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2.
J Trauma Acute Care Surg ; 88(6): 770-775, 2020 06.
Article in English | MEDLINE | ID: mdl-32118825

ABSTRACT

BACKGROUND: The American Association for the Surgery of Trauma (AAST) developed a severity scale for surgical conditions, including diverticulitis. The Hinchey classification requires operative intervention yet remains the established scoring system for acute diverticulitis. This is a pilot study to compare the AAST grading scale for acute colonic diverticulitis with the traditional Hinchey classification. We hypothesize that the AAST classification scale is equivalent to the Hinchey in predicting outcomes. METHODS: This is a retrospective cohort study at an academic medical center. A consecutive sample of patients with acute diverticulitis and computed tomography imaging was reviewed. Chart review identified demographic and physiologic data with interventional and clinical outcomes. Each computed tomography scan was assigned AAST and modified Hinchey classification scores by a radiologist. Multivariate regression and receiver operating characteristic curve analysis compared six outcomes: need for procedure, complication, intensive care unit (ICU) admission, length of stay, 30-day readmission, and mortality. RESULTS: One hundred twenty-nine patients were included. Of the total patients, 42.6% required procedural intervention, 21.7% required ICU admission, 18.6% were readmitted, and 6.2% died. Both AAST and Hinchey predicted the need for operation (AAST odds ratios, 1.55, 12.7, 18.09, and 77.24 for stages 2-5; Hinchey odds ratios, 8.85, 11.49, and 22.9 for stages 1b-3, stage 4 predicted perfectly). The need for operation c-statistics (area under the curve) for AAST and Hinchey was 0.80 and 0.83 for Hinchey and AAST, respectively (p = 0.35). The complication c-statistics curve for AAST and Hinchey was 0.83 and 0.80, respectively (p = 0.33). The AAST and Hinchey scores were less predictive for ICU admission, readmission, and mortality with c-statistics of less than 0.80. CONCLUSION: The AAST grading of acute diverticulitis is equivalent to the modified Hinchey classification in predicting procedural intervention and complications. The AAST system may be preferable to Hinchey because it can be applied preoperatively. Although this pilot study demonstrated that the AAST score predicts surgical need, a larger study is required to evaluate the AAST score for other outcomes. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level III.


Subject(s)
Diverticulitis, Colonic/diagnosis , Severity of Illness Index , Surgical Procedures, Operative/statistics & numerical data , Academic Medical Centers/statistics & numerical data , Acute Disease/mortality , Acute Disease/therapy , Adult , Colon/diagnostic imaging , Diverticulitis, Colonic/mortality , Diverticulitis, Colonic/surgery , Female , Hospital Mortality , Humans , Intensive Care Units/statistics & numerical data , Length of Stay/statistics & numerical data , Male , Middle Aged , Patient Admission/statistics & numerical data , Patient Readmission/statistics & numerical data , Prognosis , Retrospective Studies , Societies, Medical , Tomography, X-Ray Computed , Traumatology , United States , Young Adult
3.
Aesthet Surg J ; 40(5): NP223-NP227, 2020 04 14.
Article in English | MEDLINE | ID: mdl-31254463

ABSTRACT

BACKGROUND: The seventh cranial nerve (CN VII), also known as the facial nerve, is an anatomically intricate structure the branches of which serve several physiologic functions. CN VII innervates the muscles of facial expression which are crucial for eye protection, oral competence, and social interaction. The temporal branch, clinically referred to as the frontotemporal branch (FTB), is the most superior of the 5 branches and is at risk during cutaneous surgery of the parotid gland and in the temporal region. Several methods for delineating the FTB trajectory exist, the most widely known being Pitanguy's Line, which is defined as running from 0.5 cm below the tragus to 1.5 cm above the lateral eyebrow. However, variations in eyebrow location, often affected by modern-day cosmetic trends, complicate the accuracy of this approach. OBJECTIVES: The aim of this study was to develop a surgical landmark to identify FTB location without relying on soft tissue structures. METHODS: To minimize variation, we chose landmarks that were both consistent and easy to locate based on simple surface anatomy. Twenty-one cadaver hemifaces were dissected in order to locate the FTB in relation to the inferior border of the zygomatic arch and the apex of the tragus. RESULTS: We found that the mean ± SEM distance from the apex of the tragus to the point where the FTB crossed the inferior border of the zygomatic arch was 3.21 ± 0.05 cm. CONCLUSIONS: Through the use of this measurement, we aim to avoid the pitfalls of previous techniques by providing a widely applicable clinical tool based on landmarks easily found on any patient.


Subject(s)
Ear Auricle , Facial Nerve , Cadaver , Facial Nerve/anatomy & histology , Humans , Zygoma/anatomy & histology , Zygoma/surgery
4.
Cancers (Basel) ; 11(5)2019 Apr 28.
Article in English | MEDLINE | ID: mdl-31035321

ABSTRACT

The question of whether anesthetic, analgesic or other perioperative intervention during cancer resection surgery might influence long-term oncologic outcomes has generated much attention over the past 13 years. A wealth of experimental and observational clinical data have been published, but the results of prospective, randomized clinical trials are awaited. The European Union supports a pan-European network of researchers, clinicians and industry partners engaged in this question (COST Action 15204: Euro-Periscope). In this narrative review, members of the Euro-Periscope network briefly summarize the current state of evidence pertaining to the potential effects of the most commonly deployed anesthetic and analgesic techniques and other non-surgical interventions during cancer resection surgery on tumor recurrence or metastasis.

7.
Curr Opin Anaesthesiol ; 29(4): 468-74, 2016 Aug.
Article in English | MEDLINE | ID: mdl-27214644

ABSTRACT

PURPOSE OF REVIEW: Cancer is now one of the leading causes of death worldwide, and excisional surgery is an essential treatment for the four most common adult cancers. Opioids remain the most commonly prescribed analgesics in the perioperative period of cancer surgery, yet the question of whether opioids could influence recurrence or metastasis remains unanswered. RECENT FINDINGS: In-vitro cell culture, live animal models, and retrospective clinical reviews investigating the effects of opioids on outcomes after cancer surgery have yielded conflicting results, with findings ranging from deleterious, null to potentially protective effects. SUMMARY: Prospective randomized trials are required to investigate this important topic further. Several are currently ongoing. Until the results of these are available for scrutiny, there is currently insufficient evidence to recommend any changes to current clinical practice. Opioids continue to play an important role in the perioperative period.


Subject(s)
Analgesics, Opioid/therapeutic use , Neoplasm Metastasis/prevention & control , Neoplasm Recurrence, Local/prevention & control , Neoplasms/pathology , Perioperative Care/methods , Analgesia/methods , Anesthesia/methods , Carcinogenesis/drug effects , Carcinogenesis/immunology , Carcinogenesis/metabolism , Clinical Trials as Topic , Disease-Free Survival , Humans , Immune System/drug effects , Neoplasm Invasiveness/immunology , Neoplasm Invasiveness/physiopathology , Neoplasm Invasiveness/prevention & control , Neoplasm Metastasis/immunology , Neoplasm Metastasis/physiopathology , Neoplasm Recurrence, Local/immunology , Neoplasm Recurrence, Local/metabolism , Neoplasms/immunology , Neoplasms/mortality , Neoplasms/surgery , Pain Management/methods , Receptors, Opioid, mu/metabolism , Signal Transduction/drug effects , Surgical Procedures, Operative/adverse effects
9.
BMJ Case Rep ; 20142014 Aug 05.
Article in English | MEDLINE | ID: mdl-25096649

ABSTRACT

Hidden behind their common garden symptoms, malignant tumours of the nasal cavity are typically advanced when detected. Squamous cell carcinoma (SCC) is the most common histological type of these rare tumours which may simply present with epistaxis or a blocked nose. A 79-year-old woman attended our clinic with a 2-year history of progressive nasal collapse resulting in a 'saddle nose deformity'. Imaging showed a soft tissue mass with absolute destruction of the nasal septum and bones with hard palate and maxillary involvement. Histology confirmed a poorly differentiated SCC. Following discussion at the local head and neck multidisciplinary team meeting, the patient was offered radiotherapy alone due to her advanced presentation. She has had a good response to treatment with no further disease progression. Nasal septal SCC is far more successfully treated in the early stages. A suspicious clinician is the patients best ally.


Subject(s)
Carcinoma, Squamous Cell/complications , Nasal Septum , Nose Deformities, Acquired/etiology , Nose Neoplasms/complications , Aged , Biopsy , Carcinoma, Squamous Cell/diagnosis , Carcinoma, Squamous Cell/radiotherapy , Diagnosis, Differential , Female , Humans , Nose Deformities, Acquired/diagnosis , Nose Neoplasms/diagnosis , Nose Neoplasms/radiotherapy , Tomography, X-Ray Computed
10.
J Plast Reconstr Aesthet Surg ; 66(11): 1610-2, 2013 Nov.
Article in English | MEDLINE | ID: mdl-23422060

ABSTRACT

Recurrent volar displacement of the extensor digitorum communis tendon (EDC) at the metacarpophalangeal joint (MCPJ) more commonly occurs post-trauma or in the rheumatoid hand. This disabling condition of the hand results in painful swelling of the MCPJ, associated with "locking" of the extensor tendon. We report a simple surgical technique used to successfully 'secure' the EDC from recurrent displacement. This was performed for a 59-year-old man who developed the condition in his ring finger, following Vth ray amputation for severe Dupuytren's disease. First, the EDC over the IIIrd and IVth MCPJ are exposed using a longitudinal incision. The junctura tendinum between the EDC tendons was next extended proximally by 2 cm on the radial side of the IVth EDC and then divided to create a distally based junctura slip. Next, a 'lasso' was created by passing the slip beneath the IVth EDC tendon and then securing it onto itself with a 5/0 Ethibond suture (Ethicon Inc.). This reconstruction was then tested in all ranges of MCPJ flexion, successfully preventing volar displacement of the extensor tendon. The 'junctura lasso' provided a satisfactory solution for the patient, who, over the next four years; for the duration of his follow-up, suffered no further displacement of the extensor tendon.


Subject(s)
Metacarpophalangeal Joint/surgery , Tendon Injuries/surgery , Humans , Male , Metacarpophalangeal Joint/physiopathology , Middle Aged , Secondary Prevention
13.
Shock ; 21(1): 86-92, 2004 Jan.
Article in English | MEDLINE | ID: mdl-14676689

ABSTRACT

It has been suggested that hyperdynamic (HD) resuscitation improves outcomes. We hypothesized that initial HD resuscitation of burn injury using fluid and inotropes would improve metabolic function as indicated by base excess. We used an anesthetized ovine model of 60% TBSA full-thickness flame burn with delayed resuscitation started at 90 min after burn and continued for 8 h. Three groups (n = 6 each) were included: 1) HD defined as cardiac index (CI) of 1.5x baseline achieved by using Ringer's lactate alone (HD-Fluid); 2) Ringer's lactate and dobutamine (HD-Drug); and 3) Parkland Formula (Parkland) as a control group. Statistical analysis performed using analysis of variance and Tukey's HSD test. Significance accepted at P < 0.05. Higher CI was achieved in both HD-Fluid and HD-Drug groups, e.g., at 8 h the CI was 4.6 +/- 0.4 and 4.7 +/- 0.6 L/min/m respectively, as compared with Parkland 3.6 +/- 0.5 L/min/m. The net fluid balance (fluid infused - urine output) was similar in both Parkland and HD-Drug groups, which were 2.5x more in HD-Fluid (P = 0.001). The mean postburn urinary outputs were similar in both Parkland and HD-Drug groups, e.g., Parkland (0.9 +/- 0.08 mL/kg/h), HD-Drug (1.0 +/- 0.2 mL/kg/h) and increased in HD-Fluid (3.7 +/- 1.0 mL/kg/h; P = 0.0005). Base excess remained positive in both HD-Drug (+2.5 +/- 1 mmol/L) and Parkland (+1.5 +/- 1.7 mmol/L), and declined to -4.0 +/- 3.6 mmol/L in HD-Fluid group (P = 0.036). We conclude that there may be no benefit to using hyperdynamic regimens for the initial resuscitation of burn injury.


Subject(s)
Burns/therapy , Resuscitation/methods , Animals , Blood Pressure , Body Temperature , Cardiotonic Agents/pharmacology , Dobutamine/pharmacology , Heart Rate , Hemoglobins/metabolism , Isotonic Solutions , Oxygen/metabolism , Ringer's Lactate , Sheep , Time Factors , Urine
15.
Shock ; 19(5): 399-403, 2003 May.
Article in English | MEDLINE | ID: mdl-12744480

ABSTRACT

Thyroxine (T4), Tri-iodothyronine (T3), and total serum protein levels are reduced in severely burned children. T4 and T3 are carried on serum transport proteins via thyroid hormone-binding sites (THBS). Treatment of bums with recombinant human growth hormone (rhGH) increases albumin (Alb) and prealbumin (PreAlb), which bind nearly 30% of circulating T4 and T3. This study investigated the effect of rhGH on THBS sites in burned children. Records of 11 acutely burned children with a total body surface area burned >40% who were randomized to either a daily subcutaneous injection of rhGH at 0.05 mg/kg/day or placebo for 6 months after discharge from hospital were reviewed. Thyroxine uptake percentage (TU%), Total T4 levels (TT4), free thyroxine index, Alb and PreAlb, and height and weight measurements taken at discharge and 6 months later were compared in both groups. In the six children who received rhGH, mean TU% had decreased from 41 +/- 1 to 33 +/- 1% by 6 months postdischarge, (P < 0.001), mean TT4 increased from 5.8 +/- 0.3 to 8.1 +/- 0.8 microg/dL, (P < 0.02), mean Alb increased from 2.0 +/- (0.6) to 3.5 +/- (0.1) g/dL (P < 0.0001), and mean PreAlb increased from 8.7 +/- 0.7 to 16.5 +/- 2.1 mg/dL, (P < 0.006). There were no significant changes in the five children in the placebo (control group), and height and weight did not significantly change in either group. rhGH significantly increases THBS in severely burned children, possibly through increases in serum Alb and PreAlb. The increases in circulating thyroxine observed in this group may be involved in the attenuation of growth arrest.


Subject(s)
Burns/drug therapy , Human Growth Hormone/therapeutic use , Thyroxine/blood , Blood Glucose/metabolism , Burns/blood , Burns/physiopathology , Child , Follow-Up Studies , Human Growth Hormone/administration & dosage , Humans , Injections, Subcutaneous , Insulin-Like Growth Factor Binding Protein 3/blood , Placebos , Prealbumin/metabolism , Reference Values , Retrospective Studies , Serum Albumin/metabolism , Thyroxine/metabolism , Time Factors
17.
Anesthesiology ; 98(3): 670-81, 2003 Mar.
Article in English | MEDLINE | ID: mdl-12606911

ABSTRACT

BACKGROUND: The combination of isoflurane anesthesia and mechanical ventilation reduces urinary output and promotes redistribution of a crystalloid bolus into the extravascular space. The authors hypothesized that mechanical ventilation rather than isoflurane causes this alteration. METHODS: The fate of a 25-ml/kg, 20-min, 0.9% saline fluid bolus was studied in four different experiments per sheep: while conscious and spontaneously ventilating (CSV), while conscious and mechanically ventilated (CMV), while anesthetized with isoflurane and mechanical ventilated (ISOMV), and while anesthetized with isoflurane and spontaneously ventilating (ISOSV). RESULTS: By calculations based on the indicator dilution and mass balance principles, plasma expansion was similar between protocols. Isoflurane but not mechanical ventilation reduced urinary output and increased interstitial fluid volume (P < 0.001): At 180 min, mean total urinary outputs were 15.6 +/- 2.1 and 15.9 +/- 2.9 ml/kg in the CSV and CMV protocols and 2.7 +/- 0.6 and 3.1 +/- 1.1 ml/kg in the ISOSV and ISOMV protocols, respectively. The net changes in extravascular volume, assumed to be interstitial fluid volume, were 8.6 +/- 3.3 and 8.1 +/- 3.1 ml/kg, and 22.5 +/- 1.5 and 22.1 +/- 1.6 ml/kg in the corresponding protocols. Volume kinetic analysis demonstrated extravascular fluid accumulation associated with isoflurane anesthesia similar to the calculated interstitial accumulation of 20.2 +/- 0.5 and 26.5 +/- 0.3 ml/kg in the ISOSV and ISOMV protocols, respectively. CONCLUSION: Isoflurane, but not mechanical ventilation, decreased urinary excretion and increased interstitial fluid volume. Volume kinetic analysis indicated "third-space" losses due to isoflurane. Perioperative fluid retention may be associated not only with surgical tissue manipulation, but with anesthesia per se.


Subject(s)
Anesthetics, Inhalation/pharmacology , Extracellular Space/metabolism , Fluid Therapy , Isoflurane/pharmacology , Plasma Substitutes/administration & dosage , Respiration, Artificial , Animals , Crystalloid Solutions , Female , Hemodynamics/drug effects , Isotonic Solutions , Plasma Volume/drug effects , Sheep , Urination/drug effects
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