Critical analysis of thoracotomies performed in the emergency room in 10 years

OBJECTIVE: To conduct a critical analysis of thoracotomies performed in the emergency rooms.METHODS: We analyzed mortality rates and survival as outcome variables, mechanism of injury, site of injury and anatomic injury as clinical variables, and gender and age as demographic variables of patients undergoing thoracotomy in the emergency room after traumatic injury.RESULTS: Of the 105 patients, 89.5% were male. The average age was 29.2 years. Penetrating trauma accounted for 81% of cases. The most common mechanism of trauma was wound by a firearm projectile (gunshot), in 64.7% of cases. Patients with stab wounds (SW) accounted for 16.2% of cases. Overall survival was 4.7%. Survival by gunshot was 1.4%, and by SW, 23.5%. The ERT following blunt trauma showed a 100%mortality.CONCLUSION: The results obtained in the Emergency Hospital of Porto Alegre POA-HPS are similar to those reported in the world literature.

Unintentionally retained foreign bodies after surgical procedures. Analysis of 4547 cases

Objective: this study aims to explore the experience of Brazilian surgeons on Unintentionally Retained Foreign Bodies (RFB) after surgical procedures. Methods: A questionnaire was sent to surgeons by electronic mail, between March and July 2012. The questions analyzed their experience with foreign bodies (FB), foreign bodies' types, clinical manifestations, diagnoses, risk factors and legal implications. Results: in the 2872 eligible questionnaires, 43% of the surgeons asserted that they had already left FB and 73% had removed FB in one or more occasions, totalizing 4547. Of these foreign bodies, 90% were textiles, 78% were discovered in the first year and 14% remained asymptomatic. Among doctors with less than five years after graduation, 36% had already left a FB. The most frequently surgical procedures mentioned were the elective (57%) and routine (85%) ones. Emergency (26%), lack of counting (25%) and inadequate conditions of work contributed (12.5%) to the occurrence. In 46% of the cases patients were alerted about the FB, and 26% of them sued the doctors or the institution. Conclusions: challenging medical situations, omission of security protocols and inadequate work conditions contributed to RFB. However, RFB occurs mostly in routine procedures such as cesarean or cholecystectomy, and at the beginning of the professional career, highlighting, particularly in poorest countries, the need for primary prevention. Textiles predominated causing clinical repercussions and they were diagnosed in the first postoperative months. Surgeons were sued in 11.3% of the RFB cases.

Co-creating Value For Smart Phone Operating Systems Via Virtual Discussion Forums

In the traditional way, value is created by manufacturer or producer of a product without engaging the customers. So, traditionally value creation is a monopoly in the part of a manufacturer. After gathering all the raw materials the manufacturers are inserting value to a product. And the inserted value is recognized in the time of consuming the product. In the modern time though there is traditional way of value creation but with the increase of more educated, smart, and technically sound customers the idea of value creation has changed. Now, customers are also contributing in value creation as value co-creator even before the product is consumed. This scenario has been encountered in the thesis with the main purpose of how value is cocreated in smart phone operating systems. The purpose is further divided into the following supobjectives: o What is value co-creation in smart phone operating systems? o Who participates in value co-creation in smart phone operating systems? o What are the procedures that are involved in value co-creation in smart phone operating systems? The research was conducted as a qualitative desk study by observing two of the leading smart phone operating system providers. Data has been collected from the official discussion forum of both the operating system providers. Other general concepts relating to the purpose of the study has been encountered through literature review. The research findings reveal that customers and companies both together co-create value of anticipated level when they communicate and interact with each other. However, most of the time customer to customer interactions, dialogues and discussions that come out in the core conversation help the value co-creation. The value co-creation framework sets up the customer at the main focus of value creation theory. By nullifying the inherited notion that companies only create value within its boundary and provide it to their customers in exchange of currencies. Rationally, it has been commenced that the firms are merely compromising value propositions to its customers. But the value has been co-created in a point where offerings are combined and interacted with customers’ capabilities, knowledge, resources and perceptions. This new perspective has radically altered the prospect of firms towards its customers. Typically customers are now taking part in value cocreation as a crucial member.

Análisis de la calidad en la atención del paciente de cirugía general de urgencia

Objetivo: proponer un instrumento para el seguimiento de la calidad de la atención de pacientes con patologías quirúrgicas abdominales urgentes. Métodos: se revisaron restropectivamente historias clínicas de pacientes quienes requirieron cirugía general de urgencia (CGU) en agosto de 2013. Se analizaron variables demográficas, factores de riesgo, severidad y desenlace hasta el día 30 postoperatorio. Se incluyeron los indicadores de calidad del National Surgical Quality Improvement Program (NSQIP) y el National Trauma Data Bank, y se adicionaron otros. Resultados: Se intervinieron 231 pacientes de 261 procedimientos de CGU. La edad promedio fue 49 años. Los procedimientos más comunes fueron la colecistectomía laparoscópica (37.2%), la apendicectomía (35.6%), la laparotomía exploratoria (12.6%), el drenaje de colección abdominal (9.1%) y la liberación de adherencias (6.9%). La mortalidad fue de 3.46% (n=8), la morbilidad severa fue de 8.04%. La duración de la hospitalización fue de 6.54 días +/- 5.180 y la de hospitalización en Unidad de Cuidado Intensivo fue de 5.7 días +/- 4.42. La oportunidad de salas de cirugía para la apendicetomía fue de 5 horas para las apendicitis con peritonitis generalizada, y de 8 horas para las apendicitis localizadas, 37 horas para colecistitis, 7.48 horas para colangitis y 2.42 horas para diverticulitis. Conclusiones: Crear de un instrumento para la medición de la calidad de la atención de los pacientes en CGU, es necesario para la autoevaluación institucional y para definir planes de mejoramiento y distribución de los recursos.

Testing of combined heating systems for small houses: Improved procedures for whole system test methods : Deliverable 2.3

Dynamic system test methods for heating systems were developed and applied by the institutes SERC and SP from Sweden, INES from France and SPF from Switzerland already before the MacSheep project started. These test methods followed the same principle: a complete heating system – including heat generators, storage, control etc., is installed on the test rig; the test rig software and hardware simulates and emulates the heat load for space heating and domestic hot water of a single family house, while the unit under test has to act autonomously to cover the heat demand during a representative test cycle. Within the work package 2 of the MacSheep project these similar – but different – test methods were harmonized and improved. The work undertaken includes:  • Harmonization of the physical boundaries of the unit under test. • Harmonization of the boundary conditions of climate and load. • Definition of an approach to reach identical space heat load in combination with an autonomous control of the space heat distribution by the unit under test. • Derivation and validation of new six day and a twelve day test profiles for direct extrapolation of test results.   The new harmonized test method combines the advantages of the different methods that existed before the MacSheep project. The new method is a benchmark test, which means that the load for space heating and domestic hot water preparation will be identical for all tested systems, and that the result is representative for the performance of the system over a whole year. Thus, no modelling and simulation of the tested system is needed in order to obtain the benchmark results for a yearly cycle. The method is thus also applicable to products for which simulation models are not available yet. Some of the advantages of the new whole system test method and performance rating compared to the testing and energy rating of single components are:  • Interaction between the different components of a heating system, e.g. storage, solar collector circuit, heat pump, control, etc. are included and evaluated in this test. • Dynamic effects are included and influence the result just as they influence the annual performance in the field. • Heat losses are influencing the results in a more realistic way, since they are evaluated under "real installed" and representative part-load conditions rather than under single component steady state conditions.   The described method is also suited for the development process of new systems, where it replaces time-consuming and costly field testing with the advantage of a higher accuracy of the measured data (compared to the typically used measurement equipment in field tests) and identical, thus comparable boundary conditions. Thus, the method can be used for system optimization in the test bench under realistic operative conditions, i.e. under relevant operating environment in the lab.   This report describes the physical boundaries of the tested systems, as well as the test procedures and the requirements for both the unit under test and the test facility. The new six day and twelve day test profiles are also described as are the validation results.

Knowledge of firefighters with special paramedic training of the emergency management of avulsed teeth

Immediate replantation into the socket is the ideal procedure in cases of accidental avulsion of permanent teeth. In Brazil, firefighters with special paramedic training are in charge of providing first-aid care to victims of road accidents and might have to deal with tooth avulsions. This study assessed the knowledge of firefighters regarding the emergency management of avulsed teeth. Information was collected from a questionnaire submitted to 110 volunteer firefighters in seven cities in the São Paulo State (Brazil). The results revealed that 70.9% of the respondents did not know what tooth avulsion was; 53.6% did not know what tooth replantation was or defined it incorrectly; 60% would not act properly in tooth avulsion cases; 20.9% did not consider replantation of the avulsed tooth into the socket as a treatment option; the ideal time interval for tooth replantation was unknown to 40% of the interviewees; 90% of the participants answered that they would not be able to perform tooth replantation. Among those who considered themselves unable to perform tooth replantation, 47.3% chose saline as the best storage medium for an avulsed tooth, 21.8% chose milk, 3.6% chose the patient's mouth and 20% reported not knowing where to store the tooth; 81.8% of the firefighters reported not to have ever received any specific directions on tooth replantation and 100% of them considered this knowledge a requirement for first-aid care to accident victims. In conclusion, the knowledge of the surveyed firefighters regarding emergency management after tooth avulsion was unsatisfactory in several aspects that are important for the success of replantation procedures. Firefighters with special paramedic training should be educated on how to proceed in cases of dentoalveolar traumas and tooth avulsions in order to improve treatment prognosis and increase the survival rate of replanted teeth.

Knowledge of general dentists in the current guidelines for emergency treatment of avulsed teeth and dental trauma prevention

A high prevalence of dental trauma exists and its effects on function and esthetics deserve the attention of general dentists. The aim of this study was to assess the level of general dental practitioners' (GDPs) knowledge about guidelines for dental avulsion and its prevention using a questionnaire. The 21-item questionnaire was distributed among 264 GDPs and the survey was realized between August-November 2006. The data obtained were statistically analyzed using descriptive analysis and Pearson's Chi-square test to determine associations between knowledge regarding emergency treatment and dentists from public or private dental schools and years of experience. The results showed that the participants exhibited appropriate knowledge concerning procedures in cases of tooth avulsion and its prevention. The number of correct answers was low in relation to recommended treatment at the site of injury. Storage medium, preparation of the alveolus and splint time for receiving the avulsed tooth received a high number of correct answers. One statistically significant association between years of experience and recommended treatment at the site of the injury in the case an avulsed tooth (KH2 = 9.384, P = 0.009). In conclusion, this survey showed appropriate knowledge of dental avulsion management and its prevention among the surveyed dentists. The findings also showed that communication between dentists and the population is deficient, especially concerning practitioners of high risk and contact sports.

Incidência de parada cardíaca e mortalidade em pacientes geriátricos durante a anestesia em hospital universitário de atendimento terciário no período de 15 anos

Pós-graduação em Anestesiologia - FMB

Emergency response to railroad accidents involving hazardous materials

The chemical industry has to face safety problems linked to the hazards of chemicals and the risks posed by the plants where they are handled. However, their transport may cause significant risk values too: it’s not totally possible to avoid the occurrence of accidents. This work is focused on the emergency response to railway accidents involving hazardous materials, that is what has to be done once they happen to limit their consequences. A first effort has been devoted to understand the role given to this theme within legislations: it has been found out that often it’s not even taken into account. Exceptionally a few countries adopt guidelines suggesting how to plan the response, who is appointed to intervene and which actions should be taken first. An investigation has been made to define the tools available for the responders, with attention on the availability of chemical-specific safety distances. It has emerged that the ERG book adopted by some American countries has suggestions and the Belgian legislation too establishes criteria to evaluate these distances. An analysis has been conducted then on the most recent accidents occurred worldwide, to understand how the response was performed and which safety distances were adopted. These values were compared with the numbers reported by the ERG book and the results of two devoted software tools for consequence analysis of accidental spills scenarios. This comparison has shown that there are differences between them and that a more standardized approach is necessary. This is why further developments of the topic should focus on promoting uniform procedures for emergency response planning and on a worldwide adoption of a guidebook with suggestions about actions to reduce consequences and about safety distances, determined following finer researches. For this aim, the development of a detailed database of hazardous materials transportation accidents could be useful.

Point-of-care testing in the cardiovascular operating theatre

Point-of-care testing (POCT) remains under scrutiny by healthcare professionals because of its ill-tried, young history. POCT methods are being developed by a few major equipment companies based on rapid progress in informatics and nanotechnology. Issues as POCT quality control, comparability with standard laboratory procedures, standardisation, traceability and round robin testing are being left to hospitals. As a result, the clinical and operational benefits of POCT were first evident for patients on the operating table. For the management of cardiovascular surgery patients, POCT technology is an indispensable aid. Improvement of the technology has meant that clinical laboratory pathologists now recognise the need for POCT beyond their high-throughput areas.

Analysis of patient flows for orthopedic procedures using small area analysis in Switzerland

BACKGROUND: In general cantons regulate and control the Swiss health service system; patient flows within and between cantons are thereby partially disregarded. This paper develops an alternative spatial model, based upon the construction of orthopedic hospital service areas (HSAOs), and introduces indices for the analysis of patient streams in order to identify areas, irrespective of canton, with diverse characteristics, importance, needs, or demands. METHODS: HSAOs were constructed using orthopedic discharge data. Patient streams between the HSAOs were analysed by calculating three indices: the localization index (% local residents discharged locally), the netindex (the ratio of discharges of nonlocal incoming residents to outgoing local residents), and the market share index (% of local resident discharges of all discharges in local hospitals). RESULTS: The 85 orthopedic HSAOs show a median localization index of 60.8%, a market share index of 75.1%, and 30% of HSAOs have a positive netindex. Insurance class of bed, admission type, and patient age are partially but significantly associated with those indicators. A trend to more centrally provided health services can be observed not only in large urban HSAOs such as Geneva, Bern, Basel, and Zurich, but also in HSAOs in mountain sport areas such as Sion, Davos, or St.Moritz. Furthermore, elderly and emergency patients are more frequently treated locally than younger people or those having elective procedures. CONCLUSION: The division of Switzerland into HSAOs provides an alternative spatial model for analysing and describing patient streams for health service utilization. Because this small area model allows more in-depth analysis of patient streams both within and between cantons, it may improve support and planning of resource allocation of in-patient care in the Swiss healthcare system.

Care of the bariatric surgery patient in the emergency department

Obesity has reached epidemic proportions in the United States, with an estimated 50% of adults meeting the definition of being overweight. As this condition has become more prevalent, bariatric surgery has become an increasingly accepted form of treatment of the severely obese. Patients who have had bariatric surgery are presenting more commonly to Emergency Departments as a result. This article will review the most common bariatric surgery procedures, the complications that can arise post-operatively, and the approach to the assessment and management of the bariatric surgery patient in the Emergency Department.

Staged surgical therapy of basal cell carcinoma of the head and neck region: an evaluation of 500 procedures

QUESTIONS UNDER STUDY / PRINCIPLES: The surgical therapy of basal cell carcinoma (BCC) is especially demanding in the facial area. This retrospective study was undertaken to evaluate the outcome of staged surgical therapy (SST) of BCC of the head and neck region performed on an interdisciplinary basis at our institution. METHODS: Patients treated for BCC in the head and neck area between 1/1/1997 and 31/12/2001 were included in the study. The lesions were histologically evaluated. Diameter of lesion, number of stages, defect coverage, operation time, and recurrence and infection rates were analysed using descriptive and inferential statistical procedures. RESULTS: 281 patients were included in the study. SST was performed in two stages in 43.7%, in three stages in 12.9% and in four or more stages in 2.7%, depending on the type of tumour and the patient's pretreatment status. The total operating time per lesion averaged one hour. Defect coverage was achieved by direct closure (37.7%), by full thickness skin graft (39.5%), by split skin graft (1.1%), by local flaps (20.3%) or by composite grafts (1.1%). Median follow-up time was 58.5 months. Low rates of recurrence (3.6%) and infection (2%) were observed with this technique. CONCLUSIONS: The staged surgical therapy of basal cell carcinoma evaluated here offers a series of advantages in respect of patient comfort and safety and economy, while allowing precise histological safety with low infection rates and reliable long-term results.