Surgical treatment for genital prolapse in the very elderly: a continuous series of 43 patients

OBJECTIVES: To evaluate surgical treatment for genital prolapse in patients over the age of 75. PATIENTS AND METHODS: This is a continuous retrospective series of 43 patients operated for genital prolapse between March 2001 and October 2006. Surgical outcomes in terms of anatomical correction as well as urological and proctological results were analyzed. Morbidity and mortality studies were carried out. A satisfaction and quality of life assessment was carried out among 19 patients (44%) by an independent researcher at a distance from the intervention. RESULTS: Morbidity attributable to the surgery was minimal, with no cases of mortality. Mean hospital stay was five days. Anatomical correction was good without troubling urological or proctological consequences. Two surgical options were compared: surgery with vaginal occlusion in 23 patients (53.5%) and vaginal conserving surgery in 20 patients (46.5%). Surgical outcomes and morbidity were equivalent in the two groups. Seventy-nine percent of patients surveyed at a distance from the interventions estimated that the procedure had improved their quality of life. DISCUSSION AND CONCLUSION: Surgical treatment for genital prolapse in the very elderly population is a reasonable therapeutic option. Postoperative evaluation demonstrates good anatomical as well as functional results in the majority of cases.     

Prolonged sedation requiring mechanical ventilation and continuous flumazenil infusion after routine doses of clorazepam for alcohol withdrawal syndrome

We report the cases of two patients who developed prolonged sedation after routine doses of clorazepam for alcohol withdrawal syndrome. They required prolonged mechanical ventilation (10 days for both patients) followed by continuous flumazenil infusion (16 days for one patient and 3 days for the other) to avoid reintubation. In the two patients, nordazepam accumulation (main active metabolite of clorazepam) was demonstrated as the cause of the coma. This accumulation could be attributed, in one case, to impaired hepatic cytochrome P 450 3A4 activity. Caution is required when prescribing benzodiazepines to alcoholic patients and the use of benzodiazepine which do not undergo hepatic oxidation by cytochrome P 450 such as oxazepam or lorazepam is suggested. Received: 9 February 1999 Final revision received: 7 October 1999 Accepted: 13 October 1999     

Emergency-to-Elective Surgery Ratio: A Global Indicator of Access to Surgical Care

Background

Surgical care is essential to health systems but remains a challenge for low- and middle-income countries (LMICs). Current metrics to assess access and delivery of surgical care focus on the structural components of surgery and are not readily applicable to all settings. This study assesses a new metric for surgical care access and delivery, the ratio of emergent surgery to elective surgery (Ee ratio), which represents the number of emergency surgeries performed for every 100 elective surgeries.

Methods

A systematic search of PubMed and Medline was conducted for studies describing surgical volume and acuity published between 2006 and 2016. The relationship between Ee ratio and three national indicators (gross domestic product, per capital healthcare spending, and physician density) was analyzed using weighted Pearson correlation coefficients (r _w) and linear regression models.

Results

A total of 29 studies with 33 datasets were included for analyses. The median Ee ratio was 14.6 (IQR 5.5–62.6), with a range from 1.6 to 557.4. For countries in sub-Saharan Africa the median value was 62.6 (IQR 17.8–111.0), compared to 9.4 (IQR 3.4–13.4) for the United States and 5.5 (IQR 4.4–10.1) for European countries. In multivariable linear regression, the per capita healthcare spending was inversely associated with the Ee ratio, with a 63-point decrease in the Ee ratio for each 1 point increase in the log of the per capita healthcare spending (regression coefficient β = ?63.2; 95% CI ?119.6 to ?6.9; P = 0.036).

Conclusions

The Ee ratio appears to be a simple and valid indicator of access to available surgical care. Global health efforts may focus on investment in low-resource settings to improve access to available surgical care.

     

Bedside detection of retained tracheobronchial secretions in patients receiving mechanical ventilation: is it time for tracheal suctioning?

OBJECTIVE: To identify parameters that indicate retained secretions and the need for tracheal suctioning (TS) in patients receiving mechanical ventilation (MV). DESIGN: Prospective observational study. SETTING: A 14-bed medical ICU in a 946-bed university hospital. PATIENTS: Sixty-six consecutive patients receiving MV. INTERVENTIONS: Two successive tracheal suctions, TS1 and TS2, performed at a 2-h interval as usual patient care. Retained secretions were considered significant if the volume of secretions removed by TS2 was > 0.5 mL. Measurements and results: Variations between TS1 and TS2 of pulse oximetric saturation (SpO(2)), peak inspiratory pressure (Ppeak), tidal volume (VT), and Ramsay score were compared between patients with TS2 < or = 0.5 mL (group 1; n = 27) and patients with TS2 > 0.5 mL (group 2; n = 39). The presence of a sawtooth pattern on flow-volume loop displayed on the monitor screen of the ventilator and of respiratory sounds heard over the trachea before TS2 were compared between the two groups. Variations of Ppeak, VT, SpO(2), and Ramsay score between TS1 and TS2 did not differ between the two groups. However, group 2 had a sawtooth pattern (82% vs 29.6%; p = 0.0001) and respiratory sounds (66.6% vs. 25.9%; p = 0. 001) more frequently than group 1 before TS2. For the sawtooth pattern, the likelihood ratio (LR) of a positive test was 2.70 and the LR of a negative test was 0.25, while for respiratory sounds it was 2.50 and 0.45, respectively. When the presence of a sawtooth pattern and of respiratory sounds was combined, the LR of a positive test rose to 14.7 and the LR of a negative test was 0.42. CONCLUSIONS: A sawtooth pattern and/or respiratory sounds over the trachea are good indicators of retained secretions in patients receiving MV and may indicate the need for TS. Conversely, the absence of a sawtooth pattern may rule out retained secretions.     

CKD-EPI equation: A suitable Glomerular Filtration Rate estimate for drug dosing in HIV-infected patients

Objectives

To evaluate concordance between glomerular filtration rate (GFR) estimates (Cockcroft and Gault, modification of diet in renal diseases, chronic kidney disease epidemiology study group equations) for drug dosing in HIV-infected patients.

Mycoplasma hominis,a Rare but True Cause of Infective Endocarditis

Mycoplasma spp. are rarely recognized agents of infective endocarditis. We report a case of Mycoplasma hominis prosthetic valve endocarditis diagnosed by 16S ribosomal DNA (rDNA) PCR and culture of valves in a 74-year-old man. We reviewed the literature and found only 8 other cases reported.     

Evaluation of routine tracheal extubation in children: inflating or suctioning technique?

We studied prospectively the effects of the technique of tracheal extubation on arterial haemoglobin oxygen saturation (SpO2) in 120 ASA I-III children, mean age 5.3 (range 0.25-16.9) yr. At completion of surgery, tracheal extubation was performed when spontaneous ventilation had resumed, children were fully awake and SpO2 was 99-100%. Children were allocated randomly to receive a single lung inflation manoeuvre with 100% oxygen before tracheal extubation (group I; n = 59) or to have the tracheal tube removed while applying suction through the tube (group S; n = 61). SpO2 was monitored during the first 5 min after tracheal extubation in the operating room. Supplementary oxygen was given if SpO2 decreased to less than 92%. The time between tracheal extubation and decrease in SpO2 to 92% (T92) was recorded. Children in group S required oxygen administration more frequently after tracheal extubation than those in group I (65.6% vs 45.8%; P = 0.04), and had a three-fold shortening of T92 (mean 25 (SD 19) s vs 85 (63) s; P = 0.0001). These effects were more pronounced in children less than 4 yr of age compared with older children. We conclude that tracheal extubation greatly impaired oxygenation and therefore administration of oxygen was appropriate. This impairment was more marked when suction was used, and in young children. Lung inflation with 100% oxygen before removal of the tracheal tube is advised before routine tracheal extubation in children.      

Prevalence of GBV-C/hepatitis G virus RNA and E2 antibody among subjects infected with human immunodeficiency virus type 1 after parenteral or sexual exposure.

GB virus C (GBV-C) or hepatitis G virus (HGV) is transmitted by the parenteral route but the importance of sexual transmission needs to be ascertained. GBV-C/HGV infections were investigated using RNA and E2-antibody detection methods in 80 subjects infected by the human immunodeficiency virus type 1 (HIV-1) divided into 4 groups of 20 individuals each according to their main risk factor for HIV-1 infection: blood product recipients (group 1), intravenous drug users (group 2), homosexuals (group 3), or heterosexual exposure (group 4). The overall prevalence of GBV-C/HGV infection was 66.3%. No significant difference was observed in GBV-C/ HGV prevalence among the four groups: 75, 75, 55, and 60% in groups 1, 2, 3, and 4, respectively. Hepatitis C virus (HCV) antibodies, used as a control for parenteral exposure, were found in 70% and 90% of the subjects in groups 1 and 2 versus only 15% and 20% of the subjects in groups 3 and 4, respectively (P< .001). Similarly, coinfections with GBV-C/HGV and HCV were significantly associated with the parenteral route (P <.001). These data emphasized the usefulness of combining the detection of RNA and the E2 antibody to determine the actual prevalence of GBV-C/HGV infection. The high prevalence of the GBV-C/HGV markers among the HIV-1-infected subjects, especially those with sexual exposure, provides additional evidence that this route of transmission plays a key role in the epidemiology of GBV-C/HGV. The potential influence of GBV-C/HGV infection on the course of HIV-1 disease needs further evaluation.     

Hyponatremia after hip arthroplasty may be related to a translocational rather than to a dilutional mechanism

OBJECTIVE: Postoperative hyponatremia is a frequent metabolic disturbance that may cause life-threatening complications. It results from both a positive electrolyte-free water (EFW) balance and an antidiuretic hormone release. During surgery, intracellular solutes may leak out of cells because of an increased membrane permeability leading to increased osmolality, cellular water shift, and redistribution hyponatremia, a concept coined the sick cell syndrome. Because of release of osmotically active solutes, plasma or urinary osmolar gap should increase. Therefore, we tested the hypothesis that postoperative hyponatremia may be related to a translocational mechanism evidenced by a postoperative increase of the osmolar gap rather than to a positive EFW balance. SETTING: An anesthesiology department in a 1,200-bed university hospital. DESIGN: A 5-month prospective observational study. SUBJECTS: Thirty-three consecutive patients undergoing elective hip arthroplasty under general anesthesia. They were divided into two groups whether the postoperative plasma sodium concentration decrease was > or = 2 mmol/L (group 1) or <2 mmol/L (group 2). MEASUREMENTS: Plasma sodium concentration ([Na+]p) and plasma osmolality were measured before induction of anesthesia and at skin closure. Osmolality was calculated at the same times. Plasma osmolar gap (OG(p)) was calculated as the difference between measured and calculated osmolality. Postoperative urinary osmolar gap (OG(u)) was calculated in the same way. EFW balance was calculated as the ratio of (infused EFW - excreted urinary EFW) to total body water. RESULTS: In 33 patients, a significant [Na+]p decrease of -2.0 was observed. No relationship was demonstrated between EFW balance and perioperative [Na+]p variation (r =.28; p=.12). A relationship was observed between perioperative OG(p) variation and perioperative [Na+]p variation (r =.74; p<.0001). In the 19 group 1 patients, [Na+]p decreased by -3.0 mmol/L. EFW balance did not differ between group 1 and group 2 patients. No statistical relationship was observed between EFW balance and perioperative [Na+]p variation in group 1 (r =.20; p=.40) and in group 2 (r =.43; p=.14). OG(p) increased only in group 1 but not in group 2 patients, and postoperative OG(u) was greater in group 1 than in group 2 patients. A relationship was observed between perioperative OG(p) variation and perioperative [Na+]p variation in group 1 (r =.53; p=.02) but not in group 2 (r =.32; p=.26). CONCLUSION: Hyponatremia after hip arthroplasty may not be related to a positive EFW balance. The postoperative increase of the OG(p) and the greater postoperative OG(u) in patients developing postoperative hyponatremia suggest the release of osmotically active solutes leading to cellular water shift from intracellular to extracellular spaces. These data may support the clinical relevance of the sick cell syndrome in the postoperative context.