Thoracoscopic sympathectomy for hyperhidrosis palmaris: a periareolar approach.

Severe hyperhidrosis palmaris represents a disabling problem for many patients. Thoracoscopic techniques that involve dissection and removal of the upper thoracic sympathetic chain are believed to result in the lowest incidence of recurrent symptoms. However, aside from an axillary incision, an additional upper anterior chest wall approach is usually required. Over the past 2 years, we have used a periareolar incision in eight patients to improve postoperative cosmesis for this benign condition.

Risk factors associated with postoperative pulmonary complications following total abdominal hysterectomy.

The purpose of this descriptive correlational study was to describe the relationships between risk factors and the development of postoperative pulmonary complications (PPCs) following total abdominal hysterectomy (TAH). As part of a large, prospective study, data were analyzed on a subset of women who had undergone TAH. Data collection included a preoperative interview and chest exam followed by a daily postoperative interview, chest exam, and review of the medical chart. A multicriteria definition of PPC was used for atelectasis/pneumonia. This study describes the incidence of PPCs in a TAH surgical population and provides foundational work to begin identifying important risk factors to guide pulmonary care.

Esophageal cancer: an overview.

Esophageal cancer is the second most common solid intrathoracic malignancy behind lung cancer. Treatment of esophageal cancer is dependent upon the stage of presentation and the options include chemotherapy, radiation therapy, surgery, multimodality therapy, or palliative care. Early detection of this disease is the primary method to decrease its high morbidity and mortality.

How and when to reference.

References are not after thoughts, they are critical parts of a quality manuscript. The reference section is often one of the first sections of a manuscript the editor looks at to see if the author has used the journal's guidelines and format. It tells the editor and the reviewer if the author knows the field of research, how her or his idea fits, and pays attention to details. This experienced reviewer, who has identified some trends in manuscript referencing problems, gives advice on how to avoid these problems.

Validation of a predictive model for postoperative pulmonary complications.

OBJECTIVE: To test or validate a previously reported model for predicting postoperative pulmonary complications (PPCs) after elective abdominal surgical procedures. DESIGN: Prospective, descriptive. SETTING: Four midwestern hospitals serving a diverse population of patients. PATIENTS: Two hundred seventy-six adult patients who had undergone abdominal surgery (51% men, 49% women; mean age 54.1 +/- 5.3 years). OUTCOME MEASURES: PPC developed in 26.4%. DATA COLLECTION: Data were collected preoperatively during a brief interview and a pulmonary physical examination and on the first 6 postoperative days. RESULTS: A six risk-factor model was tested in this sample of subjects. The model validated relatively well in the sample of 276 subjects with use of the basic criteria of correct classification, sensitivity, and specificity. However, when a new model was developed from this sample, differing risk factors emerged as significant independent predictors. CONCLUSIONS: Further research is needed to assess the stability of the risk factors and test the models in differing settings and populations of patients.

Predictors of postoperative pulmonary complications following abdominal surgery.

STUDY OBJECTIVE: To determine how risk factors could be combined to best predict the development of a postoperative pulmonary complication (PPC) following abdominal surgery. DESIGN: Prospective model-building study. Logistic regression models were developed using significant risk factors identified in the univariate analysis. SETTING: Four midwestern hospitals. PATIENTS: Convenience sample of 400 patients who underwent abdominal surgical procedures between January 1993 and August 1995. MEASUREMENTS AND RESULTS: Multicriteria outcome for postoperative pulmonary complication used to collectively assess atelectasis and pneumonia. Twenty-three risk factors were assessed. Six risk factors were identified as independent by logistic regression: age > or = 60 years (adjusted odds ratio [Adj OR], 1.89); impaired preoperative cognitive function (Adj OR, 5.93); smoking history within the past 8 weeks (Adj OR, 2.27); body mass index > or = 27 (Adj OR, 2.82); history of cancer (Adj OR, 2.23); and incision site-upper abdominal or both upper/lower abdominal incision (Adj OR 2.30). CONCLUSIONS: These results provide a framework for identifying patients at risk of developing a PPC following abdominal surgery. A reliable and valid risk index could be used clinically to guide preoperative and postoperative pulmonary care and target limited resources for patients at risk.

Environments that support ethical practice.

Our healthcare system is fundamentally flawed in the ability to provide quality end-of-life care. The provision of quality end-of-life care involves a complex interaction of personal, professional, and societal values and practices. Attention to each dimension of end-of-life care is essential to improve the care of the dying patient and his/her family. Given the complexity of this problem, this article focuses on the critical care environment and the aspect of organizational culture and specific strategies for improvement. Several inter-related components of an environment which may foster ethical thinking, decision-making, and behaviors are discussed including organizational culture, individual agency, collaboration, and educational resources. Every member of the healthcare team has the responsibility to be a catalyst for creating a critical care environment where ethical practice is expected and rewarded rather than punished and suppressed. As a healthcare team, our ultimate goal is to provide healing and humane end-of-life care for all patients and families.

The effects of swaddling versus standard positioning on neuromuscular development in very low birth weight infants.

A randomized control design was used to compare the effect of swaddling to standard positioning on neuromuscular development in very low birth weight (VLBW) infants (< 1,250 gm). The outcome of neuromuscular development was measured at 34 weeks postconceptional age using the Morgan Neonatal Neurobehavioral Exam (MNNE). The sample included 50 infants who met criteria for birth weight, age and who were classified as appropriate for gestational age. Exclusion criteria were also used. The infants were randomly assigned to the experimental group or the comparison group. Data analysis included descriptive and inferential statistical techniques. The results demonstrated that swaddled infants had higher total scores on the MNNE as compared to infants with standard positioning. Swaddling appears to be a positioning technique that can enhance neuromuscular development of the very low birth weight infant.

Postoperative atelectasis and pneumonia: risk factors.

Postoperative pulmonary complications frequently lead to increased patient morbidity and mortality, hospital length of stay, and resource utilization. Atelectasis and infectious complications account for the majority of reported pulmonary complications. Risk factors are thought to exaggerate pulmonary function deterioration, which occurs both during and after surgical procedures. This article reviews the literature and describes risk factors frequently identified in relation to pre-, intra-, and postoperative settings, impact of each risk factor on pulmonary function, and issues related to risk factor evaluation. Eighteen risk factors are reviewed regarding their pathophysiologic impact on pre-, intra-, and postoperative pulmonary function. Key issues related to risk factor evaluation are also discussed. Identification of risk factors and prediction of postoperative pulmonary complications are important. Early identification of patients at risk for postoperative pulmonary complications can guide our respiratory care to prevent or minimize these complications.

Postoperative atelectasis and pneumonia.

Postoperative pulmonary complications, specifically atelectasis and pneumonia, are the leading cause of postoperative morbidity and death. It is crucial that the clinician have a thorough understanding of the pathophysiology, risk factors, and scientific basis for currently used respiratory interventions to tailor the patient's care in the preoperative, intraoperative, and postoperative settings. Given the changing healthcare environment and increasing economic constraints, all respiratory interventions must be reevaluated for use in patient care, keeping in mind the factors of scientific basis, patient needs, appropriate utilization, and quality patient outcomes.

Reviewing manuscripts: developing an efficient system.

By focusing on accuracy, organization, and clarity you can develop an efficient system for reviewing manuscripts. This experienced reviewer tells you what to focus on in your manuscript review.

Development of a predictive model for postoperative pulmonary complications after cholecystectomy.

The purpose of this study was to develop a model to predict the occurrence of a postoperative pulmonary complication (PPC) following cholecystectomy. Seventeen potential risk factors were extracted from the literature by identifying and ranking those most frequently referenced. The study included only those risk factors available to the nurse in the preoperative, intraoperative, and immediate postoperative setting. Three institutions were used for data collection, and data were collected by a retrospective chart review of 300 randomly chosen subjects from a population of 720. Of the 300 subjects, 37 were omitted due to exclusion criteria. A PPC was present in 54 of the remaining 263 subjects (20.5%). Of the original 17 risk factors, 10 were included in model development. The 54 subjects with a PPC and 54 subjects without a PPC (randomly chosen from the remaining 209) were used to determine which combination of risk factors best predicted subject classification (PPC or no PPC). The direct entry discriminant function that provided the highest percentage of correct classification (PPC, no PPC) consisted of five variables: sex, age, smoking history, duration of anesthesia, and nasogastric tube. The resulting equation correctly classified 75% of the cases.

Thrombolytic intervention and its effect on mortality in acute myocardial infarction: review of clinical trials.

A review of six thrombolytic trials utilizing the endpoint of mortality shows that thrombolytic therapy and time to treatment are essential elements in reducing the mortality associated with acute MI. As a critical care nurse, one must incorporate this knowledge when putting this therapy into clinical practice. Clinical trials have demonstrated that thrombolytic therapy can indeed reduce mortality, but one must critically examine study data. It is difficult to compare the results of different studies with varying inclusion-exclusion criteria, sample size, study designs, and interventions. At present, it appears that t-PA plus heparin and aspirin therapy produces the lowest mortality at 14 days, 30 days, and 3 months after MI. In addition, the time-critical nature of thrombolytic therapy must be ingrained in the critical care nurse's assessment process. To reduce mortality in the patient with acute MI, assessment and initiation of therapy must be prompt.