Categories
News

Delay in surgery can cause irreparable meniscus tears in children with ACL injuries

For children aged 14 and under, delaying reconstructive surgery for anterior cruciate ligament (ACL) injuries may raise their risk of further injury, according to a new study by pediatric orthopaedic surgeons. If surgery occurs later than 12 weeks after the injury, the injury may even be irreparable. “Treating ACL injuries in these children is controversial, because they are still growing and the surgery has a small risk of causing a growth disturbance,” said study leader J. Todd Lawrence, M.D., Ph.D., an orthopaedic surgeon at The Children’s Hospital of Philadelphia. “However, we found that the risk of additional injury outweighs the risk of growth disturbance in most children.” Lawrence’s study appeared in a recent issue of The American Journal of Sports Medicine. ACL injuries have increased among children and young adults in recent years, possibly because of increased participation in high-level sports such as football, skiing, lacrosse, hockey and soccer, all of which place a high demand on the knees, where the ACL is located.

This retrospective chart analysis looked at 70 patients 14 years of age and under with ACL injuries at The Children’s Hospital of Philadelphia between 1995 and 2005. The average age at injury was about 13 years with an average age at surgery of about 13.5 years. Twenty-nine of the patients underwent reconstructive surgery more than 12 weeks from the time of injury. In patients who were reconstructed more than 12 weeks after their injury, the rate of serious irreversible injuries, such as medial meniscus tears that could not be repaired and full thickness cartilage injuries was up to 4-fold higher. The medial meniscus plays an important role in protecting against arthritis in the knee. “We’ve developed surgical techniques to avoid the growth plates in the knee but looking forward for each patient we still think about onset of arthritis within the next 20 years in the affected knee of young children with a complete tear of their ACL. More research is needed to continue to give us information that is crucial for making informed decisions on care for children and young adults with ACL injuries, but seeing these irreparable injuries that we know can lead to arthritis down the road had helped tip the balance in favor of early surgery for most children with an ACL tear,” added Ted Ganley, M.D., the senior author on the study.

Science Daily
April 3, 2012

Original web page at Science Daily

Categories
News

Building bone from cartilage

A person has a tumor removed from her femur. A soldier is struck by an improved explosive device and loses a portion of his tibia. A child undergoes chemotherapy for osteosarcoma but part of the bone dies as a result. Every year, millions of Americans sustain fractures that don’t heal or lose bone that isn’t successfully grafted. But a study presented at the Orthopaedic Research Society (ORS) 2012 Annual Meeting in San Francisco offers new hope for those who sustain these traumas. Orthopaedic researchers with the University of California, San Francisco (UCSF), Orthopaedic Trauma Institute, have found a very promising, novel way to regenerate bone. “Cartilage graft induces bone that actually integrates with the host bone and vascularizes it,” said Ralph S. Marcucio, PhD, Associate Professor, UCSF School of Medicine. Cartilage graft is very different than the current methods used for bone grafting — autograft bone (a person’s own bone) or allograft materials (donor bone). For various reasons, these two grafting techniques can result in poor graft integration and osteonecrosis. “With millions of bone grafting procedures performed every year in just the United States, developing improved technologies could directly enhance patient care and clinical outcomes,” Dr. Marcucio said.

Chelsea S. Bahney, PhD, Postdoctoral Scholar, UCSF School of Medicine, concedes their approach is less orthodox. “It is not the pathway that most people think about, but it made a lot more sense to follow the normal developmental mechanism.” “This cartilage is naturally bioactive. It makes factors that help induce vascularization and bone formation,” added Dr. Bahney. “When people use a bone graft, it is often dead bone which requires something exogenous to be added to it or some property of the matrix in the graft.” Through a process called endochondral ossification, cartilage grafts produce new tissue that is very similar to the person’s own bone. Without additional properties to it, the researchers found the cartilage graft integrated well and was fully vascularized. “We’re just taking a very similar cartilage that can induce bone formation, putting it into a bone defect and letting it just do its thing,” Dr. Marcucio said. In the study, the researchers chose a non-stabilized tibial fracture callus as a source of a cartilage graft. “Healing of the transplanted cartilage grafts supported our hypothesis by producing a well-vascularized bone that integrated well with the host,” Dr. Bahney said. “A cartilage graft could offer a promising alternative approach for stimulating bone regeneration,” Dr. Marcucio said. “Future work will focus on developing a translatable technology suitable for repairing bone through a cartilage intermediate at a clinical level.”

Science Daily
March 6, 2012

Original web page at Science Daily

Categories
News

Potential biomarker for osteoarthritis identified

Researchers have identified for the first time two molecules that hold promise as a biomarker for measuring cartilage damage associated with osteoarthritis. The concentration of two molecules called non-coding RNAs in blood were associated with mild cartilage damage in 30 patients who were one year removed from reconstruction surgery to repair an anterior cruciate ligament, or ACL, injury. The findings are described as significant in the ongoing and tedious search of biomarkers for osteoarthritis, the most common form of arthritis that afflicts an estimated 27 million Americans aged 25 and older. It is caused by the normal aging process or wear and tear of a joint. The study is being presented at the annual Orthopaedic Research Society in San Francisco. “Our results suggest we have identified a long-awaited biomarker for this leading cause of disability,” says Gary Gibson, Ph.D., director of Henry Ford’s Bone and Joint Center and the study’s lead author. “For various pathology reasons associated with the variability of the disease and challenging blood biochemistry, developing a biomarker for osteoarthritis has been very elusive. But we believe our work shows great promise. The next step is to expand the number of patients studied and determine whether the degree in blood concentration can determine if the cartilage damage will worsen over time.

EurekAlert! Medicine
February 21, 2012

Original web page at EurekAlert! Medicine

Categories
News

Discovery uses ‘fracture putty’ to repair broken bone in days

Broken bones in humans and animals are painful and often take months to heal. Studies conducted in part by University of Georgia Regenerative Bioscience Center researchers show promise to significantly shorten the healing time and revolutionize the course of fracture treatment. “Complex fractures are a major cause of amputation of limbs for U.S. military men and women,” said Steve Stice, a Georgia Research Alliance Eminent Scholar, animal and dairy scientist in the UGA College of Agricultural and Environmental Sciences and director of the UGA Regenerative Bioscience Center. “For many young soldiers, their mental health becomes a real issue when they are confined to a bed for three to six months after an injury,” he said. “This discovery may allow them to be up and moving as fast as days afterward.” Stice is working with Dr. John Peroni to develop a fast bone healing process. “This process addresses both human and veterinary orthopedic needs,” said Peroni, an associate professor of large animal surgery in the UGA College of Veterinary Medicine and a member of the RBC. Peroni and Stice are leading a large animal research project funded by the U.S. Department of Defense (DOD) The project includes scientists and surgeons from the Baylor University College of Medicine, Rice University and the University of Texas, who conducted the early studies.

“Healing of critical-size defects is a major challenge to the orthopedic research community,” Peroni said. “Large-bone defects must be stabilized and necessitate technologies that induce rapid bone formation in order to replace the missing tissue and allow the individual to return to rapid function. To date, no single material can suffice.” The group they lead is a multidiscipline and multi-institutional group actively working on bone tissue engineering. “Our group has been working productively together on numerous projects through the last several years,” Stice said, “So, a collegial relationship and successful collaborative working relationship is already established.” Between 2009 and 2011, the collaborations received a $1.4 million grant from the DOD for the use of stem cells in fracture healing to be tested in sheep.

“In our experiences with large animal models, following the guidelines established by our animal care and use committee,” Stice said, “we have been successful in formulating a product that contains mesenchymal stem cells and allows them to survive in the environment of the fracture long enough to elicit the rapid formation of new bone.” This year, the group showed bone can be generated in sheep in less than four weeks. The speed in which bone is formed is one of the truly unique features of this study. To start the bone regeneration process, the RBC used adult stem cells that produce a protein involved in bone healing and generation. They then incorporated them into a gel, combining the healing properties into something Stice calls “fracture putty.” With Peroni’s assistance, the Houston-based team used a stabilizing device and inserted putty into fractures in rats. Video of the healed animals at two weeks shows the rats running around and standing on their hind legs with no evidence of injury. The RBC researchers are testing the material in pigs and sheep, too.

“The small-animal work has progressed, and we are making good progress in large animals,” he said. More work is needed to get to human medical trials, but the threat of losing federal funding for biomedical work through the DOD means they will have to find new ways to fund the project. “The next step is to show that we can rapidly and consistently heal fractures in a large animal,” Peroni said, “then to convert it to clinical cases in the UGA [College of Veterinary Medicine] clinics where clinicians treat animals with complex fractures all the time.” Once they have something that works for animals, it will be passed over to the DOD for human use. Peroni, who is chairman of the North American Veterinary Regenerative Medicine Association, is hopeful this material will be promoted to the veterinary and human medical fields through the educational efforts of NAVRMA and the RBC. However, the RBC isn’t the only group working on a faster fix for broken bones. “Our approach is biological with the putty,” Stice said. “Other groups are looking at polymers and engineering approaches like implants and replacements which may eventually be combined with our approach. We are looking at other applications, too, using this gel, or putty, to improve spinal fusion outcomes.” One of the best hopes for the fracture putty is in possible facial cranial replacements, an injury often seen on the battlefield. The project ends in mid-2012. “By then we are to deliver the system to the DOD,” Stice said.

Science Daily
February 21, 2012

Original web page at Science Daily

Categories
News

Headed for surgery? Hold the protein

A new study suggests that in mice, cutting protein from the diet for a week can protect organs that might otherwise be damaged by injury or surgery. That’s a common recommendation doctors give patients to ensure a safe procedure. Now a new study in mice suggests that the advice may have benefits beyond the operation itself: Extensive presurgical fasting appears to protect organs from postsurgical damage. Although preliminary, the finding builds on evidence that short-term starvation helps the body guard against stress and may be a useful medical tool. Researchers have known for decades that drastically cutting calories can help animals live longer, although exactly why is uncertain. One popular idea is that when calories are curbed, the body has to adapt to the nutrient deficiency—and in doing so, it becomes more resistant to stress generally. The type of long-term calorie restriction tested in animals is too extreme to apply widely to people, but some scientists have wondered what effect very short-term restrictions, of just a few days, might have.

James Mitchell, who studies stress resistance at the Harvard School of Public Health in Boston, was especially interested in ischemic reperfusion injury, a problem that often occurs with heart attacks and strokes, and sometimes even from heart and vascular surgery. When someone has a heart attack due to a blocked artery, the heart is deprived of oxygen (an effect called ischemia) and cells die. Counterintuitively, when blood flow is restored (called reperfusion) that can also do damage by triggering inflammation. This kind of double whammy can be induced experimentally in other organs, too. Mitchell focused on the kidney and liver in part because it’s relatively easy to measure their function. Two years ago, he and his colleagues reported in Aging Cell that cutting the calories ingested by mice by 30% for up to 4 weeks protected the rodents’ kidneys when their blood supply was cut off and then restored. Others have found that short-term calorie restriction does the same for the heart in mice. But was it just a component of the restricted diet that mattered, such as slashing sugar, or did all calories need to be trimmed? Some studies had suggested that cutting sugars and fats wasn’t all that important, so Mitchell turned to protein. Over a series of experiments, he divvied dozens of mice into two main groups: some offered as much food as they wanted to eat, and some that consumed the same number of calories as the first group but via a protein-free diet. The animals were fed this way for 6 to 14 days. Then the researchers briefly clamped off blood flow to the kidneys before allowing blood to flow back into them and then tested kidney function. In a separate study, the researchers did the same to the animals’ livers after feeding them a diet lacking tryptophan, a constituent of proteins.

Mice that were on protein-free diets had about 50% better organ function, based on common markers in the blood, than those eating as much as they liked, Mitchell’s group reports today in Science Translational Medicine. This organ protection was superior to what the researchers have seen with calorie restriction, suggesting that just cutting protein is even better—or that doing both at once might be best of all. Mitchell can’t say for sure, but he suspects that protein deprivation, like calorie restriction generally, activates some internal programs in cells that in turn improve the body’s ability to handle stress. “These animals might be better conditioned to deal with an energy depletion” that comes from cutting off oxygen to an organ “because that’s the stress they’re under” when they’re not eating protein, he says. The mice on special diets also had less inflammation, suggesting that protein restriction somehow dampens the body’s inflammatory response.

That remains a hypothesis, for now. “What we don’t understand yet is what is the exact mechanism of this, what’s actually happening in the body,” says Mark Talan, a cardiovascular researcher at the National Institute on Aging in Baltimore, Maryland. One of Mitchell’s next steps is to explore whether the dietary regimen improves surgical outcomes in humans. He’s in discussions now with vascular surgeons at Brigham and Women’s Hospital to see whether some sort of short-term fasting or protein-free diet before cardiovascular surgery is even doable in people. “You might think that the best way to be resistant to an upcoming surgery is to be well-rested and well-fed, but in fact that might not be the case,” Mitchell says. Still, he cautions that no one about to have surgery should experiment with radical diets on their own until the approach has gotten more scrutiny.

ScienceNow
February 7, 2012

Original web page at Science Now

Categories
News

Revolutionary surgical technique for treating perforations of the eardrum

A revolutionary surgical technique for treating perforations of the tympanic membrane (eardrum) in children and adults has been developed at the Sainte-Justine University Hospital Centre, an affiliate of the Université de Montreal, by Dr. Issam Saliba. The new technique, which is as effective as traditional surgery and far less expensive, can be performed in 20 minutes at an outpatient clinic during a routine visit to an ENT specialist. The result is a therapeutic treatment that will be much easier for patients and parents, making surgery more readily available and substantially reducing clogged waiting lists. “In the past five years, I’ve operated on 132 young patients in the outpatient clinic at the Sainte-Justine UHC using this technique, as well as on 286 adults at the University of Montreal Hospital Centre (CHUM) outpatient clinic,” says Dr. Saliba. “Regardless of the size of the perforation, the results are as good as those obtained using traditional techniques, with the incomparable advantage that parents don’t have to lose an entire working day, or 10 days or more off school in the case of children.”

The technique, which Dr. Saliba has designated “HAFGM” (Hyaluronic Acid Fat Graft Myringoplasty), requires only basic materials: a scalpel, forceps, a probe, a small container of hyaluronic acid, a small amount of fat taken from behind the ear and a local anesthetic. The operation, which is performed through the ear canal, allows the body by itself to rebuild the entire tympanic membrane after about two months on average, allowing patients to recover their hearing completely and preventing recurring cases of ear infection (otitis). Because it requires no general anesthetic, operating theatre or hospitalization, the technique makes surgery much more readily available, particularly outside large hospital centres, and at considerably lower cost. “With the traditional techniques, you have to be on the waiting list for up to a year and a half in order to be operated on. Myringoplasty (reconstruction of the eardrum) using the HAFGM technique reduces waiting times, cost of the procedure and time lost by parents and children. What’s more, it will help clear the backlogs on waiting lists,” Dr. Saliba says. Myringoplasty is surgical procedures to repair the tympanic membrane or eardrum when it has been perforated or punctured as the result of infection, trauma or dislodgement of a myringotomy tube (also known as a pressure equalization tube). Surgical repair of the perforation will allow the patient to recover his or her hearing and prevent repeated ear infections, particularly after swimming or shower. Traditionally, these procedures are performed using what are known as overlay and underlay techniques, which require hospitalization for at least one day, and 10 to 15 days off work. Every year in Quebec, some 750 myringoplasties are performed on adult or child patients.

This world premiere of a new form of eardrum surgery is based on results of a four-year prospective cohort study of 208 children and adolescents, 73 of whom were treated using the new HAFGM technique. This study was published on December 16, 2011 in the scientific journal Archives of Otolaryngology — Head and Neck Surgery by Dr. Issam Saliba, otolaryngologist (ear, nose and throat or ENT specialist), surgeon and researcher at the Sainte-Justine University Hospital Centre affiliated with the Université de Montréal, where he is also professor of otology and neuro-otology. Dr. Saliba is also a surgeon and researcher at the CHUM, where he conducted a similar study, applying the same HAFGM technique to cohorts of adult patients between 2007 and 2010, with publication in the August 20, 2008 issue of the scientific journal Clinical Otolaryngology and subsequently in the February 12, 2011 issue of The Laryngoscope. The University of Montreal and Sainte-Justine University Hospital Centre are known officially as Université de Montréal and Centre hospitalier universitaire Sainte-Justine, respectively.

Science Daily
February 7, 2012

Original web page at Science Daily

Categories
News

New bandage spurs, guides blood vessel growth

Researchers have developed a bandage that stimulates and directs blood vessel growth on the surface of a wound. The bandage, called a “microvascular stamp,” contains living cells that deliver growth factors to damaged tissues in a defined pattern. After a week, the pattern of the stamp “is written in blood vessels,” the researchers report. A paper describing the new approach will appear as the January 2012 cover article of the journal Advanced Materials. “Any kind of tissue you want to rebuild, including bone, muscle or skin, is highly vascularized,” said University of Illinois chemical and biomolecular engineering professor Hyunjoon Kong, a co-principal investigator on the study with electrical and computer engineering professor Rashid Bashir. “But one of the big challenges in recreating vascular networks is how we can control the growth and spacing of new blood vessels.” “The ability to pattern functional blood vessels at this scale in living tissue has not been demonstrated before,” Bashir said. “We can now write features in blood vessels.” Other laboratories have embedded growth factors in materials applied to wounds in an effort to direct blood vessel growth. The new approach is the first to incorporate live cells in a stamp. These cells release growth factors in a more sustained, targeted manner than other methods, Kong said.

The stamp is nearly 1 centimeter across and is built of layers of a hydrogel made of polyethylene glycol (an FDA-approved polymer used in laxatives and pharmaceuticals) and methacrylic alginate (an edible, Jell-O-like material). The stamp is porous, allowing small molecules to leak through, and contains channels of various sizes to direct the flow of larger molecules, such as growth factors. The researchers tested the stamp on the surface of a chicken embryo. After a week the stamp was removed, revealing a network of new blood vessels that mirrored the pattern of the channels in the stamp. “This is a first demonstration that the blood vessels are controlled by the biomaterials,” Kong said. The researchers see many potential applications for the new stamp, from directing the growth of blood vessels around a blocked artery, to increasing the vascularization of tissues with poor blood flow, to “normalizing” blood vessels that feed a tumor to improve the delivery of anti-cancer drugs. Enhancing the growth of new blood vessels in a coordinated pattern after surgery may also reduce recovery time and lessen the amount of scar tissue, the researchers said.

Science Daily
January 24, 2012

Original web page at Science Daily

Categories
News

Gunshot, stabbing victims are recovering without exploratory surgery

Although more patients with abdominal gunshot and stab wounds can successfully forego emergency “exploratory” surgery and its potential complications, new Johns Hopkins research suggests that choosing the wrong patients for this “watchful waiting” approach substantially increases their risk of death from these injuries. “Managing gunshot and stab wounds without exploratory surgery prevents complications, saves money and keeps 80 percent of patients from getting operations that end up being unnecessary,” says trauma surgeon Adil H. Haider, M.D., M.P.H., an associate professor of surgery, anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine and senior author of the study published in BJS, the British Journal of Surgery. “But not every hospital should pursue this course because if physicians make a mistake, the patient pays. It’s not a slam-dunk decision.”

Haider says management of penetrating abdominal injury has undergone a major paradigm shift in the last century. Until the early 1900s, surgery was avoided because the lack of infection-control killed many injured patients. During World War I, mandatory exploratory surgery for such wounds led to better survival rates and soon became the standard of care. For generations, surgeons have been taught to open the abdomen rapidly following nearly all gunshot and most deep stab wounds with the idea that failing to identify severe intestinal injury or bleeding is far worse than doing an abdominal exploration that turns up nothing. More recently however, some clinicians have sought ways to reduce these unnecessary “negative” surgeries with improved diagnostic imaging and careful monitoring, according to Haider and his team, which included researchers from Aga Khan University in Karachi, Pakistan. They studied records from the United States’ National Trauma Data Bank from 2002 to 2008, identifying 25,737 patients who survived long enough with abdominal gunshot or stab wounds to be admitted to a trauma center. Just over half had been stabbed. For the seven-year period, more than 22 percent of the gunshot wounds were treated without immediate surgery, together with more than one-third of stab wounds. The remaining patients received immediate exploratory abdominal surgery.

Over the study period, the rate of so-called selective non-operative management (SNOM) of these trauma patients rose 50 percent for stab wounds and 28 percent for gunshot wounds, which Haider says points to a growing acceptance of this watchful waiting approach. During the same time period, the rate of negative or unnecessary abdominal operations decreased by about 10 percent. Ultimately, some patients chosen for SNOM needed surgery — 21 percent of gunshot victims and 15 percent of stabbing victims — even though doctors initially believed that their injuries did not require operations. Such patients, called SNOM “failures,” were 4.5 times more likely to die than those who were successfully managed without surgery. It is unclear whether those patients would have died from their wounds if they had undergone surgery immediately, the team reported. SNOM failure was more common in patients with severe injuries requiring blood transfusions and those with damaged spleens. The payoff for successful SNOM is big, Haider notes. The average hospital stay for successful SNOM patients with gunshot wounds was approximately six days, compared with 13 days for those who underwent immediate exploratory surgery and 14 for those who underwent SNOM but ended up needing surgery later. For stabbing victims, the average hospital stay for those who successfully underwent SNOM was four days, compared with seven days for those who had immediate surgery and eight for those who failed SNOM and needed surgery.

“For hospitals that are practicing selective non-operative management for abdominal wounds, it’s seems to be working well with a more than 80 percent success rate” says Haider, co-director of Johns Hopkins’ Center for Surgery Trials and Outcomes Research. “But places that want to start doing it need to be very careful. This is not something you can just decide to do overnight.” Haider says success depends on having a well-staffed intensive care unit, where those undergoing SNOM can be very closely monitored, as well as in-house surgeons and a ready operating room 24 hours a day in case a SNOM patient takes a turn for the worse and requires immediate surgery.

Science Daily
January 24, 2012

Original web page at Science Daily

Categories
News

Less blood needed post-surgery, new study suggests

Patients need less blood after surgery than is widely thought. A new study comparing two plans for giving blood transfusions following surgery showed no ill effects from postponing transfusion until patients develop signs of anemia or their hemoglobin concentration falls below 8 g/dL. Results of the National Heart and Lung and Blood Institute- funded study are published in a recent edition of the New England Journal of Medicine. NewYork-Presbyterian Hospital/Columbia University Medical Center is one of 47 centers participating in the FOCUS (Transfusion Trigger Trial for Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair) study, led by Dr. Jeffrey Carson, Richard C. Reynolds Professor of Medicine at the UMDNJÂ “Robert Wood Johnson Medical School in New Brunswick, NJ. Dr. William Macaulay, a co-author and member of the FOCUS steering committee, says, “This study will help resolve the debate about how much blood patients need after surgery. More often than not, a blood transfusion isn’t necessary, even for elderly and sick patients.

“The implications are enormous. Reducing the number of blood transfusions will greatly decrease blood use, potentially saving an enormous amount of money,” continues Dr. Macaulay, director of the Center for Hip and Knee Replacement at NewYork-Presbyterian Hospital/Columbia University Medical Center, chief of the Division of Adult Reconstructive Surgery of the Hip and Knee, and the Nas S. Eftekhar Professor of Clinical Orthopaedic Surgery at Columbia University College of Physicians and Surgeons. In the United States, 14.6 million units of blood are transfused each year. Between 60 and 70 percent of blood transfusions are given to patients undergoing surgery and the majority of blood transfusions are given to older patients. Commonly, patients are given a transfusion if their hemoglobin level is at or below 10 g/dL, although a growing number of physicians follow a “restrictive” approach using a lower threshold or symptoms of anemia. In addition, some physicians choose to give blood transfusions to patients with higher blood counts if they are elderly or have cardiovascular disease. Normally, people have blood counts above 12 g/dL.

The study followed 2,016 patients aged 50 years or older with a history of or risk factors for cardiovascular disease, who underwent surgery for hip fracture. They were randomized into two groups: one that received a transfusion when their hemoglobin level fell below 10 g/dL (liberal group) and another that received a transfusion when they had symptoms of anemia, or at a physician’s discretion if their hemoglobin was below 8 g/dL (restrictive group). The two groups had similar results for a large array of clinical outcomes, including risk for death within 60 days; functional recovery; risk for heart attack, infection, and falls; and symptoms such as fatigue. Median age was 82 years. The difference in blood use was striking. Patients in the restrictive group received 65 percent fewer units of blood than the liberal group, and 58.5 percent of patients in the restrictive group did not receive any blood transfusion.

Science Daily
January 24, 2012

Original web page at Science Daily

Categories
News

Earlier tracheostomies after head injuries result in better patient outcomes

A tracheostomy performed within the first seven days after a severe head injury results in better overall patient outcome, according to a team of Penn State College of Medicine researchers. This is especially true for patients who have a greater chance of surviving when admitted to the hospital. “The CDC estimates that more than 200,000 individuals are hospitalized annually for traumatic brain injury,” said Kevin M. Cockroft, M.D., associate professor, neurosurgery. “Severely head-injured patients, particularly those with additional injuries, often require tracheostomy at some point during their hospital stay.” “Traditionally, tracheostomy, or ‘trach,’ has been recommended to prevent airway complications,” Cockroft said. “Early trach has been advocated as a means to improve outcome, with various studies suggesting that it may decrease the incidence of pneumonia, reduce intensive care unit days and shorten overall length of stay. Some evidence also exists to suggest that early trach does not improve outcomes. As a result, the timing of trach in these critically ill patients remains controversial.” Early trach patients are defined as those who have a tracheostomy performed during the first seven hospital-stay days. Late trach patients are defined as those who have a tracheostomy performed at greater than seven days after admission.

Researchers used data collected from January 1990 through December 2005 by the Pennsylvania Trauma Society Foundation for its statewide trauma registry. Because of a lack of patients with only head injury, researchers looked at patients with injury to at least one other body system. In total, 3,104 patients were included in the study, with 1,577 in the early trach group and 1,527 in the late trach group. It is the largest study to date to report the effects of tracheostomy timing on outcome after a severe head injury. In the study population, later trach patients were in the hospital three times longer than early trach patients and also spent an average of four times longer in the ICU. Early trach patients were 1.5 times more likely to be discharged in an independent state. However, later trach patients were twice as likely to live to be discharged from the hospital, potentially because more severe cases would receive an earlier trach. In addition, later trach patients were about twice as likely to suffer from an adverse pulmonary occurrence such as pneumonia, about 1.5 times as likely to suffer a cardiac event such as a heart attack, and 1.5 times more likely to have an infection. Researchers reported their results in the journal Neurocritical Care.

Science Daily
October 18, 2011

Original web page at Science Daily

Categories
News

Glowing cells guide cancer surgeons

Most malignant ovarian tumours express high numbers of receptors for the molecule folate (also known as vitamin B9), so by attaching the fluorescent molecule fluorescein iso-thiocyanate to folate, researchers created a cancer-cell probe. After injecting this into patients, labelled cells were made to glow white with a special camera and light, allowing surgeons to spot cancerous tissue even when cells were otherwise indistinguishable from their healthy counterparts. “This provides more accuracy and more certainty for clinicians to remove cancerous cells in real time during surgery,” says study leader Vasilis Ntziachristos of the Technical University of Munich in Germany. The results are published today in Nature Medicine. Of all the gynaecological cancers — ovarian, vaginal and uterine — ovarian is the greatest killer of women in both the United States and Europe. Removing as much cancerous tissue as possible during surgery is crucial to giving post-operative chemotherapy the best possible chance to kill the remaining cancer cells.

Nature
October 4, 2011

Original web page at Nature

Categories
News

Sutureless method for joining blood vessels invented

Reconnecting severed blood vessels is mostly done the same way today — with sutures — as it was 100 years ago, when the French surgeon Alexis Carrel won a Nobel Prize for advancing the technique. Now, a team of researchers at the Stanford University School of Medicine has developed a sutureless method that appears to be a faster, safer and easier alternative. In animal studies, a team led by Stanford microsurgeon Geoffrey Gurtner, MD, used a poloxamer gel and bioadhesive rather than a needle and thread to join together blood vessels, a procedure called vascular anastomosis. Results of the research are published online Aug. 28 in Nature Medicine. Lead authors of the study were Stanford postdoctoral scholar Edward Chang, MD, and surgery resident Michael Galvez, MD. The big drawback of sutures is that they are difficult to use on blood vessels less than 1 millimeter wide. Gurtner began thinking about alternatives to sutures about a decade ago. “Back in 2002, I was chief of microsurgery at Bellevue in New York City, and we had an infant — 10 to 12 months old — who had a finger amputated by the spinning wheel of an indoor exercise bike,” said Gurtner, senior author of the study and professor of surgery. “We struggled with reattaching the digit because the blood vessels were so small — maybe half a millimeter. The surgery took more than five hours, and at the end we were only able to get in three sutures.

“Everything turned out OK in that case,” he continued. “But what struck me was how the whole paradigm of sewing with a needle and thread kind of falls apart at that level of smallness.” Sutures are troublesome in other ways, too. They can lead to complications, such as intimal hyperplasia, in which cells respond to the trauma of the needle and thread by proliferating on the inside wall of the blood vessel, causing it to narrow at that point. This increases the risk of a blood clot getting stuck and obstructing blood flow. In addition, sutures may trigger an immune response, leading to inflamed tissue that also increases the risk of a blockage. The new method could sidestep these problems. “Ultimately, this has the potential to improve patient care by decreasing amputations, strokes and heart attacks while reducing health-care costs,” the authors write in the study.

Earlier in his career, as Gurtner contemplated a better way of joining together blood vessels, he considered whether ice could be used to fill the lumen, the inner space of the blood vessel, to keep both ends open to their full diameter long enough to glue them together. Not feasible, he concluded. “Water turns to ice quite slowly and you would have to drop the temperature of the surgical site a lot — from 98.6 degrees to 32 degrees Fahrenheit,” he said. Shortly after arriving at Stanford in 2005, Gurtner approached fellow faculty member Gerald Fuller, PhD, professor of chemical engineering and the Fletcher Jones II Professor in the School of Engineering, about whether he knew of a substance that could be turned easily from a liquid to a solid and back to a liquid again, and that would also be safe to use in vascular surgery. Fuller immediately suggested a Food and Drug Administration-approved thermoreversible poloxamer called Poloxamer 407. It is constructed of polymer blocks whose properties can be reversed by heating.

Fuller teamed up with Jayakumar Rajadas, PhD, director of the Stanford Biomaterials and Advanced Drug Delivery Laboratory, to modify the poloxamer so that it would become solid and elastic when heated above body temperature but dissolve harmlessly into the bloodstream when cooled. The poloxamer then was used to distend both openings of a severed blood vessel, allowing researchers to glue them together precisely. The researchers used a simple halogen lamp to heat the gel. In tests on animals, the technique was found to be five times faster than the traditional hand-sewn method, according to the study. It also resulted in considerably less inflammation and scarring after two years. The method even worked on extremely slim blood vessels — those only 0.2 mm wide — which would have been too tiny and delicate for sutures. “That’s where it really shines,” Gurtner said.

Poloxamers have been used before as a vehicle for delivering drugs, including chemotherapeutics, vaccines and anti-viral therapies. Researchers have used Poloxamer 407 to occlude blood vessels in experimental animals for the purpose of evaluating the gel’s safety and efficacy in so-called “beating heart surgery,” in which certain vessels need to be temporarily blocked to improve visibility for the surgeons performing a coronary artery bypass. Although other sutureless methods have been developed, they generally have not produced better outcomes, the authors said. “Often, the use of microclips, staples or magnets is itself traumatic to blood vessels leading to failure rates comparable to or higher than sutured anastomoses,” they wrote. “This is a novel approach to anastomosis that could play a valuable role in microvascular surgery,” said Frank Sellke, MD, chief of cardiothoracic surgery at Brown University Medical Center and associate editor of the Journal of Thoracic and Cardiovascular Surgery, who was not involved in the study. “But it really needs to show that it holds up in clinical trials.”

The authors say further testing on large animals is needed before human trials can begin, but they note that all of the components used in the technique are already approved by the FDA. “This technology has the potential to progress rapidly from the ‘bench to bedside,'” they write. Gurtner said he believes the new technique could satisfy a huge unmet need and prove especially useful in minimally invasive surgeries, in which manipulating sutures takes on a whole new level of difficulty. Michael Longaker, MD, the Deane P. and Louise Mitchell Professor in the School of Medicine and a co-author of the study, called the technique a “potential game-changer.” “When you’re bringing together hollow tubes, whether they’re large structures, like the colon or the aorta, or a small structure, like a vein in the finger of a child, you’re always worried about lining them up directly and effectively sealing them,” Longaker said. “The technique that Dr. Gurtner has pioneered could allow surgeons to perform anastomosis more quickly and with improved precision.” He continued: “Coming up with this solution was the result of the classic Stanford model of bringing together researchers from a variety of disciplines.”

Science Daily
September 20, 2011

Original web page at Science Daily

Categories
News

Use adult stem cells to grow neck vertebrae

Neurosurgery researchers at UC Davis Health System have used a new, leading-edge stem cell therapy to promote the growth of bone tissue following the removal of cervical discs — the cushions between the bones in the neck — to relieve chronic, debilitating pain. The procedure was performed by associate professors of neurosurgery Kee Kim and Rudolph Schrot. It used bone marrow-derived adult stem cells to promote the growth of the bone tissue essential for spinal fusion following surgery, as part of a nationwide, multicenter clinical trial of the therapy. Removal of the cervical disc relieves pain by eliminating friction between the vertebrae and/or nerve compression. Spinal fusion is used following surgery for degenerative disc disease, where the cushioning cartilage has worn away, leaving bone to rub against bone and herniated discs, where the discs pinch or compress nerves. “We hope that this investigational procedure eventually will help those who undergo spinal fusion in the back as well as in the neck,” said Kim, who also is chief of spinal neurosurgery at UC Davis. “And the knowledge gained about stem cells also will be applied in the near future to treat without surgery those suffering from back pain.”

Millions of Americans are affected by spine diseases, with approximately 40 percent of all spinal fusion surgery performed for cervical spinal fusion. Some 230,000 patients are candidates for spinal fusion, with the numbers of potential patients increasing by 2 to 3 percent each year as the nation’s population ages. “This is an exciting clinical trial to test the ability of the bone-forming stem cells from healthy donors to help patients with spinal disease,” said Jan Nolta, director of the UC Davis Institute for Regenerative Cures. “For the past 50 years, bone marrow-derived stem cells have been used to rebuild patients’ blood-forming systems. We know that subsets of stem cells from the marrow also can robustly build bone. Their use now to promote vertebral fusion is a new and extremely promising area of clinical study,” she said. The stem cell procedure at UC Davis took place early in August. The patient was a 53-year-old male from the Sacramento region with degenerative disc disease. In the surgery, called an anterior cervical discectomy, a cervical disc or multiple discs are removed via an incision in the front of the neck. The investigational stem cell therapy then is applied to promote fusion of the vertebrae across the space created by the disc removal.

The stem cells are derived from a healthy single adult donor’s bone marrow, and thus are very homogenous, Kim said. They are grown in culture to high concentration with minimal chance for rejection by the recipient, he said. Adequate spinal fusion fails to occur in 8 to 35 percent or more of patients, and persistent pain occurs in up to 60 percent of patients with fusion failure, which often necessitates additional surgery. “A lack of effective new bone growth after spine fusion surgery can be a significant problem, especially in surgeries involving multiple spinal segments,” said Schrot, co-principal investigator for the study. “This new technology may help patients grow new bone, and it avoids harvesting a bone graft from the patient’s own hip or using bone from a deceased donor.” Current methods of promoting spinal fusion include implanting bone tissue from the patient’s hip or a cadaver to encourage bone regrowth as well as implanting bone growth-inducing proteins. However, the Food and Drug Administration has not approved the use of bone morphogenetic proteins for cervical spinal fusion. Their use has been associated with life-threatening complications, particularly in the neck.

The leading-edge stem cell procedure is part of a prospective, randomized, single-blinded controlled study to evaluate the safety and preliminary efficacy of an investigational therapy: modified bone marrow-derived stem cells combined with the use of a delivery device as an alternative to promote and maintain spinal fusion. The study includes 10 investigational centers nationwide. The UC Davis Department of Neurological Surgery anticipates enrolling up to 10 study participants who will be treated with the stem cell therapy and followed for 36 months after their surgeries. A total of 24 participants will be enrolled nationwide.

Science Daily
September 20, 2011

Original web page at Science Daily

Categories
News

Incisionless surgery now available as an investigational treatment for esophageal disorder

The procedure is one of a growing number of surgeries to use the body’s natural orifices as an entry point, thus eliminating the need for traditional incisions. Northwestern Memorial Hospital is one of only a few centers in the U.S. with surgeons trained to perform the procedure. “This surgical approach not only eliminates the need for external incisions, but also offers greater precision and a faster healing time for patients,” said Eric Hungness, MD, gastrointestinal surgeon at Northwestern Memorial. Peroral endoscopic myotomy ( POEM) is performed by inserting an endoscope in the mouth and tunneling it down the esophagus so surgeons can access and cut abnormal muscle fibers that prevent the valve at the base of the esophagus from opening to allow food to enter the stomach. It is currently under investigation and is being offered as part of a clinical trial at Northwestern Memorial.

More than 3,000 people are diagnosed with esophageal achalasia each year. The most common symptom is difficulty eating solid food and drinking liquids. As it advances, achalasia can cause considerable weight loss and malnutrition. Common treatments for esophageal achalasia include a traditional surgical approach known as a Heller myotomy, or balloon dilation. “Previously, we had to make at least five incisions in a patients abdomen in order treat esophageal achalasia surgically,” said Hungness. “Although the research continues and final results are not known, POEM is an exciting idea that holds great promise for patients and demonstrates the bright future for incisionless surgeries.” Approximately 150 POEM procedures have been performed in the world since 2008. Hungness, together with Nathanial Soper, MD, chair of surgery at Northwestern Memorial, have been among those pioneering Natural Orifice Translumenal Endoscopic Surgery (NOTES). The team was the second in the country to perform a gallbladder removal through the mouth in 2007, and has since removed a gallbladder through the vagina as well.

Doctors stress that treatment options must be carefully selected based on the unique needs of the patient, but say minimally invasive procedures such as POEM have been shown to offer an array of potential benefits including greater surgical precision, a shorter recovery time, shorter hospital stay, less pain and in the case of POEM, a lower incidence of reflux post procedure. “This is the future of surgery,” said Soper. “With each new procedure, we learn how to apply the technique and technology to other surgeries and develop new tools.”

Science Daily
September 6, 2011

Original web page at Science Daily

Categories
News

Surgeon shows simple cotton swab slashes post-surgical wound infections

A simple item found in almost every medicine cabinet — a cotton swab — may be a key tool in the fight against post-surgical wound infections. In a sentinel trial, Cedars-Sinai Medical Center surgeon Shirin Towfigh, MD, showed that painless and gentle probing of a wound with a dry cotton swab after surgery dramatically reduced infections in post-operative incision sites: only 3 percent of patients who had the daily probings contracted infections compared to 19 percent of those who didn’t — a rate more than six times higher than that of the study group. “That a humble cotton swab could have such an impact in reducing the incidence of hospital-acquired infections is really quite remarkable,” Towfigh said. “This study reminds us that scientists can still find effective treatments when we are willing to think outside of the ‘technology box.’ ” Surgical site infections most commonly occur when patients have “dirty” or contaminated wounds, such as after a trauma, bowel surgery, or perforated appendicitis. Until now, no preventative treatment at the contaminated wound site — including topical antibiotics, under-the-skin wound drains or delayed closure of the wound — has proven to reliably decrease these infections. More than 500,000 such infections occur in the U.S each year, accounting for nearly one-quarter of hospital-acquired infections and a major source of illness and cause of death in patients.

The exact mechanism by which the technique prevents surgical site infection is unclear, though Towfigh and colleagues surmise that wound probing allows contaminated fluid trapped within soft tissues to drain, reducing the bacterial burden while maintaining a moist environment needed for successful wound healing. Besides greatly reducing incision infections, painless probing with the cotton swab resulted in less post-operative pain for patients and significantly shorter hospital stays (five vs. seven days). Patients also had better cosmetic healing of their incisions and — unsurprisingly — higher satisfaction with their outcomes. As reported in the Archives of Surgery, all study participants had undergone an appendectomy for a perforated appendicitis. Half of the 76 patients in the prospective, randomized trial had their incisions loosely closed with staples, then swabbed daily with iodine (the control group). The study group had their incisions loosely closed. Then, their wounds were probed gently between surgical staples with a dry, sterile cotton tip applicator each day.

“This practice was introduced to me as a surgical resident 15 years ago,” Towfigh says. “I’ve used it routinely since then. While I thought all surgeons were aware of this treatment approach, I learned otherwise when I began my professional career. Since it was evident to me that probing certain wounds after surgery resulted in far fewer infections, I developed this clinical trial so that my colleagues across the country could learn about — and confidently adopt — the practice.” Towfigh, part of the Cedars-Sinai’s Center for Minimally Invasive Surgery and the Department of Surgery, has taught her wound probing technique to the medical and nursing staff throughout Cedars-Sinai Medical Center. The team of colorectal surgeons at Cedars-Sinai has not only adopted the practice but has begun a clinical study in their own patient population. As a surgical educator at Cedars-Sinai, Towfigh teaches the probing technique to her medical students, residents and fellows with the expectation they will educate others as they fan out to hospitals nationwide.

Science Daily
July 12, 2011

Original web page at Science Daily

Categories
News

Artificial tissue promotes skin growth in wounds

Victims of third-degree burns and other traumatic injuries endure pain, disfigurement, invasive surgeries and a long time waiting for skin to grow back. Improved tissue grafts designed by Cornell scientists that promote vascular growth could hasten healing, encourage healthy skin to invade the wounded area and reduce the need for surgery. These so-called dermal templates were engineered in the lab of Abraham Stroock, associate professor of chemical and biomolecular engineering at Cornell and member of the Kavli Institute at Cornell for Nanoscale Science, in collaboration with Dr. Jason A. Spector, assistant professor of surgery at Weill Cornell Medical College, and an interdisciplinary team of Ithaca and Weill scientists. The research was published online May 6 in the journal Biomaterials.

The biomaterials are composed of experimental tissue scaffolds that are about the size of a dime and have the consistency of tofu. They are made of a material called type 1 collagen, which is a well-regulated biomaterial used often in surgeries and other biomedical applications. The templates were fabricated with tools at the Cornell NanoScale Science and Technology Facility to contain networks of microchannels that promote and direct growth of healthy tissue into wound sites. “The challenge was how to promote vascular growth and to keep this newly forming tissue alive and healthy as it heals and becomes integrated into the host,” Stroock said. The grafts promote the ingrowth of a vascular system — the network of vessels that carry blood and circulate fluid through the body — to the wounded area by providing a template for growth of both the tissue (dermis, the deepest layer of skin), and the vessels. Type I collagen is biocompatible and contains no living cells itself, reducing concerns about immune system response and rejection of the template.

A key finding of the study is that the healing process responds strongly to the geometry of the microchannels within the collagen. Healthy tissue and vessels can be guided to grow toward the wound in an organized and rapid manner. Dermal templates are not new; the Johnson & Johnson product Integra, for example, is widely used for burns and other deep wounds, Spector said, but it falls short in its ability to encourage growth of healthy tissue because it lacks the microchannels designed by the Cornell researchers. “They can take a long time to incorporate into the person you’re putting them in,” Spector said. “When you’re putting a piece of material on a patient and the wound is acellular, it has a big risk for infection and requires lots of dressing changes and care. Ideally you want to have a product or material that gets vascularized very rapidly.” In the clinic, Spector continued, patients often need significant reconstructive surgery to repair injuries with exposed vital structures like bone, tendon or orthopedic hardware. The experimental templates are specifically designed to improve vascularization over these “barren” areas, perhaps one day eliminating the need for such invasive surgeries and reducing the patient’s discomfort and healing time. Eventually, the scientists may try to improve their tissue grafts by, for example, reinforcing them with polymer meshes that could also act as a wound covering, Spector said.

EurekAlert! Medicine
May 31, 2011

Original web page at EurekAlert! Medicine

Categories
News

Hospitals misleading patients about benefits of robotic surgery, study suggests

An estimated four in 10 hospital websites in the United States publicize the use of robotic surgery, with the lion’s share touting its clinical superiority despite a lack of scientific evidence that robotic surgery is any better than conventional operations, a new Johns Hopkins study finds. The promotional materials, researchers report online in the Journal for Healthcare Quality, overestimate the benefits of surgical robots, largely ignore the risks and are strongly influenced by the product’s manufacturer. “The public regards a hospital’s official website as an authoritative source of medical information in the voice of a physician,” says Marty Makary, M.D., M.P.H., an associate professor of surgery at the Johns Hopkins University School of Medicine and the study’s leader. “But in this case, hospitals have outsourced patient education content to the device manufacturer, allowing industry to make claims that are unsubstantiated by the literature. It’s dishonest and it’s misleading.”

In the last four years, Makary says, the use of robotics to perform minimally invasive gynecological, heart and prostate surgeries and other types of common procedures has grown 400 percent. Proponents say robot-assisted operations use smaller incisions, are more precise and result in less pain and shorter hospital stays — claims the study’s authors challenge as unsubstantiated. More hospitals are buying the expensive new equipment and many use aggressive advertising to lure patients who want to be treated with what they think is the latest and greatest in medical technology, Makary notes. But Makary says there are no randomized, controlled studies showing patient benefit in robotic surgery. “New doesn’t always mean better,” he says, adding that robotic surgeries take more time, keep patients under anesthesia longer and are more costly. None of that is apparent in reading hospital websites that promote its use, he says. For example he points out that 33 percent of hospital websites that make robot claims say that the device yields better cancer outcomes — a notion he points out as misleading to a vulnerable cancer population seeking out the best care.

Makary and his colleagues analyzed 400 randomly selected websites from U.S. hospitals of 200 beds or more. Data were gathered on the presence and location of robotic surgery information on a website, the use of images or text provided by the manufacturer, and claims made about the performance of the robot. Forty-one percent of the hospital websites reviewed described the availability and mechanics of robotic surgery, the study found. Of these, 37 percent presented the information on the homepage and 66 percent mentioned it within one click of the homepage. Manufacturer-provided materials were used on 73 percent of websites, while 33 percent directly linked to a manufacturer website. When describing robotic surgery, the researchers found that 89 percent made a statement of clinical superiority over more conventional surgeries, the most common being less pain (85 percent), shorter recovery (86 percent), less scarring (80 percent) and less blood loss (78 percent). Thirty-two percent made a statement of improved cancer outcome. None mentioned any risks.

“This is a really scary trend,” Makary says. “We’re allowing industry to speak on behalf of hospitals and make unsubstantiated claims.” Makary says websites do not make clear how institutions or physicians arrived at their claims of the robot’s superiority, or what kinds of comparisons are being made. “Was robotic surgery being compared to the standard of care, which is laparoscopic surgery,” Makary asks, “or to ‘open’ surgery, which is an irrelevant comparison because robots are only used in cases when minimally invasive techniques are called for.” Makary says the use of manufacturer-provided images and text also raises serious conflict- of-interest questions. He says hospitals should police themselves in order not to misinform patients. Johns Hopkins Medicine, for example, forbids the use of industry-provided content on its websites.

Science Daily
May 31, 2011

Original web page at Science Daily

Categories
News

Bone marrow cells that transform into skin cells could revolutionize approach to wound treatment

Researchers at King’s College London and Osaka University in Japan have identified specific bone marrow cells that can transform into skin cells to repair damaged skin tissue, according to a study published in Proceedings of the National Academy of Sciences (PNAS). The team has uncovered how this process works, providing new insights into the mechanisms behind skin repair. This significant advance has the potential to revolutionise approaches to wound treatment in the future, which could benefit people with chronic wounds such as leg ulcers, pressure sores and burns, as well as genetic skin diseases such as epidermolysis bullosa, which causes painful blisters on the skin. The current management of chronic wounds in UK patients costs more than a billion pounds every year so this new scientific discovery could lead to significant future cost savings for the NHS. It was already known that bone marrow may play a role in skin wound healing, but until now it was not known which specific bone marrow cells this involves, how the process is triggered, and how the key cells are recruited to the affected skin area. The team of researchers carried out experiments in mice, specifically looking at the mechanisms involved when skin grafts are used, compared with non-grafted wound healing.

The findings showed that in mice with non-grafted wound healing, very few bone marrow cells travelled to the wound to repair it and they did not make a major contribution to epidermal repair. But in mice where a skin graft was used, a significantly higher number of specific bone marrow-derived cells travelled to the skin graft to heal the area more quickly and build new skin directly from the bone marrow cells. The research showed that around one in every 450 bone marrow cells has the capacity to transform into skin cells and regenerate the skin. The team also identified the signal that triggers recruitment of the bone marrow cells to repair skin. Damaged skin can release a distress protein called HMGB1 that can mobilise the cells from bone marrow and direct them to where they are needed.

Mice with skin grafts express high levels of HMGB1 in their blood that can drive the bone marrow repair process. The findings provide new insight into how skin grafts work in medicine — they do not simply cover wounds, but act as bioreactors that can kick-start regenerative skin repair. The research also showed that patients with epidermolysis bullosa have high levels of HMGB1 in their blood and that the source here is the roofs of the blisters in their skin. This finding demonstrates that HMGB1 is also important in human skin damage and wound healing responses. Professor John McGrath, Head of the Genetic Skin Disease Group at King’s, recently spent several months working on the project in Osaka. He said: “This work is tremendously exciting for the field of regenerative medicine. The key achievement has been to find out which bone marrow cells can transform into skin cells and repair and maintain the skin as healthy tissue, and to learn how this process happens. “Understanding how the protein HMGB1 works as a distress signal to summon these particular bone marrow cells is expected to have significant implications for clinical medicine, and could potentially revolutionise the management of wound healing.

“Chronic wounds and tissue injury represent a significant cost to the NHS, not to mention the debilitating effects on peoples’ quality of life. Our plan is to see if we can now use this scientific advance to develop more effective treatments to improve tissue repair in skin and perhaps other organs.” Professor McGrath is working together with colleagues at Osaka University to harness the key parts of the HMGB1 protein to create a drug treatment that can augment tissue repair. It is expected that the developed treatment will be tested in animal models in about a year and enter clinical trials shortly afterwards.

Science Daily
April 19, 2011

Original web page at Science Daily

Categories
News

Novel surgery removes rare tumor, rebuilds trachea

Using a novel surgical approach, it’s possible to rebuild the trachea and preserve a patient’s voice after removing an invasive throat tumor, according to a new report from Henry Ford Hospital in Detroit. This case study is the first of its kind to not only document a successful technique to create a fully functional trachea, or windpipe, but also report a rare type of malignant tumor in an adult’s trachea. Most commonly, this type of tumor is seen in newborns and very rarely occurs in the neck, says lead study author Samer Al-Khudari, M.D., with the Department of Otolaryngology-Head & Neck Surgery at Henry Ford Hospital. “In this case, the patient’s tumor had spread to the trachea, thyroid gland, muscles around the thyroid gland and nerves in the area,” says Dr. Al-Khudari. According to head and neck cancer surgeon Tamer A. Ghanem, M.D., Ph.D., who led the Henry Ford surgical team, the easiest approach would have been to remove the trachea and the voice box, given the tumor’s proximity to the larynx and other surrounding structures. With this method, however, the patient would no longer be able to speak or swallow normally.

Instead, the surgical team took another approach. Using tissue and bone from the patient’s arm, they were able to reconstruct the trachea, restoring airflow through the trachea and saving the patient’s voice. “We had to think outside the box to not only safely remove the tumor, but to allow for optimum functional outcome,” says Dr. Ghanem, director of the Head and Neck Oncology & Microvascular Surgery Division at Henry Ford. “This is the first time such a large portion of a patient’s trachea has been removed and rebuilt in a way that allows it to be fully functional.” This unique case will be presented Jan. 29 at the poster session for the Triological Society’s Combined Section Meeting in Scottsdale, Ariz. The case study is centered on a 27 year-old man who had a large mass blocking 90 percent of his airway, making it very difficult for him to breathe. After a biopsy and other tests, Henry Ford doctors determined the mass was a malignant immature teratoma — a cancerous tumor that was quickly spreading throughout the areas of the patient’s trachea and surrounding structures.

Such tumors are extremely rare; since the first reported case in 1854, there have only been 300 other reported cases. With the Henry Ford patient, surgeons first removed the tumor and about half of the patient’s airway, just below the voice box. Using bone and skin from the patient’s arm and two titanium plates, surgeon’s reconstructed the airway, providing it with full coverage and allowing it to be fully functional. Reconstruction of the trachea is challenging, due to the structural complexity and unique properties of the airway. The ideal reconstruction must not collapse during respiration and have some degree of mobility to allow for neck movement. Currently the patient is using a tracheostomy tube — a tube that is inserted into an opening in the trachea to assist with breathing — but the surgeons do not expect it to be permanent. The patient, however, is able to speak and swallow normally. He also underwent chemotherapy as part of his treatment.

Science Daily
February 8, 2011

Original web page at Science Daily

Categories
News

Robotic surgery of ‘tremendous benefit’ to patients

Robot-assisted surgery dramatically improves outcomes in patients with uterine, endometrial, and cervical cancer, said researchers at the Jewish General Hospital’s Lady Davis Institute for Medical Research in Montreal. Moreover, because of fewer post-operative complications and shorter hospital stays, robotic procedures also cost less. These results were published in late 2010 in a series of studies in The Journal of Robotic Surgery and The International Journal of Gynecological Cancer. To date, adoption of robotic surgery has been slowed by fears that it will raise overall healthcare costs. In Canada, robotic procedures are not yet covered by any provincial healthcare plan. “To the contrary, robotic surgery definitely benefits patients and society,” said Dr. Walter H. Gotlieb, Head of Gynecologic Oncology at the JGH Segal Cancer Centre. “Patient quality of life is dramatically improved, their hospital stays are much shorter and they use far less narcotic pain medication. The majority of our patients need nothing stronger than Tylenol.”

In a robot-assisted operating room, the physician sits at a computer console and manipulates multiple robot arms, rather than working directly on the patient. The technology was developed to overcome the limitations of minimally invasive surgery (MIS), including such notoriously difficult procedures as laparoscopy for cancer. “Laparoscopy is the gold standard of treatment for endometrial cancer, but unfortunately the learning curve is too steep for most surgeons,” said Dr. Gotlieb, also Director of Surgical Oncology at McGill University. “A recent U.S. study said that only about six percent of gynecologic oncology surgeons offer laparoscopy to most of their endometrial cancer patients, despite its well-established advantages.” “At the Jewish General Hospital, we went from only 15 percent of our endometrial cancer patients benefiting from MIS by laparoscopy to 95 percent using robotic surgery. In cervical cancer we did not perform MIS at all before, whereas now all of our patients benefit from it.”

Moreover, contrary to Isaac Asimov and other 20th-century science fiction writers, who predicted that people would react to robots with fear and loathing, patients — even elderly patients- are the most enthusiastic boosters of robotic surgery. In a letter addressed to the hospital’s director of professional services, one patient with a very complex case of endometrial cancer heaped praise on her “surgeon and his robot” and called the device a “marvel.”

Science Daily
January 24, 2011

Original web page at Science Daily

Categories
News

Five-year results show keyhole bowel cancer surgery as safe and effective

Laparoscopic or ‘keyhole’ surgery is a safe, effective way of removing bowel tumours and should be offered to all patients undergoing surgery for colorectal cancer, according to researchers from the University of Leeds. Patients who have laparoscopic surgery spend less time in hospital and recover more quickly from the operation. Now long-term follow-up data has confirmed that this way of doing surgery does not make patients with colorectal cancer more vulnerable to the disease returning, as some had feared. And overall survival rates for keyhole surgery are just the same as those for conventional, open surgery, researchers concluded after tracking the progress of patients for five years. The results are the latest from the CLASICC trial — a multicentre study funded by the Medical Research Council that involved around 400 patients with colon cancer and another 400 with rectal cancer. The trial drew on patients from 27 hospitals across the UK and unlike other head-to-head assessments of these two surgical techniques, included a detailed analysis of all tissue samples that were removed to assess the quality of surgery.

Initial results from the study, published previously, showed that keyhole surgery was as safe as open surgery for colorectal cancer and that in the short term the cancer was no more likely to return. These findings contributed to the decision by the UK National Institute of Clinical Excellence (NICE) and European regulators to back the use of laparoscopic techniques by surgeons for the treatment of colon and bowel cancers. However, some surgeons were concerned that the minimally invasive technique would not be as good at removing all cancer cells from tissue around the tumour and that after a few years, the cancer would simply come back. This risk was thought to be highest for patients with rectal cancer. These latest findings show that this is not the case and that in the hands of an experienced surgeon, the chance of colorectal cancer recurring does not depend on the surgical method. Also, the overall survival rate of patients with colorectal cancer is not affected by the type of surgery they have. Full details are published in the November issue of the British Journal of Surgery.

“There is still a body of surgeons who are sceptical about laparoscopic colorectal cancer surgery and particularly laparoscopic rectal surgery. These long-term follow-up results should now help to convince any remaining sceptics that the minimally invasive technique is safe and effective for most patients with colorectal cancer,” said David Jayne, Senior Lecturer in Surgery at the University of Leeds and lead author of the paper. “Patients too should be reassured that any short-term gains from minimally invasive surgery have not been at the expense of compromised long-term outcomes,” he said. “Where suitable, laparoscopic surgery should now be offered to all patients with colorectal cancer so that they can benefit from the recognised advantages, such as quicker recovery, shorter hospital stay and earlier return to normal function.” “Surgery remains the most important of the methods of treatment of bowel cancer and this study confirms that tumours can be removed equally well by keyhole surgery as by standard surgery. We must, however, continue to strive for surgical excellence through audit of both types of surgery and by exploration of new techniques, such as robotic surgery,” said Professor Phil Quirke, Yorkshire Cancer Research Centenary Professor of Pathology at the University of Leeds, and co-author of the paper.

Science Daily
November 23, 2010

Original web page at Science Daily

Categories
News

Origin of skillful stone-tool-sharpening method pushed back more than 50,000 years

A highly skillful and delicate method of sharpening and retouching stone artifacts by prehistoric people appears to have been developed at least 75,000 years ago, more than 50,000 years earlier than previously thought, according to a new study led by the University of Colorado at Boulder. A paper on the subject was published in the Oct. 29 issue of Science. The new findings show that the technique, known as pressure flaking, took place at Blombos Cave in South Africa during the Middle Stone Age by anatomically modern humans and involved the heating of silcrete — quartz grains cemented by silica — used to make tools. Pressure flaking takes place when implements previously shaped by hard stone hammer strikes followed by softer strikes with wood or bone hammers are carefully trimmed on the edges by directly pressing the point of a tool made of bone on the stone artifact. The technique provides a better means of controlling the sharpness, thickness and overall shape of bifacial tools like spearheads and stone knives, said Paola Villa, a curator at the University of Colorado Museum of Natural History and a study co-author. Prior to the Blombos Cave discovery, the earliest evidence of pressure flaking was from the Upper Paleolithic Solutrean culture in France and Spain roughly 20,000 years ago. “This finding is important because it shows that modern humans in South Africa had a sophisticated repertoire of tool-making techniques at a very early time,” said Villa. “This innovation is a clear example of a tendency to develop new functional ideas and techniques widely viewed as symptomatic of advanced, or modern, behavior.”

Science Daily
November 9, 2010

Original web page at Science Daily

Categories
News

Early success with laser that destroys tumors with heat

Physicians at Mayo Clinic’s Florida campus are among the first in the nation to use a technique known as MRI-guided laser ablation to heat up and destroy kidney and liver tumors. So far, five patients have been successfully treated — meaning no visible tumors remained after the procedure. Although the treatment techniques are in the development stage, the physicians say the treatment is potentially beneficial against most tumors in the body — either primary or metastatic — as long as there are only a few in an organ and they are each less than 5 centimeters in size (about 2 inches in diameter). Patients also cannot have a pacemaker or certain metallic implants, since the procedure is done inside an MRI machine. “Laser ablation offers us a way to precisely target and kill tumors without harming the rest of an organ. We believe there are a lot of potential uses of this technique — which is quite exciting,” says Eric Walser, M.D., an interventional radiologist who has pioneered the technique at Mayo Clinic, Florida. In the United States, laser ablation is primarily used to treat brain, spine and prostate tumors, but is cleared by the U.S. Food and Drug Administration (FDA) for any soft tissue tumor.

Only a few centers have adapted the technique to tumors outside of the brain. Dr. Walser has been using laser ablation since June. He learned the technique in Italy, where its use is more common, and he adapted it for patients at Mayo Clinic, Florida, many of whom are on a liver transplant waiting list. The clinic is a large liver transplant center, and a number of patients with cirrhosis have small tumors in their liver. “We treated the tumors to keep them at bay because we could not use chemotherapy in these patients, who are quite ill and are waiting for a new liver,” he says. He also adapted it for use in treating kidney tumors. The outpatient procedure is performed inside an MRI machine, which can precisely monitor temperature inside tumors. A special nonmetal needle is inserted directly into a tumor, and the laser is turned on to deliver light energy. Physicians can watch the temperature gradient as it rises, and they can see exactly in the organ where the heat is. When the tumor and a bit of tissue that surrounds it (which may harbor cancer cells) is heated to the point of destruction — which can be clearly seen on monitors — the laser is turned off. In larger tumors, several needles are inserted simultaneously.

Patients are given anesthesia because, during the 2.5-minute procedure they should not move, Dr. Walser says. Post-treatment side effects include some local pain and flulike symptoms as the body reacts to, and absorbs, the destroyed tissue, he says. These side effects usually subside in three days to one week. Dr. Walser adds that laser ablation is a much more precise technology than similar methods that use probes, such as radiofrequency ablation, which also raises a tumor’s temperature, and cryotherapy, which freezes tumors. At the March meeting of the Society of Interventional Radiology, Dr. Woodrum, presented results from the first known cases of using MRI-guided laser ablation to treat prostate tumors. He said then that the safe completion of four clinical cases using the technique to treat prostate cancer in patients who had failed surgery “demonstrates this technology’s potential.”

Mayo Clinic
October 26, 2010

Original web page at Mayo Clinic

Categories
News

SpectroPen could help surgeons see the edges of tumors in human patients in real time during surgery

Biomedical engineers are developing a hand-held device called a SpectroPen that could help surgeons see the edges of tumors in human patients in real time during surgery. Scientists at Emory University School of Medicine, the Georgia Institute of Technology, and the University of Pennsylvania describe the device in an article published this week in the journal Analytical Chemistry. What a patient with a tumor wants to know after surgery can be expressed succinctly: “Did you get everything?” Statistics indicate that complete removal, or resection, is the single most important predictor of patient survival for most solid tumors. “This technology could allow a surgeon to directly visualize where the tumors are, in real time. In addition, a post-surgery scan could check tumor margins,” said Shuming Nie, a professor in the Wallace H. Coulter Department of Biomedical Engineering at Georgia Tech and Emory University. “A major challenge is to completely remove the tumor as well as identify lymph nodes that may be involved.”

The SpectroPen can be used to detect fluorescent dyes, and also scattered light from tiny gold particles, a technology that Nie and his colleagues have been refining. The particles consist of polymer-coated gold, coupled to a reporter dye and an antibody that sticks to molecules on the outsides of tumor cells more than it sticks to normal cells. Through an effect called surface-enhanced Raman scattering, the gold in the particle greatly amplifies the signal from the reporter dye. Nie and his team have been able to show that the particles can detect tumors smaller than one millimeter grafted into rodents. The SpectroPen combines a near-infrared laser and a detector for fluorescence or scattered light. It is connected by a fiber optic cable to a spectrometer that can record fluorescence and Raman signals. In the Analytical Chemistry paper, the researchers used the pen to detect the dye indocyanine green, infused intravenously into mice with implanted human breast cancer cells. The dye accumulates at a higher rate in tumor cells because of the leaky blood vessels and membranes surrounding tumors. The SpectroPen’s signal from the tumor is ten times higher than from normal tissue. Indocyanine green has been approved by the FDA for purposes such as measuring cardiac output and liver function.

The cancer cells had a gene from fireflies added, so that tumors glow after the mice are given a “luciferin” solution. This allowed the scientists to check that the outline of the tumor seen through the SpectroPen matched the glow. “Our in vivo studies demonstrate that the tumor borders can be precisely detected preoperatively and intraoperatively, and that the contrast signals are strongly correlated with tumor bioluminescence,” Nie said. In the laboratory, the fluorescence and Raman signals are resolvable when the nanoparticles are buried 5-10 mm deep in fresh animal tissues. However, the gold nanoparticles are 40 to 50 times more sensitive than fluorescent dyes.

PhysOrg.com
October 26, 2010

Original web page at PhysOrg.com

Categories
News

Surgeons expand the use of scar-free surgical technique to more patients

A team of surgeons from Mt. Sinai Hospital in New York who have pioneered scar-free gallbladder removal are offering the procedure to all suitable patients and extending this new type of surgical procedure to other operations in the abdomen. They reported on their updated findings October 6 at the 2010 Annual Clinical Congress of the American College of Surgeons. The procedure is known as laparoendoscopic single-site surgery, or LESS. It marries laparoscopy, known commonly as minimally invasive surgery that requires small incisions in the abdomen to insert instruments, with endoscopy, a probe with a camera that lets the surgeon see inside the abdomen. Laparoscopy is an alternative to an open operation, which involves a large incision to actually open the surgical site. The LESS procedure goes one better than minimally invasive surgery, according to study coauthor Edward Chin, MD, FACS, a general surgeon at Mt. Sinai Medical Center in New York. “Minimally invasive gallbladder surgery requires the surgeon to make four small incisions in a half-moon pattern in the abdomen, but the LESS procedure requires one incision made through the navel. Moreover, laparoscopy leaves behind four visible, small scars in the abdomen following a procedure. LESS leaves virtually none,” he said.

The LESS approach to gallbladder surgery is not for everyone, Dr. Chin cautioned. Patients who need emergency surgery or who have had previous abdominal operations that built up scar tissue are probably not suitable candidates. “Those two populations aside, we try to offer this technique to everyone who is coming in for elective laparoscopic gallbladder surgery,” he explained. So far, results with LESS have been almost identical to those with laparoscopic surgery, Dr. Chin reported. Both operations typically allow for same-day discharge and require similar recovery times before patients return to their normal activities, and the costs for both are similar. “The surgeon can use a lot of expensive, new disposable instruments, but we are more inclined to use the minimum of specialized equipment,” Dr. Chin explained. “Depending on what available equipment the surgeon chooses to use, you can keep the costs relatively low, and not significantly higher than a traditional laparoscopic operation.”

The Mt. Sinai group did find two advantages to the LESS procedure: these patients required less pain medicine after the operation than their counterparts who had the traditional minimally invasive operation; and LESS patients typically reported higher satisfaction scores: –4.7 on a scale of 1 to 5 (5 equals highest score) versus 3.6 for the conventional laparoscopic surgery group. “What’s really exciting is how these patients would recommend the procedure to a friend or family member,” Dr. Chin said. “Seventy-four percent of the patients who had the single-incision operation would strongly recommend the procedure to someone else versus 36 percent of those who had laparoscopic surgery.” Since the Mt. Sinai team first used LESS for gallbladder removal, the surgeons have completed operations using the LESS approach to remove adrenal glands and spleens, Dr. Chin said. “These are more advanced and challenging procedures, but we were able to demonstrate in small numbers so far that these procedures can be safely done using a similar technique,” he said. However, he added, these procedures require more study. Earlier this year, the Mt. Sinai surgeons also completed a single-incision combined operation, removing the gall-bladder and spleen in a pediatric patient, Dr. Chin reported.

Future innovations related to the procedure may involve incorporating surgical robots, Dr. Chin said. “For gallbladder removal, very few surgeons would employ the surgical robot because it’s just not necessary,” he said. “Gallbladder surgery is a relatively straightforward procedure that can be done very well and very safely by traditional surgery.” Additionally, today’s robots are too large and expensive to use for common abdominal operations, he said. “When the surgical robot gets further miniaturized, I can see this really revolutionizing single-incision surgery,” he added.

Science Daily
October 26, 2010

Original web page at Science Daily

Categories
News

How to control massive bleeding from the hepatic artery

Delayed hepatic arterial hemorrhage after pancreaticoduodenectomy (PD) is not a common but a fatal complication, occurring in 7% of all patients. Its ideal management remains unclear and controversial. A research article published on August 7, 2010 in the World Journal of Gastroenterology addresses this question. The authors reported the clinical outcome of 9 patients with life-threatening hemorrhage from a ruptured hepatic artery pseudoaneurysm after PD after treatment with a new interventional technique, namely placement of stent-grafts. This technique provides a good alternative option for the control of hemorrhage from ruptured hepatic artery pseudoaneurysm after PD, especially in those who cannot undergo embolization. Although the number of patients was small, the procedure demonstrated a lower mortality than conventional surgical intervention. Based on their results, placement of stent-grafts for acute lifethreatening bleeding from hepatic artery pseudoaneurysm is a valuable alternative to embolization and surgical intervention. If technically possible, this technique should be considered the first-line treatment for bleeding from the common and proper hepatic artery, particularly in patients with a non-portal vein. Further data are required to evaluate its technical success rate, complications, and long-term outcome in a larger number of patients.
Reading more:http://www.wjgnet.com/1007-9327/full/v16/i29/3716.htm

Science Daily
October 12, 2010

Original we page at Science Daily

Categories
News

Scarless brain surgery is new option for patients

Surgeons at the University of California, San Diego, School of Medicine and University of Washington Medical Center have determined that transorbital neuroendoscopic surgery (TONES) is a safe and effective option for treating a variety of advanced brain diseases and traumatic injuries. This groundbreaking minimally invasive surgery is performed through the eye socket, thus eliminating the removal of the top of the skull to access the brain. These findings were published in the September issue of Neurosurgery. “By performing surgery through the eye socket, we eliminate the need for a full craniotomy, gain equivalent or better access to the front of the brain, and eliminate the large ear-to-ear scar associated with major brain surgery,” said Chris Bergeron, MD, assistant professor of Surgery, Division of Head and Neck Surgery, at UC San Diego Health System. “This novel technique is also critical to protecting neurovascular structures such as the optic and olfactory nerves.”

To achieve access, the surgeons make a small incision behind or through the eyelid. A tiny hole is then made through the paper-thin bone of the eye socket to reach the brain. This pathway permits repairs to be made without lifting the brain. The TONES approaches also protect the optic nerves, the nerves for smell, as well as the carotid and ophthalmic arteries. “This approach has opened a new field of brain surgery,” said study investigator, Kris Moe, MD, chief of the Division of Facial Plastic and Reconstructive Surgery and professor of Otolaryngology at University of Washington Medical Center. “The advantages to this transorbital approach are many, including reduced pain and decreased recovery time for the patient.” Transnasal surgery, a technique performed through the nose, offers similar access to some areas of the brain but means a more crowded operating environment for the surgeon than TONES. Moe, who pioneered the TONES in 2005, said the novel technique builds on the nasal approach but offers increased maneuverability and visibility for the surgical teams which usually require four sets of hands.

In a traditional craniotomy, a large portion of skull bone is removed. With TONES, the area of bone removed is only two to three centimeters. The operating time is much shorter since the skull does not need to be repaired and there is no need to close a large incision. Patients underwent the TONES procedure to repair cerebral spinal fluid leaks, optic nerve decompression, repair of cranial base fractures and removal of tumors. Given further research, the surgeons believe that TONES may serve as a means to treat pituitary tumors, meningiomas, and vascular malformations. TONES is currently performed at only two institutions in the world: UC San Diego Medical Center and the University of Washington Medical Center.

Science Daily
October 12, 2010

Original web page at Science Daily

Categories
News

Surgery: No sponge left behind

Using the same technology found in clothing tags used in retail store tracking systems, a study from the University of North Carolina at Chapel Hill shows that surgical sponges with implanted radio frequency (RF) tags may be an effective adjunct to manual counting and X-ray detection in preventing sponges from being left behind in patients following a surgical procedure. UNC surgeons will report the preliminary results of the study on Tuesday, Oct. 5 during a poster session at the 2010 Annual Clinical Congress of the American College of Surgeons in Washington, D.C. The reported incidence of a sponge or another foreign body, such as a surgical instrument, being left behind after operations has varied widely over the years. Previously published reports have estimated ranges of one in 1,000 operations to one in 18,000. Our preliminary data agrees with the previously reported incidence of retained surgical sponges,” said lead investigator UNC gastrointestinal surgeon Christopher C. Rupp, MD. The researchers used a radio-frequency (RF) detection device in 1,600 operations, and found a sponge in one operation in which manual counting of the sponges was correct.

Sponges used to absorb fluids and improve access to organs during surgical procedures are much different than household sponges. Surgical sponges are mostly made of cotton, and come in sizes of 12-by-12 inches or as small as 4-by-4 inches. These sponges can become difficult to see during an operation because they can mold into different shapes and take on the same color of the fluids being absorbed. Furthermore, the sponges can migrate to other areas of the operative field, and they can be difficult to feel with surgical gloves. Surgeons use various methods to track sponges during operations. The most common is manual sponge counts by a nurse, but more sophisticated methods include the radio-frequency tagged sponges used in the UNC study, X-ray of the abdomen and bar-coded sponges. The UNC investigators did not include bar-coding systems in their study. Human error involved with manual counting and X-ray interpretation were the impetus that resulted in the studies inception, Rupp reported. The RF-tagged system in the UNC study has the same technology found in the clothing tags used in retail store tracking systems and in microchips embedded in pets. During surgery, a nurse passes a wand over the patient’s body to pick up readings from the RF tags. Newer versions have detection hardware built into the mat the patient lies on. “RF detection is not going to replace counting in the operating room, but it can be used as an adjunct because, from what we’re seeing in the preliminary data, it adds a lot to the safety of the procedure,” Rupp said.

Science Daily
October 12, 2010

Original web page at Science Daily

Categories
News

Sepsis and septic shock more common than heart attacks or pulmonary blood clots after general surgery

Sepsis and septic shock appear to be more common than heart attacks or pulmonary blood clots among patients having general surgery, and the death rate for patients with septic shock is approximately 34 percent within 30 days of operation, according to a report in the July issue of Archives of Surgery, one of the JAMA/Archives journals. “Prevention of perioperative complications is a major focus in the care of the general-surgery patient,” the authors write as background information in the article. In recent years, attention has been focused on prevention of venous thromboembolism (including post-operative deep vein thrombosis, or blood clots in the deep veins of the pelvis or extremities, and pulmonary embolism, or blood clots that travel to the lungs), myocardial infarction (heart attack) and surgical site infections. These efforts have resulted in awareness and reduction of these complications.

Sepsis, an infection that usually results from bacteria in the bloodstream and can result in failure of multiple organ systems, is another potentially preventable cause of illness and death in general surgery patients, the authors note. Laura J. Moore, M.D., and colleagues at The Methodist Hospital, Weill Cornell Medical College, Houston, reviewed the incidence, mortality rate and risk factors for sepsis in general surgery patients using data from the 2005 to 2007 American College of Surgeons National Surgical Quality Improvement Program. Of 363,897 general surgery patients, sepsis occurred in 8,350 (2.3 percent), septic shock or life-threatening low blood pressure due to sepsis occurred in 5,977 (1.6 percent), pulmonary embolism occurred in 1,078 (0.3 percent) and heart attack occurred in 615 (0.2 percent). Death rates within 30 days were 5.4 percent for sepsis, 33.7 percent for septic shock, 9.1 percent for pulmonary embolism and 32 percent for heart attack.

The results suggest that sepsis continues to be a common and serious complication in general surgery patients and occurs more frequently than pulmonary embolism or heart attack. “Of note, septic shock occurs 10 times more frequently than myocardial infarction and has the same mortality rate; thus, it kills 10 times more people,” the authors write. “Therefore, our level of vigilance in identifying sepsis and septic shock needs to mimic, if not surpass, our vigilance for identifying myocardial infarction and pulmonary embolism.” Risk factors for sepsis and septic shock included age older than 60, the need for emergency surgery and the presence of any co-occurring illness. Having such an illness increased the risk of sepsis and septic shock six-fold and the risk of dying within 30 days 22-fold. “By identifying three major risk factors for the development of and death from sepsis and septic shock in general-surgery patients, we can heighten our awareness for sepsis and septic shock in these at-risk populations,” the authors conclude. “The implementation of mandatory sepsis screening for these high-risk populations has resulted in decreased sepsis-related mortality within our institution. Further evaluation of the role of sepsis screening programs in other settings is critical and could significantly reduce sepsis-related mortality in general-surgery patients.”

Science Daily
August 3, 2010

Original web page at Science Daily

Categories
News

Surgery linked to Creutzfeldt-Jakob disease, according to Spanish study

A new study spearheaded by Spanish scientists demonstrates a causal relationship between the onset of Creutzfeldt-Jakob disease (CJD), caused by a protein called a prion, and general surgery. CJD manifests itself in hereditary acquired and sporadic forms, or for unknown reasons, which accounts for the majority of cases. “Based on the monitoring records of spongiform encephalopathy in two Nordic countries, we studied the possibility of transmission of the sporadic form of CJD through general surgery,” explains Jesús de Pedro, main author of the study and head of prion monitoring in patients at the National Epidemiology Centre of the Carlos III Health Institute. The finding, published recently in the Journal of Neurology, Neurosurgery & Psychiatry, reveals that, with a few exceptions, the risk of having contracted the sporadic form of CJD manifests itself at least 20 years after having undergone an operation.

“While we are not ruling out the idea that intraoperational transfusions may play a secondary part, the data suggest that the disease enters and spreads much more quickly within the central or peripheral nervous system,” says De Pedro. According to the authors, the fact that computer records of surgeries have been in place since the early seventies in hospitals in Sweden and Denmark enables operations on residents of those countries to be linked to cases of CJD, which “extends an extraordinary quality to the information and more credibility to the findings given the almost total absence of memory bias.” Why is the idea of transmission through surgery important? The most interesting thing about this finding, which points to an external cause that could be prevented, is that “it may signify a shift in our understanding of the nature of neurodegenerative diseases, such as Alzheimer’s or Parkinson’s.” We might, therefore, ask ourselves if other types of motor neuron diseases can be transmitted through surgery and be latent for decades, such as those where risk factors, particularly physical professions and activities or certain sporting activities, for example, which are more likely to lead to surgery, have already been indicated.

“Suggesting that a disease could have been acquired during health care is a very delicate affirmation, as some relatives of patients with sporadic CJD may be tempted to seek compensation from health authorities for the alleged intraoperational transmission years previously, which would be impossible to prove in individual cases,” he reasons. Nonetheless, the most conclusive pattern that the study presents, albeit based on few cases and one that must be replicated in future studies, is that the onset of CJD occurs approximately 10 years after an operation on the retina with reused equipment.

Science Daily
July 20, 2010

Original web page at Science Daily