Utilization of Orthopaedic Trauma Surgical Time: An Evaluation of Three Different Models at a Level I Pediatric Trauma Center.

OBJECTIVE: Over the past decade, our institution has instituted three different scheduling models in an attempt to care for pediatric trauma at our Level I Trauma Center. This has been in response to a number of factors, including a limited number of physicians covering the call schedule, increasing competition for operating room (OR) time after hours (pediatric surgery, urology, neurosurgery), an attempt to fully utilize OR time during the daytime, fully staffed hours, and optimizing patients' timeliness to surgery. We examined the three on-call systems in place at our institution to determine whether a more flexible approach to pediatric trauma call resulted in delays in treatment. METHODS: We retrospectively reviewed patient records for three distinct 1-year periods with three different surgical call schedules: (i) a traditional call schedule in which the call physician was responsible for patients who presented to our emergency room; (ii) a half-day trauma block OR reserved the morning following call; and (iii) a full-day trauma block. Variables included date of injury, time of admission, admission diagnosis, cause of injury, and OR procedure and start time. RESULTS: We reviewed 951 cases over the entire study, 268 during the traditional call schedule, 282 during the half-call block and 401 over the time period of the full-day block. Mechanisms of injury were similar among the three groups, with falls and motor vehicle accidents being the leading causes. The average delay time was 17:40 for the traditional call group, 15:10 for the half-block call group, and 15:09 for the full-day block group. Our findings suggest that there was a high incidence of cases performed on weekdays after peak staffing hours with a traditional call model (59%). In contrast, half-day and full-day block models saw only 4% and 1% of the cases performed after peak staffing hours, respectively. There was a statistically significant difference in the number of patients admitted to the OR among the three groups (χ(2) = 488.8449, P < 0.0001). The number of patients seen during Monday through Friday was also statistically significant among the three groups (χ(2) = 382.0576, P < 0.0001). CONCLUSIONS: The institution of more flexible and physician-directed half-call and full-day blocks did result in delays in treatment. However, it also has demonstrated benefits to patients in reducing the number of operative cases performed after weekday peak staffing hours; helped our institution better manage its staffing and financial resources; and provided the treating surgeon flexibility in determining the timing of operative care.

Comparison of custom to standard TKA instrumentation with computed tomography.

PURPOSE: There is conflicting evidence whether custom instrumentation for total knee arthroplasty (TKA) improves component position compared to standard instrumentation. Studies have relied on long-limb radiographs limited to two-dimensional (2D) analysis and subjected to rotational inaccuracy. We used postoperative computed tomography (CT) to evaluate preoperative three-dimensional templating and CI to facilitate accurate and efficient implantation of TKA femoral and tibial components. METHODS: We prospectively evaluated a single-surgeon cohort of 78 TKA patients (51 custom, 27 standard) with postoperative CT scans using 3D reconstruction and contour-matching technology to preoperative imaging. Component alignment was measured in coronal, sagittal and axial planes. RESULTS: Preoperative templating for custom instrumentation was 87 and 79 % accurate for femoral and tibial component size. All custom components were within 1 size except for the tibial component in one patient (2 sizes). Tourniquet time was 5 min longer for custom (30 min) than standard (25 min). In no case was custom instrumentation aborted in favour of standard instrumentation nor was original alignment of custom instrumentation required to be adjusted intraoperatively. There were more outliers greater than 2° from intended alignment with standard instrumentation than custom for both components in all three planes. Custom instrumentation was more accurate in component position for tibial coronal alignment (custom: 1.5° ± 1.2°; standard: 3° ± 1.9°; p = 0.0001) and both tibial (custom: 1.4° ± 1.1°; standard: 16.9° ± 6.8°; p < 0.0001) and femoral (custom: 1.2° ± 0.9°; standard: 3.1° ± 2.1°; p < 0.0001) rotational alignment, and was similar to standard instrumentation in other measurements. CONCLUSIONS: When evaluated with CT, custom instrumentation performs similar or better to standard instrumentation in component alignment and accurately templates component size. Tourniquet time was mildly increased for custom compared to standard.

Periprosthetic femoral condyle fracture after total knee arthroplasty and saline-coupled bipolar sealing technology.

Saline-cooled bipolar radiofrequency technology has emerged as an effective method to reduce bleeding during total knee arthroplasty (TKA). No significant osseous complications have been previously reported, and animal studies have revealed no difference in bone healing, strength, or osteonecrosis compared to conventional monopolar electrocautery. This article presents 4 cases of early postoperative periprosthetic femoral condyle fractures after extensive use of saline-cooled bipolar radiofrequency requiring revision TKA. Preoperative, intraoperative, and postoperative details from 4 patients who underwent early TKA revision for periprosthetic femoral condyle fractures were retrospectively reviewed. The senior author (M.M.) had not experienced similar condyle fractures postoperatively in over 2,500 primary TKAs performed over 2 decades. The cases described here were performed between July 2009 and November 2009, shortly after increasing the usage of saline-cooled bipolar radiofrequency on the synovium overlying the femoral condyles for hemostasis. No other change in surgical technique or implant that occurred during this time was observed. The senior author has significantly decreased his use of saline-cooled bipolar radiofrequency and has seen no recurrence of these complications.

Liver transplantation at Yale-New Haven Transplantation Center.

It is possible to achieve better results after liver transplantation in adult and pediatric patients. An approach driven by multidisciplinary protocol is the most important factor, along with excellent communication skills, technical expertise, application of new technologies such as MARS and Arctic-Sun for ALF, and new knowledge/treatment protocols such as escalating-dose interferon ribavirin treatment, protocol biopsies, routine use of IL28B gene mutation and new protease inhibitors as part of antiviral therapy for hepatitis C.

ICU management of acute liver failure.

Survival of patients presenting with acute liver failure (ALF) has improved because of earlier disease recognition, better understanding of pathophysiology of various insults leading to ALF, and advances in supportive measures including a team approach, better ICU care, and liver transplantation. This article focuses on patient management and evaluation that takes place in the ICU for patients who have acute liver injury. An organized team approach to decision making about critical care delivered during this period of time is important for achieving a good patient outcome.

Erectile dysfunction in men with congenital heart disease.

There has been a tremendous focus on gynecologic health with the increasing number of women with congenital heart disease (CHD). Conversely, experience in providing sexual health screening to men with CHD is lacking. The purpose of this study was to identify sexual health issues in men with CHD. An anonymous survey was distributed to men in our adult CHD clinic. Age, type of CHD, medications, detailed sexual history including cardiovascular symptoms with intercourse, erectile dysfunction (ED), and willingness to discuss ED with a physician was obtained. A logistic regression analysis was performed to analyze the relation between medications, CHD complexity, and ED; 86 men completed the survey with a mean age of 34 +/- 10 years. The prevalence of ED was 38%. Men were treated with cardiac medications including beta blockers (BB; 24%), angiotensin-converting enzyme (ACE) inhibitors (8%), calcium-channel blockers (6%), and combination BB and ACE inhibitor therapy (16%). Men on BB were 3.13 times more likely to report ED (p = 0.045). Complexity of CHD did not increase the likelihood of ED symptoms (p >0.10). Although most men attributed symptoms to their underlying CHD, most were willing to discuss issues of ED with their cardiologist. In conclusion, ED is prevalent in young men with CHD. Although an emotional component may contribute, certain medications may exacerbate symptoms.

Critical analysis of the pediatric end-stage liver disease scoring system: a single center experience.

The Pediatric End-Stage Liver Disease (PELD) scoring system is a new nationally utilized formula developed to provide a continuous numerical assessment of the risk of death in order to allocate livers to children for transplantation. A retrospective review of the clinical course of children undergoing liver transplantation at the Mount Sinai Medical Center was performed in order to assess the effectiveness of this scoring system in the first 24 months of its utilization. Forty-eight patients underwent liver transplantation with overall patient and graft survival rates of 98% and 96%, respectively. In 23 cases the PELD scoring system determined waiting time for transplantation. Of these 23 patients, 7 moved to the intensive care unit (ICU). Only 2 of 23 patients underwent transplantation with their actual PELD score. The rest required petition for exception (17) or status 1 listing (4). Significant morbidity occurred while awaiting transplantation: failure to thrive (78%), ascites (73%), hemorrhage (49%), infectious complications (39%), encephalopathy (30%), peritonitis (17%), pathologic bone fractures (13%), and hepatopulmonary syndrome (9%). In patients with PELD scores granted by exception the average score that did not yield a liver offer was 38 with an average waiting time of 55 days. At the time of transplantation actual PELD score averaged 22, while the petitioned score was 40. Based upon our center's initial experience, the current PELD scoring system is not adequate. Actual PELD scores did not lead to timely allocation of livers to children. It appears that this scoring system underestimates the near-term risk of death. Urgent reassessment is required to prevent potential morbidity and mortality in children. In conclusion the United Network for Organ Sharing policy that permits granting of exceptions has circumvented these problems with the PELD scoring system.

Medication adherence in pediatric and adolescent liver transplant recipients.

OBJECTIVE: Nonadherence to medications is a leading cause of morbidity in children and adolescents who have had a transplant, yet there are no published data about the use of different methods for detecting whether these children are taking their medications. There are also no published data about the age of transition at which a child assumes responsibility over taking the medications. This information is important if interventions to improve adherence are contemplated. METHODS: We present an analysis of data obtained in the first year of the implementation of an adherence assessment protocol at a pediatric liver transplant clinic in a tertiary medical care center. Data were obtained for children and adolescents who had a liver transplant at least 1 year before the assessments took place. We used 5 adherence detection methods. The 4 subjective methods were self-reported, scaled questionnaires answered by nurses, physicians, caregivers, and patients. For the objective method, a standard deviation (SD) was calculated for tacrolimus blood levels obtained from each patient over time. A higher SD suggests increased variation among patients' blood levels and hence more erratic medication taking. We also asked the patients and caregivers who is responsible for taking the medications and what are the reasons for not taking them. The medical outcome measures were biopsy-proven rejection episodes, number of biopsies regardless of the results, number of hospital admissions, and number of in-patient days. RESULTS: An analysis of 81 cases (258 assessments) revealed that the only method that predicted the medical outcome variables (biopsy-proven rejection and number of biopsies) was the SD of medication blood levels. Patients', clinicians', and caregivers' reports were not predictive. Clinicians' ratings of adherence were not correlated with patients' or caregivers'. The transition of responsibility for medication taking occurred approximately at the age of 12 years. Forgetfulness was cited as the most common reason for nonadherence by patients and caregivers; medication side effects were not frequently cited. CONCLUSIONS: Our results indicate that clinical impression is not sufficient to determine whether children and adolescents are taking their medications after they have had a liver transplant. An objective assessment method should be used. Interventions targeting adherence should address the child's increasing role beginning in early adolescence. A clinical protocol incorporating objective assessments of adherence could potentially be implemented in other settings. It could form the basis for the evaluation of efficacy of interventions seeking to improve adherence to medications.

Living liver donors: a coordinator's perspective.

Living donor liver transplantation is an acceptable alternative for many patients awaiting a liver transplant. The benefits of living donor liver transplantation to the recipient are many; however, there is also an appreciable risk to the donor. Many people, including healthcare professionals, believe that living donor liver transplantation is not ethically justified because any risk to a donor outweighs the benefit to the recipient. Recent studies show adverse events in this population do not include only medical complications; any complication-medical, social, psychological, financial, or other--must be examined to analyze the true incidence of adverse outcomes in living liver donors.