Tag: Surgery (Orthopeadics)

Every day, their baby stopped breathing, his collapsed bronchus blocking the crucial flow of air to his lungs. April and Bryan Gionfriddo watched helplessly, just praying that somehow the dire predictions weren’t true. “Quite a few doctors said he had a good chance of not leaving the hospital alive,” says April Gionfriddo, about her now 20-month-old son, Kaiba. “At that point, we were desperate. Anything that would work, we would take it and run with it.” They found hope at the University of Michigan, where a new, bioresorbable device that could help Kaiba was under development. Kaiba’s doctors contacted Glenn Green, M.D., associate professor of pediatric otolaryngology at the University of Michigan. Green and his colleague, Scott Hollister, Ph.D., professor of biomedical engineering and mechanical engineering and associate professor of surgery at U-M, went right into action, obtaining emergency clearance from the Food and Drug Administration to create and implant a tracheal splint for Kaiba made from a biopolymer called polycaprolactone.

On February 9, 2012, the specially-designed splint was placed in Kaiba at C.S. Mott Children’s Hospital. The splint was sewn around Kaiba’s airway to expand the bronchus and give it a skeleton to aid proper growth. Over about three years, the splint will be reabsorbed by the body. The case is featured today in the New England Journal of Medicine. “It was amazing. As soon as the splint was put in, the lungs started going up and down for the first time and we knew he was going to be OK,” says Green. Green and Hollister were able to make the custom-designed, custom-fabricated device using high-resolution imaging and computer-aided design. The device was created directly from a CT scan of Kaiba’s trachea/bronchus, integrating an image-based computer model with laser-based 3D printing to produce the splint. “Our vision at the University of Michigan Health System is to create the future of health care through discovery. This collaboration between faculty in our Medical School and College of Engineering is an incredible demonstration of how we achieve that vision, translating research into treatments for our patients,” says Ora Hirsch Pescovitz, M.D., U-M executive vice president for medical affairs and CEO of the U-M Health System.

“Groundbreaking discoveries that save lives of individuals across the nation and world are happening right here in Ann Arbor. I continue to be inspired and proud of the extraordinary people and the amazing work happening across the Health System.” Kaiba was off ventilator support 21 days after the procedure, and has not had breathing trouble since then. “The material we used is a nice choice for this. It takes about two to three years for the trachea to remodel and grow into a healthy state, and that’s about how long this material will take to dissolve into the body,” says Hollister. “Kaiba’s case is definitely the highlight of my career so far. To actually build something that a surgeon can use to save a person’s life? It’s a tremendous feeling.” The image-based design and 3D biomaterial printing process can be adapted to build and reconstruct a number of tissue structures. Green and Hollister have already utilized the process to build and test patient specific ear and nose structures in pre-clinical models. In addition, the method has been used by Hollister with collaborators to rebuild bone structures (spine, craniofacial and long bone) in pre-clinical models.

Severe tracheobronchomalacia is rare. About 1 in 2,200 babies are born with tracheomalacia and most children grow out of it by age 2 or 3, although it often is misdiagnosed as asthma that doesn’t respond to treatment. Severe cases, like Kaiba’s, are about 10 percent of that number. And they are frightening, says Green. A normal cold can cause a baby to stop breathing. In Kaiba’s case, the family was out at a restaurant when he was six weeks old and he turned blue. “Severe tracheobronchomalacia has been a condition that has bothered me for years,” says Green. “I’ve seen children die from it. To see this device work, it’s a major accomplishment and offers hope for these children.” Before the device was placed, Kaiba continued to stop breathing on a regular basis and required resuscitation daily. “Even with the best treatments available, he continued to have these episodes. He was imminently going to die. The physician treating him in Ohio knew there was no other option, other than our device in development here,” Green says. Kaiba is doing well and he and his family, including an older brother and sister, live in Ohio. “He has not had another episode of turning blue,” says April. “We are so thankful that something could be done for him. It means the world to us.”

Science Daily
June 11, 2013

Original web page at Science Daily

Injuries caused by needles and other sharp instruments are a major occupational hazard for surgeons — with high costs related to the risk of contracting serious infectious diseases, according to a special article in the April issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS). ASPS Member Surgeon Dr. Kevin C. Chung and colleagues at The University of Michigan Health System, Ann Arbor, review the risks, health impact and costs of “sharps” injuries for surgeons and other operating room personnel. They write, “Increased attention to the health, economic, personal and social implications of these injuries is essential for appropriate management and future prevention.” Nearly 400,000 sharps injuries occur each year in the United States. About 25 percent of injured workers are surgeons — for whom the risk is highest in the operating room. “Despite healthcare policies designed to protect healthcare workers, injuries remain common,” Dr. Chung and colleagues write. Nearly all surgeons will sustain a sharps injury sometime during their career. Medical students and residents are also at high risk; fatigue and inexperience are important risk factors.

The main health concern of sharps injuries is the risk of acquiring a communicable disease from a patient. While HIV is the most-feared result, the risk of infection with hepatitis B virus is actually much higher. Sharps injuries can also have a major psychological impact on the injured person and his or her family — particularly during the time needed to confirm that the injured worker is free of infection, which may take several weeks or months. Once an injury occurs, there are standardized guidelines for post-exposure prevention, depending on whether the patient has any known transmissible infections. Recommendations include antiviral medications for healthcare workers exposed to HIV and hepatitis B or C virus — ideally starting within hours after the injury. As a result of the need for testing and treatment, sharps injuries have a major economic impact. Average costs for testing, follow-up and preventive treatment range from $375 for needlestick exposure from a patient with no known blood-borne illness, up to nearly $2,500 for injuries from a patient with known HIV.

Post-exposure prevention can only be executed if the injury is reported. One study found that 70 percent of surgeons “never or rarely” report sharps injuries. They may feel they “don’t have time” to report, or may misunderstand the risks involved. “Fortunately, the majority of sharps injuries are preventable,” Dr. Chung and colleagues write. Engineered safety devices can prevent many injuries — especially if surgeons and other workers are involved in choosing to use them. Other options include the use of “non-sharp” alternatives, creating safe procedures for passing sharp instruments and wearing double gloves to reduce the risk of infection. Over the years, regulations have been introduced to ensure that proper prevention and reporting strategies are in place. Introduction of the Needlestick Safety and Prevention Act of 2000 led to an overall 38 percent reduction in injuries in all care settings. However, one study reported that the rate of sharps injuries in the operating room actually increased. “Although preventive strategies exist, their success ultimately relies on clinician compliance,” Dr. Chung and coauthors write. The authors hope their review will help to increase awareness of the risks and potential harms of sharps injuries among surgeons and operating room personnel, and to increase awareness of efforts to reduce the risk. They conclude, “Targeting educational initiatives during medical school and training may improve knowledge among surgeons of the safest ways to practice in the operating room, and ensuring compliance among all surgeons in practice can reduce the economic and psychosocial burden of these highly prevalent injuries.”

Science Daily
April 16, 2013

Original web page at Science Daily

Notorious among athletes and trainers as career killers, Achilles tendon injuries are among the most devastating. Now, by carbon testing tissues exposed to nuclear fallout in post WWII tests, scientists have learned why: Like our teeth and the lenses in our eyes, the Achilles tendon is a tissue that does not repair itself. This discovery was published online in The FASEB Journal. “Tendon injury is a very common disease, which hinders many people from enjoying the numerous benefits of sports and recreational activities,” said Katja Heinemeier, Ph.D., a researcher involved in the work from the Institute of Sport Medicine and Center for Healthy Aging at the University of Copenhagen in Denmark. “We hope that these new results will provide the essential knowledge necessary for the development of effective treatments of tendon diseases.” Heinemeier and colleagues made this discovery by taking advantage of carbon-14 spikes resulting from post WWII nuclear bomb tests. Because of these tests, there was a large release of the radioactive carbon-14 (radiocarbon) to the atmosphere between 1955 and 1963. This sudden rise in carbon-14 — called the “bomb pulse” — reached a maximum of twice the natural atmospheric level in 1963, and then gradually dropped to the lower levels over time. This variation is reflected in all human tissue, because humans eat plants (and animals fed on plants) that take up carbon-14 from the atmosphere.

Researchers studied the Achilles tendons from people who had lived during the carbon-14 bomb pulse peak, and found that the high carbon-14 levels of this period had remained in the tendon tissue for decades after. This persistence of radiocarbon can only be explained by the fact that the rate of tissue renewal is extremely slow in the tendon, if it exists at all. In fact, the results showed that the Achilles tendon stays the same after growing ends. In comparison, muscle tissue from the same persons had been constantly renewed and contained no “memory” of the radiocarbon. “While the nation waits to see if another Olympic skier or NFL rookie recovers from serious tendon or ligament damage, this report serves as a cautionary tale to temper expectations,” said Gerald Weissmann, M.D., Editor-in-Chief of The FASEB Journal. “When it comes to our tendons, what we have may be all we have. Like our teeth, it’s far better and less painful in the long term to protect them throughout your lifetime than it is to count on a successful recovery.”

Science Daily
March 5, 2013

Original web pages at Science Daily

Injecting specialized cardiac stem cells into a patient’s heart rebuilds healthy tissue after a heart attack, but where do the new cells come from and how are they transformed into functional muscle? Researchers at the Cedars-Sinai Heart Institute, whose clinical trial results in 2012 demonstrated that stem cell therapy reduces scarring and regenerates healthy tissue after a heart attack, now have found that the stem cell technique boosts production of existing adult heart cells (cardiomyocytes) and spurs recruitment of existing stem cells that mature into heart cells. The findings, from a laboratory animal study, are published in EMBO Molecular Medicine online. “We’re finding that the effect of stem cell therapy is indirect. It stimulates proliferation of dormant surviving host heart tissue, and it attracts stem cells already in the heart. The resultant new heart muscle is functional and durable, but the transplanted stem cells themselves do not last long,” said Eduardo Marbán, MD, PhD, director of the Heart Institute. Marbán, the article’s senior author, invented the experimental stem cell procedures and technology tested in humans.

Consistent with previous studies, the researchers found that the heart’s native stem cells are not responsible for the normal replenishment of lost heart cells, but they do contribute to rebuilding heart tissue after heart attack. This study shows that existing heart cells contribute to formation of new heart cells in the normal heart: Through a gradual cycling process, dying heart cells are replaced by new ones. The researchers found that this cycling process escalates in response to heart attack, enabling existing heart cells to assist in the development of new ones. Further, these effects can be amplified through stem cell therapy. The investigational therapy turns on genes that bolster cell production from both sources — existing heart cells and existing stem cells — essentially boosting the heart’s normal means of cell replacement and its natural responses to injury. The injection of stem cells also improves heart structure and function. Marbán and his clinical and research teams in 2009 performed the first procedure in which a heart attack patient’s own heart tissue was used to grow specialized stem cells that were injected back into the heart. Earlier this year, they reported results of a clinical trial that found significant reduction in the size of heart attack-caused scars in patients who underwent the experimental stem cell procedure, compared to others who did not.

Although the preliminary results are positive, the researchers do not know precisely how the research treatment works. “Understanding the cellular sources and mechanisms of heart regeneration is the first step toward refining our strategies to more effectively regenerate healthy tissue after heart attacks,” said Marbán, the Mark S. Siegel Family Professor. The animal study was supported by National Institutes of Health grant R01 HL083109, the California Institute for Regenerative Medicine and the Cedars-Sinai Board of Governors Heart Stem Cell Center. The process to grow cardiac-derived stem cells involved in the clinical trial was developed earlier by Marbán when he was on the faculty of Johns Hopkins University. The university has filed for a patent on that intellectual property and has licensed it to Capricor Inc., a biotechnology company in which Dr. Marbán is a founder and equity holder. The company provided no funding for this study.

Science Daily
February 19, 2013

Original web page at Science Daily

A research effort called the Human Connectome Project is seeking to explore, define, and map the functional connections of the human brain. An update on progress in and upcoming plans for the Human Connectome Project appears in the July issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. Analogous to the Human Genome Project — which mapped the human genetic code — the Human Connectome Project seeks to map “the complete, point-to-point spatial connectivity of neural pathways in the brain,” according to Arthur W. Toga, PhD, and colleagues of David Geffen School of Medicine, University of California Los Angeles. They write, “For neuroscientists and the lay public alike, the ability to assess, measure, and explore this wealth of layered information concerning how the brain is wired is a much sought after prize.” The 100 billion neurons of the human nervous system interconnect to form a relatively small number of “functional neural networks” responsible for behavior and thought. However, even after more than a century of research, there is no comprehensive map of the connections of the human brain.

Historically, studies of the human brain function have employed a “modular” view — for example, “region X is responsible for function Y.” However, a more appropriate approach is to consider which network of two or more “connected or interacting” regions is involved in a given function. Until recently, it was not possible to view networks in the living brain. But newer magnetic resonance imaging (MRI) methods sensitive to water diffusion have made it possible to create detailed maps of the underlying white matter connections between different areas of the brain. This opens the way to new approaches to mapping the structural connectivity of the brain, and showing it in ways that correspond to the brain anatomy. Researchers are working out ways to analyze these data using sophisticated modeling approaches to represent the “nodes and connections” that make up the functional networks of the brain. Such efforts are in their infancy, but these network models are capturing not only the connectedness of brain networks, but also their capacity to process information. Preliminary studies have yielded tantalizing findings, such as a link between more efficient cortical networks and increased intelligence and differences in connectedness between the right and left hemispheres of the brain. “The HCP has recently generated considerable interest because of its potential to explore connectivity and its relationship with genetics and behavior,” Dr. Toga and coauthors write.

The project has far-reaching implications for a wide range of neurological and psychiatric diseases, such as autism, schizophrenia, and Alzheimer’s disease. “The similarities and differences that mark normal diversity will help us to understand variation among people and set the stage to chart genetic influences on typical brain development and decline in human disease,” according to the authors. Dr. Toga and colleagues are making their data available for download and analysis by other researchers on the project website. In the future, the data will be openly available for exploration by the public.

Science Daily
July 24, 2012

Original web page at Science Daily

When you think of Botox injections, you probably think of getting rid of unwanted wrinkles around the eyes or forehead, but recently the US Food and Drug Administration (FDA) approved using the injections to help patients with neurological conditions who suffer from incontinence, or an overactive bladder. Botox injections paralyze the bladder muscle to prevent contractions that cause urgency to urinate or leak. Although medications and behavioral modifications are treatment options, many patients, especially the elderly, do not respond to these methods and need a more aggressive approach. “About 80 percent of patients with neurological conditions, such as spinal cord injuries, Parkinson’s disease and multiple sclerosis, see improvement after about a week, and the results can last four to nine months,” said Charles Nager, MD, co-director of the UC San Diego Women’s Pelvic Medicine Center at UC San Diego Health System.

Incontinence is the seventh condition, including chronic migraines and underarm sweating, that Botox has been approved to treat since the drug first arrived on the market as a wrinkle reducer in 2002. The outpatient procedure uses a local numbing gel, followed by 15 to 20 injections in different areas of the bladder muscle. “It can really be life changing for someone with severe incontinence issues,” said Nager who also serves as director of Urogynecology and Reconstructive Pelvic Surgery in the Department of Reproductive Medicine at UC San Diego. UC San Diego Health System is currently recruiting for a clinical trial to test Botox injections versus sacral nerve stimulation as incontinence treatment options. Sacral nerve stimulation uses small, electrical impulses to the nerves that control urination. The impulses are generated by a small device surgically placed under the skin. Attached to the device is a thin, electrode-tipped wire that passes under the patient’s skin, carrying impulses to the sacral nerve. The surgery is an outpatient procedure done under local anesthesia. Patients involved in the clinical trial are required to have tried two drugs that previously failed to treat their incontinence issues.

Science Daily
April 3, 2012

Original web page at Science Daily

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

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

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

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

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

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

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

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

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

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

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

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