Efficacy of incisional negative pressure therapy in preventing post-sternotomy wound complications

BACKGROUND

Sternal wound infections represent a source of significant morbidity and mortality following median sternotomy. The use of incisional negative pressure wound therapy in prevention has yet to be elucidated.

METHODS

A retrospective study was conducted before and after a universal wound care protocol was implemented including the prophylactic use of negative pressure wound therapy (NPWT). The primary endpoint was sternal infections within 90 days of the index operation.

RESULTS

In the control period, there was a 3.0% rate of sternal infection within 90 days compared to 0.8% in the intervention period (p < 0.001). An odds ratio of 0.25 (95% confidence interval 0.11, 0.57; p < 0.001) in the intervention period as compared to the control period was demonstrated.

CONCLUSIONS

The use of a standardized wound care protocol including the universal application of NPWT for patients undergoing cardiac surgery with median sternotomy was an independent predictor of decreased rates of sternal infection.

Surgical management of hallux valgus deformity in children with cerebral palsy

Twenty-six cases of hallux valgus deformity, in 16 children with cerebral palsy, were managed with great toe metatarsophalangeal (MTP) arthrodesis. Mean age at the time of surgery was 16 years (range, 10 years and 11 months to 21 years and 11 months), and mean follow-up was 4 years and 11 months (range, 2 years and 1 month to 10 years). Significant improvement in the hallux valgus angle (preoperative, 36.3 degrees; follow-up, 9.6 degrees; p < 0.05), the intermetatarsal angle (preoperative, 12.3 degrees; follow-up, 8.4 degrees; p < 0.05), and lateral metatarsophalangeal angle (preoperative, 4.8 degrees; follow-up, 25.8 degrees; p < 0.05), were achieved and maintained after MTP arthrodesis. Functional outcome was documented by significant improvement in the modified American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale (preoperative mean score, 46.2; follow-up mean score, 90.9; p < 0.05). Patient/ parent/caregiver satisfaction (as determined by a questionnaire), with improvements in cosmesis, footwear, hygiene, activity, and pain were high, ranging from 81% to 100%. Hallux valgus deformity in children with cerebral palsy is best managed by MTP arthrodesis, in conjunction with other surgical procedures that address segmental foot malalignment and dynamic gait deviations.

Stage I ovarian carcinoma: specialty-related differences in survival and management

BACKGROUND

In patients with FIGO (International Federation of Gynecology and Obstetrics) stage I ovarian carcinoma given care with or without subspecialists, we compared completeness of initial staging and disease-free survival.

METHODS

Two groups of patients with stage I ovarian carcinoma were compared. Patients were managed by either gynecologic oncologists or community-based physicians. The two groups were compared for similarities in demographic, tumor, and substage characteristics and survival differences.

RESULTS

Fifty-four patients with stage I ovarian cancer were included. The two groups were comparable in age, gravidity, parity, grade, and substage. Substaging was determined to be adequate in 100% of the gynecologic oncologist group and 28% of the community-based group. Postoperative chemotherapy was given to 79% and 36% of the two groups, respectively. Six-year survival was 90% in the gynecologic oncologist group and 68% in the community-based group.

CONCLUSIONS

Of these two groups of patients with stage I ovarian cancer, the group managed without gynecologic oncology involvement had significantly less adequate staging, decreased administration of chemotherapy, and lower survival rates.

Enuresis in children with attention-deficit hyperactivity disorder

We did a retrospective study of the prevalence of nocturnal and diurnal enuresis in patients with attention-deficit hyperactivity disorder (ADHD). Patients with ADHD were identified at a referral center for developmental pediatrics. Control patients were identified at a general pediatric and pediatric allergy clinic. Adjusting for differences in sex and current age, ADHD children at age 6 were 2.7 times more likely than controls to have nocturnal enuresis and 4.5 times more likely to have diurnal enuresis. Results at children's current age were consistent with results at age 6; however, these differences were not statistically significant. Nocturnal and diurnal enuresis was found to be significantly more common in children with ADHD than in control subjects. Physicians who treat patients with ADHD should routinely inquire about the presence of enuresis.

The prognostic implication of ascites in advanced-stage ovarian cancer

Ovarian carcinoma accounts for greater than 50% of the gynecologic cancer deaths in the United States each year. One of the central reasons for this dismal outcome is that many patients present with advanced disease. In this series, a retrospective review of 130 patients with stage III and IV invasive epithelial ovarian carcinoma was performed to determine the prognostic significance of ascites. Patients were divided into two study groups based upon the presence or absence of ascites. Survival for the entire study group was 15%, but differed markedly when separated for the presence of ascites. In these patients, ascites was associated with a statistically decreased 5-year survival of 5% versus 45% without ascites (P = 0.0001). Individuals were found to be similar in each group when examined for age, height, weight, cell type, grade, and surgical and chemotherapeutic treatment modalities. More patients proportionately with stage IIIC disease had ascites than those without ascites (P = 0.0015). More of the individuals without ascites underwent second-look laparotomies and achieved a negative result than those with ascites (P = 0.04; P = 0.0038). We conclude that ascites in the presence of stage III and IV disease produces an almost uniformly fatal outcome.

Thoracoscopy versus thoracotomy: indications and advantages

Although the diagnosis and treatment of intrathoracic diseases have been affected by the use of thoracoscopy, the indications and advantages of this procedure are poorly defined. To review the indications and results in a community practice, 52 consecutive cases of thoracoscopy were reviewed and the postoperative courses were compared to a control group of 43 simultaneous thoracotomies. Operative indications for thoracoscopy included investigation or treatment of a lung mass (n = 33), spontaneous pneumothorax (n = 10), mediastinal mass (n = 4), pleural effusion (n = 2), mesothelioma (n = 2), and a ruptured hemidiaphragm (n = 1). General endotracheal anesthesia was used in each case. Overall, thoracoscopy was successful in 40 cases (77%). Conversion to formal thoracotomy was required in 14 cases (27%) secondary to poor visualization or to aid in further dissection. Compared to thoracotomy, complication rates were less (7.6 vs 16.2%), hospital stay shorter (5.5 vs 8 days), ICU stay shorter (0 vs 2 days) and pleural drainage time less (2 vs 5 days) in the thoracoscopy group. In summary, 73% of the patients in this study who formerly would have undergone thoracotomy were successfully managed with thoracoscopy alone, with acceptable morbidity and mortality. These data define the indications, morbidity, and mortality of thoracoscopy and suggest that thoracoscopy may emerge as the procedure of choice in the diagnosis and management of many thoracic diseases.