Pelvic bone tumor resection: post-operative imaging

The anatomic extent of a pelvic bone tumor and the need for reconstruction dictate the type of pelvic resection (limb salvage pelvic resection or amputation). If a pelvic bone tumor resection involves two or more critical anatomic structures (the sciatic nerve, femoral neurovascular bundle or the hip joint), then reasonable functional recovery after limb salvage is less likely and amputation should be considered. Both limb salvage and amputation approaches to the pelvis are technically arduous surgeries with significant associated morbidity and complications. As such, imaging plays an important role in the post-operative management of patients who have undergone pelvic bone tumor resection. In this article, we will review optimal imaging techniques as well as the expected post-operative appearance after pelvic bone tumor resection and important complications including infection, tumor recurrence, and complications related to complex soft tissue and osseous reconstruction.

Pelvic bone tumor resection: what a radiologist needs to know

Pelvic bone tumors present a diagnostic and therapeutic challenge. Due to the deep anatomic location and resultant late clinical presentation, pelvic bone tumors tend to be large and located in close proximity to pelvic viscera as well as vital neurovascular structures. Operative management of pelvic bone tumors is indicated for a variety of orthopedic oncologic conditions. In general, limb-sparing pelvic resection rather than hemipelvectomy with amputation of the ipsilateral limb is considered when a functional limb can be preserved without compromising the surgical margins. There are various options for pelvic resection and reconstruction, and the selection depends on tumor histology, anatomic location, and extent. The decision regarding choice of surgical procedure and reconstruction method for a pelvic bone tumor requires a thorough knowledge of the pelvic anatomy, and careful inspection of the anatomic extent. The surgical plan must strike a balance between acceptable functional outcome and acceptable morbidity. In this review, we describe the different types of pelvic resection techniques, and the vital role preoperative imaging plays in defining the anatomic extent of a pelvic bone tumor and subsequent surgical planning.

Examining the Rates of Anxiety, Depression, and Burnout Among Providers at a Regional Burn Center

Burnout, defined by feelings of inefficacy, cynicism, and emotional exhaustion, affects the performance and well-being of health care providers. Burn care exposes providers to factors known to cause or worsen burnout, but no research has presented prevalence rates of burnout in this population. We estimate the rates of anxiety, depression, and burnout among nonphysician providers in a regional burn center and compare those rates to a reference population of critical care nurses. In our sample of 22 providers, 64% screened positive for anxiety; 32% for depression; 82% for emotional exhaustion; 18% for personal achievement burnout; and 54% for depersonalization. When compared with a national sample of critical care nurses, burn center providers demonstrated a significantly higher rate of anxiety (risk difference [RD]: 0.453, 95% confidence interval [CI] [0.244, 0.622]), a significantly higher rate of emotional exhaustion (RD: 0.207, 95% CI [0.001, 0.323]), and a significantly lower rate of personal achievement burnout (RD: -0.325, 95% CI [-0.442, -0.119]). These findings constitute the first evidence that many burn care providers meet criteria for burnout and that burnout in burn care providers may qualitatively differ from burnout in other critical care providers. Future research should identify burn care-specific predictors of burnout and determine the feasibility and efficacy of interventions to prevent and reduce burnout in burn care providers.

Synchronous colorectal liver metastases: a national survey of surgeon opinions on simultaneous resection and multidisciplinary cooperation

Background

The management of patients with synchronous colorectal liver metastases (sCRLM) has evolved significantly (improved chemotherapy, hepatic surgery advancements, colonic stenting, consultation synergies). We sought to better understand surgeon viewpoints on optimal referral patterns and the delivery of simultaneous resections.

Methods

A 40 question on-line survey was offered to members of the Canadian surgical community. Statistical analysis was descriptive.

Results

A total of 52 surgeons responded. Most colorectal surgeons (CRS) had access to and a good working relationship with regional hepatobiliary (HPB) surgeons (86%) and medical oncologists (100%). The majority (92%) believed there was a role for simultaneous resection of sCRLM, with 69% having first hand experience. Many CRS (62%) discussed all cases of known hepatic metastases with HPB prior to any resection. When a lesion was asymptomatic/minimally symptomatic, most CRS (92%) discussed them with medical oncology/HPB prior to resection (8%). Bilobar metastases (58%), patient comorbidities (35%), portal lymphadenopathy (35%), and patient age (15%) restricted CRS from obtaining HPB consultations. Many CRS (46%) did not believe that resecting hepatic metastases prior to the primary lesion might be beneficial. Most CRS (60%) reported they could not accurately predict hepatic resectability, with only 27% familiarity with evidence-based guidelines. Despite working in smaller hospitals with less access to HPB and less experience with simultaneous resections, non-CR general surgeons more commonly supported a 'liver-first' approach.

Conclusions

There was general agreement between CRS and general surgeons on numerous topics, but additional education is required with regard to HPB surgical capabilities and to provide truly individualized patient-centered care.

Outpatient negative pressure dressing therapy for pretibial lacerations in a patient with high anaesthetic risk: a case study

Pretibial lacerations are a common cause of presentation to accident and emergency departments. The management of these wounds is contentious with a variation in practise between individual institutions. We present the case of a 49-year-old female with a background of pulmonary atresia and associated pulmonary hypertension, who underwent successful outpatient negative pressure wound therapy (NPWT) for three pretibial lacerations. We would propose that this therapy is an effective option for the management of these wounds in independently mobile patients who are at high-risk when under anaesthetic.

Efficacy of an ovine caseous lymphadenitis vaccine formulated using a genetically inactive form of the Corynebacterium pseudotuberculosis phospholipase D

Caseous lymphadenitis (CLA) is an economically significant disease of sheep caused by the gram-positive bacterium Corynebacterium pseudotuberculosis. CLA vaccines are currently formulated using formalin inactivated culture supernatants that are rich in the C. pseudotuberculosis phospholipase D (PLD) exotoxin. One alternative to chemical detoxification is to inactivate the PLD genetically. This procedure not only provides a means to remove an onerous chemical treatment step but also the opportunity to increase gene expression, therefore improve protein yields. Using site-specific mutagenesis the C. pseudotuberculosis PLD was inactivated by substituting a serine residue at histidine 20 within the enzyme active site. CLA vaccine formulated using genetically inactivated PLD protected 44% of sheep against C. pseudotuberculosis challenge compared with 95% protection offered by the formalin inactivated preparation. Since there was no apparent difference in immune response mounted by vaccinated sheep the reason for this variation in vaccine efficacy remains unclear. Although genetic inactivation can be a convenient means to produce toxoid vaccines its use to develop a new CLA vaccine provided no net benefit over the conventional formulation.

The effect of a positive T-lymphocytotoxic crossmatch on hepatic allograft survival and rejection

The influence of crossmatching in liver transplantation is still controversial, and at present, our unit does not alter management according to the result of standard lymphocytotoxicity testing. This study retrospectively assessed outcome of grafts transplanted in the presence of preformed antidonor cytotoxic antibody. One hundred twelve patients undergoing their first orthotopic liver transplantation had results available (mean follow-up: 18 months). Twelve patients had a positive crossmatch and 100 negative. The 1-year graft survival was 58% in the positive crossmatch group, compared with 81% in the negative crossmatch group (P = .02). The 1-year patient survival was 83% in the positive crossmatch group compared with 90% in the negative group (P = .41). Acute cellular rejection occurred in 6 of 7 (86%) grafts surviving more than 7 days in the positive crossmatch group compared with 46 of 88 (52%) grafts in the negative group (P = .09). However, episodes of further acute cellular rejection requiring treatment occurred in 4 of the 6 grafts in the positive crossmatch group but in only 4 of the 46 grafts with a negative crossmatch (P = .0006). The authors conclude that evidence exists in our population that preformed antidonor antibodies adversely affect the outcome of hepatic allografts but not patient survival.

Low thrombosis rate seen in blood donors and their relatives with inherited deficiencies of antithrombin and protein C: correlation with type of defect, family history, and absence of the factor V Leiden mutation

We have previously identified a group of blood donors with inherited deficiencies of either antithrombin (AT) or protein C who appear to have a relatively low thrombosis rate. In the 5 years that have elapsed since initial identification of these individuals, resistance to activated protein C (APC resistance), which is associated with the factor V Leiden gene mutation, has emerged as an important and highly prevalent inherited thrombophilic risk factor. We have followed 28 donors/relatives with deficiency of AT (median age 48 years, range 16-77) and 23 with deficiency of protein C (median age 44 years, range 15-79) over a period of 5 years. During the study period only one individual, who was previously symptomatic, has suffered a thrombotic event which occurred spontaneously whilst on warfarin. We have now excluded coinheritance of APC resistance due to the factor V Leiden mutation in our cohort. Our findings demonstrate that individuals with single inherited thrombophilic defects are not uncommon and are frequently asymptomatic. The absence of the factor V Leiden mutation may in part explain the low thrombosis rate observed, and lends support to the hypothesis that multiple thrombophilic defects may be necessary for the development of thrombosis.

Client follow-up at the Adelaide sexually transmitted disease clinic

This study investigated the extent to which doctor-client communication is associated with follow-up rates at Clinic 275, an Adelaide sexually transmitted diseases (STD) clinic. At Clinic 275, clients are routinely screened for the major STDs at their first visit. They are then asked to return in one week's time for their results and further treatment if necessary. Over a four-week period in April-May 1994, the clinical consultations between doctors and 100 clients attending for their first visit in an episode of care were observed and recorded. Data from the observation schedules were matched with data collected from interviews, either when clients returned for their follow-up visit (n = 78) or from a telephone interview when they failed to return (n = 20). In addition, 18 clients who failed to return for follow-up (but were not part of the original observation sample) were interviewed. Sociodemographic factors did not affect follow-up rates. Of those who did not return for follow-up, social and environmental reasons were cited by about two-thirds. Reasons given by the remaining clients indicate that failure to return for follow-up was related to discrepancies in doctor-client communication in that they were confused about the need to return to obtain test results. In addition, approximately half could not name the infections for which they had been tested. Changes in clinic practice may prove a more useful method of increasing follow-up rates than seeking to identify the characteristics of noncompliant individuals.

Association of HLA types A1-B8-DR3 and B27 with rapid and slow progression of HIV disease

We examined how HLA types A1-B8-DR3 and B27 were related to progression of clinical disease and rate of loss of CD4 lymphocytes in the Edinburgh City Hospital cohort of HIV-positive patients, mainly injection drug users. Patients (n = 692) were prospectively followed from 1985 through March 1994. Accurately estimated seroconversion times were determined retrospectively for a subgroup of 313 (45%). Of 262 patients (39%) who were fully or partially HLA typed, 155 (50%) had known seroconversions. Of 34 patients typed positive for A1-B8-DR3, 29 progressed to CDC stage IV, 22 to AIDS and 20 died. Twelve patients were typed positive for B27; six of these progressed to CDC stage IV, one to AIDS and none died. In a proportional hazards analysis of the 313 patients with known seroconversions, A1-B8-DR3 was significantly associated with covariate-adjusted relative risks of 3.7 (95% CI 1.9-7.2), 3.1 (1.6-6.0) and 1.9 (1.1-3.2) for progression from seroconversion to death, AIDS and CDC stage IV, respectively. Events for B27 were too rare to include B27 in analyses to death and AIDS, but B27 was significantly associated with slower progression to CDC stage IV (0.3, CI 0.1-0.9). Random effects growth curve models were used to estimate individual rates of loss of square root CD4 count and loss of CD4 percentage, for 603 and 617 patients, respectively. A1-B8-DR3 was associated with rapid loss of both markers (p = 0.02 and p = 0.01, respectively); B27 was associated with slow loss of both markers (p = 0.04 and p < 0.005).

Coping and social support as determinants of quality of life in HIV/AIDS

Coping, social support and quality of life (QOL) were examined in 120 HIV+ people (mean age = 37). The sample came from ambulatory clinics and drop-in centres in Toronto: 29% had AIDS, 35% were HIV symptomatic, and 35% were asymptomatic. Information was gathered from self-administered questionnaires. Respondents had good levels of social support and used a variety of coping strategies. Their scores on the behavioural and subjective measures of QOL were somewhat below average. The illness-related measure indicated that their diagnosis had an almost neutral effect on QOL and showed several areas where QOL had been positively affected. Data from male subjects only (n = 107) were analysed using a hierarchical block regression for each QOL measure. Income, emotional social support, and problem-oriented and perception-oriented coping were positively related to QOL. Tangible social support and emotion-oriented coping were negatively related and symptom severity was not related at all. Close friends provided most types of support. Although respondents indicated high levels of satisfaction with support generally, they expressed a need for more emotional support. Unemployment was high despite participants being relatively healthy and well-educated.

Social support intervention after stroke: results of a randomized trial

The purpose of this study was to determine if social support intervention would improve the support experienced by stroke survivors and if improvement would result in better psychosocial outcome. Subjects were drawn from a community-based sample that had received rehabilitation services in the hospital and at home. The study was a randomized trial (n = 48 experimental group, n = 40 control group), and measures were taken at entry into the study, immediately after intervention (or, at a comparable time for the control group), and again 3 months later. No significant differences were found between groups either on social support measures or psychosocial outcomes. Secondary analyses showed that significant changes in support had been experienced within the sample as a whole in relation to the subjects' gender, living situation, marital status, and employment status. Findings are discussed in terms of methodologic and programmatic concerns, and recommendations are made for further research with this potentially valuable intervention.

Disability and depression: some etiological considerations

Although the literature on this subject is fraught with ambiguity, it appears that there is a higher incidence of depression in people with disabilities than in the general population. The etiology of the disorder is by no means clear but several of the explanations which exist for depression in general, appear particularly suited when considering the disabled population. In this article, theoretical origins of the relationship between depression and disability are explored under two broad headings: Biological Factors and Psychosocial Factors. Clinical interventions and social-ecological implications pertinent to the various etiologies are discussed in relation to facilitating psychosocial adjustment and preventing serious depression. Problems of definition and methodology are noted and the importance of focusing attention on this high-risk population is stressed.

The Canadian occupational performance measure: an outcome measure for occupational therapy

The Canadian Association of Occupational Therapists, in collaboration with Health and Welfare Canada have developed and published a conceptual model for occupational therapy, the Occupational Performance model. This paper describes the development of an outcome measure, The Canadian Occupational Performance Measure (COPM), which is designed to be used with these guidelines for client-centred clinical practice. The COPM is an outcome measure designed for use by occupational therapists to assess client outcomes in the areas of self-care, productivity and leisure. Using a semi-structured interview, the COPM is a five step process which measures individual, client-identified problem areas in daily function. Two scores, for performance and satisfaction with performance are obtained. This paper describes the rationale and development of the COPM as well as information about its use for therapists.

Social support and psychosocial dysfunction after stroke: buffering effects in a community sample

This study examined the effect of social support as a mediator between stressful life events experienced by stroke survivors and outcome measured by psychosocial dysfunction. Eighty-five stroke survivors were interviewed at home two to 24 months after discharge from active rehabilitation. The sample was selected for a high number of stressful life events in the recent past, placing subjects at risk for psychosocial dysfunction. Eight components of social support were measured to determine the magnitude of their influence on adjustment. A new instrument, the Social Support Inventory for Stroke Survivors, was designed for this purpose. The General Health Questionnaire, used to measure psychosocial symptomatology, showed that 27% of the sample suffered psychosocial dysfunction. Multiple regression analysis explained 14.5% of total variance as due to social support and functional status. Risk analysis, using the odds ratio, indicated that an especially strong protective effect was produced by community social support.

Implications of the model of human occupation for intervention with native canadians

The following paper provides a theoretical framework for occuaptional therapy with Native Canadians. Traditional models of care have not been entirely satisfactory with this population, as they have failed to come to terms with cultural issues and to recognize cultural stereotyping. NAtive culture is first explored, both from a traditional and a transitional standpoint, with a focus on issues which are of particular interest to occupational therapy, such as role performance, role learning, work patterns, and interpersonal patterns. The Model of Human Occupation is then applied to dysfunction in this population, with particular emphasis on psychosocial dysfunction. Several basic principles in occupational therapy are examined with relation to Native culture. Finally, the various subsystems of the model, and their interpretation for this population are discussed.

Community occupational therapists and volunteers: a survey of utilization and satisfaction

Current estimates lead us to believe that approximately 16% of the population works in some capacity on a volunteer basis. In spite of the size of this valuable human resource, occupational therapists often remark that they are unable to find suitable volunteers to assist with patient-related activities. The present study is an attempt to explore this topic, looking specifically at how community occupational therapists use volunteers, and how satisfied they are with the services provided. A descriptive survey was carried out in two parts: a questionnaire was distributed to all therapists associated with Community Occupational Therapy Associates (COTA) in Toronto; and, a structured interview was conducted with a sample of therapists who indicated they were dissatisfied with volunteer services. The survey revealed three problems: non-availability of appropriate volunteers to do specific patient-related activities; poor communication between therapists and volunteers; and general negative feelings about the reliability and accountability of volunteers. Based on identified problems and in consultation with the literature, a program was set up at COTA to enhance the effective utilization of volunteers within the agency.