Prevalence, severity and preventability of prehospital patient safety incidents.

The provision of safe and effective healthcare is a mainstay for all services and clinicians associated with the delivery of pre-hospital care, however little is empirically known about the prevalence and impact of harm caused in the pre-hospital phase. This commentary critically appraises a recent systematic review which sought to identify the frequency of patient safety incidents and the harm associated with them in prehospital care.

Factors associated with complications of open versus laparoscopic sigmoid resection for diverticulitis.

BACKGROUND: This study critically reviews sigmoid colon resection for diverticulitis comparing open and laparoscopic techniques. METHODS: We conducted a retrospective review of all open and laparoscopic cases of diverticulitis between 1992 and 2001. Data analyzed included the following: indications for operation, postoperative complications, and incidence of laparoscopic conversion to laparotomy. Major and minor complications were analyzed in relation to patients' preoperative diagnosis, age, presence or absence of splenic flexure mobilization, length of stay, and laparoscopic sigmoid resection versus open sigmoid resection. RESULTS: Over a 10-year period, 166 resections for diverticulitis were performed including 126 open cases and 40 laparoscopic cases. No significant differences existed in patient characteristics between the groups. Major complications occurred in 14% of patients, and the laparoscopic conversion rate was 20%. The presence of abscess, fistula, or stricture preoperatively was associated with a higher complication rate only in patients > or =50 years old undergoing open sigmoid resection. The length of stay between patients undergoing laparoscopic resection was significantly less than in patients having open resection. CONCLUSION: Advanced laparoscopic sigmoid resection is an alternative to open sigmoid resection in patients with diverticulitis and its complications. Open sigmoid resection in patients >50 years may have a higher complication rate in complicated diverticulitis when compared with laparoscopic sigmoid resection (all patient ages) and open sigmoid resection (patients <50 years old). Regarding complications, no difference existed between the length of stay in patients with open vs. laparoscopic resection.

Initial clinical experience with frameless stereotactic radiosurgery: analysis of accuracy and feasibility.

PURPOSE: To report on preliminary clinical experience with a novel image-guided frameless stereotactic radiosurgery system. METHODS AND MATERIALS: Fifteen patients ranging in age from 14 to 81 received radiosurgery using a commercially available frameless stereotactic radiosurgery system. Pathologic diagnoses included metastases (12), recurrent primary intracranial sarcoma (1), recurrent central nervous system (CNS) lymphoma (1), and medulloblastoma with supratentorial seeding (1). Treatment accuracy was assessed from image localization of the stereotactic reference array and reproducibility of biteplate reseating. We chose 0.3 mm vector translation error and 0.3 degree rotation about each axis as the maximum tolerated misalignment before treating each arc. RESULTS: The biteplates were found on average to reseat with a reproducibility of 0.24 mm. The mean registration error from CT localization was found to be 0.5 mm, which predicts that the average error at isocenter was 0.82 mm. No patient treatment was delivered beyond the maximum tolerated misalignment. The radiosurgery treatment was delivered in approximately 25 min per patient. CONCLUSION: Our initial clinical experience with stereotactic radiotherapy using the infrared camera guidance system was promising, demonstrating clinical feasibility and accuracy comparable to many frame-based systems.

Ultrasonographic guidance for spinal extracranial radiosurgery: technique and application for metastatic spinal lesions.

OBJECT: The relatively stationary anatomy of the intracranial compartment has allowed the development of stereotactic radiosurgery as an effective treatment option for many intracranial lesions. Difficulty in accurately tracking extracranial targets has limited its development in the treatment of these lesions. The ability to track extracranial structures in real time with ultrasound images allows a system to upgrade and interface pretreatment volumetric images for extracranial applications. In this report the authors describe this technique as applied to the treatment of localized metastatic spinal disease. METHODS: The extracranial stereotactic system consists of an optically tracked ultrasonography unit that can be registered to a linear accelerator coordinate system. Stereotactic ultrasound images are acquired following patient positioning, based on a pretreatment computerized tomography (CT) simulation. The soft-tissue shifts between the virtual CT-based treatment plan and the actual treatment are determined. The degree of patient offset is tracked and used to correct the treatment plan. The ultrasonography-based stereotactic navigation system is accurate to within an approximate means of 1.5 mm based on testing with an absolute coordinate phantom. A radiosurgical treatment was delivered using the system for localization of a metastatic spinal lesion. Compared with the virtual CT simulation, the actual treatment plan isocenter was shifted 12.2 mm based on the stereotactic ultrasound image. The patient was treated using noncoplanar beams to a dose of 15.0 Gy to the 80% isodose shell in a single fraction. CONCLUSIONS: A system for high-precision radiosurgical treatment of metastatic spinal tumors has been developed, tested, and applied clinically. Optical tracking of the ultrasonography probe provides real-time tracking of the patient anatomy and allows computation of the target displacement prior to treatment delivery. The results reported here suggest the feasibility and safety of the technique.

103Pd loaded cartridge air kerma strength verification.

Using radioactive 125I or 103Pd seeds in large number to treat prostate cancer has become popular. This procedure's popularity translates to increased physicist and dosimetrist workloads with regard to performing source strength assays. In addition, radiation exposure to the physicists' and dosimetrists' hands as a result of source handling has increased significantly. As a result of these increases, a method of source calibration using applicator cartridges was developed to allow safe handling of sources and expedited source assays. The method uses a holder which allows a cartridge loaded with five to fifteen seeds to be placed in a standard well ionization chamber. Ionization readings are converted to air kerma source strengths which are compared with the manufacturer's stated activity. Excellent agreement between individual seed air kerma strength as well as comparison with the vendor's air kerma strength statement proves the validity of this assay technique. Absorption/geometry correction factors were experimentally derived during the development of this method. These factors allow accurate determination of air kerma source strength from a shipment of Iodine or Palladium seeds.

Dosimetric considerations of water-based bolus for irradiation of extremities.

The dosimetry of high-energy photon beams in the treatment of superficial lesions occurring in extremities was examined. Large parallel-opposed fields with different photon beam energies were used. The extremity was immersed in water contained in a commercially available plastic wastebasket. The water bolus serves to even out the surface irregularities of the extremities and to remove the skin sparing effect. A polystyrene block was placed at the floor of the wastebasket to ensure that the extremity was encompassed in the radiation fields. The photon beam energies considered were 4 MV, 6 MV, 10 MV, and 24 MV. The results show that the dose distributions are more homogeneous with higher photon beam energies. The isodose lines are more constricted at mid-plane for low energy photon beams. Higher energy photon beams, 10 MV and up would be preferable for the treatment of superficial lesions of the extremities immersed in water bolus contained in a typical wastebasket size.

Laparoscopic treatment of type IV rectovaginal fistula.

Fistulas between the anorectum and vagina may arise from several causes. Treatment depends on their etiology and location, as well as the surgeon's experience. Operative laparoscopy was successful in two women with type IV (mid)rectovaginal fistula in whom previous surgical attempts failed. Our experience suggests that mid and high rectovaginal fistulas can be effectively treated by laparoscopy in the hands of experienced endoscopic surgeons.

Mixed connective tissue disease and radiation toxicity. A case report.

BACKGROUND: Several cases of long term radiation sequelae have been reported in patients with lupus erythematosus and systemic sclerosis after breast or chest wall irradiation. To the authors' knowledge, no experience with such complications in patients with mixed connective tissue disease (MCTD) has been reported previously. METHODS: A case of a woman with occult breast carcinoma metastatic to the axilla and preexisting MCTD is presented. To the authors' knowledge, this is the first case report of the adverse effects of breast irradiation in a patient with MCTD. The pathophysiology of such radiation injury to specific anatomic structures and technical dosimetric considerations of the radiation therapy and radiation dose are analyzed. The relevant literature on other collagen vascular diseases with features related to MCTD is reviewed. RESULTS: A moderate dose of radiation to the breast and regional lymphatics resulted in marked early and late toxicity to skin and subcutaneous tissues. The tissue injury was similar to that observed in patients with lupus erythematosus and systemic sclerosis. The early skin reaction (moist desquamation) was related to the daily radiation dose delivered at the depth of the epidermis, and the late reaction (subcutaneous fibrosis) was related to the dose at the depth of the dermal capillaries and dermal connective tissue. CONCLUSIONS: Patients with MCTD may develop exaggerated radiation reactions similar to those in patients with lupus erythematosus and systemic sclerosis. Although the incidence of such radiation reactions in patients with MCTD is difficult to assess, the risks and benefits of radiation therapy should be carefully weighed in these patients, particularly if an alternative therapy is available. If there is no alternative, judicious attention to radiotherapy technique may reduce or prevent skin toxicity.

Localization of insulin-like growth factor binding protein-4 expression in the mouse uterus during the peri-implantation period.

Previous studies have suggested a role for insulin-like growth factors (IGFs) in both embryo and trophoblast growth, as well as in uterine differentiation. Included in the IGF family are the IGF binding proteins (IGFBPs). In the current study we have demonstrated, by Western ligand blot of mouse uterine tissue extracts, a dramatic increase in IGFBP-4 at the time of embryo implantation. As an extension of this finding, we used in situ hybridization to examine the ontogeny and anatomical localization of IGFBP-4 mRNA in the mouse uterus during the peri-implantation period. On gestational Day 2, while the embryos are still in the oviduct, no uterine IGFBP-4 mRNA signal was observed. However, on gestational Day 4, when the embryos are free in the uterine lumen, IGFBP-4 mRNA was present in the uterine stroma underlying the luminal epithelium. By gestational Day 6, approximately 24 h after implantation, a IGFBP-4 mRNA signal was intense at each implantation site and extended throughout the decidua. A signal was absent in the uterine tissue between implantation sites. By gestational Day 8, the IGFBP-4 mRNA signal was reduced and confined to the stroma nearest the myometrium. The specific anatomical and temporal nature of the IGFBP-4 mRNA expression suggests a physiologic role for this binding protein in the implantation process.

Laparoscopic disk excision and primary repair of the anterior rectal wall for the treatment of full-thickness bowel endometriosis.

We used a new laparoscopic technique to treat infiltrative symptomatic intestinal endometriosis. Eight women, ages 29-38, with extensive symptomatic pelvic endometriosis were included in this series. All were diagnosed as having severe pelvic endometriosis and had not responded to previous conservative surgical and hormonal therapy. In a 5-18-month postoperative followup, six women have reported complete relief of the symptoms. Two have right lower quadrant pain and menstrual cramping. Second-look laparoscopy was offered to all patients and so far, two have accepted. These procedures were performed 6 weeks postoperatively. At that surgery, we found that the anastomotic site had healed completely with filmy adhesions between the posterior aspect of the uterus and the rectosigmoid colon in one patient. The second woman had undergone extensive adhesiolysis at the first surgery, and these adhesions recurred; however, the anastomotic site had healed completely. One of the two infertility patients has achieved pregnancy. The only complications was one patient with ecchymosis of the anterior abdominal wall. Sigmoidoscopy was performed 6 weeks postoperatively, and has been or will be performed at 6 months postoperatively. To date, all anastomotic sites have healed well with no sign of stricture. Our results with this technique in a small series were positive, and it appears that, in the hands of experienced laparoscopists, it may prove useful in treating symptomatic infiltrative endometriosis.

Laparoscopic repair of small bowel and colon. A report of 26 cases.

This is a retrospective review of laparoscopic repair for enterotomies created during therapeutic or diagnostic laparoscopy in 26 women. All patients had mechanical and antibiotic bowel preparation preoperatively. The indication for operative laparoscopy was endometriosis (18), severe abdominal adhesive disease (7), and adhesions with Crohn's disease (1). Enterotomies were secondary either to CO2 laser vaporization or excision of endometriosis and/or lysis of adhesions (23) and trocar insertion (3). The injuries included small-bowel enterotomies (9), colotomies (4), and rectotomies (13). No clinical complications related to enterotomy repair were noted. Twenty-three patients were discharged 1 day after surgery; one was discharged on postoperative day 2; and two were discharged on postoperative day 3. We concluded that small- and large-bowel enterotomies can be repaired safely via the laparoscope with minimum morbidity in patients with prepared bowel.

Laparoscopic segmental resection for infiltrating endometriosis of the rectosigmoid colon: a preliminary report.

The following is a description of the first series of laparoscopic partial proctectomies performed without a separate surgical incision. Sixteen women were treated for extensive endometriosis invading the rectal wall. This original series of patients tolerated the procedure well, with no major intraoperative or postoperative complications noted.

Laparoscopic treatment of infiltrative rectosigmoid colon and rectovaginal septum endometriosis by the technique of videolaparoscopy and the CO2 laser.

OBJECTIVE: To present the technique and results of videolaparoscopy and the CO2 laser as a treatment for deep, infiltrative endometriosis of the rectovaginal septum, uterosacral ligaments, pouch of Douglas and anterior wall of the rectosigmoid colon. DESIGN: Observational study with 1-5 year follow up. SETTING: Sub-specialty practice: Endometriosis clinic and centre for special pelvic surgery. SUBJECTS: 185 women, aged 25-41 years. All had pelvic endometriosis and were referred because of the failure of previous medical and/or surgical treatment. INTERVENTIONS: Vaporization and excision of endometriotic implants and nodules, ureterolysis, ureteric stents, laparoscopic anterior rectal wall resection and reanastomosis, presacral neurectomy, laparoscopic hysterectomy, salpingo-oophorectomy and appendicectomy using the CO2 laser. MAIN OUTCOME MEASURES: 174 patients were followed for 1-5 years after surgery by office visit questionnaire or telephone interview. Eleven were lost to follow-up. RESULTS: 175 patients were discharged within 24 h. Nine with bowel perforations and one with a partial bowel resection were discharged 2-4 days postoperatively. Two patients required ureteric stents, which were removed 6 weeks postoperatively without sequelae. 162 women reported moderate to complete pain relief (145 after one procedure, 13 after two and four after three). 12 reported persistent or worse pain following the surgery. Seven eventually underwent total hysterectomy, four had bowel resections and one had a salpingo-oophorectomy. Of 61 with infertility, 25 achieved pregnancy. Postoperative complications included shoulder pain, anterior abdominal wall ecchymosis, urine retention and dyschezia for one to two weeks. CONCLUSIONS: Our experience suggests that rectosigmoid colon and infiltrative rectovaginal septum endometriosis can be effectively treated via videolaparoscopy in the hands of experienced endoscopic gynaecologists.

Laparoscopic proctectomy for infiltrating endometriosis of the rectum.

Proctectomy for deep endometriosis of the rectal wall was performed without laparotomy. Although laparoscopic pelvic surgery and transperineal proctectomy with primary double-stapled anastomosis are established procedures in gynecological and gastrointestinal surgery, this is the first reported case in which these procedures are combined to mobilize the rectum and perform an extracorporeal transanal rectal resection and anastomosis.

Dose-response effects of exogenous pulsatile human corticotropin-releasing hormone on adrenocorticotropin, cortisol, and gonadotropin concentrations in agonadal women.

Acute activation of the hypothalamic-pituitary axis with CRH has been reported to suppress gonadotropin secretion in women of reproductive age. In this study we specifically examined the effects of increasing doses of human CRH (hCRH) on circulating concentrations of ACTH, cortisol, and gonadotropins in five agonadal women, aged 46-65 (mean, 51.2) yr. The subjects had undergone either natural menopause or surgical removal of their ovaries at least 1 yr before study. Each woman was studied on four separate occasions and received either saline or hCRH at a dose of 0.5, 1.0, or 2.0 micrograms/kg BW through an indwelling iv catheter in a randomized, single blind fashion. During each experiment, five sequential iv injections of the same dose of hCRH or saline were administered at 90-min intervals over an 8-h period, followed by a 10-micrograms iv bolus of GnRH to test for pituitary gonadotropin responsiveness. Blood samples for measurement of LH, FSH, PRL, ACTH, and cortisol were obtained at 15-min intervals through an indwelling iv in the contralateral arm. Episodic pulses of LH secretion were analyzed using the Cluster computer program. Transverse mean LH, FSH, and PRL levels did not change with increasing hCRH doses. Mean (+/- SEM) LH pulse frequency [saline, 5.2 +/- 0.4/8 h; hCRH, (0.5 micrograms/kg), 4.8 +/- 0.2; hCRH (1 microgram/kg), 5.2 +/- 0.2; hCRH (2 micrograms/kg), 5.4 +/- 0.2] and amplitude [saline, 14.4 +/- 4.2 IU/L; hCRH (0.5 microgram/kg), 14.0 +/- 2.4; hCRH (1 microgram/kg), 15.8 +/- 2.5; hCRH (2 micrograms/kg), 17.2 +/- 2.9] did not differ among groups. Although the transverse mean levels of ACTH [saline, 8.7 +/- 0.2 pmol/L; hCRH (0.5 microgram/kg), 12.4 +/- 0.3; hCRH (1 microgram/kg), 11.5 +/- 0.4; hCRH (2 micrograms/kg), 12.8 +/- 0.4] did not change with increasing doses of hCRH, the duration of cortisol peaks after hCRH was longer and accounted for the increased transverse mean at each dose [saline, 152.8 +/- 4.1 nmol/L; hCRH (0.5 microgram/kg), 265.4 +/- 10.5; hCRH (1 microgram/kg), 329.7 +/- 14.3; hCRH (2 micrograms/kg), 348.2 +/- 12.1]. These findings suggest that ever larger doses of pulsatile hCRH continue to increase adrenal output of cortisol secondary to more sustained ACTH responses. However, hCRH-induced acute hypercortisolism does not alter gonadotropin secretion in agonadal women.