Three-year results of mandated work hour restrictions: attending and resident perspectives and effects in a community hospital.

In response to the Accreditation Council of Graduate Medical Education mandated resident work hour restrictions, our residency program used a night float system in 2003. We undertook a survey of attending staff and residents to assess its effects on patient care and resident education. An anonymous survey was administered to attending staff and residents 1 year and 3 years after work hour restrictions took effect. The areas of disagreement include: beneficial effect on education (residents vs faculty: in 2004, 87% vs 22%, respectively, P = 0.02; in 2006, 71% vs 22%, P = 0.03); beneficial effect on patient care (in 2004, 53% vs 10%, P = 0.03); and compromised continuity of care (in 2004, 27% vs 70%, P = 0.04; in 2006, 7% vs 89%, P = 0.0002). One area of agreement was that residents' quality of life had improved. Both disagreed that more errors were being made and that work hour restrictions should be mandated on practicing surgeons. Attending staff and residents have deeply held opinions regarding the effects of work hour restrictions. This reflects a continuing dissatisfaction with providing patient care and educating residents under a set of requirements that solely addresses resident sleepiness and fatigue.

Expanding the scope of the turnover flap.

BACKGROUND: Turnover flaps are often utilized as alternatives to more traditional flaps, especially in situations where traditional flap viability is limited. Most turnover flaps are currently used in the lower extremities. METHODS: This study examined the senior author's use of the turnover flap in 103 cases between 1987 and 2004. Postoperative follow-up ranged from 3 months to 10 years, with an average follow-up of 9 months. RESULTS: The majority (n = 90) of the cases involved the lower extremities and carried high success rates; there were 72 successful operations (complete graft take), 10 partial flap losses (partial graft take that could be treated postoperatively without surgery), and eight complete flap losses (no graft take and the necessity of additional surgery). Three of the partial flap losses and two of the complete flap losses involved patients with end-stage vascular disease. End-stage vascular disease cases represented 20.0 percent of the lower extremity cases and carried a significantly higher percentage of partial or complete flap loss (27.8 percent). These circumstances were examined in detail; the authors found that the turnover flap provided improved outcome to such end-stage patients who otherwise would have undergone amputation. In 13 cases, turnover flaps were utilized in nontraditional regions, such as the chest wall, abdominal wall, head and neck region, and upper extremities, with a high degree of success (zero partial or complete flap losses). These approaches are discussed in detail. The surgical approach is examined with recommendations regarding preferred wound size and type and overall flap design. CONCLUSIONS: This study indicates that turnover flaps are effective and useful as an alternative and, in some cases, primary procedure. In addition, the results serve to expand the present scope of the turnover flap by examining nontraditional regions in which the flap was highly successful. The authors believe the turnover flap should be given higher priority as a reconstructive option, but more research is needed to explain the sources of blood supply in these flaps.

Increased prevalence of community-acquired methicillin-resistant Staphylococcus aureus in hand infections at an urban medical center.

BACKGROUND: The purpose of this article is to report the increased incidence of community-acquired methicillin-resistant S. aureus in hand infections at an urban medical center. METHODS: The authors performed a retrospective review of all patients with hand infections over a 21-month period, and all patients with culture-positive methicillin-resistant S. aureus were identified. Cases determined to be nosocomial were excluded. The study period was divided into three 7-month periods. RESULTS: A total of 343 hand infections were treated over a 21-month period. Eighty-nine patients (26 percent) with culture positive methicillin-resistant S. aureus were identified; of these, 75 were determined to be community-acquired methicillin-resistant S. aureus patients. Statistical analysis was performed using the Fisher's exact test (p < 0.0001), the chi-square test for equal proportions, the Cochran-Armitage trend test, and two-way analysis of variance. The demographics of the patients were compared using two-way analysis of variance, and patients were found to be similar in all three time periods with respect to mean age and sex. The incidence of community-acquired methicillin-resistant S. aureus increased to 40 percent during the last 7-month period compared with 14 percent during the first two periods. Overall, the incidence of methicillin-resistant S. aureus increased to 47 percent during the last 7 months compared with 16 percent and 17 percent in the first two 7-month periods, respectively. Based on their treatment approach and literature review, the authors have developed an algorithm to treat community-acquired methicillin-resistant S. aureus hand infections. CONCLUSIONS: The authors' findings at Temple University Hospital may help to alert health care providers to take necessary steps to control the spread of methicillin-resistant S. aureus in the community and in the inpatient setting. Cultures should be carefully followed and infections should be treated with appropriate antibiotics.

Bedside insertion of vena cava filters in the intensive care unit using intravascular ultrasound to locate renal veins.

BACKGROUND: Historically, contrast venography has been used to determine renal vein location and assist with vena cava filter placement. This technique, however, exposes the patient to nephrotoxic contrast and radiation. For trauma patients in the intensive care unit (ICU), inferior vena cava filters should ideally be placed without contrast at the bedside to avoid nephrotoxic agents, radiation, and transport of a critically injured patient to the operating room or x-ray department. Previously, the authors have shown that intravascular ultrasound is a safe and accurate method for locating renal veins and assisting with vena cava filter placement. The purpose of this study was to evaluate bedside vena cava filter placement prospectively using only intravascular ultrasound for imaging. METHODS: Between August 2000 and July 2003, 29 patients met trauma service criteria for prophylactic or therapeutic placement of a vena cava filter. The 7 females and 22 males had a mean age of 51.3 years (range, 20-92 years), a mean height of 177 cm (range, 160-218.4 cm), a mean weight of 101.9 kg (range, 59.1-186.4 kg), and a body mass index of 33 (range, 14.7-56.1). Fifteen patients (55.5%) had a body mass index exceeding 30. The mean Injury Severity Score was 25.4 (range, 12-45). Intravascular ultrasound was the sole imaging method, and no contrast or fluoroscopy was used. All procedures were performed in the ICU by trauma surgeons. Data collection was prospective and included demographics, injuries, vena caval anatomy, length of procedure, complications, and follow-up radiographic confirmation of appropriate deployment. RESULTS: The location of the renal veins and vena cava diameter was imaged in all the patients. Three patients were noted to have accessory renal veins, and no patient had thrombus in the vena cava. The inferior vena cava diameter was less than 28 mm in all the patients, thus allowing standard filters to be deployed. Filter deployment was successful for all the patients. Of the 29 patients, 27 had abdominal computed tomography (CT) during their hospital stay. When the location of the renal veins identified by CT was compared with the level of the filter on abdominal x-ray, the filter tip was found to be at or below the level of the most caudal renal vein in 26 of the 27 patients (96.3%). In one patient, the filter tip was purposely placed 2 to 3 cm above an accessory caudal renal vein, but below the main right and left renal veins. The mean procedure time was 37.7 minutes (range, 12-86 minutes). No complications were associated with filter placement. CONCLUSIONS: Intravascular ultrasound is a safe and effective imaging method that may be used for the bedside placement of vena cava filters in the ICU. This technique avoids the use of nephrotoxic intravenous contrast and eliminates the risk of transporting a critically injured patient to the operating room or x-ray department.

Clonogenic analysis reveals reserve stem cells in postnatal mammals. II. Pluripotent epiblastic-like stem cells.

Undifferentiated cells have been identified in the prenatal blastocyst, inner cell mass, and gonadal ridges of rodents and primates, including humans. After isolation these cells express molecular and immunological markers for embryonic cells, capabilities for extended self-renewal, and telomerase activity. When allowed to differentiate, embryonic stem cells express phenotypic markers for tissues of ectodermal, mesodermal, and endodermal origin. When implanted in vivo, undifferentiated noninduced embryonic stem cells formed teratomas. In this report we describe a cell clone isolated from postnatal rat skeletal muscle and derived by repetitive single-cell clonogenic analysis. In the undifferentiated state it consists of very small cells having a high ratio of nucleus to cytoplasm. The clone expresses molecular and immunological markers for embryonic stem cells. It exhibits telomerase activity, which is consistent with its extended capability for self-renewal. When induced to differentiate, it expressed phenotypic markers for tissues of ectodermal, mesodermal, and endodermal origin. The clone was designated as a postnatal pluripotent epiblastic-like stem cell (PPELSC). The undifferentiated clone was transfected with a genomic marker and assayed for alterations in stem cell characteristics. No alterations were noted. The labeled clone, when implanted into heart after injury, incorporated into myocardial tissues undergoing repair. The labeled clone was subjected to directed lineage induction in vitro, resulting in the formation of islet-like structures (ILSs) that secreted insulin in response to a glucose challenge. This study suggests that embryonic-like stem cells are retained within postnatal mammals and have the potential for use in gene therapy and tissue engineering.

Radio-frequency ablation of large, nonresectable hepatic tumors.

Patients with nonresectable hepatic metastases who are not treated survive an average of 6 months. We report our experience with radio-frequency ablation (RFA) of nonresectable hepatic tumors 4 cm or greater in size. A retrospective chart review of all patients undergoing RFA of hepatic tumors 4 cm or greater from October 1, 1999, through August 31, 2002, was performed. Thirty-six patients were identified who underwent RFA of tumors 4 cm or greater. There were a total of 81 tumors ablated in the 36 patients. Twenty patients underwent RFA only; seven patients received RFA plus a wedge resection. Five patients were treated with RFA followed by chemoembolization. Two patients underwent RFA plus placement of a hepatic artery infusion pump. The median tumor size was 5 cm (range, 4-14 cm). Median patient follow-up was 26 months (range, 1-54 months). Patients with metastatic colon cancer had the longest median survival of 28 months (range, 1 and 48 months). The survival of primary hepatocellular carcinoma was worse with a median survival of 20 months (range, 1-36 months). At last follow-up, 11 (30%) of the patients remain alive and disease free. There were no perioperative deaths and one intraoperative complication. In our experience, RFA of larger tumors is effective and safe. Tumor size should not be an absolute contraindication to RFA of nonresectable hepatic tumors.

Diabetes and burns: retrospective cohort study.

Burn injuries are often associated with multisystemic complications, even in otherwise healthy individuals. It is therefore intuitive that for the diabetic patient, the underlying pathophysiologic alterations in vascular supply, peripheral neuropathy, and immune function could have a profoundly devastating impact on patient outcome. The effects of diabetes on morbidity and mortality of the burn-injured patient have not been examined in great detail. The purpose of this retrospective study was to compare clinical outcomes between diabetic and nondiabetic burn patients. We reviewed the charts of 181 diabetic (DM) and 190 nondiabetic (nDM) patients admitted with burns between January 1996 and May 2000, matched by sex and date of admission. Burn cause and size, time to presentation, clinical course, and outcomes were evaluated. Because age was a factor, the analysis was done by three age groups: younger than 18 years, 18 to 65 years, and older than 65 years. Of patients 18 to 65 years, 51% (98/191) were diabetic, whereas 84% (81/96) of those older than 65 and only 4% (3/85) of patients younger than 18 were diabetic. Because of the disproportion in numbers of diabetics compared with nondiabetics in the younger than 18 and older than 65 years-old groups, these patients will not be discussed. Diabetics were more likely to incur scald injury from tub or shower water rather than hot fluid spills (33% DM vs 15% nDM; P < or = 0.01), and have a delayed presentation (45 vs 23%; P = 0.00001). There was no difference in total burn size in all groups. Diabetics in the 18 to 65 years group had a higher rate of full-thickness burns (51 vs 31%; P = 0.025), skin grafts (50 vs 28%; P = 0.01) and burn-related procedures (57 vs 32%; P = 0.001), infections (65 vs 51%; P = 0.05), and longer lengths of stay (23 vs 12 days; P = 0.0001). Although there was no statistically significant difference in incidence of specific infections, the rates of cellulitis, wound infection, urinary tract infection, line infection, and osteomyelitis, were consistently higher in the diabetic population. Partial graft slough was 6% in diabetics 18 to 65 years with a 3% regraft rate, whereas nondiabetics had a 1% regraft rate. Comparing diabetics with controlled vs uncontrolled glucose levels, diabetics with uncontrolled glucose had higher rates of infection (72 vs 55%; P < or = 0.025), all burn-related procedures (68 vs 45%; P < or = 0.025), and longer ICU stays (24 vs 10 days; P = 0.048). Mortality rate was 2% for diabetics and for nondiabetics. In summary, presence of diabetes in the burn patient was associated with a worse outcome. A predilection for burn injuries in the diabetic was noted in the older adult population. Deeper burns, delayed presentation, higher rates of infection, graft failure and operations, and longer lengths of stay translate into an increased cost to society both economically and in lives. This data would suggest a need for better burn education for diabetics and health care professionals, recognizing the elderly population as a "high-risk" group. We believe that targeted prevention measures and treatment strategies, emphasizing earlier and more aggressive intervention for this population, may have a favorable effect on morbidity and mortality.