Why is it so hard to do the right thing in wound care?

“Doing the right thing” in wound care is not an easy task. Studies suggest that 3 factors determine compliance with performing basic wound care from an evidence‐based medicine perspective: complexity, cognitive effort, and the compensation system. Two models were explored to investigate compliance with basic wound care at hospital based wound centers: offloading of diabetic foot ulcers (DFUs) and compression bandaging for venous leg ulcers. Using a very large wound‐care registry it was determined that only 6% of DFU patients received the gold standard of care for offloading, i.e., total contact casting (TCC), but among those patients who received it, the average cost of treatment was half the cost of those who did not. Although inexpensive to administer, TCC is a relatively time‐consuming procedure which is poorly reimbursed. Other DFU treatments such as bilaminate skin, are more costly but are reimbursed much more generously. Thus, the reimbursement system favors the use of more expensive therapies over more economical ones. In the case of venous leg ulcers (VLUs), only 17% of patients received adequate compression. Provision of adequate compression among VLU patients has been similarly hindered by inadequate reimbursement policy. Lack of familiarity with clinical practice guidelines increases the cognitive effort for clinicians. Improving the economic model to favor the provision of effective basic care, creating easier‐to‐use products, and making clinical practice guidelines available at the point of service may make it easier to “do the right thing(s)” in wound care.     

Climate change and the surgeon: what is the problem? Why is it so hard? What can be done?

We know very well what causes climate change, and in general terms, what the dangers are. This is a new kind of environmental problem, it is not like taking lead out of petrol, and it is important to understand why responding to climate change is so challenging. But that is no reason to give up: in fact there are many opportunities to intervene, including actions that can be taken by surgeons and other health professionals.     

Reporting the level of evidence in the Canadian Journal of Plastic Surgery: Why is it important?

The levels of evidence (LOE) table has been increasingly used by many surgical journals and societies to emphasize the importance of proper study design. Since their origin, LOE have evolved to consider multiple study designs and also the rigour of not only the study type but multiple aspects of its design. The use of LOE aids readers in appraising the literature while encouraging clinical researchers to produce high-quality evidence. The current article discusses the benefits and limitations of the LOE, as well as the LOE of articles published in the Canadian Journal of Plastic Surgery (CJPS). Along with an assessment of the LOE in the CJPS, the authors have provided recommendations to improve the quality and readability of articles published in the CJPS.     

Why self-immolation? A qualitative exploration of the motives for attempting suicide by self-immolation

Introduction

Suicide by self-immolation is one of the great health concerns in developing countries such as Iran. Exploration of motives for attempting suicide by self-immolation in different point of view of people with experience and information on can be considered as a crucial aspect in self-immolation prevention. The study aimed to explore motives for suicide by self-immolation in Kermanshah, Iran.

Methods

A qualitative approach using semi-structure interview was employed to explore motives for attempting suicide by self-immolation in Kermanshah, Iran (2012). 15 participants including 9 self-immolated patients, a patient's husband, and 5 members of medical staff of these patients were interviewed. The interviews were taped and transcribed. A content analysis using constant comparison was performed for transcribed interviews.

Results

Five main categories were emerged that explore motives for suicide by self-immolation including mental health problems, family problems, cultural context, self-immolation as a threat, and the distinct characteristics of the method. All categories had their specific subcategories which had been integrated based on distinct properties in a given category. More than one motive might be addressed by study participants, which listed in the appropriate categories.

Conclusion

There are several reasons for suicide by self-immolation that should be considered in prevention programs. There may be an interactional pattern among the motives. Further study to explore process of the interactional pattern is recommended.     

Tuberculosis of the ilium: is it really so rare?

Tuberculosis of the ilium is a rare identity, accounting for less than 1% of all skeletal tuberculosis. We report two such lesions in immunocompetent individuals. Tuberculosis remains an important differential diagnosis when faced with unusual or chronic bony lesions, especially in endemic areas, even in non-immunocompromised individuals. It can involve any site and affect people of any age.     

Kidney-pancreas transplants: is it so difficult to start a program?

BACKGROUND: For selected patients with type 1 diabetes mellitus and end-stage renal failure, simultaneous kidney-pancreas (SKP) or pancreas after kidney (PAK) transplantation is the treatment of choice. However, it is frequently difficult to start a program for fear of serious intraabdominal complications in an immunosuppressed patient. We review our initial experience with these transplantations. METHODS: Twenty-three patients (20 SKP, 3 PAK) with type 1 diabetes mellitus received transplants between June 2000 and October 2003. All received immunosuppression therapy with thymoglobulin, prednisone, tacrolimus, and mycophenolate mofetil. The operation included portal venous drainage and exocrine enteric drainage. Rejections were biopsy-proved. Cytomegalovirus prophylaxis with gancyclovir was administered. RESULTS: The mean follow-up is 13 months (range, 1-30 months) for recipients of mean age 39 +/- 7 years (17 men, 6 women). Mean cold ischemia time for kidney was 10.2 +/- 3.9 hours, and for pancreas was 10.5 +/- 3 hours. The rate of initial graft function was 100%. Graft rejection rate was 8%. The repeat laparotomy rate was 53% (12 patients), with a mean of 0.8 procedures per patient (range, 0 to 5). At the end of follow-up, patient survival was 95%, kidney survival was 85%, and pancreas survival was 83%. Patients with a functioning graft were insulin-free, with a mean fasting glucose concentration of 79 +/- 7 mg/dL, hemoglobin A1C of 4.5% (range, 4% to 4.9%) C-peptide of 5.9 ng/mL (range, 2.1 to 12 ng/mL), and a mean serum creatinine level of 1.6 mg/dL (range, 0.9 to 4.6 mg/dL). There was 1 death, due to posttransplantation lymphoproliferative disease confined to the pancreatic graft and abdominal sepsis at 3 months posttransplantation. CONCLUSIONS: Our results are similar to those of other series of SPK or PAK transplantations: low acute rejection rates, frequent requirement for repeat laparotomy, and good patient and graft survival, permitting an excellent quality of life.     

Diagnosing endometrial hyperplasia: why is it so difficult to agree?

Current World Health Organization classification of endometrial hyperplasia is problematic because of poor diagnostic reproducibility. We sought to determine factors that cause diagnostic disagreement in a review of 2601 endometrial specimens. Blinded random specimens of normal endometrium, hyperplasias, and carcinoma were reviewed by 2 pathologists, with review by a third pathologist in cases with disagreement. All cases of endometrial hyperplasia or carcinoma were scored for degree of glandular crowding, architectural complexity, and cytologic atypia. Sample adequacy, hyperplasia volume, presence of metaplasia, or endometrial polyp were also scored. The overall kappa for agreement was 0.71, with a lower kappa of 0.36 when cases called "no hyperplasia" were excluded. The percent specific agreement was 90.3% for no hyperplasia, 31.1% for simple hyperplasia, 51.1% for complex hyperplasia, 49.8% for atypical hyperplasia, and 57.5% for adenocarcinoma. Cases categorized as "low volume hyperplasia" had more diagnostic disagreement than "high volume," (62% vs. 39%, P=0.003). Similarly, cases called "scant" had more diagnostic disagreement than "not scant" (65% vs. 57%, P=0.013). The histologic feature associated with the most diagnostic disagreement was cytologic atypia (P<0.0001). Architectural crowding, architectural complexity, or the presence of a polyp were all associated with diagnostic disagreement (P<0.0001). High diagnostic disagreement in endometrial hyperplasia is related to both sample adequacy and interpretation of histologic features present. Although obtaining additional tissue may increase diagnostic reproducibility, differences in interpretation of key histologic features like cytologic atypia remain major factors contributing to diagnostic disagreement.     

Why Did it Take so Long to Start a Non-Heart-Beating Donor Program in Belgium ?

Ischemia-reperfusion injury of the liver causes severe organ dysfunction after both extended liver resections and liver transplantation. In experimental models, ischemic preconditioning has repeatedly been shown to protect the liver from injury after warm and cold ischemia-reperfusion. Herein, we summarize the experimental and clinical evidence considering protection of tissue by ischemic preconditioning and we conclude that it is now time to initiate prospective randomized multicenter trials, in order to confirm the benefit of ischemic preconditioning for the patients undergoing major liver surgery and liver transplantation.     

Why did it take so long to start a non-heart-beating donor program in Belgium?

The first cadaver kidney transplant, performed in June 1963 in Belgium, was from a heart beating donor (HBD). It was the first ever in the world. Since that period, almost all cadaver organs were procured from brain death donors. When the Belgian law on organ donation and transplantation was published on February 1987, with its opting-out principle, no emphasis was placed on procuring organs after cardiac death. Based on the Maastricht experience, in the early nineties, the transplant community interpellated the National Belgian Council of Physicians to facilitate organ procurement in Non-Heart-Beating Donors (NHBD) following the law. But, the transplant community had to wait for the impulse of the first International Congress on NHBD in 1995,where the 4 categories of Maastricht NHBD were defined. It also published 12 Statements and Recommendations which were eventually approved by the European Council. Then all local Ethical Committees received queries for approving local NHBD programs. Almost all centres requested viability testing assessment of the NHBD organ prior to implantation, and proposed the introduction of machine perfusion technology. Finally, all centres joined their efforts and made a collaborative agreement with Organ Recovery Systems for a 24/7 machine perfusion service from a central laboratory. During a three year period (2003-2005), 46 NHBD kidneys were recovered. Among these kidneys, 32 were perfused in the Organ Recovery Systems central laboratory. The Delayed Graft Function (DGF) rate for these perfused kidneys was 25%. Only one graft was lost in this subgroup. Livers, pancreases (for islet preparation) and lungs (for experimental ex-vivo evaluation) were also recovered from these non-heart-beating donors.     

Hypertension in renal parenchymal disease: why is it so resistant to treatment?

The association between hypertension and chronic renal disease is well known. The pathogenesis of hypertension in patients with chronic kidney disease (CKD) is complex and multifactorial, which may explain why it is resistant to treatment. The traditional paradigm is that hypertension in CKD is due either to an excess of intravascular volume (volume dependent) or to excessive activation of the renin-angiotensin system in relation to the state of sodium/volume balance (renin-dependent hypertension). This review focuses on the importance of less established mechanisms, such as increased activity of the sympathetic nervous system, increased endothelin production, decreased availability of endothelium-derived vasodilators and structural changes of the arteries, renal ischemia, and sleep apnea.     

What is the best hydration regimen to prevent contrast media-induced nephrotoxicity?

BACKGROUND: Hydration is a commonly used method to prevent the decline in GFR after contrast media (CM) application. So far, there have been no controlled, randomized trials investigating the most effective route of fluid administration. METHODS: Thirty-nine patients with normal renal function (65 +/- 9 years, serum creatinine 0.9 +/- 0.2 mg/dl, GFR = 110 +/- 31 ml/min/1.73 m2) receiving at least 80 ml of low-osmolality CM during an angiographic procedure were randomized to one of the following hydration regimens: Group 1: volume expansion with 300 ml saline during CM administration (n = 20, serum creatinine 0.8 +/- 0.1 mg/dl, GFR 119 +/- 27 ml/min/1.73 m2); Group 2: intravenous administration of at least 2,000 ml saline within 12 h before and after CM application (n = 19, serum creatinine 0.9 +/- 0.2 mg/dl, GFR 101 +/- 32 ml/min/1.73 m2). GFR was measured by CM clearance (Renalyzer) at baseline and 48 hours after CM administration. The primary end point was the mean change in the GFR after 48 hours, the secondary one was the incidence of CM-induced nephropathy (CMIN), defined as a decrease in GFR of more than 50% from the baseline GFR within 48 hours. RESULTS: Patients of group 1 showed a significantly (p < 0.05) higher decline in GFR (delta GFR 34.6 +/- 25.7 ml/min/1.73 m2) compared to patients receiving the intravenous prehydration regimen (delta GFR 18.3 +/- 25.0 ml/min/1.73 m2). The incidence of CMIN was lower in prehydrated patients (5.3%) compared to the other group (15%). CONCLUSION: In patients with normal renal function, intravenous prehydration seems to be a very effective and feasible method to prevent the decline in GFR after contrast media exposure. Volume expansion given only during the CM exposure appears not to be sufficient enough to prevent renal damage.     

Hyperhidrosis: What is it and Why Does it Occur?

Hyperhidrosis is excessive sweating in response to heat or emotional stimuli beyond physiologic need. The ailment is not new and has been described in the literature dating back several centuries. It can be classified as either primary or secondary based on its etiology. Mechanisms that cause excessive sweating can be traced to the sympathetic nervous system, part of the autonomic nervous system. It has been speculated that the primary abnormality is central, and that the hypothalamic sweat center that controls the palms, axillae, and soles is distinct in hyperhidrosis individuals.