Surgical wound morbidity in an austere surgical environment

Surgical wound morbidity was analyzed for a U.S. military field hospital deployed to the Republic of Haiti in support of Operation New Horizons 1998. The purpose of the analysis was to determine whether procedures performed in the field hospital had greater infectious risks as a result of the environment compared with historical reports for traditional hospital or clinic settings. Acceptable historical infection rates of 1.5% for clean surgical cases, 7.7% for clean contaminated cases, 15.2% for contaminated cases, and 40% for dirty cases have been noted. There were 827 operations performed during a 6-month period, with the majority of patients assigned American Society of Anesthesiologists (ASA) Physical Status Classification class I or II. The distribution of these cases was: 72% clean cases, 5% clean contaminated cases, 4% contaminated cases, and 19% dirty cases. The overall wound complication rate was 3.6%, which included 5 wound infections, 11 wound hematomas, 8 superficial wound separations, and 6 seromas. The infectious morbidity for clean cases, the index for evaluation of infectious complications, was 0.8%, well within the accepted standards. There were two major complications that required a return to the operating room: a wound dehiscence with infection in an orchiectomy and a postoperative hematoma with airway compromise in a subtotal thyroidectomy. There were no surgical mortalities. The infectious wound morbidity for operations performed in the field hospital environment was found to be equivalent to that described for the fixed hospital or clinic settings. No special precautions were necessary to ensure a low infection rate. The safety for patients undergoing elective surgical procedures has been established. Further training using these types of facilities should not be limited based on concerns for surgical wound morbidity.

Cerebellar herniation after cervical transforaminal epidural injection

OBJECTIVE

The purpose of this study is to inform readers of potential catastrophic complications associated with performing cervical transforaminal epidural steroid injections.

CASE REPORT

A 31-year-old man presented to the pain clinic with a history of cervical radicular pain and right upper-extremity radicular symptoms. He was referred from the orthopedic spine clinic for evaluation for epidural steroid injection, having failed conservative treatment consisting of nonsteroidal anti-inflammatory drugs, muscle relaxants, oral steroids, and physical therapy. After undergoing a transforaminal epidural steroid injection at the right C8 nerve root, he developed a cerebellar infarct and brainstem herniation. He survived but has residual deficits of persistent diplopia on right lateral gaze and difficulties with short-term memory loss and concentration.

CONCLUSIONS

Although transforaminal epidural steroid injections are an efficacious treatment for radicular syndromes, there can be catastrophic complications. In light of the growing body of similar case reports, further investigation is warranted to establish a safe protocol for the use of this modality.

Surgical wound morbidity in an austere surgical environment

Surgical wound morbidity was analyzed for a U.S. military field hospital deployed to the Republic of Haiti in support of Operation New Horizons 1998. The purpose of the analysis was to determine if procedures performed in the field hospital had greater infectious risks as a result of the environment compared with historical reports for traditional hospital or clinic settings. Acceptable historical infection rates of 1.5% for clean surgical cases, 7.7% for clean contaminated cases, 15.2% for contaminated cases, and 40% for dirty cases have been noted. There were 827 operations performed during a 6-month period, with the majority of patients assigned American Society of Anesthesiologists Physical Status Classification class I or II. The distribution of these cases was: 72% clean cases, 5% clean contaminated cases, 4% contaminated cases, and 19% dirty cases. The overall wound complication rate was 3.6%, which included 5 wound infections, 11 wound hematomas, 8 superficial wound separations, and 6 seromas. The infectious morbidity for clean cases, the index for evaluation of infectious complications, was 0.8%, well within the accepted standards. There were two major complications that required a return to the operating room: a wound dehiscence with infection in an orchiectomy, and a postoperative hematoma with airway compromise in a subtotal thyroidectomy. There were no surgical mortalities. The infectious wound morbidity for operations performed in the field hospital environment was found to be equivalent to that described for the fixed hospital or clinic settings. No special precautions were necessary to ensure a low infection rate. The safety for patients undergoing elective surgical procedures has been established. Further training using these types of facilities should not be limited based on concerns for surgical wound morbidity.

The use of generalized cell-survival data in a physiologically based objective function for hyperthermia treatment planning: a sensitivity study with a simple tissue model implanted with an array of ferromagnetic thermoseeds

PURPOSE

A physiologically based objective function for identifying a combination of ferromagnetic seed temperatures and locations that maximizes the fraction of tumor cells killed in pretreatment planning of local hyperthermia.

METHODS AND MATERIALS

An objective-function is developed and coupled to finite element software that solves the bioheat transfer equation. The sensitivity of the objective function is studied in the optimization of a ferromagnetic hyperthermia treatment. The objective function has several salient features including (a) a physiological basis that considers increasing the fraction of cells killed with increasing temperatures above a minimum therapeutic temperature (Tmin,thera), (b) a term to penalize for heating of normal tissues above Tmin,thera, and (c) a scalar weighting factor (gamma) that has treatment implications. Reasonable estimates for gamma are provided and their influence on the objective function is demonstrated. The cell-kill algorithm formulated in the objective function is based empirically upon the behavior of published hyperthermic cell-survival data. The objective function is shown to be independent of normal tissue size and shape when subjected to a known outer-surface, thermal boundary condition. Therefore, fractions of cells killed in tumors of different shapes and sizes can be compared to determine the relative performance of thermoseed arrays to heat different tumors.

RESULTS

In simulations with an idealized tissue model perfused by blood at various rates, maxima of the objective function are unique and identify seed spacings and Curie-point temperatures that maximize the fraction of tumor cells killed. In ferromagnetic hyperthermia treatment planning, seed spacing can be based on maximizing the minimum tumor temperature and minimizing the maximum normal tissue temperature. It is shown that this treatment plan is less effective than a plan based on seed spacings that maximize the objective function.

CONCLUSIONS

It is shown that under the assumptions of the model and based on a desired therapeutic goal, the objective function identifies a combination of thermoseed temperatures and locations that maximizes the fraction of tumor cells killed.

Effect of interseed spacing, tissue perfusion, thermoseed temperatures and catheters in ferromagnetic hyperthermia: results from simulations using finite element models of thermoseeds and catheters

Finite element heat-transfer models of ferromagnetic thermoseeds and catheters are developed for simulating ferromagnetic hyperthermia. These models are implemented into a general purpose, finite element computer program to solve the bioheat transfer equation. The seed and catheter models are unique in that they have fewer modeling constraints than other previously developed thermal models. Simulations are conducted with a 4 x 4 array of seeds in a multicompartment tissue model. The heat transfer model predicts that fractions of tumor greater than 43 degrees C are between 8 and 40% lower when seed temperatures depend on power versus models which assume a constant seed temperature. Fractions of tumor greater than 42 degrees C, in simulations using seed and catheter models, are between 3.3 and 25% lower than in simulations with bare seeds. It is demonstrated that an array of seeds with Curie points of 62.6 degrees C heats the tumor very well over nearly all blood perfusion cases studied. In summary, results herein suggest that thermal models simulating ferromagnetic hyperthermia should consider the power-temperature dependence of seeds and include explicit models of catheters.

Temperature-dependent versus constant-rate blood perfusion modelling in ferromagnetic thermoseed hyperthermia: results with a model of the human prostate

Finite-element solutions to the Pennes bioheat equation are obtained with a model of a tumour-containing, human prostate and surrounding normal tissues. Simulations of ferromagnetic hyperthermia treatments are conducted on the tissue model in which the prostate is implanted with an irregularly spaced array of thermoseeds. Several combinations of thermoseed temperatures with different Curie points are investigated. Non-uniform, constant-rate blood perfusion models are studied and compared with temperature-dependent descriptions of blood perfusion. Blood perfusions in the temperature-dependent models initially increase with tissue temperature and then decrease at higher temperatures. Simulations with temperature-dependent versus constant-rate blood perfusion models reveal significant differences in temperature distributions in and surrounding the tumour-containing prostate. Results from the simulations include differences (between temperature-dependent and constant-rate models) in (1) the percentage of normal tissue volume and tumour volume at temperatures > 42 degrees C, and (2) temperature descriptors in the tumour (subscript t) and normal (subscript n) tissues including Tmax.t, Tmin.t and Tmax.n. Isotherms and grey-scale contours in the tumour and surrounding normal tissues are presented for four simulations that model a combination of high-temperature thermoseeds. Several simulations show that Tmin.t is between 1.7 and 2.6 degrees C higher and Tmax.n is between 2.1 and 3.3 degrees C higher with a temperature-dependent versus a comparable constant-rate blood perfusion model. The same simulations reveal that the percentages of tumour volume at temperatures > 42 degrees C are between 0 and 68% higher with the temperature-dependent versus the constant-rate perfusion model over all seed combinations studied. In summary, a numerical method is presented which makes it possible to investigate temperature-dependent, continuous functions of blood perfusion in simulations of hyperthermia treatments. Simulations with this numerical method reveal that the use of constant-rate instead of temperature-dependent blood perfusion models can be a conservative approach in treatment planning of ferromagnetic hyperthermia.

Solar heating and cooling

We have adequate theory and engineering capability to design, install, and use equipment for solar space and water heating. Energy can be delivered at costs that are competitive now with such high-cost energy sources as much fuel-generated, electrical resistance heating. The technology of heating is being improved through collector developments, improved materials, and studies of new ways to carry out the heating processes. Solar cooling is still in the experimental stage. Relatively few experiments have yielded information on solar operation of absorption coolers, on use of night sky radiation in locations with clear skies, on the combination of a solar-operated Rankine engine and a compression cooler, and on open cycle, humidification-dehumidification systems. Many more possibilities for exploration exist. Solar cooling may benefit from collector developments that permit energy delivery at higher temperatures and thus solar operation of additional kinds of cycles. Improved solar cooling capability can open up new applications of solar energy, particularly for larger buildings, and can result in markets for retrofitting existing buildings. Solar energy for buildings can, in the next decade, make a significant contribution to the national energy economy and to the pocketbooks of many individual users. very large-aggregate enterprises in manufacture, sale, and installation of solar energy equipment can result, which can involve a spectrum of large and small businesses. In our view, the technology is here or will soon be at hand; thus the basic decisions as to whether the United States uses this resource will be political in nature.