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Berlin Brandenburg

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  • 1
    In: ANZ Journal of Surgery, March 2016, Vol.86(3), pp.167-172
    Description: Byline: Daniel T. Breen, Nuttaya Chavalertsakul, Eldho Paul, Russell L. Gruen, Jonathan Serpell Keywords: blood loss; elective; heparin; low-molecular-weight; surgical procedure; surgical; thromboembolism; warfarin Abstract Background Patients taking warfarin are often given interim anticoagulation in the perioperative period. Institutional guidelines that use low-molecular-weight heparin (LMWH) 'bridging' while the international normalized ratio (INR) is sub-therapeutic are often based on the American College of Chest Physicians Anticoagulation Guidelines. Purpose This study aims to identify if patients at a tertiary referral hospital were anticoagulated in line with these guidelines, and the incidence and nature of bleeding and thromboembolic complications. Methods A retrospective review of the Alfred Hospital General Surgical and 'Hospital at Home' databases was conducted, identifying patients who underwent elective general surgical procedures and received bridging anticoagulation with enoxaparin. Demographics, indication for anticoagulation, bleeding and thromboembolism rates were recorded. Thromboembolic risk was estimated. Results The study identified 108 patients. Three-quarters of all patients were anticoagulated with LMWH doses in accordance with the guidelines. Thirty of the 108 patients suffered bleeding complications. This group was younger, weighed less, received higher doses of enoxaparin and were at higher predicted risk of thromboembolism than non-bleeding patients. Wound haematoma, rectal bleeding and intra-abdominal bleeding were the most frequent complications. The peak time of bleeding was 3.5 days after surgery. Twelve patients returned to theatre, 13 were readmitted and 3 received blood transfusion. One patient suffered pulmonary emboli on the first post-operative day. Conclusion LMWH bridging therapy when prescribed appropriately is associated with low rates of inpatient thromboembolism in elective general surgical patients within our institution, but an unexpectedly high rate of bleeding complications. Article Note: D. T. Breen MBBS; N. Chavalertsakul MBBS; E. Paul MSc; R. L. Gruen MBBS, PhD, FRACS; J. Serpell MB, BS, MD, MEd, FRACS, FACS. This study is based on research presented at the 2012 RACS ASM.
    Keywords: Blood Loss ; Elective ; Heparin ; Low‐Molecular‐Weight ; Surgical Procedure ; Surgical ; Thromboembolism ; Warfarin
    ISSN: 1445-1433
    E-ISSN: 1445-2197
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  • 2
    In: ANZ Journal of Surgery, March 2010, Vol.80(3), pp.157-161
    Description: There has been a shift from operative to conservative management of splenic injuries in the last two decades, but the current practice in Australia is not known. This study aims to determine the profile of splenic injury in major trauma victims and the approach to treatment in Victoria for the last 2 years. A review of prospectively collected data from the Victorian State Trauma Registry (VSTR) from July 2005 to June 2007 was conducted. Demographic data, details of the event, clinical observations, management and associated outcomes were extracted from the database. The patients were categorized into four groups according to management (conservative, splenectomy, embolization and repair) and were compared accordingly. Multivariate binary logistic regression was performed to identify predictors of treatment (conservative versus splenectomy) on arrival. Of the 318 major trauma patients with splenic injuries, 186 (59%) were treated conservatively, 103 (32%) with splenectomy, 17 (5%) with arterial embolization and 12 (4%) with repair. Of these, 14 (14%) splenectomy cases and 2 (12%) embolization cases did not receive their respective treatments within 24 h. The severity of the spleen injury (as measured by the Abbreviated Injury Scale (AIS)) and age were identified as significant independent predictors of the form of treatment provided. In Victoria, conservative management is the preferred approach in patients with minor (AIS = 2) to moderate (AIS = 3) splenic injuries. The low rates of embolization warrant further research into whether splenectomy is overused.
    Keywords: Conservative Management ; Embolization ; Epidemiology Of Splenic Injuries ; Spenorrhaphy ; Splenectomy
    ISSN: 1445-1433
    E-ISSN: 1445-2197
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  • 3
    In: ANZ Journal of Surgery, May 2018, Vol.88(5), pp.455-459
    Description: To purchase or authenticate to the full-text of this article, please visit this link: http://onlinelibrary.wiley.com/doi/10.1111/ans.14479/abstract Byline: Cino Bendinelli, Dominic Ku, Shane Nebauer, Kate L. King, Teresa Howard, Russel Gruen, Tiffany Evans, Mark Fitzgerald,Zsolt J. Balogh Keywords: intubation; prehospital; traumatic brain injury Background The role of prehospital endotracheal intubation (PETI) for traumatic brain injury is unclear. In Victoria, paramedics use rapid sequence induction (RSI) drugs to facilitate PETI, while in New South Wales (NSW) they do not have access to paralysing agents. We hypothesized that RSI would both increase PETI rates and improve mortality. Methods Retrospective comparison of adult primary admissions (Glasgow Coma Scale2) to either Victorian or NSW trauma centre, which were compared with univariate and logistic regression analysis to estimate odds ratio for mortality and intensive care unit (ICU) length of stay. Results One hundred and ninety-two Victorian and 91 NSW patients did not differ in: demographics (males: 77% versus 79%; P=0.7 and age: 34 (18-88) versus 33 (18-85); P=0.7), Glasgow Coma Scale (3 (3-8) versus 5 (3-8); P=0.07), and injury severity score (38 (26-75) versus 35 (18-75); P=0.09), prehospital hypotension (15.4% versus 11.7%; P=0.5) and desaturation (14.6% versus 17.5%; P=0.5). Victorians had higher abbreviated injury scale head and neck (5 (4-5) versus 5 (3-6); P=0.04) and more often successful PETI (85% versus 22%; P〈0.05). On logistic regression analysis, mortality did not differ among groups (31.7% versus 26.3%; P=0.34; OR=0.84; 95% CI: 0.38-1.86; P=0.67). Among survivors, Victorians had longer stay in ICU (364 (231-486) versus 144 (60-336) h), a difference that persisted on gamma regression (effect=1.58; 95% CI: 1.30-1.92; P〈0.05). Conclusion Paramedics using RSI to obtain PETI in patients with traumatic brain injury had a higher success rate. This increase in successful PETI rate was not associated with an improvement in either mortality rate or ICU length of stay. Article Note: C. Bendinelli MD, FRACS; D. Ku MD; S. Nebauer MD, MT; K. L. King RN, MN; T. Howard MD, PhD; R. Gruen MD, PhD, FRACS; T. Evans MMedStat; M. Fitzgerald MBBS, MD, FACEM, AFRACMA; Z. J. Balogh MD, PhD, FRACS. CAPTION(S): Table S1. Corrected mortality odds ratio for Victorian and NSW cohorts of patients with first prehospital GCS below or equal to five and AIS H/N higher or equal to three. Table S2. Corrected mortality odds ratio for Victorian and NSW cohorts of patients with prehospital GCS between six (included) and eight (included) and AIS H/N higher or equal to three. Table S3. Corrected comparison of the length of ICU stay among patients with prehospital GCS below nine and AIS H/N higher or equal to three from the Victorian and NSW cohorts, who were discharged alive.
    Keywords: Intubation ; Prehospital ; Traumatic Brain Injury
    ISSN: 1445-1433
    E-ISSN: 1445-2197
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  • 4
    In: ANZ Journal of Surgery, April 2002, Vol.72(4), pp.282-286
    Description: : The foot complications of diabetes are severe, disabling, costly and common in the Northern Territory. An understanding of the pathogenesis, the disease spectrum and treatment efficacy, however, is poor. The patterns of disease are documented in the present study; factors associated with good and poor outcomes are identified; and improved management strategies are proposed. : All patients presenting to the High Risk Foot Service at Royal Darwin Hospital between March 1997 and March 2000 were included in the present study, and details regarding the status of their feet, their demographics, their treatment and their outcomes were recorded prospectively. Logistic regression analysis was undertaken to determine associations between factors of interest and outcomes of healing and amputation. : One hundred and twenty‐six patients were recorded, 41% of whom had neuropathic ulcers and 63% of whom had severe disease at presentation. Two types of diabetic foot pathology were recognized that are not usually classified: acute injury without neuropathy (10%) and deep soft tissue infection alone (9%).Thirty‐seven percent and 23% of patients required minor and major amputations, respectively. The total number of hospital bed‐days was 5813. Total contact casting was associated with good healing rates in 16 patients. Major amputation was associated with ischaemia, severe disease at presentation and increasing age. : Patterns of diabetic foot disease which are not commonly recognized are described in the present study; the severity and cost of the problem are documented; and some factors which lead to poor outcome, such as late presentation, are identified. Attention should be paid, through a multidisciplinary team, to timely referral from primary care, patient education, total contact casts and appropriate revascularization.
    Keywords: Complications ; Diabetic Foot ; Outcomes
    ISSN: 1445-1433
    E-ISSN: 1445-2197
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  • 5
    In: ANZ Journal of Surgery, October 2004, Vol.74(10), pp.863-868
    Description:  Optimal planning for surgical training and the surgical workforce requires knowledge of the need and demand for surgical care in the community. This has previously relied on indirect indicators, such as hospital throughput. We aimed to describe referrals from general practitioners (GPs) to surgeons in Australia using a classification of surgical disorders developed especially for primary care settings.  Terms in the International Classification of Primary Care Version 2‐Plus were reclassified into categories delineated by specialist surgeons, resulting in the Surgical Nosology In Primary‐care Settings (SNIPS). Referrals to surgeons were analysed using data on 303 000 patient encounters by a random sample of 3030 GPs involved in the Bettering the Evaluation and Care of Health (BEACH) study.  Thirty‐two per cent (143 013) of all problems were classified as potential surgical problems, of which 9.5% (13 570) were referred to surgeons at an overall rate of 44.8 referrals per 1000 GP encounters. Patients with surgical problems were significantly older than the overall general practice patient population. Women and patients with health care cards were significantly less likely than men and patients without health care cards to be referred when a surgical problem was managed by the GP. Forty‐two per cent of all surgical referrals were accounted for by the following categories: skin lesions, skin infection/injury, upper gastrointestinal, breast lumps/cancer, spine, knee arthritis/pain, knee injury/instability, infective and non‐infective ear disorders. Many commonly referred problems are usually managed as outpatients.  The data from this study may have application for surgical workforce planning and ensuring trainees receive adequate exposure to commonly referred conditions. The classification system (SNIPS) may be useful for future research concerning the interface between primary care and specialist surgical practice.
    Keywords: Classification ; Family Practice ; Health Service Needs And Demand ; Referral And Consultation ; Surgery
    ISSN: 1445-1433
    E-ISSN: 1445-2197
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