Randomized prospective clinical trial comparing reamer irrigator aspirator (RIA) to standard reaming (SR) in both minimally injured and multiply injured patients with closed femoral shaft fractures treated with reamed intramedullary nailing (IMN).

PURPOSE: To investigate whether inflammatory markers are improved among patients with traumatic femur fractures who undergo RIA reamed intramedullary nailing (IMN) prior to fixation when compared to patients treated with standard reamed (SR) IMN. METHODS: A prospective, randomized, single-blind trial was conducted on patients who had a closed femoral shaft fracture amenable to reamed IMN. Patients were randomized to undergo IMN with standard reaming or IMN with the RIA in a 1:1 ratio. Patients were stratified by Injury Severity Score (ISS) and by presence or absence of chest injury with AIS > 3. Patients had blood samples and bronchioalveolar lavage samples taken at specified time points pre- and postoperatively. Specimens from SR and RIA cohorts were compared for the presence of IL-2, IL-6, IL-8, TNF, and IL-10 in plasma and IL-1b and IL-8 in bronchioalveolar lavage (BAL) samples to determine the relationship between inflammatory markers and intramedullary reaming. RESULTS: Nineteen consecutive patients participated in the study with 9 assigned in the RIA group and 10 in SR group. Significant differences existed for ISS between SR and RIA groups (p=0.04). Bronchial lavage data showed no statistical significant differences when RIA and standard reamers were compared and when ISS >16 and <16 were compared, however there were differences for the bronchial IL-8 change when those with chest injury were compared to those without chest injury. Plasma samples showed a trend towards increased IL-6 and IL-10 levels after reaming consistent with the second hit impact. A trend towards higher levels for IL-6 in the SR group was noted at 24 hours post-operatively whereas the IL-10 levels at the post-reaming time point were higher in the RIA group. CONCLUSIONS: This prospective study of reamer type indicates that RIA may be protective of systemic inflammation. This is supported by data showing decreased levels of IL-8 in the bronchial washings and increased level of IL-10 in the serum. Reaming and intramedullary fixation may cause an increase in IL-6 levels regardless of reamer type. Further investigations with a larger cohort of patients are desirable.

Adjustment to colostomy: stoma acceptance, stoma care self-efficacy and interpersonal relationships.

AIM: This paper is a report of a study to examine adjustment and its relationship with stoma acceptance and social interaction, and the link between stoma care self-efficacy and adjustment in the presence of acceptance and social interactions. BACKGROUND: There have been significant advances in stoma appliances and an increase in nurses specialising in stoma care. Despite this, a large proportion of patients continue to experience adjustment problems, which suggests that improvements in the management of the stoma are by themselves not enough to enhance psychosocial functioning. Illness acceptance and interpersonal relationships are widely reported as correlates of adjustment to chronic illness, but these have not been specifically examined in patients with a colostomy. Evidence of their association could offer stoma therapists alternative ways of aiding adjustment. METHOD: Between 2000 and 2002, 51 patients with colostomies provided demographic and clinical data and completed validated questionnaires to measure acceptance of the stoma, relationship with others and stoma care self-efficacy 6 months after surgery. FINDINGS: Multiple regression analysis showed that stoma care self-efficacy, stoma acceptance, interpersonal relationship and location of the stoma were strongly associated with adjustment. The model explained 77% of the variance. Stoma-care self-efficacy accounted for 57.5%, the psychosocial variables 13% and location of the stoma 4.6%. The addition of gender, which was not statistically significant (P > 0.05), explained a further 1.9% of the variance. CONCLUSION: Addressing psychosocial concerns should become part of the care routinely given to stoma patients. We recommend more emphasis on dispelling negative thoughts and encouraging social interactions.