Oral retinoids for chemoprevention of skin cancers in organ transplant recipients: results of a survey.

Systemic retinoid therapy is thought to be beneficial for chemosuppression of skin cancers in solid organ transplant recipients. We present the results of a survey of 28 dermatologists with experience managing transplant recipients to clarify when and how systemic retinoids are used in this population. Almost 80% of respondents use retinoids in some transplant recipients. Factors influencing the use of retinoids include the incidence and aggressiveness of cutaneous squamous cell carcinomas and the extent of concomitant actinic keratoses. Patients are monitored more closely during periods of dose adjustment than during the maintenance phase of therapy. Adverse effects are variably managed symptomatically, with dose adjustment, by discontinuation of retinoids, or by referral to another specialist for further evaluation. In the absence of large randomized controlled trials, the practice habits of experienced physicians serve as a useful guide for the use of oral retinoids in transplant recipients.

Estimated blood loss and transfusion requirements of radical cystectomy.

PURPOSE: Radical cystectomy has been associated with significant blood loss and/or transfusion requirement. We defined and characterized blood loss and transfusion parameters in this population. MATERIALS AND METHODS: We reviewed the records of 304 consecutive patients who underwent radical cystectomy and urinary diversion between October 1995 and July 2000. Charts were examined, and univariate and multivariate logistic regression analysis was performed to evaluate estimated blood loss and the transfusion requirement. RESULTS: Complete blood loss data were available in 297 cases. Overall 45% of patients had anemia preoperatively. Median estimated blood loss was 600 ml. (range 100 to 3,000). On univariate analysis increased estimated blood loss was related to patient age, American Society of Anesthesiologists score, longer operative time and paralytic ileus. Overall transfusion was done in 88 of 297 cases (30%) with a median requirement of 2 units (range 1 to 10). The transfusion rate in male and female patients was 26% and 40%, respectively (p <0.05). On univariate analysis female gender, ileal conduit diversion and lower preoperative hematocrit correlated with transfusion need (p = 0.04, <0.001 and <0.001, respectively). On multivariate logistic regression analysis lower preoperative hematocrit, increased estimated blood loss, major complications and ileal conduit diversion type correlated with a higher transfusion rate (odds ratio 8.34, 5.88 and 4.60, respectively). CONCLUSIONS: Acute blood loss anemia is common in patients undergoing radical cystectomy, and predicting blood loss and transfusion requirements remains difficult. These data indicate the need for continued refinement in surgical techniques to decrease blood loss as well as for strategies designed to decrease the need for blood transfusion.

The "Airmedical F.A.S.T." for trauma patients--the initial report of a novel application for sonography.

BACKGROUND: While established as an initial screening tool for the evaluation of injured patients at the trauma center, sonographic evaluation of the patient in the prehospital setting remains untested. The purpose of this study was to determine the feasibility of this procedure during prehospital helicopter transport. METHODS: Two qualified flight surgeons performed all imaging studies. Confirmatory endpoints were documented for all images obtained in flight. RESULTS: For this preliminary study, 100 patients are presented; 84 studies were analyzed; 16 were excluded due to patient weight (8), hemodynamic instability (6), or problems with machine calibration (2). Sensitivity was 81.3%; specificity was 100%. The positive predictive value was 100%; the negative predictive value was 95.7%. The accuracy was 96.4%. CONCLUSION: Sonographic studies obtained during air-medical transport are of similar quality and consistency as those obtained in the emergency department. The ability to detect hemoperitoneum in the field may challenge traditional algorithms for prehospital care as a result.

Efficacy of 24-hour shifts: prepared or impaired? A prospective study.

BACKGROUND: The effect of duty duration on performances is unknown. In a prospective cohort study model using repeated measures, we evaluated the effect of shift length on a battery of neuropsychologic performance indicators using our flight program as the test site. METHODS: Flight nurses completing 24- and 12-hour shifts were tested on memory, attention, reasoning, motor, and speed measures. Ratings of stress, fatigue, sleep quality, and logged amount of work and sleep were evaluated from personal journals kept for this purpose. Data were analyzed by linear regression and repeated measures multivariate analysis of variance (MANOVA) and analysis of variance (ANOVA). Clinical significance was set at P < 0.05. RESULTS: Fifteen subjects completed the testing and evaluation process. Neuropsychologic testing demonstrated that performance was not predicted by shift length, time of shift (day versus night), amount or quality of sleep before or during shift, or fatigue ratings. Age, gender, and education did not mediate shift length/test performance relationships. Uninterrupted sleep, stress ratings, and number of flights per shift modestly reduced some test scores. Predictably, repeated testings resulted in practice effects that reduced analysis power. We found that 24-hour shifts per se do not result in a cognitive decline compared with 12-hour shifts. Inconsistent sleep, number of flights, and the stressfulness of flights may have greater impact.

Trauma triage: do AAMS transport guidelines do it effectively?

PURPOSE: Appropriateness of helicopter transport for trauma patient transfer is under closer scrutiny with the development of regionalized trauma systems and managed care. This study was conducted to determine the effectiveness of the 14 Association of Air Medical Services (AAMS) guidelines in triaging trauma patients. METHODS: The application of the trauma transport guidelines for 511 patients flown to our trauma center with hospital stays of fewer than 3 days were analyzed to ensure high sensitivity to overtriage. Injury severity score (ISS), revised trauma score (RTS), Glasgow coma scale (GCS), and mortality rates associated with each of the guidelines were analyzed. RESULTS: Each guideline was associated with mortality greater than or equal to 20%, except motor vehicle, falls, amputation, and degloving. All guidelines had significant ISS (> 14), RTS (< 10), and GCS (< 12), except falls (ISS-6.7, RTS-11, GCS-13.3) and amputations (ISS-6.3, RTS-11, GCS-13.5). Degloving, motor vehicle, spinal cord, airway, and extrication also had a significantly higher RTS (> 12). CONCLUSION: The AAMS transport guidelines for trauma patients accurately predict the potential for serious or life-threatening injury, with the exception of falls and amputations. The rapid access to highly skilled reimplantation teams required by patients with amputations justifies helicopter transport. However, falls greater than 20 feet do not appear to identify potential for life-threatening injury.