24 hours stay after hip replacement

Background and purpose — The length of stay after total hip arthroplasty has been reduced to 2–4 days after implementing fast-track surgery. We investigated whether a new time-based patient-centered primary direct anterior approach (DAA) total hip arthroplasty (THA) treatment protocol in a specialized clinic, with a planned length of stay of about 24?hours, could be achieved in all patients or only in a selected group of patients.

Patients and methods — We analyzed prospectively collected data in a cohort of 378 consecutive patients who underwent a primary direct anterior THA as a patient-centered time-based procedure between March 1, 2012 and December 31, 2015. Patients with complicated medical comorbidity and those over the age of 85 were excluded from the study. The average length of stay was recorded and all complications, re-admissions, and reoperations were registered and analyzed. The primary outcome measures were length of stay and complication rate, at discharge and 90 days postoperatively.

Results — The average length of stay for all patients was 26?hours. All patients were discharged from the clinic on the day after the operation and were able to continue their recovery at home or in a rehabilitation facility. The overall complication rate within 3 months of surgery was 6%. The 3-month re-admission rate and the 3-month reoperation rate were both 2%.

Interpretation — Performing a time-based, patient-centered fast-track program for DAA total hip arthroplasty can result in a standardized length of stay of about 24?hours and a high level of patient satisfaction with few complications, re-admissions, and reoperations.     

Management of severely head-injured patients during the first 24 hours. Which specific therapeutics?

Intracranial and systemic mechanisms of the secondary brain lesion are the targets of specific therapy for the head-injured patient. Recommendations for good clinical practice have recently defined the role of the main therapeutic measures. There is no indication for corticosteroids in head injury. Mannitol is the first-choice therapy for increased intracranial pressure, and barbiturates are still considered as a rescue therapy in case of refractory intracranial hypertension. The place of hypothermia remains to be defined. Although controversial, optimized hyperventilation, induced systemic hypertension and vasoconstrictive therapy are optimally used under multimodal monitoring. New therapeutic perspectives, aimed at controlling biochemical disorders at a cellular level, are under investigation, but are still inconclusive at the present time.     

The reliability of Tc-99m-DMSA scintigraphy in obstructive uropathy: is late scanning at 24 hours necessary?

Summary Differential kidney function is usually studied by quantification of relative renal uptake at 2–4 h after injection of the radiopharmaceutical^99mTc-dimercaptosuccinic acid (DMSA). The outcome of this measurement, however, may be unreliable in cases of obstructive uropathy. The obstructed kidney may retain the radiopharmaceutical in the dilated system, which may lead to relatively high values for functioning cortical mass. In this situation, determination of the split kidney function at 24 h instead of 4 h after application of^99mTc-DMSA has been advocated. In order to compare results at 4 h and 24 h an investigation was performed in 8 patients with obstructive renal disease present for more than 2 weeks, and in 7 patients who did not suffer from obstruction. In these 15 patients the differential function measured at 4 h and at 24 h was the same. From our results we conclude that overestimation of the function of an obstructed kidney by^99mTc-DMSA scanning at 4 h is not a major problem. According to the literature, however, in cases of acute obstruction or complicated obstruction with stones or infection,^99mTc-DMSA scintigraphy can underestimate the potential function of the obstructed kidney.     

Should we discard the renal allografts from cardiac death donors that have total ischemic time longer than 24 hours?

PURPOSE: The objective of this study was to investigate the outcome of transplantation using kidney grafts donated after cardiac death (DCD) with a total ischemic time (TIT) longer than 24 hours. PATIENTS AND METHODS: We followed 373 kidneys recovered from DCD donors and transplanted at 41 centers. All kidneys were procured from uncontrolled DCD donors. Grafts were classified into two groups according to TIT. We recorded renal function and duration of the survival period for each graft. RESULTS: Fifty-three grafts had a TIT longer than 24 hours (group 1). The other 320 grafts had a TIT less than 24 hours (group 2). The number of never functioning grafts were three in group 1 (5.7%) and 17 in group 2 (5.3%). Delayed graft function (DGF) occurred in 44 group 1 (83.0%) and 254 group 2 kidneys (79.4%) for intervals of 13.5 +/- 12.6 versus 10.9 +/- 12.6 days, respectively. Graft survival rates at 3, 5, and 10 years posttransplant were 84.9%, 73.0%, 64.1% for group 1, and 76.3%, 69.9%, 57.1% for group 2. In a Cox proportional hazards model, TIT longer than 24 hours was not a significant independent risk factor. CONCLUSION: Our results showed that even kidneys with TITs of over 24 hours yielded comparable results despite a higher incidence of DGF.     

Has the 80-hour work week increased faculty hours?

OBJECTIVE: The 80-hour work week has affected not only surgical residents but also faculty. The aim of this study was to determine the effect of resident hour restrictions on faculty hours and attitudes. DESIGN: Anonymous survey. SETTING: A single, large academic medical center. PARTICIPANTS: All faculty in the Departments of Surgery, Neurosurgery, Orthopedics, and Otolaryngology. METHODS: Faculty were surveyed 6 months before and 6 months after the institution of the resident 80-hour work week. Surgeons detailed hours worked over 1 week and answered yes/no questions about changes in patient care and resident education. P values were determined by Chi-square tests or Student t-tests as appropriate. RESULTS: Of the 118 surveys distributed, 88 were returned (75%). Respondents were evenly divided between general surgeons (GS) and subspecialists (SS). Initially, 70% of faculty predicted that resident work-hour restrictions would increase faculty hours; however, only 47% of faculty felt that this had occurred. When current faculty work hours were compared with previously collected data, no differences were found. Faculty reported working an average of 69.9 +/- 12.2 hours per week this year, compared with 70.4 +/- 12.5 hours last year. When asked about the global impact of the 80-hour work week on faculty, 46% viewed the changes as harmful to the faculty. More concerning, 50% of all faculty felt the care their patients received was worse than previously, with only 2% feeling patient care had improved. This perception was significantly more common among GS faculty (70% GS vs 37% SS; p < 0.01), 94% of whom felt that the current lack of continuity compromises patient care. When the data were stratified by faculty work hours, interesting differences are seen. Of those faculty with work weeks less than 60 hours, only 6% thought the changes were harmful to patients and 64% thought resident training had suffered. In contrast, of those faculty who worked greater than 80 hours per week, 56% thought patients were harmed (p = 0.03) and 100% thought training had suffered (p < 0.01). CONCLUSIONS: Faculty work hours have not increased in the 6 months after the institution of the 80-hour resident work week. However, the majority of the faculty feels that both patient care and resident education have deteriorated.     

Does resident hours reduction have an impact on surgical outcomes?

BACKGROUND: We assessed the impact of restricting surgical resident work hours as required by the Accreditation Council for Graduate Medical Education (ACGME), on postoperative outcomes. MATERIALS AND METHODS: The divisions of General and Vascular Surgery at the Michael E. DeBakey Houston Veteran Affairs Medical Center implemented a limited work hours schedule effective October 1, 2002. We compared the rate of postoperative morbidity and mortality before and after the new schedule. Clinical data were collected by the VA National Surgical Quality Improvement Program (NSQIP) for the periods of October 1, 2001 to September 30, 2002 (preintervention), and October 1, 2002 to September 30, 2003 (postintervention). We assessed risk-adjusted observed to expected (O/E) ratios of mortality and prespecified postoperative morbidity for each study period. RESULTS: In the preintervention period, there were 405 general surgery and 202 vascular surgery cases as compared to 382 and 208 cases, respectively in the postintervention period. There were no significant differences in mortality O/E ratios between the pre- and postintervention periods (0.63 versus 0.60 in general surgery; 0.78 versus 0.81 in vascular surgery; P = 0.90 and 0.94, respectively) or in morbidity O/E ratios (1.06 versus 1.27 in general surgery; 1.47 versus 1.50 in vascular surgery; P = 0.20 and 0.90, respectively). CONCLUSION: The restricted resident work hour schedule in general and vascular surgery in our facility did not significantly affect postoperative outcomes.     

Resident work hours: can we meet the ACGME requirements?

The Accreditation Council for Graduate Medical Education (ACGME) requires all programs to limit resident work hours to 80 hours per week with some programs allotted an extra 10 per cent for specific educational purposes. The purpose of this study was to evaluate data reflecting changes in resident schedules made in 2002-2003 to be compliant with ACGME requirements without compromising patient care or resident education. Surgery residents originally completed a work-hour survey in May 2002. The survey contained 14 daily time sheets. Residents were asked to document how their time was spent between 14 different categories delineating in-house and out-of-house hours. Changes were made to resident schedules in order to become compliant with the new regulations. After making changes in the schedule, two more surveys were completed and evaluated, once in May 2003 and again in November 2003. Final analyses compared results from May 2002 to November 2003. Surveys were distributed to 30 residents in May 2002. Twenty-two residents completed the survey with 16 surveys eligible for analysis following exclusion of abnormal rotations (i.e., research and vacation). Eighty-eight per cent of junior residents (PGY 1, 2, and 3), 50 per cent of senior residents (PGY 4-5), and 33 per cent of chief residents (PGY 6) worked more than 88 hours per week. In November 2003, surveys were sent to 32 residents. Twenty-four residents who were on our normal call schedule completed the survey. Fourteen per cent of junior residents, 33 per cent of senior residents, and 0 per cent of chief residents worked more than 88 hours per week. By making the changes described, we have substantially reduced the number of resident work-hours while maintaining our academic and patient care missions.     

Are long hours and hard work detrimental to end-clerkship examination scores?

BACKGROUND: Third-year medical students' complaints focus on the number of hours worked and subsequent lack of study time among three general surgery blocks. We hypothesize that this difference between the surgical blocks does not adversely influence student examination scores. METHODS: Student scores for the academic years 1996-97 to 1997-98 for the National Board of Medical Examiners (NBME) surgery subtests were compiled. A comparison of two "slow" general surgery blocks (B/C) with one "busy" block (A) was made using a two-tailed t test. A multiple regression analysis was also employed. Finally, United States Medical Licensing Examination (USMLE) part I scores were used to determine equivalency of groups. RESULTS: No significant difference existed between block A and blocks B/C in USMLE part I and NBME (P = 0.35 and 0.16 respectively). However, USMLE and rotation sequence influenced NBME scores (P < 0.001). CONCLUSION: The data suggest that no difference exists in examination scores between students assigned to a busy general surgery block versus those students assigned to slow blocks.     

Duty hours and perceived competence in surgery: are interns ready?

Background

A fundamental shift in the structure of many surgical training programs has occurred after the July 2011 rule changes. Our intern didactic program was intensified in 2011 with targeted lectures, laboratories, and clinical cases as well as direct supervision until competency was achieved for basic clinical problems. We sought to compare interns' perceived preparedness throughout and at the end of the academic years before and after July 2011.

Materials and methods

Intern perceptions of preparedness to manage common clinical scenarios and perform procedures in general surgery were serially surveyed in academic years ending in 2011 and 2012 based on the Residency Review Committee supervision guidelines.

Results

Interns felt less prepared across all measured domains from 2011–2012. Interns felt significantly less prepared to manage hypotension (3.00/4 points to 2.67/4 points; P = 0.04), place a tube thoracostomy (2.45/4 points to 1.92/4 points; P = 0.04), or perform an inguinal hernia repair (1.91/4 points to 0.92/4 points; P = 0.01) without supervision. Interns were also significantly less likely to agree that they were able to gain clinical skills based on experience (4.31/5 points versus 4.15/5 points; P = 0.02). Longitudinal analysis throughout internship demonstrated improved preparedness to manage common clinical problems and perform procedures between the second and the fifth months of internship.

Conclusions

First-year residents after July 2011 felt less prepared in the topics surveyed than those before July 2011. Interns made the greatest gains in preparedness between months 2 and 5, suggesting that despite planned interventions, no substitute currently exists for actual clinical experience. Planned educational interventions to improve intern preparedness are also indicated.     

Intact endothelial and contractile function of coronary artery after 8 hours of heart preservation

Abstract

Objectives. The aim of the study was to investigate if adequate preservation of coronary artery endothelium-dependent relaxation and contractility may be obtained after 8?hours of non-ischemic heart preservation. Design. Porcine hearts were perfused for 8?hours at 8?°C, either in cycles of 15?minutes perfusion and 60?minutes non-perfusion, or by continuous perfusion. The perfusate consisted of a cardioplegic, hyperoncotic nutrition solution with oxygenated red cells, and the perfusion pressure was 20?mmHg. In organ baths, coronary artery segments from the preserved hearts were studied and compared to fresh controls. Results. Endothelium-dependent relaxation and contractility were fully preserved after both intermittent and continuous perfusion, as compared to fresh controls. No myocardial edema was seen; water content of the myocardium was 79.5?±?0.2%, 79.0?±?0.4% and 79.0?±?0.3% (ns) for fresh controls, intermittently perfused, and continuously perfused hearts, respectively. Conclusion. Intact endothelial and contractile function of coronary artery may be obtained after 8?hours of non-ischemic heart preservation.     

Investigation on nurses′ effective working hours in the high-quality nursing service demonstration units

目的 了解优质护理服务示范工程实施过程中护士的有效护理工时,为护理人力资源合理配置提供依据.方法 采用分层抽样法分别从内、外、妇、儿、监护病房和综合病区等10个护理单元抽取139名护士,以护理项目操作时间调查表调查护士的有效护理工时.结果 护士日人均有效护理工时为(489.51士169.08)min,直接护理工时为(298.20±170.03)min,间接护理工时为(191.30±130.38)min;不同护理单元、不同学历和职称护士的直接护理工时和间接护理工时比较,差异有统计学意义(P＜0.05,P＜0.01).结论 优质护理服务示范工程的实施增加了护士的护理工时,护理管理者需合理配置护理人力资源,以增加直接护理工时,提高优质护理服务质量.     

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欧洲肠外与肠内营养协会 (ＥＳＰＥＮ)第 2 4届会议于2 0 0 2年 8月 31日至 9月 4日在苏格兰的格拉斯哥举行。大会对糖尿病、ＣＯＰＤ、肿瘤、儿科等领域的营养支持进展和肠衰竭的治疗等方面进行了总结。现将有关议题及进展综述如下。1　糖尿病病人的营养支持研究显示 ,采用固态肠内营养制剂、添加膳食纤维以及在肠内营养制剂中用果糖代替蔗糖有助于血糖的控制。但Ｂａｎｔｌｅ等发现 ,当果糖含量达到总热量的 2 0 %时 ,可以增加餐后乳酸水平、空腹总胆固醇和ＬＤＬ水平 ,并有导致胃肠功能紊乱、白内障以及神经系统病变的危险。在 1型、2型…