Criteria for Selective Utilization of the Intensive Care Unit following Carotid Endarterectomy

n = 62, p < 0.05), emergent CEA (n= 2, p= 0.01), and need for postoperative anticoagulation (n= 2, p= 0.01). Only 56 (15%) of patients had indications for ICU admission, 57 (16%) would have been admitted to an EKG-monitored nursing unit, and 252 (69%) would have been admitted to a standard nursing unit. Immediate admission to the ICU after CEA is indicated for patients undergoing emergent CEA, those requiring anticoagulation postoperatively, those with intraoperative stroke or major cardiac complication, and possibly those with chronic renal failure. All other patients should be admitted to the RR. Patients experiencing stroke, major cardiac events, significant wound hemorrhage, or reintubation in the RR, and those requiring vasoactive medication more than 3 hours after surgery should be transferred to the ICU. Patients with indications of cardiac disease within 6 months prior to CEA but no indications for ICU admission may be discharged from the RR to an EKG monitored unit. All others may be discharged to a standard nursing unit.     

Nationwide survey on the use of image-guided functional endoscopic sinus surgery.

OBJECTIVE: To evaluate impressions and usage of sinus surgery image-guided surgical (IGS) systems by ENT surgeons in the United States. STUDY DESIGN AND SETTING: A survey was mailed to selected practicing ENT physicians, investigating regional information, practice type, IGS usage patterns, perceived benefits and limitations, and usage of the 61795 surgery code. RESULTS: Seventy-three percent of respondents use IGS. Nonusers respond that it provides no benefit or is too expensive. Eighty percent of respondents replied that IGS may allow for increased safety in certain procedures. Most users attempt reimbursement with the 61795 code. CONCLUSION: IGS usage is increasing but appears to be perceived as expensive and nonbeneficial in certain situations. Most respondents, however, felt that IGS may lead to safer surgery in certain situations, including revision and frontal procedures. Several factors appear to limit routine use including ease of use, technical setup, code reimbursement, and initial purchase costs. SIGNIFICANCE: IGS use appears to be increasing. The most frequent users appear to agree with the previously issued AAO-HNS guidelines regarding appropriate indications. Expanded use may depend on ease of use, reimbursement, and affordability. EBM rating: D-5.     

Spinal lipomas in childhood]

Spinal lipomas account for 5% of the tumors of the spinal cord, frequently present already at birth. Most commonly they are associated with forms of dysraphism, but lipomas without bony involvement are considered dysembriogenetic lesions too. Children with lipoma frequently have intact neurological functions, but may become symptomatic later on. Diagnosis is possible also in neurologically intact patients because of skin lesions or subcutaneous masses. Many surgeons suggest early surgery to prevent injury to neural structures from traction due to cord tethering; others prefer to wait for the rise of any symptom before considering surgery. However, neurological recovery after surgery is rarely observed, and, when present, is always partial; the primary goal of surgery is to stop the clinical progression through the detethering of the cord.     

An algorithm for the treatment of pain in advanced cancer

An algorithm is presented that has been developed over the past three years to provide pain relief in advanced cancer. The hospital records of 92 patients were reviewed to evaluate the validity of the algorithm. The algorithm is as follows: the 24 hour oral consumption of opioids was converted to sustained release morphine. If ineffective usually over 360 mg daily the total 24 hour oral dose was divided by 6 to convert to I.V. If this was ineffective, usually over 10 mg/hr of morphine, the intravenous dose was divided by 10 and infused epidurally. Local anesthetic was added for plexus involvement. After four days, the patient was weaned from local anesthetic solution. If sharp pain or pain to movement persisted, 6% phenol in 1 to 2 ml aliquots was injected every 8-12 hours to a total of 5-8 ml. While the conversion from intravenous to epidural morphine was 10:1 that from epidural to intravenous was only 1:3. Intravenous dose converts directly to the subcutaneous. The conversion from intravenous to oral is 1:3. There view showed that the dosages at which the conversions were made varied considerably. The reasons for the wide variation are presented. In summary the algorithm is a good practical guide for treatment of cancer pain.     

Use of a 2.0-mm locking plate/screw system for mandibular fracture surgery.

PURPOSE: In this study, we examined the use of a 2.0-mm locking bone plate/screw system in mandibular surgery. PATIENTS AND METHODS: All patients who were treated with a 2.0-mm locking bone plate/screw system during an 8-month period for fractures of the mandible or other defects of the mandible were prospectively studied. Ease of use of locking plate/screw system, characteristics of the fractures and defects, and complications were tabulated. RESULTS: A total of 80 fractures in 59 patients were treated with the 2.0-mm locking plate/screw system. One hundred two 2.0-mm locking plates were applied to the 80 fractures; 58 fractures received 1 plate and 22 fractures received 2 plates. There were no intraoperative difficulties associated with their application. Fracture reductions were considered to be excellent in all cases. At the latest follow-up, all fractures had healed, but 2 patients had slight malocclusions. Six patients developed postsurgical infections. Only 1 patient required hospitalization for treatment of the infection; all others were managed in the outpatient clinic. Four patients required removal of their plates for varying reasons. CONCLUSIONS: The use of a 2.0-mm locking plate/screw system was found to be simple and to provide sound fixation in all cases.     

Radical cystectomy after coronary artery bypass graft

Nine patients have undergone single-stage radical cystectomy and ileal conduit urinary diversion two to fifty-one months after coronary artery bypass procedures. Two patients presenting with intractable angina at the time their malignant disease was being evaluated required bypass surgery before cystectomy could be undertaken. No significant cardiac morbidity occurred postoperatively, and all remain alive without evidence of malignant disease.     

Intussesception after jejunoileal bypass as diagnosed by ultrasound

Eighty patients who had undergone jejunoileal bypass for morbid obesity were examined by ultrasound at their routine follow-up visits to the clinic. Ultrasonographic evidence of intestinal intussusception was found in 15 patients (19%). Two of these patients were asymptomatic. Ultrasonographic findings were confirmed by operation in 6 patients (5 with intussusception, 1 negative).