Nursing Hours and Nurse Staffing according to Korean Triage Acuity Scale and Patient Dependency / 임상간호연구

Purpose@#The purpose of this study was to analyze nurse staffing according to patients' acuity and dependency by measuring nursing hours. @*Methods@#The study sample included patients who visited the adult emergency departments (EDs) of three tertiary referral hospitals and nurses who worked on shifts for 48 hours from October 24 to 26, 2019. Hourly patient census and nurse staffing were analyzed. Patient acuity was measured using the Korean Triage and Acuity Scale (KTAS), ranging from Level 1 (highest) to Level 5 (lowest). Patient dependency was measured using six items (e.g., clinical attention and communication) and classified into four groups. Nursing activities were observed every 10 minutes and nursing hours per patient and nurse staffing were analyzed according to acuity and dependency. @*Results@#Nurse-to-patient ratio ranged from 1:1.8 to 1:4.2 during the 48 hours of observation. The average work hours of nurses, excluding breaks and meals, was 8.57 hours; 42.5% of which was spent providing direct care. Higher acuity and dependency were associated with higher nursing hours and staffing level. Patients with KTAS Level 1 were provided 74.3 minutes per hour, 5.02 times higher than Level 5 (14.8 minutes). Patients in the highest dependency group were provided 87.4 minutes per hour, 5.75 times higher than the lowest group (15.2 minutes). Newly arrived patients received more nursing hours than continuously stayed patients within the same KTAS Levels. @*Conclusion@#Large variations were found in hourly patient census, acuity, and dependency. Nurse staffing in EDs should be determined based on patient acuity and dependency.

Nursing Hours and Nurse Staffing according to Korean Triage Acuity Scale and Patient Dependency / 임상간호연구

Purpose@#The purpose of this study was to analyze nurse staffing according to patients' acuity and dependency by measuring nursing hours. @*Methods@#The study sample included patients who visited the adult emergency departments (EDs) of three tertiary referral hospitals and nurses who worked on shifts for 48 hours from October 24 to 26, 2019. Hourly patient census and nurse staffing were analyzed. Patient acuity was measured using the Korean Triage and Acuity Scale (KTAS), ranging from Level 1 (highest) to Level 5 (lowest). Patient dependency was measured using six items (e.g., clinical attention and communication) and classified into four groups. Nursing activities were observed every 10 minutes and nursing hours per patient and nurse staffing were analyzed according to acuity and dependency. @*Results@#Nurse-to-patient ratio ranged from 1:1.8 to 1:4.2 during the 48 hours of observation. The average work hours of nurses, excluding breaks and meals, was 8.57 hours; 42.5% of which was spent providing direct care. Higher acuity and dependency were associated with higher nursing hours and staffing level. Patients with KTAS Level 1 were provided 74.3 minutes per hour, 5.02 times higher than Level 5 (14.8 minutes). Patients in the highest dependency group were provided 87.4 minutes per hour, 5.75 times higher than the lowest group (15.2 minutes). Newly arrived patients received more nursing hours than continuously stayed patients within the same KTAS Levels. @*Conclusion@#Large variations were found in hourly patient census, acuity, and dependency. Nurse staffing in EDs should be determined based on patient acuity and dependency.

Laparoscopy Assisted Subtotal Gastrectomy in Gastric Cancer Patient with Situs Inversus in Korea

Situs inversus totalis is a congenital condition in which there is complete right to left reversal of the thoracic and abdominal organ. According to an increase in minimally invasive treatments, laparoscopic surgery for patients with situs inversus totalis has also been increasing. We performed laparoscopy-assisted subtotal gastrectomy on a 60-year-old gastric cancer patient with situs inversus totalis. He was diagnosed with early stage gastric adenocarcinoma at antrum of the anterior wall. We experienced some technical difficulties because of the position and anatomic variation of major vessels. However, the subtotal gastrectomy was completed with D1+ beta lymph node dissection followed by extracorporeal gastroduodenostomy. The patient was discharged six days after operation without any complications. The pathologic report showed that tumor invasion was limited to the submucosa and one lymph node was positive for metastasis. We believe our experience is the first reported case of laparoscopic gastric cancer surgery for situs inversus in Korea.

Linear-Shaped Gastroduodenostomy in Totally Laparoscopic Distal Gastrectomy

PURPOSE: Laparoscopic gastrectomy has been common treatment modality for gastric cancer. But, most surgeons tend to perform laparoscopy-assisted distal gastrectomy using epigastric incision. Delta-shaped anastomosis is known as intracorporeal gastroduodenostomy, but it is technically difficult and needed many staplers. So we tried to find simple and economical method, here we report on the results of liner-shaped gastroduodenostomy in totally laparoscopic distal gastrectomy. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 25 patients who underwent totally laparoscopic distal gastrectomy using liner-shaped anastomosis at School of Medicine, Ajou University between January to October 2009. The indication was early gastric cancer as diagnosed by preoperative workup, the anastomoses were performed by using laparoscopic linear stapler. RESULTS: There were 12 female and 13 male patients with a mean age of 55.6+/-11.2. The following procedures were performed 14 laparoscopic gastrectomies, 11 robotic gastrectomies. The mean operation time was 179.5+/-27.4 minutes, the mean anastomotic time was 17.5+/-3.4 minutes. The mean number of stapler cartridges was 5.6+/-0.8. Postoperative complication occurred in one patient, anastomotic stenosis, and the patient required reoperation to gastrojejunostomy. The mean length of postoperative hospital stay was 6.7+/-1.0 days except the complication case, and there was no case of conversion to open procedure and postoperative mortality. CONCLUSIONS: Linear-shaped gastroduodenostomy in totally laparoscopic distal gastrectomy is technically simple and feasible method.

Mini-T Plate Fixation for Neer Type II Distal Clavicle Fracture

PURPOSE: To evaluate and report the clinical and radiological outcomes of open reduction and internal fixation with a mini-T plate for unstable distal clavicle fractures. MATERIALS AND METHODS: From December 2004 to July 2007, fifteen patients who had a fracture of the distal clavicle (Neer type II fracture) were treated with an open reduction and internal fixation using a mini-T plate. They were followed up for a minimum of one year and the clinical and radiological results were analyzed. RESULTS: The average time to fracture union was 3.1(3~4) months. There were no complications, such as deep infection or fixation loss. The mean ASES score was 97 points (85~100points) at the last follow up period, and 14 patients had a full range of motion of the shoulder. CONCLUSION: Open reduction and internal fixation with a mini-T plate for unstable distal clavicle fracture is a good surgical method with good clinical and radiological results.

The Role and Efficacy of Diagnostic Laparoscopy to Detect the Peritoneal Recurrence of Gastric Cancer

PURPOSE: Peritoneal recurrence has been reported to be the most common form of recurrence of gastric cancer. Peritoneal recurrence can generally be suggested by several types of image studies and also if there is evidence of ascites or Bloomer's rectal shelf. It can be confirmed by explorative laparotomy, but diagnostic laparoscopy is a good alternative method and laparoscopic surgery has also been widely used. We reviewed and analyzed the ability of diagnostic laparoscopy to detect peritoneal recurrence or carcinomatosis, and especially for gastric cancer. MATERIALS AND METHODS: We performed a retrospective review the 45 gastric cancer patients who were operated via diagnostic laparoscopy between 2004. 2. and 2009. 3. We analyzed the perioperative clinical characteristics and the accuracy of the diagnostic methods. RESULTS: The study groups included 14 patients who had confirmed gastric cancer, but they suspected to have carcinomatosis, and 31 patients who had previously underwent gastric resection, but they suspected to have recurrence. The mean operation time was 44.1+/-6.9 minutes and the mean postoperative hospital stay was 2.7+/-.8 days. There was one case of operation-related complication and no postoperative mortality occurred. The sensitivities for detecting peritoneal recurrence or carcinomatosis were 92.1% for diagnostic laparoscopy, 29.7% for detecting ascites and rectal shelf on the physical examination, 86.5% for abdominal computed tomography, 69.2% for PET CT and 18.8% for CEA. CONCLUSION: Diagnostic laparoscopy does not require a long operation time or a long hospital stay, and it showed a low complication rate in our study. It has high sensitivity for detecting peritoneal recurrence of gastric cancer. It can be an alternative diagnostic confirmative method and it is useful for deciding on further treatment.

The Surgical Outcome for Gastric Submucosal Tumors: Laparoscopy vs. Open Surgery

PURPOSE: Laparoscopic gastric resection (LGR) is increasingly being used instead of open gastric resection (OGR) as the standard surgical treatment for gastric submucosal tumors. Yet there are few reports on which technique shows better postoperative outcomes. This study was performed to compare these two treatment modalities for gastric submucosal tumors by evaluating the postoperative outcomes. We also provide an analysis of the learning curve for LGR. MATERIALS AND METHODS: Between 2003.4 and 2008.8, 103 patients with a gastric submucosal tumor underwent either LGR (N=78) or OGR (n=25). A retrospective review was performed on a prospectively obtained database of 103 patients. We reviewed the data with regard to the operative time, the blood loss during the operation, the time to the first soft diet, the postoperative hospital stay, the tumor size and the tumor location. RESULTS: The clinicopatholgic and tumor characteristics of the patients were similar for both groups. There was no open conversion in the LGR group. The mean operation time and the bleeding loss were not different between the LGR group and the OWR group. The time to first soft diet (3.27 vs. 6.16 days, P<0.001) and the length of the postoperative hospital stay (7.37 vs. 8.88 days, P=0.002) were shorter in the LGR group compared to the OGR group. The tumor size was bigger in the OGR group than that in the LGR group (6.44 vs. 3.65 cm, P<0.001). When performing laparoscopic gastric resection of gastric SMT, the surgeon was able to decrease the operation time and bleeding loss with gaining more experience. We separated the total cases into 3 periods to compare the operation time, the bleeding losses and the complications. The third period showed the shortest operation time, the least bleeding loss and the fewest complications. CONCLUSION: LGR for treating a gastric submucosal tumor was superior to OGR in terms of the postoperative outcomes. An operator needs some experience to perform a complete laparoscopic gastric resection. Laparoscopic resection could be considered the first-line treatment for gastric submucosal tumors.

Treatment of Highly Unstable Trochanteric Fractures

PURPOSE: This study analyzed the treatment results of highly unstable trochanteric fractures and made treatment guidelines. MATERIALS AND METHODS: Among three hundred six cases of trochanteric fractures from October 2001 to February 2006, the patients were divided into group 1(highly unstable trochanteric fracture, 69 cases) and group 2(age and gender-matched control group, 70 cases). The two groups were compared clinically and radiologically. A highly unstable trochanteric was defined as a fracture with a neck-shaft angle<100degrees and anterior angulation. The mean follow-up duration in groups 1 and 2 was 13.2 and 15.5 months, respectively. The mean neck-shaft angle in groups 1 and 2 was 92.1degrees and 118.9degrees , respectively. The mean anterior angulation in groups 1 and 2 was 23.0degrees and 4.6degrees. RESULTS: In group 1, 39 cases were treated with a dynamic hip screw (DHS), 22 cases were treated with a proximal femoral nail (PFN), and 8 cases(11.6%) were treated with primary bipolar hemiarthroplasty. The average amount of sliding of the lag screw in groups 1 and 2 was 10.5 mm and 3.7 mm, respectively (p<0.05). The average change in the neck-shaft angle in groups 1 and 2 was 7.0degrees 1 and 2.1degrees , respectively (p<0.05). There were 7 complications in group 1, including 5 cutting-out, 1 back-out and 1 Z-effect, and 2 cases of cutting-out in group 2. CONCLUSION: A highly unstable trochanteric fracture has a high risk of the need for additional surgery. Therefore, considerable care should be taken to treat it with a consideration of the possible need for arthroplasty.

Flexible Intramedullary Pin Fixation of Both Forearm Bone Fractures in Children

PURPOSE: To evaluate the efficacy of Flexible intramedullary pin fixation in pediatric forearm diaphyseal fractures. MATERIALS AND METHODS: In this retrospective study, we reviewed 15 cases of forearm diaphyseal fractures operated using flexible intra-medullary nail fixation technique between January 2000 and December 2004. Of these 15 children, there were 11 boys and 4 girls with an average age of 11.6 years (range, 7~15 years). The implants were introduced in the distal radius and proximal ulna in all patients. An average duration of fixation was 5.3 months in the radius, 4.7 months in the ulna. After operation, all patient were applied with a long arm cast and the duration of immobilization was 5.2 weeks (range, 4~6 weeks) on average. RESULTS: All fractures in this series healed with normal range of supination (average 80.0) and pronation (average, 71.6 degrees). Average operation time including anesthesia was 123 minutes and hospital stay was 5.4 days. Time to union was 8.4 weeks on average. Range of motion and functional results were satisfactory in all cases. There were one case of incomplete ulnar nerve injury and two cases of refracture which were treated conservatively without any permanent complication. CONCLUSION: Flexible intramedullary pin fixation technique is a good method in case of unstable displaced fracture and difficult or failed closed treatment.

Brain Metastases Developed in Advanced Colorectal Cancer Patients who Underwent Multi-drug Chemotherapy

PURPOSE: Brain metastasis from colorectal cancer is a rare clinical condition. We have experienced five cases of brain metastases in a relatively short period of time during extensive chemotherapy for advanced colorectal cancer. To examine whether this phenomenon is a simple coincidence or there is a correlation with prolongation of life span in patients with stage IV colorectal cancer, we analysed five patients with brain metastases. METHODS: The case histories of 47 patients with unresectable systemic metastases who had undergone sequential chemotherapy (FOLFOX and FOLFIRI) in Ajou University Hospital from August 2002 to December 2004 were reviewed and analyzed for clinical characteristics. The sites of unresectable metastases were the liver (n=28), the lung (n=28), and the paraaortic nodes (N=6). Diagnostic criteria of unresectable metastasis were multiple or bilobar lesions in hepatic metastasis and multilobar involvement in pulmonary metastasis. RESULTS: There was no complete remission. Partial remission was noted in 31.9% of the patients and stable disease in 8.5%. Sequential chemotherapy showed no effect in 59.6% of the patients. Brain metastases occurred in five patients (10.6%). Accompanying metastases were found in the lung (n=4), the liver (n=3), the paralortic lymph nodes (n=2), and bone (n=1). Four patient (21.0%) were noted in the response group. The mean interval from primary cancer surgery to the diagnosis of brain metastasis was 27.5 (20~44) months. From the start of chemotherapy, brain metastasis was diagnosed at an average of 10.5 (8~16) months. Metastasectomies were performed in three patients, and stereotaxic radiosurgery was performed in two patients. One patient died with the disease, and four patients have been alive with the disease for more than six months. CONCLUSIONS: It is still unclear whether the increasing incidence of brain metastasis is related with prolongation of life expectancy in patients with stage IV colorectal cancer. However, about half of the stage IV colorectal cancer patients were found to obtain meaningful survival benefits by sequential chemotherapy, and 20% of chemo- responders showed brain metastases. Therefore, we conclude that the increasing incidence of brain metastasis seems to correlate with prolongation of life expectancy in stage IV colorectal cancer.

Prognostic Value of Bone Marrow Micrometastasis Detected by Nested RT-PCR for Cytokeratin 19 and Mammaglobin in Breast Cancer

PURPOSE: Breast cancers frequently undergo distant metastasis during the early phase, on which the survival of patients is greatly dependent. It has been suggested that the occurrence of micrometastasis relates with other prognostic features of breast cancer, such as lymph node metastasis and the presence of vascular invasion. The aim of this study was to examine the presence of keratin-19 and mammaglobin mRNA in bone marrow aspirates obtained from breast cancer patients, and their possible correlation with tumor staging and disease free survival. METHODS: Bone marrow samples were obtained from 254 breast cancer patients at the time of surgery. We separated the mononuclear fraction from the samples and carried out nested reverse transcriptase polymerase chain reaction for the detection of keratin-19 and mammaglobin mRNA using two different pairs of primers. We also studied the possible correlations between the tumor size, nodal involvement, stage, and distant metastasis. RESULTS: Seventy-five of the 254 samples were studied for cytokeratin 19 and the others for cytokeratin and mammaglobin. The median follow-up time was 21.1 months. Sixty-five (26%) of the 254 samples were cytokeratin 19 positive and 25 (14.3%) of the 175 were mammaglobin positive. Eight cases (12.3%) in the cytokeratin positive group showed a recurrent disease in distant organs. Whereas, six (3.2%) out of 185 cytokeratin negative patients had distant recurrences. Mammaglobin positivity was not correlated with distant metastasis. The stage, nodal status, and estrogen receptor were independent of bone marrow micrometastasis. CONCLUSION: Bone marrow micrometastasis, detected by nested RT-PCR for cytokeratin 19, could be a useful predictive marker for the distant metastasis of breast cancer.

The Peridural Hematoma after Surgery on the Degenerative Lumbar Spine Disease / 대한척추외과학회지

STUDY DESIGN: A retrospective study of neurologic complication with peridural hematoma was performed in the cases of operation for the lumbar degenerative disease. OBJECTIVES: To prove the risk factors of the postoperative neurologic complication, and the relationship between the symptom onset, the evacuation time and the neurologic recovery. SUMMARY OF LITERATURE REVIEW: There are rarely proven risk factors related with perioperative hematologic change, and the proper evacuation time is in controversy. MATERIALS AND METHODS: In 1280 operations from 1995 to 1999, there were 20 cases of neurologic complication with peridural hematoma. We considered age, sex, operative method, number of operation segment, hematologic variables, operation time and estimated blood loss as possible risk factors. The mean follow up was 19 months. The recovery was evaluated by comparison with the preoperative motor power, and we considered the time relationship of surgical outcome with the symptom onset and the time to hematoma evacuation. RESULTS: Neurologic sequelae occurred in 1.6%. The only detected risk factor was the increased number of operation segment more than 4. There were two types of onset, less than 12 hours and beyond 30 hours. Neurologic sequelae were completely recovered in 14 cases, 75% in acute onset and 83% in the delayed (p>0.05). According to the evacuation time, rapid hematoma evacuation within four hours made better recovery. CONCLUSIONS: We thought that the best way to prevent the neurologic sequelae is close observation and rapid evacuation if peridural hematoma is suspected.

Comparison of Osteosyntheses in Various Types of Porous Calcium Phosphate Compounds: An Experimental Study by Posterolateral Fusion of Rabbits' Lumbar Vertebrae / 대한척추외과학회지

PURPOSE: The purpose of the present study was to compare the osteoconduction in porous bodies made of various compositions of calcium phosphate compounds and other porous artificial bones. MATERIALS AND METHODS: Single-level posterolateral spinal fusions were performed on ninety rabbits. The animals were divided into nine groups by graft materials: autograft (positive control), implantation of HA, TCP, CPP, HA/TCP composite, TCP/CPP composite, Lubboc(R) and Calcium sulfate pellet (CSP), no-graft after decortication (negative control). Serial radiography, serum calcium and phosphorus levels were checked. All animals were sacrificed 12 weeks after surgery and the fusion masses were compared by manual palpation, uniaxial tensile strength measurement and histological evaluation. RESULTS: Autografted and CPP implanted groups showed significantly higher fusion ratio than TCP, TCP/CPP composite, and no-graft groups. Meanwhile, HA and HA/TCP groups showed no significant difference with other groups in fusion ratio. From the radiological examination, TCP and CPP groups seemed to show more rapid absorption of implant than HA group. The mean values of tensile strength of autografted and CPP group were significantly larger than those of TCP, TCP/CPP composite, and no-graft groups. The result of direct inspection and microscopic examination showed the TCP-contained implants lost their porous structure, whereas the other implants did not. On the light microscopy, both HA and CPP groups showed more abundant new bone growth into the pores than TCP-contained groups, but the pore size of CPP became larger than that of the HA, which manifested more rapid absorption of CPP in the living body. CONCLUSION: The porous CPP implant is considered to be more desirable bone graft substitute because it has satisfactory osteoconductive ablility and better biodegradation than porous HA. And the maintenance of porous structure is considered to be indispensable for osteoconduction.