Study Of Postoperative Patients Research Articles

Finding peace in a new version of oneself- a qualitative study of post operative patients after aorta dissection and their experiences of cardiac rehabilitation

Abstract Background Aortic dissection, characterized by a sudden rupture in the carotid artery allowing blood to enter the aortic wall. The mortality rate is 1% per hour, and half of the patients die within 48 hours. Following surgery, patients are advised to limit arm lifting to 2 kg, maintain strict blood pressure control for life, and engage in physical activities that do not strain the aorta. Despite the limited evidence on optimal rehabilitation, our University Hospital in Denmark has established a team that secure patients with aortic dissection a structured post operative rehabilitation program. Aim This study aims to explore the experiences and importance of a specialized rehabilitation program for individuals post-surgery for aortic dissection. Method A qualitative interview study, analyzed using content analysis inspired by Graneheim & Lundman. Interview participants were recruited through the physiotherapist at the hospital either at the end or shortly after their rehabilitation program. Interviews were conducted over the phone or in a private room at the hospital. Results Based on interviews with eight patients (three women and five men aged 43-73), an overarching theme emerged; "Finding peace in a new version of oneself." This theme encapsulates the journey of adapting to a new identity with a changed body that has limitations, combined with a sense of gratitude for being alive. Three subthemes describe the period from surgery to the end of the rehabilitation course: 1) Surviving the operation - the initial miracle and the subsequent uncertainties, 2) The rehabilitation course enhance a sense of security and well-being, and 3) Reclaiming wholeness. Conclusion A specialized rehabilitation program proves to be a crucial support in helping individuals with aortic dissection find peace in their altered selves after facing a life-threatening trauma. These patients require comprehensive physical and psychological support through cardiac rehabilitation provided by cardiac nurses, along with prompt initiation of specialized rehabilitation led by physiotherapists with expertise in aortic dissection.

Drug utilization study in post-operative patients in obstetrics and gynecology ward of a tertiary care teaching hospital

Background: The World Health Organization (WHO) defines drug utilization as “the marketing, distribution, prescription, and use of drug in a society with special emphasis on resulting medical, social, and economic consequences.” Prescription monitoring and drug utilization patterns should be taken care, so it will provide better efficacy and reduce the adverse drug reactions. Aim and Objective: The aim of the study was to assess the prescribing pattern (using the WHO prescription Indicators). Materials and Methods: A retrospective drug utilization study was conducted in the post-operative patients of obstetrics and gynecology (OBG) department over a period of 4 months after getting approval from Institutional Ethics Committee. Name, sex, age, diagnosis, and treatment were recorded from patient’s case sheet of post-operative patients. The data were analyzed using descriptive analysis with the help of Statistical Package for the Social Sciences software. Result: A total of 238 cases were recorded. The average number of drugs per encounter was seven. Antacids, analgesics, antibiotics, and intravenous fluids were common. About 99.57% of encounters were prescribed an antibiotic. Average number of injections prescribed was 95.8% and 525 (31.47%) were prescribed by their generic name. About 99.8% were from the National list of essential medicine-2015. Conclusion: It was observed that most of the drugs were prescribed according to the national essential list of medicines. Major advantage in of the study is to prevent irrational prescription and reduce health-care burden in the community.

The Thai version of the nursing delirium screening scale-Thai: Adaptation and validation study in postoperative patients.

BackgroundThe Nursing Delirium Screening Scale (Nu-DESC) is an effective instrument for assessing postoperative delirium (POD). This study translated the Nu-DESC into Thai (“Nu-DESC-Thai”), validated it, and compared its accuracy with the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5).MethodsThe translation process followed the International Society for Pharmacoeconomics Outcome Research guidelines. Recruited participants were ≥ 70 years old, fluent in Thai, and scheduled for surgery. The exclusion criteria were cancellation or postponement of an operation, severe visual or auditory impairment, and patients with a Richmond Agitation Sedation Scale score of –4 or less before delirium assessment. Post-anesthesia care unit (PACU) nurses and residents on wards each used the Nu-DESC to assess delirium in 70 participants (i.e., 140 assessments) after the operation and after patient arrival at wards, respectively. Geriatricians confirmed the diagnoses using video observations and direct patient contact.ResultsThe participants’ mean age was 76.5 ± 4.6 years. The sensitivity and specificity of the Nu-DESC-Thai at a threshold of ≥ 2 were 55% (95% CI, 31.5–76.9%) and 90.8% (84.2–95.3%), respectively, with an area under a receiver operating characteristic curve (AUC) of 0.73. At a threshold of ≥ 1, the sensitivity and specificity were 85% (62.1–96.8%) and 71.7% (62.7–79.5%), respectively (AUC, 0.78). Adding 1 point for failing backward-digit counting (30–1) to the Nu-DESC-Thai and screening at a threshold of ≥ 2 increased its sensitivity to 85% (62.1–96.8%) with the same specificity of 90.8% (84.2–95.3%).ConclusionThe Nu-DESC-Thai showed good validity and reliability for postoperative use. Its sensitivity was inadequate at a cutoff ≥ 2. However, the sensitivity improved when the threshold was ≥ 1 or with the addition of backward counting to Nu-DESC-Thai and screening at a threshold of ≥ 2.

A drug utilization study in post-operative patients of obstetrics and gynecology of a tertiary care teaching hospital

A drug utilization study in post-operative patients of obstetrics and gynecology of a tertiary care teaching hospital

Drug utilization study in post operative patients in surgical ward of tertiary care teaching hospital

Background: This study was aimed to evaluate the drug prescription pattern and to analyze the drug usage in post operative surgical patients with appendicitis, cellulitis, diabetic foot ulcer, hernia and hydrocele in tertiary care teaching hospital.Methods: A prospective observational study was conducted over a period of six months in post-operative surgical patients at Mahatma Gandhi Memorial Hospital, Warangal, Telangana, India, which was approved by Institutional Ethics Committee. The data obtained was analyzed using graph pad prism 7.0 and the conclusions were drawn using descriptive analysis.Results: A total of 429 cases were recruited during the following study period of which, parenteral drugs were pantoprazole 399 (93%), ceftriaxone 319 (74.35%), metronidazole 239 (55.71%). Oral drugs were multivitamin 400 (93.24%), serratiopeptidase 299 (69.69%), voveran 162 (37.76%). Majority of the drugs prescribed were intravenous fluids, antacids, antibiotics, analgesics were accounted. The percentage encounters with generic drugs was 99% in present study.Conclusions: The present study provides valuable insight about the overall pattern of drug use profile in postoperative patients in the surgical unit of a tertiary care hospital. The study is useful in decreasing the irrational prescription, which helps to decrease the morbidity and health care burden in the society. The prescribing pattern was according to the National Essential Drug List is very low and needs improvement.

Drug utilization study in postoperative patients in obstetrics and gynaecology ward of tertiary care hospital

Background: A growing number of pharmaceutical products are available in the world market and there has been an increase both in the consumption of the drugs and in expenditure on them. The aim of the study was to analyse drug usage in post-operative patients in obstetrics and gynaecological ward and to assess the prescribing indicators (WHO: Core Drug Use Indicators). Methods: A prospective observational study was conducted over a period of six months, after getting approval from Institutional Ethics committee. A specially designed proforma was used to collect the data of post-operative patients in Obstetrics and Gynaecological ward of a tertiary care hospital. The data was analysed using descriptive analysis with the help of SPSS software. Results: A total of 582 cases were analysed during the study. Out of 582 patients, 559 (96%) were prescribed with parenteral cefotaxime and metronidazole. Post-operative pain was managed with tramadol (96%). All patients were prescribed with an antibacterial agent and analgesic (100%). The percentage of encounters with an injection prescribed was 100% in our study. Out of 19 different drugs prescribed, 16 (84.21%) were from the Essential Medicines WHO Model List (2015) and 10 (52.63%) were prescribed by their generic name. Conclusions: The present study provides valuable insight about the overall pattern of drug used in postoperative patients. The study is useful in decreasing the irrational prescription, which helps to decrease the morbidity and health care burden in the society.

Drug utilization study in post-operative patients in obstetrics and gynecology ward of a tertiary care teaching hospital

Objective: This study was aimed to identify pattern of drug use in post-operative patients in obstetrics and gynecology department in tertiary care hospital attached with medical college. Materials and Methods: We collected data from 615 postoperative patients in the obstetrics and gynecology ward of a tertiary care hospital over a period of 15 months. We analyzed the data using various drug use indicators given by the WHO. Results: The average number of drugs per encounter was 10.56. Antacids, analgesics, antibiotics, intravenous fluids accounted for majority of the drugs prescribed. 100% of the encounters were prescribed with an antibiotic. The percentage of encounters with an injection prescribed was 88.13% in our study. Out of 27 different drugs prescribed, 23 (85.18%) were from the National list of essential drugs, India (2011) and 21 (77.77%) were prescribed by their generic name. Average drug cost per encounter in a postoperative patient in our study was 1084.49 INR. Conclusion: The present study provides valuable insight about the overall pattern of drug used in postoperative patients in the obstetrics and gynecology unit of a tertiary care hospital. It is intended to be a step in broader evaluation of safety and efficacy of drug prescription in surgical wards of a teaching hospital.

Qualidade de vida de doentes esofagectomizados: adenocarcinoma versus carcinoma epidermoide

To evaluate and compare the quality of life (QOL) of patients undergoing esophagectomy for treatment of adenocarcinoma of the esophagogastric junction and squamous cell carcinoma. We conducted a cross-sectional study in postoperative patients submitted to esophagectomy for adenocarcinoma of the esophagogastric junction (ACA) and squamous cell carcinoma (SCC), using the SF-36 questionnaire applied in 24 patients (10 ACAs and 14 SCCs), from the 5th months postoperatively, including clinical symptoms and weight change. The assessment of QOL showed the best functional capacity (p = 0.018) in the ACA group. There was a correlation between the fields "mental health" and "Role of Emotions" (p = 0.003) and between "pain" and "physical aspects limitation" (p = 0.003) in both histological types. Weight loss was greater in ACA (45.9 kg), with no significant difference between current BMI (p> 0.66). Dysphagia was reported by 83.3% of patients, anorexia by 58.3%, chewing difficulty by 42%, nausea and vomiting by 41.7% and diarrhea by 29.2%, with no correlation with QOL reported (p> 0.05). The highest score for functional capacity indicates that ACA patients were able to perform all types of physical activity, including the more demanding, at a higher level than patients with SCC. Some symptoms persisted postoperatively, but did not affect the quality of life of patients.

Discordant growth hormone and IGF-1 levels post pituitary surgery in patients with acromegaly naïve to medical therapy and radiation: what to follow, GH or IGF-1 values?

New criteria that define acromegaly remission are more stringent: normal (age/sex-adjusted) insulin-like growth factor type 1 (IGF-1), growth hormone (GH) random (GHr) <1 μg/L, and a GH nadir (GHn) during oral glucose tolerance test (OGTT) of <0.4 μg/L. Discordance between GH and IGF-1 values is often attributed to somatostatin receptor ligands (SRLs) or radiation. The purpose of this study was to evaluate rates of discordant IGF-1 and GH levels in patients with GH secreting adenomas (after pituitary surgery), who were naïve to any other treatment. We retrospectively analyzed data over a 5 year time period (2006-2010), in post-surgery acromegaly patients who had elevated IGF-1 but normal GH levels (per the new cure criteria). Symptoms of acromegaly were scored according to a 4-point scale. Fifty-four patients had post-operative GHr and IGF-1 measurements, 28 patients had GHn during OGTT, and 16 patients had 5-point 2-h GH day curve tests. Thirteen of 54 (24%) patients were found to have intermittent persistent discordant values; high IGF-1 and normal GH at final evaluation (77% of these patients were women). Patients had a median number of IGF-1 evaluations of 7.5 (range: 2-15) over a median of 22 months (range: 3-47 months). Mean elevated IGF-1 in the discordant population was 1.25 × upper limit of normal (ULN) ± 0.17 (range: 1.01-1.6 × ULN). Twelve of the 13 (92%) patients had macroadenomas; 10 of the 13 (69%) patients had mammosomatotroph, mixed lacto/somatotroph tumors or prolactin staining. No patient in the discordant population was on estrogen replacement therapy or had overt cardiac disease. When the relatively asymptomatic discordant population was compared with 35 patients from the concordant population (six were excluded because of preoperative medical treatment for acromegaly), no significant difference between age, gender distribution, body mass index (BMI), presence of diabetes mellitus (DM) or glucose intolerance and adrenal insufficiency between groups was noted. In our study of postoperative patients with acromegaly naïve to both SRLs and radiation, using new GH cut-off levels, 24% had intermittent or persistent discordant values. Our results highlight that relying on IGF-1 or GH measurements alone is not adequate for assessing disease control in surgically treated acromegaly patients. Management of such patients needs to be individualized and long-term studies evaluating morbidity and mortality incorporated into treatment decisions. Further studies with larger patient populations and longer follow-up are required to determine the long-term implications of discordant GH and IGF-1 value patterns.

Determination of hydromorphone in human plasma by a sensitive RP-HPLC–ESI-MS method and its application to a clinical pharmacokinetic study in postoperative patients after low dose intravenous administration with infusion pump

A sensitive reverse phase high performance liquid chromatography–electrospray ionization-mass spectrometry (RP-HPLC–ESI-MS) method has been developed and validated for the determination of hydromorphone in human plasma using naloxone as the internal standard (IS). After alkalization with saturated sodium bicarbonate, the plasma samples were extracted with ethyl acetate. Chromatographic separation was performed on a C18 column with the column temperature of 50 °C and a mobile phase of 5 mM ammonium acetate buffer containing 1% formic acid–methanol (88:12, v/v). Hydromorphone and the IS were detected by selected ion monitoring using the protonated molecules at m/ z 286.2 for hydromorphone and m/ z 328.2 for the IS. Calibration curve was linear over the range of 0.01–50 ng/mL. The lower limit of quantification was 0.01 ng/mL. The method was successfully applied to the pharmacokinetic study in postoperative patients after intravenous infusion of 1.5 mg hydromorphone hydrochloride. The obtained main pharmacokinetic parameters of hydromorphone in postoperative patients were as follows: the maximum hydromorphone plasma concentration ( C max) was (24.15 ± 12.51) ng/mL, the time to the C max was (10.0 ± 0.0) min, and the elimination half-life was (2.7 ± 0.8) h.

Comparison of Outpatient Narcotic Prescribing Patterns After Minimally Invasive Versus Retropubic and Perineal Radical Prostatectomy

Studies comparing pain after minimally invasive vs retropubic and perineal radical prostatectomy are conflicting. We characterized population based outpatient narcotic prescribing patterns after minimally invasive, retropubic and perineal radical prostatectomy. We evaluated outpatient prescription data after minimally invasive, retropubic and perineal radical prostatectomy from 2003 to 2006 using MarketScan®. Baseline and postoperative narcotic prescriptions were identified using the National Drug Code. Total prescribed narcotic strength in morphine sulfate equivalents, the number of prescriptions filled and costs were compared. We performed multivariate analysis adjusted for surgical approach, age, comorbidity, baseline narcotic use, health plan and geographic region. We identified 2,206 minimally invasive, 8,037 retropubic and 463 perineal radical prostatectomies with no differences in baseline narcotic prescription use. Perineal and retropubic operations were associated with greater total morphine sulfate equivalent use than the minimally invasive operation. Perineal prostatectomy was associated with more narcotic refills than minimally invasive and retropubic prostatectomy (42.3% vs 20.2% and 28.9%, respectively, p <0.001). Median narcotic costs were lower for minimally invasive than for perineal and retropubic prostatectomy. On adjusted analysis perineal radical prostatectomy, younger age, baseline narcotic use and preferred provider organization health plan were associated with greater morphine sulfate equivalents and narcotic refills while minimally invasive surgery was associated with fewer refills and lower costs but not with total morphine sulfate equivalents. There was significant geographic variation in narcotic use and costs. Postoperatively minimally invasive radical prostatectomy required fewer narcotic refills and had lower narcotic costs while perineal radical prostatectomy required the greatest amount of narcotics. However, minimally invasive vs retropubic radical prostatectomy morphine sulfate equivalent requirements did not differ on adjusted analysis. While our findings support the purported advantage of minimally invasive radical prostatectomy of less postoperative pain, confirmatory prospective studies with objective outcomes are needed.

Analysis of the pyramidal tract in tumor patients using diffusion tensor imaging

In this work, we propose to use fiber tracking in order to analyze and quantify the state of the pyramidal tracts in patients affected by tumors. We introduce a framework that includes an automatic method to obtain the fibers involved in the pyramidal tract of any subject, in order to compare robustly fiber bundles affected by tumors with healthy fiber tracts from control subjects and also to quantify the relative state of degeneration between the fiber tracts in the two hemispheres of the same patient. The comparative analyses proposed in our methodology are based on a new set of measures on the pyramidal tract, which take into account intrinsic properties of the fibers involved in the bundle as well as the similarity with the pyramidal tract of a standard healthy subject, modeled as the average of a set of controls. In order to perform better comparison studies and to take into account more information of the whole bundle, a mapping technique is used to represent the fiber tracts in 2D. Here, we show a set of experiments using 5 tumor patients and 10 control subjects, including pre- and post-operative studies in patients that have been treated with partial or total tumor resection. The results obtained indicate the usefulness of the method showing good overall performance. A reproducibility study using several acquisitions of the same patient is also presented to validate the techniques employed.

Intra-operative assessment of biventricular function using trans-esophageal echocardiography pre/post-pulmonary thromboembolectomy in patient with chronic thromboembolic pulmonary hypertension

Postoperative studies in patients with chronic thromboembolic pulmonary hypertension (CTPH) have shown that pulmonary thromboembolectomy (PTE) results in a rapid decrease of right ventricular (RV) size, improvement in the RV systolic function and left ventricular (LV) diastolic function. However, the extent to which the biventricular function recovers immediately after embolectomy in post-cardiopulmonary bypass period is not clear. A 45-year-old male patient was operated for retrieval of thrombus from pulmonary trunk and right pulmonary artery. Intraoperative transesophageal echocardiography (TOE) before surgery revealed signs of RV dysfunction and enlargement. The interventricular septum was seen moving paradoxically during end-systole and early-diastole. E/A ratio on transmitral Doppler flow velocity profile was about 0.63 and S/D ratio on pulmonary venous Doppler profile was 2.25, indicative of LV diastolic dysfunction. After weaning the patient from bypass, navigation on TOE showed marginal recovery of the RV systolic function and abatement of septal paradox to some extent. However, significant improvement was observed in the LV diastolic parameter (normal E/A ratio, S/D ratio of 1.08). We conclude that the geometrically altered LV recovers more than the hypertrophied and hypokinetic RV in a patient with CTPH in the post-bypass period.

CT of pelvic fractures

Although magnetic resonance imaging has become the dominant modality for cross-sectional musculo-skeletal imaging, the widespread availability, speed, and versatility of computed tomography (CT) continue to make it a mainstay of emergency room (ER) diagnostic imaging. Pelvic ring and acetabular fractures occur as the result of significant trauma secondary to either a motor vehicle accident or a high-velocity fall. These injuries are correlated with significant morbidity and mortality, both from the complications of pelvic ring fractures and from commonly associated injuries. The most commonly used classification of pelvic and acetabular fractures has been based on conventional radiographs that are, in the majority of cases, sufficient to determine the type of injury. However, because of the complexity of pelvic and acetabular fractures, precise pathological anatomy is not easily demonstrated by routine radiographs and in many cases details of fractures are not visible. Moreover, the insufficient co-operation of the patient or the difficulty of maintaining special positions can be overcome by using computed tomography. Spiral computed tomography provides information regarding the extent of the fractures and is complementary to radiography for ascertaining the spatial arrangement of fracture fragments. Spiral computed tomography is an effective tool for understanding complex fracture patterns, particularly when combined with multi-planar reconstruction two-dimensional (MPR 2D) reformatted images or three-dimensional images (3D) images. Including these techniques of reconstruction in routine pelvic imaging protocols can change management in a significant number of cases. Subtle fractures, particularly those oriented in the axial plane, are better seen on MPR images or 3D volume-rendered images. Complex injuries can be better demonstrated with 3D volume-rendered images, and complicated spatial information about the relative positions of fracture fragments can be easily demonstrated to the orthopaedic surgeons. The use of intravenous (i.v.) contrast material allows simultaneous evaluation of osseous and vascular structures within the affected area. Postoperative studies in patients with orthopaedic hardware also benefit from volume-rendered imaging. Volume rendering eliminates most streak artifact and produces high-quality images on which the relationships among hardware, bones, and bone fragments are well demonstrated.

Significance of "abnormal" nadir growth hormone levels after oral glucose in postoperative patients with acromegaly in remission with normal insulin-like growth factor-I levels.

Our initial study in postoperative patients with acromegaly identified a group of patients in remission, as defined by normal IGF-I levels, but who had a subtle abnormality of GH suppression after oral glucose. To investigate the significance of this abnormality, we have undertaken further detailed testing of GH secretion and a longitudinal follow-up of some of these patients. Of the 110 postoperative patients with acromegaly evaluated by oral glucose tolerance test, 76 were in remission (i.e. normal IGF-I level), and of these subjects with acromegaly in remission, 50 had normal nadir GH (<0.14 microg/ml) (group I), and 26 had abnormal nadir GH (>0.14 microg/ml) (group II). Fourteen subjects in remission, seven from remission group I and seven from remission group II, underwent additional testing consisting of both hourly GH sampling over 8 h and, on a separate day, arginine stimulation testing. The mean of hourly GH was higher in group II (0.47 +/- 0.04 microg/liter) than in group I (0.19 +/- 0.07 microg/liter; P = 0.002). GH response to arginine was greater in group II than in group I (P < 0.01). Of those patients in remission from the initial cohort studied, 49 (30 subjects from group I and 19 from group II) underwent serial longitudinal oral glucose tolerance testing every 1-2 yr over a 1- to 6.5-yr period (mean follow-up, 3.2 yr). The initial pattern of GH suppression persisted in most patients. IGF-I levels remained normal in all patients in group II, but five subjects from group II developed an elevated IGF-I level and, thus, a biochemical recurrence. The rate of disease recurrence was greater in group II than in group I (P = 0.003). We have found that some postoperative subjects with acromegaly in remission with normal IGF-I levels have persistently abnormal nadir GH levels after oral glucose that may be accompanied by other evidence of greater GH secretion than postoperative patients with normal GH suppression. This abnormal pattern of GH suppression may be associated with increased risk of disease recurrence in some patients.

BARIUM SULFATE AS CONTRAST MEDIUM FOR EVALUATION OF POSTOPERATIVE ANASTOMOTIC LEAKS

Objective: To assess the value of barium swallow as a method for immediate re-examination after the failure of an aqueous iodinated agent in detection of clinically suspected postoperative esophageal leakage, and as the initial study in asymptomatic postoperative patients. Material and Methods: Prospective examinations were performed in 114 postoperative patients, 95 males and 19 females (mean age 60 years). Initial esophagography with an aqueous contrast agent was performed in all cases. The patients who had no evidence of leakage underwent immediate re-examination with barium sulfate. Leakage volume was calculated in cm3. Clinical presentations of leakage before the examinations and the complications after the study were recorded. Results: Leakage was shown with the initial study, using aqueous medium, in 23 patients (20%). The volume of leakage was between 0.05 and 36 cm 3 (mean 3.95 cm 3). Clinical signs and symptoms presented in 13 cases (56%). Fourteen of 91 patients (15%), who had negative results with the initial study, had evidence of leakage at barium swallow. The leakage volume ranged between 0.06 and 0.53 cm3 (mean 0.18 cm3). Clinical evidence of leakage was shown in 3/14 (21%) cases. No complications were detected over a 6-month period following the study. Conclusion: A barium swallow should follow a negative study using an aqueous agent in clinically suspected postoperative leakage, and could be considered as a safe initial study in postoperative patients where a leak is not suspected on clinical grounds.

Barium sulfate as contrast medium for evaluation of postoperative anastomotic leaks.

To assess the value of barium swallow as a method for immediate re-examination after the failure of an aqueous iodinated agent in detection of clinically suspected postoperative esophageal leakage, and as the initial study in asymptomatic postoperative patients. Prospective examinations were performed in 114 postoperative patients, 95 males and 19 females (mean age 60 years). Initial esophagography with an aqueous contrast agent was performed in all cases. The patients who had no evidence of leakage underwent immediate re-examination with barium sulfate. Leakage volume was calculated in cm3. Clinical presentations of leakage before the examinations and the complications after the study were recorded. Leakage was shown with the initial study, using aqueous medium, in 23 patients (20%). The volume of leakage was between 0.05 and 36 cm3 (mean 3.95 cm3). Clinical signs and symptoms presented in 13 cases (56%). Fourteen of 91 patients (15%), who had negative results with the initial study, had evidence of leakage at barium swallow. The leakage volume ranged between 0.06 and 0.53 cm3 (mean 0.18 cm3). Clinical evidence of leakage was shown in 3/14 (21%) cases. No complications were detected over a 6-month period following the study. A barium swallow should follow a negative study using an aqueous agent in clinically suspected postoperative leakage, and could be considered as a safe initial study in postoperative patients where a leak is not suspected on clinical grounds.

Volume-rendered three-dimensional spiral CT: musculoskeletal applications.

Spiral computed tomography (CT) is a powerful modality for evaluation of the musculoskeletal system, particularly when coupled with real-time, volume-rendering reconstruction techniques. Including volume-rendered spiral CT in routine musculoskeletal imaging protocols can change management in a significant number of cases. In cases of trauma, subtle fractures--particularly those oriented in the axial plane--are better seen on volume-rendered images. Complex injuries can be better demonstrated with volume-rendered images, and complicated spatial information about the relative positions of fracture fragments can be easily demonstrated to the orthopedic surgeons. The use of intravenously administered contrast material allows simultaneous evaluation of osseous and vascular structures within the affected area. Evaluation of suspected infectious or neoplastic disease is also aided by including volume-rendered imaging in the musculoskeletal spiral CT examination. The extent of disease can be thoroughly evaluated with volume-rendered images, and therapeutic planning--be it surgical or medical--is aided by the anatomic information available from volume-rendered images. Postoperative studies in patients with orthopedic hardware also benefit from volume-rendered imaging. Volume rendering eliminates most streak artifact and produces high-quality images on which the relationships among hardware, bones, and bone fragments are well demonstrated.

Ketamine enhances local anesthetic and analgesic effects of bupivacaine by peripheral mechanism: a study in postoperative patients

Patients with unilateral ( n=14) and bilateral ( n=4) herniorrhaphy participated in this study. With bilateral herniorrhaphy, at the end of the surgery, the wound was infiltrated with a solution of bupivacaine 0.5% and ketamine 0.3% on one side and a solution of bupivacaine 0.5% only, on the other. With unilateral herniorrhaphy, the patients were randomly assigned to one of two groups ( n=7). One group at the end of the surgery received the infiltration with a solution of bupivacaine 0.5% and ketamine 0.3%, the other group received the infiltration with a solution of bupivacaine 0.5% only. The duration of the local anesthetic (response to a von Frey filament) and postoperative analgesic (time to mild spontaneous pain) effects of the infiltrations, as well as wound pain threshold 24 h after surgery (pressure algometry), were determined. In patient with unilateral herniorrhaphy, the addition of ketamine for wound infiltration enhanced the duration of infiltration anesthesia (206±76 versus 343±108 min, P<0.02) and analgesia (240±45 versus 420±151 min, P<0.03). Similar enhancement of the local anesthetic effect was observed in patients with bilateral herniorrhaphy. The increase in pain threshold to pressure on the wound with the addition of ketamine was evident in bilateral herniorrhaphy patients and also with a combination of bilateral and unilateral results (1.39±0.40 versus 2.35±0.92 kg, P<0.02). In the group of five volunteers, the subcutaneous infiltration with 0.3% ketamine produced a local anesthetic effect lasting only 10–20 min. The results indicate that ketamine acting via a peripheral mechanism can profoundly enhance anesthetic and analgesic actions of a local anesthetic administered for infiltration anesthesia.

エネルギー需要実測値に基づいた消化器外科術後の栄養管理に関する検討

エネルギー需要実測値に基づいた消化器外科術後の栄養管理に関する検討