Phaeochromocytoma: experience from a referral hospital in southern India.

BACKGROUND: Phaeochromocytoma has been traditionally called the 'Tumour of Tens'. Many investigators have reported the prevalence of extra-adrenal phaeochromocytoma to be more than 10%. METHODS: All consecutive adult patients diagnosed to have phaeochromocytoma by the departments of endocrinology and surgical endocrinology of the Christian Medical Hospital, India, over a period of 10 years from 1988 to 1998, were included in the study. RESULTS: A total of 30 patients were diagnosed to have phaeochromocytoma. Extra-adrenal phaeochromocytoma accounted for 26.6% of cases, Ten per cent of cases were bilateral, 6.6% were malignant and one patient had a familial tumour (multiple endocrine neoplasia IIB). The tumours were localized pre-operatively in all patients. Multicentric extra-adrenal tumours were not found in this series. All patients except one were explored by the anterior transperitoneal approach. Persistent hypertension was noted in 30% of patients. CONCLUSIONS: Our series shows a higher prevalence (26.6%) of extra-adrenal tumours than the traditionally described 10%. With accurate pre-operative localization, a transperitoneal approach may not be necessary. The laparoscopic approach needs to be evaluated in light of these findings.     

Laminectomy: a review of the Pennsylvania hospital experience

Two hundred seventy-four patients were reviewed 1-5 years after laminectomy for spinal stenosis or herniated disks. All patients were treated according to the Pennsylvania Plan Algorithm for Degenerative Disk Disease. Ninety to ninety-five percent of the patients noted good to excellent relief of their leg pain, whereas only 80% noted low-back pain relief. The majority returned to work within 4 months. This review demonstrates that by following an algorithm for the treatment of back and leg pain from degenerative disk disease, the surgical results can be extremely gratifying, assuming the goals are relief of leg pain, the operative findings are definite, and the preoperative surgical indications and patient selection are well developed.     

Infectious complications in infants with gastroschisis: an 11-year review from a referral hospital in southern Thailand

Main Purposes

The study aimed to (1) examine the incidence of infectious complications (ICs) in our referral hospital in southern Thailand in infants with gastroschisis, with analysis of the impact of these complications on outcomes, and (2) identify associated factors to improve the practice at our institution for dealing with this condition.

Methods

A retrospective review of consecutive gastroschisis cases at the major teaching and referral hospital in southern Thailand was conducted for an 11-year period (1996-2006). Cases referred after a primary operation at other hospitals were excluded. The study focused on postoperative nosocomial infections as identified by Centers for Disease Control and Prevention criteria.

Results

Sixty-eight patients with gastroschisis were operated on. Twenty-seven patients (39.71%) underwent primary closure. Mortality was 4 of 68 patients (5.9%). Infectious complication occurred in 43 patients (63.2%). The complications significantly increased mechanical ventilation days (10.8 vs 3.8 days in noncomplicated cases), need for parenteral nutrition (25.3 vs 14.5 days), and postoperative stay (33.7 vs 21.1 days). Common ICs were wound infection (32.35%), isolated septicemia (19.1%), and pneumonia (13.24%). Univariate analysis identified an association between the occurrence of IC and birth order (multigravida), time from birth until arrival at our center (5 hours or more), hypoalbuminemia, hypoglycemia, type of operation (staged closure), use of central venous line, and prolonged use of ventilator. On multiple logistic regression, prolonged referral time, use of a central venous line, multigravida, and staged closure independently predicted the risk of IC.

Conclusion

Infectious complication was significantly related to outcome in gastroschisis cases and should not be overlooked. Our data suggest that prompt referral, limiting central line practice on a selective basis, and an attempt to reduce wound infection in cases that require a temporary silo may improve the overall outcomes.     

Arterial embolectomy in the leg: Results in a referral hospital

The clinical characteristics and course of 90 patients in whom 121 arterial emboli occurred from 1968 to 1978 were reviewed. The factor that correlated most significantly with a favorable outcome was the interval from onset of symptoms until arterial embolectomy was performed. The results of embolectomy were excellent in the patients operated on within 6 hours of symptoms (amputation rate 4 percent, mortality rate 15 percent), but less favorable in the patients operated on within 6 to 12 hours of onset of symptoms (amputation rate 27 percent, mortality 40 percent). Mortality (48 percent) and amputation (52 percent) rates in the patients operated on 12 to 48 hours after onset of symptoms were excessive. It is recommended that immediate embolectomy be performed in all potentially viable extremities in patients who present within 12 hours of symptoms, but that after 12 hours only those limbs with obvious viability (not paralyzed or anesthetic) should be operated on. Alternatives for the remainder are high dose intravenous heparinization or expedient amputation. In patients who present greater than 60 hours after the onset of symptoms, embolectomy can be performed with low morbidity and mortality.     

Arterial embolectomy in the leg: results in a referral hospital

A review of 66 patients undergoing femoral embolectomy showed that 38 (58%) obtained a good final outcome (discharge from hospital with viable limb) while 28 (42%) died or required amputation prior to discharge. The major association with poor final outcome was pre-operative life-threatening cardiac disease which occurred in 17 (61%) of those patients who later died or underwent amputation and in six (16%) of those who were discharged with viable limbs (p less than 0.001). Age, sex, source of embolus, duration of ischaemia and pre-existing vascular disease had little effect on final outcome. Surgical dissatisfaction, at the time of operation, with the result of attempted revascularisation was of major prognostic significance in terms of future amputation or death.     

Reverse epidemiology in peritoneal dialysis patients: the Canadian experience and review of the literature

High Body Mass Index (BMI) has been associated with improved survival of End-Stage Renal Disease (ESRD) patients on chronic hemodialysis (HD); however, studies on the relationship of BMI with survival in Peritoneal Dialysis (PD) patients have yielded conflicting results. The purpose of this study was to evaluate the impact of BMI on survival of Canadian ESRD patients on PD, correcting for their age, sex, race, diabetes mellitus, and arterial hypertension. In an intent to treat study, we reviewed data of the Canadian Organ Replacement Register (CORR), of incident patients, starting PD between 1994 and 1998 and followed up from their initial PD treatment to the end of 2003. Patients were censored at loss to follow up, transplantation, and the end of the observation period. Cox regression (multivariate) analysis was performed and adjustments were made for age, gender, race, primary renal disease and BMI. During these years, 4054 patients commenced PD, 1742 (43%) of them were females and 1471 (36.3%) were diabetics. The majority were Caucasians (n=3058, 75.4%); 120 (3%) belonged to the First Nations, 137 (3.4%) were black, and the rest (739 pts—18.2%) belonged to various other ethnicities. Based on quartiles of the BMI distribution, 1130 patients (28%) had a BMI < 18.5 kg/m²; 1163 (28.7%), 18.5–24.9 kg/m²; 1214 (30%), 25–29.9 kg/m²; 547 (13.5%) > 30 kg/m². Intent to treat Cox regression analysis showed that being underweight was a strong risk factor for death. Specifically, a BMI less than 18.5 was associated with a death hazard ratio (HR) 1.3, (CI: 1.1–1.6). On the contrary, BMI > 30 was not associated with worse survival than those with normal BMI (HR = 1.009, CI = 0.89–1.14). High-BMI patients should not be discouraged from PD just because of their size.     

Terrorist attacks in Paris: Surgical trauma experience in a referral center

BackgroundOn November 13th, 2015, terrorist bomb explosions and gunshots occurred in Paris, France, with 129 people immediately killed, and more than 300 being injured. This article describes the staff organization, surgical management, and patterns of injuries in casualties who were referred to the Teaching European Hospital Georges Pompidou.MethodsThis study is a retrospective analysis of the pre-hospital response and the in-hospital response in our referral trauma center. Data for patient flow, resource use, patterns of injuries and outcomes were obtained by the review of electronic hospital records.ResultsForty-one patients were referred to our center, and 22 requiring surgery were hospitalized for >24 h. From November 14th at 0:41 A.M. to November 15th at 1:10 A.M., 23 surgical interventions were performed on 22 casualties. Gunshot injuries and/or shrapnel wounds were found in 45%, fractures in 45%, head trauma in 4.5%, and abdominal injuries in 14%. Soft-tissue and musculoskeletal injuries predominated in 77% of cases, peripheral nerve injury was identified in 30%. The mortality rate was 0% at last follow up.ConclusionRapid staff and logistical response, immediate access to operating rooms, and multidisciplinary surgical care delivery led to excellent short-term outcomes, with no in-hospital death and only one patient being still hospitalized 45 days after the initial event.     

MRSA in urology: a UK hospital experience

OBJECTIVE: Methicillin-resistant Staphylococcus aureus (MRSA) infection appears to be increasing, the UK has one of the worst MRSA rates in Europe. As urological patients are at high risk, the aim of this study was to determine the number of newly diagnosed cases of MRSA detected in a urology ward. PATIENTS AND METHODS: The urology department serves an annual local population of greater than 500,000 with 30 inpatient beds and a tertiary population of 1 million. Over a five year period, we retrospectively recorded all patients with a new diagnosis of MRSA. We also determined colonization site and if the diagnosis of MRSA was made in an elective surgical patient or a patient admitted as an emergency. RESULTS: The mean number of newly diagnosed cases of MRSA was 20.6 per year. The percentage of patients with a new diagnosis of MRSA was less than or equal to 1% per year with no significant difference of new cases of MRSA over five years. Emergency patients had a trend towards a mean higher rate of MRSA. The commonest site of MRSA colonization was from catheters (32%) and open wounds (18%). DISCUSSION: MRSA is of concern, as compared to methicillin-sensitive staphylococcus aureus, because it is associated with high rates of clinically relevant infection, increased hospital stay and cost, greater mortality and high vancomycin usage. Mandatory reporting has shown a steady increase in the number of cases of MRSA infection over the past four years. We found that the number of newly diagnosed cases of MRSA was low, at less than or equal to 1% of patients per year. Furthermore, the number of new cases of MRSA remained constant over five years suggesting low acquisition rates in a busy UK urology ward.     

Motorcycle injuries at a tertiary referral hospital in Kenya: injury patterns and outcome

Background

The rise in the use of motorcycles in Kenya in the last 10 years has been associated with increased injury rates. Between 2004 and 2009, motorcycle injuries increased at a rate of 29 % and, in some hospitals, motorcycle users have become the predominant road user category injured. Although most road traffic injuries occur in Nairobi, there has been no previous account of motorcycle injury and associated outcomes at its main hospital.

Objective

To describe the injury patterns and outcomes following motorcycle trauma at the Kenyatta National Hospital.

Methods

All motorcycle trauma admissions during one calendar year were analyzed. The data captured included demographics, injury patterns and outcomes, lengths of hospital stay, hospitalization cost, and early hospital mortality. Factors associated with outcomes were analyzed by univariate and multivariate means. The probability of survival was estimated using the Trauma and Injury Severity Score (TRISS) methodology for each patient.

Results

Two hundred and five patients were reviewed. Motorcycle trauma admissions formed 22.3 % of all road traffic injury admissions. Male riders predominated. The average age and modal age group was 30.78 and 21–30 years, respectively. Half of riders and 20 % of passengers used protective helmets. Injuries were mostly to the extremities (60.7 %) and head/neck (32.07 %), and the average Injury Severity Score (ISS) was 7.57 + 4.0 (median 9.0). At 2 weeks, 9.0 % of patients had died. The estimated probability of survival ranged from 0.86 to 0.97. Surgical interventions were needed for 51.7 % of patients. The mean length of stay in the hospital was 24.3 days, while the cost of treatment was 31,783 Kenya Shillings (Kshs). Injury severity (P < 0.001), admission to the intensive care unit (ICU) (P < 0.001), non-surgical treatment (P = 0.003), blood transfusion (P = 0.029), head injury (P < 0.001), and low Glasgow Coma Scale (GCS) score at admission were significantly associated with mortality.

Conclusion

Injuries to the lower limbs and the head predominate in motorcycle trauma. The high mortality rate, need for surgery in the majority of patients, and prolonged admission days call for motorcycle control and expedited care. Significant head injury mortality calls for efforts to embrace helmet laws for riders and passengers.     

Safety of outpatient tonsillectomy in children: a review of 6 years in a tertiary hospital experience.

OBJECTIVE: We present our experience with outpatient tonsillectomy in children and critically review safety to support the outpatient policy. STUDY DESIGN AND SETTING: We conducted a retrospective chart review from January 1995 through December 2000 in the pediatric otolaryngology unit of a tertiary care university hospital. RESULTS: One thousand two hundred forty-three patients were accepted in the outpatient program with permissive criteria. Postoperative observation time ranged from 3 to 5 hours (median, 4.5 hours). The overall rate of complications was 9.3% (n = 116). Primary and secondary bleeding rates were 6.27% (n = 78) and 0.48% (n = 6), respectively. Thirty-six children (2.9%) had major bleeding; 2 of them were not identified in day-hospital (0.16%). Discharge was delayed in 103 patients (8.3%), and 13 patients showed complications after discharge (about 1% readmission rate). CONCLUSION: Our program outcomes support safety. Outpatient surgery is meant to provide comfort to the patient and efficiency to the health care system, without impairing safety; in our experience, most tonsillectomies in children comply with these objectives. SIGNIFICANCE: Outpatient tonsillectomy in children may be safe even with permissive criteria, when an appropriate setting is available.     

Thyroid cancer in children: management and outcome experience of a referral center.

OBJECTIVE: To shed light on the discrepancy between the advanced stage at presentation and high recurrence rate of well-differentiated thyroid cancer in children and the overall good survival. DESIGN AND METHODS: The files of 75 children with well-differentiated thyroid cancer treated from 1954 to 2001 in a major tertiary-care hospital were reviewed for disease course, management, and outcome. RESULTS: Sixty patients (80%) had positive neck metastases with involvement of central compartment lymph nodes in all, lateral neck nodes in 36, and distant metastases in 4. Sixty-seven patients underwent total thyroidectomy with adjuvant radioiodine treatment and 8 underwent hemithyroidectomy; all had concomitant neck treatment. The rate of local (5%) and neck (9%) recurrence was similar to the total rate reported in adults. Total thyroidectomy led to a significantly lower recurrence rate (7.5%) than hemithyroidectomy (38%; P < 0.005). Type of neck dissection did not affect recurrence or appearance of distant metastases. All deaths (n = 2) were due to distant metastases, whereas 30% of adult deaths are due to local or neck disease. CONCLUSIONS: The treatment of choice for well-differentiated thyroid cancer in young patients is total thyroidectomy. Neither regional disease at presentation nor recurrences affect survival.     

The impact of second opinion surgical pathology on the practice of head and neck surgery: a decade experience at a large referral hospital

BACKGROUND: A second review of histopathologic diagnoses is a quality assurance practice that helps expose diagnostic errors and guide management of patients being referred from outside hospitals. Identification of anatomic regions and specimen types that are prone to diagnostic error will be helpful in guiding policy decisions regarding mandatory second opinion surgical pathology. METHODS: All available outside pathology reports were retrieved for patients referred to The Johns Hopkins Hospital Department of Otolaryngology-Head and Neck Surgery between January 1, 1990, and January 1, 2000. The outside diagnosis was compared with diagnosis rendered at the referral hospital. A discrepant diagnosis was regarded as any change resulting in a significant modification in therapy or prognosis. RESULTS: Of the 814 cases reviewed, the second opinion surgical pathology diagnosis resulted in 54 (7%) changed diagnoses. Of the changed diagnosis, 13 (24%) involved a change from a benign to a malignant diagnosis; 8 (15%) involved a change from a malignant to a benign diagnosis; and 33 (61%) involved a change in tumor classification. Follow-up information supported the second opinion diagnosis in 41 of 43 cases (95%). CONCLUSIONS: In a consequential number of cases, second opinion surgical pathology results in major therapeutic and prognostic modifications for patients sent to large referral hospitals for head and neck oncologic surgery.     

Coronary artery bypass grafting for octogenarians: experience in a private hospital and review of the literature.

BACKGROUND AND METHODS: Indications for coronary artery bypass grafting (CABG) are expanding. We retrospectively analyzed the results of isolated CABG performed at Shin-Tokyo Hospital between January 1, 1992, and August 31, 2000. Preoperative, perioperative, and follow-up data of patients 80 years of age or older (group E, n=55) were collected and compared with those of patients between 75 and 79 years of age (group Y, n=197). RESULTS: Patient demographics were not significantly different except there was a greater incidence of co-existing valvular disease in group E. CABG was completed without any significant differences, except fewer distal anastomoses and more frequent off-pump CABG were performed in group E than in group Y. The in-hospital mortality rates of group E and Y were 1.8% and 2.5%, respectively (p=NS). The postoperative recovery (intubation time, ICU stay, and postoperative hospital stay) of group E was similar to group Y. During the mean follow-up of 2.6 years (maximum 8.4 years), the actuarial 3-year survival of groups E and Y was 84.5% and 94.9% (p=NS), respectively, excluding in-hospital mortality. The actuarial 3-year cardiac event-free rates were 100% in group E and 88.4% in group Y (p=NS). CONCLUSION: CABG for octogenarians can be performed safely. Once adequate revascularization was established, the long-term cardiac events were similar to those of the younger patients.     

Patient influx and trauma types in a front-line hospital and a secondary referral hospital after the Wenchuan earthquake: a retrospectively comparative study

Purpose  

To better understand the differences of patient influx and types of trauma between front-line and referral hospitals after the Wenchuan earthquake, so as to improve the efficiency of injury management.     

Porcelain gallbladder: a clinical case and a review of the literature

Porcelain bladder is defined as calcification of the gallbladder wall. It is a rare condition and is seen in 0.06% to 0.8% of cholecystectomies. It origin is still unknown.We report two cases of patients with a porcelain gallbladder. One case is a 60 year-old male patient who was seen due to having biliary symptoms. The diagnosis was made by ultrasound and computed tomography, and he was surgically intervened by performing a partial cholecystectomy. The histopathology reported a gallbladder wall with sclerohyalinosis and dystrophic calcification foci. The other case is a 98 year-old female patient, whose form of presentation was incidental given that she suffered from symptoms of an intestinal obstruction. A cholecystectomy was performed with a good post-surgical outcome.A series published in between 1950 and 1960 show that the porcelain bladder can be frequently observed in patients with cancer of the gallbladder, although this relationship is currently being rejected. The reason why these cases are being presented is because of their low incidence and the controversy over what treatment to use, due to its association with gallbladder cancer.