Thirty-day and 90-day hospital readmission after outpatient upper extremity hemodialysis access creation

Objective

Patients with end-stage renal disease have multiple comorbidities and are at increased risk for postoperative complications and resource utilization. Our goal was to determine the rate and causes of 30-day and 90-day hospital readmissions after the creation of outpatient hemodialysis access.

The effect of glossopexy on weight velocity in infants with Pierre Robin syndrome

Aim

In infants with Pierre Robin syndrome (PRS), mandibular distraction may be more advantageous than glossopexy as it not only relieves oropharyngeal airway obstruction but also reverses body growth retardation. Because no data are available on body weight velocity after glossopexy, we assessed longitudinally the body weight velocity in a cohort of children undergoing glossopexy.

Methods

The records of 48 infants with PRS undergoing glossopexy after unsuccessful nonoperative treatment between 1981 and 2005 were reviewed. Weight measurements were analyzed at 4 time-points: at birth, on admission for glossopexy, on admission for lysis of lip-tongue adhesion (TLA), and at follow-up. Weight velocity was assessed using Tanner's tables.

Main Results

Adhesion dehiscence occurred in 9 patients (18.7%). Lip-tongue adhesion resolved airway compromise in 36 infants (75%). Release of TLA was accomplished in 34 patients. Data on weight velocity from birth to follow-up (mean, 5.57 ± 0.59 years) were available for 31 patients. After glossopexy, mean body weight increased from the 9.7 ± 2.6th to the 17.5 ± 4.6th percentile (P > .05), whereas mean weight velocity increased from the 19.1 ± 4.9th to the 74.2 ± 4.7th percentile (P < .001). No temporal correlation was found between glossopexy and oropharyngeal dysphagia.

Conclusion

In infants with PRS, glossopexy is a valid alternative to mandibular distraction because it does not cause decline in body growth.     

Circumumbilical pyloromyotomy in the era of minimally invasive surgery

Background/purpose

No studies have investigated the cosmetic outcome of current approaches to pyloromyotomy in infants with hypertrophic pyloric stenosis. The purpose of this study was to evaluate the final appearance of the scar in patients undergoing circumumbilical pyloromyotomy.

Methods

During a 16-year period, 86 infants underwent circumumbilical pyloromyotomy at our institution. A detailed questionnaire was created to document the family members' perceptions of the esthetic appearance of the scar. Data were collected by telephone interview and at clinic visit. In addition, cosmesis was assessed by 5 staff members who scored blindly the esthetic outcome of the scars with comparative photographs, using a categorical scale.

Results

Fifty-seven families were tracked by telephone contact. In the family questionnaire, 100% of families reported an excellent or good scar. Of these, forty-one (72%) were available for cosmetic assessment. Follow-up ranged between 5 months and 15 years (mean, 6 years). The panel members ranked the scar, on average, as excellent or good for 90% of the patients. No assessor stated that a scar was unacceptable. Intra- and interobserver agreement was 0.72 and 0.78, respectively.

Conclusions

Overall satisfaction with the cosmetic outcome of circumumbilical pyloromyotomy is very high.     

Endovascular management of visceral artery aneurysms: When to watch,when to intervene?

Visceral artery aneurysms (VAA) include splanchnic and renal artery aneurysms. They represent a rare clinical entity, although their detection is rising due to an increased use of cross-sectional imaging. Rupture is the most devastating complication, and is associated with a high morbidity and mortality. In addition, increased percutaneous endovascular interventions have raised the incidence of iatrogenic visceral artery pseudoaneurysms (VAPAs). For this reason, elective repair is preferable in the appropriately chosen patient. Controversy still exists regarding their treatment. Over the past decade, there has been steady increase in the utilization of minimally invasive, non-operative interventions, for vascular aneurysmal disease. All VAAs and VAPAs can technically be fixed by endovascular techniques but that does not mean they should. These catheter-based techniques constitute an excellent approach in the elective setting. However, in the emergent setting it may carry a higher morbidity and mortality. The decision for intervention has to take into account the size and the natural history of the lesion, the risk of rupture, which is high during pregnancy, and the relative risk of surgical or radiological intervention. For splanchnic artery aneurysms, we should recognize that we are not, in reality, well informed about their natural history. For most asymptomatic aneurysms, expectant treatment is acceptable. For large, symptomatic or aneurysms with a high risk of rupture, endovascular treatment has become the first-line therapy. Treatment of VAPAs is always mandatory because of the high risk of rupture. We present our point of view on interventional radiology in the splanchnic arteries, focusing on what has been achieved and the remaining challenges.     

Clinical and radiological outcome of anterior–posterior fusion versus transforaminal lumbar interbody fusion for symptomatic disc degeneration: a retrospective comparative study of 133 patients

Abundant data are available for direct anterior/posterior spine fusion (APF) and some for transforaminal lumbar interbody fusion (TLIF), but only few studies from one institution compares the two techniques. One-hundred and thirty-three patients were retrospectively analyzed, 68 having APF and 65 having TLIF. All patients had symptomatic disc degeneration of the lumbar spine. Only those with one or two-level surgeries were included. Clinical chart and radiologic reviews were done, fusion solidity assessed, and functional outcomes determined by pre- and postoperative SF-36 and postoperative Oswestry Disability Index (ODI), and a satisfaction questionnaire. The minimum follow-up was 24 months. The mean operating room time and hospital length of stay were less in the TLIF group. The blood loss was slightly less in the TLIF group (409 vs. 480 cc.). Intra-operative complications were higher in the APF group, mostly due to vein lacerations in the anterior retroperitoneal approach. Postoperative complications were higher in the TLIF group due to graft material extruding against the nerve root or wound drainage. The pseudarthrosis rate was statistically equal (APF 17.6% and TLIF 23.1%) and was higher than most published reports. Significant improvements were noted in both groups for the SF-36 questionnaires. The mean ODI scores at follow-up were 33.5 for the APF and 39.5 for the TLIF group. The patient satisfaction rate was equal for the two groups. This work is dedicated to the memory of Grace and Julia Hanson.     

Cervical degenerative index: a new quantitative radiographic scoring system for cervical spondylosis with interobserver and intraobserver reliability testing

Background  The lack of a widely available scoring system for cervical degenerative spondylosis encouraged the authors to establish and validate a systematic quantitative radiographic index. Materials and methods  This study included intraobserver and interobserver reliability testing among three reviewers with different years of experience. Each observer independently scored four cervical radiographs of 48 patients at separate intervals, and statistical analysis of the grading was performed. Results  There was high intraobserver and interobserver reliability between the two experienced observers. There was fair reliability between the less experienced observer and the more experienced observers. Conclusions  The cervical degenerative index appears to be a reliable and reproducible radiographic assessment of cervical spondylosis. The index will have direct applicability for longitudinal study of cervical spondylosis and may be clinically relevant as well.     

Breast necrosis following use of the internal mammary artery for coronary artery bypass

Coronary artery bypass grafting is a common surgical procedure for myocardial revascularization. This operation usually involves the use of the left internal mammary artery to bypass the left anterior descending coronary artery. The internal mammary artery and its perforators are also an important blood supply to the female breast, though not considered a critical blood supply. Due to an abundant blood supply from multiple sources, complications of the female breast are rare. We present a case report of a patient who developed necrosis of the entire medial left breast and superior abdominal wall following coronary artery bypass grafting which used the left internal mammary artery.     

Orthopaedic trauma care: a two-tier system?

Orthopaedic trauma requiring surgical admission presents to our hospitals right throughout the week. However, the level of service provided to trauma patients appears to fluctuate with more surgery facilities available during weekday "office-hours" with reduced facilities at the weekend. The National Confidential Enquiry into Peri-operative Deaths (NCEPOD) in 1999 laid down guidelines for orthopaedic trauma surgery in elderly patients clearly stating that no elderly patient requiring an urgent operation should have to wait for more than 24 h once fit for surgery. We see no reason to exclude the younger population from such a directive and have hence applied the same standard of "surgery within 24 h of admission" as our index of appropriate practice. Audit of our consultant delivered performance confirmed that while an average 88% of "weekday service" patients admitted Sunday through Thursday achieved this standard, only an average of 64% of weekend service patients admitted on Friday or Saturday achieved the same standard. The purpose of this report is to increase awareness of what we believe to be a widespread dilemma. The day of the week should not dictate the treatment of the patient.     

Laparoscopic-assisted percutaneous endoscopic gastrostomy in children and adolescents.

OBJECTIVE: Pediatric gastric access for long-term enteral feeding may be performed via a laparotomy, laparoscopy, or a percutaneous approach. In children and adolescents, laparoscopic-assisted gastrostomy may be difficult due to a thick abdominal wall. Therefore, if the abdominal wall is estimated to be >2 cm on physical examination, or in children in whom a percutaneous endoscopic gastrostomy was unsuccessfully attempted by a gastroenterologist, we routinely perform a laparoscopic-assisted percutaneous endoscopic gastrostomy. METHODS: From January 1998 through February 2003, we retrospectively reviewed 15 cases of a laparoscopic-assisted percutaneous endoscopic gastrostomy. Instruments used to perform this technique are a percutaneous endoscopic gastrostomy kit, an Olympus flexible endoscope, and one 5-mm STEP port placed through an infraumbilical incision for a 5-mm, 30-degree scope. RESULTS: Age range was 2 years to 20 years (mean, 10). Operative time ranged from 20 minutes to 45 minutes. When a concurrent laparoscopic Nissen fundoplication was performed (n = 6), the percutaneous endoscopic gastrostomy was placed after completion of the Nissen fundoplication. No intraoperative complications occurred, and all tubes were successfully placed. Feeds were instituted the following day and advanced to goal. To date, no postoperative complications have occurred, and revision has not been necessary. CONCLUSIONS: Laparoscopic-assisted percutaneous endoscopic gastrostomy in children and adolescents is safe and effective. Utilizing laparoscopy permits evaluation of the peritoneum and lysis of adhesions, if necessary. Moreover, laparoscopy provides excellent exposure for accurate placement of the PEG, while avoiding injury to other organs.     

Polymerase chain reaction identification in aqueous humor of patients with postoperative endophthalmitis

PURPOSE: To identify bacterial agents in the aqueous humor of patients with postoperative endophthalmitis using eubacterial polymerase chain reaction (PCR) and conventional culture. SETTING: University Hospital of Lyon E. Herriot, Lyon, France. METHODS: Broad-range eubacterial PCR amplification followed by direct sequencing was used to identify microbial pathogens in ocular samples from 30 patients with acute or delayed-onset endophthalmitis, mainly after cataract surgery. Ocular samples included aqueous humor collected before the first intravitreal injection of antibiotics and vitreous samples collected at the time of the therapeutic pars plana vitrectomy. RESULTS: Cultures were positive in 32% of cases and PCR in 61% of cases with aqueous humor samples. When associated, culture and PCR of aqueous humor samples allowed for a microbiological diagnosis in 71% of cases. Microorganisms cultured by conventional techniques matched those identified by PCR. When applied on vitreous pretreated with intravitreal antibiotics, PCR increased the identification rate from 18% to 62%. CONCLUSIONS: Polymerase chain reaction assay of initial aqueous humor samples contributed to the diagnosis of endophthalmitis in 30% of cases. Previous use of intravitreal antibiotics did not seem to affect the ability to PCR-amplify DNA in the short term. Polymerase chain reaction-based technology was a useful adjunct to conventional culture because when used with aqueous humor samples only, the association of both techniques allowed for a microbiological diagnosis in 71% of cases of postoperative acute and delayed-onset endophthalmitis.