Patient outcomes in the acute revovery phase following robotic-assisted prostate surgery : a prospective study

Background: Robotic-assisted minimally invasive urologic surgery was developed to minimise surgical trauma resulting in quicker recovery. It has many potential benefits for patients with localised prostate cancer over traditional surgical techniques without taking a risk with the oncological result.

Objectives: To report the specific surgical outcomes for the first Australian cohort of patients with localised prostate cancer that had undergone robotic-assisted radical prostatectomy (RARP) surgery. The outcomes represent the acute (in-hospital) recovery phase and include pain, length of stay (LOS), urinary catheter management and wound management.

Methods: Prospective descriptive survey of 214 consecutive patients admitted to a large metropolitan private hospital in Melbourne, Australia between December 2003 and June 2005. Patients had undergone RARP surgery for localised prostate cancer. Data were collected from the medical records and through interview at the time of discharge. Descriptive statistics were used to describe the frequency and proportion of outcomes. Patient characteristics were tabulated using cross tabulation frequency distribution and measures of central tendency.

Results: The findings from this study are highly encouraging when compared to outcomes associated with traditional surgical techniques. Transurethral catheter duration (median 7 days (IQ range 2)) and LOS (median 3 days (IQ range 2)) were considerably reduced. While operation time (median 3.30 h (IQ range 1.07)) was marginally reduced we would expect a further reduction as the surgical team becomes more skilled.

Conclusion: The findings from this study contribute to building a comprehensive picture of patient outcomes in the acute (in-hospital) recovery phase for a cohort of Australian patients who have undergone RARP surgery for localised prostate cancer. As such, these findings will provide valuable information with which to plan care for patients’ who undergo robotic-assisted surgery.

The nature and impact of incontinence in men who have undergone prostate surgery and implications for nursing practice

Aim: The aim of this study was to increase knowledge and understanding of the nature and experiences of incontinence in men one or more years post prostate surgery.

Methods: This descriptive study used a sample of convenience. Two hundred and twelve male participants who had undergone prostate surgery more than a year ago were asked about their experiences of incontinence. Participants were asked to fill in two questionnaires: The Expanded Prostate Cancer Index Composite and the Incontinence Impact Questionnaire. Participants were also asked about their prostate surgery, their health seeking behaviour in relation to incontinence, the type of discharge information they were given, and demographic information.

Results: Sixty-six percent of participants indicated that, in the last four weeks, their overall urinary function had been a problem and 36.3% reported their bowel habits were problematic, which affected the quality of their lives. In addition, 41% of participants reported that they were not given discharge information regarding the possibility of developing urinary incontinence and sexual problems post prostate surgery.

Conclusions: Health care professionals should pay more attention to routinely providing information to all men regarding the possibility of developing incontinence or sexual problems post prostate surgery. This may assist them to better manage these problems.

Oxygen delivery to patients after cardiac surgery : a medical record audit

OBJECTIVE: To describe how intensive care nurses manage the administration of supplemental oxygen to patients during the first 24 hours after cardiac surgery.
METHODS: A retrospective audit was conducted of the medical records of 245 adult patients who underwent cardiac surgery between 1 January 2005 and 31 May 2008 in an Australian metropolitan hospital. Physiological data (oxygen saturation measured by pulse oximetry and respiratory rate) and intensive care unit management data (oxygen delivery device, oxygen flow rate and duration of mechanical ventilation) were collected at hourly intervals over the first 24 hours of ICU care.
RESULTS: Of the 245 patients whose records were audited, 185 were male; mean age was 70 years (SD, 10), and mean APACHE II score was 17.5 (SD, 5.14). Almost half the patients (122, 49.8%) were extubated within 8 hours of ICU admission. The most common oxygen delivery device used immediately after extubation was the simple face mask (214 patients, 87%). Following extubation, patients received supplemental oxygen via, on average, two different delivery devices (range, 1-3), and had the delivery device changed an average of 1.38 times (range, 0-6) during the 24 hours studied. Twenty-two patients (9%) received non-invasive ventilation or high-flow oxygen therapy, and 16 (7%) experienced one or more episode of hypoxaemia during mechanical ventilation. A total of 148 patients (60%) experienced one or more episodes of low oxygenation or abnormal respiratory rate during the first 24 hours of ICU care despite receiving supplemental oxygen.
CONCLUSION: These findings suggest that the ICU environment does not protect cardiac surgical patients from suboptimal oxygen delivery, and highlights the need for strategies to prompt the early initiation of interventions aimed at optimising blood oxygen levels in cardiac surgical patients in the ICU.

The contributions of first nations ethnicity, income, and delays in surgery on mortality post-fracture : a population-based analysis

Summary We examined the independent contributions of First Nations ethnicity and lower income to post-fracture mortality. A similar relative increase in mortality associated with fracture appears to translate into a larger absolute increase in post-fracture mortality for First Nations compared to non-First Nations peoples. Lower income also predicted increased mortality post-fracture.

Introduction First Nations peoples have a greater risk of mortality than non-First Nations peoples. We examined the independent contributions of First Nations ethnicity and income to mortality post-fracture, and associations with time to surgery post-hip fracture.

Methods Non-traumatic fracture cases and fracture-free controls were identified from population-based administrative data repositories for Manitoba, Canada (aged ≥50 years). Populations were retrospectively matched for sex, age (within 5 years), First Nations ethnicity, and number of comorbidities. Differences in mortality post-fracture of hip, wrist, or spine, 1996–2004 (population 1, n = 63,081), and the hip, 1987–2002(Population 2, n = 41,211) were examined using Cox proportional hazards regression to model time to death. For hip fracture, logistic regression analyses were used to model the probability of death within 30 days and 1 year.

Results Population 1: First Nations ethnicity was associated with an increased mortality risk of 30–53 % for each fracture type. Lower income was associated with an increased mortality risk of 18–26 %. Population 2: lower income predicted mortality overall (odds ratio (OR) 1.15, 95 % confidence interval (CI) 1.07–1.23) and for hip fracture cases (OR 1.18, 95%CI 1.05–1.32), as did older age, male sex, diabetes, and >5 comorbidities (all p ≤ 0.01). Higher mortality was associated with pertrochanteric fracture (OR 1.14, 95 % CI 1.03–1.27), or surgery delay of 2–3 days (OR 1.34, 95 % CI 1.18–1.52) or ≥4 days (OR 2.35, 95 % CI 2.07–2.67).

Conclusion A larger absolute increase in mortality post-fracture was observed for First Nations compared to non-First Nations peoples. Lower income and surgery delay >2 days predicted mortality post-fracture. These data have implications regarding prioritization of healthcare to ensure targeted, timely care for First Nations peoples and/or individuals with lower income.

Impact of early valve surgery on outcome of Staphylococcus aureus prosthetic valve infective endocarditis: analysis in the International Collaboration of Endocarditis-Prospective Cohort Study

BACKGROUND: The impact of early valve surgery (EVS) on the outcome of Staphylococcus aureus (SA) prosthetic valve infective endocarditis (PVIE) is unresolved. The objective of this study was to evaluate the association between EVS, performed within the first 60 days of hospitalization, and outcome of SA PVIE within the International Collaboration on Endocarditis-Prospective Cohort Study. METHODS: Participants were enrolled between June 2000 and December 2006. Cox proportional hazards modeling that included surgery as a time-dependent covariate and propensity adjustment for likelihood to receive cardiac surgery was used to evaluate the impact of EVS and 1-year all-cause mortality on patients with definite left-sided S. aureus PVIE and no history of injection drug use. RESULTS: EVS was performed in 74 of the 168 (44.3%) patients. One-year mortality was significantly higher among patients with S. aureus PVIE than in patients with non-S. aureus PVIE (48.2% vs 32.9%; P = .003). Staphylococcus aureus PVIE patients who underwent EVS had a significantly lower 1-year mortality rate (33.8% vs 59.1%; P = .001). In multivariate, propensity-adjusted models, EVS was not associated with 1-year mortality (risk ratio, 0.67 [95% confidence interval, .39-1.15]; P = .15). CONCLUSIONS: In this prospective, multinational cohort of patients with S. aureus PVIE, EVS was not associated with reduced 1-year mortality. The decision to pursue EVS should be individualized for each patient, based upon infection-specific characteristics rather than solely upon the microbiology of the infection causing PVIE.

Influence of the timing of cardiac surgery on the outcome of patients with infective endocarditis and stroke

BACKGROUND: The timing of cardiac surgery after stroke in infective endocarditis (IE) remains controversial. We examined the relationship between the timing of surgery after stroke and the incidence of in-hospital and 1-year mortalities. METHODS: Data were obtained from the International Collaboration on Endocarditis-Prospective Cohort Study of 4794 patients with definite IE who were admitted to 64 centers from June 2000 through December 2006. Multivariate logistic regression and Cox regression analyses were performed to estimate the impact of early surgery on hospital and 1-year mortality after adjustments for other significant covariates. RESULTS: Of the 857 patients with IE complicated by ischemic stroke syndromes, 198 who underwent valve replacement surgery poststroke were available for analysis. Overall, 58 (29.3%) patients underwent early surgical treatment vs 140 (70.7%) patients who underwent late surgical treatment. After adjustment for other risk factors, early surgery was not significantly associated with increased in-hospital mortality rates (odds ratio, 2.308; 95% confidence interval [CI], .942-5.652). Overall, probability of death after 1-year follow-up did not differ between 2 treatment groups (27.1% in early surgery and 19.2% in late surgery group, P = .328; adjusted hazard ratio, 1.138; 95% CI, .802-1.650). CONCLUSIONS: There is no apparent survival benefit in delaying surgery when indicated in IE patients after ischemic stroke. Further observational analyses that include detailed pre- and postoperative clinical neurologic findings and advanced imaging data (eg, ischemic stroke size), may allow for more refined recommendations on the optimal timing of valvular surgery in patients with IE and recent stroke syndromes.

Habituation of male sexual arousal: effects of attentional focus

Three experiments are reported demonstrating that levels of penile tumescence and subjective sexual arousal are greater when men employ participant-oriented rather than spectator-oriented attentional focus while viewing an erotic film segment. Under each instructional set, there was a reduction in sexual arousal during repeated erotic stimulation. As sexual arousal habituated, the men reported feeling less absorbed during erotic stimulation. When these associated changes in attentional focus (absorption) were partialled out through analysis of covariance, sexual arousal remained relatively stable over trials, suggesting that sexual arousal is less likely to habituate if attentional focus remains constant during repeated erotic stimulation. Further directions for studying associations between habituation of sexual arousal and cognitive processing are discussed.

Recovery from gynaecological day surgery : are we underestimating the process

This paper reports a study investigating the post operative experiences of 80 women following gynaecological day surgery. Women kept a diary for the first 4 days following surgery. The diary included a recovery rating scale and a symptom management index focusing particularly on symptoms. A telephone interview conducted on post-operative day 10 further explored experiences. Results at day 4 indicated women experienced significant problems with pain, moving around and tiredness. By day 10, women were still experiencing tiredness, pain and other lingering problems. The study indicates that patients experience more problems than discharge education assumes.

Three dimensions of the male gender role as correlates of alcohol and cannabis involvement in young Australian men

This study examined 3 aspects of the male gender role and their relationship to alcohol and cannabis involvement in young adult Australian men (N = 160) aged between 18 and 25 years. Higher scores on the Restrictive Emotionality scale, which assessed gender ,role conflict, were found to relate to both alcohol-related problems and cannabis use. Higher scores on the Antifemininity scale, which assessed traditional attitudes toward men, were also found to be associated with alcohol-related problems. However, lower scores on another aspect of gender role conflict, Restrictive Affectionate Behavior Between Men, and lower scores on one aspect of traditional attitudes toward men, Status Rationality, correlated with higher frequency levels of alcohol and cannabis use.

"I could see, and yet, mon, I could na` see" : William Macewen, the agnosias, and brain surgery

Two little noticed cases in which William Macewen used symptoms of visual agnosia to plan brain surgery on the angular gyrus are reviewed and evaluated. Following a head injury, Macewen’s first patient had an immediate and severe visual object agnosia that lasted for about 2 weeks. After that he gradually became homicidal and depressed and it was for those symptoms that Macewen first saw him, some 11 months after the accident. From his examination, Macewen concluded that the agnosia clearly indicated a lesion in “the posterior portion of the operculum or in the angular gyrus.” When he removed parts of the internal table that had penetrated those structures the homicidal impulses disappeared. Macewen’s second patient was seen for a chronic middle ear infection and, although neither aphasic nor deaf, was ‘word deaf.’ Slightly later he became ‘psychically blind’ as well. Macewen suspected a cerebral abscess pressing on both the angular gyrus and the first temporal convolution. A large subdural abscess was found there and the symptoms disappeared after it was treated. The patients are discussed and Macewen’s positive results analysed in the historical context of the dispute over the proposed role of the angular gyrus as the visual centre.

Localisation and William Macewen`s early brain surgery part I: the controversy

Neurosurgery for the removal of brain tumours based on localising signs is usually dated from the 1884 operation by Bennett and Godlee. However, within weeks of that operation claims were made on behalf of William Macewen, the Glasgow surgeon, to have been the real pioneer of such surgery. According to Macewen's protagonists, he had conducted seven similar operations earlier than Bennett and Godlee and, in a notable 1888 address, Macewen described these seven pre-1884 cases and a number of others operated on after 1884. This paper, which is in two parts, contains an evaluation of the claims made for the priority of Macewen's pre-1884 operations. Part I deals mainly with Macewen's work in fields other than brain surgery that are relevant to it and sets out the facts of the controversy. It begins with a brief biography of Macewen, describes his pioneering work in antiseptic and aseptic surgery, his work on osteotomy and bone regeneration, and his use in brain surgery of the knowledge so gained. Part I concludes with an examination of the battle waged in the newspapers between Macewen's and Bennett's and Godlee's supporters, and of previously unpublished correspondence between Macewen himself, David Ferrier and Hughes Bennett. The primary records of the patients on whom Macewen operated, together with other materials relevant to the controversy, are examined in Part II.

Postoperative pulmonary dysfunction in adults after cardiac surgery with cardiopulmonary bypass: clinical significance and implications for practice

Postoperative pulmonary complications are the most frequent and significant contributor to morbidity, mortality, and costs associated with hospitalization. Interestingly, despite the prevalence of these complications in cardiac surgical patients, recognition, diagnosis, and management of this problem vary widely. In addition, little information is available on the continuum between routine postoperative pulmonary dysfunction and postoperative pulmonary complications. The course of events from pulmonary dysfunction associated with surgery to discharge from the hospital in cardiac patients is largely unexplored. In the absence of evidence-based practice guidelines for the care of cardiac surgical patients with postoperative pulmonary dysfunction, an understanding of the path ophysiological basis of the development of postoperative pulmonary complications is fundamental to enable clinicians to assess the value of current management interventions. Previous research on postoperative pulmonary dysfunction in adults undergoing cardiac surgery is reviewed, with an emphasis on the pathogenesis of this problem, implications for clinical nursing practice, and possibilities for future research.

Speaking of gender: teachers' metaphorical constructs of male and female students

This article explores the images and metaphors that teachers use when speaking of their relations with students and examines how these images work to call into play particular constructs of gender relations. Of specific interest is the way teachers use binaries of open/closed, in control/out of control and maturity/immaturity to make sense of feminine and masculine conduct respectively. It is argued that such binary differentiations work not only as descriptors of `truths' concerning student-teacher relations, but also as means of constituting and normalizing particular forms of gender  relations. Implications of such metaphorical constructions for gender reform within schools are considered.