Sutures, incisions, and anastomoses

The properties of different types of suture material are reviewed, with particular reference to the complications which may result from their use. The aetiology, prevention, diagnosis, and treatment of wound dehiscence are discussed. The factors which are believed to be important in performing successful bowel anastomosis are considered.     

Ageing,hormones, body composition,metabolic effects

The age-associated, progressive changes in body composition are paralleled by a progressive decrease in hormone levels, among which there are testosterone (T) and growth hormone (GH). Moreover, the age-associated changes are rather similar to the changes in body composition seen in hypogonadism or hyposomatotropism, respectively. These age-associated changes in body composition are rather important: a decline in muscle mass by 20%-40% between the ages of 25 and 75, a doubling of fat mass and a decrease in bone mineral density by 0.3% per year after age 35. They have important functional and metabolic consequences. Most studies show a significant positive correlation between muscle mass and bone mineral density, respectively, and plasma T or GH levels, whereas abdominal fat mass is generally negatively correlated with T and GH levels. Whether, however, the hormone levels play a causal role or are the consequence of the changes in body composition is still an unsettled problem. The beneficial effects of hormone substitution on body composition suggest, nevertheless, that T and GH are at least co-determinants of the observed age-associated changes.     

Pediatric malignancies: neuroblastoma, Wilm's tumor, hepatoblastoma, rhabdomyosarcoma, and sacroccygeal teratoma

Common pediatric malignancies are reviewed: neuroblastoma, Wilms tumor, hepatoblastoma, rhabdomyosarcoma, and sacrococcygeal teratoma. Elements of presentation, diagnosis, staging, treatment, and longterm prognosis are discussed, with particular attention to surgical management.     

Thursday,September 10, 2009

In any collaborative endeavor, when fields like medicine and bioengineering overlap, the proper use of technical vocabulary takes on added importance. It is important that scientists and clinicians, while coming from different backgrounds and educational systems, agree upon and utilize a common language based on mutually understood concepts and definitions. Regarding biomaterial testing applications, numerous terms are used to describe a wide variety of material behaviors when test specimens are subjected to mechanical, chemical, electrical and thermal stressors. In this discussion we will limit ourselves to the mechanical properties of materials which are utilized for soft tissue or fascial-based repairs. Following a literature search combining the keywords surgical mesh and biomaterials testing, common terms used to describe the mechanical properties of mesh were selected. Our analysis seeks to define the following terms and describe their applicability within the context of biomaterials for hernia repair: elasticity, stiffness, flexibility, tensile strength, distension, deformation, bending stiffness, and compliance. Unfortunately, in the technical literature, terms are often altered or extrapolated without adequate explanation. In other cases, related but technically different terms are mistakenly used interchangeably. With the mounting interest in biomaterials for the use in repair of abdominal wall defects, there is a need to standardize the terminology used to describe the biomechanical properties of mesh. Presented at the American Hernia Society Annual Meeting, 7–11 February, 2007.     

Crystalloids,colloids, blood,blood products and blood substitutes

The choice of fluid in a given clinical scenario relies on knowledge of the physiology and pharmacology of the fluid. A broad range of fluids are discussed in this article, with particular emphasis on problems associated with excess administration of 0.9% saline. Colloids, blood, blood products and blood substitutes are also discussed. Balancing the risks of allogenic blood transfusion for a patient and transfusion thresholds are considered. The potential of haemoglobin substitutes are still yet to be realized; however PolyHeme is currently in a phase 3 pre-hospital trauma trial.     

Panniculectomy, documentation, reimbursement, and the WOC nurse.

Panniculectomy surgery is a reconstructive procedure performed to remove a panniculus, sometimes referred to as a pannus or abdominal apron. The pannus frequently contributes to a number of health concerns, including chronic wounds. Panniculectomy surgery becomes necessary for many patients who have had massive weight loss as a result of successful bariatric weight-loss surgery. Bariatric weight-loss surgery is one of the fastest growing specialties in America, and therefore, nurses can expect to care for increasing numbers of patients who require this reconstructive procedure. Despite the medical necessity of panniculectomy surgery, barriers to reimbursement exist. An update on the demographics of obesity, nationally and worldwide, are presented, especially as this information relates to the growing interest in panniculectomy surgery following massive weight loss. Bariatric weight-loss surgery and panniculectomy surgery are described and barriers to reimbursement are explained. The importance of wound care documentation in making the case for reimbursement is described, and a sample letter of appeal is provided.     

Biopharmaceuticals for rheumatic diseases in Latin America,Europe, Russia,and India: Innovators,biosimilars, and intended copies

A biosimilar is a biopharmaceutical product intended to be comparable to a previously licensed biopharmaceutical agent. The goal of such products is to increase the accessibility of biopharmaceutical therapy for rheumatoid arthritis by reducing costs. They are not like generic drugs, in that they may differ from the reference products in manufacturing, composition, and formulation. Regulatory authorities strive to ensure the absence of clinically meaningful differences between biosimilars and their reference drugs. However, small molecular differences may potentially affect pharmacodynamics (including affinity), pharmacokinetics, and immunogenicity. Intended copies are non-innovator biopharmaceutical products that, unlike biosimilars, do not have enough clinical evidence to demonstrate biosimilarity. For approval of a biosimilar, most countries require preclinical and clinical studies demonstrating comparability with the reference drug. The margin for determining equivalence or non-inferiority is determined on a case-by-case basis in each country, as there are no general criteria. The European Medicines Agency and US Food and Drug Administration have stringent regulatory processes to ensure comparability of biosimilars with their reference drugs. There are also post-marketing surveillance requirements to monitor safety. Only one biosimilar, CT-P13, has been approved for rheumatoid arthritis. However, in countries with less stringent regulation, intended copies are being commercialized and safety problems have been documented. Consequently, in such countries, there is an urgent need for appropriate regulatory processes to be established. Attempts to close the affordability gap of biopharmaceuticals should not open another gap between patients treated with an innovator drug and an intended copy.     

Librarians, surgeons, and knowledge

are indicative of the ferment of change brought about by the digital revolution, and of the continuing determination of health information professionals to rise to the challenges involved in supporting surgeons and everyone in the surgical team, as they endeavor to provide the best possible care for their patients. Libraries as we know them have changed, and are changing. The scholarly communications process is also undergoing profound transformation. The authors discuss these changes and their implications for surgeons.     

Herbs, menopause, and dialysis

Women with chronic kidney disease (CKD) are at increased risk for menstrual disorders, early menopause, and osteoporosis, and rarely discuss gynecologic and reproductive issues with their nephrologist. Various complementary and alternative medicine (CAM) products are of interest to women with end-stage renal disease (ESRD) who have these disorders. However, very little is known about the specifics of using herbal medicines in patients on chronic dialysis, resulting in numerous problems when patients and providers try to ascertain the safety and efficacy of these products. This article reviews evidence regarding the safety and efficacy of black cohosh, ginseng, chastetree, dong quai, evening primrose oil, soy products, and the so-called natural hormones. Pharmacologic parameters important to evaluating the quality of botanical products are discussed, along with recommendations and information resources.     

Obesity, panniculitis, panniculectomy, and wound care: understanding the challenges.

Sixty-one percent of Americans are overweight, and 20% are considered obese. The number of obese adults has doubled since 1960, and the number of overweight teenagers has tripled. In many overweight people, skin and wound conditions develop over the abdominal area, largely because of the consequences related to a large abdominal apron or panniculus. Panniculectomy surgery is performed to remove a massive pannus, or abdominal apron, which frequently contributes to a number of health concerns and threatens quality of life. Some patients are candidates for surgical removal of the pannus, and some are not candidates for this surgery. Occasionally cellulitis develops over the panniculus, leading to panniculitis. Panniculitis can lead to skin and wound problems; likewise, skin injury can lead to panniculitis. Additionally, in obese patients who require general surgery in the abdominal area, skin and wound complications may develop simply as a result of having a large panniculus. In this article, local wound care and preoperative and postoperative nursing care are discussed and case studies are presented.     

Arthroscopic ankle surgery. Indications, surgical technique, results, complications

Based on the one experience and the information that is available in the literature indications for ankle arthroscopy are given, surgical equipment, patient placement and surgical technique of different procedures are described. Finally the results and possible complications are presented. Removal of loose bodies as well as synovectomies in case of an acute infection or rheumatoid arthritis are good indication. Arthroscopic treatment of anterior pathology in the athletic ankle need a thorough diagnostic work-up; the results of the treatment do not always meet the expectations of this especially demanding population. Cartilage treatment is technically possible, however, long term results are still missing. This is also true for the treatment on osteochondritis dissecans. In patients with degenerative joint disease arthroscopic debridement can only lead to a temporary benefit. Arthroscopic assisted arthrodeses (AAA) is technically demanding, but can serve as an excellent alternative to conventional open techniques. The complication rate in ankle arthroscopy is high compared to other joints, which is especially true for neurologic complications and postoperative infections. This should be addressed when performing the informed consent.     

Decency, honor, integrity, and the law

In its guidelines for hand care professionals, the American Society for Surgery of the Hand has set the following criteria as guidelines for the ethical hand surgeon in the 21st century: decency, honor, and integrity. This article reviews these criteria in detail, relates how they apply in practice, and describes how they interact with state and federal law in both legislative and judicial aspects. Matters pertaining to informed consent, privacy issues, patient autonomy, shared decision making, and conflict of interest are described, and recent developments in this area are examined. Are hand surgeons ready for an enforceable system of ethics to be handed down by the ASSH or by the government?     

Influence on bone metabolism of dietary trace elements, protein, fat, carbohydrates, and vitamins

Osteoporosis is a multifactorial disease driven primarily by the genetic factors that control bone metabolism. Among environmental factors, diet may play a key role, affording a target for low-cost intervention. Calcium and vitamin D are well known to affect bone metabolism. Other nutrients may influence bone mass changes; for instance, a number of trace elements and vitamins other than vitamin D are essential to many of the steps of bone metabolism. A wide variety of foods provide these nutrients, and in industrialized countries deficiencies are more often due to idiosyncratic eating habits than to cultural influences. Both culture and vogue influence the amount of carbohydrate, fat, and protein in the typical diet. In children, the current trend is to reduce protein and to increase carbohydrate and fat. Data from epidemiological and animal studies suggest that this may adversely affect bone mass and the fracture risk.     

Superiority, equivalence, and non-inferiority trials

When the aim of the randomized controlled trial (RCT) is to show that one treatment is superior to another, a statistical test is employed and the trial (test) is called a superiority trial (test). Often a nonsignificant superiority test is wrongly interpreted as proof of no difference between the two treatments. Proving that two treatments are equal in performance is impossible with statistical tools; at most, one can show that they are equivalent. In an equivalence trial, the statistical test aims at showing that two treatments are not too different in characteristics, where "not too different" is defined in a clinical manner. Finally, in a non-inferiority trial, the aim is to show that an experimental treatment is not (much) worse than a standard treatment. In this report, the three types of trials are compared, but the main focus is on the non-inferiority trial. Special attention is paid to the practical implications when setting up a non-inferiority trial. Illustrations are taken from a clinical trial in osteoarthritis and from thrombolytic research.     

Nurses, bowel continence, stigma, and taboos.

This article explores why fecal incontinence remains a taboo subject and why it is often so difficult for patients to discuss their bowel symptoms. People's attitudes toward feces are complex and rooted in arbitrary social rules and conventions. It is difficult to encompass the full implications of fecal incontinence to those with this problem within a traditional medical model of illness and with cure as the goal of intervention. Many individuals are not cured, despite our best efforts. By recognizing the social dimension of this problem and by incorporating knowledge about coping and control into patient teaching and clinical practice, nurses may better meet the needs of those with fecal incontinence.     

Pneumothorax, bullous disease, and emphysema

This article addresses several distinct but related pulmonary conditions that are commonly referred to general thoracic surgeons for decision making and management. The management of various types of pneumothorax is reviewed, with particular attention to the selection of the appropriate level of surgical intervention. The related entities of bullous lung disease and diffuse emphysema are discussed, with a focus on the identification of appropriate circumstances for surgical intervention. The summarized work and the treatment recommendations are supported with an extensive bibliography of important work in this area.     

Calf,buttock, and pectoral implants

Breast, chin, and other facial implants are common and accepted approaches to body and facial contouring problems, but calf, buttock, and male pectoral implant surgeries are rare in most plastic surgery practices. Aesthetic Surgery Journal invited Adrien E. Aiache, MD; Lloyd N. Carlsen, MD; and practice associates Hugo Amezcua, MD, and Rafael Vergera, MD, to address some common questions about those procedures. Here are their responses to questions posed by “Comparing Notes”.     

Macronutrients,minerals, vitamins and energy

Macronutrients comprise carbohydrates, fats and proteins and make up most of the body's soft tissue structure. Carbohydrates are organic molecules made of carbon, hydrogen and oxygen atoms. Fats are composed of carbon, hydrogen and oxygen, but the proportion of oxygen atoms to carbon and hydrogen is lower than in carbohydrates. Proteins are usually made up of more than 100 amino acids linked into chains by peptide bonds. Amino acids consist of an asymmetrical carbon atom with both an amino group (NH₂) and a carboxyl group (COOH) attached. Energy used for metabolic homeostasis, thermoregulation, physical activity and normal organ function is obtained from the oxidation of these macronutrients. Micronutrients (trace minerals and vitamins) are dietary components necessary to sustain health. Most trace minerals appear to function as cofactors for a number of enzymes. Vitamins have many roles in intermediary metabolism and in the specialized metabolism of specifc organs.     

Crystalloids,colloids, blood,blood products and blood substitutes

Understanding the physiology of fluid distribution within the human body is fundamental to the practice of anaesthetists and intensivists of all grades. There is a necessity to recognize the range of actions and consequences of the commonly infused intravenous fluids if safe patient care is to be provided. There are many historical and on-going trials surrounding fluid therapy and it is important for the physician to keep up to date with current guidelines.There is a continued drive to improve the safety of donor blood and prevent transfusion errors. Knowledge of how blood products are collected separated and stored is essential to prevent harm to patients through transfusions. Work in producing blood substitutes is progressing, but to date, trials have failed to market a product in Europe and the USA with an acceptable risk profile.     

Healing,Inflammation, and Fibrosis: Updates in Diabetic Wound Healing,Inflammation, and Scarring

Diabetic patients can sustain wounds either as a sequelae of their disease process or postoperatively. Wound healing is a complex process that proceeds through phases of inflammation, proliferation, and remodeling. Diabetes results in several pathological changes that impair almost all of these healing processes. Diabetic wounds are often characterized by excessive inflammation and reduced angiogenesis. Due to these changes, diabetic patients are at a higher risk for postoperative wound healing complications. There is significant evidence in the literature that diabetic patients are at a higher risk for increased wound infections, wound dehiscence, and pathological scarring. Factors such as nutritional status and glycemic control also significantly influence diabetic wound outcomes. There are a variety of treatments available for addressing diabetic wounds.