Management of postoperative swallowing dysfunction after ependymoma surgery

Purpose  

This study aims to share a new postoperative care technique team approach for the management of children after they have recovered from the anesthetic and has passed through the immediate postoperative period of a day or so from their posterior fossa ependymoma surgery.     

全科医生札记——布朗医生日记

丢了西瓜捡芝麻 上周，一个名叫鲍勃的病人给我打来电话，问我是否能给他的保险公司写一封信，因为这家保险公司拒绝支付他的心脏扫描费用，保险公司认为这种检查属于临床研究性质，所以拒付。我立即给这家保险公司写了一封短信，信中列出了鲍勃患心脏病的风险因素，并说明了无症状要做检查的理由。今天这家保险公司终于让步了，并表示此类检查仅允许这一次。     

Comparison of anterior colporrhaphy and retropubic urethropexy for patients with genuine stress urinary incontinence

OBJECTIVE: Our purpose was to compare the efficacy of anterior colporrhaphy and retropubic urethropexy performed for genuine stress urinary incontinence.STUDY DESIGN: A retrospective analysis was performed on women who underwent either anterior colporrhaphy or retropubic urethropexy for genuine stress urinary incontinence. Patients were identified by a computer-assisted search, and these women were contacted by telephone. The interview was used to assess current continence status. Variables reviewed included demographic data, medications, hormonal status, current smoking history, significant medical and surgical history, and time to recurrence of incontinence. Operative procedure, prior or concomitant hysterectomy, history of previous incontinence procedures, concomitant surgery for repair of other pelvic floor defects, experience level of the primary surgeon, and duration of postoperative catheterization were also documented.RESULTS: Seventy-six women who had undergone surgery for genuine stress incontinence during a 4-year period were identified and evaluated by telephone interview. Fifty-six had undergone anterior colporrhaphy and 20 retropubic urethropexy. Both groups of patients were comparable in age, social status, race, parity, and weight. The duration of follow-up (mean ± SD) was 66.6 ± 14.2 months (range 48 to 96 months). Concurrent surgery to repair other pelvic floor defects was more common in patients undergoing anterior colporrhaphy than in patients undergoing retropubic urethropexy (p < 0.05). Of the 56 patients treated with anterior colporrhaphy, 26 (46%) were continent at the time of interview versus 15 of 20 (75%) treated with retropubic urethropexy (p < 0.05). Times to recurrence for anterior colporrhaphy and retropubic urethropexy were not significantly different. History of previous incontinence procedures, concomitant hysterectomy, previous hysterectomy, duration of postoperative catheterization, obesity, chronic lung disease, and smoking were not correlated with success for either procedure. Experience of the primary surgeon did have a significant effect on success, with attending staff having a better cure rate than resident surgeons (p < 0.05).CONCLUSION: Retropubic urethropexy was significantly more effective than anterior colporrhaphy for long-term cure of genuine stress urinary incontinence. We believe these conclusions should be tempered because of the complex nature of genuine stress incontinence. Patients having anterior colporrhaphy may represent a high-risk group because nearly all of them had associated pelvic floor defects. Experience of the surgeon seems to enhance the liklihood of success and may reflect subtle modifications of technique.     

Correlation of neonatal acid-base status with Apgar scores and fetal heart rate tracings

In this study the immediate neonatal acid-base status, obtained via a double-clamped segment of umbilical cord, in 75 term, singleton vaginal deliveries was compared to electronic fetal heart rate recordings and Apgar scores. Of 75 neonates, 59 had 1-minute Apgar scores greater than or equal to 7 and 52 had an initial pH greater than 7.20. Six of the 16 neonates with a 1-minute Apgar score less than 7 demonstrated a low pH (less than 7.20). At 5 minutes only eight of 75 neonates had Apgar scores less than 7 with six of the eight having pH values less than 7.20. Of those neonates with Apgar scores greater than or equal to 7 and pH less than 7.20 (seven neonates at 1 minute, two at 5 minutes), none had metabolic acidosis. Eighteen fetal heart rate tracings were considered abnormal; acidosis was confirmed in eight (44%) by pH criteria, yet only three of the eight neonates had low Apgar scores. Our investigations suggest that the combination of fetal heart rate monitoring, cord blood pH, and Apgar assessment is better than any one parameter alone as an evaluation of fetal status just after delivery.     

External cephalic version of the breech presentation under tocolysis

External cephalic version with tocolysis at or near term has been advocated to avoid cesarean birth for breech presentation. In our institution this maneuver was successfully performed in 207 of 304 parturients without major complications, and all but six had vertex presentation at delivery. The success of version was inversely correlated with gestational age but was not correlated with ease of version, number of attempts, or placental location. When this 3-year period was compared with the previous three years (1979 to 1981), there was a significant reduction in the number of breech presentations during labor, whereas the total delivery rate remained relatively constant over the 6-year period. It appears that in a carefully selected population, external version near term can be used safely to reduce the need for abdominal birth because of breech presentation.     

Effects of delayed wound excision and grafting in severely burned children

HYPOTHESIS: Advances in burn treatment including early excision of the wound have increased survival in patients treated at specialized burn centers. We hypothesized that the patients with delayed wound excision and grafting would experience deleterious outcomes. METHODS: From 1995 to 1999, 157 children with acute burns covering 40% or more of total body surface area and having more than 10% of full-thickness burns were admitted to our institution within 2 weeks of injury. Among them, 86, 42, and 29 patients underwent first operation on days 0 to 2, days 3 to 6, and days 7 to 14 after burn, respectively. Outcomes observed were mortality, number of operative procedures, length of hospitalization, blood transfused, incidence of wound bacterial and fungal contamination, invasive wound infection, and sepsis. RESULTS: Demographic data for the groups showed no differences in sex or total body surface area burned. Mortality and number of operative procedures and blood transfusions were not different between groups. Hospitalizations were longer in the delayed groups, which was associated with a higher incidence of significant wound contamination (P =.008). Invasive wound infection also increased significantly with delay of excision (P<.001). An increased incidence of sepsis was seen in patients with delayed wound excision and grafting (P =.04). CONCLUSIONS: Delays in excision were associated with longer hospitalization and delayed wound closure, as well as increased rates of invasive wound infection and sepsis. Our data indicate that early excision within 48 hours is optimal for pediatric patients with massive burns.