Comparative effectiveness of surgeon-performed transversus abdominis plane blocks and epidural catheters following open hernia repair with transversus abdominis release.

PURPOSE: Recovery protocols aim to limit narcotic administration following ventral hernia repair (VHR). However, little is known about the contribution of a protocol's individual components on patient outcomes. We previously reported that surgeon-performed transversus abdominis plane block (TAP-block) is more effective than ultrasound-guided TAP-block following VHR. This study evaluates the effectiveness of two postoperative analgesia modalities: epidural catheter and surgeon-performed TAP-block following VHR performed with transversus abdominis release (TAR). METHODS: A retrospective analysis was performed on data prospectively collected between 2012 and 2019. All patients undergoing open VHR with TAR performed by a single surgeon were identified. Parastomal hernia repairs and any patients receiving ultrasound-guided TAP blocks or paraspinal blocks were excluded. Primary outcome was length of stay (LOS) with secondary outcomes including pain scores, opioid requirements, and 30-day morbidity. Linear regression was used to model LOS. RESULTS: One hundred thirty-five patients met inclusion criteria (63 epidural, 72 TAP-block). The majority (67.4%) of patients were modified ventral hernia working group grade 2. The only statistically significant difference in postoperative pain scores between the groups was on postoperative day 2 (TAP block 3.19 versus epidural 4.11, p = 0.0126). LOS was significantly shorter in the TAP block group (4.7 versus 6.2 days, p = 0.0023) as was time to regular diet (3.2 versus 4.7 days, p < 0.0001). After controlling for confounders, epidural was associated with increased LOS by 1.3 days (p = 0.0004). CONCLUSION: Epidural use following VHR with TAR is associated with increased LOS and increased time to regular diet without reducing pain or opioid use when compared to surgeon-performed TAP block.

Changes in the lateral abdominal wall following endoscopic subcutaneous anterior component separation.

PURPOSE: Although changes in lateral abdominal wall musculature after posterior component separation with transversus abdominis release have been investigated, the effects of endoscopic subcutaneous anterior component separation (ES-ACS) on postoperative muscle anatomy have not been evaluated. The purpose of this study was to evaluate changes in the lateral abdominal muscles after ES-ACS. METHODS: Computed tomography (CT) images of patients who underwent ES-ACS were retrospectively evaluated. Lateral abdominal wall thickness and external oblique displacement were measured at the level of fixed retroperitoneal structures. Measurements on the ES-ACS side were compared with those on the contralateral undivided side or with preoperative images in patients with bilateral procedures. RESULTS: Fifteen patients met the criteria for study inclusion. Most patients (n = 13, 86.7%) underwent unilateral ES-ACS. The most commonly performed procedure was laparoscopic intraperitoneal onlay mesh-plus hernia repair (n = 12, 80.0%; the remaining patients underwent open repair). The Mean defect width was 8.4 cm (range 6-15 cm). There was no difference in the thickness of the lateral abdominal musculature between ES-ACS and undivided sides. There was a significant lateral displacement of the external oblique muscle from the lateral edge of the rectus abdominis on the ES-ACS side (mean distance 3.7 cm; p = 0.0006). No midline hernia recurrences, iatrogenic linea semilunaris hernias, or lateral eventrations were observed during a mean follow-up period of 2.6 years (range 0.5-7.4 years). CONCLUSION: ES-ACS resulted in no atrophy of the lateral abdominal muscles in long-term CT follow-up. The procedure is a safe and effective adjunct to complex hernia repair in selected patients.

A case of extensive Aplasia Cutis Congenita with underlying skull defect and central nervous system malformation: discussion of large skin defects, complications, treatment and outcome.

Aplasia Cutis Congenita (ACC) is a rare condition characterized by the absence of a portion of skin at birth. Skin defects are usually small (0.5 to 3 cm) and located on the scalp. Although there can be other physical or genetic abnormalities, ACC is most often a benign isolated condition. Rarely is an underlying bony defect present, and this association increases the rate of complications. We report a case of a newborn male with ACC of the entire crown and vertex scalp, non-ossified parietal skull and dysplastic corpus callosum. The patient's skull and skin defects were treated non-surgically, and he recovered well.

Eccrine angiomatous hamartoma: a report of symmetric and painful lesions of the wrists.

Eccrine angiomatous hamartoma (EAH) is a rare, benign cutaneous lesion histologically defined as a proliferation of eccrine glands within a closely associated vascular stroma. Typically EAH presents as a solitary flesh-colored, hyperhidrotic, painful papule or plaque appearing at birth or during childhood. Only two previously reported cases have been described involving multiple, symmetrically located lesions. The occurrence of knuckle pads in patients with EAH has not been reported. We present an instance of multiple painful EAH lesions occurring symmetrically on the extensor wrists in a 14-year-old girl with knuckle pads.

Characteristics and quality of Papanicolaou smears obtained by primary care clinicians using a single commercial laboratory.

BACKGROUND: Few data are available on factors associated with the quality of Papanicolaou smears performed in primary care. OBJECTIVE: To identify the patterns and proficiency of cervical cancer screening among different primary care specialties. MATERIALS AND METHODS: Clinical and cytologic data from 21,833 Papanicolaou smears, submitted to a single large commercial laboratory by 176 clinicians during a 7-month period, were correlated with individual clinician and specialty characteristics according to indexes of specimen quality. RESULTS: Obstetrician-gynecologists, nurse practitioners, and physician assistants provided screening to a younger population of women compared with family physicians, internists, and general practitioners. Factors positively associated with a greater probability of a "satisfactory" smear or the presence of endocervical cells (as a marker of adequate sampling) were increasing patient age, use of the cytobrush, and the specialty of the obstetrician-gynecologist. Satisfactory smears were not associated with any increased identification of cytologic abnormalities compared with "limited" smears. In contrast, smears with endocervical cells showed a higher proportion of abnormalities compared with specimens without such cells. CONCLUSIONS: Differences in the performance of obtaining Papanicolaou smears exist between primary care specialties, but need further clarification. The use of the cytobrush and the presence of endocervical cells are criteria that reflect clinician proficiency more realistically than the laboratory criterion of satisfactory smear.

The effect of the quality of Papanicolaou smears on the detection of cytologic abnormalities.

BACKGROUND: Controversy continues regarding the relation between the quality of Papanicolaou (Pap) smears, especially the presence of endocervical cells (ECC), with the finding of cytologic abnormalities. METHODS: As part of a study regarding performance feedback on the quality of Pap smears, data from 56,475 Pap smears obtained by 176 participating clinicians over a 20-month period were analyzed to assess the relation between the presence of ECC, the categorization of global specimen adequacy as "satisfactory" or "satisfactory with limitations," and the prevalence of atypia and squamous intraepithelial lesions (SILs). RESULTS: Atypia was less likely to be found in "satisfactory" Pap smears than in "satisfactory with limitations" quality Pap smears (odds ratio [OR], 0.6; 95% confidence interval [CI], 0.5-0.6; P < 0.001), even though the latter could contain ECC. No association was found between satisfactory Pap smears and cytologic abnormalities. Compared with specimens with no ECC, an ECC count of > or = 50 on a slide was associated positively with the detection of atypia (OR, 2.1; 95% CI, 1.8-2.4; P < 0.001) or SILs (OR, 1.7; 95% CI, 1.3-2.2; P < 0.001). A similar relation existed between ECC counts of 25-50 (OR, 1.9; 95% CI, 1.1-2.2; P = 0.01) and the detection of SILs. No relation was found between specimens with < 25 ECC and the presence of atypia or abnormalities. CONCLUSIONS: The global adequacy criterion of "satisfactory" assigned to a Pap smear does not indicate that there is a greater likelihood of detecting cytologic abnormalities compared with lower quality Pap smears. To the authors' knowledge, previous studies regarding the link between ECC in the Pap smear and cytologic abnormalities have not addressed the relevance of how many ECC are needed to maximize the identification of abnormalities. The data from the current study support the value of obtaining at least 25 ECC as a quality indicator of sampling.

Recall and treatment decisions of primary care providers in response to Pap smear reports.

INTRODUCTION: Although the frequency of cervical cancer screening has been extensively studied, little is known about how clinicians decide to screen or recall patients for Pap smears. This study reports the management decisions made by office-based clinicians for 10 different Pap smear reports describing adequacy limitations and cytological diagnoses. METHODS: We surveyed 186 clinicians using a commercial laboratory in the southeastern United States and analyzed results by frequency and comparison statistics. RESULTS: Our respondents were 148 clinicians (79.6% response rate) from different specialties. There was variation in reported management of inflammation, atypia, and low-grade abnormalities (LGSIL), in regard to recall for repeat or routine testing as well as arranging colposcopy. In only 3 of 10 Pap smear results did more than 50% of respondents agree on a specific test recall interval. CONCLUSIONS: The variation in responses from office-based clinicians suggests either uncertainty or different opinions in making recall and treatment decisions for smears of limited quality even when associated with cytologic abnormalities. These differences may have relevance to outcomes, clinician workload, and costs of care in cervical cancer screening.

Perceptions and opinions on the performance of Pap smears: a survey of clinicians using a commercial laboratory.

Office-based clinicians play a major role in cervical cancer screening in the United States, but little is known about their specific knowledge and understanding of the technical aspects of obtaining an adequate Pap smear. We surveyed 186 office-based clinicians using a major commercial laboratory for cytology services to obtain their opinions regarding the technical adequacy of Pap smears, collection procedures, and methods of communicating test results to patients. There was an 80.1% response rate. Two thirds of the respondents were men. Cytobrush use was reported significantly more by female clinicians. Respondents varied in reported rotation of the cytobrush, from 90 degrees to greater than 360 degrees. More female than male clinicians appropriately indicated that inflammation and heavy vaginal discharge caused sampling difficulties. Approximately half of the respondents believed that errors in cervical screening most often resulted from sampling the cervix or preparation of the Pap smear. Nineteen percent reported that ectocervical cells were not necessary for an adequate smear to be reported. Just over 25% of respondents indicated they did not report normal Pap smear results to the patient. The results indicate differences between clinicians by gender and specialty in reported knowledge, understanding, and technique in cervical cancer screening. The differences suggest that targeted education in this population may be important to improve the quality of cervical cancer screening. Medical Subject Headings (MeSH): screening; neoplasms, cervical; Papanicolaou smear; diagnosis, laboratory.

The quality of cervical cancer screening: a primary care perspective.

The bulk of cervical cancer screening is performed by primary care providers; mostly nurses and physicians. The literature regarding the quality of this screening is largely described from three perspectives; clinical, laboratory, and public health. This article describes the primary care perspective regarding issues of quality in cervical cancer screening and suggests areas for improvement. The authors discuss how effectiveness of the test, sampling methods, interpretation by the laboratory, and reporting results impact on the quality of cervical cancer screening. Other factors which influence the quality of screening such as access to care, recall intervals, communication with the patient, costs of testing, and organizational issues are also reviewed.

Changing trends in the management of splenic injury.

BACKGROUND: A gradual change in the management of splenic injuries has occurred at our institution. This study was therefore undertaken to determine whether changes in management of splenic injury influenced outcomes during the past 30 years. PATIENTS AND METHODS: A retrospective study of patients admitted with splenic trauma between 1965 and 1994 was performed. Two hundred seven patients were identified and demographic and outcome data were recorded. Patients were then grouped based upon the period in which they received treatment (ie, Period I [1965 to 1974], Period II [1975 to 1984], and Period III [1985 to 1994]), and the type of treatment received (ie, splenectomy, splenorrhaphy, or observation). RESULTS: More patients were treated in Period III than in the other two periods, and Period III patients had shorter hospital stays. Splenectomy was solely used during Period I; splenorrhaphy and observation were occasionally performed during Period II; and splenectomy, splenorrhaphy, and observation were performed in near-equal numbers during Period III. Mortality was similar for each period, though Injury Severity Scores (ISS) were higher during later years. When compared by treatment modality, patients receiving splenectomy had higher ISS and splenic injury classifications. CONCLUSION: Patients treated by splenorrhaphy and observation for splenic injury have markedly increased over the past 30 years without adverse outcome.

General practitioners' background knowledge of their patients.

The aim of the study was to describe the background knowledge of their patients used by general practitioners in decision making in the consultation. Tape-recorded interviews with 22 general practitioners randomly selected from one FHSA, concerning 198 consultations, were used. General practitioners were asked to describe their background knowledge of the first ten patients seen that day, and to describe how their management decisions were influenced by this information. The interviews were analysed from transcripts. All except one doctor appeared to identify patients as 'copers' or 'non-copers'. Decisions which appeared to be linked with coping were: (1) expecting them to have a physical illness; (2) offering reassurance, expecting that to be effective; (3) deciding that there was no need to take action; (4) allowing the patient to decide on some aspect of management. Decisions linked with not coping were: (1) to look for a psychological diagnosis; (2) to offer reassurance, but expecting that not to be effective; (3) to examine or refer because of the doctor's perception of the patient's expectations. General practitioners also appeared to make decisions based on their perception of their patients' social support. If there was thought to be adequate support, or no social stress, the doctors decided (1) to look for a physical diagnosis; (2) to leave some decisions to the patient; (3) not to involve outside agencies in management; and (4) to ignore those areas of the patient's life which were thought not to be a problem. If doctors believed that there were problems with support, they seemed to try to give more of their time, and to refer or investigate more.(ABSTRACT TRUNCATED AT 250 WORDS)

Total intravenous anesthesia using propofol and alfentanil for coronary artery bypass surgery.

Total intravenous anesthesia (TIVA) using alfentanil and propofol was used in 10 patients undergoing coronary artery bypass grafting. In an attempt to diminish unwanted side effects, lower doses were chosen than if either drug had been used alone. Anesthesia was induced with alfentanil, 75 micrograms/kg, followed by a sleep dose of propofol (mean dose 0.5 mg/kg). Maintenance in the precardiopulmonary bypass (CPB) period was achieved by infusions of propofol (6 mg/kg/h) and alfentanil (100 micrograms/kg/h). These were decreased by two thirds on commencement of CPB, and increased to half the initial rate on rewarming to 32 degrees C. Additional boluses of alfentanil were used to control breakthrough hypertension. The mean arterial pressure (MAP) and left ventricular stroke work index (LVSWI) fell significantly on induction. MAP but not LVSWI returned to baseline levels at skin incision. The cardiac index (CI) was maintained. A degree of myocardial depression was suggested by a fall in LVSWI despite maintaining preload, and by the failure of CI to increase in the presence of a reduced SVR. Anesthesia was satisfactory in all but one patient who developed breakthrough hypertension on sternotomy with transient ST segment depression, and awareness after CPB despite a plasma alfentanil concentration of 450 ng/mL. Mean time to wakening was 55 minutes. The study indicated that TIVA using propofol and alfentanil in the dosages described provides satisfactory basal anesthesia for coronary artery bypass surgery in patients with good left ventricular function, but requires additional pharmacologic manipulation, particularly with boluses of alfentanil, to control breakthrough hypertension.

The effect of dopamine on graft function in patients undergoing renal transplantation.

We studied the effect of a low-dose dopamine infusion on graft function in 60 patients undergoing transplantation with cadaveric kidneys in a prospective controlled trial. Recipients were allocated to either a control or a dopamine group, the latter receiving a 3 micrograms.kg-1 x min-1 infusion of dopamine starting intraoperatively. Evaluation of dopamine's effect was undertaken in two stages, namely, (i) initial graft function 1 wk after transplantation and (ii) graft survival at 3 mo. Initial graft function was determined by the ability of the transplanted kidney to reduce serum creatinine, and the development of acute tubular necrosis as confirmed by renal biopsy. Of the dopamine group 33.3% developed acute tubular necrosis compared to 23.3% of the control group. The second-stage evaluation was based on plasma creatinine levels and the requirement for dialysis within 3 mo of transplantation. 92.8% of the dopamine group and 76.9% of the control group had good graft function. No statistically significant difference between the two groups was found. The perioperative infusion of dopamine at 3 micrograms.kg-1 x min-1 was not shown to have any beneficial effect on the transplanted kidney in patients who do not have serious vascular disease, or who do not receive kidneys subjected to prolonged hypotension or prolonged preservation or anastomotic times.

Insulin-like growth factor (IGF)-I, -II and IGF binding protein-2 (IGFBP-2) in the plasma of children with Wilms' tumour.

Insulin-like growth factors (IGF)-I, -II and IGF binding protein-2 (IGFBP-2) have been measured in plasma of children with Wilms' tumour. The mean levels for total serum IGF-I and -II were not significantly altered in Wilms' tumour as compared with normal control plasma. However, the chromatographic profiles for IGF-I and -II in these groups were different with regard to the presence of IGF binding proteins and high molecular weight forms of IGFs; the high molecular weight form (9-15 kD) of IGF-II was significantly reduced in Wilms' tumour. Levels of IGFBP-2 were substantially elevated in serum from Wilms' tumour patients (1025 +/- 112 ng/ml compared with 416 +/- 44 ng/ml in controls), and inversely correlated with the levels of high molecular weight forms of IGF-II. We suggest that IGFBP-2 measurements might be of value as a marker for monitoring this type of tumour, either as an adjunct to diagnosis or surveillance of tumour growth during therapy.

Postoperative intensive care and the South African Society of Anaesthetists' patient category.

A group of 412 postoperative patients admitted to an intensive care unit of an academic hospital were evaluated in terms of their need for intensive care. The Acute Physiology and Chronic Health Evaluation score, the Therapeutic Intervention Scoring System (TISS) and the South African Society of Anaesthetists' (SASA) patient category were utilised to determine the level of care required by each patient. A further objective of the study was to determine if the SASA patient category, on its own, adequately described the need for intensive care in postoperative patients. Evaluation of the data indicated that, in terms of TISS, 66% of the patients required intensive care. These patients were distributed throughout all three SASA categories. Of the 137 patients who, according to TISS, did not require intensive care, 122 were SASA category 3 patients. However, of the total number of category 3 patients, just less than half required intensive care. In order to identify better those patients within a specific SASA category who require intensive care we suggest further subdivision of each category into groups A, B and C, according to the number of TISS points scored at 24 hours postoperation. In this way a retrospective audit using SASA categories would clearly identify those postoperative patients who required intensive care.

Laparoscopic cholecystectomy during pregnancy in symptomatic patients.

BACKGROUND: The management of symptomatic biliary tract disease during pregnancy is controversial. Although most patients receive temporizing medical therapy, some authors have advocated a more aggressive surgical approach. We have extended this surgical approach to include laparoscopic cholecystectomy. METHODS: Five women with pregnancies at 13 to 23 weeks' estimated gestational age underwent laparoscopic cholecystectomy for symptomatic cholelithiasis or acute cholecystitis between March and September 1991. RESULTS: No complications occurred, and the postoperative courses of all patients were unremarkable. Four patients have been delivered of healthy babies, and the fifth patient is still pregnant at the time of this report. CONCLUSIONS: Laparoscopic cholecystectomy appears to be a safe treatment for selected patients with symptomatic biliary tract disease during pregnancy. Further study is warranted to determine its proper role in managing this difficult clinical problem.