Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics

We performed a retrospective review of a vascular surgery quality assurance database to evaluate the perioperative and long-term morbidity and mortality of above-knee amputations (AKA, n = 234) and below-knee amputations (BKA, n = 720) and to examine the effect of diabetes mellitus (DM) (181 of AKA and 606 of BKA patients). All patients in the database who had AKA or BKA from 1990 to May 2001 were included in the study. Perioperative 30-day cardiac morbidity and mortality and 3-yr and 10-yr mortality after AKA or BKA were assessed. The effect of DM on 30-day cardiac outcome was assessed by multivariate logistic regression and the effect on long-term survival was assessed by Cox regression analysis. The perioperative cardiac event rate (cardiac death or nonfatal myocardial infarction) was at least 6.8% after AKA and at most 3.6% after BKA. Median survival was significantly less after AKA (20 mo) than BKA (52 mo) (P < 0.001). DM was not a significant predictor of perioperative 30-day mortality (odds ratio, 0.76 [0.39-1.49]; P = 0.43) or 3-yr survival (Hazard ratio, 1.03 [0.86-1.24]; P = 0.72) but predicted 10-yr mortality (Hazard ratio, 1.34 [1.04-1.73]; P = 0.026). Significant predictors of the 30-day perioperative mortality were the site of amputation (odds ratio, 4.35 [2.56-7.14]; P < 0.001) and history of renal insufficiency (odds ratio, 2.15 [1.13-4.08]; P = 0.019). AKA should be triaged as a high-risk surgery while BKA is an intermediate-risk surgery. Long-term survival after AKA or BKA is poor, regardless of the presence of DM.     

Postoperative nausea and vomiting and opioid-induced nausea and vomiting: guidelines for prevention and treatment

Postoperative nausea and vomiting (PONV) causes patient discomfort, lowers patient satisfaction, and increases care requirements. Opioid-induced nausea and vomiting (OINV) may also occur if opioids are used to treat postoperative pain. These guidelines aim to provide recommendations for the prevention and treatment of both problems. A working group was established in accordance with the charter of the Sociedad Espa?ola de Anestesiología y Reanimación. The group undertook the critical appraisal of articles relevant to the management of PONV and OINV in adults and children early and late in the perioperative period. Discussions led to recommendations, summarized as follows: 1) Risk for PONV should be assessed in all patients undergoing surgery; 2 easy-to-use scales are useful for risk assessment: the Apfel scale for adults and the Eberhart scale for children. 2) Measures to reduce baseline risk should be used for adults at moderate or high risk and all children. 3) Pharmacologic prophylaxis with 1 drug is useful for patients at low risk (Apfel or Eberhart 1) who are to receive general anesthesia; patients with higher levels of risk should receive prophylaxis with 2 or more drugs and baseline risk should be reduced (multimodal approach). 4) Dexamethasone, droperidol, and ondansetron (or other setrons) have similar levels of efficacy; drug choice should be made based on individual patient factors. 5) The drug prescribed for treating PONV should preferably be different from the one used for prophylaxis; ondansetron is the most effective drug for treating PONV. 6) Risk for PONV should be assessed before discharge after outpatient surgery or on the ward for hospitalized patients; there is no evidence that late preventive strategies are effective. 7) The drug of choice for preventing OINV is droperidol.     

Similarities and differences between female and male sexual functions and dysfunctions

Men and women have 23 pairs of chromosomes. They share 22 of them. In physiologic conditions they differ systematically in only one pair, the sexual one. Females (normally) have what is called an “XX” on the 23rd pair of chromosomes, whereas males have an “XY” pair. The striking sexual differences –anatomic, functional, reproductive, psychological and sociocultural - between men and women depends on or derive from the difference in one critical chromosome out of 46, which contains on average 2% of all the genetic code. Biochemical, neuroendocrine, hormonal, vascular, nervous, and metabolic similarities that both sexes share, based on the common 45 chromosomes and related biologically determined similarities contributing to the secret sexual symmetry between genders, is reviewed. Furthermore the role of the genetically determined brain and somatic gender dymorphism, contributing to gender sexual differences is analyzed. Neuroplasticity and psychoplasticity are praised as basic mechanisms that bridge together and re-shape the individual biological and psychological world through the continuous interaction with the environment. Enhancement of sexual differences in behaviour, meaning of, and motivation to sex by cultural constructs, by religious and social dynamics, and the continuous interaction of each person with a usually role-polarized society during the whole life span will be finally acknowledged. To contribute to a better understanding of the shared biological sexual similarities between genders and their dialectic and continuous relation with biological and socioculturally related sexual differences is the ultimate goal of this introductory article and the following papers of the series.     

Temporal and malar-zygomatic reduction and augmentation

The temporal fossa, zygomatic arch, and malar-midface should be considered jointly when augmentation of the temporal area or reduction of the zygomatic arch are to be carried out. These anatomic areas relate so closely to one another that altering one affects the other. In addition, augmentation of the malar-midface area may be done if one of the other two procedures is to be considered, or if a brow lift, subperiosteal face lift, or other reason for using a coronal incision exists. Use of the coronal incision for malar augmentation is probably not justified because of the large amount of surgery required in spite of the lesser morbidity associated with this approach in terms of amount of infections, lip stiffness, and hypesthesia. Planning a surgical procedure must be done in the office, by examining the patient at eye level to determine the amount of zygomatic arch reduction and the amount of temporal fossa augmentation necessary. Similarly, the three zones of the malar-midface complex must be assessed, with the amount of augmentation of each zone determined prior to the day of surgery. The surgical procedure is then executed through a coronal incision, with the dissection extending down to the zygomatic arch. If the temporal muscle is to be elevated out of its fossa, it is cut on its anterior, superior, and posterior edges, elevating it out of its fossa so that a Proplast implant, typically 3 to 4 mm thick and finely tapered on its superior and posterior edges, with suturing done anteriorly, may be inserted. The muscle is then resutured to its aponeurosis on all three edges. If the zygomatic arch and malar-midface area are to be approached, the dissection is carried to the deep and superior edge of the zygomatic arch, and the periosteal elevator is used to elevate the soft tissue off the lateral and inferior edge. The arch and malar-midface are cleared of soft tissue, extending the tunnel to the upper buccal sulcus. The arch is then reduced with a contouring burr to the thinness desired. Alternatively, the malar-midface area may be augmented with synthetic material precisely positioned, with a suture around the zygomatic arch, holding it in position as measured from the lateral orbital rim. The incision in the temporal fascia is then resutured, and the coronal incision is closed.(ABSTRACT TRUNCATED AT 400 WORDS)     

The German emergency and disaster medicine and management systemdhistory and present

As well for optimized emergency management in individual cases as for optimized mass medicine in disaster management, the principle of the medical doctors approaching the patient directly and timely, even close to the site of the incident, is a long-standing marker for quality of care and patient survival in Germany. Professional rescue and emergency forces, including medical services, are the “Golden Standard” of emergency management systems. Regulative laws, proper organization of resources, equipment, training and adequate delivery of medical measures are key factors in systematic approaches to manage emergencies and disasters alike and thus save lives. During disasters command, communication, coordination and cooperation are essential to cope with extreme situations, even more so in a globalized world. In this article, we describe the major historical milestones, the current state of the German system in emergency and disaster management and its integration into the broader European approach.     

Uptake and elimination of isoflurane and halothane by children and adults

The rate of increase of alveolar concentrations (FA/FI) of isoflurane and halothane was studied in children and adults during general anaesthesia and controlled ventilation. After 30 min of body equilibrium, elimination curves of the volatile anaesthetics were determined by measurement of alveolar (FA/FA0; infrared technique) and venous concentrations (gas chromatography). The distribution and elimination half-times (t1/2 alpha, t1/2 beta), clearance (Cl), volume of central and peripheral compartment (V1, Vz) and the volume of distribution at steady state (Vss) were calculated from the intercepts and slopes of a two-compartment model. During the uptake of anaesthetic concentrations of isoflurane and halothane, the FA/FI ratio of each gas was found to rise significantly faster in children than in adults. The reason for the more rapid approach to equilibrium in children seems to be related to physiological differences. Irrespective of age, uptake of isoflurane was more rapid than that of halothane, as it is less soluble. Similarly, isoflurane was eliminated from the lung or blood faster than halothane. Moreover, anaesthetic wash-out in children differed from that in adults. In the paediatric age group t1/2 beta under isoflurane was shorter than in adults, whereas halothane excretion took longer in children. This could be accounted for by the larger volumes of distribution Vz and Vss in the young, due to higher organ affinity of halothane. From our data we conclude that age significantly affects uptake and elimination of volatile anaesthetics and the control of anaesthesia is easiest with isoflurane in paediatric patients.     

Stem cells and cardiovascular and renal disease: today and tomorrow

The traditional view that organs have only limited regenerative capacity has been challenged in recent years as adult bone marrow stem cells as well circulating progenitor cells have been identified to retain the plasticity to participate in neovascularization, a process so far believed not to be possible after birth. An organ that is damaged by ischemia causes the release of cytokines; these act via the flowing blood and stimulate the bone marrow, which then mobilizes progenitor cells to the blood and directs them to adhere to and migrate into the damaged organ. Thus, these progenitor cells most likely constitute a natural repair mechanism that counteracts degenerative or aging processes. On the basis of encouraging experimental data, first clinical trials have been established to demonstrate the safety and the feasibility of progenitor cell therapy in case of peripheral artery disease or myocardial infarction. Trials investigating injection of bone marrow or circulating progenitor cells into the coronary artery after an acute myocardial infarction not only demonstrates safety of the procedure but also gave hints toward efficacy. Nevertheless, these findings have to be validated by subsequent larger, prospective, randomized, controlled trials. There are also potential topics in nephrology, where modification of progenitor cell activity might be of benefit, such as renal ischemic disease, glomerular disease, and renal transplant vasculopathy. Finding a way to integrate the principle of progenitor cell action into therapeutic efforts might provide a completely new therapeutic strategy that not only attempts to retard disease progression but furthermore targets to regenerate damaged organs.     

Trends and perspectives in pancreas and simultaneous pancreas and kidney transplantation

Pancreas transplantation is still the best option to achieve normoglycaemia and insulin independence in patients with type I diabetes. As a result of improvements in surgical techniques, immunosuppression and patient selection, one year survival rates of 95, 83, and 88% for patient, pancreas, and kidney survival, respectively, are reported for patients with simultaneous pancreas and kidney transplantation. The main goals for the future are to reduce postoperative morbidity, to identify the relevant indications for single pancreas transplantation, to adopt the best surgical technique for individual patients' needs (bladder versus enteric drainage with or without portal venous delivery of insulin), and to develop immunosuppressive strategies with low nephrotoxic and diabetogenic potential.     

Wrist and hand examination and interpretation

Hand rehabilitation is an area with the potential for providing orthopaedic physical therapists a challenging and rewarding practice. However, success in treating the patient with hand dysfunction is closely associated with the therapist's understanding of essential anatomic and pathokinesiologic principles and the related ability to adequately evaluate, plan, and perform treatment. The first article (Wadsworth CT: Clinical anatomy and mechanics of the wrist and hand. J. Orthop Sports Phys Ther 4:205-216) in this two-part series covered the background anatomic and pathokinesiologic concepts. This, the second article of the series, describes the format for examination of the patient with hand dysfunction and presents a practical but comprehensive evaluation form for clinical use. It also supplies information for interpretation of the examination which lays the foundation for goal setting and treatment planning.J Orthop Sports Phys Ther 1983;5(3):108-120.     

Moped and motorcycle accidents--similarities and discrepancies

Injury patterns and epidemiologic data from 211 moped accident victims and 214 motorcycle accident casualties admitted to hospital over a 5-year period (1977-1981) have been analyzed and compared. The number of those injured in motorcycle accidents tripled; the number of moped accident victims slightly decreased in the period studied. Differences in injury pattern, sex ratio, cause of accident, and age distribution were noted. Among mopedists, head injuries were more common but these injuries decreased significantly after the adoption of helmet use laws for mopedists also in 1978. There were more females involved in moped accidents and the mean age was considerably higher among mopedists. Of those injured in moped accidents, 21% were 60 years old or older and accounted for 56% of fatalities in this group. The most frequent cause of moped accidents was collision with a car, and over turning or running off the road in motorcycle accidents. The difference in injury severity was unexpectedly small, although there was a tendency toward more severe injuries in motorcyclists. Moped accidents are so similar to motorcycle accidents that it seems unjustified to regard mopeds as harmless 'bicycles with a helper motor.' The need for formal registration, driving license, and helmet use laws for mopeds is apparent.     

Surgical and anesthetic coordination during tracheal and carinal resections and reconstruction

A retrospective study of anesthetic and surgical techniques involved in 55 consecutive cases of tracheal and carinal resections completed from 2001 to 2007, is presented. The anesthetic maneuvers and surgical approach differed in relation with the site of the tracheal lesions (upper, middle, lower trachea or carinal), the degree of the obstruction, the emergency of the surgical intervention and the concomitant presence of the eso-tracheal fistula. Ventilatory support during anesthesia involved special equipment adapted to the particular techniques used in this type of surgery. Cross field intubation of trachea or a mainstem bronchus, and High Frequency Jet Ventilation-HFJV- have been frequently used. Perfect coordination of the anesthetic techniques with every surgical step is mandatory and for good long term results special anesthetic equipment and a good preoperative anesthetic and surgical assessment of the strategy is needed.     

Body composition assessment and methodology in nonathletic and athletic adolescent and adult males and females

The purpose of this review is to outline methodology for assessing body composition utilizing anthropometric and densitometric techniques. The objective of body composition assessment is to measure body fat and lean body mass. The quantity of these components varies due to growth, physical activity, dietary regimens, and aging. Anthropometric techniques incorporate selected skinfolds, circumferences, skeletal widths, or other variables to estimate body composition within k2.0-4.0%. These techniques are adequate for field testing of groups or individuals, but are population specific. Densitometry measures body volume irrespective of physique, sex, or age. This laboratory technique estimates body composition within 1.0-2.0%, is more difficult to administer, but is not population specific. Some limitation exists with any present technique due to biological variability and incomplete research of reference body composition in children, females, and the aged. J Orthop Sports Phys Ther 1984;5(6):336-347.     

European Union and Spanish Regulations on Quality and Safety of Tissues and Cells: Overview and Biovigilance

Background

The increasing therapeutic possibilities offered by tissues and cells during the last years, the existing discrepancies in regulation between Member States (MS), and the associated risks have led legislators in the European Union (EU) and its MS to establish a set of supranational standards that ensure quality and safety of human tissues/cells as well as processes related to donation, procurement, processing, and utilization. MS are under the obligation to incorporate the requirements of the European rules in their internal regulations.

Regulation

The regulations in the European Directives on tissues and cells range from the broad principles stated in Directive 2004/23/EC, to the detailed requirements described in Directives 2006/17/EC and 2006/86/EC. The aspects related to biovigilance were described in the latter. Spain has already complied with the obligation to transpose these Directives through the Royal Decree 1301/2006.

Biovigilance

Surveillance is a methodology often used in public health. The design of a surveillance system implies a decision-making process on the elements, procedures, and principles of the system. Regarding Spain, some of the elements have already been defined in the European or Spanish rules; however, other components of the biovigilance system have been discussed and developed in working documents outside of regulation.     

Organ donation and islam-challenges and opportunities

The issue of organ donation in Islam has been debated for decades, with most religious authorities sanctioning both living-organ and deceased-organ donation. However, disquiet among the Islamic community on the compatibility of organ donation with their faith remains, especially in relation to deceased-organ donation. This remains a topical, controversial, and challenging component of organ procurement at both local and international levels. In this article, I will explore Islamic arguments both for and against organ donation, in the context of both living-donor and deceased-donor models. By discussing both practical and philosophical perspectives, the aim is to facilitate discussion on how best to achieve consensus on this issue by driving the debate forward in an open and all-encompassing manner. Although every attempt should be made to achieve consensus among key Muslim opinion makers (individuals, authorities, and institutions), encouraging personalized decision making by intellectual effort should be the goal to achieve genuine informed consent.     

Characterisation and differentiation of chondroblastomas and chondromyxoidfibromas - presence and expression of collagen types I and II

AIM: Chondroblastomas and chondromyxoidfiibromas are rare benign skeletal neoplasms with reported overlapping histology. Aim of this study was to analyse the biochemical composition of the matrix of these tumour entities in order to further characterise the cellular phenotypes of these neoplasms using typical cell biological marker genes. METHODS: The matrix compositions of chondroblastomas and chondromyxoidfibromas were analyzed by HE-histology, histochemistry, and immunolocalization techniques. Cellular gene expression patterns were detected by mRNA in situ hybridization. RESULTS: Chondroblastomas are rich in collagen type I and show foci of an osteoid-like matrix, whereas collagen type II as a typical marker of chondrocytic differentiation was not detected in any of the specimens. Chondromyxoidfiibromas had foci of chondroid appearance with chondroblastic cellular differentiation characterised by collagen type II expression. CONCLUSION: These results characterise chondroblastomas and chondromyxoidfiibromas as skeletal neoplasms that have a different biology and which can be distinguished by matrix protein expression products: collagen type II, the typical marker of chondroblast differentiation, could only be detected in chondromyxoidfibromas, but not in chondroblastomas. Thus, both neoplasms are clearly different on the cell biological level.     

Anemia and cardiovascular and kidney disease

PURPOSE OF REVIEW: The joint occurrence of cardiovascular disease, kidney disease and anemia has been termed the 'cardio-renal-anemia syndrome'. This review will examine each of these relationships as they pertain to coronary heart disease. RECENT FINDINGS: Important contributions from the recent literature included observations suggesting that African-Americans with chronic kidney disease and no previous history of cardiovascular disease were more likely than caucasians to have incident cardiovascular disease than caucasians with chronic kidney disease but that this difference did not apply to risk of recurrent cardiovascular disease. Recent reports have brought attention to a continued lack of clinical trials evidence to support anemia treatment for cardioprotection, further concern that higher hemoglobin levels may increase cardiovascular risk and evidence that anemia and kidney function interact to increase risk for coronary heart disease. Finally, additional observational studies and small clinical trials continue to support a role of anemia treatment in protection of residual kidney function, although a recent meta-analysis failed to demonstrate a conclusive benefit of erythropoietin treatment on progressive kidney disease. SUMMARY: The cardio-renal-anemia syndrome is a set of complex and interrelated phenomena that are poorly understood. Current evidence is insufficient to demonstrate a conclusive benefit of treatment with erythropoietin on risk of cardiovascular disease or progression of kidney disease. Future research is needed to further clarify these issues.     

Teens and tanning knowledge and attitudes

Background: The incidence of skin cancer, including melanoma, continues to increase. Teenagers are especially vulnerable, as are young females. The incidence of melanoma among young women in their twenties and thirties has begun to increase again. These young people are also the population that frequent tanning salons. Objective: This voluntary, anonymous, New York University, Institutional Review Board-approved survey was given to students in grades 9 through 12 to ascertain their understanding of what causes skin cancers and the dangers of excessive sun exposure and tanning salons. Methods and materials: An Institutional Review Board-approved, 22-question survey was administered anonymously to more than 450 students with 368 returned responses. The survey was administered to students in grades 9 through 12 at two high schools in New York and New Jersey. Results: More than 80 percent of students view movie stars as tan and almost 60 percent see "tan" people as better looking. In addition, more than 90 percent believe that a tan does not prevent further damage to the skin (as opposed to the customary belief that a "base" tan can protect against extreme sun exposures, such as when on a tropical vacation). There appears to be a disconnect between knowledge and sun tanning behaviors. Most teenagers still believe that tans are attractive and teenage girls continue to use tanning salons and tan naturally. We need to address the connection between sun tanning in youth and skin cancers years later. Legislation to limit access of tanning salons to teenagers needs to be enacted.     

Halothane, isoflurane, and enflurane MAC in pregnant and nonpregnant female and male mice and rats

The MAC of halothane, isoflurane, and enflurane was determined using the tail-clamp technique in pregnant female, nonpregnant female, and male Swiss Webster mice (n = 216) and Sprague-Dawley rats (n = 112). Mean MAC values (+/-SD) for halothane, isoflurane, and enflurane in mice were 0.95 +/- 0.07%, 1.34 +/- 0.10%, and 1.95 +/- 0.16%, respectively; values in rats were 1.03 +/- 0.04%, 1.46 +/- 0.06%, and 2.21 +/- 0.08%, respectively, all significantly higher than in mice. Neither the sex of the animals nor whether female animals were pregnant influenced the results.