Platelet function point-of-care tests in post-bypass cardiac surgery: are they relevant?

Background. Platelet dysfunction is an important cause of excessivebleeding after cardiac surgery. We assessed two platelet functionpoint-of-care tests: the platelet function analyser (PFA-100)and the Hemostatus^TM in patients with and without excessivebleeding after cardiac surgery with cardiopulmonary bypass. Methods. Mediastinal chest tube drainage (MCTD) was measuredfor the first 6 h in the intensive care unit (ICU). Haematologyand coagulation tests were done on arrival in the ICU, and whenexcessive bleeding occurred (MCTD >1 ml kg^–1 h^–1)or after 3 h. Results. Eighteen patients bled excessively and 27 had normalMCTD. Hemostatus measurements were prolonged in those with excessivebleeding compared with the normal group. The times for PFA-100adenosine diphosphate (ADP) and epinephrine were 91 vs 71 s(P=0.004) and 155 vs 114 s (P=0.02) in the bleeding and normalgroup s, respectively. None of the Hemostatus or PFA-100 valuescorrelated with total MCTD. Depending on the agonist used, maximumaggregation was 33–81% and 52–86% in bleeding andnormal groups, respectively. Only poor correlations were foundbetween PFA-100 epinephrine and maximum aggregation in responseto ADP (r=–0.52, P=0.03) or to collagen (r=–0.48,P=0.04). Conclusion. Patients bleeding excessively in the ICU had abnormalmeasurements in point-of-care tests without a dramatic decreasein aggregation. Except for patients with increased risk of postbypassbleeding, point-of-care tests are not useful for routine useafter cardiac surgery. Br J Anaesth 2002; 89: 715–21     

Complications after hip fracture surgery: are they preventable?

European Journal of Trauma and Emergency Surgery - Surgery for hip fractures is frequently followed by complications that hinder the rehabilitation of patients. The aim of this study was to...     

Patient-reported complications after elective joint replacement surgery: are they correct?

Using general practitioner records and hospital notes and through direct telephone conversation with patients, we investigated the accuracy of nine patient-reported complications gathered from a self-completed questionnaire after elective joint replacement surgery of the hip and knee. A total of 402 post-discharge complications were reported after 8546 elective operations that were undertaken within a three-year period. These were reported by 136 men and 240 women with a mean age of 71.8 years (34 to 93). A total of 319 reported complications (79.4%; 95% confidence interval 75.4 to 83.3) were confirmed to be correct. High rates of correct reporting were demonstrated for infection (94.5%) and the need for further surgery (100%), whereas the rates of reporting deep-vein thrombosis (DVT), pulmonary embolism, myocardial infarction and stroke were lower (75% to 84.2%). Dislocation, peri-prosthetic fractures and nerve palsy had modest rates of correct reporting (36% to 57.1%). More patients who had knee surgery delivered incorrect reports of dislocation (p = 0.001) and DVT (p = 0.013). Despite these variations, it appears that post-operative complications may form part of a larger patient-reported outcome programme after elective joint replacement surgery.     

Spatial awareness in urologists: are they different?

OBJECTIVE: To compare innate spatial awareness skills, using the MIST-VR system (Ethicon Ltd, Edinburgh, a computer-based virtual reality system that objectively tests spatial awareness) among three groups of people (consultant urologists, urological trainees and controls who were not surgeons), because urological surgeons require spatial awareness for endoscopic and laparoscopic surgery, but trainees are selected by academic prowess rather than surgical aptitude. SUBJECTS AND METHODS: The MIST-VR system was used to test 122 volunteers in three groups, i.e. 39 consultant urologists, 46 urological trainees and 37 controls (not surgeons). The demographic data recorded for each group included age, sex, eyesight, handedness, and endoscopic and laparoscopic experience. Volunteers performed a repetitive series of three tasks using the system. Their performance was measured in terms of time, errors and economy of movement, as well as the duration and accuracy of diathermy in Task 3. RESULTS: The consultants were significantly older than the trainees and controls (both P<0.001) and had more endoscopic experience (P=0.005). In Task 1, the trainees made significantly fewer errors (P=0.045) and had a greater economy of movement (P=0.03) than the controls. In Task 2 the trainees performed the task more rapidly than the consultants (P=0.04) and controls (P=0.02). Trainees were more economical in movement than were consultants (P=0.031) and controls (P=0.046). In the more complex Task 3, trainees outperformed consultants in terms of errors (P=0.03), economy of movement (P=0.046), total diathermy time (P=0.005) and diathermy error (P=0.03). Controls performed similarly to the consultants. Although there was a trend towards better performance by trainees over controls, this was only significant for time (P=0.04) and total diathermy time (P=0.011). A few participants had results that were >2 SD above the mean and several people could not complete Task 3. CONCLUSIONS: Urologists do not differ from the general population in terms of innate spatial ability in this setting. There are several people who may have a defect in spatial awareness but the incidence was the same in each group. Urological trainees outperformed consultants in these tasks; the reasons for this are unclear. The MIST-VR system is of no help in aptitude testing for urological trainees, although it may have a role in teaching laparoscopic surgery. Testing other psychometric components may be more important for acquiring surgical skills than innate spatial-awareness skills. Further studies are required to investigate this possibility.     

Aging and exercise: are they compatible in women?

The benefits of physical exercise and fitness have long been understood. With the aging of society and longevity of women relative to men, interest finally is being given to the female population. There are many benefits to maintaining an active lifestyle as women age. These benefits include maintenance of bone mineral density and prevention of osteoporosis, decreased susceptibility to falls, and decreased susceptibility to breast cancer and other chronic diseases. There are great psychologic benefits to maintaining an active lifestyle, and the connection between cardiovascular fitness and lowering the incidence of cardiac disease is well established. Finally, physical activity and exercise can decrease the symptoms of arthritis. The Centers for Disease Control recommends at least 30 minutes of moderately intensive activity on most days of the week. In older women, the loss of lean body mass (sarcopenia) can be diminished through a strength training program. With these benefits of maintaining an active lifestyle, healthcare providers should become proactive in emphasizing the benefits of physical activity to the older female population.     

A ten-year experience of multiple flaps in head and neck surgery: how successful are they?

Ablative surgery in the head and neck often results in defects that require free flap reconstruction. With improved ablation/reconstructive and adjuvant techniques, improved survival has led to an increase in the number of patients undergoing multiple free flap reconstruction. We retrospectively analyzed a single institution's 10-year experience (August 1993 to August 2003) in free flap reconstruction for malignant tumors of the head and neck. Five hundred eighty-two flaps in 534 patients were identified with full details regarding ablation and reconstruction with a minimum of 6-month follow-up. Of these 584 flaps, 506 were for primary reconstruction, 50 for secondary reconstruction, 12 for tertiary reconstruction, and 8 patients underwent two flaps simultaneously for extensive defects. Overall flap success was 550/584 (94%). For primary free flap surgery, success was 481/506 (95%), compared with 44/50 (88%) for a second free flap reconstruction and 9/12 (75%) for a third free flap reconstruction ( P < 0.05). Eight extensive defects were reconstructed with 16 flaps, all of which were successful. More than one free flap may be required for reconstruction of head and neck defects, although success decreases as the number of reconstructive procedures increases.     

Quality control in outpatient surgery: what data are useful?

Quality control is mandatory, not only for inpatients but also for ambulatory surgery. We propose a list of indices which respond to the key properties of health care that have been defined by Donabedian. These indices should be part of a computerized quality control program which allows comparative evaluation between different centers.