Global disease burden of conditions requiring emergency surgery.

BACKGROUND: Surgical disease is inadequately addressed globally, and emergency conditions requiring surgery contribute substantially to the global disease burden. METHODS: This was a review of studies that contributed to define the population-based health burden of emergency surgical conditions (excluding trauma and obstetrics) and the status of available capacity to address this burden. Further data were retrieved from the Global Burden of Disease Study 2010 and the University of Washington's Institute for Health Metrics and Evaluation online data. RESULTS: In the index year of 2010, there were 896,000 deaths, 20 million years of life lost and 25 million disability-adjusted life-years from 11 emergency general surgical conditions reported individually in the Global Burden of Disease Study. The most common cause of death was complicated peptic ulcer disease, followed by aortic aneurysm, bowel obstruction, biliary disease, mesenteric ischaemia, peripheral vascular disease, abscess and soft tissue infections, and appendicitis. The mortality rate was higher in high-income countries (HICs) than in low- and middle-income countries (LMICs) (24.3 versus 10.6 deaths per 100,000 inhabitants respectively), primarily owing to a higher rate of vascular disease in HICs. However, because of the much larger population, 70 per cent of deaths occurred in LMICs. Deaths from vascular disease rose from 15 to 25 per cent of surgical emergency-related deaths in LMICs (from 1990 to 2010). Surgical capacity to address this burden is suboptimal in LMICs, with fewer than one operating theatre per 100,000 inhabitants in many LMICs, whereas some HICs have more than 14 per 100,000 inhabitants. CONCLUSION: The global burden of surgical emergencies is described insufficiently. The bare estimates indicate a tremendous health burden. LMICs carry the majority of emergency conditions; in these countries the pattern of surgical disease is changing and capacity to deal with the problem is inadequate. The data presented in this study will be useful for both the surgical and public health communities to plan a more adequate response.

Meeting the need for emergency obstetric care in Mozambique: work performance and histories of medical doctors and assistant medical officers trained for surgery.

OBJECTIVE: Nonphysicians in Mozambique have been performing major surgery for more than 20 years, with documented outcomes equivalent to those of specialists. The purpose of this study was to make an inventory of all government hospitals so as to document obstetric surgery performed by 'técnicos de cirurgia' (TCs) and to elucidate their retention at district level. DESIGN: Cross-sectional study of surgical procedures during 2002; longitudinal study of TCs and doctors graduating in 1987, 1988 and 1996. SETTING: All 34 hospitals with an operating theatre in Mozambique. POPULATION: Records of 12,178 major surgical obstetric operations were examined, and 59 medical officers and 34 TCs were interviewed. METHODS: Analysis of all surgical registers during 2002 in all government rural, provincial, general and central hospitals in Mozambique. TCs and doctors who had graduated in the specified years were traced and interviewed; health ministry records were reviewed to confirm assignments. MAIN OUTCOME MEASURES: Proportion of major obstetric surgeries performed by TCs. Proportion of TCs and medical doctors still at rural/district level at 7 years after graduation. RESULTS: Major obstetric surgery is conducted by nonphysicians in 57% of the 12,178 operations scrutinised. In district hospitals, they conducted 92% of 3246 operations. Retention of TCs and medical doctors at district hospital level differed markedly: after 7 years, 88% of the TCs remained in post compared with none of the medical doctors. CONCLUSION: Nonphysicians, trained in surgery, do most of the emergency obstetric surgery in Mozambique, and almost all of that performed in district hospitals. Nonphysicians, compared with physicians, stay longer in rural areas. After 7 years, around 90% of nonphysicians are still working in district hospitals, while almost no physicians remain there.

Treatment of essential blepharospasm. II. A modification of exposure for the muscle stripping technique.

The refinement of a muscle excision technique for the correction of essential blepharospasm has been a major contribution to treatment. In this procedure, incisions are made directly above the eyebrow to excise the brow muscles, often resulting in adherent scars and poor brow position. The bicoronal scalp flap has been used by many other surgical subspecialities for exposure of the frontal bone area, eg, in neurosurgical procedures, sinus surgery, and cosmetic forehead lifts. The use of the coronal flap exposure for excision of the corrugator and procerus muscles has allowed them to be more easily excised and has avoided the problems associated with the direct brow incisions. The Anderson muscle stripping technique, combined with the coronal flap exposure for the brow muscles, provides the best correction for the spasms in patients who have essential blepharospasm. The frequency of complications is low, and patient acceptance is high.

Treatment of essential blepharospasm. I. Comparison of facial nerve avulsion and eyebrow-eyelid muscle stripping procedure.

Benign essential blepharospasm is an incurable disease for which many treatment modalities have been suggested. The two surgical procedures that have been used most commonly are avulsion of the facial nerve and stripping of the protractor muscles of the eyelid and brow. We compare two matched series of 22 patients; one group underwent facial nerve avulsion ("Reynold's" procedure), and the other underwent "muscle stripping" ("Anderson's" procedure). We noted the number of procedures required for the patient to obtain a functional visual result and the side effects produced. Additional surgical procedures required by patients undergoing facial nerve avulsion were additional facial nerve avulsion, repair of ectropion, and correction of dermatochalasis and brow droop. Additional procedures required in patients who had muscle stripping were excision of lower lid orbicular fibers or residual brow fibers. The Reynold group required 16 additional procedures (38 separate procedures) to obtain functional results, as opposed to the four additional procedures (26 separate procedures) required in the Anderson group. Two patients in the Reynold group who needed surgery have not yet undergone it at this writing. If they did, that would boost the total number of procedures to 40. Secondary procedures are needed 4.5 times more often with the Reynold procedure than with the Anderson procedure. The patient's subjective response to and acceptance of the procedure are much greater for the Anderson procedure.

Risk factors for excess mortality in Harlem. Findings from the Harlem Household Survey.

INTRODUCTION: In 1980, age-adjusted mortality rates in Central Harlem were the highest among New York City's 30 health districts. This population-based study was designed to describe the self-reported frequency of selected health conditions, behavioral risk factors, preventive health practices, and drug use in the Harlem community. METHODS: From 1992 to 1994, in-person interviews were conducted among 695 adults aged 18 to 65 years who were randomly selected from dwelling-unit enumeration lists for the Central Harlem health district. Descriptive statistics were computed for men and women separately, and compared to other population-based surveys. RESULTS: Self-reported medical insurance coverage in Harlem was unexpectedly high (74% of men, 86% of women) as was lifetime use of preventive health practices, e.g., blood cholesterol screening (58% of men, 70% of women). However, lifetime rates of substance use, e.g. crack cocaine (14%) and self-reported history of traumatic events, e.g., witnessing someone seriously injured or violently killed (49% of men, 21% of women) were also high in Harlem, especially in comparison to other populations. CONCLUSIONS: This study has identified important patterns of similarities and differences in risk behaviors between Harlem and other populations. Potential solutions to the health problems of Harlem may lie in the creation of strategies that operate at the community, municipal, and regional level, as well as at the level of individual behavior and risk-taking.

Anatomic changes in involutional blepharoptosis.

Involutional blepharoptosis is a degenerative process involving the levator aponeurosis. Clinical and histopathologic evidence for involvement of the levator palpebrae superioris muscle has not been firmly established. We examined 20 patients with involutional blepharoptosis who demonstrated additional clinical, anatomic, and histopathologic findings consisting of a dehiscence of the medial limb of Whitnall's ligament, a lateral displacement of the tarsal plate of the upper eyelid, and a fatty degeneration of the levator muscle in the area of Whitnall's ligament. These findings suggest that a primary myopathic process may be involved in some cases of involutional blepharoptosis. The tarsal displacement complicates surgical correction of eyelids with blepharoptosis secondary to this myopathic process.

Height of the tarsus of the lower eyelid.

The vertical height of the lower eyelid tarsus of 20 patients submitting to lower eyelid resections and the lower tarsus of 17 cadavers was 3.7 mm (+/- 0.3) and 3.9 mm (+/- 0.5), respectively. The average value found in our patients was statistically different (P less than .05) than the values of 5 to 7 mm reported previously. The lower tarsus should be clearly identified in procedures involving eyelid repair or eyelid reconstruction so that tension-bearing sutures can be placed through the tarsus.

Dermis-fat graft for orbital reconstruction after subtotal exenteration.

A surgical technique for reconstruction after subtotal orbital exenteration uses an autogenous dermis-fat graft. A musculocutaneous flap is advanced over the graft to provide the anterior vascular supply for the free dermis-fat graft. The periorbita and remaining orbital tissue provide the vascular supply posteriorly. This technique eliminates extensive skin grafting and delayed spontaneous healing. Wound healing is rapid and surgical morbidity is minimized. We have used this procedure in three patients with sebaceous gland adenocarcinoma, two patients with severe posttraumatic contracted sockets, and as a palliative procedure in one patient with a fungating choroidal melanoma and widespread metastasis.

Recurrence of sebaceous carcinoma of the eyelid after radiation therapy.

Sebaceous carcinoma originating in the meibomian gland recurred in six patients (four women, 61, 68, 71, and 88 years old, and two men, 52 and 65 years old) who had undergone radiation therapy. The patients had received radiation dosages ranging from 3,300 to 11,900 rads. The tumors recurred two months to two years after treatment. All six patients then underwent surgical excision of the tumors and have remained tumor-free for follow-up periods of as long as 42 months. These data indicated that radiation therapy of sebaceous carcinoma of the eyelid should be considered palliative rather than curative.

Ganglioglioma of the optic nerve.

We examined a 15-year-old boy who had a ganglioglioma involving the left optic nerve, which caused proptosis, decreased vision, and optic atrophy. Computed tomography demonstrated an intraconal mass along the course of the orbital portion of the optic nerve. The only evidence of systemic neurofibromatosis was axillary freckling. The patient underwent a combined medial and lateral orbitotomy and excision of the tumor. Histologic examination demonstrated a mass composed of neurons and glial cells characteristic of ganglioglioma. After a one-year follow-up period, we have found no evidence of recurrence.

Blepharochalasis.

Blepharochalasis is an uncommon disorder distinguished by recurrent episodes of eyelid oedema in young patients. A hypertrophic form, manifested as fat herniation, and an atrophic form, manifested as fat atrophy, have been described. Ptosis with excellent levator function, laxity of the lateral canthal structures with rounding of the lateral canthal angle, nasal fat pad atrophy, and redundant eyelid skin develop after many episodes of eyelid swelling. Fine wrinkling, atrophy, and telangiectasias characterise the excess eyelid skin. We describe four cases of this syndrome in which external levator aponeurosis tuck, blepharoplasty, lateral canthoplasty, and dermis fat grafts were used to correct atrophic blepharochalasis after the syndrome had run its course.

Orbital decompression.

A new technique for exposure of the orbit for decompression of the orbit is described. It may be used for other purposes such as orbital fracture repair, orbital exploration for tumors in the inferior orbit, or reconstruction of the orbit by a variety of methods. The technique provides ready, broad exposure. The approach also avoids not uncommon complications of the eyelid, approaches to the orbit such as skin shrinkage and ectropion of the lower lid. It also results in minimal cosmetic deformity.

The evaluation and management of the patient with ptosis.

This article deals with fundamentals in evaluation and correction of ptosis, with some references to special situations. Ptosis defies a cookbook approach if one wishes predictable results. In a certain percentage of patients, the result will remain unpredictable and the surgeon must be prepared to perform revisional surgery.

Dry eye syndrome and other tear film abnormalities.

The goal of cosmetic blepharoplasty is to obtain an improvement in the appearance of the eyelids without causing functional or symptomatic alterations in the patients. Patients with undiagnosed problems in tear production who have cosmetic blepharoplasties are a common source of extremely dissatisfied patients with alarming ocular symptoms. Although keratoconjunctivitis sicca is the most common manifestation of an abnormal tear film state, there are other conditions of which the eyelid surgeon should be aware. Knowledge of methods used in the diagnosis of states of tear deficiency will allow the surgeon to better select candidates for cosmetic eyelid procedures.

The correction of lower lid malposition following lower lid blepharoplasty.

Lower eyelid malposition is the most common complication following lower eyelid blepharoplasty. This may take the form of a mild scleral show with the round eye syndrome or may progress to frank ectropion in some patients. When this problem occurs, it is imperative to soothe an already distressed patient by correcting the malposition by the most efficient method. A horizontal tightening of the lower lid at the lateral canthus can be helpful in many patients; however, in the more severe cases or in those in which the medial component is prominent, this procedure may not give the best correction. It is preferable to avoid using autogenous grafts in these patients because in most cases they will induce another incision line with potential deformity and, more important, are perceived by these sensitive patients as being more of an involved procedure. The preserved fasciae latae sling is an alternative procedure which is effective in the more severe cases of postblepharoplasty lower eyelid malposition, particularly in those cases in which the medial component of malposition is prominent.

Browplasty and browpexy: an adjunct to blepharoplasty.

Surgical approaches to the eyelids and eyebrows have been refined by application of their anatomy and appreciation of their pathophysiology. Sexual variations in eyebrow appearance can be attributed in part to the eyebrow fat pad. In females, the eyebrow is generally arched and above the level of the supraorbital rim. The male eyebrow is flatter and at the level of the supraorbital rim. The eyebrow fat pad is more prominent in the male, producing a fuller appearance in the lateral brow area. Many women are concerned about the flatter, full lateral brow, which assumes a masculine quality. The authors describe a surgical technique that permits identification of the brow fat pad and then the ability to debulk the eyebrow (browplasty). In addition, the brow can be elevated by internal plication suture to physically elevate the eyebrow (browpexy). This procedure is designed to utilize an eyelid crease incision, and it reduces the indications for more involved procedures to eliminate brow ptosis, such as midforehead or coronal approaches.

Superior oblique paresis after blepharoplasty.

A case of superior oblique paresis is presented which appeared to be due to cautherization of the superior oblique tendon. The torsional diplopia and head tilt were corrected with recession of the contralateral inferior rectus muscle.

Redraping the inferior orbicularis arc.

The surgical technique of redraping of the inferior arc of the orbicularis oculi muscle is used primarily to produce lower lid and midfacial smoothing in patients undergoing aesthetic surgery. The midfacial fat compartments, suborbicularis oculi fat and malar fat, are bound to the orbicularis muscle by the superficial muscular aponeurotic system so that redraping the orbicularis muscle also repositions the midface. Orbicularis arc redraping should be accompanied by lateral canthoplasty to ensure stability to the shape of the eyelid fissure postoperatively. Modifications in orbicularis redraping and canthoplasty technique are necessary in patients with prominent eyes and distensible lower lids. Supraplacement of canthal fixation is needed in patients with prominent eyes, and lid shortening is needed in patients who have distensible lower lids. This technique also can be used in patients undergoing reconstructive surgery for correction of lower lid retraction because of its ability to recruit periorbital skin upward into the lower lid. For more severe cases of lower lid retraction after aesthetic surgery, adjunctive procedures such as spacer implants in the lower lid and periosteal flap canthoplasty can be used together with the orbicularis arc redraping to rehabilitate patients.

Evolution of technique of the direct transblepharoplasty approach for the correction of lower lid and midfacial aging: maximizing results and minimizing complications in a 5-year experience.

During the past 5 years, the authors have used a direct trans-lower lid blepharoplasty subperiosteal approach to the lower lid and midface for the purpose of correction of midfacial aging in 757 patients. In a smaller but significant group, this approach has proven valuable in difficult reconstructive situations. The purpose of this article is twofold: (1) to provide a comprehensive retrospective evaluation of the value and promise of the technique and (2) to provide a comprehensive discussion of the pitfalls and complications that have been associated with use of this technique. In addition, technical modifications that may lower the rate of morbidity associated with the use of the procedure are described.

Preliminary evaluation of the Abbott TDx for benzoylecgonine and opiate screening in whole blood.

A method for the detection of benzoylecgonine (cocaine metabolite) and opiates in whole blood is described. This method employs the Abbott TDx fluorescence polarization immunoassay technique, which was designed for urine analysis. Drug-free whole blood was spiked with varying concentrations of benzoylecgonine, morphine, and codeine. Samples were prepared for analysis by adding 300 microL of 10% trichloroacetic acid to 300 microL of blood. Specimens were vortexed and centrifuged with 50 microL of supernatant required per assay. Precision studies of six replicate samples spiked with benzoylecgonine at 0.5 mg/L gave a within-run CV of 4.7% and a between-run CV of 4.7% with a detection limit of 0.1 mg/L. Within-run CVs for morphine at 0.5 mg/L and 0.1 mg/L were 1.7% and 7.9% respectively. The detection limits for morphine and codeine were 0.05 mg/L. Correlation coefficients for spiked whole blood calibration curves of benzoylecgonine, morphine, and codeine were 0.984, 0.999, and 0.997 respectively. This preliminary evaluation demonstrates a potential application of the TDx fluorescence polarization immunoassay technique to the analysis of drugs in whole blood.