Survey on the preoperative evaluation in Catalonian surgical centers. II. What is the attitude and opinion of the professionals involved?

OBJECTIVE: Previous studies have provided evidence of the existence of differences in preoperative assessment practices and have questioned the usefulness of generalized testing for all patients. The objective of this study was to determine the attitudes and opinions of anesthesiologists and surgeons about their application of preoperative assessment procedures and their knowledge of the scientific principles underlying their practice. SUBJECTS AND METHODS: A questionnaire was mailed to 227 specialists in anesthesiology and postoperative intensive care, general and gastrointestinal surgery, orthopedic surgery and traumatology of all hospitals in Catalonia (Spain) with active operating theaters. RESULTS: The overall response rate was 61% of the surveyed population, with 86% of the Catalan hospitals represented. The medical literature supports the routine performance of a chest x-ray and an ECG in the opinion of 17 and 26% of the respondents, respectively. Those two procedures are always ordered by 43 and 37%, respectively, even if they believe that the medical literature does not support generalized application. Legal protection was given as the reason for routine ordering of preoperative tests in asymptomatic patients, and 89% believed that a protocol for selective preoperative assessment procedures would improve efficiency. CONCLUSIONS: This study reveals a discrepancy between the opinions of professionals involved in preoperative assessment and their real practice in Catalan hospitals, probably influenced by perceived need for legal protection.     

Cerebrospinal fluid drainage and deep systemic hypothermia with total absence of circulation for spinal cord protection during surgery on the thoracic aorta

A 53-yearold man with a dissecting aneurysm of Stanford's type-B or Crawford's type I measuring 8.5 cm in diameter underwent replacement of the distal descending aorta and the thoracic aorta using techniques for spinal cord protection involving deep hypothermia at 17 degrees C and lasting 38 minutes with total absence of circulation. A subarachnoid catheter was inserted at the lumbar level to monitor spinal fluid pressure as well as to provide drainage if pressure exceeded 10 mm Hg. During surgery 60 ml was drained, followed by 95 ml after surgery on the same day and 325, 262 and 169 ml on the following three days.No signs of neurological deficit were observed during the postoperative period. Clinical course was good until hypovolemic shock developed 27 days after the operation due to upper digestive tract bleeding caused by two duodenal ulcers that perforated the gastroduodenal artery. Emergency antrectomy and vagotomy were performed. The patient died from multiple organ failure.Spinal cord injury continues to be one of the most feared complications after excision of thoracic and thoracoabdominal aorta aneurysm. Currently, various ways of protecting the spinal cord are practiced, including drainage of cerebrospinal fluid, partial bypass of the femoral artery, intercostal artery reimplantation, drug therapy and local spinal and/or systemic hypothermia. These methods, together with shorter clamping time have achieved a reduction in the incidence of spinal cord injuries.     

Aortocava fistula: experience with five patients.

Combined injuries of the aorta and inferior vena cava are rare. Mortality is over 70%, primarily from exsanguinating hemorrhage. Post-traumatic aortocava fistula can develop in survivors, who present in the postoperative period with manifestations of high output heart failure. This is a retrospective review of five male patients, age from 9 to 39 years, with aortocava fistulas that were referred with congestive heart failure, 2 days to 6 months after abdominal penetrating injuries. They had undergone surgery at another hospital and several organ injuries were treated. Retroperitoneal hematomas were not seen or were seen and left undisturbed. Four patients received a gunshot injury, had the fistula at the infrarenal level, and survived surgical repair. In one of the survivors, a left popliteal artery bullet embolism also occurred and was treated. Another patient sustained a thoracoabdominal stab injury and an aortocava fistula developed at the suprarenal level; he was in severe congestive heart failure and died during surgery. There are very few reports on this sequelae of vascular injuries at the abdominal level. Patients with aortic and cava injuries have a high mortality rate and arteriovenous fistula may develop with communicating pseudoaneurysms. If high output heart failure develops in a patient with a history of abdominal penetrating injury, an arteriovenous fistula must be suspected and arteriography will disclose the location of the fistula. Surgical treatment is necessary to prevent further heart damage. In the future endovascular procedures may have a role in the management of these difficult conditions.     

Neurobehavioural and cognitive profile of traumatic brain injury patients at risk for depression and suicide

The possibility that patients who have suffered a traumatic brain injury will commit suicide is high, and in many cases clinicians tend to underestimate this possibility. In this study, 39 consecutive patients are studied through a Rorschach technique more than 1.5 years after their hospital discharge. The data show that 48.6% of the patients fulfil the criteria that classifies them as depressive, and, of these, 65% are at clinical risk to commit suicide (33.3% of the total of TBI patients); 25.6% have not met the criteria of depression or suicidal tendencies, and another 25.6% show very low suicide tendency scores. Only 15.6% of the total patients presented only depression without risk of suicide. The neurobehavioural and cognitive profile of the TBI suicide-prone patient shows an emotional person with cognitive difficulties in how they interpret reality, the person tries to understand what is happening around them, but is unable to cope. They show concrete thoughts, although they have difficulties solving problems and have few intellectual resources to cope with their surroundings. They do not know how to distance themselves from the emotional aspects of situations.     

Methylene blue as a successful treatment alternative for pharmacologically induced priapism

OBJECTIVE: Priapism is defined as prolonged and persistent erection of the penis without sexual stimulation. Etiologies of this condition are numerous. Treatment of priapism varies from a conservative medical to a drastic surgical approach. Recent findings indicate methylene blue (MB), a guanylate cyclase inhibitor, to be a potential inhibitor of endothelial-mediated cavernous relaxation. This prompted us to assess the feasibility, use and effectiveness of MB in the treatment of priapism. METHODS: 12 patients were treated for priapism. Etiologies were: 10 drug-mediated (PGE(1) or papaverine/phentolamine mixture) after corpus cavernosum injection therapy (CCIT); 1 leukemia-induced, and 1 idiopathic high-flow priapism. The age range for all patients was 13-67 years, the average duration of priapism was 5.5 h after CCIT. MB was administered after blood aspiration of the corpora cavernosa. 5 ml of MB was injected intracavernously (i.c.) and left for 5 min. MB was then aspirated and the penis compressed for an additional 5 min. RESULTS: All patients with CCIT-induced priapism were cured with MB alone. The 2 patients who did not respond to MB underwent i.c. phenylephrine administration and embolization of the pudendal artery, respectively. The etiology and duration of priapism were the strongest predictors for success with i.c. administered MB. The primary side effects were a transient burning sensation and blue discoloration of the penis on injection of MB. The initial baseline erectile status was restored in all patients cured by MB. CONCLUSION: These results confirm that MB is a safe and highly effective treatment agent for short-term pharmacologically induced priapism. The application of MB shows virtually no significant side effects compared to the systemic and local complications induced by alpha-adrenergic agonists.     

Prevalence of herpesvirus DNA in MS patients and healthy blood donors

OBJECTIVES: The aim of this study is to determine the DNA prevalence of different members of Herpesviridae in multiple sclerosis (MS) patients and to describe the possible effect of beta-interferon treatment on such prevalence. MATERIAL AND METHODS: With a nested polymerase chain reaction (PCR) assay we have studied the DNA of the peripheral blood mononuclear cells (PBMCs) of 204 whole blood samples, [102 from patients with relapsing-remitting MS (RRMS), of which 62 were treated with beta-interferon, and 102 from healthy blood donors]. RESULTS: We only found a statistically significant difference for human herpesvirus type 6 (HHV-6) DNA prevalence (P < 0.0001): HHV-6 is 2.26 times more frequent in MS patients than in healthy donors. There was no difference in the HHV-6 prevalence between beta-interferon treated and untreated patients. CONCLUSION: 1. Among the herpesviruses, HHV-6 was the only one showing altered prevalence. This either indicates that HHV-6 is involved in the pathogenesis of MS, or it simply indicates that MS influences latency or reactivation of HHV-6 without any direct involvement of HHV-6 in the disease process of MS. 2. Treatment with beta-interferon does not make a difference on the DNA prevalence of the herpesviruses studied in our MS patients.     

The role of hypnosis in the detection of psychogenic seizures

In this preliminary clinical investigation, hypnosis was used in the differential diagnosis of epileptic versus psychogenic seizures (PS). Eight patients with a clinical profile suggesting the presence of PS were given a hypnotic suggestion in which they had to go back in time to the exact moment of their last seizure. They were then asked to concentrate their attention on any unusual feeling or bodily sensation. All 8 patients presented a PS during the age regression protocol. In 6 cases, independent testimony from family members corroborated the morphological similarity of the induced attack and the ones presented in their natural environment. Also, the seizures ended abruptly after a command was given to stop them. A control group of 5 epileptic subjects did not present any signs of discomfort or seizure behavior during the hypnotic protocol. It is argued that a simple procedure as the one described in this investigation can be useful as a diagnostic tool in the differentiation of epileptic from PS attacks.