Minor Gynaecological Outpatient Operations

Altogether 143 patients had minor gynaecological operations performed under general anaesthesia in the outpatient department. This method proved to be very acceptable to patient, gynaecologist, and anaesthetist. No complications occurred requiring admission to hospital, and the short recovery time confirmed the safety of early discharge from hospital. This procedure had a beneficial effect on the waiting list, and expensive beds were used more efficiently for major surgical cases. It is recommended that this procedure should be more widely practised, provided that the patients are adequately screened.     

Use of local anaesthetics and adjuncts for spinal and epidural anaesthesia and analgesia at German and Austrian University Hospitals: an online survey to assess current standard practice

Background

The present anonymous multicenter online survey was conducted to evaluate the application of regional anaesthesia techniques as well as the used local anaesthetics and adjuncts at German and Austrian university hospitals.

Methods

39 university hospitals were requested to fill in an online questionnaire, to determine the kind of regional anaesthesia and preferred drugs in urology, obstetrics and gynaecology.

Results

33 hospitals responded. No regional anaesthesia is conducted in 47% of the minor gynaecological and 44% of the urological operations; plain bupivacaine 0.5% is used in 38% and 47% respectively. In transurethral resections of the prostate and bladder no regional anaesthesia is used in 3% of the responding hospitals, whereas plain bupivacaine 0.5% is used in more than 90%. Regional anaesthesia is only used in selected major gynaecological and urological operations. On the contrary to the smaller operations, the survey revealed a large variety of used drugs and mixtures. Almost 80% prefer plain bupivacaine or ropivacaine 0.5% in spinal anaesthesia in caesarean section. Similarly to the use of drugs in major urological and gynaecological operations a wide range of drugs and adjuncts is used in epidural anaesthesia in caesarean section and spontaneous delivery.

Conclusions

Our results indicate a certain agreement in short operations in spinal anaesthesia. By contrast, a large variety concerning the anaesthesiological approach in larger operations as well as in epidural analgesia in obstetrics could be revealed, the causes of which are assumed to be primarily rooted in particular departmental structures.     

Pursuing efficiency in surgical practice.

To examine fluctuations in numbers of patients on surgical wards the dates of admission from January of each of the 5556 patients admitted from 1 January 1985 to 31 December 1987 were examined during computerised audit of a single surgical firm. The numbers of patients under the care of the firm fluctuated widely, often exceeding the 38 beds nominally available. Duration of stay varied from two days or less (3062 admissions) to more than a month (163 admissions). One patient was in hospital for 278 days. The patients admitted for more than a month (2.9% of the total) filled 28% of the beds; not all these patients were elderly. A further increase in throughput of patients undergoing elective operations might be achieved by always admitting patients on the day of operation, and perhaps by discharging patients even sooner than at present. Efficiency would increase but so would overall costs.     

10-year survey of 485 sterilisations. Part I--Sterilisation or hysterectomy?

A survey was made of all sterilisations performed in an obstetric and gynaecological unit in Dunfermline in 1965-74 to determine the outcome and complications. Altogether 547 women were sterilised by the modified Pomeroy method, and 485 (88.7%) were interviewed and examined. No sterilisation was followed by serious complications, and the incidence of even minor complications was low (4.12%). There were no subsequent pregnancies. Altogether 57 women had to be referred for gynaecological operations in the years after sterilisation but only 18 of these had to have hysterectomies. At interview 59 women were found to have gynaecological symptoms (menstrual disorders in 46), and examination showed that 83 women had a gynaecological condition, which was in most cases unsuspected by the patient. Most of these conditions were minor but three women had carcinoma-in-situ of the cervix. Although 46 women suffered menstrual disorders after sterilisation 104 had done so at some time before the operation. These results therefore offer little support for the wider use of hysterectomy as a form of sterilisation.     

Traditional Chinese acupuncture: a potentially useful antiemetic?

Two consecutive studies were undertaken to evaluate the effectiveness of acupuncture as an antiemetic used in addition to premedication with opioids in patients undergoing minor gynaecological operations. In the first study 25 of the 50 patients underwent acupuncture immediately after premedication with 100 mg meptazinol, the rest receiving the drug alone, and in the second 75 patients were allocated randomly to one of three groups: a group receiving 10 mg nalbuphine and acupuncture, a group receiving premedication and dummy acupuncture, and a group receiving premedication alone. Manual needling for five minutes at the P6 acupuncture point (Neiguan) resulted in a significant reduction in perioperative nausea and vomiting in the 50 patients who underwent acupuncture compared with the 75 patients who received no acupuncture. These findings cannot be explained, but it is recommended that the use of acupuncture as an antiemetic should be explored further.     

Differences in durations of stay for surgery in the NHS and private sector in England and Wales.

Median durations of stay in England and Wales for eight "marker" operations were consistently shorter for patients in pay beds in the National Health Service than for patients in independent acute hospitals or public sector beds. This pattern was seen for both preoperative and postoperative stay and among specific age groups. Differential use of other hospitals for part of the period of care was not a factor, except for patients having hip replacement operations treated in NHS pay beds, one in seven of whom appeared to transfer to public sector care postoperatively. These findings suggest that there is scope for a possible further reduction in durations of stay in public sector beds and, within the private sector, for an assessment of whether spells in independent hospitals need be longer than in NHS pay beds.     

"Homeward bound": a minimal care rehabilitation unit.

A 20 bed minimal care rehabilitation unit was set up by Newham District Health Authority in a small hospital originally scheduled for closure when a new district general hospital was opened. During the first year 114 patients were admitted (throughput 5.7), with a median length of stay of 30 days; in the second year 173 patients were admitted (throughput 8.65) with a median length of stay of 28.5 days. The cost per inpatient day was less than that of an inpatient day at the district''s long stay geriatric unit. Before the unit opened 24% of the acute beds had been occupied for more than six weeks, whereas two years later only 6% of the acute beds were occupied for such a period.     

Caseload or workload? Scoring complexity of operative procedures as a means of analysing workload.

OBJECTIVE--To present a more realistic assessment of surgical workload than that provided by a case count. DESIGN--Prospective study of all the operative procedures performed in one year, classified according to the British United Provident Association''s schedule of procedures and scored by the "intermediate equivalent" value (taking the recommended fee value of an intermediate operation as 1.0) compared with the number of operations performed. SETTING--General surgical unit of Taunton and Somerset Hospital, comparing four consultant surgeons and their teams. PATIENTS--Inpatients and day patients admitted under the care of general surgeons during 1989. MAIN OUTCOME MEASURE--Difference between the apparent workload represented by simple case counting (caseload) and the actual workload represented by calculation of the total "intermediate equivalent" value. RESULTS--The workload assessed in terms of intermediate equivalent values was greater than that suggested by case counting for complex operations (12% v 4%), operations at the district hospital (82% v 74%), and operations performed by consultants (53% v 35%) and was lower for minor operations (20% v 42%), operations at the community hospitals (18% v 26%), and operations performed by surgeons in training grades and clinical assistants (47% v 66%). CONCLUSIONS--The use of the intermediate equivalent values as an indicator of complexity allows a more realistic assessment of the operative workload than a simple case count of the number of different operations and is recommended for comparing workload in different hospitals and departments.     

Dextran 70 in Prophylaxis of Postoperative Venous Thrombosis. A Controlled Trial

A controlled prospective trial was carried out in a group of 80 women undergoing gynaecological surgery and thought to be at risk of developing postoperative venous thrombosis. The patients, who had been randomly allocated to prophylaxis with either dextran 70 or warfarin, were well matched in age, weight and other predisposing factors.In the warfarin group, 12 out of 40 patients developed deep vein thrombosis, six of these episodes being classified as major and six as minor. In the dextran 70 group, 4 out of 40 patients developed deep vein thrombosis, all of them minor. The protective effect of dextran 70 is significantly better than that of warfarin (P<0·01) as used in the present study.     

Incidences of fatal postoperative pulmonary embolism after prophylaxis with dextran 70 and low-dose heparin: an international multicentre study.

A total of 4352 patients were admitted to a prospective'' randomised multicentre trial comparing the prophylactic efficacy of dextran 70 and low-dose heparin against fatal pulmonary embolism after elective operations for general, orthopaedic, urological, and gynaecological conditions. Out of 3984 patients correctly admitted, 1993 were allocated to receive dextran 70 and 1991 to receive low-dose heparin. Withdrawal of prophylaxis because of bleeding or technical difficulties occurred more often in the heparin group, but allergic reactions were more common in the dextran group. Of the 75 patients who died within 30 days after operation, 38 had been given dextran and 37 low-dose heparin. Necropsy was performed in 33 and 32 of these cases respectively. In six patients in each group pulmonary embolism was the sole or a contributory cause of death. Of these, five patients in the dextran group and two in the heparin group had received a full course of prophylaxis. There was no statistically significant difference between the two treatment groups in the incidence of fatal pulmonary embolism after a full course of prophylaxis.     

Five-year study of surgical rates in Ontario's counties.

The surgical rates for eight operations (hysterectomy, tonsillectomy/adenoidectomy, cholecystectomy, prostatectomy, appendectomy, mastectomy, colectomy and cesarean section) done in Ontario''s 44 counties from 1973 to 1977 were examined. There was considerable variation among the counties for all the operations studied, although the degree of intercounty variation decreased over the 5 years. Differences in resources (hospital beds and surgeons) explained little of the variation in the rates, but this may be because people crossed county lines for certain operations. Although some counties had consistently high or low rates for individual operations during the 5-year period, only four had consistently high rates for four or more operations, and only five had consistently low rates for four or more. The five counties with teaching health science centres had the highest ratios of specialists and surgeons to population, and, with the exception of one county in 1973, had above-average numbers of hospital beds. Despite the greater resources in these counties, their residents had consistently low rates for cholecystectomy, appendectomy, mastectomy and tonsillectomy/adenoidectomy. However, three of these counties had the highest rates for cesarean section. The variation in the rates is likely due to lack of agreement about indications for surgery or to variation in the use of technology rather than to differences in the incidence or prevalence of disorders.     

Outpatient Termination of Pregnancy

Termination of pregnancies ranging from 6 to 10 weeks'' gestation is described in 127 women who attended the hospital as outpatients. The technique employed was to aspirate the products of conception through a narrow plastic tube using a high negative pressure. Infiltration of the cervix with local anaesthetic proved so effective that the procedure could be carried out on the fully conscious patient. The short time taken to evacuate the uterus, the small blood loss, and the low incidence of complications in the latter part of the study suggest that the technique is a valuable procedure. Relatively more women can be terminated as outpatients than as inpatients with a corresponding reduction in the demands made on gynaecological beds.     

Predators or prey? Spatio-temporal discrimination of human-derived risk by brown bears

Prey usually adjust anti-predator behavior to subtle variations in perceived risk. However, it is not clear whether adult large carnivores that are virtually free of natural predation adjust their behavior to subtle variations in human-derived risk, even when living in human-dominated landscapes. As a model, we studied resting-site selection by a large carnivore, the brown bear (Ursus arctos), under different spatial and temporal levels of human activity. We quantified horizontal and canopy cover at 440 bear beds and 439 random sites at different distances from human settlements, seasons, and times of the day. We hypothesized that beds would be more concealed than random sites and that beds would be more concealed in relation to human-derived risk. Although human densities in Scandinavia are the lowest within bear ranges in Western Europe, we found an effect of human activity; bears chose beds with higher horizontal and canopy cover during the day (0700?C1900?hours), especially when resting closer to human settlements, than at night (2200?C0600?hours). In summer/fall (the berry season), with more intensive and dispersed human activity, including hunting, bears rested further from human settlements during the day than in spring (pre-berry season). Additionally, day beds in the summer/fall were the most concealed. Large carnivores often avoid humans at a landscape scale, but total avoidance in human-dominated areas is not possible. Apparently, bears adjust their behavior to avoid human encounters, which resembles the way prey avoid their predators. Bears responded to fine-scale variations in human-derived risk, both on a seasonal and a daily basis.     

Incidence and pathophysiological relevance of postoperative endotoxemia

Abstract Patients who underwent surgical procedures usually develop elevated body temperature, changes of plasma levels of some proteins, and leucocytosis. These alterations are summarized as the postoperative acute-phase reaction. Also endotoxin can induce the described phenomena suggesting that endotoxin may play a role concerning the induction of the acute phase reaction. In order to test that hypothesis we determined endotoxin plasma levels preoperatively and daily postoperatively in patients who were operated on because of goiter ( n = 20), colonic, pancreatic and gastric diseases ( n = 58). A significant increase of endotoxin plasma levels was found at the first and third day after abdominal surgery whereas after goiter surgery the increase revealed to be only very slight. However, the decrease between the first and second postoperative day in the latter group was again statistically significant suggesting postoperative endotoxemia even after minor operations. Furthermore a correlation between the amount of circulating endotoxin and pulmonary or infectious complications could be established in patients after major operations even at the first postoperative day suggesting a pathogenetic relevance of postoperative endotoxemia.     

Relation between bed use,social deprivation,and overall bed availability in acute adult psychiatric units,and alternative residential options: a cross sectional survey,one day census data,and staff interviews.

OBJECTIVES: To examine the relation between bed use, social deprivation, and overall bed availability in acute adult psychiatric units and to explore the range of alternative residential options. DESIGN: Cross sectional survey, combined with one day census data; ratings by and interviews with staff; examination of routine data sources. SETTINGS: Nationally representative sample of acute psychiatric units. SUBJECTS: 2236 patients who were inpatients on census day. MAIN OUTCOME MEASURES: Bed occupancy levels, judged need for continuing inpatient care, reasons preventing discharge, scores on the Health of the Nation outcome scales. RESULTS: Bed occupancy was related to social deprivation and total availability of acute beds (r = 0.66, 95% confidence interval 0.19 to 0.88, F = 8.72, df = 2.23; P = 0.002). However, 27% (603/2215) of current inpatients (61% (90/148) of those with stays of > 6 months) were judged not to need continuing admission. The major reasons preventing discharge were lack of suitable accommodation (37% (176/482) of patients in hospital < 6 months v 36% (31/86) of those in hospital > 6 months); inadequate domiciliary based community support (23% (113) v 9% (8)); and lack of long term rehabilitation places (21% (100) v 47% (40)). Scores on the Health of the Nation outcome scale were generally consistent with these staff judgments. CONCLUSIONS: The shortage of beds in acute psychiatric units is related to both social deprivation and the overall availability of acute beds. Patients currently inappropriately placed on acute admission wards should be relocated into more suitable accommodation, either in hospital or in the community. A range of provisions is required; simply providing more acute beds is not the answer.     

Analyses sédimentologiques,géochimiques et malacologiques d'une carotte prélevée dans le Golfe du Lion (Méditerranée Française)

The analysis of this core taken from the French continental shelf makes it possible to trace the sedimentological evolution of the area from Würmian times to the present day. Apart from relatively coarse deposits laid down in shallow water, with intercalations of sandy beds and a cold water Arctica islandica fauna, there is a progressive change, in post-glacial and Recent times, to more and more fine-grained sediments. Immigrant Atlantic species disappear in the higher beds of the core. This change is also reflected in an increase in salinity of the interstitial water in the higher beds. The indigenous molluscan assemblage remains the same throughout.     

An earthquake disaster in Turkey: assessment of the need for plastic surgery services in a crisis intervention field hospital

On August 17, 1999, an earthquake of 7.4 magnitude struck Turkey, resulting in the destruction of the cities Golcuk, Izmit, Adapazari, and Yalova. Three days later, the Israel Defense Force Field Hospital arrived at Adapazari, serving as a reinforcement hospital until the rehabilitation of the local medical facilities. Surgical services in the field hospital were supplied by general, orthopedic, and plastic surgeons. The authors evaluated all soft-tissue injuries managed at the hospital and assessed the need for plastic surgery services in a crisis intervention field hospital. Information was gathered regarding soft-tissue injuries throughout the activity of the hospital. In addition, patients' charts, operations' reports, and entry and evacuation logs were reviewed for all patients accepted and treated in the field hospital. Interviews of patients, local physicians, and citizens of Adapazari were performed to evaluate the medical situation in the first 3 days after the earthquake. A total of 1205 patients were treated by the field hospital in Adapazari; 138 (11.45 percent) of these patients sought aid for isolated soft-tissue injuries, 105 of which (76.09 percent) were earthquake-related. Twenty (51.28 percent) of the operations performed in the hospital were to treat soft-tissue injuries; 1.49 percent of all patients underwent minor surgical manipulations by the plastic surgeon on staff. Plastic surgery patients occupied 13.6 percent of the hospital beds. In conclusion, the authors find it beneficial to supply plastic surgery services at a field hospital in an earthquake situation.     

Diel differences in the seagrass fish assemblages of a Caribbean island in relation to adjacent habitat types

The fish fauna of Thalassia testudinum (König) seagrass beds was studied at two sites in the Grand Cul-de-Sac Marin Bay (Guadeloupe, French West Indies). The first seagrass bed was located near a coral reef and the second was near coastal mangroves. Both habitats were sampled during day and night, using a purse-seine and a trap net. A total of 98 species belonging to 36 families were observed. Distance-based redundancy analyses revealed two site-specific assemblages of fishes. Diel assemblage shifts were more pronounced in the seagrass beds near coral reefs than in those near mangroves, due to the existence of nocturnal trophic incursions of coral reef fishes into seagrass beds. First-order carnivores dominated the trophic structure of the fish assemblages during both day and night. At night, Haemulidae, Holocentridae and Apogonidae took the place of Labridae, Chaetodontidae and Mullidae present by day near the reef. This switch did not occur near the coast where the exchanges between seagrass beds and mangrove appear to be less important than with the reef ecosystem. Thus, it appears that the adjacent seascape habitat setting affects the intensity in diel variability of the seagrass bed fish community.     

The changing picture in surgery of pulmonary tuberculosis

In a review of the operative treatment of 1,271 patients with pulmonary tuberculosis in an 11-year period, it was noted that, beginning with 1947, there was a great increase, relatively, in the number of cases in which pulmonary resection was carried out. In 1943, the first year of the period of study, there were six minor operative procedures to every four major operations; in 1953 the ratio was one minor to nine major. This reversal reflects the discoveries of antibiotics for conservative therapy on the one hand and the advances in surgical techniques for major operative treatment on the other. Now that it is safer, resection will probably be used more and more-including bilateral resection in "salvage" cases. On the other hand, with specific antibiotics available, there is a tendency at present to treat conservatively for longer periods in cases in which, formerly, minor operative procedures would have been carried out early.     

Trends in Severity of Illness on ICU Admission and Mortality among the Elderly

Background

There is an increase in admission rate for elderly patients to the ICU. Mortality rates are lower when more liberal ICU admission threshold are compared to more restrictive threshold. We sought to describe the temporal trends in elderly admissions and outcomes in a tertiary hospital before and after the addition of an 8-bed medical ICU.

Methods

We conducted a retrospective analysis of a comprehensive longitudinal ICU database, from a large tertiary medical center, examining trends in patients’ characteristics, severity of illness, intensity of care and mortality rates over the years 2001–2008. The study population consisted of elderly patients and the primary endpoints were 28 day and one year mortality from ICU admission.

Results

Between the years 2001 and 2008, 7,265 elderly patients had 8,916 admissions to ICU. The rate of admission to the ICU increased by 5.6% per year. After an eight bed MICU was added, the severity of disease on ICU admission dropped significantly and crude mortality rates decreased thereafter. Adjusting for severity of disease on presentation, there was a decreased mortality at 28- days but no improvement in one- year survival rates for elderly patient admitted to the ICU over the years of observation. Hospital mortality rates have been unchanged from 2001 through 2008.

Conclusion

In a high capacity ICU bed hospital, there was a temporal decrease in severity of disease on ICU admission, more so after the addition of additional medical ICU beds. While crude mortality rates decreased over the study period, adjusted one-year survival in ICU survivors did not change with the addition of ICU beds. These findings suggest that outcome in critically ill elderly patients may not be influenced by ICU admission. Adding additional ICU beds to deal with the increasing age of the population may therefore not be effective.