Occupational exposure to platinum drugs during intraperitoneal chemotherapy. Biomonitoring and surface contamination.

BACKGROUND: Hyperthermic intraperitoneal chemotherapy (HIPEC) has been introduced over the last decade for the treatment of peritoneal carcinomatosis. In this procedure, heated cytotoxic drugs are administered directly into the abdominal cavity, ensuring cancer cells to be exposed while reducing systemic toxicity. More recently, pressurized intraperitoneal aerosol chemotherapy (PIPAC), where the chemotherapeutic drug is injected into the peritoneal cavity as an aerosol under pressure, has been proposed to patients in palliative situation, as a new approach. The amount of drug used is up to 10 fold lower than in HIPEC. The use of cytotoxic drugs poses an occupational risk for the operating room personnel. This study investigated the potential exposure of the medical staff by biomonitoring and surface contamination measurements, during a HIPEC procedure and a PIPAC procedure. METHOD: Wipe samples were collected from various locations in operating rooms including gloves, hands, devices and floor. Urines samples were collected from 10 volunteers of the medical staff and from a control group. The platinum analysis was performed by inductively coupled plasma mass spectrometry. RESULTS: Significant contaminations were observed on the floor, gloves, shoes and devices. However, urinary platinum was below the limit of quantification (<10 ng/L) for more than 50% of samples from the healthcare workers performing HIPEC and PIPAC. Concentrations did not differ significantly from those reported for the control group. CONCLUSION: There appears to be little risk of exposure to platinum drugs during HIPEC and PIPAC providing the adequate safety measures are implemented.

Cost analysis of percutaneous fixation of hand fractures in the main operating room versus the ambulatory setting.

PURPOSE: To date, there have been no studies identifying the cost differential for performing closed reduction internal fixation (CRIF) of hand fractures in the operating room (OR) versus an ambulatory setting. Our goal was to analyse the cost and efficiency of performing CRIF in these two settings and to investigate current practice trends in Canada. METHODS: A detailed analysis of the costs involved both directly and indirectly in the CRIF of a hand fracture was conducted. Hospital records were used to calculate efficiency. A survey was distributed to practicing plastic surgeons across Canada regarding their current practice of managing hand fractures. RESULTS: In an eight-hour surgical block we are able to perform five CRIF in the OR versus eight in an ambulatory setting. The costs of performing a CRIF in the OR under local anaesthetic, not including surgeon compensation, is $461.27 Canadian (CAD) compared to $115.59 CAD in the ambulatory setting, a 299% increase. The use of a regional block increases the cost to $665.49 CAD, a 476% increase. The main barrier to performing CRIFs in an outpatient setting is the absence of equipment necessary to perform these cases effectively, based on survey results. CONCLUSION: The use of the OR for CRIF of hand fractures is associated with a significant increase in cost and hospital resources with decreased efficiency. For appropriately selected hand fractures, CRIF in an ambulatory setting is less costly and more efficient compared to the OR and resources should be allocated to facilitate CRIF in this setting.

Wolf Piranha Versus Lumenis VersaCut Prostate Morcellation Devices: A Prospective Randomized Trial.

PURPOSE: Holmium laser enucleation of the prostate for the management of benign prostatic hyperplasia involves the 2 steps of enucleation and morcellation. Few prostate morcellation devices are available. In this study we compare the Wolf Piranha and Lumenis® VersaCut™ prostate morcellation devices. MATERIALS AND METHODS: After institutional review board approval and patient informed consent, a prospective, randomized trial was initiated for patients with symptomatic benign prostatic hyperplasia undergoing holmium laser enucleation of the prostate. All procedures were performed by a single surgeon (JEL) at Indiana University Health Methodist Hospital using the Piranha or VersaCut prostate morcellation device. Patient demographics, and preoperative, intraoperative and postoperative data for patients in the 2 treatment groups were analyzed and compared in a prospective fashion. RESULTS: A total of 74 patients were enrolled and randomized for the treatment device. Both groups were comparable in terms of age, prostate specific antigen and prostate size. There was no difference in patient demographic and preoperative characteristics. The Piranha achieved a slightly higher morcellation rate at 5.6 gm per minute (range 1.4 to 18), compared to the VersaCut at 4.8 gm per minute (range 1.3 to 9.5). However, the difference was not statistically significant (p = 0.14). Cost analysis (USD per patient) favored the VersaCut ($241 vs $471, p <0.001). CONCLUSIONS: Morcellation rates for the Piranha and VersaCut prostate morcellation devices are comparable, with the Piranha having a statistically significant increased cost. The Wolf Piranha also has a more complicated design, making it less user-friendly for the operating room staff and, therefore, more difficult to troubleshoot than the Lumenis VersaCut. Nevertheless, 75% of urology faculty, fellows and residents preferred the Piranha over the VersaCut, reporting that when working properly, it was more efficient in tissue removal.

Ex vivo comparison of available morcellation devices during holmium laser enucleation of the prostate through objective parameters.

UNLABELLED: BACKGROUND and Purpose: Holmium laser enucleation of the prostate (HoLEP) is a recognized option for surgical management of benign prostatic hyperplasia (BPH). While laser parameters and enucleation techniques have been widely investigated, morcellation techniques remain poorly evaluated in the literature. Our goal was to objectively evaluate the available devices used for morcellation during HoLEP. MATERIAL AND METHODS: An in vitro evaluation of two morcellators (Lumenis and Wolf) and two nephroscopes (Wolf and Storz) was conducted. For morcellators, the following parameters were assessed: Aspiration power (time to aspirate 1 L of water), morcellation power (g of baked chicken meat morcellated in 2 minutes), and visual control of the cutting part of the device (visible or not visible). For nephroscopes, data collected were: Field of vision (measured on a 4 cm distant sight) and irrigation flow (time needed to drain a 3-liter bag of water suspended at 1 m of height). RESULTS: For the Wolf and Lumenis morcellators, aspiration power parameters were 20.4 mL/s and 22.2 mL/s, and morcellating power parameters were 2.5 g and 6 g of tissue per minute, respectively. The cutting part of the Wolf morcellator was permanently under control during the procedure, whereas the distal part of the cutting device was out of vision control with the Lumenis. Evaluation of Storz and Wolf nephroscopes showed that field of vision was larger with the Storz, and irrigation flow was 0.35 and 0.52 L/min, respectively. CONCLUSIONS: The Storz nephroscope has a greater field of vision but less important blood flows. The Lumenis morcellator is faster than the Wolf morcellator. These objective data could set up the basis for a prospective trial comparing the two devices.

Neurosurgery in India: an overview.

This overview of neurosurgery in India during the last six decades gives a holistic perspective of the phenomenal advances made. Neurosurgical education, the change in clinical spectrum of diseases and their presentation, evolution of various subspecialties and societies, the state of research, the issues peculiar to India, including the urban-rural health divide, the increasing role of information and communication technology in neurosurgery, and the gradual but definite global recognition of Indian neurosurgery will be addressed.

Minimizing the risk of non-vertical, non-sexual HIV infection in children--beyond mother to child transmission.

After witnessing an episode of poor injection safety in large numbers of children in a rural under-resourced hospital in Uganda, we briefly review our own experience and that of others in investigating HIV infection in children considered unlikely to be through commonly identified routes such as vertical transmission, sexual abuse or blood transfusion. In the majority of cases, parents are HIV uninfected. The cumulative experience suggests that the problem is real, but with relatively low frequency. Vertical transmission is the major route for HIV to children. However, factors such as poor injection safety, undocumented surrogate breast feeding, an HIV-infected adult feeding premasticated food to a weaning toddler, poor hygienic practice in the home and using unsterilised equipment for minor surgical or traditional procedures are of cumulative concern.

The use of xylazine hydrochloride in an analgesic protocol for claw treatment of lame dairy cows in lateral recumbency on a surgical tipping table.

The objective of this study was to investigate the effect of xylazine on the stress and pain response of lame cows undergoing claw treatment in lateral recumbency (LR). Twenty-four lame, German Holstein-Friesian cows were included in a prospective, blinded, placebo-controlled clinical case study. Cows were randomly allocated to two groups (n=12) and either treated with xylazine (0.05 mg/kg BW, i.m.) or an equal volume of saline (controls) 15 min before placing them in LR. Before surgical treatment, each cow received retrograde intravenous local anaesthesia (LA). Over a period of 6h, heart rate (HR), respiratory rate (RR), plasma concentrations of cortisol, glucose, lactate and non-esterified fatty acids (NEFA) were determined at preset time intervals and the animals' behaviour was recorded via video recording and pedometer. All xylazine-treated cows showed signs of mild sedation, a reduced pain response on insertion of the needle for LA, reduced ear flicking during surgery, reduced lameness score and longer standing periods as well as improved appetite in the first hour postoperatively. Mean HR and RR, as well as plasma concentrations of NEFA were significantly reduced after xylazine treatment. Cortisol concentrations were significantly lower in xylazine-treated cows after being placed in LR but were similar to controls during surgery. The use of a low dose of xylazine in the analgesic protocol for the treatment of lame cows in LR alleviates stress and potentiates the analgesic effects of LA.

Medical care issues in Japan highlighted by the regulatory approval of the da Vinci Surgical System.

Twelve years have passed since the emergence of the da Vinci Surgical System in the medical field, and highly advanced medical technology continues to develop rapidly. Surgeons are on a mission to provide better medical service every day. Yet, the Japanese Ministry of Health, Labour, and Welfare is taking a conservative stance against medical advancement. Two major issues that puzzle surgeons are the time-consuming process and delay in approval of medical devices, and limitations on health insurance coverage. The author of this article insists that now is the time to speak up for the reality that the more medical technology develops, the higher the costs that are necessary. He believes that all who are involved need to come together to share values for a better perspective.

Impact of clean delivery kit use on clean delivery practices in Beni Suef Governorate, Egypt.

OBJECTIVE: A major factor contributing to neonatal and maternal infections is unhygienic delivery practices. This study explores the impact of clean delivery kit (CDK) use on clean delivery practices during home and facility deliveries. DESIGN: Kits were distributed from primary care facilities and mothers and birth attendants received training on kit importance and use. The study was designed as a cross-sectional cohort study. Raedat (community health workers) visited 349 women during the postpartum period to administer a structured questionnaire. SETTING: The study was conducted from mid-March through mid-July 2001 in two rural areas of Ihnasia district in Beni Suef Governorate (Upper Egypt). RESULT: In bivariate analysis, CDK users in the home were more likely to report that the birth attendant had clean hands (P<0.001), washed/wiped the mother's perineum (P<0.001), used a sterile cord tie (P=0.001), applied antiseptic to the cord after cutting (P<0.001), and used a sterile cord cover (P<0.001) as compared with non-CDK users. CDK users at the facility were more likely to report that the birth attendant washed/wiped the mothers perineum (P=0.049) and used a sterile cord cover (P=0.030) as compared with non-CDK users. CONCLUSION: In settings in which unhygienic practices during home as well as facility deliveries are prevalent, use of inexpensive CDKs can promote clean delivery practices.

The use of cell salvage during obstetric procedures: an audit of Scotland's maternity units.

BACKGROUND: Concerns about the safety and supply of donor blood mean that clinicians are increasingly looking for alternatives to allogenic blood transfusion. One such alternative is cell salvage. Theoretical concerns about the safety of giving salvaged blood to obstetric patients have so far limited its use in maternity patients, but its use in obstetrics is now growing. AIMS: To determine how many Scottish maternity units use cell salvage and what barriers anaesthetists see to its use in obstetrics. METHODS: A survey was posted to one consultant anaesthetist at each of Scotland's 18 consultant led maternity units. RESULTS: Two out of 18 maternity units in Scotland use cell salvage. Perceived barriers to use include lack of machine, insufficient cases and lack of familiarity with the technology. Only 4/15 anaesthetists saw safety concerns as a barrier to using the technology. CONCLUSION: It would appear that practical issues such as staff training and maintaining familiarity with the technology are greater barriers to the use of cell salvage during obstetric procedures than concerns over safety or financial costs. Although cell salvage would appear to be safe, its use in obstetrics must be accompanied by ongoing audit and detailed data should be collected for each case.

World's first magnetic resonance imaging/x-ray/operating room suite: a significant milestone in the improvement of neurosurgical diagnosis and treatment.

OBJECT: In February 2006, the magnetic resonance/x-ray/operating room (MRXO) suite opened at the authors' institution. This is the first hybrid neurosurgical procedure suite to combine magnetic resonance (MR) imaging, computed tomography (CT), and angiography within a neurosurgical operating room (OR). In the present paper the authors describe the concept of the MRXO as well as their first 10 months of experience using this suite, and discuss its advantages and limitations. METHODS: In the MRXO suite, the combined OR and angiography (OR-angiography) station is located in the middle of the suite, and the MR imaging and CT scanning stations are each installed in an adjoining bay connected to the OR-angiography station by shielded sliding doors. The surgical, MR imaging, angiography, and CT tables are positioned in order of use. The patient lies on a fully MR imaging- and radiography-compatible mobile patient tabletop that is used to move the patient quickly and safely among the tables in the imaging and operating components of the MRXO suite. RESULTS: The authors performed all interventional procedures safely. The specially designed operating tabletop of the MRXO suite reduced the limitations on neurosurgeons during standard neurosurgical procedures. This hybrid suite helps to provide high-quality intraoperative imaging, greatly reducing the risk of unexpected events during the procedure. CONCLUSIONS: The MRXO suite, which combines OR and imaging equipment, represents a significant milestone in the improvement of neurosurgical diagnosis and treatment and other interventional procedures. Another advantage of the MRXO suite is its cost-effectiveness, which is partly due to its streamlined imaging procedure.

The use of curare during anesthesia to prevent iatrogenic muscle damage caused by lumbar spinal surgery through a posterior approach.

STUDY DESIGN: Prospective randomized study of patients undergoing lumbar arthrodesis. OBJECTIVES: To evaluate the use of curare during anesthesia to limit muscle lesions caused by surgery. SUMMARY OF BACKGROUND DATA: It has been shown that lumbar spine surgery through a posterior approach can induce iatrogenic lesions in the erector spinae. The prevention of these lesions by intraoperative cholinergic blockade has never been evaluated. METHODS: Twenty patients scheduled to undergo pedicle-screw enhanced L4-L5 arthrodesis were enrolled in this study. The average age was 48.9 years. Ten patients received curare during anesthesia and 10 patients did not. Postoperative pain was assessed using a visual analog scale (VAS) and the consumption of morphine by patient-controlled analgesia during the first 24 hours. Intramuscular pressure (IMP) in the multifidus was monitored during the intervention. A biopsy of the multifidus muscle was performed at the end of the intervention for histologic study. Serum activity of the MM iso-enzyme of the creatine phosphokinase (CPK-MM) was measured 24 hours after surgery. RESULTS: The average consumption of morphine and the mean value of the VAS at 24 hours were not statistically different between these 2 groups. The use of a self-retaining retractor during lumbar surgery resulted in a substantial increase in IMP, resulting in histologic muscle lesions and an increase in serum CPK-MM activity. There was no significant difference between the 2 groups of patients. CONCLUSIONS: The use of curare during anesthesia did not limit the muscle damage caused by surgery.

Double-clip technique in cataract surgery using topical anesthesia.

We describe a simple technique that reduces the effect of blepharospasm in the presence of sub-Tenon's or topical anesthesia without the administration of a lid block or a reduction in adequate analgesia.