Preoperative planning with three-dimensional CT vs. three-dimensional magnetic resonance imaging does not change surgical management for shoulder instability.

Background: This study aims to determine the effect of time and imaging modality (three-dimensional (3D) CT vs. 3D magnetic resonance imaging (MRI)) on the surgical procedure indicated for shoulder instability. The hypothesis is there will be no clinical difference in procedure selection between time and imaging modality.

Surgical treatment for recurrent shoulder instability: factors influencing surgeon decision making.

Background: The optimal surgical approach for recurrent anterior shoulder instability remains controversial, particularly in the face of glenoid and/or humeral bone loss. The purpose of this study was to use a contingent-behavior questionnaire (CBQ) to determine which factors drive surgeons to perform bony procedures over soft tissue procedures to address recurrent anterior shoulder instability.

Methods: A CBQ survey presented each respondent with 32 clinical vignettes of recurrent shoulder instability that contained 8 patient factors.

Arthroscopic Rotator Cuff Repair With Allograft Augmentation: Making It Simple.

Rotator cuff tears are increasing in frequency in the aging population and are a common issue seen by orthopaedic surgeons. In patients with large, multi-tendon rotator cuff tears or retears, treatment can be challenging. Failure rates of up to 90% have been reported for rotator cuff repair (RCR) of large, multi-tendon tears.

Arthroscopic Surgical Stabilization of Glenohumeral Dislocations with Clavicular Graft and Remplissage.

Surgical repair of the unstable shoulder begins with reattachment of the detached capsulolabral complex. The degree of damage to the glenohumeral articulation can be variable and is often related to the degree of trauma, duration of dislocation, and the number of instability events. There have been many surgical procedures proposed for the treatment of shoulder instability in the athlete, ranging from soft-tissue repair to coracoid transfer or the addition of a bone graft.

Disseminated Granulomatous Disease from Intravesical Instillation of Bacillus Calmette-Guerin.

Intravesical instillation of Bacillus Calmette-Guerin is one of the standard treatment options for superficial bladder cancer. While Bacillus Calmette-Guerin therapy is usually well tolerated with most patients experiencing only cystitis, in rare cases, it can lead to disseminated granulomatous disease. We present a case of a 72-year-old man with disseminated granulomatous disease from intravesical BCG instillation whose treatment was complicated by antimycobacterial drug toxicity.

Rapidly Progressive Muscle Paralysis and Acute Respiratory Failure Following Endoscopic Botulinum Toxin Injection.

Botulism toxin injection (BTI) is a well-known and relatively safe endoscopic treatment for achalasia. We report a case of a 90-year-old female diagnosed with achalasia who subsequently underwent BTI with symptomatic relief. The therapy was complicated by systemic botulism, however, leading to progressive muscle paralysis with diaphragmatic involvement requiring mechanical ventilation support.

Impact of complete mesenteric closure on small bowel obstruction and internal mesenteric hernia after laparoscopic Roux-en-Y gastric bypass.

Background: Although it is generally accepted that closure of mesenteric defects after laparoscopic Roux-en-Y gastric bypass (LRYGB) reduces the incidence of small bowel obstruction (SBO), data supporting this belief are inconsistent. After a spike in acute SBO cases in our LRYGB patients, we changed our technique of mesenteric closure. The objective of this study was to determine whether modification of our technique of mesenteric closure would decrease the incidence of SBO and internal hernia after LRYGB.

Bilateral multi-injection iliohypogastric-ilioinguinal nerve block in conjunction with neuraxial morphine is superior to neuraxial morphine alone for postcesarean analgesia.

Study Objective: To determine whether bilateral iliohypogastric and ilioinguinal (IHII) peripheral nerve blocks, given in conjunction with neuraxial morphine, reduce postcesarean analgesic requirements and side effects, resulting in improved maternal satisfaction.

Design: Randomized, prospective, double-blinded, placebo-controlled study.

Setting: Labor and delivery suite at Johns Hopkins Hospital.

Treatment of gastric leaks after Roux-en-Y gastric bypass: a paradigm shift.

Background: During the past decade, nonoperative treatment of leaks after bariatric surgery has been deemed acceptable in selected patients. The setting of our study was 2 university affiliated hospitals.

Methods: We reviewed gastric leaks in 1069 consecutive bariatric operations that were performed by 1 surgeon during the past 8 years, including 836 primary laparoscopic Roux-en-Y gastric bypass (RYGB), 114 primary open RYGBs, and 119 revisional procedures.

Hospital room design and health outcomes of the aging adult.

Objective: To determine differences in the rate of falls, healthcare-acquired infections (HAIs), and the degree of social isolation in hospitalized older adults admitted to private versus semi-private rooms.

Background: The American Institute of Architects recommends that private rooms become the industry standard for all new construction of acute care hospitals. Healthcare design researchers contend that private rooms decrease infection, facilitate healthcare workers' efficiency, provide space for families, and afford greater access to privacy.

Accidental subcutaneous remifentanil infusion as a cause of delayed awakening after craniotomy.

We report a case of accidental subcutaneous infusion of remifentanil as a cause of delayed awakening after a craniotomy.

Unmet needs in managing hypertension: potential role of direct renin inhibition.

Hypertension is the most prevalent and important risk factor for cardiovascular and renal disease worldwide. Despite the large armamentarium of available blood pressure-lowering agents, the need remains for safer and more effective antihypertensive treatment. Based on current target levels of < 140/90 mm Hg, only one-third of hypertensive Americans have achieved goal blood pressure.

Liquid nitrogen ingestion followed by gastric perforation.

Ingestion of liquid nitrogen is rare but carries catastrophic complications related to barotrauma to the gastrointestinal tract. We describe a case of ingestion of liquid nitrogen followed by gastric perforation and respiratory insufficiency and discuss the mechanism of injury and management of this condition. Liquid nitrogen is widely available and is frequently used in classroom settings, in gastronomy, and for recreational purposes.

Rationale for reversal of failed bariatric operations.

Background: No guidelines are available to assist surgeons in determining whether reversal is appropriate for patients with problematic bariatric operations.

Methods: A retrospective review of 2573 primary and 252 revisional bariatric operations was performed to determine the indications for the reversal of problematic bariatric operations.

Results: Of the 82 patients who had undergone reoperation for complications of the primary operation, 13 had undergone reversal rather than revision.

Elective laparoscopy for herald symptoms of mesenteric/internal hernia after laparoscopic Roux-en-Y gastric bypass.

Background: Mesenteric internal hernia (MIH) is the most common cause of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass. Because MIH is a potentially life-threatening complication, we hypothesized that elective repair of MIH before developing acute SBO could decrease morbidity in this population.

Methods: The records of 702 consecutive patients undergoing primary laparoscopic Roux-en-Y gastric bypass from January 2002 and August 2007 were retrospectively reviewed to determine the incidence and etiology of SBO.

Revisional operations for marginal ulcer after Roux-en-Y gastric bypass.

Background: Marginal ulcer is a potentially serious complication of Roux-en-Y gastric bypass (RYGB). This study reviewed 1 surgeon's experience with 39 revisional operations for intractable marginal ulcer after primary RYGB.

Methods: A total of 2282 consecutive patients underwent RYGB by 1 surgeon from 1984 to 2006, of which 1621 were open and 661 laparoscopic.

Weight loss outcome of revisional bariatric operations varies according to the primary procedure.

Background: Revisional bariatric operations performed for weight loss failure are frequently associated with inconsistent weight reduction and serious perioperative complications.

Methods: Outcomes of 151 consecutive revisional operations performed by one surgeon for unsatisfactory weight loss were compared to determine whether postoperative weight loss is influenced by the type of primary procedure. Minimum follow-up was 12 months.

12-hour shifts: an ethical dilemma for the nurse executive.

Flexible work hours, including 12-hour shifts, have become a common scheduling option for nurses. The author explores whether 12-hour shifts are an ethical scheduling option for nurses because recent research suggests that 12-hour shifts are a potential hazard to patients. A multistep model for ethical decision making, reflecting the concept of procedural justice, is used to examine this issue.

Complementary and alternative medicine and the management of the metabolic syndrome.

More than one third of the population has the metabolic syndrome. Although aspects of the metabolic syndrome (MSDR) are readily treatable with evidence-based interventions, many patients and practitioners are looking for alternatives to pills and injectables. Complementary and alternative medicine may offer patients safe and effective options to target components of MSDR.