直肠切除术后理想尿引流时间的前瞻性研究

目的:前瞻性地研究直肠切除术后留置尿管1d和5d的尿潴留及尿路感染结果,以探寻术后理想的尿引流时间。方法:126例直肠切除病例,随机分为术后尿引流1d和5d二组,比较二组的结果。结果:1d组64例,5d组62例。1d组尿潴留率25％,5d组为10％(P<0.05);1d组尿路感染率为20％,5d组为42％(p<0.01)。多因素分析表明:1d组低位直肠癌和淋巴结转移是术后急性尿潴留的危险因素(p<0.05)。除外低位直肠癌病例,二组急性尿潴留率无显著差异,但尿路感染率5d组明显高于1d(组(p<0.01)。结论:直肠切除术后尿引流1d适应于多数病人,而低位直肠癌术后需要留置尿管引流5d。     

Prewarming operating rooms for prevention of intraoperative hypothermia during total knee and hip arthroplasties

Prewarming operating rooms has been shown to limit hypothermia in pediatric surgical patients but may be associated with extreme discomfort for surgeons. We examined the effect of prewarming operating rooms on core temperatures during knee and hip arthroplasties. Sixty-six patients were randomized to the prewarmed group at 24°C or control group at 17°C. The prewarmed group core temperature (mean, 36.14°C) before active warming was significantly higher (P = .018) than that of the control group (mean, 35.83°C). By the start of surgery, the difference was 36.01°C prewarmed vs 35.83°C control, P = .038. There was no significant difference in the last recorded mean temperatures between groups: 36.35°C (prewarmed) vs 36.16°C (control). A prewarmed operating room for adults undergoing knee or hip arthroplasty had minimal effect on preventing intraoperative hypothermia.     

Bisphosphonate Treatment in Osteoporosis: Optimal Duration of Therapy and the Incorporation of a Drug Holiday

Background

Bisphosphonates are the most widely used treatment for osteoporosis. They accumulate in the bone for years, and therefore, their inhibitory effects on osteoclasts may persist after drug discontinuation. The ideal duration of therapy remains controversial.

Questions/Purposes

The purpose of this study is to review the literature to determine the (1) indications for drug holiday, (2) the duration of drug holiday, (3) the evaluation during drug holiday, and (4) the proper treatment and maintenance after drug holiday.

Methods

A review of two electronic databases (PubMed/MEDLINE and EMBASE) was conducted using the term “(Drug holiday),” in January 29, 2015. Inclusion criteria were as follows: (1) clinical trials and case control, (2) human studies, (3) published in a peer-review journal, and (4) written in English. Exclusion criteria were as follows: (1) case reports, (2) case series, and (3) in vitro studies.

Results

The literature supports a therapeutic pause after 3–5 years of bisphosphonate treatment in patients with minor bone deficiencies and no recent fragility fracture (low risk) and in patients with moderate bone deficiencies and/or recent fragility fracture (moderate risk). In these patients, a bone health reevaluation is recommended every 1–3 years. Patients with high fracture risk should be maintained on bisphosphonate therapy without drug holiday.

Conclusion

The duration and length of drug holiday should be individualized for each patient. Evaluation should be based on serial bone mass measurements, bone turnover rates, and fracture history evaluation. If after drug therapy, assessments show an increased risk of fracture, the patient may benefit from initiating another treatment. Raloxifene, teriparatide, or denosumab are available options.

     

Prewarming of the i-gel facilitates successful insertion and ventilation efficacy with muscle relaxation: a randomized study

Study ObjectiveTo determine if prewarming of the i-gel (Intersurgical, Wokingham, United Kingdom) improves insertion and ventilation efficacy with muscle relaxation in patients undergoing elective surgery.DesignClinical randomized study.SettingOperating room.PatientsSixty-eight adult patients scheduled for elective surgery under general anesthesia with American Society of Anesthesiologists physical status 1-3.InterventionsThe i-gel was warmed to 42°C for 30 minutes before insertion (W group; 34 patients) or kept at room temperature (approximately 23°C) (C group; 34 patients).MeasurementsThe number of attempts for a successful insertion and the sealing pressure and leak volume 30 seconds and 30 minutes after initiating mechanical ventilation.Main ResultsThe total insertion attempts were 1 (W group, 31 cases; C group, 24 cases) and 2 (W group, 3 cases; C group, 10 cases), which was significant (P = .001). Sealing pressure was significantly higher in the W group than the C group (W group, 21.8 ± 3.7 cm H₂O; C group, 18.5 ± 3.4 cm H₂O; P = .001). Leak volume was significantly smaller after 30 seconds in the W group than the C group (P = .002), but not after 30 minutes (P = .69).ConclusionsPrewarming the i-gel to 42°C demonstrated a higher successful ventilation initiation.     

A Prospective Randomized Study to Assess the Optimal Duration of Intravenous Antimicrobial Prophylaxis in Elective Gastric Cancer Surgery

The duration of antimicrobial prophylaxis in gastric cancer surgery is not yet established. This prospective randomized study was performed to confirm the noninferiority of single-dose versus multiple-dose antimicrobial prophylaxis in terms of the incidence of surgical-site infection in gastric cancer surgery. Three hundred twenty-five patients undergoing elective resection for gastric cancer were randomized to receive only single-dose cefazolin (1 g) during surgery (single-dose group) or an additional 5 doses every 12 hours postoperatively (multiple-dose group). The overall incidence of surgical-site infections was 9.1% in the single-dose group and 6.2% in the multiple-dose group [difference (95% confidence interval): −2.9% (−5.9%–0.0%)]. Multivariate logistic regression analysis identified blood loss, being overweight, and advanced age as significant independent risk factors for surgical-site infection. Single-dose antimicrobial prophylaxis seemed to be acceptable, and choosing multiple-dose prophylaxis may have little impact on the prevention of surgical-site infections in elective gastric cancer surgery.     

Optimal Timing and Temperature for Hyperthermic Preconditioning in an Animal Model of Fecal Peritonitis

The impact of immune parameters in the mechanism of hyperthermia is yet to be explained. In this study, the optimal timing and temperature of thermal treatment for reversing the abnormal immunologic parameters obtained in a rat model of peritonitis were planned to be determined. Male Sprague-Dawley rats were grouped as sham, control peritonitis, and thermally treated rats at the time of peritonitis or 4 h prior to induction of peritonitis both at 40 and 42°C. Peritonitis was induced by the cecal ligation and perforation model. Eight hours after the induction of peritonitis, rats were sacrified and samples were taken for measurements of CD 4 + , CD 8 + , CD 11b , B cells, NK cells, and tumor necrosis factor &#102 (TNF &#102 ) and thiobarbituric acid-reactive substances (TBARS) levels. CD 4 + expression and B cell amount were decreased whereas TNF &#102 levels, CD 8 + and CD 11b expression, and NK cell amount were found to be increased in the control peritonitis group when compared to the sham group. Peritonitis induction also increased TBARS levels in liver tissue. Hyperthermic preconditioning at either 40 or 42°C applied 4 h prior to peritonitis induction returned all parameters to their normal levels, which is similar to the results of the sham laparotomy group. The results of TNF &#102 values in preconditioned rats were varied according to the temperature that was applied. The levels were increased at 40°C, whereas they showed a decline at 42°C. Hyperthermic preconditioning prevented the oxidative damage in liver as well as TNF &#102 elevation, particularly at 42°C. Results from this study suggest that hyperthermic preconditioning 4 h prior to the onset of septic events may improve the adverse outcome in sepsis.     

Duration of postlaparoscopic pneumoperitoneum

Background: Patients who present with abdominal pain after recent laparoscopic surgery present a diagnostic dilemma when pneumoperitoneum is present. Previous studies do not define the duration of postlaparoscopic pneumoperitoneum. In this study, we attempted to define the duration of laparoscopic pneumoperitoneum and to identify factors which affect resolution time. Methods: We followed 57 patients who underwent laparoscopic cholecystectomy (34), inguinal herniorraphy (20), or appendectomy (three). Serial abdominal films were taken until all residual gas was resolved. Results: Thirty patients resolved their pneumoperitoneum within 24 h; 16 patients resolved between 24 h and 3 days; nine patients resolved between 3 and 7 days; two patients resolved between 7 and 9 days. Mean resolution time for all patients was 2.6 ± 2.1 days. There was no apparent difference in resolution time between the three types of procedures; however, the sample size may be insufficient. Duration of the pneumoperitoneum did not correlate with gender, age, weight, initial volume of CO₂ used, length of time for the procedure, or postoperative complications. Sixteen patients had bile spillage during cholecystectomy which significantly reduced the duration of postoperative pneumoperitoneum (p < 0.008), resulting in a mean resolution time of 1.3 ± 0.9 days. While 14 patients reported postoperative shoulder pain, no correlation was found between the presence or duration of shoulder pain and the extent or duration of pneumoperitoneum. Conclusions: We conclude that the residual pneumoperitoneum following laparoscopic surgery resolves within 3 days in 81% of patients and within 7 days in 96% of patients. The resolution time was significantly less in patients sustaining intraoperative bile spillage during cholecystectomy. There was no correlation found between postoperative shoulder pain and the presence or duration of the pneumoperitoneum. Received: 22 March 1996/Accepted: 12 July 1996     

Duration of involuntary infertility and subsequent pregnancy

During 1978-1983, 1,040 couples had been evaluated at our infertility clinic and subsequently followed up for an average of two years. The length of time the couple had been trying for a pregnancy (trying time) is shown to be strongly related to the subsequent chances of pregnancy. There are few effective treatments for male infertility and, therefore, these data may represent the spontaneous fertility rates from an untreated population. This background pregnancy rate should be useful to any physician planning a trial of treatment for the infertile couple when pregnancy is the success criterion, and allowance needs to be made for this spontaneous pregnancy rate when analyzing the results of treatments. Review of the literature suggests that some reported results could be misleading because of failure to allow for this background pregnancy rate.     

Duration of symptoms and disc configuration in chemonucleolysis

Previous studies have compared the effectiveness of chemonucleolysis with surgery, but currently, no objective criteria have been correlated with the clinical outcome. The authors reviewed 28 cases where the patients had undergone chymopapain injection to determine the significance of disc herniation size, disc space height reduction, and the duration of symptoms on clinical outcome. All patients had a complete history, physical examination, and discogram, and most had pre- and post-injection computerized tomography (CT) or myelogram. Nine of the 28 patients were considered clinical failures. Seven underwent laminectomy and discectomy and were improved markedly. Two patients were advised to have surgery but refused and were considered clinical failures. The causes of failure were unknown in three patients, free fragment in two patients, and diabetic neuropathy in one. Only two patients who did well showed complete resolution of the disc deformity on repeat CT scan. The remainder still had evidence of an avascular deformity that persisted although reduced in size. The failures showed no changes in disc size. The height of the disc space was too variable to be correlated with clinical outcome. Patients who failed had a longer duration of symptoms than the ones who did well (15.1 months for failures vs. 5 months). Therefore, some reduction of disc deformity size, but not necessarily complete reduction, is necessary for a good result, and the enzyme is not as effective in patients with long-standing symptoms.