Operating room briefings and wrong-site surgery

BACKGROUND: Wrong-site surgery can be a catastrophic event for a patient, caregiver, and institution. Although communication breakdowns have been identified as the leading cause of wrong-site surgery, the efficacy of preventive strategies remains unknown. This study evaluated the impact of operating room briefings on coordination of care and risk for wrong-site surgery. STUDY DESIGN: We administered a case-based version of the Safety Attitudes Questionnaire (SAQ) to operating room (OR) staff at an academic medical center, before and after initiation of an OR briefing program. Items questioned overall coordination and awareness of the surgical site. Response options ranged from 1 (disagree strongly) to 5 (agree strongly). MANOVA was used to compare caregiver assessments before and after the implementation of briefings, and the percentage of OR staff agreeing or disagreeing with each question was reported. RESULTS: The prebriefing response rate was 85% (306 of 360 respondents), and the postbriefing response rate was 75% (116 of 154). Respondents included surgeons (34.9%), anesthesiologists (14.0%), and nurses (44.4%). Briefings were associated with caregiver perceptions of reduced risk for wrong-site surgery and improved collaboration [F (6,390)=10.15, p < 0.001]. Operating room caregiver assessments of briefing and wrong-site surgery issues improved for 5 of 6 items, eg, "Surgery and anesthesia worked together as a well-coordinated team" (67.9% agreed prebriefing, 91.5% agreed postbriefing, p < 0.0001), and "A preoperative discussion increased my awareness of the surgical site and side being operated on" (52.4% agreed prebriefing, 64.4% agreed postbriefing, p < 0.001). CONCLUSIONS: OR briefings significantly reduce perceived risk for wrong-site surgery and improve perceived collaboration among OR personnel.     

Acquired erythroderma in adults: a clinical and prognostic study

Background Erythroderma is a severe syndrome and prognostic studies are rare in the literature. Objectives Through a retrospective study of erythroderma in adults, we have analysed epidemiological and clinical data and precised the relevant aetiologies and survival in our patients. Methods This study was performed at the Department of Dermatology of Charles Nicolle Hospital of Tunis (1995–2007) including 82 cases of acquired erythroderma (>16 years). We have recorded epidemio‐clinical, biological and histological data, treatment and outcome. Clinical–histological correlation was analysed [kappa coefficient (κ)]. Follow‐up time and disease‐free survival time were calculated as were Kaplan–Meier estimates of overall survival and relapse‐free survival for some aetiologies. Results Erythroderma represented 0.44‰ of all dermatoses with an age of 55.13 ± 18.16 and no sex predilection. Psoriasis was the predominant aetiology (32.9%) with a median duration of 6.75 years and previous one or more episodes of erythroderma. Psoriasis was significantly associated with pruritus (P = 0.0001), pachyonychia (P = 0.00001), palmoplantar keratoderma (P = 0.0001) and hypereosinophilia (P = 0.008). The latter is then not specific for drug induced erythroderma (P = 0.004). Carbamazepine (27.8%) and penicillin (22.2%) were the most implicated drugs. Positive Clinical–histological correlation was found in 77% of cases (κ = 0.753). Relapse was seen in all aetiologies, but drug reactions and had occurred in the first 3 years in 90% of them. Mortality rate was 11.3 per 1000 patients‐years. Conclusions Our study illustrates the severity of erythroderma. It alters heavily the quality of life of patients which is initially altered by the pre‐existent dermatosis. It may be life threatening as mortality rate is high.     

Subcutaneous zygomycosis: report of 10 cases from two institutions in North India

Background Subcutaneous zygomycosis is an uncommon condition observed in tropics. Few series have been published, particularly from the northern regions of India. Objectives The aim of this study was to describe clinical, investigative and therapeutic details in subcutaneous zygomycosis observed in two teaching hospitals in Delhi. Patients and methods Ten patients seen over a period of 10 years (1999–2009) form the material for this report. Results There were four children and six adults. In four children, the presentation was a subcutaneous localized mass or gradually spreading plaque. In the others, it was observed over nasal region of face, spreading inward into mucosal sites and paranasal sinuses, and outward to the contiguous areas. Regional lymphadenopathy was present in two with facial lesions. Majority showed a granulomatous infiltrate with admixture of other cells, mainly eosinophils. Aseptate or poorly septate hyphae were observed in seven. In one patient in whom no hyphae were observed, there was dense perivascular inflammation. Organisms were cultured from four patients, Basidiobolus ranarum in two and Syncephalastrum racemosum in two. The main therapy used was a saturated solution of potassium iodide (KI). Four received only KI of which two attained cure after 3 months and 9 months respectively, and the other two showed signs of regression. In one boy subsidence was associated with reduced circumference of thigh. Ketoconazole or itraconazole was given with KI to hasten regression when response was slow or there were side‐effects to KI. Conclusion Awareness and early recognition will prevent disfigurement produced by advanced disease, misdiagnosis and unnecessary surgical intervention.     

An external audit of laparoscopic cholecystectomy performed in medical treatment facilities of the department of Defense.

OBJECTIVE: This study provided an objective survey by an outside auditing group of a large, complete patient population undergoing laparoscopic cholecystectomies, determined the frequency of complications, especially bile duct injuries, and presented a system for classifying and comparing the severity of bile duct injuries. SUMMARY BACKGROUND DATA: This is the first study of laparoscopic cholecystectomy to encompass a large and complete patient population and to be based on objectively collected data rather than self-reported data. The Civilian External Peer Review Program (CEPRP) of the Department of Defense health care system conducted a retrospective study of 5642 patients who underwent laparoscopic cholecystectomies at 89 military medical treatment facilities from July 1990 through May 1992. METHODS: The study sample consisted of the complete records of 5607 (99.38%) of the 5642 laparoscopic cholecystectomy patients. RESULTS: Of the sample, 6.87% of patients experienced complications within 30 days of surgery, 0.57% sustained bile duct injuries, and 0.5% sustained bowel injuries. Among 5154 patients whose procedures were completed laparoscopically, 5.47% experienced complications. Laparoscopic procedures were converted to open cholecystectomies in 8.08% of cases. Intraoperative cholangiograms were attempted in 46.5% of cases and completed in 80.59% of those attempts. There were no intraoperative deaths; 0.04% of the patients died within 30 days of surgery. CONCLUSIONS: The frequency of complications found in this study is comparable to the frequency of complications reported in recent large civilian studies and earlier, smaller studies. The authors present a system for classifying bile duct injuries, which is designed to standardize references to such injuries and allow for accurate comparison of bile duct injuries in the future.     

In-hospital and mid-term adverse clinical outcomes of a direct stenting strategy versus stenting after predilatation for the treatment of coronary artery lesions

Background

Direct stenting without balloon dilatation may reduce procedural costs and duration, and hypothetically, the restenosis rate. This study was designed to compare the in-hospital and long-term outcomes of direct stenting (DS) versus stenting after pre-dilatation (PS) in our routine clinical practice.

Methods

The 1 603 patients treated with stenting for single coronary lesions were enrolled into a prospective registry. Patients with acute myocardial infarction (MI) within the preceding 48 hours, and those with highly calcified lesions, total occlusions, or a lesion in a saphenous graft were excluded. The baseline, angiographic and procedural data, inhospital outcomes and follow-up data were recorded in our database and analysed with appropriate statistical methods.

Results

Eight hundred and fifty-seven patients (53.5%) were treated with DS and 746 (46.5%) underwent PS. In the DS group, lesions were shorter in length, larger in diameter and had lower pre-procedural diameter stenosis. Type C and diffuse lesions and drug-eluting stents were found less often (p < 0.001). With univariate analysis, dissection and non-Q-wave MI occurred less frequently in this group (0.2 and 0.6% vs 3.9 and 2.1%, p < 0.001 and p = 0.01, respectively). However, the cumulative major adverse cardiac events (MACE) did not differ significantly (4.9 vs 4.6%, p = 0.79). With multivariate analysis, direct stenting reduced the risk of dissection (OR = 0.07, 95% CI: 0.01–0.33, but neither the cumulative endpoint of MACE (OR = 1.1, 95% CI = 0.58–2.11, p = 0.7) nor its constructing components were different between the groups.

Conclusions

Direct stenting in the real world has at least similar long-term outcomes in patients treated with stenting after pre-dilatation, and is associated with lower dissection rates.