Is Calcaneal Inclination Higher in Patients with Insertional Achilles Tendinosis? A Case-controlled,Cross-sectional Study

Insertional Achilles tendinosis is a condition where a patient complains of isolated pain at the Achilles tendon insertion site due to intratendinous degeneration. It has been suggested that this condition is associated with cavus foot deformity. However, to our knowledge, there is no study that has confirmed this observation. We carried out a cross-sectional, case-controlled study to explore the association of increased calcaneal inclination—a surgically important characteristic of cavus foot deformity—with insertional Achilles tendinosis. Patients with Achilles tendinosis and matched controls without the pathology were compared. Although a statistically significant difference was detected in calcaneal inclination angle between these 2 groups (p = .038), we felt that the difference was not clinically significant (calcaneal inclination angle = 20.9 vs. 18.9, respectively). Within the limitations of the study, we conclude that there is no clinically significant difference in calcaneal inclination between those with or without insertional Achilles tendinosis.     

Study on the Use of T-tube for Patients with Persistent Duodenal Fistula: Is It Useful?

Background

The commonest surgical treatment used for peptic ulcer perforation is omental patching. If, however, the perforation leaks, it rarely heals by itself due to persistence of duodenal fistula (DF). We present our experience with a T-tube placed into the DF for better outcome of the patients.

Methods

All patients in our hospital with DF following failure of surgery for duodenal perforation were included in this study. After identification of the perforation, a size 16 French T-tube was put in place. The patients were analyzed on basis of duration of hospital stay, complications related to the T-tube and overall complications, start of oral feeds, and follow-up.

Results

In this 3-year study, ten patients with DF were admitted. The mean age was 50 years. The T-tube was kept in place within the fistula for 20.5 days. The mean duration to start oral feeds was 8.8 days. The mean duration of hospital stay was 23.2 days, and the mean follow-up period was 6.3 months. The complications observed in the postoperative period were fever in four patients, wound dehiscence in four patients, and peritoneal collection in two patients, all of which were managed easily. There was no peritubal leakage and no failure of surgery as regards placement of a T-tube. There were no deaths in this study.

Conclusions

Placement of a T-tube into a DF appears to be very effective procedure for managing this complication of surgical repair of a perforated peptic ulcer with an omental patch. The technique appears to be simple and rewarding. Further use of this method by other workers will substantiate our efforts.     

A Method for Working with Displeased Patients—Blast

Clinicians inevitably encounter patients with complaints and concerns about the quality of their care. This causes some to experience anxiety, fear, anger, resentment, guilt, and depression, especially when they believe they may have erred or caused harm. Lack of customer-service training and experience may contribute to these emotions. The “BLAST” technique is a complaint-resolution method that is useful in patient care and as a clinical teaching tool. The mnemonic stands for: Believe (what the patient is saying), Listen (actively, to assess and restate the patient’s unmet expectations), Apologize (for the patient’s unmet expectations), Satisfy (the patient), and Thank (the patient for expressing his/her concerns and providing a second chance to satisfy the patient). The technique appears to help clinicians become more at ease and confident when handling patient complaints. This may be especially helpful for clinicians who must routinely interact with post-treatment and post-procedure patients who commonly express surprise, concern, or complaints about their results and healing. BLAST may be an effective teaching tool enabling students, residents, and clinicians to become more comfortable and adept at working with displeased and concerned patients.Clinicians inevitably encounter patients with complaints and concerns about the quality of their care. Some experience anxiety, fear, anger, resentment, guilt, and depression when their care is criticized,1,2 especially when they believe they may have erred3 or caused harm.4 These reactions may, in part, be due to a lack of customer-service training5 and interfere with clinician effectiveness.1The BLAST technique is a complaint-resolution method developed by Albert Barneto. The mnemonic stands for Believe, Listen, Apologize, Satisfy, and Thank (6 This article describes its usefulness in patient care and as a clinical teaching tool. Anecdotal experience suggests its use helps clinicians remain more calm and effective when working with displeased patients.

TABLE 1

The BLAST technique is a complaint-resolution method

What Factors Affect Whether Patients Return to the Same Surgeon to Replace the Contralateral Joint? A Study of Over 200,000 Patients

BackgroundPatients with hip and knee arthritis often undergo bilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA) in a staged or simultaneous fashion. However, when staged, the incidence and factors associated with having both procedures performed by the same surgeon or different surgeon are not well studied.MethodsAll patients undergoing nonsimultaneous bilateral THA or TKA for osteoarthritis were abstracted from the 2010 to 2020 PearlDiver Mariner administrative database. The National Provider Identifier number was used to determine whether the same surgeon performed both surgeries. Demographics, comorbidities, and 90-day complications after the first joint replacement were assessed as possible independent predictors of utilizing a different surgeon for the contralateral joint.ResultsOf 87,593 staged bilateral THAs, the same surgeon performed 40,707 (46.5%) arthroplasties. Of 147,938 staged bilateral TKAs, the same surgeon performed 77,072 (52.1%) arthroplasties. Notably, older cohorts of patients had independent, stepwise, and significantly greater odds of changing surgeons for the contralateral THA and TKA. Those patients who were insured by Medicare and Medicaid had significantly lower odds of changing surgeons. For both THA and TKA, surgical and implant-related adverse events (surgical site infection/periprosthetic joint infection, periprosthetic fracture, dislocation, manipulation) carried the greatest odds of undergoing the contralateral replacement with a different surgeon.ConclusionPatients covered by Medicaid and sicker patients were significancy less likely to switch surgeons for their contralateral THA or TKA. Additionally, patients experiencing a surgery-related adverse event within 90 days of their first THA or TKA had significantly, increased odds of switching surgeons for their subsequent TJA.     

Who Is Lost to Followup?: A Study of Patients with Distal Radius Fractures

Distal radius fractures are the most common upper extremity fracture, representing one-sixth of all fractures treated in emergency departments nationwide. Beyond the initial reduction and immobilization of these fractures, providing proper followup to ensure maintenance of the reduction and identify complications is necessary for optimal recovery of forearm and wrist functions. We sought to identify the clinical and demographic factors that characterize patients with distal radius fractures who do not return for followup and to assess the underlying causes for their poor followup rates. Compared with patients who were compliant with followup, those lost to followup had lower Physical and Mental Health scores on the SF-36 forms, more often were treated nonoperatively, and more likely had not surpassed secondary education. However, we found no difference between these two groups based on age, gender, mechanism of injury, marital status, or hand dominance. Early identification of patients who potentially are noncompliant can result in additional measures being taken to ensure the patient’s return to the treating hospital and physicians. This in turn will prevent complications attributable to lack of followup and allow more accurate assessment of results, thereby improving patient outcomes.     

Call-associated Acute Fatigue in Surgical Residents—Subjective Perception or Objective Fact? A Cross-sectional Observational Study to Examine the Influence of Fatigue on Surgical Performance

Background

The effect of acute partial sleep deprivation on surgical proficiency is still controversially discussed. The present study correlated physiological parameters of fatigue with objective technical and cognitive skills, as well as subjective sleepiness of surgical residents. The aim of the study was to assess the effect of acute partial sleep deprivation on surgical performance.

Methods

Thirty-eight surgeons were interviewed on three consecutive mornings: prior to a 24?h call, post-call, and after 24?h of rest. Reported hours of sleep were recorded. Subjective alertness was assessed with the standardized Stanford-Sleepiness-Scale (SSS). Saliva cortisol concentrations and pupillary activity were measured by standardized ELISA and pupillography. The virtual reality (VR)-simulator LapSim was used to assess technical skills through low-fidelity VR-tasks (“cutting,” “clip applying”) and cognitive skills through high-fidelity VR-tasks (“intracorporeal suturing,” “VR-cholecystectomy”). Objective alertness was measured by the standardized d2-Paper-Pencil Test.

Results

Recorded hours of sleep (p?=?0.001) and subjective alertness (SSS) decreased (p?=?0.001) significantly post-call. None of the three factors studied—saliva cortisol concentration (p?=?0.313), pupillary activity (p?=?0.998), or VR-performance of low-fidelity VR-tasks—differed significantly between assessments. Surprisingly, VR-performance of high-fidelity VR-tasks (error-score p?=?0.044, time to complete task p?=?0.0001, economy of instrument motion p?=?0.0001) and objective alertness (d2-Paper-Pencil Test p?=?0.027) significantly improved in the post-call setting.

Conclusions

Acute call-associated fatigue seems to be a predominantly subjective perception. Physiological factors seem to outbalance an anticipated fatigue-associated impairment of technical performances within low-fidelity VR-tasks. In surgical residents, acute partial sleep deprivation seems to have a positive short-term effect on cognitive skills, leading to enhanced technical performance and increased objective alertness within complex tasks.     

Is Resection Equivalent to Transplantation for Early Cirrhotic Patients with Hepatocellular Carcinoma? A Meta-Analysis

Background

Whether liver resection or liver transplantation is optimal therapy for patients with hepatocellular carcinoma (HCC) remains undefined. A meta-analysis was conducted to answer this question.

Study Design

This study performed a systematic review of the published literature between January 2000 and April 2012.

Results

Nine retrospective studies, totaling 2,279 patients (989 resected and 1,290 transplanted), met the selection criteria. Older patients with larger tumors and less severe cirrhosis were identified in the resection group. At 1?year, resection demonstrated significantly higher overall [odds ratio (OR)?=?1.54; 95?% confidence interval (CI), 1.19?C1.98; p?=?0.001], but equivalent disease-free survival (OR?=?0.93; 95?% CI, 0.53?C1.63; p?=?0.80). At 5?years, there was no difference in overall survival (OR?=?0.86; 95?% CI, 0.61?C1.21; p?=?0.38), but a higher disease-free survival in transplanted patients was observed (OR?=?0.39; 95?% CI, 0.24?C0.63; p?<?0.001). When limiting our analysis to studies conducted in an intent-to-treat fashion, there was no difference in 5?year overall survival (OR?=?1.18; 95?% CI, 0.92?C1.51; p?=?0.19), but a significantly higher disease-free survival (OR?=?0.76; 95?% CI, 0.57?C1.00; p?=?0.05) in transplanted patients. At 10?years, transplantation had higher overall and disease-free survival rates.

Conclusion

Liver transplantation in patients with HCC results in increased late disease-free and overall survival when compared with liver resection. Nonetheless, the benefit of liver transplantation is offset by higher short-term mortality, donor organ availability, and long transplant wait times associated with more patient deaths. Understanding these differences in survival is helpful in guiding treatment. However, a properly controlled prospective trial is needed to define how best to treat HCC patients who are candidates for either therapy.     

How Does Osteonecrosis About the Knee Progress in Young Patients with Leukemia?: A 2- to 7-year Study

Background  

Osteonecrosis is a major treatment complication of pediatric leukemias owing to its potential to cause joint deterioration. Because of potential long-term effects of osteonecrosis on joints, information regarding its progression and collapse in different patients can be used to identify high-risk groups, advise the patients and parents of this complication, and potentially consider the risk for development of osteonecrosis in planning primary treatment.     

Plantarflexory Osteotomy for a Plantar Flexed First Ray? A Cross-sectional Study of the Relationship between Frontal Plane Forefoot Deformity and Lateral Intermetatarsal Angle in 190 Patients

Many surgeons consider performing plantarflexory osteotomy when a lateral weightbearing radiograph shows an elevated first metatarsal. In our study, we clinically evaluated the first metatarsal position in terms of the forefoot-to-rearfoot relationship and radiographically evaluated the lateral intermetatarsal angle in 190 patients. We divided the subjects into forefoot varus, valgus, and neutral groups and compared their mean lateral intermetatarsal angle. The mean lateral intermetatarsal angle for those with forefoot varus, valgus, and neutral was 1.4° ± 3.10°, 1.3° ± 3.30°, and 0.4° ± 2.67°, respectively. Neither analysis of variance nor post hoc tests showed any significant difference among the groups. We hypothesized that the ground reacting force alters the first ray position on the weightbearing radiographs; thus, it would not be advisable to rely solely on this angular measurement for surgical decision-making.     

A Multicenter Phase I/II Study of the BCNU Implant (Gliadel ? Wafer) for Japanese Patients with Malignant Gliomas

Carmustine (BCNU) implants (Gliadel^® Wafer, Eisai Inc., New Jersey, USA) for the treatment of malignant gliomas (MGs) were shown to enhance overall survival in comparison to placebo in controlled clinical trials in the United States and Europe. A prospective, multicenter phase I/II study involving Japanese patients with MGs was performed to evaluate the efficacy, safety, and pharmacokinetics of BCNU implants. The study enrolled 16 patients with newly diagnosed MGs and 8 patients with recurrent MGs. After the insertion of BCNU implants (8 sheets maximum, 61.6 mg BCNU) into the removal cavity, various chemotherapies (including temozolomide) and radiotherapies were applied. After placement, overall and progression-free survival rates and whole blood BCNU levels were evaluated. In patients with newly diagnosed MGs, the overall survival rates at 12 months and 24 months were 100.0% and 68.8%, and the progression-free survival rate at 12 months was 62.5%. In patients with recurrent MGs, the progression-free survival rate at 6 months was 37.5%. There were no grade 4 or higher adverse events noted due to BCNU implants, and grade 3 events were observed in 5 of 24 patients (20.8%). Whole blood BCNU levels reached a peak of 19.4 ng/mL approximately 3 hours after insertion, which was lower than 1/600 of the peak BCNU level recorded after intravenous injections. These levels decreased to less than the detection limit (2.00 ng/mL) after 24 hours. The results of this study involving Japanese patients are comparable to those of previous studies in the United States and Europe.     

11-Year Experience with Laparoscopic Adjustable Gastric Banding for Morbid Obesity—What Happened to the First 123 Patients?

Background Few long-term studies regarding the outcome of laparoscopic adjustable gastric banding for morbid obesity have so far been published. We report our 11-year experience with the technique by looking closely at the first 123 patients that have at least 5 years (mean 86 months) of follow-up. Methods Data have been collected prospectively among 280 patients operated since March 1996. Until March 2002 (minimum 5-year follow-up), 123 patients have been operated laparoscopically with the Swedish band. We report major late complications, reoperations, excess weight losses (EWL) and failure rates among these patients, with a mean (range) follow-up time of 86 months (60–132). EWL < 25% or major reoperation was considered as a failure. EWL > 50% was considered a success. Results Mean (range) age of the patients (male/female ratio 31:92) was 43 years (21–44). Mean (range) preoperative weight was 130 kg (92–191). Mean (range) preoperative body mass index was 49.28 kg/m² (35.01–66.60). Patients lost to follow-up was nearly 20% at 5 years and 30% at 8 years. Major late complications (including band erosions 3.3%, slippage 6.5%, leakage 9.8%) leading to major reoperation occurred in 30 patients (24.4%). Nearly 40% of the reoperations was performed during the third year after the operation. The mean EWL at 7 years was 56% in patients with the band in place, but 46% in all patients. The failure rates increased from about 15% during years 1 to 3 to nearly 40% during years 8 and 9. The success rate declined from nearly 60% at 3 years to 35% at 8 and 9 years. Conclusions Complications requiring reoperations are common during the third year after the operation, and almost 25% of the patients will need at least one reoperation. Mean EWL in all patients does not exceed 50% in 7 years or 40% in 9 years and failure rates increase with time, up to 40% at 9 years.     

Histologic Study of Tissue Reaction to the Gastric Band: Does it Contribute to the Problem of Band Erosion?

Background: One of the major complications of gastric banding is intragastric migration of the band. The frequency ranges from 0.5% to 3.8%, and removal of the band is always required. We undertook a prospective study with the aim to determine the reasons for this significant complication in bariatric surgery. Methods: 480 morbidly obese patients underwent adjustable gastric banding in our Surgical Department, from February 1998 to October 2005. 31 of them were reoperated for different surgical problems, at an average time of 39 months after the bariatric procedure. During the reoperation, some fragments of fibro-adipose tissue in close contact with the band were removed. They were examined, focusing on the following parameters: acute and chronic inflammation, fibrosclerosis, and foreign body granulomatous reaction. Results: Histological assessment showed the presence of acute and chronic inflammation, generally of mild and medium grade; fibrosclerosis was present mostly in a severe form, indicating a biological periprosthesic wall that separates and protects the gastric wall from the band; no cases of foreign body reaction were observed, nor were silicone inclusions found inside the inflammatory cells. Conclusion: The histologic changes of periprosthesic tissue do not appear to account for endoluminal migration of the gastric band. Thus, band erosion could have a closer correlation with other causes, such as infection of the band or intraoperative surgical damage, possibly due to direct mechanical action or to the thermal effect of the electric scalpel.