History of a Protocol

Entrapment neuropathies are common disorders that are often misdiagnosed. Accurate identification is important because the outlook for patients is good if appropriate treatment is initiated early. Drs Parachuri and Adams tell how to differentiate nerve entrapment from the neurologic, vascular, and articular diseases that it can resemble, and they discuss the diagnosis and treatment of nine common entrapment neuropathies.     

The use of care pathways as tools to support the implementation of evidence-based practice

This article presents some of the data from a study exploring the experiences and views of a range of professional staff using care pathways in their everyday practice. It focuses on the views of doctors, nurses, and therapists. Within the context of delivering integrated care, several themes are explored in relation to the successful implementation of evidence-based care pathways.     

Dignity Amidst Liminality: Healing Within Suffering Among Chinese Terminal Cancer Patients

This study critically examines the concepts of dignity and liminality at the end-of-life, in an effort to better understand the processes of healing within suffering among Chinese terminal cancer patients receiving palliative care services in Hong Kong. Meaning-oriented interviews were conducted with 18 Chinese terminal patients, aged 44 to 98, to elicit the narratives and stories of their illness experience. All interviews were analyzed using grounded theory and supplemented by ethnographic observations and field notes. Two major themes and eight subprocesses of healing adopted by patients to achieve and maintain dignity were identified: (a) personal autonomy, which encompasses the need to (i) regain control over living environments, (ii) maintain self-sufficiency despite institutional care, (ii) make informed care decisions to reduce sense of burden, and (iv) engage in future planning to create a lasting legacy; and (b) family connectedness, which encompasses the need to (i) maintain close ties with family members to express appreciation, (ii) achieve reconciliation, (iii) fulfill family obligations, and (iv) establish a continuing bond that transcends generations. Implications of these themes for advanced care planning and life review interventions were discussed with the goal of enhancing patient autonomy and family connectedness, and thereby providing structure and meaning for Chinese terminal patients and their families at the end of life.     

Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity

OBJECTIVE: To determine the safety and efficacy of laparoscopic Roux-en-Y gastric bypass for the treatment of morbid obesity. SUMMARY BACKGROUND DATA: Laparoscopic Roux-en-Y gastric bypass is a new and technically challenging surgical procedure that requires careful study. METHODS: The authors attempted total laparoscopic Roux-en-Y gastric bypass in 281 consecutive patients. Procedures included 175 proximal bypasses, 12 long-limb bypasses, and 9 revisional procedures from previous bariatric operations. The gastrojejunostomy and jejunojejunostomy were primarily constructed using linear stapling techniques. RESULTS: Eight patients required conversion to an open procedure (2.8%). The mean age of the patients was 41.6 years (range 15-71) and 87% were female. The mean preoperative body mass index was 48.1 kg/m2. The operative time decreased significantly from 234 +/- 77 minutes in the first quartile to 162 +/- 42 minutes in the most recent quartile. Postoperative length of stay averaged 4 days (range 2-91), with 75% of patients discharged within 3 days. The median hospital stay was 2 days. No patient died after surgery. Complications included three (1.5%) major wound infections (each followed a reoperation for a complication or open conversion), incisional hernia in 5 patients (1.8%), and anastomotic leak with peritonitis in 14 patients (5.1%). Three gastrojejunal leaks were managed without surgery, four by laparoscopic repair/drainage, and three by open repair/drainage. Only three patients had anastomotic leaks in the most recent 164 procedures (1.8%) since the routine use of a two-layer anastomotic technique. Data at 1 year after surgery were available in 69 of 96 (72%) patients (excludes revisions). Weight loss at one year was 70 +/- 5% of excess weight. Most comorbid conditions resolved by 1 year after surgery; notably, 88% of patients with diabetes no longer required medications. CONCLUSIONS: Laparoscopic gastric bypass demonstrates excellent weight loss and resolution of comorbidities with a low complication rate. The learning curve is evident: operative time and leaks decreased with experience and improved techniques. The primary advantage is an extremely low risk of wound complications, including infection and hernia.     

Postoperative Cognitive Dysfunction in Patients with Preoperative Cognitive Impairment: Which Domains Are Most Vulnerable?

Background: The authors explored the database of the first International Study of Postoperative Cognitive Dysfunction study to specify the domains of cognitive function that were most vulnerable and to determine the pattern of deterioration in patients with preoperative cognitive impairment.

Methods: One thousand two hundred eighteen patients were included in the first International Study of Postoperative Cognitive Dysfunction, where neuropsychological testing was performed at entry to the study, at 1 week, and at 3 months after surgery. The authors' analyses determined the extent to which seven neuropsychological measures changed after surgery with focus on the relation with preoperative cognitive impairment, defined as a preoperative score 1.5 SD below healthy controls in the memory test.

Results: Preoperative cognitive impairment was found in 74 patients at baseline. At 1 week, cognitive deterioration was seen in all tests, but in particular in the Letter Digit Coding and the time of the Stroop interference test, with 14% and 16% of the total sample (n = 1,016) exceeding 2 SD, respectively. At 3 months, deterioration was more uniform. Significantly fewer in the preoperative cognitive impairment group had deterioration in the memory test, both at 1 week and at 3 months, with no patient displaying a deterioration exceeding 2 SD.     

Five-year review of infections in a burn intensive care unit: High incidence of Acinetobacter baumannii in a tropical climate

A 5-year review of nosocomial infections, bacteraemia and wound colonization in patients admitted to a burn intensive care unit from June 2001 to May 2006 was carried out. All patients required intubation at some point, and ICU support. Data on bacterial and fungal isolates were entered prospectively into a hospital-wide computerized database. Nosocomial infections (NIs) were defined using standard CDC criteria. Seventy-six patients were admitted during the study period, with 57 qualifying for analysis. Forty-two patients (74%) developed 137 NIs, with 240 NIs/100 admissions. The most common NI was pneumonia (43%), followed by burn wound infection (34%), primary bloodstream infection (20%) and urinary tract infection (3%). The device specific rate of pneumonia was 143 infections per 1000 ventilator days. There were 113 episodes of bacteraemia and 173 episodes of wound colonization without infection. The most common organisms causing nosocomial infections were Acinetobacter sp. (n = 33), followed by methicillin resistant Staphylococcus aureus (MRSA) (n = 24) and Pseudomonas aeruginosa (n = 22). A. baumannii isolates were highly multiresistant, with 82 distinct strains isolated from 47 patients (82% of patients). Data from this and other studies supports the hypothesis that A. baumannii is more common in tropical, warm climes necessitating vigorous infection control measures to optimise patient outcome.