Laparoscopic coagulation of the uterine blood supply in laparoscopic-assisted vaginal hysterectomy is associated with less blood loss

BACKGROUND: Does laparoscopic coagulation of the uterine blood supply decrease blood loss compared with transvaginal ligature of the uterine vessels? METHODS: Intra- and postoperative data of 446 patients undergoing laparoscopic-assisted vaginal hysterectomy at the Department of Gynecology, University of Jena, between 1998 and 2001 were analysed. In 213 patients the uterine blood supply was transected laparoscopically at the origin of the uterine vessels (LAVH type II) and in 233 patients (LAVH type I) transvaginally. RESULTS: Patients in both groups were comparable with respect to median age, Quetelet index, and parity. The drop of hemoglobin between the preoperative day and postoperative day 3 was 0.8 mmol/l or 0.6 mmol/l for LAVH type I without or with BSO vs 0.3 mmol/l or 0.4 mmol/l for LAVH type II without or with BSO (p = 0.001), respectively. Median operative time was similar for both techniques: LAVH type I 136 min or with BSO 128 min vs LAVH type II 126 min or with BSO 131 min. The weight of the removed uteri was significantly lower in LAVH type I vs type II (220 vs 270 grams), but similar when LAVH was combined with BSO (160 vs 178 grams). The rate of intraoperative complications was 2.2% vs 0.9% between LAVH type I or II (n.s.), but 9% vs 3.3% for overall postoperative complications (p = 0.01). CONCLUSIONS: Laparoscopic coagulation of the uterine blood supply at the origin of uterine vessels is a safe technique which minimizes blood loss in LAVH. In patients with a low preoperative hemoglobin value this technique is indicated.     

Pathological characteristics of ovarian cancer occurring after hysterectomy

OBJECTIVE: The aim of the current study was to examine the pathological characteristics of ovarian cancer occurring in women with previous hysterectomy. METHODS: Newly diagnosed cases of ovarian primary epithelial or primary peritoneal cancer, operated on in our department between January 2000 and December 2002, were included in this retrospective study. The patients were divided into two groups, group I included eight patients with ovarian cancer and previous hysterectomy, and group II comprised 70 patients with ovarian or primary peritoneal cancer, but without previous hysterectomy. RESULTS: There was no significant difference between the eight patients with ovarian cancer and previous hysterectomy and the 70 patients without previous hysterectomy considering the patients' characteristics. Conversely, there was a difference between the two study groups regarding the histology of the tumor, its grade and the stage of the disease. All patients with ovarian cancer and previous hysterectomy had poorly differentiated mixed epithelial or undifferentiated tumors. Nevertheless, only 25% of these patients were diagnosed in Stage IIIC. CONCLUSION: It seems that besides reducing the risk of further ovarian cancer, hysterectomy also causes a change in the main histological sub-group of ovarian cancer, that develops in patients with previous hysterectomy. The greatest protective effect was observed for serous ovarian tumors.     

Managing congestive heart failure using home telehealth

Congestive heart failure (CHF) is the leading cause of rehospitalization and loss of revenue for home care agencies and hospitals. This article outlines how an agency used telehealth to provide CHF patients quality care and improved outcomes while decreasing the number of skilled home nursing visits and reducing rehospitalization rates to 1.2%.     

Coaching for competence.

The preceptors and leadership team on a busy acute care general medical unit collaborated on a temporary plan to provide clinical support for 38 nurses who had been hired during the year. A pilot role was created and designated "unit coach." Each coach questioned and prompted reflective practice in building confidence and critical thinking.     

Signal verification of middle latency auditory evoked potentials by automated detection of the brainstem response

BACKGROUND: The midlatency components of auditory evoked potentials (AEPs) are gradually suppressed with increasing concentrations of anesthetics. Thus, they have been proposed as a monitor of anesthetic depth. However, undetected malfunction or disconnection of headphones and undetected hearing loss also result in suppressed midlatency AEPs that in turn may be misinterpreted as signs of deep anesthesia. As the brainstem component of the AEP is minimally influenced by anesthetics, its presence or absence can be used to verify that the recorded signal is a true AEP rather than an artifact. In this study, an online-capable procedure for detection of the brainstem component of the AEP was developed. METHODS: One hundred and ninety perioperatively recorded AEPs (binaural stimuli, 500 sweeps) were selected from a database with electroencephalographic and concomitant AEP stimulus information. Identical electroencephalogram regions were used to produce nonstimulus synchronized averaged signals (500 sweeps, "non-AEP"). The 190 AEPs and 190 "non-AEPs" were used to develop a detector of the brainstem component of AEPs. AEPs and "non-AEPs" were wavelet transformed (discrete wavelet decomposition, biorthogonal 2.2 mother-wavelet), and the coefficient with the best separation of the two classes of signals was selected. Receiver operating characteristic curve analysis was performed to determine the optimum threshold value for this coefficient. RESULTS: The third coefficient of the third level was selected. In AEP signals, retransform of this coefficient produces a peak that resembles peak V of the brainstem response. The developed detector of the brainstem component of AEP had a sensitivity of 97.90% and a specificity of 99.48%. CONCLUSIONS: This detector of the AEP brainstem component can be used to verify that the signal reflects the response to an auditory stimulus. An alternative approach, used in the Danmeter AEP monitor, is based on the signal-to-noise ratio of the midlatency components of the AEP. Because the midlatency components of AEP are suppressed by anesthesia, a false alarm "low AEP/no AEP" is generated during deep anesthesia. This, in turn, may suggest disconnection of headphones or technical problems whenever anesthesia is deep. This disadvantage has been overcome by our detector, which is based on the identification of the brainstem component of AEP.     

The effect of epidural analgesia in labour on maternal respiratory function

Lumbar epidural analgesia during labour has gained widespread acceptance. The impact of epidural analgesia based on mixtures of low-dose local anaesthetic solutions and lipophilic opioids on most clinically relevant obstetric outcomes is minimal. Since the pregnant state per se is associated with important alterations in respiration, we assessed whether a subtle degree of motor blockade brought about by epidural analgesia might compromise respiratory function as assessed by spirometry. Sixty consenting parturients receiving epidural analgesia were consecutively included in this prospective study. We performed spirometry during the antepartum visit and in labour after effective epidural analgesia was established; at both assessments the women were pain-free. Values were within normal ranges but increased significantly after effective epidural analgesia; median (IQR [range]) increase for vital capacity 7.4 (3.0-13 [-12-27])% (p < 0.001); forced vital capacity 4.4 (1.7-9.8 [-13-26])% (p < 0.001); forced expiratory volume in 1 s 5.5 (1.7-8.6 [-14-28])% (p < 0.001); and peak expiratory flow rate 2.3 (-1.6-5.8 [-18-16])% (p = 0.01)). We conclude that epidural analgesia for labour significantly improved respiratory function.     

Heart transplantation in a patient with a left ventricular assist device and methicillin-resistant Staphylococcus aureus infection

We report a patient who underwent implantation of a DeBakey left-ventricular assist device and developed a methicillin-resistant Staphylococcus aureus drive line infection on postoperative day 304. The patient was forwarded to urgent heart transplantation with a successful outcome.     

Autoantibodies to neutrophil cytoplasmic antigens (ANCA) do not bind to polymorphonuclear neutrophils in blood

BACKGROUND: Autoantibodies to neutrophil cytoplasmic antigens (ANCA), particularly to proteinase 3 (PR3), are found in the majority of patients with systemic Wegener's granulomatosis. The autoantibodies are widely used as diagnostic markers. Their role in the development and progression of the disease, however, is still under investigation. The primary target of ANCA, PR3, is located in the cytoplasm of polymorphonuclear neutrophils (PMN) or monocytes and is translocated to the cell surface upon stimulation. In patients with Wegener's granulomatosis PR3 is up-regulated most prominently during active disease. Despite the fact that both autoantibodies to PR3 and PMN expressing PR3 are present in patients with Wegener's granulomatosis, there is no evidence for binding of the autoantibodies to PMN. The present study was designed to analyze binding characteristics of autoantibodies to PR3 on PMN. METHODS AND RESULTS: PMN of patients with active Wegener's granulomatosis (N= 10) were tested for autoantibody binding. Despite high autoantibody titer and PR3 expression on the PMN, no surface-bound IgG was found on PMN ex vivo. When ANCA-containing plasma from patients was incubated with isolated PMN, stimulated to express PR3, again no specific binding of the autoantibody could be detected. Also keeping the samples on ice did not allow surface detection of IgG, ruling out degradation or internalization of the autoantibodies. Only when purified IgG fractions were used, binding to PMN was seen in 14 of 25 patients. Already 1% of plasma, however, was sufficient to greatly reduce the IgG binding. Reduced binding of the IgG fraction was also seen when a larger reaction volume was used. CONCLUSION: Our data indicate that autoantibodies to PR3 have a rather low affinity for surface-associated PR3 on PMN. This, in turn, argues against the hypothesis that ANCA contributes to the pathogenesis of the disease by stimulating viable PMN in whole blood.