The future of anesthesiology is perioperative medicine

Anesthesiology faces many challenges in the years ahead. To meet these challenges, the author hypothesizes that perioperative medicine, which includes the spectrum of care from preoperative assessment to postoperative care, offers the best chance for the specialty to survive and prosper. The history of perioperative medicine is reviewed and a discussion of how such change will benefit anesthesiology is included. Implementation may be difficult and the author explores how a transition from traditional procedure-focused anesthesiology to a broader based specialty may be accomplished. The special needs of perioperative medicine and how they differ from anesthesiology are also presented.     

The expert witness

The worst mistake any attorney or physician involved in a case of medical negligence can make is to underestimate the opponent. The expert witness may know a lot more about a certain field than the physician, or at least a lot more about what the basic standard of care is for a particular case. This article discusses the importance of the deposition and delineates four aspects of the deposition that are of utmost importance in a medical negligence case.     

Vascularized urethroplasty flaps. The use of vascularized flaps of preputial and penopreputial skin for urethral reconstruction in hypospadias

The long-term growth potential offered by vascularized urethroplasty flaps has allowed the author to operate on patients with hypospadias between 8 months and 2 years of age with excellent morphofunctional and psychological results and a short hospitalization. The author argues that the one-stage procedure is the best approach, supported by an analysis of more than 5000 cases treated in the Plastic Surgery Department of the Bambino Gesù Hospital in Rome since 1972.     

The operative therapy of the acquired pes plano-valgus and pes planus of the child (author's transl)]

The author shows the importance of the development of the leg axis for the diagnosis and the indication for the treatment of the acquired infantile pes plano-valgus and pes planus. Only when this development is finished an operative therapy can be indicated. The experience gained on a very treat number ofpatients shows that it is evident that the best method is the transposition of the tendons M. fib. III or IV. The author also discusses the reasons for indication and the limitation of this operation. (The author prefers the modified techniques of K. Niederecker (1959) based on the idea of E. Müller (1903).     

The oath of Hippocrates: an historical review

This presentation is designed to share with fellow neurosurgeons a topic, namely the oath of Hippocrates, that has been a subject of fascination to physicians, scholars, historians, and even the public for the past 2500 years. Its moral and ethical message has exhibited remarkable resiliency through the ages, in varied cultures. Although its language may appear odd, its precepts are as valid today as they were in Hippocrates' time. This can be best understood through an historical review of the oath's transmission and acceptance in different eras of western history. The longevity of the oath, however, is clearly attributable to its intrinsic merit, its high moral reverent tone, and a literary eloquence that placed Hippocrates among the best writers of antiquity. Despite the fame of its author, the oath has experienced a life of its own, from relative obscurity during the Dark Ages to reverential study since the Renaissance. Five aspects are considered in this discussion, i.e., 1) oaths in antiquity; 2) a biographical sketch of Hippocrates; 3) the chain of transmission from antiquity to modern times; 4) comments on other oaths, prayers, codes, and credos; and 5) an analysis and some personal views of the oath.     

Models of facial aging and implications for treatment

In this article, which focuses on concepts rather than techniques, the author emphasizes that the best predictor of a good facelift outcome is an already attractive face that has good enough tissue quality to maintain a result past the swelling stage. The author notes that too often, surgeons gravitate toward a particular facial support technique and use it all the time, to often unsatisfactory results. He singles out different areas (the brows, the tear trough, the cheeks, and so forth) and shows how the addition of volume may give results better than traditional methods. As he points out, a less limited and ritualistic approach to the face seems to be how cosmetic surgery is evolving; all factors that might make a face better are reasonable to entertain.     

How to select counsel and participate in your own defense. The plaintiff's perspective

The most important initial step a physician can take in a malpractice case is to secure the best possible representation for his or her defense. This article enumerates the criteria for obtaining quality representation. Among other points, the author cautions the physician to consider the motivation of those who are defending him or her and explains how to determine if an attorney has one's best interests in mind.     

Is prophylactic haemofiltration during cardiopulmonary bypass of benefit during cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether prophylactic haemofiltration during cardiopulmonary bypass is of benefit during cardiac surgery? Altogether 273 papers were found using the reported search, of which nine presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that haemofiltration will increase the haematocrit, reduce some inflammatory markers and may increase the variability of heparin levels. It may also reduce post-operative blood transfusion and possibly increase BP and cardiac index immediately after haemofiltration, although no differences in morbidity or mortality has ever been shown.     

The surgical treatment of intractable epilepsy.

The author reviewed the various surgical approaches for intractable epilepsy and proposes that any surgical operation for the treatment of intractable epilepsy be performed actively but prudently. It is important to identify the operation indication and to use combinations of anterior callosotomy, epileptogenic focus resection and multiple subpial transection (MST), tailored to the individual patient. Selective temporal lobe removal can also provide a fairly good result in temporal lobe seizures. For epileptogenic foci in functional areas, MST was an effective approach that protected neural function and blocked epileptic discharge. For epileptogenic foci in the free-functional areas, however, epileptogenic focus resection was still the best therapy. Hemisphere removal should be chosen cautiously and only for patients with intractable epilepsy with progressive neurological deficits in the hemisphere. The author notes that using minimally invasive neurosurgery techniques to treat epilepsy and to protect neural function will become more widely recommended.     

Is antero-posterior position superior to antero-lateral position for placement of electrodes for external cardioversion of atrial fibrillation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the antero-posterior position is superior to the antero-lateral position for the placement of electrodes for cardioversion of atrial fibrillation. Altogether 167 papers were found using the reported search, of which 5 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is no clinical difference between the two positions although if one position fails to convert the patient, the alternative position may still achieve success.     

Is there a role for prophylaxis against atrial fibrillation for patients undergoing lung surgery?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed whether prophylactic anti-arrhythmic drugs may prevent atrial fibrillation (AF) following lung resection. Altogether 457 papers were found using the reported search, of which 14 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. We identified single randomized trials that have demonstrated a benefit for Diltiazem, Bupivacaine epidural and magnesium for prophylaxis against AF in patients undergoing non-cardiac thoracic surgery, with a number needed to treat of between 4 and 8 with these regimes.     

Approaches to Field Therapy for Actinic Keratoses: Relating Clinical Trial Results to Real-world Practice—A Commentary

There have been multiple direct and indirect comparison studies evaluating different field therapies used in the treatment of actinic keratosis (AK). A recent clinical trial directly compared 5% fluorouracil (5-FU), imiquimod, ingenol mebutate, and methyl aminolevulinate photodynamic therapy (MAL-PDT), reporting that 5-FU was superior to the other treatments in achieving sustained clearance of 75 percent or greater of AK lesions compared to baseline. In this commentary, the author reviews and discusses the methods and results of this comparison study and propose these results are limited by a number of factors, such as the selected primary % clearance endpoint, grade range of included AKs, and treatments included in the comparison, when considered in the context of other clinical and real-world comparison studies evaluating AK field therapies. The author postulates that patient acceptance of and adherence to field therapy regimens for the treatment of AK may be better evaluated in a real-world setting. Additionally, the author suggests that selection of field therapy in the treatment of AK should be driven by consideration of relevant patient-, disease-, and treatment-related factors, and what is considered best may differ from patient to patient, depending on each patient’s individual needs and expectations.     

Using non-steroidal anti-inflammatory drugs (NSAIDs) following pleurodesis

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether non-steroidal anti-inflammatory drugs (NSAIDs) decrease the effect of pleurodesis. Only 17 papers were identified using the search below. Three papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of the papers are tabulated. We conclude that despite a limited number and type of study, there is some histopathological evidence to support the concern that NSAIDs may reduce effectiveness of pleurodesis. Until further clinical studies with appropriate outcome measures are available, NSAIDs following pleurodesis should be used with caution and probably avoided routinely.     

The role of secretory IgA and complement in IgA nephropathy

IgA nephropathy (IgAN) is characterized by glomerular deposition of IgA, often together with complement components. This deposited IgA is mainly polymeric in nature. Although early studies suggested a role for local complement activation in the development of glomerular injury in IgAN, recent attention has focused on the involvement of the lectin pathway of complement activation in the progression of renal disease in IgAN. In addition, we have found that glomerular secretory IgA deposition may be one of the initiators of local complement activation in the kidney. In the present review we discuss recent developments in this area and provide a model of how mucosal immunity and renal inflammation may be interconnected.     

The glomerular mesangium

The mesangium is more than simply a support structure for glomerular capillary circulation. Mesangial cells respond to various vasoactive mediators and probably contribute to the regulation of mesangial cell contractility and, consequently, glomerular perfusion. The surrounding extracellular matrix contains several glycoproteins and collagens that may affect the immune interactions of antigens and antibodies and may possibly influence the disposition of immune complexes. These properties may modulate the consequences of deposition of IgA-containing immune complexes in the mesangium in patients with IgA nephropathy and the consequent expression of clinical disease.     

Does magnesium offer any additional benefit in patients having anti-arrhythmic treatment for atrial fibrillation following cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether treatment with magnesium in addition to an anti-arrhythmic is beneficial to patients who have gone into atrial fibrillation after cardiac surgery. Altogether 466 papers were identified using the below mentioned search, of which 8 papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses were tabulated. We conclude that while the literature on magnesium prophylaxis and non-cardiac surgical studies on magnesium therapy for atrial fibrillation suggest that magnesium may be of benefit, there are currently no studies in post-cardiac surgery atrial fibrillation to support the use of magnesium therapy for these patients.     

The difficult laparoscopic cholecystectomies--technical problems

Referring to the difficult laparoscopic cholecistectomies, the author underlines the actuality of theme and the value of the dialogue between surgeons. The author discusses the anatomo-pathological formes, generating of intraoperative difficulties and emphasises that such historical interventions for difficult cholecistectomies, may be reactualised, with good results in practice. Punctually, he refers to some variants of cholecistectomy: cholecistendesis for sclero-atrophic cholecist and Pribram mucoclasic for cirrhotic patient. The author invites to debate these technical modalities which can evitate or limit, for determined situations, intraoperative risks or failure causes.     

Should lobectomy patients with microscopic involvement of the bronchial resection margin undergo re-operation to improve their long-term survival?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether re-operative surgery or radiotherapy should be given to patients with residual microscopic tumour at the bronchial resection margin. Altogether 427 papers were identified using the reported search of which 13 represented the best evidence on this topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that for patients with stage I-II tumours who could easily tolerate re-operation, further resection is an acceptable treatment option and may improve survival. However, only 4 of the 13 studies that we identified recommend this strategy. In addition, there is no convincing evidence that radiotherapy significantly improves survival for patients not selected for re-operation.     

Is prophylactic administration of steroids of benefit to children undergoing cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether prophylactic administration of steroids is of benefit to children undergoing cardiac surgery? Altogether 302 papers were found using the reported search, of which six represented the best evidence. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We conclude that steroids may reduce Troponin I release, CRP and reduce Interleukin-6. In addition, two studies, each in only 30 patients, found some evidence for improvements in clinical parameters such as ICU stay and fluid requirement. These findings need confirmation prior to any firm recommendations as to the clinical benefits of steroids.     

Is sildenafil effective for treating pulmonary hypertension after pediatric heart surgery?

A best evidence topic in pediatric cardiac surgery was written according to a structured protocol. The question addressed was whether sildenafil was effective in treating postoperative pulmonary hypertension after pediatric heart surgery. Altogether 28 papers were found using the reported search, of which three represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We conclude that oral sildenafil may be useful in reducing pulmonary vascular resistance and can be considered for treatment of postoperative pulmonary hypertension after pediatric heart surgery. However, evidence from a large, multicenter, randomized controlled trial is needed to validate the safety and efficacy of sildenafil for use in postoperative pediatric cardiac surgical patients.