Is the knowledge of contact force beneficial in pulmonary vein antrum isolation?

Objective: To investigate the effect of the operator knowing the real-time contact force (CF) on the efficacy of pulmonary vein antrum isolation (PVAI).

Methods: Fifty patients with paroxysmal atrial fibrillation (AF) or short lasting persistent AF were randomized to CF guided PVAI (n?=?25) or conventional PVAI (n?=?25). In the CF guided group, CF between 10 and 40?g was aimed at. Efficacy of PVAI was measured as reduction in AF burden (AFB) and time to AF recurrence detected by implantable cardiac monitor (ICM), inserted three months before PVAI. Blanking period was three months and follow-up 12 months.

Results: All pulmonary veins were isolated in the CF guided group and all but one in the conventional group. Mean CF was 25?g in the CF guided group and 24?g in the conventional group (p?=?0.75). Compared to pre-ablation, median [IQR] relative reduction in AFB 3–12 months after ablation was 100 [99–100]% in the CF guided group (p?p?p?=?0.09). Nine patients (36%) had AF recurrence in the CF guided group and 13 (52%) in the conventional group (p?=?0.21, log-rank test). CF differed between operators. When adjusted for operator by regression analysis, patients without recurrent AF had lower proportion of ablation time with CF <10?g than recurrent patients (p?=?0.034). No complications occurred.

Conclusions: Operator knowledge of real-time CF had no significant effect on AFB reduction or time to AF recurrence. Larger trials should be done to study benefit of real-time CF.     

Frequency of blood lactate elevation following esophagectomy and its association to postoperative complications

Background

Esophagectomy is a major surgical intervention and a cornerstone in the treatment of esophageal cancer. There is clinical experience that blood lactate concentration often is elevated in the period following esophagectomy, but the incidence and clinical consequences are sparsely studied.

Methods

We extracted data from all patients undergoing esophagectomy at Karolinska University Hospital 2016–2018, n = 153. Most were performed with minimally invasive technique, n = 130. Blood lactate values directly after surgery, highest value during the first night, and morning level on postoperative day one were recorded. Primary outcome was hospital length of stay and secondary outcome was a composite of postoperative infection, additional surgery, or intensive care during the hospital stay. Development of anastomotic leak was analyzed separately.

Results

Postoperative hyperlactatemia was common as 93% of patients had peak lactate concentration >1.6 mmol/L and 27% >3.5 mmol/L in the first night following operation. Median hospital length of stay was 14 days. Blood lactate showed a weak correlation to hospital stay and intensive care the morning following surgery, but not at arrival to postoperative ward. There were no statistical differences between those with and without anastomotic leak at any of the time points. Elevated lactate in the first 12–16 h postoperatively was related to surgical factors (open technique, surgery time, and perioperative bleeding) but not to patient related factors (ASA-class, Charlson comorbidity index, sex, age) or cumulative fluid balance.

Conclusion

In conclusion, elevated blood lactate in the immediate time following esophagectomy showed a weak association to intensive care and length of stay but not anastomotic leak.     

Calcineurin inhibitor sparing in renal transplantation

Although calcineurin inhibitors (CNIs) are effective at preventing acute rejection, their long-term use is associated with nephrotoxicity that may compromise long-term renal allograft survival. Consequently, there is considerable interest in identifying immunosuppressive regimens that permit reduced exposure to CNIs while maintaining adequate immunosuppression. Introducing such strategies early after transplantation may mean that the development of CNI-associated nephrotoxicity could be minimized or prevented. Several CNI-sparing regimens have shown at least comparable efficacy with standard-dose CNI regimens. In particular, a regimen of mycophenolate mofetil (MMF), corticosteroids, interleukin-2 receptor antagonist induction, and low-dose tacrolimus from the time of transplantation provided superior renal function and a lower acute rejection rate than the same regimen but with low-dose cyclosporine or low-dose sirolimus, or standard-dose cyclosporine, MMF, and corticosteroids. The use of low-dose cyclosporine does not seem to eliminate nephrotoxicity in de novo renal transplant recipients. The early withdrawal of CNIs from MMF-based regimens generally improves renal function but has been associated with an increased risk of acute rejection, in particular when the levels of mycophenolic acid were not adjusted to maintain the same total level of immunosuppression. Research aiming to achieve the "best" balance of efficacy and toxicity of available immunosuppressive regimens continues.     

Prevention of severe contractures might replace multilevel surgery in cerebral palsy: results of a population-based health care programme and new techniques to reduce spasticity

During the 1990s three new techniques to reduce spasticity and dystonia in children with cerebral palsy (CP) were introduced in southern Sweden: selective dorsal rhizotomy, continuous intrathecal baclofen infusion and botulinum toxin treatment. In 1994 a CP register and a health care programme, aimed to prevent hip dislocation and severe contractures, were initiated in the area. The total population of children with CP born 1990-1991, 1992-1993 and 1994-1995 was evaluated and compared at 8 years of age. In non-ambulant children the passive range of motion in hip, knee and ankle improved significantly from the first to the later age groups. Ambulant children had similar range of motion in the three age groups, with almost no severe contractures. The proportion of children treated with orthopaedic surgery for contracture or skeletal torsion deformity decreased from 40 to 15% (P = 0.0019). One-fifth of the children with spastic diplegia had been treated with selective dorsal rhizotomy. One-third of the children born 1994-1995 had been treated with botulinum toxin before 8 years of age. With early treatment of spasticity, early non-operative treatment of contracture and prevention of hip dislocation, the need for orthopaedic surgery for contracture or torsion deformity is reduced, and the need for multilevel procedures seems to be eliminated.     

Large femoral bone loss after hip revision using the uncemented proximally porous-coated Bi-Metric prosthesis: 22 hips followed for a mean of 6 years

Background and purpose Periprosthetic bone loss after uncemented femoral hip revision is a matter of concern. We have used a proximally porous- and hydroxyapatite-coated prosthesis (Bi-Metric) in revision since 1989 and now we report the bone changes. This prosthesis is intended to distribute the forces more evenly and to avoid proximal femoral unloading.Methods 22 patients were unilaterally reoperated because of aseptic loosening. Only patients with a healthy contralateral hip were included. Mean age at revision was 69 (55–80) years. Bone defects were graded by Gustilo-Pasternak and Endo-Klinik classifications. Clinical assessment was performed with Harris hip score. We used radiographs and dual-energy X-ray absorptiometry to evaluate migration, femoral remodeling, and bone mineral density after 72 (30–158) months.Results The mean Harris hip score was 74 (30–100) points at follow-up. Mild thigh discomfort was present in 1 patient and moderate thigh pain in 3 patients. There was no loosening or subsidence. Osteolysis seen at revision had diminished in 19 of the 22 hips at follow-up. We noted a large reduction in bone mineral density. It was most pronounced in Gruen regions 1, 2, 6, and 7.Interpretation Revision with this stem is a reliable procedure; however, we noted a large degree of proximal bone loss that could lead to later mechanical complications or fractures.     

Cost consequences due to reduced ulcer healing times – analyses based on the Swedish Registry of Ulcer Treatment

Resource use and costs for topical treatment of hard‐to‐heal ulcers based on data from the Swedish Registry of Ulcer Treatment (RUT) were analysed in patients recorded in RUT as having healed between 2009 and 2012, in order to estimate potential cost savings from reductions in frequency of dressing changes and healing times. RUT is used to capture areas of improvement in ulcer care and to enable structured wound management by registering patients with hard‐to‐heal leg, foot and pressure ulcers. Patients included in the registry are treated in primary care, community care, private care, and inpatient hospital care. Cost calculations were based on resource use data on healing time and frequency of dressing changes in Swedish patients with hard‐to‐heal ulcers who healed between 2009 and 2012. Per‐patient treatment costs decreased from SEK38 223 in 2009 to SEK20 496 in 2012, mainly because of shorter healing times. Frequency of dressing changes was essentially the same during these years, varying from 1·4 to 1·6 per week. The total healing time was reduced by 38%. Treatment costs for the management of hard‐to‐heal ulcers can be reduced with well‐developed treatment strategies resulting in shortened healing times as shown in RUT.     

Use of a virtual reality, real-time, simulation model for the training of urologists in transurethral resection of the prostate

OBJECTIVE: There is a growing need to develop surgical skills outside the operating theatre. In this study we describe the development of a virtual reality training system for practising transurethral resection of the prostate (TURP). MATERIAL AND METHODS: A face validity study was performed using a questionnaire sent to 28 experienced urologists to find out the ideal characteristics of a simulated TURP. Based on the comments a simulator was constructed and a content validity study was then performed in which nine experienced urologists tested the simulator and answered a second questionnaire. After corrections to the simulator, a basic construct validity test was performed. RESULTS: We have developed a computer-based simulator based on the requirements listed by 17 urologists. It consists of a modified resectoscope connected to a haptic device and supported by a frame. The software provides a virtual view of the prostatic lumen and resectoscope tip, a haptic rendering that generates force feedback and a simulation module that computes the information from the haptic device, resectoscope fluid tap and handle and the foot pedals. The software also simulates bleeding, absorption of irrigation fluid and pressure gradients. Variables are measured and presented in a result file after each "operation". Nine experienced urologists performed a content validity study and changes were made accordingly. A basic construct validity test performed by seven inexperienced students showed a significant improvement in performance after they each performed six simulated procedures. CONCLUSION: We have developed a simulator that may be used to practise TURP and which meets most of the demands raised in a face validity study. A basic construct validity test showed improved performance after repeated practice in the simulated environment.     

Why are patients still in hospital after fast-track,unilateral unicompartmental knee arthroplasty

Background and purpose — Previous studies have investigated risk factors related to prolonged length of stay following total knee arthroplasty (TKA), but little is known about specific factors resulting in continued hospitalization within the 1st postoperative days after unicompartmental knee arthroplasty (UKA). We investigated what specific factors prevent patients from being discharged on the day of surgery (DOS) and the first postoperative day (POD-1) following primary UKA in a fast-track setting.Patients and methods — We prospectively collected data on 100 consecutive and unselected medial UKA patients operated from December 2017 to May 2019. All patients were operated in a standardized fast-track setup with functional discharge criteria continuously evaluated from DOS and until discharge.Results — Median length of stay for the entire cohort was 1 day. 22% and 78% of all patients were discharged on DOS and POD-1, respectively. Lack of mobilization and pain separately delayed discharge in respectively 78% and 24% of patients on DOS. The main reasons for lack of mobilization were motor blockade (37%) and logistical factors (26%). For patients placed 1st or 2nd on the operating list, we estimate that the same-day discharge rate would increase to 55% and 40% respectively, assuming that pain and mobilization were successfully managed.Interpretation — One-fifth of unselected UKA patients operated in a standardized fast-track setup were discharged on DOS. Pain and lack of mobilization were the major reasons for continued hospitalization within the initial postoperative 24–48 hours. Strategies aimed at decreasing length of stay after UKA should strive to improve analgesia and postoperative mobilization.

The number of unicompartmental knee arthroplasties (UKAs) performed in patients suffering from osteoarthritis has steadily increased. UKA has the potential benefit of not only improving patient-reported outcomes, but also to reduce morbidity, complications, and cost (Liddle et al. 2014, Beard et al. 2019). In the United Kingdom, 9% of all primary knee arthroplasties performed in 2018 were UKAs while this number is as high as 20% in Denmark (Danish Knee Arthroplasty Register 2019, National Joint Registry for England 2019).UKA is effective and safe when performed in a fast-track setting and outpatient UKA in selected patients has been shown to be feasible and safe (Munk et al. 2012, Cross and Berger 2014, Bovonratwet et al. 2017, Kort et al. 2017). However, the number of patients actually being discharged on DOS that were scheduled for outpatient surgery differs between studies and ranges from 37% to 100% (Gondusky et al. 2014, Bradley et al. 2017, Jenkins et al. 2019, Rytter et al. 2019).Studies have shown an association between increased length of stay (LOS) and an increase in both complication and readmission rates (Otero et al. 2016). In order to reduce LOS and increase patient satisfaction, a focus on successfully managing well-defined discharge criteria in a multimodal approach is imperative (Husted et al. 2008, Cross and Berger 2014). In addition, decreased LOS and outpatient procedures are associated with financial benefits, which have further fueled interest in decreasing LOS and ensuring DOS discharged following UKA (Bradley et al. 2017). Finally, decreased LOS is also shown to increase patient satisfaction levels (Reilly et al. 2005, Richter and Diduch 2017).A study has been conducted to explore reasons for prolonged hospitalization in a fast-track setting following TKA (Husted et al. 2011). However, in spite of a growing number of UKAs performed each year, no study explicitly exploring reasons for prolonged hospitalization beyond DOS following UKA in a fast-track setting has been published at present.Therefore, we investigated reasons for continued hospitalization beyond DOS following UKA in a fast-track setting.     

The Third World Integrative Medicine Congress Abstracts (Excerption)

The 3rd World Integrative Medicine Congress (3rd WIMCO) was held on September 22-24, 2007 in Guangzhou, China. The Congress has showed the academic achievements of integrative medicine in the recent five years covering a wide range of fields, such as basic and experimental research; clinical research; theory, education and management research; new drug research and development; and application of evidence-based medicine.