Nonsurgical Setting Research Articles

Bilateral and Recurrent Myositis Ossificans in an Athlete: A Case Report and Review of Treatment Options

Miller AE, Davis BA, Beckley OA. Bilateral and recurrent myositis ossificans in an athlete: a case report and review of treatment options. An unusual case of recurrent myositis ossificans (MO) bilaterally in the hamstring muscles of a 47-year-old athlete secondary to trauma is presented with a review of the literature of current treatment options. MO is a common condition that occurs among athletes in association with muscle and/or tendon strain or contusion. After an extensive literature review, we believe this to be the first case reported of recurrent and bilateral MO in a nonsurgical setting from recurrent hamstring strains. Plain radiographs and physical examination revealed the appearance and chronology of this pathology. Treatment options to improve flexibility and decrease morbidity are discussed along with prophylaxis for future injury. Treatment of mobility and flexibility, rehabilitation goals and treatment with nonsteroidal anti-inflammatory drugs, bisphosphonates, and magnesium are discussed along with prophylaxis.

Factor V Leiden and perioperative risk.

Factor V Leiden (FVL) is the most common known inherited cause of thrombophilia; it is present in approximately 5% of the Caucasian population. Although the risk of venous thrombosis associated with this polymorphism in various medical settings is well described, its effect on perioperative risk is only beginning to be explored. Specifically, there are few studies addressing the potential risks of FVL in the surgical population, in which both hemorrhagic and thrombotic complications convey substantial clinical and economic significance. There are speculations and unproven hypotheses regarding FVL in this population, and these therefore highlight the need to comprehensively address this issue. This review will describe the physiology of the FVL mutation, briefly clarify its risk in the nonsurgical setting, and assess current data regarding FVL in noncardiac and cardiac surgery. Finally, a summary of current clinical evidence and a plan for more detailed investigation of this potentially significant risk factor will be proposed.

Attitudes Toward Randomized, Controlled Trials in Surgery: Opinions of Gynecologists of the Gruppo Italiano di Studio sull'Endometriosi

In order to assess barriers and the attitudes of gynecologists toward randomized controlled trials (RCT) in surgery for endometriosis, we identified 62 gynecologists affiliated with the Gruppo Italiano di Studio sull'Endometriosi and sent them a questionnaire. A total of 52 (83.9%) gynecologists completed and sent it back to the coordinating center. Most gynecologists strongly agreed or agreed that RCTs should be the study design of choice for evaluating surgical procedures, but 66% also strongly agree/agree that RCTs are best suited to nonsurgical setting. With regard to the feasibility of RCT in surgery, there was a high level (>50%) of agreement with the statement: RCTs are insufficiently funded; the surgical community gives to RCTs too low priority; patients are unlikely to accept random allocation. A total of 43% agree or strongly agree that there is often consensus on new procedures without the need for RCTs, but 49% disagree or strongly disagree. Considering the statements on methodological problems in conducting RCTs in surgery, the main one was that comparisons of new and standard surgical procedures are often basically flawed because they cannot be performed with equal skill. This analysis indicates that RCTs are perceived as an important choice in the development of surgical treatments. However lack of funding, the impression that patients are unlikely to accept randomization, and the idea that comparison of new and old surgical procedures is flawed by the lack of skill in new procedures are important barriers to RCT in this field.

Safety and efficacy of methods for reducing perioperative allogeneic transfusion: a critical review of the literature.

A number of pharmacologic and nonpharmacologic technologies are in current use to minimize perioperative homologous blood use. Clinical trials, many of them randomized controlled trials, have been done evaluating these approaches and have demonstrated their efficacy. However, data on safety has relied mostly on case reports, uncontrolled studies, and, for the pharmacologic agents, extrapolation from the nonsurgical setting. In this review I analyze the data from the randomized trials and the lower-level evidence studies to provide the best estimates in safety with these alternatives. In general, these alternatives are safe with proper dosing and monitoring of effects. With aprotinin, the primary concern is anaphylaxis, and this predominantly with re-exposure. With aprotinin and with the anti-fibrinolytics, increased venous thromboembolic risk has not been a consistent finding. Tranexamic acid use intraoperatively is advantageous, but postoperative use appears to have no advantage and may be associated with renal dysfunction. DDAVP is low-risk, provided it is not overused, which can induce hyponatremia. Autologous predonation probably has similar risks as homologous blood with respect to transfusion errors and bacterial infection. As with most medical interventions, we must be vigilant to prevent human error.

Can Tissue Engineering Mend Broken Hearts?

Cardiac tissue engineering is an emerging field that may hold great promise for advancing the treatment of heart diseases. Cardiac tissue engineering is in its infancy, and the overall field of tissue engineering, which was formalized in the late 1980s at conferences and workshops sponsored by the National Science Foundation, is still new enough to warrant some description. By broad definition, tissue engineering involves the construction of tissue equivalents through the manipulation and combination of living cells and biomaterials. It is a multidisciplinary field combining diverse aspects of the life sciences, engineering, and clinical medicine. The overall goal of tissue engineering is to develop tissue equivalents for use in the repair, replacement, maintenance, or augmentation of tissues or organs. Although some aspects of cardiac tissue engineering research have been ongoing for generations, albeit without being known as such, directed efforts in the field are only beginning. The main justification for cardiac tissue engineering initiatives is straightforward: congenital and acquired heart diseases are substantial health problems, and there is a limited amount of donor tissue for use in surgical repairs. Heart defects are the most common congenital defect and are the leading cause of death in the first year of life.1,2⇓ Congenital heart defects may occur in as many as 14 of every 1000 live births,3 and approximately 25 000 surgical procedures are performed each year to correct them. Acquired heart diseases also have a profound effect on the population, and despite tremendous advances in medical and surgical treatments, it is estimated that each year 20 000 to 40 000 Americans could benefit from a heart transplant.4 Unfortunately, fewer than 2500 heart transplants are performed each year.4,5⇓ One of the principal reasons for the disparity between patient need and procedures performed is the lack of …

The impact of a 10-year audit cycle on blood usage in a district general hospital.

As clinical governance moves from concept to practice, it is emerging as a realistic strategy to promote and improve quality within the National Health Service, as well as satisfying the demand for external accountability. In the context of blood transfusion, the area of responsibility encompasses product liability, as well as efficient use of blood as a resource and transfusion as an appropriate clinical response. Clinical governance may be a modern catch phrase, but the principles it enshrines have long been established within blood transfusion, and in other aspects of haematology. Here, an audit cycle comprising four audits over a 10-year period to monitor the use of cross-matched blood in a large district general hospital is described. Initially, blood use was considered by hospital site, and by the surgical procedure for which it was requested. Later, the scope of the audit was expanded to consider usage by individual consultant. A standard of efficient use of cross-matched blood was taken to be a cross-match to transfusion ratio of < 1.5. The information was reviewed by the hospital transfusion committee, who have a key role in co-ordinating and assessing the practice of transfusion within a hospital. In this hospital, audit has been one of the main tools for improving practice, in particular by enabling the implementation and continuous revision of a maximum blood order schedule. Further, as the process of audit has developed, problem areas have been highlighted, and strategies to improve usage have been brought in with encouraging results. The audit is now being expanded again to include a greater focus on usage of cross-matched blood in the nonsurgical setting.

Genetic basis of procoagulant and fibrinolytic perioperative adverse events

Thrombotic adverse outcomes contribute to significant morbidity and mortality after major invasive surgery. Surgery creates an acute phase or ‘stress’ response, that causes the release of prothrombotic proteins and thrombocytosis. Some patients exhibit an exaggerated response. In cardiothoracic surgery the same acute phase response contributes to a variety of adverse outcomes from abnormal bleeding to coronary artery thrombosis and stroke. A number of genetic variants or polymorphisms have been elucidated that have bearing on peri-operative risk and adverse outcomes. These polymorphisms have been correlated with venous thrombosis, accelerated atherosclerosis, unstable angina and acute myocardial infarction (MI) in the non-surgical setting. The contribution of these polymorphisms to adverse outcomes after surgery is being investigated. By understanding some key polymorphisms and potentially testing for them in the future, we may be better able to target expensive pharmacological therapies as well as predicting or preventing certain adverse prothrombotic outcomes.

Estrogen deficiency, obesity, and skeletal abnormalities in follicle-stimulating hormone receptor knockout (FORKO) female mice.

Targeted disruption of the receptor for glycoprotein hormone, FSH (FSH-R) causes a gene dose-related endocrine and gametogenic abnormality in female mice. The resulting FSH-R knockout (FORKO) mutants have disordered estrous cycles, ovulatory defects, and atrophic uterus. The heterozygous animals that initially show reduced fertility undergo early reproductive senescence and stop breeding altogether. Lack of FSH-R signaling in females causes severe ovarian underdevelopment producing chronic estrogen deficiency. This was accompanied by increases in serum testosterone levels. Ovarian aromatase gene transcription and translation are unaltered in the mutants. Early loss of estrogen in the null mutants leads to obesity and skeletal abnormalities that intensify with age producing (kyphosis), a hunchback appearance. Both these changes also become apparent in older heterozygous mice coincident with early reproductive senescence. The expression of nuclear estrogen receptor(s) alpha and beta genes and the corresponding proteins in the ovary and uterus of FORKO mice appear to be intact. The loss of ovarian estrogen creates an imbalance in A and B forms of the progesterone receptor in the uterus of both heterozygotes and null mutants. Some of the changes we have documented here in FORKO mice are reminiscent of the ovarian dysfunction and other major symptoms that are usually associated with estrogen deficiency. In null mutants, estradiol-17beta administration promptly induced uterine growth and reversed the accumulation of adipose tissue indicating that estrogen receptors are functional. Thus, the phenotypes evident in these genetically altered FSH-R mutants may provide an experimental system to explore the effects of estrogenic compounds on different targets including the ovary in a nonsurgical setting.

Estrogen Deficiency, Obesity, and Skeletal Abnormalities in Follicle-Stimulating Hormone Receptor Knockout (FORKO) Female Mice

Targeted disruption of the receptor for glycoprotein hormone, FSH (FSH-R) causes a gene dose-related endocrine and gametogenic abnormality in female mice. The resulting FSH-R knockout (FORKO) mutants have disordered estrous cycles, ovulatory defects, and atrophic uterus. The heterozygous animals that initially show reduced fertility undergo early reproductive senescence and stop breeding altogether. Lack of FSH-R signaling in females causes severe ovarian underdevelopment producing chronic estrogen deficiency. This was accompanied by increases in serum testosterone levels. Ovarian aromatase gene transcription and translation are unaltered in the mutants. Early loss of estrogen in the null mutants leads to obesity and skeletal abnormalities that intensify with age producing (kyphosis), a hunchback appearance. Both these changes also become apparent in older heterozygous mice coincident with early reproductive senescence. The expression of nuclear estrogen receptor(s) α and β genes and the corresponding proteins in the ovary and uterus of FORKO mice appear to be intact. The loss of ovarian estrogen creates an imbalance in A and B forms of the progesterone receptor in the uterus of both heterozygotes and null mutants. Some of the changes we have documented here in FORKO mice are reminiscent of the ovarian dysfunction and other major symptoms that are usually associated with estrogen deficiency. In null mutants, estradiol-17β administration promptly induced uterine growth and reversed the accumulation of adipose tissue indicating that estrogen receptors are functional. Thus, the phenotypes evident in these genetically altered FSH-R mutants may provide an experimental system to explore the effects of estrogenic compounds on different targets including the ovary in a nonsurgical setting.

Atrial fibrillation after cardiac operation: risks, mechanisms, and treatment

Atrial fibrillation (AF) is a common complication of cardiac operations that leads to increased risk for thromboembolism and excessive health care resource utilization. Advanced age, previous AF, and valvular heart operations are the most consistently identified risk factors for this arrhythmia. Dispersion of repolarization leading to reentry is believed to be the mechanism of postoperative AF, but many questions regarding the pathophysiology of AF remain unanswered. Treatment is aimed at controlling heart rate, preventing thromboembolic events, and conversion to sinus rhythm. Multiple investigations have examined methods of preventing postoperative AF, but the only firm conclusions that can be drawn is to avoid β-blocker withdrawal after operation and to consider β-blocker therapy for other patients who may tolerate these drugs. Preliminary investigations showing sotalol and amiodarone to be effective in preventing postoperative AF are encouraging, but early data have been limited to selective patient populations and have not adequately evaluated safety. Newer class III antiarrhythmic drugs under development may have a role in the treatment of postoperative AF, but the risk of drug-induced polymorphic ventricular tachycardia must be considered. Nonpharmacologic interventions under consideration for the treatment of AF in the nonsurgical setting, such as automatic atrial cardioversion devices and multisite atrial pacing, may eventually have a role for selected cardiac surgical patients.

Improving Neurologic Outcome after Cardiac Surgery

Improving Neurologic Outcome after Cardiac Surgery

Adverse effects of methods for minimizing perioperative allogeneic transfusion: A critical review of the literature

T RANSMISSION of human immunodeficiency virus (HIV) and hepatitis from allogeneic blood products has led to marked improvements in the safety of the blood supply but also has led to a dramatic increase in the use of various methods of decreasing allogeneic transfusion. Other adverse effects of allogenic blood products, such as bacterial contamination, transfusion reactions, graftversus-host disease, alloimmunization to donor blood components, and a possible immunosuppressive effect, have contributed to the continuing demand for alternative products and blood conservation methods. Both pharmacological and nonpharmacological technologies to minimize perioperafive transfusion are available. Pharmacological agents include aprotinin, desmopressin, tranexamic acid, epsilon-aminocaproic acid, and erythropoietin. The latter can be used alone or in conjunction with predonation of autologous blood. Nonpharmacological techniques include intraoperative and postoperative cell salvage devices and the rapidly growing technique of predonation of autologous blood. The clinical trials that have been done evaluating these approaches have been concerned primarily with the efficacy of these interventions. Therefore, infon-nation about their safety has relied mostly on case reports, uncontrolled studies, and, for the pharmacological agents, extrapolation from the nonsurgical setting. This review is an attempt to synthesize the evidence available in the literature concerning the safety of these blood conservation methods in adults undergoing elective surgery. The emphasis is mostly on clinically important adverse

Detection of p53 gene mutations in cytopathology and biopsy specimens from patients with lung cancer.

In order to ascertain the feasibility of detecting p53 gene mutations in patients with lung cancer in a nonsurgical diagnostic setting before starting treatment, we screened for p53 gene mutations in tumor specimens obtained using diagnostic methods such as fiberoptic bronchoscopy, thoracentesis, and percutaneous needle aspiration. We examined 206 specimens from 66 patients diagnosed with primary lung cancer at Hiroshima University Hospital between October 1991 and July 1993 using the polymerase chain reaction/denaturing gradient gel electrophoresis technique. p53 gene mutations were found in 64 of 159 (40%) cytologically positive specimens, but in none of 47 cytologically negative specimens. The PCR-based assay did not increase the sensitivity of the cytopathologic examination in detecting malignant cells. The type and location of the p53 gene mutation was the same in cytologically positive specimens obtained by different methods, but from the same patient. Of the 66 patients, p53 gene mutations were found in 27 (41%) at the time of the first nonsurgical diagnostic examination: 7 of 12 (58%) with small cell carcinoma, 9 of 20 (45%) with squamous cell carcinoma, and 11 of 34 (32%) with adenocarcinoma of the lung. The incidence of p53 gene mutation for each histologic subtype was comparable to previously published data examining surgically and/or autopsy-obtained specimens. These results indicate that detection of p53 gene mutations in a nonsurgical, diagnostic setting is feasible. This technique will make it possible to assess the significance of p53 gene mutations in relation to survival and response to therapy before starting treatment, in future prospective studies.

Improved patient survival after cardiac arrest using a cardiopulmonary support system

A portable cardiopulmonary bypass system that can be rapidly deployed in a nonsurgical setting using nursing staff was used in 38 patients with cardiovascular collapse refractory to ACLS protocol. Percutaneous or cutdown cannulation sites were: femoral vein-femoral artery (n = 18), right internal jugular vein-femoral artery (n = 2), right atrium-ascending aorta (n = 12), or a combination approach (n = 4). Two patients could not be cannulated. Patient diagnoses were pulmonary emboli (n = 3), failed coronauy angioplasty (n = 7), myocardial infarction with cardiogenic shock (n = 5), trauma (n = 7), aortic stenosis (n = 2), postcardiotomy deterioration (n = 10), deterioration after cardiac transplantation (n = 2), cardiomyopathy with shock (n = 1), and ruptured ascending aortic dissection (n = 1). Ninety-five percent of patients (36 of 38) were successfully resuscitated to a stable rhythm. Eight diagnostic procedures (coronary angiography, n = 4; pulmonary angiography, n = 3; and aortography, n = 1) were performed while patients were on cardiopulmonary support. Early deaths resulted from massive hemorrhage (n = 8), inability to cannulate (n = 2), and irreversible myocardial injury (n = 10). Sixty-six percent (24 of 36) of patients successfully cannulated underwent conversion to standard cardiopulmonary bypass with attendant operative procedure or placement of ventricular assist device or total artificial heart. Fifty percent (18 of 36) of patients cannulated were successfully weaned from cardiopulmonary support, and 17% ( 6 / 36 ) are long-term survivors. Postweaning deaths resulted from central nervous system failure (n = 8), multisystem failure (n = 3), anemia (n = 1, Jehovah's Witness), peripheral pulmonary emboli (n = 1), support withdrawn (n = 1), and sudden death due to arrhythmia (n = 1). Cardiopulmonary support has salvaged 6 patients in our series of 38 who were not able to be resuscitated by conventional techniques. The cardiopulmonary support system supports patients who have experienced sudden death and allows diagnostic and therapeutic interventions to be applied. Survival is coupled to early implementation and reversibility of the conditions that led to patient death. Cardiopulmonary support is ineffective in late cardiogenic shock resulting from massive myocardial infarction or in trauma patients with uncontrolled hemorrhage.

STUDIES OF CONTROLLED REPERFUSION AFTER ISCHEMIA: V. Superiority of surgical versus medical reperfusion after regional ischemia

This study tests the hypothesis that surgical revascularization (i.e., simulating coronary artery bypass grafting) with control of reperfusion conditions (total vented bypass) and of reperfusate composition (substrate-enriched blood cardioplegic solution) produces better recovery than is possible in the non-surgical setting (i.e., normal blood in beating, working hearts to simulate streptokinase and angioplasty). Eighteen dogs underwent 2 hours of left anterior descending coronary artery ligation (35% of the left ventricle at risk) followed by 2 hours of reperfusion. In five dogs the ligature was released to simulate streptokinase thrombolysis and angioplasty in working hearts (medical). In 13 dogs, surgical reperfusion was accomplished during total vented bypass, where six dogs received normal blood and seven others received substrate-enriched blood cardioplegic solution with 1 additional hour of aortic clamping (i.e., a total of 3 hours of ischemia). Segmental shortening with ultrasonic crystals, tissue water content, and vital staining (triphenyltetrazolium chloride) were assessed. Ischemia produced severe systolic bulging (-42% of control systolic shortening, p less than 0.05). Medical reperfusion resulted in failure to restore regional contractility (-27% systolic shortening, p less than 0.05), severe edema (82.4% H2O content, p less than 0.05), and extensive transmural nonstaining (44%, p less than 0.05). In contrast, surgical reperfusion with substrate-enriched blood cardioplegic solution during total vented bypass restored regional contraction to 46% of control values (p less than 0.05) and resulted in less edema (80.6% H2O content, p less than 0.05), and only mild nonstaining (21%, p less than 0.05) restricted to the subendocardial region. Surgical revascularization with controlled reperfusion conditions and reperfusate composition produces better myocardial salvage than is possible in the medical setting, despite a longer period of ischemia.

Subclavian artery approach for insertion of intra-aortic balloon

Subperiosteal clavicular resection for access to the subclavian artery is described. In those patients requiring intra-aortic balloon placement in the nonsurgical setting, such an approach provides a reasonably benign alternative when aortoiliac atherosclerosis prevents the usual retrograde femoral placement. Little morbidity or functional compromise is associated with clavicular wedge resections, and the anatomic availability of a large artery without the need for major surgical maneuvers in these gravely ill patients is a distinct advantage.