rural hospitals and a level I trauma center was performed. The objectives of this study were to report the initial experience with a telemedicine program connecting 5 rural hospitals with a level I trauma center.

Results

A total of 59 trauma and general surgery patients were evaluated. Of those, 35 (59%) were trauma patients, and 24 (41%) were general surgery patients. Fifty patients (85%) were from the first hospital at which teletrauma was established. For 6 patients, the teletrauma consults were considered potentially lifesaving; 17 patients (29%) were kept in the rural hospitals (8 trauma and 9 general surgery patients). Treating patients in the rural hospitals avoided transfers, saving an average of $19,698 per air transport or $2,055 per ground transport.

Conclusions

The telepresence of a trauma surgeon aids in the initial evaluation, treatment, and care of patients, improving outcomes and reducing the costs of trauma care.     

What is the optimal treatment for children with primary hyperparathyroidism?

Purpose

Little information exists regarding the optimal surgical treatment of pediatric primary hyperparathyroidism. We hypothesized that primary hyperparathyroidism in children, in the absence of a family history, is caused by single-gland disease and is amenable to minimally invasive parathyroidectomy (MIP).

Methods

We reviewed the records of individuals younger than 25 years who underwent parathyroidectomy in a prospectively collected database at a single tertiary hospital from 2003 to 2009.

Results

Twenty-five patients were identified, with a mean (SD) age of 19 (3.7) years. Sixty percent had single-gland disease (n = 15). Familial disease was present in 6 patients. All of the children younger than 18 years without a family history of disease (9/9) were found to have a single-gland disease (P < .001). Seventy-eight percent of patients without a family history were successfully treated without a bilateral exploration. Average length of stay was less than 1 day with no complications or recurrences.

Conclusions

Primary hyperparathyroidism in patients younger than 18 years without a family history was uniformly caused by single-gland disease. Minimally invasive parathyroidectomy was successful in these patients and avoided the morbidity of bilateral exploration. We recommend MIP be used in pediatric patients at large referral centers with prior successful institutional experience with the technique.     

Platelet-dense granule deficiency causes postoperative hemorrhage in patients receiving enoxaparin: a novel observation with dramatic clinical implications

Background

Inherent hemorrhage risk has impeded the universal adoption of low-molecular-weight heparin (LMWH) for venous thromboembolic prophylaxis in surgical patients. Coagulation pathway parameters and platelet numbers routinely are evaluated preoperatively; scant attention has been directed toward evaluation of platelet function. We hypothesized that administration of LMWH may unmask latent platelet dysfunction and result in postoperative hemorrhage.

Methods

Postoperative hemorrhage occurred in 15 (3.5%) of 423 consecutive patients undergoing laparoscopic gastric bypass. All patients received LMWH (enoxaparin, 40 mg) preoperatively. Hematologic evaluation included measurement of von Willebrand's factor level and activity, factor VIII level, and electron microscopic enumeration of platelet-dense granules.

Results

All patients had normal preoperative platelet counts and coagulation profiles. Ten patients underwent hematologic evaluation: coagulation pathway parameters were normal in all; however, all patients had a markedly decreased number of platelet-dense granules.

Conclusions

Platelet-dense granule deficiency may cause postoperative hemorrhage in patients receiving LMWH.