Objectives. - The purpose of this study was to identify the skills found most important to gain patient's trust from a patient's perspective.Methods. - One hundred and twenty-two patients were surveyed prospectively using a questionnaire assessing professionalism, physical environment, verbal and non-verbal communication skills. Factors required to establish a trusting patient-surgeon relationship were ranked in order of importance before and after initial consultation with a surgeon in a hand surgery clinic model.Results. - No significant relationship was identified between gender, age, education or income, and answers provided by respondents. Technical ability, verbal communication skills and respect of patient's autonomy by the physician were found most important.Conclusion. - The visit with the surgeon significantly affected the ranking of some of the skills deemed important. Patients view respect of autonomy and verbal communication skills as the most important attributes when developing trust and confidence in a surgeon, followed by technical proficiency. (C) 2012 Published by Elsevier Masson SAS.

Although microvascular free-tissue transfer has become a reliable reconstructive method, vascular compromise of the flap necessitating surgical exploration and attempts at flap salvage commonly occurs. Thrombectomy using Fogarty vascular catheters can be used in the setting of vascular pedicle thrombosis. However, this is not without potential complications. The following report describes a case in which the use of a Fogarty vascular catheter during a thrombectomy for microsurgical flap salvage resulted in complete separation of the balloon from the catheter.

PURPOSE:Our aim was to analyze the communications about three outstanding medical reports. Was there any difference in the reports of the three allografts? Was there a correlation between the media and the scientific world?METHODS:The Internet sites of three major newspapers were used for the media database. Those results were compared with PubMed between 2005 and 2007 using these key words: "facial graft," "facial allograft," "composite tissue allograft," and names of surgeons of the graft. We did a comparative analysis using a word processor and a quality analysis software.RESULTS:We analyzed 51 articles from the media and six from the PubMed database. In PubMed, 100% of the articles were on the first graft and respected the privacy of the patient compared to 67% of the media who unveiled the identity.CONCLUSION:The communication following a medical premiere depends on the team, which performes the act. We observed a major difference between the three cases. Ethical considerations are different for the media and for scientists. The communication management of a medical premiere takes preparation and evaluation.

Treatment for mediastinal wound infection after median sternotomy for heart surgery requires early aggressive debridement and reconstruction. Muscle flap coverage has become the gold standard. The pectoralis major muscle flap (PMMF) and the rectus abdominis muscle flap are well accepted techniques for sternal reconstruction. As previously described, the PMMF can be used unilaterally or bilaterally as an advancement, turnover or as a pure island muscle flap when freed from all insertions. 1 Brutus J.P. Cordoba C. The unilateral pectoralis major island flap, an efficient and straightforward procedure for reconstruction of full length sternal defects after postoperative mediastinal wound infection. Br J Plast Surg. 2004; 57 (correspondence): 803-805 Google Scholar Indeed, the PMMF can be dissected off the sternum, detached from the humerus and advanced on the squeletonised thoracoacromial pedicule alone. As shown in the previous description, most defects can be covered with one flap. In some cases, especially with larger defects, the caudal portion cannot be adequately reconstructed. In these cases, an abdominal rectus flap is desirable.

PURPOSE:Detailed knowledge of the anatomy of the cutaneous innervation to the dorsal surface of the hand is valuable information. Because surgical access to the wrist often is obtained via the dorsal skin it would be helpful particularly to delineate an area where surgical incisions would not injure underlying nerves.METHODS:Thirty cadaver forearms were dissected carefully to examine in detail the anatomy of the lateral antebrachial cutaneous nerve, the superficial branch of the radial nerve, and the dorsal branch of the ulnar nerve. Each hand then was evaluated for an area free of any major nerve branches over the dorsal wrist.RESULTS:Although the innervation to the dorsal hand varies certain patterns exist. The innervation pattern between the superficial branch of the radial nerve and the dorsal branch of the ulnar nerve is distributed evenly, dual innervation is frequent between the 2 nerves, and the lateral antebrachial cutaneous nerve is a common contributor to the innervation of the thumb. The superficial branch of the radial nerve and the dorsal branch of the ulnar nerve have identifiable branching patterns and have been classified according to a system developed for this study.CONCLUSIONS:Two classification systems based on detailed dorsal hand cutaneous innervation patterns can be used to specify the placement of a safe dorsal skin incision away from major nerve branches.

BACKGROUND:The purpose of this study was to describe the functional status and quality of life (QOL) of patients at 12 months after injury. METHODS:Retrospective study consisting of patients treated at three tertiary trauma centers for injuries. Functional capacity (FC) was measured using the Sickness Impact Profile and QOL was measured using the Medical Outcomes Study Short Form (MOS SF-36) at approximately 12 months after the date of injury. RESULTS:There were 144 patients that fulfilled the study inclusion and exclusion criteria. The mean duration of follow-up was 1.3 years, with a range of 0.8 to 1.5 years. Age and gender were not associated with the FC or QOL. The mean(standard deviation) Injury Severity Score (ISS) was 18.9(9.4), whereas ISS category distribution was 1 to 11 (22.9%), 12 to 24 (50.0%), and 25 to 49 (27.1%). Patients with an ISS of 25 to 49 had significantly worse physical (p = 0.008) and total (p = 0.023) Sickness Impact Profile scores and had more physical functioning (p = 0.096), emotional role functioning (p = 0.080), and energy (p = 0.017) impairments when compared with those with an ISS less than 24. Patients injured in motor vehicle collisions had significantly impaired psychosocial function (p = 0.031), whereas those injured in falls had reduced quality of life scores for physical function (p = 0.089), physical role (p = 0.066), and mental health (p = 0.081). CONCLUSION:Patients who survive injuries experience residual impairments in FC and QOL for as long as 1 year after injury. Changes to the long-term management of these patients should be considered.

Data on the management of perioperative airway and ventilatory support in children undergoing craniofacial surgery are limited. The purpose of this study was to review the authors' experience with airway management and ventilatory support during the perioperative period in children undergoing craniofacial surgery. Ninety-five consecutive children underwent 99 craniofacial procedures from July 1, 1999, through June 30, 2002. Direct laryngoscopy was successfully used to establish an airway in 86 (86.8%) cases, whereas 13 (13.1%) cases required the use of fiberoptic bronchoscopy to establish an airway before surgery. The oral route was used in 82 (83%) cases, and the nasal route was used in 17 (17%) cases. Length of anesthesia was 330 +/- 160 minutes, and the actual surgical time was 246 +/- 151 minutes. The volume of crystalloids infused during surgery was 87 +/- 78 mL/kg body weight (BW), and the volume of packed red blood cells infused during surgery was 10 +/- 14 mL/kg BW (range, 0-60 mL/kg BW). Tracheal extubation was successfully accomplished in the postanesthesia recovery unit (PACU) in 57 (58%) patients, whereas 42 patients were admitted to the pediatric intensive care unit (PICU) and received mechanical ventilation for 10 +/- 9 hours (range, 1-60 hours). Of these, 37 (37%) were extubated in the PICU, whereas 5 patients were extubated in the operating room with the craniofacial surgeon in attendance in the event an emergency tracheostomy was needed. However, none of these patients required tracheostomy to maintain a secure airway. Three patients required reintubation after the first attempt at tracheal extubation in the PICU. All three of those patients subsequently were extubated without the need for tracheostomy. The length of tracheal intubation and mechanical ventilation was longer (24 +/- 13 hours versus 8.6 +/- 7 hours, P < 0.001) in patients who required bronchoscopic intubation than in those who were intubated using direct laryngoscopy. The length of hospital stay, although clinically relevant, did not reach statistical significance between the two groups (5 +/- 7 days versus 3.7 +/- 2.7 days, P = 0.5). A positive correlation was observed between the duration of tracheal intubation and mechanical ventilation and the following perioperative factors: anesthesia time (rho = 0.6, P < 0.01), surgical time (rho = 0.55, P < 0.01), volume of crystalloids (rho = 0.5, P < 0.01), and the volume of packed red blood cells infused (rho = 0.55, P < 0.01) during surgery. No episodes of cardiorespiratory arrest or death occurred in any of the patients. This study demonstrates that when performing complex craniofacial procedures in children, a thorough evaluation of the airway before surgery and continuous communication between specialists during the perioperative period is imperative for a successful outcome. Furthermore, most pediatric patients who require mechanical ventilation during the postoperative period do so for a short period of time following surgery.

The unilateral pectoralis major island flap, an efficient and straightforward procedure for reconstruction of full length sternal defects after postoperative mediastinal wound infection.

BACKGROUND:Regional anesthesia of a single finger is commonly achieved by the traditional ring block, which requires at least two painful injections in the digit. Single injection digital block techniques have been described to avoid this problem. Among these, the subcutaneous technique described by Harbison appears to be safe and to allow most procedures to be carried out with good tolerance.OBJECTIVES:A prospective study was designed to evaluate the results of the subcutaneous technique in terms of patient tolerance, distribution of anesthesia and efficiency.METHODS:All blocks were performed by a single investigator. A visual analog scale was used to evaluate pain associated with the injection. Prick testing was used to evaluate the quality of anesthesia at the volar and dorsal aspects of the phalanxes. Tolerance to the surgical procedure and the need for additional injections were also recorded.RESULTS:This technique allowed surgery to be performed without complementary injection most of the time and was very well tolerated. The dorsum of the proximal phalanx, however, was unpredictably included in the anesthetized territory.CONCLUSION:The subcutaneous single injection digital block is safe, efficient and easy to perform. It allows the treatment of all conditions on the volar aspect of the finger and on the dorsal aspect of the distal and middle phalanxes. For surgery on the dorsal aspect of the proximal phalanx, a combined single injection technique or a supplementary dorsal block should be used.

Three patients with carpal tunnel syndrome secondary to atypical mycobacteria flexor tenosynovitis are presented. Aggressive surgical debridement combined with long term antitubercular pharmacotherapy resulted in a good outcome, but the lag time to diagnosis and course of disease were long. Diagnosis of these infections requires a high suspicion index, adequate surgical biopsy and appropriate cultures. Atypical mycobacteria infections must be considered in the differential diagnosis in any patient with evolving chronic tenosynovitis, even if the patient has no history of immunosuppression, and especially if environmental risk factors are present.

Many finger holding devices have been developed to retract digits and provide exposure during hand surgery. We describe a simple, and cheap trick to keep fingers out of the way using adhesive strips that has proven efficient and helpful.

BACKGROUND Regionalization of trauma care services in our region was initiated in 1993 with the designation of four tertiary trauma centers. The process continued in 1995 with the implementation of patient triage and transfer protocols. Since 1995, the network of trauma care has been expanded with the designation of 33 secondary, 30 primary, and 32 stabilization trauma centers. In addition, during this period emergency medical personnel have been trained to assess and triage trauma victims within minimal prehospital time. The objective of the present study was to evaluate the impact of trauma care regionalization on the mortality of major trauma patients. METHODS This was a prospective study in which patients were entered at the time of injury and were followed to discharge from the acute-care hospital. The patients were identified from the Quebec Trauma Registry, a review of the records of acute-care hospitals that treat trauma, and records of the emergency medical services in the region. The study sample consisted of all patients fulfilling the criteria of a major trauma, defined as death, or Injury Severity Score (ISS) > 12, or Pre-Hospital Index > 3, or two or more injuries with Abbreviated Injury Scale scores > 2, or hospital stay of more than 3 days. Data collection took place between April 1, 1993, and March 31, 1998. During this period, four distinct phases of trauma care regionalization were defined: pre-regionalization (phase 0), initiation (phase I), intermediate (phase II), and advanced (phase III). RESULTS A total of 12,208 patients were entered into the study cohort, and they were approximately evenly distributed over the 6 years of the study. During the study period, there was a decline in the mean age of patients from 54 to 46 years, whereas the male/female ratio remained constant at 2:1. There was also an increase in the mean ISS, from 25.5 to 27.5. The proportion of patients injured in motor vehicle collisions increased from less than 45% to more than 50% (p < 0.001). The mortality rate during the phases of regionalization were: phase 0, 52%; phase I, 32%; phase II, 19%; and phase III, 18%. These differences were clinically important and statistically significant (p < 0.0001). Stratified analysis showed a significant decline in mortality among patients with ISS between 12 and 49. The change in mortality for patients with fatal injuries (ISS > or = 50) was not significant. During the study period, the mean prehospital time decreased significantly, from 62 to 44 minutes. The mean time to admission after arrival at the hospital decreased from 151 to 128 minutes (p < 0.001). The latter decrease was primarily attributable to changes at the tertiary centers. The proportion of patients with ISS between 12 and 24 and between 25 and 49 who were treated at tertiary centers increased from 56 to 82% and from 36 to 84%, respectively (p < 0.001). Compared with the secondary and primary centers, throughout the course of the study the mortality rate in the secondary and tertiary centers showed a consistent decline (p < 0.001). In addition, the mortality rate in the tertiary centers remained consistently lower (p < 0.001). The results of multivariate analyses showed that after adjusting for injury severity and patient age, the primary factors contributing to the reduced mortality were treatment at a tertiary center, reduced prehospital time, and direct transport from the scene to tertiary centers. CONCLUSION This study produced empirical evidence that the integration of trauma care services into a regionalized system reduces mortality. The results showed that tertiary trauma centers and reduced prehospital times are the essential components of an efficient trauma care system.

The movement towards trauma care regionalization in Quebec was initiated in 1990, with formal designation of three level I trauma centers in 1993, The purpose of this study is to evaluate the impact of trauma center designation on mortality. The study design is that of a two-cohort study, one assembled during 1987 when designation was not in effect, and the other during the first 5 months of designation. The study focuses on patients that fulfilled the following criteria: i) arrived alive at the hospital, and ii) were admitted, The outcome measures are adjusted mortality, and excess mortality as measured by the TRISS methodology, A total of 158 patients treated in 1987, and 288 treated in 1993, were identified, The mean age of the patients treated in 1993 was significantly higher (40.0, +/- 18.1), when compared with the 1987 group (30.9 +/- 18.1; p < 0.001), Patients in the 1987 cohort had a significantly higher proportion of injuries caused by stabbing (p = 0.02), and a significantly lower proportion caused by falls (p = 0.003), The 1987 cohort had a higher rate of abdominal injuries (p = 0.0001), and external injuries (p = 0.0001), and a significantly lower rate of head or neck injuries (p = 0.003), and injuries to the extremities (p 0.0001), The mean Injury Severity Score (ISS) for the 1987 cohort was 14.96 (+/- 12.36), and 15.49 (+/- 11.61) in 1993 (p = 0.65), The crude mortality rate was 20% for 1987, and 10% for 1993, The crude odds ratio for mortality in 1987 was 2.10 with 95% confidence intervals between 1.22 and 3.62 (p = 0.006), The ISS-based z scores for these two cohorts were 3.62 (p 0.0002), and 0.68 (p = 0.49) respectively, The Standardized Mortality Rates (95% confidence intervals) were 1.64 (1.10-2.53) for 1987, and 1.11 (0.75-1.59) for 1993, indicating a statistically significant reduction In excess mortality (p < 0.05). Multiple Logistic Regression, adjusting for patient age, ISS, body regions injured, and mechanism of injury, showed a significantly higher mortality risk for the 1987 cohort (relative odds = 3.25, p = 0.009), These data show that the process of trauma center designation has significantly improved the survival of the patients treated in these facilities, This is likely due to increased surgical staffing, nursing support, and availability of the required high level technology at the designated hospitals.

The study is based on 44 preventable deaths occurring in a cohort of 360 patients with major trauma. These cases were reviewed by a committee of nine experts. The mean Injury Severity Score (ISS) was 28, and most cases had injuries to the head/neck (68%) and chest (64%). The mean (+/-SD) observed prehospital times, and those considered the maximum allowable by the committee, were 40.6 +/- 12.0 minutes for head/neck injuries and 23.9 +/- 12.2 minutes for chest injuries (p < 0.05). Intravenous (IV) lines were started in 38 (86%) of the patients. The committee classified this procedure as harmful for 16 (42%) and neutral for 19 (50%). Among the 18 (46%) that were intubated, this intervention was considered harmful for 17% and neutral for 39%. In two of the three patients for whom a pneumatic antishock garment was applied, this procedure was considered harmful. Of the 34 patients that required direct transport at a level I trauma center, 50% were transferred to such a hospital. These results show significant prehospital delays and high rates of inappropriate IV line initiation and intubation in trauma patients receiving on-site care by physicians. We conclude that prehospital care protocols for trauma patients should emphasize prompt transport and specific on-site care algorithms.

AbstractIntroduction:The controversy surrounding the use of advanced life support (ALS) for the prehospital management of trauma pivots on the fact that these procedures could cause significant and life-threatening delays to definitive in-hospital care.In Montreal, Québec, on-site ALS to injured patients is provided by physicians only. The purpose of this study was to identify parameters associated with the duration of scene time for patients with moderate to severe injuries treated by physicians at the scene.Hypothesis:The use of on-site ALS by physicians is associated with a significant increase in scene time.Methods:A total of 576 patients with moderate to severe injuries are included in the analysis. This group was part of a larger cohort used in the prospective evaluation of trauma care in Montreal. Descriptive statistics, analysis of variance, multiple linear regression, and multiple logistic regression techniques were use to analyze the data.Results:Use of ALS in general was associated with a statistically significant increase in the mean scene time of 6.5 min. (p = .0001). Significant increases in mean scene time were observed for initiation of an intravenous route (mean = 6.6 min., p = .0001), medication administration (mean =5.7 min., p = .0001), and pneumatic antishock garment (PASG) application (mean = 9.3 min., p = .03). Similar differences were observed for total prehospital time. A significant increase in the relative odds for having long scene times (>20 min.) also was associated with the use of ALS. This level of scene time was associated with a significant increase in the odds of dying (OR = 2.6, p = .009).Conclusion:This study shows that physician-provided, on-site ALS causes significant increase in scene time and total prehospital time. These delays are associated with an increase in the risk for death in patients with an severe injuries.

The presence of mitogen(s) in leiomyoma extracts stimulating cells with the fibroblast, myoblast, and osteoblast phenotype was documented. Mitogenic activity in leiomyoma extracts was acid stable and sensitive to tryptic digestion. Reverse-phase high-performance liquid chromatography successfully separated mitogen(s) with preferential activity for myoblast cells from mitogens with a broad type of cell specificity and from inhibitors. This leiomyoma-derived preferential activity for myoblasts was absent in identically treated myometrial and endometrial extracts. This suggests that leiomyoma-derived substances with preferential growth factor activity for myoblast-like cells may play a role in the pathophysiologic characteristics of uterine leiomyomas. (Am J Obstet Gynecol 1990;163:1665-70.)

Τα ενέσιμα υαλουρονικού οξέος εφαρμόζονται για τη διόρθωση παραμορφώσεων του κροταφικού βόθρου που σχετίζονται με την ηλικία, παρέχοντας αύξηση μαλακών ιστών καθώς και υποστήριξη αυτών (ιστών). Αν και γενικά θεωρούνται ασφαλή, σημαντικές ανεπιθύμητες ενέργειες (ΑΕ) έχουν συσχετιστεί με χρήση αυτών. Η ενδελεχής γνώση της ανατομίας της περιοχής, καθώς και η αξιολόγηση των κινδύνων και τα οφέλη που σχετίζονται με τις διαφορετικές τεχνικές έγχυσης, είναι θεμελιώδεις για τη διασφάλιση βέλτιστων αποτελεσμάτων και την αποφυγή των ΑΕ. Ειδικότερα, η αγγείωση της κροταφικής περιοχής απαιτεί ιδιαίτερη προσοχή καθώς μπορεί να σχετίζεται με σοβαρές ΑΕ, όπως η αρτηριακή απόφραξη, ισχαιμία και εμβολή. Στα πλαίσια αυτά, διερευνήσαμε την ανατομία του κροταφικού βόθρου και τον τρόπο με τον οποίο σχετίζεται με τις αγγειακές AE ύστερα από ενέσιμα υαλουρονικού οξέος. Επιπλέον, εξαιτίας της έλλειψης δεδομένων στον τομέα της αισθητικής καθώς και των επιπτώσεων στις βαθιές κροταφικές αρτηρίες (deep temporal arteries), διερευνήσαμε και αξιολογήσαμε την ανατομία της περιοχής και την επίδραση αυτών των ενέσιμων θεραπειών επί των αγγείων.