Publications by authors named "Michael C Ott"

30 Publications

  • Page 1 of 1

Prophylactic Negative Pressure Wound Therapy for Closed Laparotomy Incisions: A Meta-analysis of Randomized Controlled Trials.

Ann Surg 2020 01;271(1):67-74

Department of Surgery, Division of General Surgery, Schulich School of Medicine & Dentistry, Western University, Ontario, Canada.

Objective: The aim of this study was to determine whether negative pressure wound therapy (NPWT) applied to primarily closed incisions decreases surgical site infections (SSIs) following open abdominal surgery.

Background: SSIs are a common cause of morbidity following open abdominal surgery. Prophylactic NPWT has shown promise for SSI reduction. However, the results of randomized controlled trials (RCTs) conducted among patients undergoing laparotomy have been inconsistent.

Methods: We performed a meta-analysis of English language RCTs comparing the use of prophylactic NPWT to standard dressings on primarily closed laparotomy incisions following open abdominal surgery. Medline, EMBASE, Cochrane Library, and CINAHL databases were searched from inception to December 31, 2018, for relevant studies. A random-effects model was used for statistical analysis.

Results: Five RCTs totaling 792 patients were included in our meta-analysis after application of our exclusion and inclusion criteria. There was no significant difference in the risk of SSIs identified among those patients who had NPWT compared to standard dressings; relative risk (RR) 0.56 (95% confidence interval 0.30-1.03, P = 0.064). There was significant statistical heterogeneity across studies (I = 67.4%; P = 0.015).

Conclusion: The adoption of NPWT for routine SSI prophylaxis following laparotomy is currently not supported and should be used primarily in the context of a clinical trial.
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http://dx.doi.org/10.1097/SLA.0000000000003435DOI Listing
January 2020

Negative Pressure Wound Therapy Use to Decrease Surgical Nosocomial Events in Colorectal Resections (NEPTUNE): A Randomized Controlled Trial.

Ann Surg 2019 07;270(1):38-42

Division of General Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

Objective: Determine if negative pressure wound therapy (NPWT) reduces surgical site infection (SSI) in primarily closed incision after open and laparoscopic-converted colorectal surgery.

Background: SSIs after colorectal surgery are a common cause of morbidity. The prophylactic effect of NPWT has not been established. We undertook this study to evaluate if, among patients undergoing open colorectal resection, NPWT, as compared with standard postoperative dressings, is associated with a reduction in the rate of postoperative SSI.

Methods: In a randomized, controlled trial, 300 patients undergoing elective open colorectal surgery were assigned to receive prophylactic NPWT or standard gauze dressing. The primary end-point was 30-day SSI, as assessed by wound care experts blinded to treatment arm. Secondary outcomes included length of stay. Statistical analysis was performed on an intention-to-treat basis. A priori subgroup analysis was planned for patients who received a stoma at the time of initial operation.

Results: The incidence of SSI at 30-days postoperatively was no different between experimental and control groups (32% vs 34% respectively, P = 0.68). Length of stay was also no different at a median of 7 days (IQR 5) for both groups. Among patients receiving a stoma, there was also no difference in SSI between the experimental and control groups (38% vs 33% respectively, P = 0.66).

Conclusions: Prophylactic use of NPWT on primarily closed incisions after open colorectal surgery was not associated with a decrease in SSI rate when compared with standard gauze dressing.

Trial Registration Number: Clinicaltrials.gov (NCT02007018).
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http://dx.doi.org/10.1097/SLA.0000000000003111DOI Listing
July 2019

Statistical Techniques in General Surgery Literature: What Do We Need to Know?

J Am Coll Surg 2018 10 30;227(4):450-454.e1. Epub 2018 Jul 30.

Department of Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada; Department of Clinical Epidemiology and Biostatistics, Western University, London, Ontario, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.jamcollsurg.2018.07.656DOI Listing
October 2018

Proper Antibiotic Use in a Home-Based Primary Care Population Treated for Urinary Tract Infections.

Consult Pharm 2018 Feb;33(2):105-113

Objective: To evaluate the trends associated with diagnosis and treatment of urinary tract infections (UTI) in a home-based primary care population of Veterans Health System patients from 2006 to 2015.

Design: Retrospective cohort study.

Setting: Veterans Healthcare System.

Participants: Home-based primary care patients treated for UTI from 2006 to 2015.

Interventions: None.

Main Outcome Measure: Appropriate therapy was determined based on the McGeer criteria. Multivariate logistic regression was used to determine factors leading to appropriate UTI treatment.

Results: Of 366 available patients, 68 (18.6%) were tested for a UTI. Appropriate therapy occurred in 26% of patients. Allergy to any antibiotic increased the odds of appropriate treatment (odds ratio [OR] = 5.6, 95% confidence interval [CI] 1.5-23.2). Flank pain and increased urinary frequency also increased the likelihood of being treated appropriately (OR = 25.9, 95% CI 2.9-584.0 and OR = 4.49, 95% CI 0.99-21.2, respectively).

Conclusion: Antibiotics were overused for treating UTIs in the homebound population. Patients with flank pain, increased urinary frequency, and antibiotic allergy were more likely to receive appropriate treatment. Pharmacists, therefore, have a viable opportunity to increase appropriate antibiotic prescribing in the home-based primary care population.
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http://dx.doi.org/10.4140/TCP.n.2018.105DOI Listing
February 2018

Early Rescue from Acute Severe Clostridium Difficile: A Novel Treatment Strategy.

Surg Infect (Larchmt) 2018 Jan 11;19(1):78-82. Epub 2017 Dec 11.

1 Division of General Surgery, Western University , London, Ontario, Canada .

Background: Severe Clostridium difficile infections (CDI) can lead to significant impediments to effective treatment. We developed a novel treatment protocol utilizing bedside gastrointestinal lavage (GIL) for the management of patients with severe, complicated CDI. We describe the development and early outcomes of non-operative bedside GIL in hospitalized patients with severe, complicated CDI following the Idea, Development, Exploration, Assessment, Long Term Study (IDEAL) framework at the Idea stage. We compared our results with those of a cohort of patients managed with colectomy.

Methods: We conducted a retrospective cohort study of hospitalized patients with severe, complicated CDI who failed conventional medical therapy and were referred for surgical consultation at two academic tertiary-care hospitals between January 2009 and January 2015. After surgical assessment, the attending surgeon decided to proceed either with bedside GIL or directly to colectomy. Bedside GIL involved nasojejunal tube insertion followed by flushing with 8 L of polyethylene glycol 3350/electrolyte solution over 48 h. Both patient groups received standard medical treatment with vancomycin 500 mg q 6 h enterally and metronidazole 500 mg intravenously three times daily for 14 d. The main outcomes of interest were the incidence of colectomy, complications, and mortality rate.

Results: Nineteen and seventeen patients underwent GIL and direct colectomy, respectively. There were no significant differences between the groups in terms of demographics, American Society of Anesthesiologists class, disease severity, need for intensive care unit admission, mechanical ventilation, vasopressor use, serum lactate concentration, or proportion presenting with hypotension, acute kidney injury, or a white blood cell count >16,000/mcL or <4,000/mcL (p > 0.1). The in-hospital mortality rate was 26% (5/19) and 41% (7/17) for the GIL and colectomy groups, respectively (p = 0.35). Only one patient in the GIL group failed the protocol, requiring colectomy. There were no significant differences in complications in the two groups.

Conclusions: Bedside GIL appeared to be safe for the treatment of patients with severe, complicated CDI who had failed conventional medical therapy. It did not appear to increase the risk of morbidity or death compared with the traditional strategy of proceeding directly to colectomy.
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http://dx.doi.org/10.1089/sur.2017.147DOI Listing
January 2018

Benefits of multimodal enhanced recovery pathway in patients undergoing kidney transplantation.

Clin Transplant 2018 02 26;32(2). Epub 2017 Dec 26.

University at Buffalo Department of Surgery, Buffalo, NY, USA.

Background: Use of enhanced recovery after surgery (ERAS) pathways to accelerate functional recovery and reduce length of stay (LOS) has rarely been investigated in kidney transplantation (KTX).

Materials And Methods: Consecutive adult isolated KTXs between July 2015 and July 2016 (ERAS, n = 139) were compared with a historical cohort between January 2014 and July 2015 (HISTORIC, n = 95).

Results: Enhanced recovery after surgery recipients were significantly more likely to receive kidneys that were non-local (56.1% vs 4.2%), higher Kidney Donor Profile Index (36-85, 58.4% vs 45.2%; >85, 15.2% vs 10.7%), cold ischemia time ≥30 h (62.4% vs 4.7%), induced with antithymocyte globulin (97.1% vs 87.4%), and to develop delayed graft function (46.4% vs 25.0%). LOS was shorter by 1 day among ERAS (mean 4.59) compared to HISTORIC patients (mean 5.65) predominantly due to a shift in discharges within 3 days (32.4% vs 4.2%); 30-day readmission to the hospital (27.3% vs 27.4%) or emergency room visit (9.4% vs 7.4%) was similar. There was one 30-day death in the ERAS group and none in the HISTORIC group. Return to bowel function and early meal consumption were significantly associated with ERAS, however, with somewhat higher diarrhea and emesis rates.

Conclusion: ERAS following KTX correlated with lower LOS without change in readmissions or ER visits despite higher delayed graft function rates.
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http://dx.doi.org/10.1111/ctr.13173DOI Listing
February 2018

Impact of Penicillin Allergy on Time to First Dose of Antimicrobial Therapy and Clinical Outcomes.

Clin Ther 2017 Nov 9;39(11):2276-2283. Epub 2017 Oct 9.

Veterans Affairs Western New York Healthcare System, Buffalo, New York. Electronic address:

Purpose: The objective of this study was to evaluate the impact of a listed penicillin allergy on the time to first dose of antibiotic in a Veterans Affairs hospital. Additional clinical outcomes of patients with penicillin allergies were compared with those of patients without a penicillin allergy.

Methods: A retrospective chart review of veterans admitted through the emergency department with a diagnosis of pneumonia, urinary tract infection, bacteremia, and sepsis from January 2006 to December 2015 was conducted. The primary outcome was time to first dose of antibiotic treatment, defined as the time from when the patient presented to the emergency department to the medication administration time. Secondary outcomes included total antibiotic therapy duration and treatment outcomes, including mortality, length of stay, and 30-day readmission rate.

Findings: A total of 403 patients were included in the final analysis; 57 patients (14.1%) had a listed penicillin allergy. The average age of the population was 75 years and 99% of the population was male. The mean time to first dose of antibiotic treatment for patients with a penicillin allergy was prolonged compared with those without a penicillin allergy (236.1 vs 186.6 minutes; P = 0.03), resulting in an approximately 50-minute delay. Penicillin-allergic patients were more likely to receive a carbapenem or fluoroquinolone antibiotic (P < 0.0001).

Implications: Patients with a penicillin allergy had a prolonged time to first dose of antibiotic therapy. No significant differences were found in total antibiotic duration, length of stay, or 30-day readmission rate. The small sample size, older population, and single-center nature of this study may limit the generalizability of the present findings to other populations.
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http://dx.doi.org/10.1016/j.clinthera.2017.09.012DOI Listing
November 2017

Decreased mortality in patients prescribed vancomycin after implementation of antimicrobial stewardship program.

Am J Infect Control 2017 Nov 21;45(11):1194-1197. Epub 2017 Jul 21.

Veterans Affairs Western New York Healthcare System, Buffalo, NY. Electronic address:

Background: The impact of an antimicrobial stewardship program (ASP) on 30-day mortality rates was evaluated in patients prescribed vancomycin in a Veterans Affairs hospital.

Methods: A retrospective chart review of patients receiving a minimum of 48 hours of vancomycin during October 2006-July 2014. A multivariate logistic regression analysis was used to determine predictors of mortality. Interventions of the ASP consist of appropriate antibiotic selection, dosing, microbiology, and treatment duration.

Results: Death occurred in 12.4% of 453 patients. Of the 56 deaths, 64.3% occurred during prestewardship versus 35.7% during stewardship (P = .021). Increased mortality was associated with pre-ASP (odds ratio [OR], 2.17; 95% confidence interval [CI], 1.13-4.27), age (unit OR, 1.08; 95% CI, 1.05-1.12), nephrotoxicity (OR, 3.24; 95% CI, 1.27-8.01), and hypotension (OR, 3.28; 95% CI, 1.42-7.44). Patients treated in the intensive care unit were associated with increased mortality. Patients in the stewardship group experienced lower rates of mortality, which may be caused by interventions initiated by the stewardship team, including minimizing nephrotoxicity and individualized chart review.

Conclusions: Mortality in patients treated with vancomycin was decreased after antimicrobial stewardship was implemented. As anticipated, older age, hypotension, nephrotoxicity, and intensive care unit admission were associated with an increased incidence of mortality.
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http://dx.doi.org/10.1016/j.ajic.2017.06.012DOI Listing
November 2017

Changing the Learning Curve in Novice Laparoscopists: Incorporating Direct Visualization into the Simulation Training Program.

J Surg Educ 2017 Jan - Feb;74(1):30-36. Epub 2016 Oct 4.

Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada; Department of Anatomy and Cell Biology, Corps for Research of Instructional and Perceptual Technologies, The University of Western Ontario, London, Ontario, Canada. Electronic address:

Objective: A major challenge in laparoscopic surgery is the lack of depth perception. With the development and continued improvement of 3D video technology, the potential benefit of restoring 3D vision to laparoscopy has received substantial attention from the surgical community. Despite this, procedures conducted under 2D vision remain the standard of care, and trainees must become proficient in 2D laparoscopy. This study aims to determine whether incorporating 3D vision into a 2D laparoscopic simulation curriculum accelerates skill acquisition in novices.

Design: Postgraduate year-1 surgical specialty residents (n = 15) at the Schulich School of Medicine and Dentistry, at Western University were randomized into 1 of 2 groups. The control group practiced the Fundamentals of Laparoscopic Surgery peg-transfer task to proficiency exclusively under standard 2D laparoscopy conditions. The experimental group first practiced peg transfer under 3D direct visualization, with direct visualization of the working field. Upon reaching proficiency, this group underwent a perceptual switch, changing to standard 2D laparoscopy conditions, and once again trained to proficiency.

Results: Incorporating 3D direct visualization before training under standard 2D conditions significantly (p < 0.0.5) reduced the total training time to proficiency by 10.9 minutes or 32.4%. There was no difference in total number of repetitions to proficiency. Data were also used to generate learning curves for each respective training protocol.

Conclusions: An adaptive learning approach, which incorporates 3D direct visualization into a 2D laparoscopic simulation curriculum, accelerates skill acquisition. This is in contrast to previous work, possibly owing to the proficiency-based methodology employed, and has implications for resource savings in surgical training.
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http://dx.doi.org/10.1016/j.jsurg.2016.07.012DOI Listing
November 2017

Male veterans with complicated urinary tract infections: Influence of a patient-centered antimicrobial stewardship program.

Am J Infect Control 2016 12 4;44(12):1549-1553. Epub 2016 Jul 4.

Veterans Affairs Western New York Healthcare System, Buffalo, NY. Electronic address:

Background: The influence of antimicrobial stewardship programs (ASPs) on outcomes in male veterans treated for complicated urinary tract infection has not been determined.

Methods: This was a retrospective cohort study encompassing the study period January 1, 2005-October 31, 2014, which was conducted at a 150-bed Veterans Affairs Healthcare System facility in Buffalo, NY. Male veterans admitted for treatment of complicated urinary tract infection were identified using ICD-9-CM codes. Outcomes before and after implementation of a patient-centered ASP, including duration of antibiotic therapy, length of hospitalization, readmission within 30 days, and Clostridium difficile infection were compared. Interventions resulting from the ASP were categorized.

Results: Of the 1,268 patients screened, 241 met criteria for inclusion in the study (n = 118 and n = 123 in the pre-ASP and ASP group, respectively). Duration of antibiotic therapy was significantly shorter in the ASP group (10.32 days vs 11.96 days; P < .0001), as was length of hospitalization (5.76 days vs 6.76 days; P = .015). There was no difference in 30-day readmission. A total of 170 interventions were identified that resulted from the ASP (1.39 interventions per patient).

Conclusions: ASPs may be useful to improve clinical outcomes in men with complicated urinary tract infection. Implementation of an ASP was associated with significant decreases in duration of antibiotic therapy and length of hospitalization, without adversely affecting 30-day readmission rates.
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http://dx.doi.org/10.1016/j.ajic.2016.04.239DOI Listing
December 2016

Impact of Antimicrobial Stewardship on Outcomes in Hospitalized Veterans With Pneumonia.

Clin Ther 2016 Jul 24;38(7):1750-8. Epub 2016 Jun 24.

Infectious Diseases Department, Veterans Affairs Western New York Healthcare System, Buffalo, New York.

Purpose: The purpose of this study was to evaluate the impact of an antimicrobial stewardship program (ASP) on outcomes for inpatients with pneumonia, including length of stay, treatment duration, and 30-day readmission rates.

Methods: A retrospective chart review comparing outcomes of veterans admitted with pneumonia before (2005-2006) and after (2013-2014) implementation of an ASP was conducted; pneumonia was defined according to International Classification of Diseases, Ninth Revision (ICD-9) codes. Infectious diseases physicians and pharmacist in the ASP provided appropriate recommendations to the primary medicine teams. Bivariate analysis of baseline characteristics and comorbid conditions were performed between the time frames. Least squares regression was used to analyze length of stay, time of IV to PO conversions, and duration of antibiotics. Multivariate logistic regressions were used to determine odds of 30-day readmission and odds of Clostridium difficile infections between time periods.

Findings: There were 86 patients in the pre-ASP period and 88 patients in the ASP period. Mean length of stay decreased from 8.1 to 6.6 days (P = 0.02), total duration of antibiotic therapy decreased from 12 to 8.5 days (P < 0.0001), and time of IV to PO antibiotic conversions decreased from 5.3 to 3.9 days (P = 0.0003), before ASP and during ASP, respectively. The odds ratio of 30-day readmission before ASP was 2.78 and 0.36 during the ASP (P = 0.05). The odds ratios of Clostridium difficile infections before ASP was 2.08 and 0.48 during the ASP (P = 0.37).

Implications: The ASP interventions were associated with shorter durations of therapy, shorter lengths of stay, and lower rates of readmission and Clostridium difficile infections within 30 days. Limitations of this study are retrospective cohort design, small study population, limited study population diversity, and non-concurrent cohort times periods.
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http://dx.doi.org/10.1016/j.clinthera.2016.06.004DOI Listing
July 2016

GPs with enhanced surgical skills: a questionable solution for remote surgical services.

Can J Surg 2015 Dec;58(6):369-71

From the Schulich School of Medicine and Dentistry, Western University, London, Ont. (Vinden, Ott).

Summary: The Canadian College of Family Physicians recently decided to recognize family physicians with enhanced surgical skills (ESS) and has proposed a 1-year curriculum of surgical training. The purpose of this initiative is to bring or enhance surgical services to remote and underserviced areas. We feel that this proposed curriculum is overly ambitious and unrealistic and that it is unlikely to produce surgeons, or a system, capable of delivering high-quality surgical services. The convergence of a new training curriculum for general surgeons, coupled with the current oversupply of surgeons, provide an alternate pathway to meet the needs of these communities. A long-term solution will also require alternate funding models, a sophisticated and coordinated national locum service and a national review of the population and infrastructure requirements necessary for both sustainable resident surgical services and surgical outreach services.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4651685PMC
http://dx.doi.org/10.1503/cjs.015215DOI Listing
December 2015

Negative pressure wound therapy use to decrease surgical nosocomial events in colorectal resections (NEPTUNE): study protocol for a randomized controlled trial.

Trials 2015 Jul 30;16:322. Epub 2015 Jul 30.

Division of General Surgery, Department of Surgery, University of Western Ontario, London, ON, Canada.

Background: Surgical site infections (SSIs) are the second most common form of nosocomial infection. Colorectal resections have high rates of SSIs secondary to the inherently contaminated intraluminal environment. Negative pressure wound therapy dressings have been used on primarily closed incisions to reduce surgical site infections in other surgical disciplines. No randomized control trials exist to support the use of negative pressure wound therapy following elective open colorectal resection to reduce surgical site infection.

Methods/design: In this single-center, superiority designed prospective randomized open blinded endpoint controlled trial, patients scheduled for a colorectal resection via a laparotomy will be considered eligible. Patients undergoing laparoscopic resection will be enrolled but only randomized and included if the operation is converted to an open procedure. Exclusion criteria are patients receiving an abdominoperineal resection or a palliative procedure, as well as pregnant patients and those with an adhesive allergy. After informed consent, 300 patients will be randomized to the use of a standard adhesive gauze dressing or to a negative pressure wound device. Patients will be followed in hospital and reassessed on post-operative day 30. The primary outcome measure is SSI within the first 30 post-operative days. Secondary outcomes include the length of hospital stay, the number of return visits related to a potential or actual SSI, cost, and the need for homecare. The primary endpoint analysis follows the intention-to-treat principle.

Discussion: NEPTUNE is the first randomized controlled trial to investigate the role of incisional negative pressure wound therapy in decreasing the rates of surgical site infections in the abdominal incisions of patients following an elective, open colorectal resection. This low-risk intervention may help decrease the morbidity and costs associated with the development of an SSI in our patients.

Trial Registration: NCT02007018--clinicaltrials.gov; 5 December 2013.
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http://dx.doi.org/10.1186/s13063-015-0817-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518608PMC
July 2015

Factors associated with antibiotic misuse in outpatient treatment for upper respiratory tract infections.

Antimicrob Agents Chemother 2015 Jul 13;59(7):3848-52. Epub 2015 Apr 13.

VA Western New York Healthcare System, Infectious Diseases and Pharmacy Departments, Buffalo, New York, USA

The Centers for Disease Control and Prevention has promoted the appropriate use of antibiotics since 1995 when it initiated the National Campaign for Appropriate Antibiotic Use in the Community. This study examined upper respiratory tract infections included in the campaign to determine the degree to which antibiotics were appropriately prescribed and subsequent admission rates in a veteran population. This study was a retrospective chart review conducted among outpatients with a diagnosis of a respiratory tract infection, including bronchitis, pharyngitis, sinusitis, or nonspecific upper respiratory tract infection, between January 2009 and December 2011. The study found that 595 (35.8%) patients were treated appropriately, and 1,067 (64.2%) patients received therapy considered inappropriate based on the Get Smart Campaign criteria. Overall the subsequent readmission rate was 1.5%. The majority (77.5%) of patients were prescribed an antibiotic. The most common antibiotics prescribed were azithromycin (39.0%), amoxicillin-clavulanate (13.2%), and moxifloxacin (7.5%). A multivariate regression analysis demonstrated significant predictors of appropriate treatment, including the presence of tonsillar exudates (odds ratio [OR], 0.6; confidence interval [CI], 0.3 to 0.9), fever (OR, 0.6; CI, 0.4 to 0.9), and lymphadenopathy (OR, 0.4; CI, 0.3 to 0.6), while penicillin allergy (OR, 2.9; CI, 1.7 to 4.7) and cough (OR, 1.6; CI, 1.1 to 2.2) were significant predictors for inappropriate treatment. Poor compliance with the Get Smart Campaign was found in outpatients for respiratory infections. Results from this study demonstrate the overprescribing of antibiotics, while providing a focused view of improper prescribing. This article provides evidence that current efforts are insufficient for curtailing inappropriate antibiotic use.
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http://dx.doi.org/10.1128/AAC.00652-15DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4468652PMC
July 2015

Local resection compared with radical resection in the treatment of T1N0M0 rectal adenocarcinoma: a systematic review and meta-analysis.

Dis Colon Rectum 2015 Jan;58(1):122-40

1 Department of Surgery, Western University, London, Ontario, Canada 2 School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.

Background: Local resection for early rectal cancer is thought to be less invasive but oncologically inferior to radical resection.

Objective: The aim of this study was to compare local with radical resection in terms of oncologic control (survival and local recurrence), postoperative complications, and the need for a permanent stoma in adult patients with T1N0M0 rectal adenocarcinoma.

Data Sources: Data were retrieved from Medline, Embase, Central, www.clinicaltrials.gov, and conference proceedings.

Study Selection: Two reviewers independently screened studies and assessed the risk of bias.

Interventions: Local resection (transanal procedures, excluding endoscopic polypectomy) versus radical resection were considered.

Main Outcome Measures: The primary outcomes measured were overall survival, major postoperative complications, and the 'need for permanent stoma.'

Results: : One randomized controlled trial and 12 observational studies contributed 2855 patients for analysis. The randomized controlled trial was inadequately powered. Observational study meta-analysis showed that local resection was associated with significantly lower 5-year overall survival (72 more deaths per 1000 patients; 95%CI 30-120). However, the transanal endoscopic microsurgery subgroup did not yield significantly lower overall survival than radical resection. Local resection was associated with higher local recurrence but with lower perioperative mortality (relative risk 0.31, 95% CI 0.14-0.71), major postoperative complications (relative risk 0.20, 95% CI 0.10-0.41), and need for a permanent stoma (relative risk 0.17, 95% CI 0.09-0.30). Findings were robust to sensitivity analyses. Meta-regression suggests that the higher overall survival associated with radical resection may be explained by increased use of local resection on tumors in the lower third of the rectum, which have poorer prognosis.

Limitations: This systematic review of nonrandomized studies had inherent biases that may persist despite our rigorous use of systematic review methodology and sensitivity analyses.

Conclusions: Local resection does not offer oncologic control comparable to radical surgery. However, this finding may be driven by the higher prevalence of cancers with poorer prognosis in local resection groups. Local resection is associated with lower postoperative complications, mortality, and the need for a permanent stoma. Local resection with transanal endoscopic microsurgery appears to offer oncologic control similar to that of radical resection while offering all the benefits of local resection.
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http://dx.doi.org/10.1097/DCR.0000000000000293DOI Listing
January 2015

What's behind the scenes? Exploring the unspoken dimensions of complex and challenging surgical situations.

Acad Med 2014 Nov;89(11):1540-7

Dr. Cristancho is assistant professor, Department of Surgery, and scientist, Centre for Education Research & Innovation, Western University, London, Ontario, Canada. Ms. Bidinosti is research associate, Centre for Education Research & Innovation, Western University, London, Ontario, Canada. Dr. Lingard is professor, Department of Medicine, and director and scientist, Centre for Education Research & Innovation, Western University, London, Ontario, Canada. Dr. Novick is professor, Department of Surgery, Division of Cardiac Surgery, Western University, London, Ontario, Canada. Dr. Ott is associate professor, Department of Surgery, Division of General Surgery, Western University, London, Ontario, Canada. Dr. Forbes is professor and division chair/chief, Department of Surgery, Division of Vascular Surgery, Western University, London, Ontario, Canada.

Purpose: Physicians regularly encounter challenging and/or complex situations in their practices; in training settings, they must help learners understand such challenges. Context becomes a fundamental construct when seeking to understand what makes a situation challenging and how physicians respond to it; however, the question of how physicians perceive context remains largely unexplored. If the goal is to teach trainees to deal with challenging situations, the medical education community requires an understanding of what "challenging" means for those in charge of training.

Method: The authors relied on visual methods for this research. In 2013, they collected 40 snapshots (i.e., data sets) from a purposeful sample of five faculty surgeons through a combination of interviews, observations, and drawing sessions. The analytical process involved three phases: analysis of each drawing, a compare-and-contrast analysis of multiple drawings, and a team analysis conducted in collaboration with three participating surgeons.

Results: Findings demonstrate that experts perceive the challenge of surgical situations to extend beyond their procedural dimensions to include unspoken, nonprocedural dimensions-specifically, team dynamics, trust, emotions, and external pressures.

Conclusions: Findings show that analysis of surgeons' drawings is an effective means of gaining insight into surgeons' perceptions. The findings refine the common belief that procedural complexity is what makes a surgery challenging for expert surgeons. Focusing exclusively on the procedure during training may put trainees at risk of missing the "big picture." Understanding the multidimensionality of medical challenges and having a language to discuss these both verbally and visually will facilitate teaching around challenging situations.
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http://dx.doi.org/10.1097/ACM.0000000000000478DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5578758PMC
November 2014

Incisional negative pressure wound therapy decreases the frequency of postoperative perineal surgical site infections: a cohort study.

Dis Colon Rectum 2014 Aug;57(8):999-1006

1Division of General Surgery, London Health Sciences Centre, London, Ontario, Canada 2Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

Background: Abdominoperineal resection is a procedure associated with high rates of perineal surgical site infections, causing distress to the patient, costs to the hospital system, and delays in further treatment.

Objective: The aim of this study was to investigate the role of incisional negative pressure wound therapy in decreasing the rates of perineal surgical site infection.

Design: This retrospective cohort study had a historical, consecutively sampled control group.

Settings: This study was conducted at a single-institution tertiary care academic institution.

Patients: All patients undergoing an abdominoperineal resection between 2008 and 2012 were assessed.

Interventions: Perineal incisional negative pressure wound therapy was applied to all patients following an abdominoperineal resection between 2010 and 2012 at 125 mmHg continuous suction for 5 days postoperatively.

Main Outcome Measures: The development of a perineal surgical site infection within the first 30 days postoperatively was the primary outcome measured.

Results: Fifty-nine patients were included: 27 in the incisional negative pressure wound therapy group and 32 in the control group. A statistically lower proportion of perineal surgical site infections were detected in the incisional negative pressure wound therapy group than in the standard dressing group (15% vs 41%; p = 0.02). Both populations were similar in perioperative risk factors, with the exception of increased levels of blood urea nitrogen, a higher proportion of hypertensive patients, and a longer mean operative time in the incisional negative pressure wound therapy group. Additionally, an increased length of stay was observed in the incisional negative pressure wound therapy group (11 vs 8 days; p = 0.03). After adjusting for confounders, including the type of perineal dissection, incisional negative pressure wound therapy was found to be an independent predictor of not developing an surgical site infection (adjusted OR, 0.11; 95% CI, 0.04-0.66; p = 0.01).

Limitations: The study's retrospective nature limits the results because of the risk of interpreter bias, although this was addressed in part by reviewing data in duplicate. We controlled for the potential for selection bias with our consecutive sampling model.

Conclusions: Our study demonstrates a role for incisional negative pressure wound therapy in decreasing rates of perineal surgical site infection following abdominoperineal resection. Prospective randomized trials will be required to further investigate this intervention.
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http://dx.doi.org/10.1097/DCR.0000000000000161DOI Listing
August 2014

Laparoscopic surgery for Crohn's disease: a meta-analysis of perioperative complications and long term outcomes compared with open surgery.

BMC Surg 2013 May 24;13:14. Epub 2013 May 24.

Division of General Surgery, The University of Western Ontario London, Ontario, ON, Canada.

Background: Previous meta-analyses have had conflicting conclusions regarding the differences between laparoscopic and open techniques in patients with Crohn's Disease. The objective of this meta-analysis was to compare outcomes in patients with Crohn's disease undergoing laparoscopic or open surgical resection.

Methods: A literature search of EMBASE, MEDLINE, The Cochrane Central Register of Controlled Trials and the US National Institute of Health's Clinical Trials Registry was completed. Randomized clinical trials and non-randomized comparative studies were included if laparoscopic and open surgical resections were compared. Primary outcomes assessed included perioperative complications, recurrence requiring surgery, small bowel obstruction and incisional hernia.

Results: 34 studies were included in the analysis, and represented 2,519 patients. Pooled analysis showed reduced perioperative complications in patients undergoing laparoscopic resection vs. open resection (Risk Ratio 0.71, 95% CI 0.58 - 0.86, P = 0.001). There was no evidence of a difference in the rate of surgical recurrence (Rate Ratio 0.78, 95% CI 0.54 - 1.11, P = 0.17) or small bowel obstruction (Rate Ratio 0.63, 95% CI 0.28 - 1.45, P = 0.28) between techniques. There was evidence of a decrease in incisional hernia following laparoscopic surgery (Rate Ratio 0.24, 95% CI 0.07 - 0.82, P = 0.02).

Conclusions: This is the largest review in this topic. The results of this analysis are based primarily on non-randomized studies and thus have significant limitations in regards to selection bias, confounding, lack of blinding and potential publication bias. Although we found evidence of decreased perioperative complications and incisional hernia in the laparoscopic group, further randomized controlled trials, with adequate follow up, are needed before strong recommendations can be made.
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http://dx.doi.org/10.1186/1471-2482-13-14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3733939PMC
May 2013

Effect of azithromycin on anticoagulation-related outcomes in geriatric patients receiving warfarin.

Clin Ther 2013 Apr 28;35(4):425-30. Epub 2013 Feb 28.

Department of Pharmacy, VA Western New York Healthcare System, Buffalo, New York, USA.

Background: Warfarin is known to have multiple pharmacokinetic and pharmacodynamic interactions. Of the macrolide family, erythromycin and clarithromycin have been shown to interact with warfarin, leading to an elevated international normalized ratio (INR). The incidence of overanticoagulation in patients prescribed azithromycin stabilized on a warfarin regimen is controversial.

Objectives: The primary objective was to assess warfarin dosage adjustments and their effect on the INR after treatment with azithromycin. The secondary objective was to examine the occurrence of hemorrhage in patients taking warfarin who received azithromycin.

Methods: This retrospective review included 100 patients from the Western New York Veterans Affairs Healthcare System aged ≥65 years who received a prescription for azithromycin and warfarin between January 1, 2004, and December 31, 2009. The inclusion criteria consisted of a stable warfarin dose (2 INR values within 0.2 of the therapeutic range and the last INR determined ≤30 days before the introduction of azithromycin) and no medication changes in the 30 days before azithromycin therapy initiation. A repeated INR was determined 3 to 30 days after azithromycin therapy was initiated. Patients were excluded if they discontinued warfarin use, had a history of hemorrhage, or were taking antiplatelets, anti-inflammatory agents, or any other antibiotics.

Results: The impact on the INR was analyzed using a paired samples t test comparing INR values and warfarin doses before and after azithromycin exposure. There was a significant change in the INR between the 2 groups (before vs after azithromycin exposure, P < 0.001). This change was clinically significant given that the values before and after exposure to azithromycin lead to a decrease in warfarin from a mean weekly dose of 30 mg to 29.2 mg (P = 0.001). However, changes in the INR did not result in vitamin K administration or adverse bleeding events.

Conclusions: The addition of azithromycin to a stable warfarin regimen resulted in a significant change in the INR and warfarin dosage alteration without an increase in bleeding.
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http://dx.doi.org/10.1016/j.clinthera.2013.02.012DOI Listing
April 2013

Safe administration of hyperbaric oxygen after bleomycin: a case series of 15 patients.

Undersea Hyperb Med 2012 Sep-Oct;39(5):873-9

Department of Anesthesiology, Duke University, Durham, NC, USA.

Introduction: Supplemental oxygen has been reported to cause pulmonary complications after bleomycin. We describe the safe administration of hyperbaric oxygen (HBO2) after bleomycin in 15 patients.

Methods: Paper and electronic records were reviewed for bleomycin-exposed patients at the Duke Center for Hyperbaric Medicine and Environmental Physiology from 1979 to 2010.

Results: Fourteen bleomycin-exposed patients received HBO2 at Duke under a special-precautions protocol. One was treated for DCS elsewhere. The protocol included: pretreatment evaluation; chest radiograph; spirometry; blood gases; a single, 2-atmospheres absolute (atm abs), 120-minute HBO2 treatment; and a gradual acceleration over one week to a twice-daily schedule contingent on clinical and laboratory findings. Bleomycin indications were: head-and-neck squamous cell carcinomas (11), Hodgkin's lymphoma (2), other carcinomas (2). HBO2 indications were: osteoradionecrosis (10), soft-tissue radionecrosis (3), DCS (1) and a provocative oxygen toxicity test for a military aviator (1). Total bleomycin doses ranged from 40 to 225u/m2 (mean +/- SD, 105 +/- 57) given in conjunction with other chemotherapies and/or radiation. Radiation was 63.3 +/- 31.72 Gy (mean +/- SD), none to the chest with the exception of one patient treated for DCS elsewhere. Other chemotherapies included: vinblastine (11), methotrexate (11), CCNU (6) cisplatinum (7), dacarbazin (2), Adriamycin (1), and vincristine (1). Median age at time of HBO2 was 52 years (range 22-77). Median bleomycin-to-HBO2 latency was 34 months (range 1-279). Three patients received HBO2 within six months, and seven patients received HBO2 within two years of their last bleomycin exposure. There were no adverse pre-to-post HBO2 changes in: arterial blood gases, spirometry, chest radiograph findings or clinical reports. There were no persistent post-HBO2 pulmonary complications on follow-up. Post-HBO2 data were available for 40%, 53%, 87% and 100% of these parameters respectively.

Discussion: Bleomycin and oxygen can individually cause acute pulmonary toxicity. However, evidence for increased long-term susceptibility based on their synergy may be overstated.
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October 2012

Pharmacist- versus physician-initiated admission medication reconciliation: impact on adverse drug events.

Am J Geriatr Pharmacother 2012 Aug 20;10(4):242-50. Epub 2012 Jul 20.

Department of Pharmacy, Veterans Affairs Western New York Healthcare System, Buffalo, USA.

Background: Medication reconciliation (MR) has proven to be a problematic task for many hospitals to accomplish. It is important to know the clinical impact of physician- versus pharmacist-initiated MR in the resource-limited hospital environment.

Methods: This quasi-experimental study took place from December 2005 to February 2006 at an urban US Veterans Affairs hospital. MR was implemented on 2 similar general medical units: one received physician-initiated MR and the other received pharmacist-initiated MR. Adverse drug events (ADEs) and a 72-hour medication-prescribing risk score were ascertained by research pharmacists for all admitted patients by structured record review. Multivariable models were tested for intervention effect, accounting for quasi-experimental design and clustered observations, and were adjusted for patient and encounter covariates.

Results: Pharmacists completed the MR process in 102 admissions and physicians completed the process in 116 admissions. In completing the MR process, pharmacists documented statistically more admission medication changes than physicians (3.6 vs 0.8; P < 0.001). The adjusted odds of an ADE caused by an admission prescribing change with pharmacist-initiated MR compared with a physician-initiated MR were 1.04 with a 95% CI of 0.53 to 2.0. The adjusted odds of an ADE caused by an admission prescribing change that was a prescribing error with pharmacist-initiated MR compared with a physician-initiated MR were 0.38 with a confidence interval of 0.14 to 1.05. No difference was observed in 72-hour prescribing risk score (coefficient = 0.10; 95% CI, -0.54 to 0.75).

Conclusion: MR performed by pharmacists versus physicians was more comprehensive and was followed by lower odds of ADEs from admission prescribing errors but with similar odds of all types of ADEs. Further research is warranted to examine how MR tasks may be optimally divided among clinicians and the mechanisms by which MR affects the likelihood of subsequent ADEs.
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http://dx.doi.org/10.1016/j.amjopharm.2012.06.001DOI Listing
August 2012

Implications of current resident work-hour guidelines on the future practice of surgery in Canada.

J Surg Educ 2012 Jul-Aug;69(4):487-92. Epub 2012 Feb 2.

Division of General Surgery, The University of Western Ontario, London, Ontario, Canada.

Objective: Work-hour restrictions have had a profound impact on surgical training. However, little is known of how work-hour restrictions may affect the future practice patterns of current surgical residents. The purpose of this study is to compare the anticipated career practice patterns of surgical residents who are training within an environment of work-hour restrictions with the current practice of faculty surgeons.

Design: An electronic survey was sent to all surgery residents and faculty at 2 Canadian university-affiliated medical centers. The survey consisted of questions regarding expected (residents) or current (faculty) practice patterns.

Results: A total of 149 residents and 125 faculty members completed the survey (50.3% and 52.3% response rates, respectively). A greater proportion of males were in the faculty cohort than in the resident group (77.6% vs 62.4%, p = 0.0003). More faculty than residents believed that work-hour restrictions have a negative impact on both residency education (40.8% vs 20.8%, p = 0.008) and preparation for a surgical career (56.8% vs 19.5%, p < 0.0001). Compared with current faculty, residents plan to take less call (p < 0.0003), work fewer days of the week (p < 0.0001), are more likely to limit their duty hours on postcall days (p = 0.009), and take parental leave (p = 0.02) once in practice. Male and female residents differed somewhat in their responses in that more female residents plan to limit their postcall duty hours (55.4% vs 36.5%, p = 0.009) and to take a parental leave (51.8% vs 16.1%, p < 0.0001) compared with their male resident colleagues.

Conclusions: Current surgical residents expect to adopt components of resident work-hour guidelines into their surgical practices after completing their residency. These practice patterns will have surgical workforce implications and might require larger surgical groups and reconsideration of resource allocation.
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http://dx.doi.org/10.1016/j.jsurg.2011.12.005DOI Listing
October 2012

Low-dose inhaled carbon monoxide attenuates the remote intestinal inflammatory response elicited by hindlimb ischemia-reperfusion.

Am J Physiol Gastrointest Liver Physiol 2009 Jan 16;296(1):G9-G14. Epub 2008 Oct 16.

Dept. of Medical Biophysics and Surgery, Univ. of Western Ontario, Centre for Critical Illness Research, London Health Sciences Centre, Victoria Hospital, Rm A6-132, London, Ontario, Canada N6A 4G5.

Heme oxygenase (HO) represents the rate-limiting enzyme in the degradation of heme into carbon monoxide (CO), iron, and biliverdin. Recent evidence suggests that several of the beneficial properties of HO, may be linked to CO. The objectives of this study were to determine if low-dose inhaled CO reduces remote intestinal leukocyte recruitment, proinflammatory cytokine expression, and oxidative stress elicited by hindlimb ischemia-reperfusion (I/R). Male mice underwent 1 h of hindlimb ischemia, followed by 3 h of reperfusion. Throughout reperfusion, mice were exposed to AIR or AIR + CO (250 ppm). Following reperfusion, the distal ileum was exteriorized to assess the intestinal inflammatory response by quantifying leukocyte rolling and adhesion in submucosal postcapillary venules with the use of intravital microscopy. Ileum samples were also analyzed for proinflammatory cytokine expression [tumor necrosis factor (TNF)-alpha and interleukin (IL)-1beta] and malondialdehyde (MDA) with the use of enzyme-linked immunosorbent assay and thiobarbituric acid reactive substances assays, respectively. I/R + AIR led to a significant decrease in leukocyte rolling velocity and a sevenfold increase in leukocyte adhesion. This was also accompanied by a significant 1.3-fold increase in ileum MDA and 2.3-fold increase in TNF-alpha expression. Treatment with AIR + CO led to a significant reduction in leukocyte recruitment and TNF-alpha expression elicited by I/R; however, MDA levels remained unchanged. Our data suggest that low-dose inhaled CO selectively attenuates the remote intestinal inflammatory response elicited by hindlimb I/R, yet does not provide protection against intestinal lipid peroxidation. CO may represent a novel anti-inflammatory therapeutic treatment to target remote organs following acute trauma and/or I/R injury.
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http://dx.doi.org/10.1152/ajpgi.90243.2008DOI Listing
January 2009

Colonic intussusception.

CMAJ 2006 Jun;174(12):1710

Faculty of Medicine, University of Toronto, Toronto, Ont.

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http://dx.doi.org/10.1503/cmaj.051445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1471805PMC
June 2006

Inhalation of carbon monoxide prevents liver injury and inflammation following hind limb ischemia/reperfusion.

FASEB J 2005 Jan 28;19(1):106-8. Epub 2004 Oct 28.

Victoria Research Lab, 6th Floor, Rm. A6-105, 800 Commissioners Rd., London, ON, Canada N6A 4G4.

The induction of heme oxygenase (HO), the rate limiting enzyme in the conversion of heme into carbon monoxide (CO) and biliverdin, limits liver injury following remote trauma such as hind limb ischemia/reperfusion (I/R). Using intravital video microscopy, we tested the hypothesis that inhaled CO (250 ppm) would mimic HO-derived liver protection. Hind limb I/R significantly decreased sinusoidal diameter and volumetric flow, increased leukocyte accumulation within sinusoids, increased leukocyte rolling and adhesion within postsinusoidal venules, and significantly increased hepatocyte injury compared with naive animals. Inhalation of CO alone did not alter any microcirculatory or inflammatory parameters. Inhalation of CO following I/R restored volumetric flow, decreased stationary leukocytes within sinusoids, decreased leukocyte rolling and adhesion within postsinusoidal venules, and significantly reduced hepatocellular injury following hind limb I/R. HO inhibition did not alter microcirculatory parameters in naive mice, but did increase inflammation, as well as increase hepatocyte injury following hind limb I/R. Inhalation of CO during HO inhibition significantly reduced such microcirculatory deficits, hepatic inflammation, and injury in response to hind limb I/R. In conclusion, these results suggest that HO-derived hepatic protection is mediated by CO, and inhalation of low concentrations of CO may represent a novel therapeutic approach to prevent remote organ injury during systemic inflammatory response syndrome, or SIRS.
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http://dx.doi.org/10.1096/fj.04-2514fjeDOI Listing
January 2005

Management of blunt thoracic aortic injuries: endovascular stents versus open repair.

J Trauma 2004 Mar;56(3):565-70

Trauma Program, Department of Surgery, London Health Sciences Centre, London, Ontario, Canada.

Background: Endovascular stent graft (EV) technology has been successfully adapted to the repair of blunt traumatic aortic injuries. The purpose of this study was to compare the outcomes of patients treated with EV repair and open repair after blunt thoracic aortic trauma.

Methods: A review of a tertiary trauma center's prospective trauma registry identified all patients who suffered a blunt traumatic thoracic aortic injury over an 11-year period (1991-2002). Operative interventions and outcomes were then compared.

Results: Over an 11-year period, 18 patients underwent repair of a blunt thoracic aortic injury (EV, 6; open, 12). There were no significant differences in demographics, injury, or crash statistics between groups. The open group had a 17% early mortality rate (n = 2), a paraplegia rate of 16% (n = 2), and an 8.3% incidence of recurrent laryngeal nerve injury (n = 1). This is in contrast to a 0% rate of mortality, paraplegia, and recurrent laryngeal nerve injury in the EV group. A definite trend toward decreased morbidity, mortality, intensive care unit length of stay, and number of ventilator-dependent days was seen with EV repair.

Conclusion: We observed a clear trend toward improved outcomes after EV repair of thoracic aortic injuries compared with standard open repair. EV repair is emerging as the preferred method of repairing blunt thoracic aortic injuries in trauma patients with multiple injuries.
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http://dx.doi.org/10.1097/01.ta.0000114061.69699.a3DOI Listing
March 2004

Pulmonary toxicity in patients receiving low-dose amiodarone.

Chest 2003 Feb;123(2):646-51

Mayo Clinic, Jacksonville, FL 32224, USA.

Rationale: Although there have been reports of pulmonary toxicity with low-dose amiodarone, it is generally believed that low-dose therapy is safe.

Methods: The clinical data for eight patients identified from a retrospective chart review are presented.

Results: All of the patients were receiving amiodarone, 200 mg/d, for an average of 2 years. The average age was 77 years (range, 65 to 89 years). Seven of the eight patients were male. Seven of the eight patients presented with dyspnea on exertion, and three of the eight patients presented with cough. All of the patients had a clinical diagnosis of amiodarone-induced pulmonary toxicity. Open-lung biopsies were obtained on two patients that were consistent with amiodarone-induced pulmonary toxicity. None of the patients were in congestive heart failure. Treatment involved cessation of amiodarone. In addition, three patients received corticosteroids. Five of the patients improved symptomatically with this conservative approach, and four patients improved radiographically. One patient died with progressive respiratory insufficiency (presumably from amiodarone pulmonary toxicity). One patient was unavailable for follow-up.

Conclusion: Amiodarone-induced pulmonary toxicity can occur at a daily dose of 200 mg. Clinicians must remain alert to this possibility even with this low-dose therapy.
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http://dx.doi.org/10.1378/chest.123.2.646DOI Listing
February 2003

Pulmonary microcrystalline cellulose deposition from intravenous injection of oral medication in a patient receiving parenteral nutrition.

JPEN J Parenter Enteral Nutr 2003 Jan-Feb;27(1):91-2

Division of Pulmonary Medicine, Mayo Clinic, Jacksonville, Florida, USA.

A 50-year-old man who had been dependent on home parenteral nutrition (HPN) for 24 years presented with shortness of breath. A computed tomography scan of the lungs revealed a diffuse micronodular parenchymal infiltrate. On bronchoscopy, a crystalloid material was identified. This organic material was determined to be consistent with codeine. The patient had been injecting codeine into his intravenous catheter.
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http://dx.doi.org/10.1177/014860710302700191DOI Listing
July 2003
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