Air leaks following pulmonary resection for lung cancer: is it a patient or surgeon related problem?

INTRODUCTION: Prolonged air leak (PAL) is the most common complication after partial lung resection and the most important determinant of length of hospital stay for patients post-operatively. The aim of this study was to determine the risk factors involved in developing air leaks and the consequences of PAL. METHODS: All patients undergoing lung resection between January 2002 and December 2007 in our hospital were studied retrospectively. Univariate analysis to predict risk factors for developing post-operative air leaks included patient demographics, smoking status, pulmonary function tests, disease aetiology (benign, malignant), neoadjuvant therapy (pre-operative radiotherapy/chemotherapy), extent and type of resection, and different consultant surgeons' practice. A logistic regression model was used for multivariate analysis. RESULTS: A total of 1,911 lung resections were performed over the 6-year study period. An air leak lasting more than 6 days post-operatively was present in 129 patients (6.7%). This included 100 out of the 1,250 patients (8%) from the lobectomy group and 29 out of the 661 patients (4.4%) from the wedge/segmentectomy group. Using the multivariate analysis, the risk factors for developing an air leak included a low predicted forced expiratory volume in 1 second (pFEV(1)) (p<0.001), performing an upper lobectomy (p=0.002) and different consultant practice (p=0.02). PAL was associated with increased length of stay (p<0.0001), in-hospital mortality (p=0.003) and intensive care unit readmission (p=0.05). CONCLUSIONS: Air leaks after pulmonary resections were at an acceptable rate in our series. Particular patients are at a higher risk but meticulous surgical technique is vital in reducing their incidence. Our study shows that pFEV1 is the strongest predictor of post-operative air leaks.

Registered nurses' experiences with an evidence-based home care pathway for myocardial infarction clients.

OBJECTIVES: To obtain home health nurses' comments on an evidence-based care pathway for post myocardial infarction. DESIGN: A qualitative design was used. SETTING: Culturally diverse, lower income area of a large city. PARTICIPANTS: All home health nurses from one nursing agency who participated in a comparative study on the impact of the evidence-based care pathway. RESULTS: The largest number of comments made by the nurses were related to the beneficial impact of the pathway on the provision of quality nursing care and on increased job satisfaction. The home health nurses reported that the pathway increased clients' knowledge of medications and diet. In addition, they commented that they were able to use the pathway effectively because of the training they received from the inpatient cardiac nurses. CONCLUSIONS: This qualitative study demonstrates the benefits of investing in the implementation of best practice guidelines by home health nurses. However, nursing associations, such as the Canadian Community Health Nurses Initiatives Group, will need to continue to champion for additional funds to support the additional expenses incurred.

Gender influences on career opportunities, practice choices, and job satisfaction in a cohort of physicians with certification in sports medicine.

OBJECTIVE: To examine the gender differences in practice patterns, experiences, and career opportunities for family physicians who practice sports medicine. DESIGN: Descriptive, self-administered questionnaire. PARTICIPANTS: Family physicians with Certificate of Added Qualification (CAQ) in sports medicine were surveyed. The survey was sent to all women with a CAQ in Sports Medicine and a random sample of 20% of the men with CAQs in sports medicine. MAIN OUTCOME MEASURE: Survey consisted of multiple choice, Likert scale, and opened-ended questions. The data was analyzed with contingency tables, with gender as the dependent variable. RESULTS: Response rate to the survey was 75%, which included 42 females and 102 males. Demographics of our population demonstrated some gender differences. Males were of higher average age (41.1 vs. 38.1), and more likely to be married and have children. Practice types, location, and time spent in sports medicine did not differ with the exception of training room and event coverage. Males were more likely to cover all levels of training room except at the Division I level, where the percent of males and females covering training rooms were equal. Males were also more likely to cover all types of sporting events. Job satisfaction and reasons for choosing current jobs did not show significant gender differences. However, factors affecting career opportunities did vary. Professional relationships with athletic trainers and coaches were perceived to be different by males and females surveyed. CONCLUSIONS: Our survey of sports medicine physicians showed some gender differences in practice patterns relative to training room and sporting event coverage. Surprisingly, there were not many differences in the factors that affected job choice and factors affecting job opportunities with the exception of gender itself. However, our study does not conclude how or when gender begins to affect the female sports medicine physician's career opportunities.

Analysis of lipoproteins and body mass index in professional football players.

Exercise is known to improve lipoprotein levels, whereas an elevated body mass index (BMI) is associated with less favorable lipoprotein levels. To date, there have been no reports of lipid analyses in elite athletes who also have BMIs in ranges considered unhealthful. The purpose of this study was to evaluate the lipid-lipoprotein profiles in a group of professional football players and to determine what association exists between these profiles and the players' BMIs. An observational study was conducted of 70 professional football players from one National Football League team. Measurements included BMI (kgcenter dotm(-2)), and fasting serum lipid analysis. BMI and position played were found to correlate (p<0.001), with linemen having the highest mean BMI, 38.1 kgcenter dotmsuperset or impliesminus sign2;. Comparing mean lipid values among BMI categories demonstrated lower high-density lipoprotein cholesterol levels (p<0.01), higher triglycerides (p<0.05), and higher total cholesterol/high-density lipoprotein cholesterol ratios (p<0.001) with an increasing BMI. Among the professional football players studied, a lower BMI was associated with a more favorable lipid-lipoprotein profile. Among the elite athletes in this study with the highest BMIs, exercise may not confer the same protective benefits on cardiovascular risk as it does in those athletes with normal BMIs. (c)2001 CHF, Inc.

Osteitis pubis: solving a perplexing problem.

Osteitis pubis is a painful condition that affects the pubic symphysis and surrounding tendinous attachments. One common cause stems from unusual biomechanical stress to the pelvis. Patients typically have a variety of vague and nonspecific symptoms, which makes accurate diagnosis of this condition difficult, particularly for clinicians not familiar with the disorder. A systematic approach to evaluating these patients is essential because the differential can be quite large and includes isolated muscle tears, lumbar radiculopathy, and stress fractures. Fortunately, once the diagnosis is confirmed, conservative treatment such as rest and nonsteroidal anti-inflammatory drugs usually leads to a favorable outcome.

Postcompetition elevation of muscle enzyme levels in professional football players.

Strenuous exercise causes a rise in circulating levels of creatine kinase (CK), and well-trained athletes liberate smaller amounts than do untrained individuals. Plasma CK, aspartate aminotransferase, and lactate dehydrogenase were measured in a group of 23 professional football players 48 hours after competition. All players were asymptomatic for myalgias or chest discomfort despite elevations of CK levels. Physicians should be aware of these elevations in muscle enzymes postexertion and interpret each in conjunction with the athlete's symptoms.

Lumbar spondylolysis in adolescent athletes.

Lumbar spondylolysis is a common cause of low back pain in adolescent athletes. The early diagnosis and treatment of this condition will result in decreased morbidity and an earlier return to full activity for most patients. We report a case of lumbar spondylolysis in an adolescent athlete and review current diagnosis and management of this condition.

Evaluation of a single dilution ELISA system for detection of seroconversion to bovine viral diarrhea virus, bovine respiratory syncytial virus, parainfluenza-3 virus, and infectious bovine rhinotracheitis virus: comparison with testing by virus neutralization and hemagglutination inhibition.

A single-dilution quantitative enzyme-linked immunosorbent assay (ELISA) system, based on commercial ELISA kits, for the simultaneous detection of seroconversion to bovine viral diarrhea virus (BVDV), bovine respiratory syncytial virus (BRSV), parainfluenza-3 virus (PI3V), and infectious bovine rhinotracheitis virus (IBRV) was evaluated by testing acute and convalescent serum pairs from 564 cattle in 145 outbreaks of respiratory disease. Seroconversion to BVDV, BRSV, PI3V and IBRV was detected in 8.0%, 19.0%, 13.7%, and 7.4%, respectively, of serum pairs tested. Seroconversion was detected in 60.7% of herds and 34.6% of animals tested. Infection with 2 or more viruses was found in 46.6% of these herds and in 27.2% of these animals. The majority of BVDV infections (62%) were associated with other virus infections, suggesting that BVDV may potentiate infection with other agents rather than being a primary pathogen of the respiratory tract. The results were compared with those obtained by virus neutralization and hemagglutination inhibition testing, and the sensitivity, specificity, and overall correlation were calculated. Sensitivities of 92%, 95%, 100%, and 100% were obtained for BVDV, BRSV, PI3V, and IBRV, respectively. The corresponding specificity values were 89%, 92%, 86%, and 91%. The overall correlation for each virus was 90%, 93%, 90%, and 93%, respectively. These results demonstrate that this ELISA system may be used successfully to detect seroconversion in serum pairs, highlight the frequency of multiple viral infections in outbreaks of respiratory disease, and provide further evidence of an immunosuppressive role for BVDV infections.

Endoscopic preperitoneal herniorrhaphy in professional athletes with groin pain.

INTRODUCTION: Surgical exploration of the groin with subsequent herniorrhaphy has been recommended for obscure groin pain in athletes. The purpose of this study was to evaluate the efficacy of endoscopic preperitoneal herniorrhaphy and, if indicated, contralateral groin exploration in professional athletes with groin pain. PATIENTS AND METHODS: Eight professional athletes presented with groin pain and underwent endoscopic preperitoneal herniorrhaphy between February 1994 and May 1996. All athletes were male with a median age of 25.1 years (range: 22-30). Seven of the athletes complained of unilateral groin pain while one patient had bilateral pain. Seven had undergone previous conservative treatment without success. Despite multiple examinations, only two patients had been diagnosed with hernias prior to referral to the surgeon. Of the remaining six patients, all were found to have small inguinal hernias in the symptomatic groin. Seven of the patients were noted to have bilateral pathology. RESULTS: Operative time averaged 55.3 min. All patients were ambulatory without significant difficulty within the first 24 h, discontinued oral narcotic use within 72 h of surgery, and were back to recreational activities within 1 week. Aerobic conditioning was resumed within a maximum of 2 weeks. Full conditioning and/or return to full competition occurred within a 2- to 3-week period. At the time of 4 week follow-up, all athletes reported no more than minimal postexertional discomfort, with near total relief of early postoperative symptoms. No athletes noted any impairment in their ability to perform at peak levels. CONCLUSIONS: Groin pain in athletes is a difficult problem requiring a multidisciplinary approach to diagnosis and treatment planning. Endoscopic preperitoneal herniorrhaphy is an effective treatment for obscure groin pain when the pain is associated with an inguinal hernia and allows for a short recovery time back to full athletic activity.

Standardization of enzyme-linked immunosorbent assays (ELISAs) for quantitative estimation of antibodies specific for infectious bovine rhinotracheitis virus, respiratory syncytial virus, parainfluenza-3 virus, and bovine viral diarrhea virus.

Commercial enzyme-linked immunosorbent assays (ELISAs) for detection of serum antibodies to bovine viral diarrhea virus (BVDV), parainfluenza-3 virus (PI3V), respiratory syncytial virus (RSV), and infectious bovine rhinotracheitis virus (IBRV) were standardized to give a quantitative result when testing was performed at a single optimum dilution. For each test, serum samples were titrated and their end point titers calculated by an algebraic method directly from a plot of each titration series and also from a regression line fitted to this plot. The corrected optical density (COD) of each sample when tested at dilutions of 1/25, 1/50, and 1/100 was expressed as a percentage of the COD of a positive reference serum included on each plate, this value was the sample/positive (S/P) ratio. For each test, the linear relationship between the S/P ratio obtained at a dilution of 1/25, 1/50, and 1/100 and the end point titer calculated by each method was determined. In each case, the best linear relationship existed when samples were tested at a dilution of 1/100 (r = 0.973 for BVDV, 0.962 for PI3V, 0.961 for RSV, 0.947 for IBRV). From the equation of these lines, an increase in the S/P ratio between acute and convalescent serum samples of 31%, 23%, 21%, and 35% would correspond to a 4-fold rise in ELISA titer to BVDV, PI3V, RSV, and IBRV, respectively. ELISA titers calculated from S/P ratios at 1/100 were significantly related to virus neutralization titers to BVDV, RSV, and IBRV and to hemagglutination inhibition titers to PI3V (P < < 0.001 in all cases). Samples with low S/P ratios had the greatest intraassay and interassay variation. Intraassay reproducibility ranged from 3.5% to 22.3% (coefficient of variation), with a median value of 9.5%. Interassay reproducibility was lower, ranging from 6.0% to 50.6%, with a median of 17.4%.

Osteitis pubis in collegiate football players.

Osteitis pubis in athletes is an inflammatory condition of the pubic symphysis and surrounding muscular insertions. It is of uncertain etiology, however, and is seen particularly in those sports requiring sprinting and sudden changes of direction. There is a paucity of literature of this condition occurring in players of American football. This report presents two such cases and details proposed etiology and a specific management protocol.

Depression and chronic fatigue in athletes.

For the most part, the competitive athlete is a well-adjusted individual who demonstrates considerable vigor and well-being, as well as less depression, anxiety, and fatigue than nonathletic counterparts. The well-trained athlete, however, may also have a personality that is somewhat rigid, strongly goal oriented, and perfectionist. It is not unrealistic to expect that when confronted with diminished performance or success, such an athlete may be compelled to drive himself or herself harder to succeed. Such behavior typically leads to the phenomenon of overtraining, which can express itself in the form of chronic fatigue and depression. There are a number of other organic causes of chronic fatigue and depression, however, which must be excluded by careful evaluation and appropriate diagnostic testing. Although the evaluation of the athlete who presents with chronic fatigue and depression can be somewhat complex, a diagnostic framework has been outlined here to assist the clinician in the assessment of an athlete who presents with such complaints.

Depression and chronic fatigue in the college student-athlete.

For the most part, the intercollegiate athlete is a well-adjusted individual who demonstrates considerable vigor and well-being and less depression, anxiety, and fatigue when compared with nonathletic counterparts. The well trained athlete also demonstrates a personality that may be somewhat rigid, is strongly goal oriented, and strives for excellence. It is not unrealistic to expect that when confronted with diminished performance or success, athletes may be compelled to drive themselves harder to succeed. Such behavior typically leads to the phenomenon of overtraining, which can express itself in the form of chronic fatigue and depression. A number of other organic causes of chronic fatigue and depression must be excluded by careful evaluation and appropriate diagnostic testing. Although the evaluation of the athlete who presents with chronic fatigue and depression can be somewhat complex, a diagnostic framework has been outlined that may assist the clinician in the assessment of the athlete who presents with such complaints.

Pulmonary carcinogenesis in rats given implants of shale oil in beeswax pellets.

Pellets of crude shale oil, neutral, basic, or polynuclear aromatic fractions of shale oil, or crude petroleum were implanted in the lungs of rats through a thoracotomy. The pellets had a beeswax-tricaprylin vehicle that allowed the slow release of material into the surrounding parenchyma. A dose-related incidence of lung cancer was observed with each of the materials studies. A greater risk for lung cancer was not demonstrated for crude shale oil compared to crude petroleum.

Gross anatomy of the liver, biliary tree, and pancreas in the black-tailed prairie dog (Cynomys ludovicianus).

The gross anatomy of the liver, extrapetatic biliary tree, sphincter of Oddi, and pancreas in the black-tailed prairie dog (Cynomys ludovicianus), a widely used animal model for investigations into biliary physiology, pathophysiology, and pathology, was studied in 10 animals. The liver consists of 4 lobes, the left lateral, median, right lateral, and caudate. The gallbladder lies on the ventral surface of the right lobule of the median lobe. The cystic and hepatic ducts unite to form the common bile duct which enters the duodenum approximately 5 mm distal to the pylorus. The lower end of the common duct dilates forming an ampulla which is surrounded proximally by a band of circular muscle fibres which constitute the choledochal sphincter. The pancreatic duct opens separately into the duodenum approximately 80 mm from the pylorus. Earlier physiologic studies have demonstrated that the choledochal sphincter has intrinsic motility distinct from the duodenum.