Prioritizing patients for hip fracture surgery: the role of frailty and cardiac risk.

Introduction: The number of patients with hip fractures continues to rise as the average age of the population increases. Optimizing outcomes in this cohort is predicated on timely operative repair. The aim of this study was to determine if patients with hip fractures who are frail or have a higher cardiac risk suffer from an increased risk of in-hospital mortality when surgery is postponed >24 h. Methods: All patients registered in the 2013-2021 TQIP dataset who were ≥65 years old and underwent surgical fixation of an isolated hip fracture caused by a ground-level fall were included. Adjustment for confounding was performed using inverse probability weighting (IPW) while stratifying for frailty with the Orthopedic Frailty Score (OFS) and cardiac risk using the Revised Cardiac Risk Index (RCRI). The outcome was presented as the absolute risk difference in in-hospital mortality. Results: A total of 254,400 patients were included. After IPW, all confounders were balanced. A delay in surgery was associated with an increased risk of in-hospital mortality across all strata, and, as the degree of frailty and cardiac risk increased, so too did the risk of mortality. In patients with OFS ≥4, delaying surgery >24 h was associated with a 2.33 percentage point increase in the absolute mortality rate (95% CI: 0.57-4.09, p = 0.010), resulting in a number needed to harm (NNH) of 43. Furthermore, the absolute risk of mortality increased by 4.65 percentage points in patients with RCRI ≥4 who had their surgery delayed >24 h (95% CI: 0.90-8.40, p = 0.015), resulting in a NNH of 22. For patients with OFS 0 and RCRI 0, the corresponding NNHs when delaying surgery >24 h were 345 and 333, respectively. Conclusion: Delaying surgery beyond 24 h from admission increases the risk of mortality for all geriatric hip fracture patients. The magnitude of the negative impact increases with the patient's level of cardiac risk and frailty. Operative intervention should not be delayed based on frailty or cardiac risk.

Cardiac risk stratification and adverse outcomes in surgically managed patients with isolated traumatic spine injuries.

INTRODUCTION: As the incidence of traumatic spine injuries has been steadily increasing, especially in the elderly, the ability to categorize patients based on their underlying risk for the adverse outcomes could be of great value in clinical decision making. This study aimed to investigate the association between the Revised Cardiac Risk Index (RCRI) and adverse outcomes in patients who have undergone surgery for traumatic spine injuries. METHODS: All adult patients (18 years or older) in the 2013-2019 TQIP database with isolated spine injuries resulting from blunt force trauma, who underwent spinal surgery, were eligible for inclusion in the study. The association between the RCRI and in-hospital mortality, cardiopulmonary complications, and failure-to-rescue (FTR) was determined using Poisson regression models with robust standard errors to adjust for potential confounding. RESULTS: A total of 39,391 patients were included for further analysis. In the regression model, an RCRI ≥ 3 was associated with a threefold risk of in-hospital mortality [adjusted IRR (95% CI): 3.19 (2.30-4.43), p < 0.001] and cardiopulmonary complications [adjusted IRR (95% CI): 3.27 (2.46-4.34), p < 0.001], as well as a fourfold risk of FTR [adjusted IRR (95% CI): 4.27 (2.59-7.02), p < 0.001], compared to RCRI 0. The risk of all adverse outcomes increased stepwise along with each RCRI score. CONCLUSION: The RCRI may be a useful tool for identifying patients with traumatic spine injuries who are at an increased risk of in-hospital mortality, cardiopulmonary complications, and failure-to-rescue after surgery.

Contemporary Management and Outcomes of Blunt Traumatic AAST-OIS Grade III and IV Pancreatic Injuries in Children: A TQIP analysis.

BACKGROUND: The Trauma Quality Improvement Program (TQIP) database has delineated management strategies and outcomes for adults with AAST-OIS grade III-IV pancreatic injuries and suggests that non-operative management (NOM) is a viable option for these injuries. However, management strategies vary for children following significant pancreatic injuries and outcomes for these intermediate/high grade injuries have not been sufficiently studied. Our aim is to describe the management and outcomes for grade III-IV pancreatic injuries utilizing TQIP. We hypothesize that pediatric patients with intermediate/high grade injuries can be safely managed with NOM. METHODS: All pediatric patients (<18 years old) registered in TQIP between 2013-2021 who suffered a grade III or IV pancreatic injury due to blunt trauma were included in the current study. Patient demographics, clinical characteristics, complications, and in-hospital mortality were compared between the different treatment strategies for pancreatic injury: NOM versus drainage and/or pancreatic resection. RESULTS: 580 patients meeting criteria were identified. A total of 416 pediatric patients suffered a grade III pancreatic injury; 79% (N = 332) were NOM, 7% (N = 27) received a drain, and 14% (N = 57) underwent a pancreatic resection. A further 164 patients suffered a grade IV pancreatic injury; 77% (N = 126) were NOM, 11% (N = 18) received a drain, and 12% (N = 20) underwent a pancreatic resection. No differences in overall injury severity or demographical data were observed between the treatment groups. No difference in in-hospital mortality was detected between the different management strategies. Patients who received a drain had a longer hospital length of stay (LOS). CONCLUSION: The majority of children with AAST-OIS grade III-IV pancreatic injuries are managed nonoperatively. NOM is a reasonable strategy for these injuries and results in equivalent in-hospital adverse outcome profiles as pancreatic drainage or resection with a shorter hospital LOS. LEVEL OF EVIDENCE: Level III.

Predictors of outcomes in geriatric patients with moderate traumatic brain injury after ground level falls.

Introduction: The elderly population constitutes one of the fastest-growing demographic groups globally. Within this population, mild to moderate traumatic brain injuries (TBI) resulting from ground level falls (GLFs) are prevalent and pose significant challenges. Between 50 and 80% of TBIs in older individuals are due to GLFs. These incidents result in more severe outcomes and extended recovery periods for the elderly, even when controlling for injury severity. Given the increasing incidence of such injuries it becomes essential to identify the key factors that predict complications and in-hospital mortality. Therefore, the aim of this study was to pinpoint the top predictors of complications and in-hospital mortality in geriatric patients who have experienced a moderate TBI following a GLF. Methods: Data were obtained from the American College of Surgeons' Trauma Quality Improvement Program database. A moderate TBI was defined as a head AIS ≤ 3 with a Glasgow Coma Scale (GCS) 9-13, and an AIS ≤ 2 in all other body regions. Potential predictors of complications and in-hospital mortality were included in a logistic regression model and ranked using the permutation importance method. Results: A total of 7,489 patients with a moderate TBI were included in the final analyses. 6.5% suffered a complication and 6.2% died prior to discharge. The top five predictors of complications were the need for neurosurgical intervention, the Revised Cardiac Risk Index, coagulopathy, the spine abbreviated injury severity scale (AIS), and the injury severity score. The top five predictors of mortality were head AIS, age, GCS on admission, the need for neurosurgical intervention, and chronic obstructive pulmonary disease. Conclusion: When predicting both complications and in-hospital mortality in geriatric patients who have suffered a moderate traumatic brain injury after a ground level fall, the most important factors to consider are the need for neurosurgical intervention, cardiac risk, and measures of injury severity. This may allow for better identification of at-risk patients, and at the same time resulting in a more equitable allocation of resources.

Tourniquet self-application assessment in cold weather conditions.

BACKGROUND: Our study aimed to assess the ability of nonmedical civilians to self-apply extremity tourniquets in cold weather conditions while wearing insulating technical clothing after receiving basic training. METHODS: A field study was conducted among 37 voluntary participants of an expedition party to the Spanish Antarctic base. The researchers assessed the participant's ability to self-apply five commercial extremity tourniquets (CAT, OMNA, RMT, SWAT-T, and RATS) over cold-weather clothing and their achieved effectiveness for vascular occlusion. Upper extremity self-application was performed with a single-handed technique (OHT), and lower extremity applying a two-handed technique (THT). Perceptions of self-application ease mean values ± standard deviation (SD) were compared by applying a 5% statistical significance threshold. Frequency count determined tourniquet preference. RESULTS: All the tested ETs, except the SWAT-T, were properly self-applied with an OHT, resulting in effective vascular occlusion in the upper extremity. The five devices tested were self-applied correctly in the lower extremities using THT. The ratcheting marine-designed OMNA ranked the highest for application easiness on both the upper and lower extremities, and the windlass CAT model was the preferred device by most participants. CONCLUSIONS: Civilian extremity tourniquet self-application on both upper and lower extremities can be accomplished in cold weather conditions despite using cold-weather gloves and technical clothing after receiving brief training. The ratcheting marine-designed OMNA ranked the highest for application ease, and the windlass CAT model was the preferred device.

Adverse outcomes following pelvic fracture: the critical role of frailty.

PURPOSE: Pelvic fractures among older adults are associated with an increased risk of adverse outcomes, with frailty likely being a contributing factor. The current study endeavors to describe the association between frailty, measured using the Orthopedic Frailty Score (OFS), and adverse outcomes in geriatric pelvic fracture patients. METHODS: All geriatric (65 years or older) patients registered in the 2013-2019 Trauma Quality Improvement Program database with an isolated pelvic fracture following blunt trauma were considered for inclusion. An isolated pelvic fracture was defined as any fracture in the pelvis with a lower extremity AIS ≥ 2, any abdomen AIS, and an AIS ≤ 1 in all other regions. Poisson regression models were employed to determine the association between the OFS and adverse outcomes. RESULTS: A total of 66,404 patients were included for further analysis. 52% (N = 34,292) were classified as non-frail (OFS 0), 32% (N = 21,467) were pre-frail (OFS 1), and 16% (N = 10,645) were classified as frail (OFS ≥ 2). Compared to non-frail patients, frail patients exhibited a 88% increased risk of in-hospital mortality [adjusted IRR (95% CI): 1.88 (1.54-2.30), p < 0.001], a 25% increased risk of complications [adjusted IRR (95% CI): 1.25 (1.10-1.42), p < 0.001], a 56% increased risk of failure-to-rescue [adjusted IRR (95% CI): 1.56 (1.14-2.14), p = 0.006], and a 10% increased risk of ICU admission [adjusted IRR (95% CI): 1.10 (1.02-1.18), p = 0.014]. CONCLUSION: Frail pelvic fracture patients suffer from a disproportionately increased risk of mortality, complications, failure-to-rescue, and ICU admission. Additional measures are required to mitigate adverse events in this vulnerable patient population.

Sex disparities in adverse outcomes after surgically managed isolated traumatic spinal injury.

BACKGROUND: Traumatic spinal injury (TSI) encompasses a wide range of injuries affecting the spinal cord, nerve roots, bones, and soft tissues that result in pain, impaired mobility, paralysis, and death. There is some evidence suggesting that women may have different physiological responses to traumatic injury compared to men; therefore, this study aimed to investigate if there are any associations between sex and adverse outcomes following surgically managed isolated TSI. METHODS: Using the 2013-2019 TQIP database, all adult patients with isolated TSI, defined as a spine AIS ≥ 2 with an AIS ≤ 1 in all other body regions, resulting from blunt force trauma requiring spinal surgery, were eligible for inclusion in the study. The association between the sex and in-hospital mortality as well as cardiopulmonary and venothromboembolic complications was determined by calculating the risk ratio (RR) after adjusting for potential confounding using inverse probability weighting. RESULTS: A total of 43,756 patients were included. After adjusting for potential confounders, female sex was associated with a 37% lower risk of in-hospital mortality [adjusted RR (95% CI): 0.63 (0.57-0.69), p < 0.001], a 27% lower risk of myocardial infarction [adjusted RR (95% CI): 0.73 (0.56-0.95), p = 0.021], a 37% lower risk of cardiac arrest [adjusted RR (95% CI): 0.63 (0.55-0.72), p < 0.001], a 34% lower risk of deep vein thrombosis [adjusted RR (95% CI): 0.66 (0.59-0.74), p < 0.001], a 45% lower risk of pulmonary embolism [adjusted RR (95% CI): 0.55 (0.46-0.65), p < 0.001], a 36% lower risk of acute respiratory distress syndrome [adjusted RR (95% CI): 0.64 (0.54-0.76), p < 0.001], a 34% lower risk of pneumonia [adjusted RR (95% CI): 0.66 (0.60-0.72), p < 0.001], and a 22% lower risk of surgical site infection [adjusted RR (95% CI): 0.78 (0.62-0.98), p < 0.032], compared to male sex. CONCLUSION: Female sex is associated with a significantly decreased risk of in-hospital mortality as well as cardiopulmonary and venothromboembolic complications following surgical management of traumatic spinal injuries. Further studies are needed to elucidate the cause of these differences.

A nationwide analysis on the interaction between frailty and beta-blocker therapy in hip fracture patients.

INTRODUCTION: Hip fracture patients, who are often frail, continue to be a challenge for healthcare systems with a high postoperative mortality rate. While beta-blocker therapy (BBt) has shown a strong association with reduced postoperative mortality, its effect in frail patients has yet to be determined. This study's aim is to investigate how frailty, measured using the Orthopedic Hip Frailty Score (OFS), modifies the effect of preadmission beta-blocker therapy on mortality in hip fracture patients. METHODS: This retrospective register-based study included all adult patients in Sweden who suffered a traumatic hip fracture and subsequently underwent surgery between 2008 and 2017. Treatment effect was evaluated using the absolute risk reduction (ARR) in 30-day postoperative mortality when comparing patients with (BBt+) and without (BBt-) ongoing BBt. Inverse probability of treatment weighting (IPTW) was used to reduce potential confounding when examining the treatment effect. Patients were stratified based on their OFS (0, 1, 2, 3, 4 and 5) and the treatment effect was also assessed within each stratum. RESULTS: A total of 127,305 patients were included, of whom 39% had BBt. When IPTW was performed, there were no residual differences in observed baseline characteristics between the BBt+ and BBt- groups, across all strata. This analysis found that there was a stepwise increase in the ARRs for each additional point on the OFS. Non-frail BBt+ patients (OFS 0) exhibited an ARR of 2.2% [95% confidence interval (CI) 2.0-2.4%, p < 0.001], while the most frail BBt+ patients (OFS 5) had an ARR of 24% [95% CI 18-30%, p < 0.001], compared to BBt- patients within the same stratum. CONCLUSION: Beta-blocker therapy is associated with a reduced risk of 30-day postoperative mortality in frail hip fracture patients, with a greater effect being observed with higher Orthopedic Hip Frailty Scores.

The mortality burden of frailty in hip fracture patients: a nationwide retrospective study of cause-specific mortality.

PURPOSE: Frailty is a condition characterized by a reduced ability to adapt to external stressors because of a reduced physiologic reserve, which contributes to the high risk of postoperative mortality in hip fracture patients. This study aims to investigate how frailty is associated with the specific causes of mortality in hip fracture patients. METHODS: All adult patients in Sweden who suffered a traumatic hip fracture and underwent surgery between 2008 and 2017 were eligible for inclusion. The Orthopedic Hip Frailty Score (OFS) was used to classify patients as non-frail (OFS 0), pre-frail (OFS 1), and frail (OFS ≥ 2). The association between the degree of frailty and both all-cause and cause-specific mortality was determined using Poisson regression models with robust standard errors and presented using incidence rate ratios (IRRs) with corresponding 95% confidence intervals (CIs), adjusted for potential sources of confounding. RESULTS: After applying the inclusion and exclusion criteria, 127,305 patients remained for further analysis. 23.9% of patients were non-frail, 27.7% were pre-frail, and 48.3% were frail. Frail patients exhibited a 4 times as high risk of all-cause mortality 30 days [adj. IRR (95% CI): 3.80 (3.36-4.30), p < 0.001] and 90 days postoperatively [adj. IRR (95% CI): 3.88 (3.56-4.23), p < 0.001] as non-frail patients. Of the primary causes of 30-day mortality, frailty was associated with a tripling in the risk of cardiovascular [adj. IRR (95% CI): 3.24 (2.64-3.99), p < 0.001] and respiratory mortality [adj. IRR (95% CI): 2.60 (1.96-3.45), p < 0.001] as well as a five-fold increase in the risk of multiorgan failure [adj. IRR (95% CI): 4.99 (3.95-6.32), p < 0.001]. CONCLUSION: Frailty is associated with a significantly increased risk of all-cause and cause-specific mortality at 30 and 90 days postoperatively. Across both timepoints, cardiovascular and respiratory events along with multiorgan failure were the most prevalent causes of mortality.

Extremity Tourniquet Training at High Seas.

BACKGROUND: Future navy officers require unique training for emergency medical response in the isolated maritime environment. The authors issued a workshop on extremity bleeding control, using four different commercial extremity tourniquets onboard a training sail ship. The purposes were to assess participants' perceptions of this educational experience and evaluate self-application simplicity while navigating on high seas. METHODS: A descriptive observational study was conducted as part of a workshop issued to volunteer training officers. A post-workshop survey collected their perceptions about the workshops' content usefulness and adequacy, tourniquet safety, self-application simplicity, and device preference. Tourniquet preference was measured by frequency count while the rest of the studied variables on a one-to-ten Likert scale. Frequencies and percentages were calculated for the studied variables, and application simplicity means compared using the ANOVA test (p < 0.05). RESULTS: Fifty-one Spanish training naval officers, aged 20 or 21, perceived high sea workshop content's usefulness, adequacy, and safety level at 8.6/10, 8.7/10, and 7.5/10, respectively. As for application simplicity, CAT and SAM-XT were rated equally with a mean of 8.5, followed by SWAT (7.9) and RATS (6.9), this one statistically different from the rest (p < 0.01). Windlass types were preferred by 94%. CONCLUSIONS: The training sail ship's extremity bleeding control workshop was perceived as useful and its content adequate by the participating midshipmen. Windlass types were regarded as easier to apply than elastic counterparts. They were also preferred by nine out of every ten participants.

General Versus Neuraxial Anesthesia for Appendectomy: A Multicenter International Study.

BACKGROUND: In resource-limited countries, open appendectomy is still performed under general anesthesia (GA) or neuraxial anesthesia (NA). We sought to compare the postoperative outcomes of appendectomy under NA versus GA. METHODS: We conducted a post hoc analysis of the International Patterns of Opioid Prescribing (iPOP) multicenter study. All patients ≥ 16 years-old who underwent an open appendectomy between October 2016 and March 2017 in one of the 14 participating hospitals were included. Patients were stratified into two groups: NA-defined as spinal or epidural-and GA. All-cause morbidity, hospital length of stay (LOS), and pain severity were assessed using univariate analysis followed by multivariable logistic regression adjusting for the following preoperative characteristics: age, gender, body mass index (BMI), smoking, history of opioid use, emergency status, and country. RESULTS: A total of 655 patients were included, 353 of which were in the NA group and 302 in the GA group. The countries operating under NA were Colombia (39%), Thailand (31%), China (23%), and Brazil (7%). Overall, NA patients were younger (mean age (SD): 34.5 (14.4) vs. 40.7 (17.9), p-value < 0.001) and had a lower BMI (mean (SD): 23.5 (3.8) vs. 24.3 (5.2), p-value = 0.040) than GA patients. On multivariable analysis, NA was independently associated with less postoperative complications (OR, 95% CI: 0.30 [0.10-0.94]) and shorter hospital LOS (LOS > 3 days, OR, 95% CI: 0.47 [0.32-0.68]) compared to GA. There was no difference in postoperative pain severity between the two techniques. CONCLUSIONS: Open appendectomy performed under NA is associated with improved outcomes compared to that performed under GA. Further randomized controlled studies should examine the safety and value of NA in lower abdominal surgery.

International cooperation group of emergency surgery during the COVID-19 pandemic.

PURPOSE: The COVID-19 pandemic has changed working conditions for emergency surgical teams around the world. International surgical societies have issued clinical recommendations to optimize surgical management. This international study aimed to assess the degree of emergency surgical teams' adoption of recommendations during the pandemic. METHODS: Emergency surgical team members from over 30 countries were invited to answer an anonymous, prospective, online survey to assess team organization, PPE-related aspects, OR preparations, anesthesiologic considerations, and surgical management for emergency surgery during the pandemic. RESULTS: One-hundred-and-thirty-four questionnaires were returned (N = 134) from 26 countries, of which 88% were surgeons, 7% surgical trainees, 4% anesthetists. 81% of the respondents got involved with COVID-19 crisis management. Social media were used by 91% of the respondents to access the recommendations, and 66% used videoconference tools for team communication. 51% had not received PPE training before the pandemic, 73% reported equipment shortage, and 55% informed about re-use of N95/FPP2/3 respirators. Dedicated COVID operating areas were cited by 77% of the respondents, 44% had performed emergency surgical procedures on COVID-19 patients, and over half (52%), favored performing laparoscopic over open surgical procedures. CONCLUSION: Surgical team members have responded with leadership to the COVID-19 pandemic, with crisis management principles. Social media and videoconference have been used by the vast majority to access guidelines or to communicate during social distancing. The level of adoption of current recommendations is high for organizational aspects and surgical management, but not so for PPE training and availability, and anesthesiologic considerations.

Opioids After Surgery in the United States Versus the Rest of the World: The International Patterns of Opioid Prescribing (iPOP) Multicenter Study.

OBJECTIVE: The International Patterns of Opioid Prescribing study compares postoperative opioid prescribing patterns in the United States (US) versus the rest of the world. SUMMARY OF BACKGROUND DATA: The US is in the middle of an unprecedented opioid epidemic. Diversion of unused opioids contributes to the opioid epidemic. METHODS: Patients ≥16 years old undergoing appendectomy, cholecystectomy, or inguinal hernia repair in 14 hospitals from 8 countries during a 6-month period were included. Medical records were systematically reviewed to identify: (1) preoperative, intraoperative, and postoperative characteristics, (2) opioid intake within 3 months preoperatively, (3) opioid prescription upon discharge, and (4) opioid refills within 3 months postoperatively. The median/range and mean/standard deviation of number of pills and OME were compared between the US and non-US patients. RESULTS: A total of 4690 patients were included. The mean age was 49 years, 47% were female, and 4% had opioid use history. Ninety-one percent of US patients were prescribed opioids, compared to 5% of non-US patients (P < 0.001). The median number of opioid pills and OME prescribed were 20 (0-135) and 150 (0-1680) mg for US versus 0 (0-50) and 0 (0-600) mg for non-US patients, respectively (both P < 0.001). The mean number of opioid pills and OME prescribed were 23.1 ±â€Š13.9 in US and 183.5 ±â€Š133.7 mg versus 0.8 ±â€Š3.9 and 4.6 ±â€Š27.7 mg in non-US patients, respectively (both P < 0.001). Opioid refill rates were 4.7% for US and 1.0% non-US patients (P < 0.001). CONCLUSIONS: US physicians prescribe alarmingly high amounts of opioid medications postoperatively. Further efforts should focus on limiting opioid prescribing and emphasize non-opioid alternatives in the US.

Caring for the surgical patient with limited ICU resources.

PURPOSE OF REVIEW: The current review aims to discuss the management of surgical patients in an ICU in countries where resources are limited. RECENT FINDINGS: ICU beds in low-income and middle-income countries (LMICs) are limited and also have limited human and structural resources. The working force has been described to be the costliest factor. Nevertheless, costs for intensive care in LMICs are one third from the cost reported from high-income countries. Alternative options have been described, so intensive care can be delivered outside ICU. Examples are Rapid-Response Systems and Medical Emergency Teams. SUMMARY: The care of the surgical patients in an intensive care setting in countries with resource limitations should be optimized, protocols for standardized care implemented and Better research and resource allocation, as well as investment in healthcare training are essential for the development of intensive care in LMICs is necessary.

Comparative study of abdominal cavity temporary closure techniques for damage control.

The damage control surgery, with emphasis on laparostomy, usually results in shrinkage of the aponeurosis and loss of the ability to close the abdominal wall, leading to the formation of ventral incisional hernias. Currently, various techniques offer greater chances of closing the abdominal cavity with less tension. Thus, this study aims to evaluate three temporary closure techniques of the abdominal cavity: the Vacuum-Assisted Closure Therapy - VAC, the Bogotá Bag and the Vacuum-pack. We conducted a systematic review of the literature, selecting 28 articles published in the last 20 years. The techniques of the bag Bogotá and Vacuum-pack had the advantage of easy access to the material in most centers and low cost, contrary to VAC, which, besides presenting high cost, is not available in most hospitals. On the other hand, the VAC technique was more effective in reducing stress at the edges of lesions, removing stagnant fluids and waste, in addition to acting at the cellular level by increasing proliferation and cell division rates, and showed the highest rates of primary closure of the abdominal cavity. RESUMO A cirurgia de controle de danos, com ênfase em peritoneostomia, geralmente resulta em retração da aponeurose e perda da capacidade de fechar a parede abdominal, levando à formação de hérnias ventrais incisionais. Atualmente, várias técnicas oferecem maiores chances de fechamento da cavidade abdominal, com menor tensão. Deste modo, este estudo tem por objetivo avaliar três técnicas de fechamento temporário da cavidade abdominal: fechamento a vácuo (Vacuum-Assisted Closure Therapy - VAC), Bolsa de Bogotá e Vacuum-pack. Realizou-se uma revisão sistemática da literatura com seleção de 28 artigos publicados nos últimos 20 anos. As técnicas de Bolsa de Bogotá e Vacuum-pack tiveram como vantagem o acesso fácil ao material, na maioria dos centros, e baixo custo, ao contrário do que se observa na terapia a vácuo, VAC, que além de apresentar alto custo, não está disponível em grande parte dos hospitais. A técnica VAC, por outro lado, foi mais eficaz na redução da tensão nas bordas das lesões, ao remover fluidos estagnados e detritos, além de exercer ação a nível celular, aumentando as taxas de proliferação e divisão celular, e apresentou as maiores taxas de fechamento primário da cavidade abdominal.

Discussing the Notion of Decent Work: Senses of Working for a Group of Brazilian Workers without College Education.

Despite recent stability and socioeconomic development, Brazil's history is marked by social inequality, informality, precarious work, and psychosocial vulnerability, with little opportunity for decent and meaningful work, as recommended by the International Labour Office (ILO), for people in the country. Nevertheless, based on a social constructionist view, the hypothesis can be raised that there is no substantive definition of decent work, but rather a psychosocial one, constructed based on the discourse, narratives, and practices produced through the relational processes which grant sense and meaning to work. Therefore, the examination of narratives and discourses is an important methodological strategy to understand the socio-occupational reality of Brazil. Thus, this study aims to understand the senses attributed to working through content analysis of the narratives produced by a set of 20 urban workers and contrast them with the ILO definition of decent work, in an effort to analyze the relationships, similarities, and differences between an established collective social discourse and the interviewees' singular narratives. The main results point out that the participants look for working with fair wages, social protection, safety, and personal development opportunities, as the ILO recommends. The main difference is that these characteristics do not derive from the State's actions, as in the employment and formal qualification model, but come from informal sources, such as family and community relationship networks. The informal relationship networks produce job opportunities as well as social protection; qualification takes place through practical learning from more experienced colleagues; the opportunity to be able to keep working (employed or working informally) leads to success and safety; and the possibility to make choices and have control over one's life translates into personal and occupational development. In conclusion, the participants searched for working according to the principles recommended by the ILO. Nevertheless, in contexts of vulnerability and with restricted support from the State, these principles are constructed in the community and not offered by the public power, which generates distinguished forms of decent work.

Anterior hepatic transection for caudate lobectomy.

Resection of the caudate lobe (segment I- dorsal sector, segment IX- right paracaval region, or both) is often technically difficult due to the lobe's location deep in the hepatic parenchyma and because it is adjacent to the major hepatic vessels (e.g., the left and middle hepatic veins). A literature search was conducted using Ovid MEDLINE for the terms "caudate lobectomy" and "anterior hepatic transection" (AHT) covering 1992 to 2007. AHT was used in 110 caudate lobectomies that are discussed in this review. Isolated caudate lobectomy was performed on 28 (25.4%) patients, with 11 case (11%) associated with hepatectomy, while 1 (0.9%) was associated with anterior segmentectomy. Complete caudate lobectomy was performed on 82 (74.5%) patients. Hepatocellular carcinoma was observed in 106 (96.3%) patients, while 1 (0.9%) had hemangioma and 3 (2.7%) had metastatic caudate tumors. AHT was used in 108 (98.1%) caudate resections, while AHT associated with a right-sided approach was performed in 2 (1.8%) cases. AHT is recommended for tumors located in the paracaval portion of the caudate lobe (segment IX). AHT is usually a safe and potentially curative surgical option.

Hepatic adenoma. Timing for surgery.

BACKGROUND/AIMS: Hepatic adenoma (HA) is a rare benign tumor of the liver. Tumor resection has been recommended for symptomatic or enlarging HA because of the risk of intraperitoneal, intrahepatic hemorrhage or even the development of hepatocellular carcinoma. From 1989 to 2003 we reviewed the medical records and radiology files of 28 patients with a proved diagnosis of hepatic adenoma. This article summarizes a single-center experience with surgical treatment of hepatic adenoma. METHODOLOGY: 24 patients were female and 4 were male. Twenty-two patients had a history of oral contraceptive use. Abdominal pain was presented in 19 patients and 3 of them had had an acute episode. The mean age was 36.3 years. Preoperative assessment included liver test, ultrasonography and computed tomography in all patients plus technetium (99mTc)-sulfur colloid and 99mTc-labeled DISIDA (dimethyliminoacetic acid) liver scintigraphy (n=19) and magnetic resonance imaging (n=22). RESULTS: Operative procedures included enucleation in 3 patients, two of them associated with hepatic segmentectomy; resection of one or two segments in 14 patients; left and right hemihepatectomy respectively in 7 and 3 patients; right extended hepatectomy in one patient and nonanatomic resection in one patient. There was no postoperative death and the complications were: bile leakage (re-operation) one patient, intraperitoneal abscess (re-operation) one patient, pleural effusion two patients, venous thrombosis one patient and wound infection one patient. CONCLUSIONS: We recommend that since the diagnosis has been well-established both enucleation or anatomically based resections of hepatic adenoma should be performed in all cases mainly in female patients taking oral contraceptives with tumors greater than 3cm for the risk of hepatic hemorrhage or even when malignancy cannot be excluded.

Radiofrequency ablation of primary and metastatic liver tumors--4 years experience.

BACKGROUND/AIMS: Radiofrequency ablation of primary and metastatic liver tumors has been shown to be one of the promising new modalities to treat or to palliate liver tumors. It has been used as a bridge to liver transplantation as well as an approach to recurrent tumors after resection. METHODOLOGY: We present a series of 78 cases, 39 females and 39 males with a mean age of 61 years, the RFA has been used either by laparotomy or percutaneously to treat 117 lesions. There were 32 cases of hepatocellular carcinoma, 35 metastases of colorectal cancer and 11 cases of other tumors. RESULTS: The mean number of lesions treated were 1.5 per case with a average size of 3.6 cm per lesion. All liver segments were compromised specially IV, VII, VIII. The morbidity was 28% and the mortality was 2.5%. In 20.5% of the cases we were able to find recurrence after the procedure, with a mean time of 10.5 months. CONCLUSIONS: The RFA procedure is safe, can be performed by different ways and in the group of patients who are candidates to liver transplantation, while waiting for the organ. For the metastatic diseases it does not substitute surgery but can be used in patients who cannot be operated.