Corneal characteristics in myopic patients

OBJECTIVES

To evaluate the characteristics of the cornea in myopic patients.

MATERIAL AND METHOD

A retrospective study of 420 eyes in 210 patients who visited the Excimer Laser Surgery Clinic at Siriraj Hospital, Mahidol University from January 1999 to June 2002 was conducted. All cases that were eligible for myopic refractive surgery were included in the present study. A preoperative ocular examination was done in a fashionable method, including manifest refraction and Orbscan Topography to evaluate corneal thickness, corneal curvature and corneal diameter Statistical analysis was performed to identify the characteristics of the cornea in the patients.

RESULTS

The mean age of the patients was 31.66 +/- 7.77 years. (ranging from 16-51). The mean manifest refraction (spherical equivalent) was -4.9 +/- 2.29 diopters (ranging from -0.50 to -13.75). The mean corneal diameter (white to white) was 11.60 mm +/- 0.37 mm (ranging from 10.8-12.9). The thinnest point of the cornea varied from 409 to 597 microns (mean = 522.55) and located mostly in the infero-temporal quadrant of the eye (23.69% in the right and 32.05% in the left). The mean curvature of the corneal was 44.6 +/- 13.8 diopters (ranging from 39.05-47.65). The mean corneal astigmatism was 1.34 +/- 0.71 diopters and 93.96% were with the rule astigmatism. Positive angle kappa was found in 408 eyes (97%) but all cases were within a 0.5 mm horizontal and 0.3 mm vertical radius from the pupillary axis.

CONCLUSION

Characteristics of the cornea in Thai myopic patients were demonstrated in the present study. Most of the cornea showed with the rule astigmatism with positive angle kappa and the thinnest point, located at the infero-temporal quadrant.

Pre-operative fasting guidelines: an update

Liberal pre-operative fasting routines have been implemented in most countries. In general, clear fluids are allowed up to 2 h before anaesthesia, and light meals up to 6 h. The same recommendations apply for children and pregnant women not in labour. In children <6 months, most recommendations now allow breast- or formula milk feeding up to 4 h before anaesthesia. Recently, the concept of pre-operative oral nutrition using a special carbohydrate-rich beverage has also gained support and been shown not to increase gastric fluid volume or acidity. Based on the available literature, our Task Force has produced new consensus-based Scandinavian guidelines for pre-operative fasting. What is still not clear is to what extent the new liberal fasting routines should apply to patients with functional dyspepsia or systematic diseases such as diabetes mellitus. Other still controversial areas include the need for and effect of fasting in emergency patients, women in labour and in association with procedures done under 'deep sedation'. We think more research on the effect of various fasting regimes in subpopulations of patients is needed before we can move one step further towards completely evidence-based pre-operative fasting guidelines.

Patient Anxiety and Patient Satisfaction in Hospital-based and Freestanding Ambulatory Surgery Centers

The study examined differences in patient anxiety and patient satisfaction between patients who experienced surgery at a hospital-based ambulatory surgery center versus a freestanding ambulatory surgery center. Forty-seven participants completed the State Trait Anxiety Inventory and Press Ganey Ambulatory Surgery Survey. Patients at both types of facilities experienced moderate levels of preoperative anxiety and were highly satisfied with care received. No significant differences were found in preoperative anxiety, overall satisfaction with care, or overall satisfaction with nursing care. The site where the surgery was performed may not be a determining factor in patient anxiety or satisfaction levels.

An extra letter, care gets better? Informing general practitioners about planned surgery for head and neck cancer

OBJECTIVE

To investigate how general practitioners (GPs) value an additional letter from the hospital. This so-called preadmission letter informs the GP about planned surgery for head and neck cancer in one of their patients.

DESIGN

Prospective survey among GPs by means of a questionnaire attached to the preadmission letter.

SETTING

Department of Otolaryngology and Head and Neck Surgery of a tertiary care centre in the Netherlands and 104 different GPs in primary care.

PARTICIPANTS

All GPs of patients undergoing surgery for head and neck cancer received the preadmission letter during a 1-year study period.

MAIN OUTCOME MEASURES

GPs' appreciation of the received preadmission letter, GPs' opinion on the content of the preadmission letter, and GPs' general opinion on information provided by our hospital.

RESULTS

Of the 145 preadmission letters sent during the study year, 115 questionnaires were returned (response rate of 79%). All GPs positively appreciated receiving the preadmission letter and considered its content relevant. They valued the letter, with a mean mark of 8.3 on a 10-point scale. The majority of the GPs agreed that the preadmission letter allows them to provide better care.

CONCLUSIONS

GPs highly appreciate an extra letter informing them about intended surgery for head and neck cancer in one of their patients. Despite the basic content of the preadmission letter (five items only), the majority of GPs consider the information sufficient. The results of this study have led to the implementation of the preadmission letter to GPs of head and neck cancer patients on a permanent basis in our institution.

Efficacy of preoperative antimicrobial skin preparation solutions on biofilm bacteria

RESEARCH ON THE MEDICAL EFFICACY of topical antimicrobials and antibiotics against infections has focused largely on the effect on free-floating, planktonic bacteria. IN THE PRESENCE OF nonbiological surfaces (eg, catheters, prosthetic devices, biomaterials), however, bacteria form highly complex biofilm systems that resist traditional medical treatment. BACTERIAL PATHOGENS commonly found in chronic infections in both the planktonic and biofilm state were challenged with a variety of commonly used topical antimicrobial formulations. BIOFILM BACTERIA were shown to be more resistant to killing than planktonic bacteria. Antimicrobial skin preparation times were adequate to significantly reduce bacterial populations protected in biofilms.

Propuesta y fundamentos para una norma de manejo quirúrgico del paciente obeso: Año 2004

Obesity is a chronic disease with an increasing prevalence in all groups of age, and is associated to increased general mortality and cardiovascular risk. The multidisciplinary non surgical approach must be the treatment of choice for obese subjects. However, the results of such approach among subjects with severe or morbid obesity, are unsatisfactory. In this group of patients, bariatric surgery and specifically gastric bypass achieves good long term results, maintaining a low body mass index, reducing complications and improving quality of life. Considering the widespread practice of bariatric surgery in Chile, the Nutrition Unit of the Ministry of Health formed a task force to propose update guidelines for the surgical treatment of obesity. These guidelines were proposed after a thorough literature review and discussion with groups that practice bariatric surgery using defined protocols. This document provides a summarized version of the guidelines. The first section discusses the background for bariatric surgery and the second part give specific recommendations for patient management and the formation of reference centers for surgical management of obesity.

Preoperative cardiovascular evaluation for noncardiac surgery

Cardiovascular complications following noncardiac surgery constitute an enormous burden of perioperative morbidity and mortality. Annually, more than one million operations are complicated by adverse cardiovascular events, such as perioperative myocardial infarction or death from cardiac causes. In order to combat this problem, cardiac evaluation prior to noncardiac surgery should ask two questions about the patient: What is the risk of cardiac complications during and after surgery? How can that risk be reduced or eliminated? Risk assessment evaluates patients' co-morbidities and exercise tolerance, as well as the type of surgery to be performed, to determine the overall risk of perioperative cardiac complications. Previous or current cardiac disease, diabetes and renal insufficiency all confer higher risks for perioperative cardiac complications. Poor exercise tolerance and high-risk surgical procedures (e.g., vascular, prolonged thoracic or abdominal operations) also predict worse perioperative outcomes. Noninvasive stress testing is widely used to help predict risk of perioperative complications, but the poor predictive power of these tests hampers their usefulness. After estimating the risk of cardiac complications, one should take measures to reduce it. Beta blockade has shown clear benefits in risk reduction. At this time, there are no data suggesting benefits of percutaneous coronary intervention or coronary artery bypass grafting in reducing noncardiac surgical risk. In addition, angioplasty with stenting and its attendant need for anticoagulation can expose patients to increased risk of perioperative bleeding. Thus, the use of coronary revascularization prior to noncardiac surgery should be reserved for those patients with an independent cardiac need for the procedure, such as unstable angina or stable angina refractory to medical therapy. In summary, patients with low clinical risk factors and good functional status, undergoing a low or intermediate risk surgery, have an excellent prognosis and may proceed to surgery without further delay. In addition, stable patients who have previously undergone coronary revascularization may also safely undergo surgery. Patients requiring urgent surgery should proceed immediately, since the consequences of delay usually outweigh the benefits of preoperative risk assessment. However, elective surgery should be indefinitely deferred for those patients with unstable coronary syndromes, since consequences of the cardiac disease usually negate the benefits of surgery. Controversy involves the intermediate or high clinical risk patient considering high-risk, but elective, surgery. Noninvasive testing offers only limited assistance in estimating risk for these patients. The best risk reduction strategy for these patients is perioperative beta blockade use. The role of coronary revascularization specifically to reduce perioperative cardiac complications remains unproven.

Preoperative and postoperative evaluation of airways compression in pediatric patients with 3-dimensional multislice computed tomographic scanning: Effect on surgical management

OBJECTIVES

Surgical management of airway compression of vascular origin requires an accurate analysis of anatomy and various mechanisms of compression. This study assessed the usefulness of 3-dimensional computed tomographic scanning in the preoperative and postoperative evaluation of airways compression in a pediatric population.

METHODS

Thirty-seven consecutive patients (median age, 4 months) were examined with multislice 3-dimensional computed tomographic scanning: 18 patients before surgical treatment of anomalies of vascular rings, 2 patients because of respiratory symptoms after repair of esophageal atresia, and 17 patients because of persisting respiratory symptoms or prolonged mechanical ventilation after cardiac surgery for congenital heart disease.

RESULTS

The procedure was successful, with high-quality diagnostic imaging obtained in all cases without any complications. The anatomy and relationship between the vascular arches and airways was analyzed in all referred patients with vascular arch anomalies confirmed on the basis of the surgical findings, and this helped the surgeon to plan the procedure and choose the best approach. After cardiac surgery, the airway and vascular structures involved and the mechanism of compression were specified in all but one case, and the 3-dimensional computed tomographic scan serves as an important tool for deciding whether to perform reoperation on patients requiring prolonged mechanical ventilation.

CONCLUSION

Three-dimensional computed tomographic scanning is a safe, fast, and noninvasive method useful for accurately analyzing the mechanisms of airway compression of vascular origin and thus possible improving the surgical management of pediatric patients.

[Principles of preoperative and postoperative management of patients with hypospadias]

Retrospective analysis of the operated patients (during 1995-2000) with different forms of the hypospadias have been performed. It was shown that early onset postoperative complications as well as remote complications (relapse of a meatostenosis, uric fistulas, a divergence of the lips of the wounds, urethral diverticulum, concrement formation and urethral pilosis) are associated with cutaneal insufficiency of the penis, low-quality suture material, and the age of patients (older than 4-6 years). On the basis of the analysis of unsuccessful surgical interventions authors have developed a complex of activities on prevention of complications at different stages of correction of the defect. At the same time new methods of one-stage surgery using new types of suture material and carrying out of operations in the age under 3-4 years have been introduced. In 309 patients operated during 2001-2004 significant decrease in the frequency of postoperative complications has been noted.

Empfehlung für die Durchführung von intravitrealen Injektionen

The intravitreal injection as a minimally invasive intervention has proved to be an effective therapy in the management of numerous vitreoretinal diseases. However, non-standardized performance of the procedure might cause severe complications. The recommendations for intravitreal injections discussed here are intended to contribute to a minimization of the risk for complications. Of particular importance are a meticulous preoperative antisepsis with povidone iodine, a sterile environment using a sterile lid speculum, drape and gloves, the use of an adequate injection technique and the exclusion of postoperative retinal non-perfusion.

Guidelines for preoperative assessment: impact on clinical practice and costs

OBJECTIVE

To describe preoperative evaluation in the San Giovanni Battista Hospital in Turin and to forecast the economic impact when preoperative assessment guidelines are implemented.

DESIGN

We enrolled, in a month, 702 consecutive patients, excluding cardiac, thoracic, neuro- and vascular surgery, as well as emergency operations. Preoperative assessment data were collected individually, followed by simulating various applications of guidelines based on: (i) preoperative tests relying on full medical history and physical examination to discriminate preoperative risk patients; (ii) organization of a preoperative evaluation unit and tests before patient hospitalization.

MAIN MEASURES

Mean number of tests prescribed, preoperative assessment cost per patient.

RESULTS

The application of preoperative guidelines would decrease the mean number of tests prescribed from 20 laboratory and 1.9 instrumental to, respectively, 3 and 1.4 per patient. Tests deemed inappropriate by guidelines did not add any relevant clinical information to our study. Economic analysis estimates a reduction of 63% in cost per patient for preoperative tests by introducing guideline criteria (from 69 euros to 26 euros). As regards the cost per patient for preoperative evaluation and hospital stay (115 euros considering only variable costs, 580 euros including all costs), the application of the guidelines would reduce costs by 41-52% according to different cost evaluation approaches for hospital stay.

CONCLUSION

Preoperative guidelines fully introduced in practice could notably increase efficiency without affecting the quality of care.

An evaluation of preoperative skin antiseptics

An underpinning tenet of evidence-based practice is that all routine practices should be open to scrutiny. Questioning practice should not be limited to new, experimental procedures, but should also include examination of 'tried and trusted' techniques. Taking this perspective, the author recently contributed to a systematic review evaluating the use of antiseptics preoperatively.

Preoperative Assessment of Surgical Risk in Oncogeriatric Patients

Cancer is a prevalent disease in our aging population; however, few oncologists are familiar with caring for oncogeriatric patients. Surgery is presently the treatment of choice for most solid tumors, but it is frequently delivered in a suboptimal way in this patient subsetting. Undertreatment is often justified with the concern of an unsustainable toxicity, while overtreatment can be related to the lack of knowledge in optimizing preoperative risk assessment. To draw new light on this issue, several surgeons presented their series, providing hard evidence that surgical options can be offered to the elderly with cancer, with only a limited postoperative mortality and morbidity. As it is likely that much of these data suffer from selection bias, we concentrated on Comprehensive Geriatric Assessment (CGA), which can add substantial information on the functional assessment of elderly cancer patients. A validated instrument such as the CGA allows a comparison of series, predicting short-term surgical outcomes more precisely, and offers appropriate information when consenting elderly patients. Preoperative Assessment of Cancer in the Elderly is a prospective international study conceived and launched to outline the fitness of elderly surgical patients with malignant tumors. This paper reports on preliminary results and analysis from the ongoing study.

[Postoperative nursing care of patients submitted to thoracoabdominal aortic surgery]

Patients who underwent surgery of the thoracoabdominal aorta require, in the post-operative period, special nursing care, related to the specificity and complexity of the disease and surgical procedure. This paper is aimed at to describe the nurse's experience of the Intensive Care Unit of the Vascular Surgical Department at Santa Maria Hospital in the management of these critical patients.

[What is "Fast-track"-surgery?]

"Fast-track"-surgery -- also called "fast-track"-rehabilitation -- is an interdisciplinary, multimodal concept to accelerate postoperative reconvalescence and reduce general morbidity. "Fast-track"-rehabilitation focuses on preoperative patient education, atraumatic and minimal-invasive access to the operative field, optimized anesthesia under normovolemia and prevention of intraoperative hypoxia and hypothermia, effective analgetic therapy without high systemic doses of opioids, enforced postoperative patient mobilisation, early postoperative oral feeding, and avoidance of tubes and drains. "Fast-track"-rehabilitation plans have been published for numerous operative procedures in general-, visceral-, vascular- and thoracic surgery, as well for orthopaedic, urological and gynaecological operations. Until today, "fast-track"-rehabilitation was evaluated most thoroughly in elective colonic surgery. Here, the multimodal regime decreased general morbidity from 20 - 30 % to below 10 %, while postoperative hospital stay was reduced from 10 - 15 to 2 - 5 days. "Fast-track"-rehabilitation for major surgery should be evaluated in randomised, controlled trials.

General principles of surgery applied to cattle

Basic principles of surgery are important to review, even for experienced surgeons. Although aseptic surgical principles are not always applicable in the field, we have to respect some guidelines. Recent research will influence the way that we do things, based on what we have been taught and our experience. Respecting those simple principles can make a big difference in the final outcome.

[Ambulatory surgery -- requirements of the anaesthetist]

The requirements of the anaesthetist regarding ambulatory surgery correspond to those in surgical procedures in hospital. This applies especially to the examination of the patients prior to anaesthesia. Anamnesis and physical examination are more important than radiological or laboratory examinations. According to jurisdiction in ambulatory surgery a shorter period of time between the declaration of consent and the operation is allowed. However, the patient must be guaranteed an adequate period of time for consideration. Since regional anaesthesia involves more organization and requires more time, general anaesthesia with short-acting drugs should be preferred. In observance to the recommendations of anaesthesiological associations and institutions both personnel and technical equipment should meet hospital standards. In day case surgery especially postoperative care must be well planned. This contains the prevention of postoperative nausea or vomiting and a sufficient postoperative analgesia.