PRACTICE advisories are systematically developed reports that are intended to assist decision making in areas of patient care. Advisories provide a synthesis and analysis of expert opinion, clinical feasibility data, open forum commentary, and consensus surveys. Advisories are not intended as standards, guidelines, or absolute requirements. They may be adopted, modified, or rejected according to clinical needs and constraints.The use of practice advisories cannot guarantee any specific outcome. Practice advisories summarize the state of the literature and report opinions derived from a synthesis of task force members, expert consultants, open forums, and public commentary. Practice advisories are not supported by scientific literature to the same degree as are standards or guidelines because sufficient numbers of adequately controlled studies are lacking. Practice advisories are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice.Intraoperative awareness under general anesthesia is a rare occurrence, with a reported incidence of 0.1–0.2%.1–4Significant psychological sequelae (e.g. , post–traumatic stress disorder) may occur after an episode of intraoperative awareness, and affected patients may remain severely disabled for extended periods of time.5However, in some circumstances, intraoperative awareness may be unavoidable to achieve other critically important anesthetic goals.The following terms or concepts discussed in this Advisory include: consciousness, general anesthesia, depth of anesthesia or depth of hypnosis, recall, amnesia, intraoperative awareness, and brain function monitors. Consistent definitions for these terms are not available in the literature. For purposes of this Advisory, these terms are operationally defined or identified as follows:Consciousness is a state in which a patient is able to process information from his or her surroundings. Consciousness is assessed by observing a patient’s purposeful responses to various stimuli. Identifiers of purposeful responses include organized movements following voice commands or noxious/painful stimuli.*For example, opening of the eyes is one of several possible identifiers or markers of consciousness. Purposeful responses may be absent when paralysis is present as a consequence of neurologic disease or the administration of a neuromuscular blocking drug.General anesthesia is defined as a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.†The ability to maintain ventilatory function independently is often impaired. Patients often require assistance in maintaining a patent airway, and positive-pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.Depth of anesthesia or depth of hypnosis refers to a continuum of progressive central nervous system depression and decreased responsiveness to stimulation.For the purpose of this Advisory, recall is the patient’s ability to retrieve stored memories. Recall is assessed by a patient’s report of previous events, in particular, events that occurred during general anesthesia. Explicit memory is assessed by the patient’s ability to recall specific events that took place during general anesthesia. Implicit memory is assessed by changes in performance or behavior without the ability to recall specific events that took place during general anesthesia that led to those changes.6A report of recall may be spontaneous or it may only be elicited in a structured interview or questionnaire. This Advisory does not address implicit memory.Amnesia is the absence of recall. Many anesthetic drugs produce amnesia at concentrations well below those necessary for suppression of consciousness. Anterograde amnesia is intended when a drug with amnestic properties is administered before induction of anesthesia. Retrograde amnesia is intended when a drug such as a benzodiazepine is administered after an event that may have caused or been associated with intraoperative consciousness in the hope that it will suppress memory formation and “rescue” from recall.Intraoperative awareness occurs when a patient becomes conscious during a procedure performed under general anesthesia and subsequently has recall of these events. For the purpose of this Advisory, recall is limited to explicit memory and does not include the time before general anesthesia is fully induced or the time of emergence from general anesthesia, when arousal and return of consciousness are intended. Dreaming is not considered intraoperative awareness.Brain function monitors are devices that record or process brain electrical activity and convert these signals mathematically into a continuous measure typically scaled from 0 to 100. In addition to monitoring spontaneous cortical electrical activity (electroencephalogram [EEG]), these devices may also record and process evoked cortical and subcortical activity (auditory evoked potentials [AEPs]) as well as electromyographic (EMG) activity from scalp muscles. For the purpose of this Advisory, only monitors purported to measure depth of anesthesia or hypnosis will be considered. Other, non-EEG, non-AEP, non-EMG devices are also available but are not addressed by this Advisory.Intraoperative awareness under general anesthesia is an important clinical problem that clearly is within the foundation of training and continuing medical education in anesthesiology. The purposes of this Advisory are to identify risk factors that may be associated with intraoperative awareness, provide decision tools that may enable the clinician to reduce the frequency of unintended intraoperative awareness, stimulate the pursuit and evaluation of strategies that may prevent or reduce the frequency of intraoperative awareness, and provide guidance for the intraoperative use of brain function monitors as they relate to intraoperative awareness.This Advisory focuses on the perioperative treatment of patients who are undergoing a procedure during which general anesthesia is administered. This Advisory is not intended for the perioperative management of minimal, moderate, or deep sedation in the operating room or intensive care unit; regional or local anesthesia without general anesthesia; monitored anesthesia of patients or those undergoing in after the administration of a neuromuscular or intraoperative (e.g. , for the purposes of intraoperative neurologic In this Advisory is not intended to address the perioperative treatment of Advisory is intended for use by other who the administration of general anesthesia, and other who general anesthesia. The Advisory may also as a for other and who are in the perioperative management of patients general of this of to and the available scientific literature on intraoperative awareness, expert consensus and public opinion, and a practice The is of from various areas of the an from The and from the on Practice the to the because of or in the medical of and the of practice The include but are not limited to with or in the of of the of from or a in a or brain function these have a in the use of such monitors. may also have from or have a in other such as or of that may be affected by the use of brain function monitors. The not for to such because they and to present of in from consultants, of who knowledge, in intraoperative awareness and brain function monitors. or is in in some on or by a or brain function monitors. of the of from or a in a or brain function monitors. also may have from or have a in other that may be affected by the use of brain function monitors. The not for to such because they and to present of a the consensus on the for of perioperative for the of intraoperative they in to this who or in intraoperative awareness and who or in (e.g. , in and to in on the of various perioperative management strategies and to and on a of the Advisory developed by the opinions from a of of the the open at and anesthesia to on the concepts of this available information to consensus within the on the available for on the and to considered by the in the advisories are developed by a to that of an practice a and evaluation of the literature. practice advisories the of a sufficient of adequately controlled studies to of with such as from reports and other studies are considered during the of the This literature often the of of clinical with a practice information is from and of the The following terms responses for any are on a from to with a of responses are on as of of the responses are of of the responses are or and of of the responses are or other or of at of the of of responses are or and of of responses are information is from open forum and other and public The in this a of the of clinical and evaluation a , medical patient or a patients at risk for intraoperative awareness (e.g. , of and patients of the of intraoperative studies and reports that patient may be associated with intraoperative awareness, and drug or studies and reports that (e.g. , well as anesthetic (e.g. , anesthetic with or without the of be associated with an risk of intraoperative studies that the clinical of the patient before of the of intraoperative and that a evaluation may be in patients at risk for intraoperative awareness In they that a evaluation to identify patients at risk of intraoperative awareness include of a patient’s medical a and a patient or They that patient that may place a patient at risk for intraoperative awareness include use or limited and of or The and the that a of intraoperative awareness may place a patient at The and the are patients be of the of intraoperative The and that only patients considered to be at risk of intraoperative awareness be of the of intraoperative the and the that the patient of the risk of intraoperative awareness the risk of intraoperative that some of the evaluation may be in a patient at risk for evaluation a of a patient’s medical for previous of awareness or other risk a patient interview to of or previous with anesthesia, and a risk factors to for patients undergoing general anesthesia include use or (e.g. , a of awareness, a of or patients of and anesthetic in the of use of during the of general anesthesia, anesthesia, the use of anesthesia, of or and limited The consensus of the is that patients the clinician to be at risk of intraoperative awareness be of the of intraoperative awareness when the of anesthesia to the of intraoperative awareness include the of anesthesia and the administration of the of anesthesia is some of intraoperative awareness have from concentrations of or drug drug clinical the of the administration of as an anesthetic during under anesthesia and reported a frequency of intraoperative awareness in the with the clinical amnesia by as after administration of but before induction of general anesthesia. these studies reported recall in patients administered the of consciousness during general anesthesia and intraoperative awareness not and that the of anesthesia (e.g. , be to reduce the risk of intraoperative The and the are that a benzodiazepine or be as a of the anesthetic to reduce the risk of intraoperative awareness for The that a benzodiazepine or be for patients of patients undergoing and patients undergoing They are patients undergoing and anesthesia. The that a benzodiazepine or be for patients of and patients undergoing and anesthesia. They are patients undergoing intraoperative awareness may be caused by or the that be to a for anesthesia and to that the anesthetic drugs and will be be extended to include of the of and The consensus is that the decision to a benzodiazepine be on a for patients (e.g. , patients of The that emergence may the use of awareness cannot be during the intraoperative of general anesthesia, because the recall of awareness only be by information from the the intraoperative monitoring addressed by this Advisory is the use of clinical monitoring or brain function monitors the of intraoperative of literature during the and process not address these or monitors reduce the frequency of intraoperative studies that report intraoperative or from monitoring This not the of an on awareness, often reported or that occurred at during the perioperative with the of or in the depth of anesthesia. reported from this literature are literature for is in the following clinical studies (e.g. , studies (e.g. , of with concentrations of drugs or with in to reports of monitored at during a and reports of or unintended or during a monitoring studies often report a measure of continuous (e.g. , the and anesthetic drug include a that a measure of well a or clinical (e.g. , to of an and a clinical a of a to the clinical to intraoperative consciousness are for to responses or and monitoring include well as the anesthetic clinical or other studies that the of clinical or monitoring on the incidence of intraoperative studies reported from to for the or purposeful and for depth of reported a to and memory when continuous of as the induction for from to for a state from an state and from to for an state from emergence after anesthesia , for from to for a state from an state and from to for of and reported during various intraoperative reported of as before induction or at during at emergence or of and during reported as before induction or at during at emergence or of and during has been reported to occur in the absence of or and that clinical (e.g. , for purposeful or are and be to intraoperative consciousness. In the and that monitoring (e.g. , anesthetic are and be to intraoperative of the devices to brain electrical activity for the purpose of anesthetic record activity from on the be into those that process spontaneous and electromyographic activity and those that evoked responses to and of the to the various are to the derived from the or to a often to as an typically scaled 0 and 100. This the of clinical of consciousness with a of associated with the state and of 0 with an absent may be and in the public or of the various to may be intended to and are an important of the in electromyographic activity from scalp be considered an from the of it may be an important of of electromyographic activity to from and may of For this some monitors provide information on the of electromyographic The is a that a of into an of is available as a or under from in by various anesthesia the several derived from the time frequency are into a of are scaled from 0 to with specific (e.g. , reported to a of consciousness under general anesthesia. The factors for the various in the that the derived from a of The for the of activity by to the as the changes with concentrations of various in a in have available and as and to suppress have been of the and have been controlled have with anesthetic administration clinical practice without In one that patients at risk of intraoperative awareness, explicit recall occurred in of patients when monitors and in of patients by clinical practice , the to the monitoring with clinical during and reported one episode of recall in the clinical with in the other to or opening and of anesthetic drugs with the use of of the use of monitoring a of explicit recall in of the patients of the to the incidence of awareness with recall during general anesthesia and to associated with intraoperative awareness events reported when of with when not of studies reported on in the care and anesthetic use patients monitored with with patients not monitored with studies reported for from to for loss of after induction with or without and from to for reported a of for from electrical of have been reported during various intraoperative of as before induction or at or after during at emergence or of and during reports that intraoperative events to of anesthetic produce changes in (e.g. , or of anesthesia drug reports that intraoperative events (e.g. , administration of of or patient or may with reports that reported patients intraoperative awareness monitored an depth of other reports that patient may the or of a a from a The for of in the as in the is in the public and have been is of absolute such as the or the frequency of the The available time of and reports is an from 0 to the frequency from to the cortical state of the is an from 0 to a frequency from to the and will also to the electromyographic activity from clinical or other studies that the of monitoring on the incidence of intraoperative clinical reported to to and of anesthetic drugs with the use of studies report the following for loss of for for the following are for and for of and as before induction or and during and and at emergence or of and The is derived from a system developed for the of the associated with various of and the the according to the following anesthesia with deep anesthesia with The system a of in a of possible and the of the the has been into a the scaled from 0 to with the of a to the clinical or other studies that the of monitoring on the incidence of intraoperative has the use of controlled anesthetic administration and a time in the , after of for from to for loss of after induction with with an and from to for are as after induction of and at emergence or of state The is derived from a The of the is on the that are changes in of at loss and return of consciousness. The has a of with of consciousness or of to and The analysis on of derived after of the and to be to changes in the of clinical or other studies that the of monitoring on the incidence of intraoperative reported a of for to with a of and of reported a of the with are as before induction or during at emergence or of and during The a from a of The is on a analysis of activity in the 0 to and to frequency and a suppression are on the to the which is on a of and clinical or other studies that the of monitoring on the incidence of intraoperative that reported a of to be of a loss of consciousness in of The is a that a and a scaled from 0 to 100. In it also suppression and a measure of electromyographic activity literature that the of the on the incidence of intraoperative evoked potentials are the electrical responses of the the and the to The of on have been the is to cortical as the with concentrations of and The to anesthetic concentrations is and decreased of the various signals are from the spontaneous time have in an that record and a of from a analysis of the the an that a of anesthetic The or is scaled from 0 to 100. In to the with of consciousness is the associated with the other monitors. The is by the and but is not in controlled that monitoring (e.g. , to to clinical practice without reported to opening or of reported for loss of after induction with and an of and reported for responsiveness after of or reported a of for reported a of for awareness after studies reported of as before induction or at or after during at emergence or of and during who in this Advisory typically a or an in intraoperative awareness and brain function monitors. The of these of from or a in a or brain function monitors. not to with other that may be affected by the use of brain function monitors. from a of of the and that a brain electrical activity is and be to reduce the risk of intraoperative awareness for The and that a brain electrical activity is and be to reduce the risk of intraoperative awareness for The that a brain electrical activity be for patients with that may place at risk and patients of general and anesthesia. They are the use of brain electrical activity monitoring for and The with the use of such monitors for patients with that may place at patients of general and patients undergoing They are the use of these monitors for patients undergoing and and that a brain electrical activity is and be to intraoperative depth of anesthesia for The and with the that brain electrical activity is and be to intraoperative depth of anesthesia for The that a brain electrical activity be to intraoperative depth of anesthesia for The with the use of brain electrical activity monitors for patients with that may place at risk and patients of general They are the use of such monitors for patients undergoing and monitoring of depth of anesthesia, for the purpose of the of awareness, on clinical (e.g. , for clinical such as purposeful or and monitoring (e.g. , anesthetic The use of neuromuscular blocking drugs may purposeful or movements and to the use of monitoring that the of function monitors are to the of the of on the brain and provide information that with some depth of anesthesia such as concentrations of (e.g. , In the by these monitors in with other of depth of anesthesia, the by devices in any anesthetic state the various monitoring In the by devices in the of a depth of anesthesia by of anesthetic drugs (e.g. , with or without also In other a specific may not with a specific depth of anesthesia. the not have anesthetic drugs or of with other in the operating room may into the derived by these monitors (e.g. , general clinical of these monitors in the of intraoperative awareness has not been a clinical reported a in the frequency of awareness in is to a or absolute that these devices be to reduce the of intraoperative awareness in patients undergoing general anesthesia. In is to a or absolute that these devices be to reduce the of intraoperative awareness for any other of patients undergoing general is the consensus of the that brain function monitoring is not for patients undergoing general anesthesia, to reduce the frequency of intraoperative awareness or to depth of anesthesia. This consensus is in on the state of the literature and responses from the and who with the following function monitors are and be to reduce the risk of intraoperative awareness for patients under general and function monitors are and be when possible to intraoperative depth of anesthesia for patients under general is the consensus of the that the decision to use a brain function be on a by the for patients (e.g. , This consensus is in on the state of the literature and from and specific risk factors The that maintaining brain function in an to prevent intraoperative awareness may with other important anesthesia (e.g. , of the of is the of the that brain function monitors have the of the other monitoring that are in at the of and include the intraoperative administration of to patients who may have a structured interview to patients to the of the episode after an episode of intraoperative awareness has been a to patients to the of the and or psychological studies that the of the intraoperative administration of to patients who have conscious in the of clinical amnesia by as to patients before administration of and induction of general anesthesia. The studies reported of these studies not the of a benzodiazepine to patients after the of consciousness during general several studies have structured and to information reported of intraoperative studies that in patient or psychological state after such studies that on the of or psychological to patients who a incidence of intraoperative are and that or be administered to prevent awareness after a patient has The and the that an episode of intraoperative awareness has been a structured interview be to the of the the and are a be to the of the The and the that in of intraoperative awareness, patients be or psychological the and the that in of intraoperative awareness, an report the event be for the purpose of consensus is that the decision to a benzodiazepine after a patient becomes conscious be on a This consensus is in on the state of the literature and on responses from the and the following or be administered to prevent awareness after a patient has the that from the literature is not sufficient to provide guidance this the that the use of may in unintended (e.g. , emergence with patients who report recall of intraoperative events to of the event and to possible for or structured interview may be to a of the patient’s an episode of intraoperative awareness has been an report the event be for the purpose of the patient be or psychological this Advisory, a literature in with opinions from and other (e.g. , members, open forums, to provide guidance to intraoperative the literature and on , of specific perioperative and intraoperative The are or report that in the literature is in the of an the is to one of the reports a or of that be or (e.g. , that only are not and is the of an or report , or studies that summarize previous are not the literature studies identified and of the literature. The a from The a of time from a of that addressed to the and for of the studies not provide and subsequently of studies with and information to a analysis , and by a for as of of and literature for of and literature to of of this Advisory to studies with such as that the of an as a brain function on the or frequency of intraoperative only controlled that reported intraoperative awareness as the controlled will be necessary before from literature be to provide a for , other that reported other intraoperative awareness, emergence of anesthetic and In other studies to or For example, literature , reports of frequency or may provide an of the of the or provide information the and of of from patient monitoring devices with other intraoperative such as concentrations of anesthetic time to loss of and time to reports are typically as a forum for and or unintended or reports as well as or provide information that may stimulate of the of intraoperative studies on when that use of the following for the of for intraoperative awareness is studies the of one other to treatment with and of of and The because intraoperative awareness is a such studies may be and The required for a to the of an (e.g. , brain function on the incidence of intraoperative awareness is The also with data, a in the of one or of intraoperative awareness the of the to patient to have a risk for intraoperative awareness (e.g. , may for a and provide information these the that the of these to the of general anesthesia patients may be from from who on or in intraoperative awareness, opinions from a of of the from of open at anesthesia commentary, and and The of return of for and for the are in the of the and in and of the and of the that they a brain function in the of the that they use in practice of a brain function or of the that they use in practice of a brain function or also to of the clinical the Advisory The of return of The of associated with as patients of the of intraoperative anesthesia use of as use of clinical to for intraoperative use of monitoring to for intraoperative use of brain function monitors to for intraoperative intraoperative use of for use of a structured interview for patients who report recall of intraoperative use of a for patients who report recall of intraoperative and for patients who report recall of intraoperative of the that the Advisory have on the of time on a that be an in the of time they on a with the of this The of time by these from to
The Journal of Bone and Joint Surgery. British volumeVol. 70-B, No. 1 ArticlesFree AccessPelvic ring fractures: should they be fixed?M TileM TileSearch for more papers by this authorPublished Online:1 Jan 1988https://doi.org/10.1302/0301-620X.70B1.3276697AboutSectionsPDF/EPUB ToolsAdd to FavouritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byPreoperative CT simulation of iliosacral screws for treating unstable posterior pelvic ring injury8 March 2022 | BMC Musculoskeletal Disorders, Vol. 23, No. 1Functional outcome of unstable pelvic fractures treated in a level III hospital in a developing country: a 10-year prospective observational study4 April 2022 | Journal of Orthopaedic Surgery and Research, Vol. 17, No. 1Percutaneous posterior transiliac plate versus iliosacral screw fixation for posterior fixation of Tile C-type pelvic fractures: a retrospective comparative study16 June 2022 | BMC Musculoskeletal Disorders, Vol. 23, No. 1Equestrian-Related Pelvic Trauma in Women of Childbearing Age — a Review of the Experience of a National Pelvic & Acetabular Referral Centre27 July 2022 | SN Comprehensive Clinical Medicine, Vol. 4, No. 1CT of Sacral Fractures: Classification Systems and ManagementRadioGraphics, Vol. 42, No. 7Moving forward with the management of minimally displaced lateral compression pelvic ring injuries18 June 2022 | European Journal of Orthopaedic Surgery & Traumatology, Vol. 32, No. 7Biomechanical Comparison of 4 Transsacral Fixation Constructs in a Type 61C, Zone II Pelvic Fracture ModelJournal of Orthopaedic Trauma, Vol. 36, No. 10Rami Comminution Is Associated With Displacement of Minimally Displaced Lateral Compression Type 1 Injuries on Lateral Stress RadiographsJournal of Orthopaedic Trauma, Vol. 36, No. 10Surgical management of paediatric pelvic fractures: a prospective case series and early experience from a level one Egyptian trauma centre23 July 2022 | International Orthopaedics, Vol. 46, No. 10A Review on Management of Insufficiency Fractures of the Pelvis and AcetabulumOrthopedic Clinics of North America, Vol. 53, No. 4Lumbo-sacral Junction Instability by Traumatic Sacral Fractures: Isler’s Classification Revisited – A Narrative Review22 February 2022 | Global Spine Journal, Vol. 12, No. 8Prolonged ileus in traumatic pelvic ring injury patients who underwent arterial angio-embolization: A retrospective studyMedicine, Vol. 101, No. 39Surgical Versus Non-surgical Treatment of Unstable Lateral Compression Type I (LC1) Injuries of the Pelvis With Complete Sacral Fractures in Non-fragility Fracture Patients: A Systematic ReviewCureus, Vol. 15Analysis of Postoperative Gait, Hip Strength, and Patient-Reported Outcomes After OTA/AO 61-B and 61-C Pelvic Ring InjuriesJournal of Orthopaedic Trauma, Vol. 36, No. 9Dual-Energy CT and Cinematic Rendering to Improve Assessment of Pelvic Fracture InstabilityRadiology, Vol. 304, No. 2Mortality and functional outcomes of fragility fractures of the pelvis by fracture type with conservative treatment: a retrospective, multicenter TRON study1 December 2021 | European Journal of Trauma and Emergency Surgery, Vol. 48, No. 4Pelvic Fracture Urethral Distraction DefectUrologic Clinics of North America, Vol. 49, No. 3Paediatric pelvic fractures – an updated literature review3 July 2022 | ANZ Journal of Surgery, Vol. 36Sakrumfrakturen beim geriatrischen Patienten1 June 2022 | Zeitschrift für Gerontologie und Geriatrie, Vol. 55, No. 4Evolution of the AO Spine Sacral and Pelvic Classification System: a systematic reviewJournal of Neurosurgery: Spine, Vol. 78Nonoperative Management of Minimally Displaced Lateral Compression Type 1 Pelvic Ring Injuries With and Without Occult InstabilityJournal of Orthopaedic Trauma, Vol. 36, No. 6Reliability and reproducibility analysis of the AOSpine Sacral Fractures Classification System by spinal and pelvic surgeonsInjury, Vol. 53, No. 6Outcomes and complications of the INFIX technique for unstable pelvic ring injuries with high-velocity trauma: a systematic review and meta-analysis11 January 2021 | Archives of Orthopaedic and Trauma Surgery, Vol. 142, No. 5Anatomic reduction of the sacroiliac joint in unstable pelvic ring injuries and its correlation with functional outcome30 September 2020 | European Journal of Trauma and Emergency Surgery, Vol. 48, No. 2Emergency Department Stress Radiographs of Lateral Compression Type-1 Pelvic Ring Injuries Are Safe, Effective, and Reliable17 December 2021 | Journal of Bone and Joint Surgery, Vol. 104, No. 4Ligaments stabilizing the sacrum and sacroiliac joint: a comprehensive review25 August 2021 | Neurosurgical Review, Vol. 45, No. 1Pelvic ring and acetabular fracture: Concepts of traumatological forensic interestInjury, Vol. 53, No. 2Danger zone - 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results of a prospective study13 August 2021 | BMC Musculoskeletal Disorders, Vol. 22, No. 1Comparison of lumbopelvic fixation and iliosacral screw fixation for the treatment of bilateral sacral fractures16 October 2021 | Journal of Orthopaedic Surgery and Research, Vol. 16, No. 1Minimally displaced acetabulum fractures in geriatric patients: a comparison of open, percutaneous and non-operative treatment from the German Pelvic Injury Register data8 April 2020 | European Journal of Trauma and Emergency Surgery, Vol. 47, No. 6Transarterial embolisation is associated with improved survival in patients with pelvic fracture: propensity score matching analyses19 September 2020 | European Journal of Trauma and Emergency Surgery, Vol. 47, No. 6A retrospective study about functional outcome and quality of life after surgical fixation of insufficiency pelvic ring injuries13 December 2021 | BMC Musculoskeletal Disorders, Vol. 22, No. 1Is Anterior Plating Superior to the Bilateral Use of Retrograde Transpubic Screws for Treatment of Straddle Pelvic Ring Fractures? A Biomechanical Investigation28 October 2021 | Journal of Clinical Medicine, Vol. 10, No. 21Verification of High-Rate Vertical Loading Laboratory Skeletal Fractures by Comparison with Theater Injury Patterns15 October 2021 | Annals of Biomedical Engineering, Vol. 49, No. 11Reproductibilité intra- et inter-examinateur de la classification AO/OTA 2018 des ruptures de l’anneau pelvien à haute énergie : une étude rétrospectiveRevue de Chirurgie Orthopédique et Traumatologique, Vol. 107, No. 6Inter- and intraobserver reliability assessment of the 2018 AO/OTA classification for high-energy pelvic ring injuries: A retrospective studyOrthopaedics & Traumatology: Surgery & Research, Vol. 107, No. 6Management and outcomes of open pelvic fractures: An updateInjury, Vol. 52, No. 10One sacroiliac screw for posterior ring fixation in unstable pelvic fractures1 November 2021 | Acta Orthopaedica Belgica, Vol. 87, No. 3Endovascular management of haemorrhage in pelvic traumaSurgery in Practice and Science, Vol. 6The FFP-classification: From eminence to evidenceInjury, Vol. 94The Influence of Surgeon Experience and Subspeciality on the Reliability of the AO Spine Sacral Classification SystemSpine, Vol. Publish Ahead of PrintAssociation Between Stability and Urologic Lesions in Pelvic Ring Fractures. A Case Series Report6 January 2020 | Journal of Investigative Surgery, Vol. 34, No. 7Pelvic Ring Fractures and Lower Urinary Tract Injuries8 January 2020 | Journal of Investigative Surgery, Vol. 34, No. 7Validation of the AO Spine Sacral Classification SystemJournal of Orthopaedic Trauma, Vol. Publish Ahead of PrintLateral compression type 1 (LC1) pelvic ring injuries: a spectrum of fracture types and treatment algorithms16 April 2021 | European Journal of Orthopaedic Surgery & Traumatology, Vol. 31, No. 5An independent inter- and intraobserver agreement assessment of the AOSpine sacral fracture classification systemThe Spine Journal, Vol. 21, No. 7Incidence and Clinical Features of Urethral Injuries with Pelvic Fractures in Males: A 6-Year Retrospective Cohort Study at a Single Institution in South KoreaJournal of Trauma and Injury, Vol. 34, No. 2Short-Term Functional Outcomes and Quality of Life after B2.1 Type Pelvic Fractures for Surgically and Non-Surgically Treated Young 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Developed by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies: Gregory A. Nuttall, M.D. (Chair), Rochester, Minnesota; Brian C. Brost, M.D., Rochester, Minnesota; Richard T. Connis, Ph.D., Woodinville, Washington; James S. Gessner, M.D., Chestnut Hill, Massachusetts; Chantal R. Harrison M.D., San Antonio, Texas; Ronald D. Miller, M.D., San Francisco, California; David G. Nickinovich, Ph.D., Bellevue, Washington; Nancy A. Nussmeier, M.D., Houston, Texas; Andrew D. Rosenberg, M.D., Roslyn Heights, New York; Richard Spence, M.D., Baltimore, Maryland.Click on the links below to access all the ArticlePlus for this article.Please note that ArticlePlus files may launch a viewer application outside of your web browser.PRACTICE guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints.Practice guidelines are not intended as standards or absolute requirements. The use of practice guidelines cannot guarantee any specific outcome. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by analysis of the current literature and by a synthesis of expert opinion, open forum commentary, and clinical feasibility data.This update includes data published since the “Practice Guidelines for Blood Component Therapy” were adopted by the American Society of Anesthesiologists (ASA) in 1995; it also includes data and recommendations for a wider range of techniques than was previously addressed.Blood transfusion refers to the perioperative administration of blood and blood components (e.g. , autologous blood, allogeneic whole blood, red blood cells, fresh frozen plasma [FFP], platelets, and cryoprecipitate). Adjuvant therapies refer to drugs and techniques to reduce or prevent blood loss and the need for transfusion of allogeneic blood.The purposes of these Guidelines are to improve the perioperative management of blood transfusion and adjuvant therapies and to reduce the risk of adverse outcomes associated with transfusions, bleeding, or anemia. In addition, these Guidelines provide an update on the relative risks that cause morbidity and mortality associated with blood transfusion and adjuvant therapies.These Guidelines focus on the perioperative management of patients undergoing surgery or other invasive procedures in which significant blood loss occurs or is expected. This includes but is not limited to (1) patients undergoing cardiopulmonary bypass or cardiac surgery, urgent or emergent procedures, obstetric procedures, organ transplantation, and major noncardiac surgery; (2) patients with preexisting blood disorders or acquired deficiency secondary to massive bleeding; (3) critically ill patients; and (4) patients who elect not to undergo transfusion. Excluded from the focus of these Guidelines are neonates, infants, children weighing less than 35 kg, and nonsurgical patients.These Guidelines apply to both inpatient and outpatient surgical settings and to procedures performed in operating rooms as well as in other locations (e.g. , interventional radiology, critical care units) where blood transfusion or other adjuvant therapy is indicated. They are directly applicable to care administered by anesthesiologists and individuals who deliver care under the medical direction or supervision of an anesthesiologist. They are also intended to serve as a resource for other physicians and patient care personnel who are involved in the perioperative care of these patients.The ASA appointed a Task Force of 10 members to (1) review the published evidence, (2) obtain the opinion of a panel of consultants including anesthesiologists and nonanesthesiologist physicians concerned with perioperative blood transfusion, and (3) obtain opinions from practitioners likely to be affected by the Guidelines. The Task Force included anesthesiologists in both private and academic practices from various geographic areas of the United States, a surgeon, a pathologist specializing in transfusion medicine, an obstetrician, and two consulting methodologists from the ASA Committee on Practice Parameters.The Task Force developed the Guidelines by means of a seven-step process. First, they reached consensus on the criteria for evidence of effective blood transfusion and adjuvant therapies. Second, original published research studies from peer-reviewed journals relevant to the perioperative management of patients undergoing blood transfusions were reviewed. Third, the panel of expert consultants was asked to (1) participate in opinion surveys on the effectiveness of various perioperative management strategies and (2) review and comment on a draft of the Guidelines developed by the Task Force. Fourth, opinions about the Guideline recommendations were solicited from random samples of active members of the ASA. Fifth, the Task Force held open forums at two major national meetings to solicit input on its draft recommendations. National organizations representing specialties whose members typically care for patients undergoing perioperative transfusion were invited to participate in the open forums. Sixth, the consultants were surveyed to assess their opinions on the feasibility of implementing the Guidelines. Seventh, all available information was used to build consensus within the Task Force to finalize the Guidelines.Preparation of these Guidelines followed a rigorous methodologic process. To convey the findings in a concise and easy-to-understand fashion, these Guidelines use several descriptive terms.When sufficient numbers of studies are available for evaluation, the following terms describe the strength of the findings.The lack of scientific evidence in the literature is described by the following terms.Formal survey information is collected from consultants and members of the ASA. The following terms describe survey responses for any specified issue. Responses are solicited on a five-point scale; ranging from 1 (strongly disagree) to 5 (strongly agree), with a score of 3 being equivocal. Survey responses are summarized based on median values as follows:Preoperative evaluation of a patient for blood transfusion and adjuvant therapies includes (1) reviewing previous medical records, (2) conducting a patient or family interview, and (3) reviewing laboratory test results. Although comparative studies are insufficient to evaluate the perioperative impact of reviewing medical records or conducting a patient interview, the literature reports certain patient characteristics that may be associated with blood transfusion complications. These characteristics include, but are not limited to, congenital or acquired conditions such as factor VIII deficiency, sickle cell anemia, idiopathic thrombocytopenic purpura, and liver disease. In addition, the literature suggests that some preoperative laboratory tests (e.g. , hemoglobin, hematocrit, coagulation profile) may predict the need for blood transfusion or excessive blood loss. The consultants and ASA members strongly agree that reviewing previous medical records, interviewing the patient, and reviewing hemoglobin/hematocrit test results should be part of a preoperative evaluation.†The consultants strongly agree and the ASA members agree that a coagulation profile should be reviewed.Preoperative evaluation should include reviewing previous medical records, conducting a physical examination of the patient, and an interview of the patient or family to identify risk factors for (1) organ ischemia (e.g. , cardiorespiratory disease), which may influence the ultimate transfusion trigger for red blood cells (e.g. , hemoglobin level), and (2) coagulopathy (e.g. , use of warfarin, clopidogrel, aspirin), which may influence transfusion of non–red blood cell components. In addition, a preoperative evaluation should include checking for the presence of congenital or acquired blood disorders, the use of vitamins or herbal supplements that may affect coagulation (appendix 2), or previous exposure to drugs (e.g. , aprotinin) that may, upon repeat exposure, cause an allergic reaction. Patients should be informed of the potential risks versus benefits of blood transfusion, and their preferences elicited. Available preoperative laboratory results including, but not limited to, hemoglobin, hematocrit, and coagulation profiles should be reviewed if they are appropriate and available. Additional laboratory tests should be ordered based on a patient's condition (e.g. , clinical coagulopathy) or institutional policy.Preoperative patient preparation includes (1) discontinuation or modification of anticoagulation therapy, (2) the prophylactic administration of drugs to promote coagulation and minimize blood loss (e.g. , aprotinin, ϵ-aminocaproic acid, tranexamic acid), and (3) prevention or reduction of allogeneic transfusion requirements.The impact of discontinuing anticoagulation therapy on blood loss has not been sufficiently addressed in the literature. In addition, the literature is insufficient to address the impact of delaying surgery until the effects of anticoagulation drugs have dissipated. The literature supports the use of aprotinin in reducing blood loss and in reducing the number of patients transfused in major surgical procedures (e.g. , selected cardiac and orthopedic procedures). In addition, the literature is supportive of the use of ϵ-aminocaproic acid and tranexamic acid in reducing blood loss; however, the impact of these drugs on reducing the number of patients transfused is equivocal. The literature is insufficient to evaluate the use of these drugs in a nonprophylactic manner. Some literature has reported adverse outcomes associated with the use of antifibrinolytic drugs such as graft thrombosis or closure and rare massive thrombosis. Severe anaphylactic reactions may occur with aprotinin reexposure.The efficacy of erythropoietin in reducing the volume of allogeneic blood transfused per patient as well as reducing the number of patients requiring such transfusions is supported by the literature in select populations (e.g. , renal insufficiency, anemia of chronic disease, refusal of transfusion). The literature is insufficient to address the effects of vitamin K.The efficacy of preadmission blood collection to reduce the volume of allogeneic blood transfused per patient and to reduce the number of patients requiring such transfusions is supported by the literature. However, the literature indicates that certain adverse outcomes (e.g. , transfusion reaction due to clerical errors, bacterial contamination) may still occur with the use of autologous blood.The consultants agree and the ASA members strongly agree that anticoagulation drugs (e.g. , warfarin, clopidogrel, aspirin) should be discontinued before elective or nonemergent surgery, and both agree that such surgery should be delayed until the anticoagulation effects wear off. They agree that, when significant blood loss is expected, antifibrinolytics should be administered. In addition, the consultants and ASA members agree that erythropoietin may be used to reduce the use of allogeneic blood. They agree that vitamin K should be administered preoperatively for reversal of warfarin to potentially avoid transfusion of FFP. The ASA members agree and the consultants are equivocal that preadmission donation of blood should be offered to patients when transfusion of autologous blood is required or preferred. They disagree that autologous blood should be administered to the patient who donated it if his or her hemoglobin is greater than 10 g/dl.If possible, the preoperative evaluation should be done well enough in advance to correct or plan for the management of risk factors associated with transfusions. For elective surgery, patient preparation should include discontinuing anticoagulation therapy for a sufficient time in advance of surgery, if clinically possible. If sufficient time has not elapsed, surgery should be delayed until the effects of these drugs dissipate. The Task Force notes that the effect of clopidogrel may last for approximately a week, and the effects of warfarin may last for several days depending on patient response and the administration of reversal agents (e.g. , vitamin K, prothrombin complex concentrate, recombinant activated factor VII, or FFP). The risk of thrombosis versus the risk of increased bleeding should be considered when altering anticoagulation status. Assure that blood and blood components are available for patients when significant blood loss or transfusion is expected.Antifibrinolytic therapy should not be routinely administered. However, such therapy may be used for reducing the volume of allogeneic blood transfused for patients at high risk of excessive bleeding (e.g. , repeat cardiac surgery). The risks and benefits of instituting antifibrinolytic therapy should be assessed on a case-by-case basis.Erythropoietin should be administered when possible to reduce the need for allogeneic blood in certain selected patient populations (e.g. , renal insufficiency, anemia of chronic disease, refusal of transfusion). The Task Force recognizes that erythropoietin administration is perceived as being expensive and requires time (in weeks) to induce a significant increase in hemoglobin concentration. Vitamin K or another warfarin antagonist should be used for reversal of warfarin to potentially avoid transfusion of FFP.Where autologous blood is required or preferred, the patient may be offered the opportunity to donate blood before However, the Task Force that preoperative anemia may be in to an increase in autologous or allogeneic transfusions, as well as and include red blood cell transfusion, management of and and of adverse effects of and management of potential or blood loss includes (1) the of blood (2) hemoglobin or hematocrit, (3) for the presence of and of (e.g. , blood blood and (4) transfusion of allogeneic red blood cells or autologous blood , and red blood cell literature is insufficient to evaluate the efficacy of specific or techniques for the presence of or of or as for the transfusion of red blood The literature supports the efficacy of as well as red blood cell in reducing the number of allogeneic transfused per patient in certain appropriate surgical procedures (e.g. , cardiac surgery, liver surgery, orthopedic However, the literature is equivocal the of to reduce the number of patients Although the practice is in the United States, the literature suggests that red blood cell reduce the number of patients a volume of that has been published since the last practice the information to when a blood transfusion should be is not available in the literature. Although have transfusion on patient the literature is insufficient to a transfusion trigger in surgical patients with blood consultants and ASA members strongly agree that a of the surgical and with the surgical should be done to assess the presence of excessive bleeding , The consultants and ASA members strongly agree that for the presence of and of should be They strongly agree that red blood cells should be administered when the hemoglobin is less than and strongly agree that red blood cells are when the is than 10 In addition, the consultants and ASA members agree that, when autologous blood is required or preferred, and or red blood cell are The consultants are equivocal and the ASA members agree that red blood cell is a in or allogeneic transfusion. they agree that and other laboratory may be a of significant blood of the surgical should be to assess the presence of excessive bleeding , for of blood loss (e.g. , and should be (e.g. , blood should be used to assess the of and of should be used when appropriate (e.g. , blood hemoglobin or when blood loss or any of organ ischemia blood cells should be administered when the hemoglobin is (e.g. , less than in a when the anemia is blood cells are when the hemoglobin is than 10 These may be in the presence of blood loss. The of hemoglobin , or red blood cell transfusion should be based on any of organ potential or bleeding and the patient's volume and the patient's risk factors for of These risk factors include a cardiopulmonary and high volume and blood with or until the criteria for red blood cell transfusion are of red blood cells should be transfused to organ or blood and other means to blood loss (e.g. , may be may also be and management of potential or coagulopathy includes (1) of the surgical and laboratory for (2) transfusion of platelets, (3) transfusion of (4) transfusion of administration of drugs to excessive bleeding (e.g. , and recombinant activated factor of the surgical is practice and of the presence of bleeding and the of blood includes or In a bleeding patient, coagulation tests is also and the literature suggests that coagulation test results with perioperative blood depending on the of used for volume The literature supports the use of and to excessive Although are insufficient numbers of published clinical the efficacy of recombinant activated factor in excessive bleeding , reports its efficacy as a when therapy has a volume of that has been published since the last practice the information to when transfusion of a blood should occur is not available in the literature. Although have transfusion on patient and transfusion in cardiac surgery, the literature is insufficient to specific transfusion for coagulopathy in surgical patients with blood consultants and ASA members strongly agree that, in to a of the surgical with the surgical should include an of the presence of The consultants and ASA members agree that, in a bleeding patient, should be administered when the is below They also agree that, in a bleeding patient, should be administered when or activated time is and that should be when are less than The consultants agree and the ASA members are equivocal that recombinant activated factor is an appropriate when have been The ASA members agree and the consultants are equivocal that should be administered when excessive bleeding the consultants and ASA members agree that (e.g. , or should be administered for the of excessive of the surgical should be by the and to excessive bleeding , coagulopathy) is for excessive blood loss should also include checking surgical and surgical for coagulopathy should include of prothrombin time or and tests may include of and possible, a should be before transfusion of in a bleeding patient, and a test of should be done in patients with or (e.g. , In surgical or obstetric patients with transfusion is if the is to be greater than and is when the is below in the presence of excessive or procedures associated with limited blood loss may be performed in patients with less than transfusion may be an if is or (e.g. , the presence of cardiopulmonary and of patients with and therapy, including prophylactic therapy, should be based on the potential for or bleeding, and the risk of bleeding a (e.g. , or the cannot be done in a in the presence of excessive bleeding , may be when is is due to increased (e.g. , idiopathic thrombocytopenic purpura, thrombocytopenic prophylactic transfusion is and possible, coagulation tests , or and should be before the administration of in a bleeding Transfusion of is not if and are transfusion is for (1) of excessive bleeding , coagulopathy) in the presence of a greater than or greater than or an greater than (2) of excessive bleeding secondary to coagulation factor deficiency in patients transfused with than blood volume and when or and cannot be in a (3) urgent reversal of warfarin (4) of coagulation factor for which specific are or in a patient requiring is not for of plasma volume or frozen plasma should be in to a of of plasma factor with administration of for urgent reversal of warfarin for which to 1 platelets, or 1 fresh whole a of coagulation factors to that in 1 possible, a should be before the administration of in a bleeding Transfusion of is if is greater than Transfusion of is (1) when the is less than in the presence of excessive bleeding, (2) to correct excessive bleeding in transfused patients when cannot be in a fashion, and (3) for patients with congenital possible, decisions patients with congenital should be in with the patient's The of patients with and therapy should be based on the potential for or bleeding and the risk of bleeding a (e.g. , or patients with should be with specific if available. If are not is indicated. of of it should be that of the of as or such as or should be considered when excessive bleeding for excessive bleeding , coagulopathy) have been recombinant activated factor should be effects of transfusions include, but are not limited to, bacterial of and transfusion of blood platelets, is the cause of from blood transfusions. The increased risk of bacterial is to a of blood are their If a patient a within platelets, from may be a is from of certain a transfusion. and transfusion and are in within and in the may is specific therapy other than transfusion and instituting critical care supportive patients in is of the of transfusion major adverse effect of transfusion therapy is the of For the and deficiency were allogeneic blood These risks are of the major for the in has been the use of acid The and be by this To disease, and cannot be may the of both and transfusion of reactions include and bleeding, but these may be to other in the The of a transfusion reaction in patients include or However, these may not be consultants and ASA members strongly agree that checking for and of a transfusion reaction should be done in the The consultants agree and the ASA members strongly agree that and should be the consultants and ASA members agree that should be assessed to for transfusion for and of bacterial and transfusion including increased and instituting therapy for transfusion the blood transfusion and appropriate scientific of these Guidelines was based on evidence or potential clinical and The below were to assess their impact on a of outcomes to perioperative blood transfusion and adjuvant they are not included in the focus of these areas of research include (1) the use of to improve making and reduce transfusion and (2) or other blood to reduce transfusion requirements. evidence was from research and evidence was from open and other (e.g. , For purposes of literature potentially relevant clinical studies were and of the literature. The and a from than were a of that addressed to the evidence review of the studies not provide evidence and were of reported in a was as an evidence a or equivocal. The results were summarized to obtain a for evidence before conducting a to evidence enough studies with and information sufficient for These were (1) erythropoietin versus (2) preadmission blood donation versus autologous blood (3) antifibrinolytics ϵ-aminocaproic acid tranexamic acid (4) transfusion of autologous blood red blood cell and versus or tests were for and were for tests were as (1) the values based on of the reported values from the and (2) the of the studies by of the by the of the based on the for results was used with was at for of the studies were to the results. were when significant was To for potential a was for studies was and tests for research results were results are reported in To be as significant agree with test results both of data are In the of findings from both the and tests agree with other to be as Task Force members and two methodologists was by a for were as (1) of (2) of (3) evidence and (4) literature for values were (1) (2) of (3) and (4) literature These values to high of was from including (1) survey opinion from consultants who were selected based on their or in perioperative blood transfusion and adjuvant (2) survey opinions from a selected of active members of the (3) from of two held open forums at two national commentary, and Task Force opinion and The survey of was of for and of for of the surveys are reported in and in the of the consultants were asked to if of the evidence their clinical practices if the Guidelines were The of was of The of consultants associated with were as preoperative discontinuation of anticoagulation and of drugs to perioperative drugs to promote coagulation and minimize blood preoperative autologous blood for and for transfusion transfusion of allogeneic red blood transfusion of autologous transfusion of transfusion of transfusion of of excessive and and laboratory for transfusion of the that the Guidelines have effect on the of time on a that be an increase in the of time they on a with the of these Guidelines. The of increased time by these from 5 to 10
The Journal of Bone and Joint Surgery. British volumeVol. 86-B, No. 3 Aspects of Current ManagementFree AccessPosterior dislocation of the shoulderN. CicakN. CicakOrthopaedic SurgeonSearch for more papers by this authorPublished Online:1 Apr 2004https://doi.org/10.1302/0301-620X.86B3.14985AboutSectionsPDF/EPUB ToolsAdd to FavouritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited bySurgical management of bilateral concomitant posterior fracture-dislocation of the shoulderTrauma Case Reports, Vol. 41Posterior shoulder dislocation with associated reverse Hill–Sachs lesion: clinical outcome 10 years after joint-preserving surgery3 June 2022 | Archives of Orthopaedic and Trauma Surgery, Vol. 39Posterior Shoulder InstabilityTreatment of chronic locked posterior dislocation of the shoulder with the modified McLaughlin procedureJournal of Shoulder and Elbow Surgery, Vol. 31, No. 1Principles of Radiological Examination28 September 2022Posterior Instability4 October 2022Mid-Term outcomes following fresh-frozen humeral head osteochondral allograft reconstruction for reverse Hill Sachs lesion: a case series8 September 2021 | BMC Musculoskeletal Disorders, Vol. 22, No. 1Management of Locked Posterior Shoulder Dislocation with Reverse Hill–Sachs Lesions via Anatomical Reconstructions11 October 2021 | Orthopaedic Surgery, Vol. 232Traumi della spalla e del braccioEMC - Urgenze, Vol. 25, No. 3Arthroscopic Knotless Subscapularis Bridge Technique for Reverse Hill-Sachs Lesion With Posterior Shoulder InstabilityArthroscopy Techniques, Vol. 10, No. 1A Modified Reverse Remplissage Procedure for Management of a Locked Posterior Shoulder DislocationCase Reports in Orthopedics, Vol. 2020Shoulder Dislocations in the Emergency Department: A Comprehensive Review of Reduction TechniquesThe Journal of Emergency Medicine, Vol. 58, No. 4Missed posterior shoulder fracture dislocations: a new protocol from a London major trauma centre18 March 2020 | BMJ Open Quality, Vol. 9, No. 1New Reduction Technique for Traumatic Posterior Glenohumeral Joint Dislocations24 January 2020 | Clinical Practice and Cases in Emergency Medicine, Vol. 4, No. 1Glenohumeral Joint16 April 2020Conservative Treatment in Posterior Dislocation16 June 2020Surgical Treatment of Humeral Head Defect in Shoulder Posterior Instability16 June 2020Shoulder and proximal humerusIndications for Reverse Shoulder ArthroplastyAll-Arthroscopic McLaughlin's Procedure in Patients with Reverse Hill–Sachs Lesion Caused by Locked Posterior Shoulder Dislocation31 December 2019 | Joints, Vol. 07, No. 03The dual subscapularis procedure: a modified Hawkins’ technique for neglected posterior fracture/dislocation of the shoulder19 March 2019 | European Journal of Orthopaedic Surgery & Traumatology, Vol. 29, No. 5Remplissage With Bankart Repair in Anterior Shoulder Instability: A Systematic Review of the Clinical and Cadaveric LiteratureArthroscopy: The Journal of Arthroscopic & Related Surgery, Vol. 35, No. 4McLaughlin artroscópico modificado no tratamento de luxação glenoumeral posterior – nota técnica10 May 2019 | Revista Brasileira de Ortopedia, Vol. 54, No. 02Posterior Shoulder Dislocation During Morning PT: A Case Report13 June 2018 | Military Medicine, Vol. 184, No. 3-4The aetiology of posterior glenohumeral dislocations and occurrence of associated injuriesa systematic reviewM. 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Priorova, No. 3Experience in Use of Modified McLaughlin Procedure for Neglected Locked Posterior Subluxation of the Humeral Head15 September 2017 | N.N. 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Cyberpsychology, Behavior, and Social NetworkingVol. 23, No. 7 EditorialConnecting Through Technology During the Coronavirus Disease 2019 Pandemic: Avoiding “Zoom Fatigue”Brenda K. WiederholdBrenda K. WiederholdBrenda K. Wiederhold, Editor-in-Chief Search for more papers by this authorPublished Online:10 Jul 2020https://doi.org/10.1089/cyber.2020.29188.bkwAboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookXLinked InRedditEmail View article"Connecting Through Technology During the Coronavirus Disease 2019 Pandemic: Avoiding “Zoom Fatigue”." 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Parent–Child Activities at Home from Spring 2020 to Spring 2021 from a Cross-Cultural View7 October 2023 | Education Sciences, Vol. 13, No. 10A look back at mandatory online instruction: Preserving a record of student preferences and experiences28 September 2023 | Journal of Education for Business, Vol. 15MeetScript: Designing Transcript-based Interactions to Support Active Participation in Group Video Meetings4 October 2023 | Proceedings of the ACM on Human-Computer Interaction, Vol. 7, No. CSCW2Best Practices for Technology in Clinical Social Work and Mental Health Professions to Promote Well-being and Prevent Fatigue1 June 2023 | Clinical Social Work Journal, Vol. 51, No. 3Investigating autistic traits, social phobia, fear of COVID-19, and internet use disorder variables in the context of videoconference fatigueTelematics and Informatics Reports, Vol. 11Virtual reality as an immersive projective and autodriving advancement technique24 August 2023 | Journal of Consumer Behaviour, Vol. 33Reconfiguring togetherness in the virtual drama classroom23 August 2023 | Research in Drama Education: The Journal of Applied Theatre and Performance, Vol. 44“I really don’t know what I would have done without it”: Crafting as a means of stress coping during COVID-1923 August 2023 | Journal of Leisure Research, Vol. 13Virtual interdisciplinary collaboration during the COVID-19 pandemic: pain and joy in an international joint university7 July 2023 | Frontiers in Psychology, Vol. 14Nonverbal immediacy cues and impression formation in video therapy1 August 2022 | Counselling Psychology Quarterly, Vol. 36, No. 3Digital dependence: Online fatigue and coping strategies during the COVID-19 lockdown11 February 2023 | Media, Culture & Society, Vol. 45, No. 5Using group-based interactive video teleconferencing to make self-compassion more accessible: A randomized controlled trialJournal of Contextual Behavioral Science, Vol. 29Researcher-patient partnership generated actionable recommendations, using quantitative evaluation and deliberative dialogue, to improve meaningful engagementJournal of Clinical Epidemiology, Vol. 159Peer-to-peer: The Social Transmission of Symptoms Online10 April 2023 | Annals of Behavioral Medicine, Vol. 57, No. 7Online panel work through a gender lens: implications of digital peer review meetings23 December 2022 | Science and Public Policy, Vol. 50, No. 3The effect of wearing a head-mounted display on the boundaries of the cervical range of motion based on perceived comfort in a static posture14 September 2022 | Virtual Reality, Vol. 27, No. 2Phase 2 of collaborative action around the implementation of virtual hearing aid care: Evaluation of a clinical practice guideline23 April 2023 | Journal of Evaluation in Clinical Practice, Vol. 29, No. 4Phase 1 of collaborative action around the implementation of virtual hearing aid care: Development of a clinical practice guideline21 April 2023 | Journal of Evaluation in Clinical Practice, Vol. 29, No. 4Is Virtual Learning Here to Stay? A Multispecialty Survey of Residents, Fellows, and FacultyCurrent Problems in Cardiology, Vol. 48, No. 6Digital transformation in higher education: A qualitative evaluative study of a hybrid virtual format using a smart classroom systemHeliyon, Vol. 9, No. 6How mothers manage and make sense of their early adolescent’s interactive screen use: an IPA study in the UK17 May 2023 | Journal of Family Studies, Vol. 39Examining undergraduate student perceptions and engagement during the second year of the COVID-19 pandemicThe Journal of Academic Librarianship, Vol. 49, No. 3Who Needs Zoom? Female Arab Students’ Perceptions of Face-to-Face Learning and Learning on Zoom18 May 2023 | Sustainability, Vol. 15, No. 10Online Conversations for Equity, Action, and Networking: A Pilot Project Highlighting Diversity in the Ocean Sciences3 March 2023 | Limnology and Oceanography Bulletin, Vol. 32, No. 2Improved self-efficacy in human factors skills in early-stage psychiatric trainees following online simulation: a quantitative comparison study with in-person training18 April 2023 | International Journal of Healthcare SimulationNavigating the interlanguage space: Chinese international students’ perceptions of a virtual chemistry laboratory course1 January 2023 | Chemistry Education Research and Practice, Vol. 24, No. 2Evolution in Congenital Cardiology Education: The Rise of Digital-Learning ToolsCJC Pediatric and Congenital Heart Disease, Vol. 2, No. 2Videoconference-based Creativity Workshops for mental health staff during the COVID-19 pandemic13 March 2023 | Arts & Health, Vol. 133Advancing the partnership between Japan and Thailand on global health and UHC: "new normal" approach during COVID-19 pandemicGlobal Health & Medicine, Vol. 5, No. 1Optimising online transversal skills delivery in STEM doctoral education19 February 2023 | Irish Educational Studies, Vol. 39Liminal design: A conceptual framework and three-step approach for developing technology that delivers transcendence and deeper experiences8 February 2023 | Frontiers in Psychology, Vol. 14Towards a Funambulist Leadership in Researchers Well-Being: Managing Equilibriums and Tensions in the Hybrid Work Era17 February 2023 | Administrative Sciences, Vol. 13, No. 2Facilitator reflections on online delivery of simulation-based mental health education during COVID-1918 August 2022 | The Journal of Mental Health Training, Education and Practice, Vol. 18, No. 1Mainstreaming Zoom: Covid-19, Social Distancing, and the Rise of Video-Mediated Remote Cooperation3 March 2023Adapting to Digital Changes in Health Education: A Case Study31 May 2023Mixed Migration Flows into Turkey and the Impact of the Pandemic17 June 2023TOO MUCH SCREEN? AN EXPLORATORY EXAMINATION OF DIGITAL EXHAUSTION OF EDUCATORS IN TURKIYE1 January 2023 | Turkish Online Journal of Distance Education, Vol. 24, No. 1Moving Beyond Web Conferencing Tools: ESL Professional Development Workshops in Virtual Reality Platforms30 June 2023The Tribrid-Meeting-Setup – Improving Hybrid Meetings Using a Telepresence Robot9 July 2023Videoconferencing: Miracle Tool or Policy Trap in the Governance of Smart and Sustainable Mobility?18 July 2023“A Terrible Beauty Is Born”: Opportunities and New Perspectives for Online Teaching and AssessmentLingue Culture Mediazioni - Languages Cultures Mediation (LCM Journal), Vol. 10, No. 1HoloLearn: Towards a Hologram Mediated Hybrid Education27 September 2023Hardiness and Zoom Fatigue on Nursing Students: A Cross-Sectional Study in Indonesia During Online Learning1 October 2023 | Advances in Medical Education and Practice, Vol. Volume 14“Am I Ready for This Change?”: Challenges in Optimizing the Use of Online Learning in Medical and Health Professions Education During the Pandemic and Beyond7 November 2023Atuação da Psicologia em Unidade Neonatal no Contexto da Pandemia da Covid-191 January 2023 | Psicologia: Ciência e Profissão, Vol. 43Efficacy of PEERS® for Adolescents via Telehealth Delivery27 May 2022 | Journal of Autism and Developmental Disorders, Vol. 52, No. 12Proactive strategies for an inclusive faculty search process16 June 2022 | Communications Biology, Vol. 5, No. 1The impact of COVID-19 on digital communication patterns23 May 2022 | Humanities and Social Sciences Communications, Vol. 9, No. 1Medical student’s perception of the COVID-19 pandemic effect on their education and well-being: a cross-sectional survey in the United States5 March 2022 | BMC Medical Education, Vol. 22, No. 1Lessons learned from a pandemic: implications for a combined exercise and educational programme for medical students8 April 2022 | BMC Medical Education, Vol. 22, No. 1Conducting a randomised controlled trial of a psychosocial intervention for adolescents with type 1 diabetes during COVID-19: recommendations to overcome the challenges complicated by inconsistent public health guidelines on research27 April 2022 | Trials, Vol. 23, No. 1Digital temperance: adapting an ancient virtue for a technological age22 November 2022 | Ethics and Information Technology, Vol. 24, No. 4Online-Supervision14 July 2022 | Zeitschrift für Psychodrama und Soziometrie, Vol. 21, No. S2Navigating learners towards technology-enhanced learning during post COVID-19 semestersTrends in Neuroscience and Education, Vol. 29An Educational Perspective on Online Learning PlatformsTechnologically-assisted communication attenuates inter-brain synchronyNeuroImage, Vol. 264Virtual recruitment - should this be the future for dental core training?25 November 2022 | British Dental Journal, Vol. 233, No. 10Zoom fatigue under covid-19-pandemien: Hva innebærer fenomenet, og hvordan kan det forebygges?Uniped, Vol. 45, No. 4Early Field Experiences Through Telepresence RobotsWhere to Look? Alcohol, Affect, and Gaze Behavior During a Virtual Social Interaction14 November 2022 | Clinical Psychological Science, Vol. 2Vers une appropriation du télétravail en contexte de criseRevue Management & Innovation, Vol. N° 6, No. 2Zoom Face: Self-Surveillance, Performance and Display1 October 2022 | Journal of Intercultural Studies, Vol. 43, No. 6Medical Education in a Global Pandemic: A Novel Case-Based Learning Approach to Teaching Plastic Surgery Topics to Preclerkship Students25 November 2021 | Plastic Surgery, Vol. 30, No. 4Creating an Immersive XR Learning Experience: A Roadmap for Educators30 October 2022 | Electronics, Vol. 11, No. 21Beyond Zoom Fatigue: Ritual and Resilience in Remote Meetings29 December 2022 | Ethnographic Praxis in Industry Conference Proceedings, Vol. 2022, No. 1Introducing online training for health staff: An institutional perspective22 June 2022 | THE ELECTRONIC JOURNAL OF INFORMATION SYSTEMS IN DEVELOPING COUNTRIES, Vol. 88, No. 6Keep It Brief: Videoconferencing Frequency and Duration as Predictors of Visual and Body Discomfort31 October 2022 | International Journal of Human–Computer Interaction, Vol. 24Overcoming the liability of distance? An exploratory study of the associations between social networks, sense of community and spatial colocation28 December 2021 | Journal of Corporate Real Estate, Vol. 24, No. 4Governing in the time of Covid-19: how board meetings went online and the implications of this for considering the role of the governing board19 October 2022 | Journal of Further and Higher Education, Vol. 51The Effects of Attributes of Non-Immersive Virtual Reality on Customers’ Experience of Video Tours under Social Distancing for COVID-1914 October 2022 | International Journal of Human–Computer Interaction, Vol. 6Moving intensive onsite courses online: responding to COVID-19 educational disruption15 June 2022 | International Journal of Ethics Education, Vol. 7, No. 2Webinars, podcasts, Tweetorials, oh my!Journal of Vascular Surgery, Vol. 76, No. 4Resilience and Wellbeing Strategies for Pandemic Fatigue in Times of Covid-1930 September 2022 | International Journal of Applied Positive Psychology, Vol. 78Zoom Yorgunluğu: Bir Gözden Geçirme30 September 2022 | Psikiyatride Güncel Yaklaşımlar, Vol. 14, No. 3Being Prepared and Preparing the Students for the Central Exam with Distance Education22 September 2022 | Pamukkale University Journal of EducationBridging social distance during social distancing: exploring social talk and remote collegiality in video conferencing11 November 2021 | Human–Computer Interaction, Vol. 37, No. 5Variations in consumer acceptance, sensory engagement and method practicality across three remote consumer-testing modalitiesFood Quality and Preference, Vol. 100Remote learning experiences of African Nova Scotian households in Canada during the COVID-19 temporary school closure: implications for inclusive education policy implementation7 August 2022 | International Journal of Inclusive Education, Vol. 36Individual and Situational Factors Influencing Active Behavior in Professional Video Conferences With Strangers7 August 2022 | Social Science Computer Review, Vol. 6From frequency to fatigue: Exploring the influence of videoconference use on videoconference fatigue in SingaporeComputers in Human Behavior Reports, Vol. 7“Seeing and Being Seen” or Just “Seeing” in a Smart Classroom Context When Videoconferencing: A User Experience-Based Qualitative Research on the Use of Cameras4 August 2022 | International Journal of Environmental Research and Public Health, Vol. 19, No. 15Understanding patterns of internal migration during the COVID‐19 pandemic in Spain16 June 2022 | Population, Space and Place, Vol. 28, No. 6Blended (online and in‐person) Women’s Health Interprofessional Learning by Simulation (WHIPLS) for medical and midwifery students18 April 2022 | Australian and New Zealand Journal of Obstetrics and Gynaecology, Vol. 62, No. 4Ten simple rules for leveraging virtual interaction to build higher-level learning into bioinformatics short courses28 July 2022 | PLOS Computational Biology, Vol. 18, No. 7AbGradCon 2021: lessons in digital meetings, international collaboration, and interdisciplinarity in astrobiology6 July 2022 | International Journal of Astrobiology, Vol. 17Recommendations for Building Telemental Health Relationships with Youth: A Systematic Review and Resource for Clinicians22 October 2021 | Evidence-Based Practice in Child and Adolescent Mental Health, Vol. 7, No. 3A National Study of Zoom Fatigue and Mental Health During the COVID-19 Pandemic: Implications for Future Remote Work Eric B. 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No AccessWorld Development Report1 Feb 2013World Development Report 1993Investing in Health, Volume1Authors/Editors: World BankWorld Bankhttps://doi.org/10.1596/0-1952-0890-0AboutView ChaptersPDF (6.2 MB) ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookTwitterLinked In Abstract:This is the sixteenth in the annual series and examines the interplay between human health, health policy and economic development. Because good health increases the economic productivity of individuals and the economic growth rate of countries, investing in health is one means of accelerating development. More important, good health is a goal in itself. During the past forty years life expectancy in the developing world has risen and child mortality has decreased, sometimes dramatically. But progress is only one side of the picture. The toll from childhood and tropical diseases remains high even as new problems - including AIDS and the diseases of aging populations - appear on the scene. And all countries are struggling with the problems of controlling health expenditures and making health care accessible to the broad population. This report examines the controversial questions surrounding health care and health policy. Its findings are based in large part on innovative research, including estimation of the global burden of disease and the cost-effectiveness of interventions. These assessments can help in setting priorities for health spending. The report advocates a threefold approach to health policy for governments in developing countries and in the formerly socialist countries. First, to foster an economic environment that will enable households to improve their own health. Policies for economic growth that ensure income gains for the poor are essential. So, too, is expanded investment in schooling, particulary for girls. Second, redirect government spending away from specialized care and toward such low-cost and highly effective activities such as immunization, programs to combat micronutrient deficiencies, and control and treatment of infectious diseases. By adopting the packages of public health measures and essential clinical care dsecribed in the report, developing countries could reduce their burden of disease by 25 percent. Third, encourage greater diversity and competition in the provision of health services by decentralizing government services, promoting competitive procurement practices, fostering greater involvement by nongovernmental and other private organizations, and regulating insurance markets. These reforms could translate into longer, healthier, and more productive lives for people around the world, and especially for the more than 1 billion poor. As in previous editions, this report includes the World Development Indicators, which give comprehensive, current data on social and economic development in more than 200 countries and territories. Previous bookNext book FiguresreferencesRecommendeddetailsCited byLatin America at the margins? 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Editorials21 September 2004Clinical Trial Registration: A Statement from the International Committee of Medical Journal EditorsFREECatherine De Angelis, MD, MPH, Jeffrey M. Drazen, MD, Frank A. Frizelle, MBChB, MMedSc, FRACS, Charlotte Haug, MD, PhD, MSc, John Hoey, MD, Richard Horton, FRCP, Sheldon Kotzin, MLS, Christine Laine, MD, MPH, Ana Marusic, MD, PhD, A. John P.M. Overbeke, MD, PhD, Torben V. Schroeder, MD, DMSc, Harold C. Sox, MD, and Martin B. Van Der Weyden, MDCatherine De Angelis, MD, MPH, Jeffrey M. Drazen, MD, Frank A. Frizelle, MBChB, MMedSc, FRACS, Charlotte Haug, MD, PhD, MSc, John Hoey, MD, Richard Horton, FRCP, Sheldon Kotzin, MLS, Christine Laine, MD, MPH, Ana Marusic, MD, PhD, A. John P.M. Overbeke, MD, PhD, Torben V. Schroeder, MD, DMSc, Harold C. Sox, MD, and Martin B. Van Der Weyden, MDAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-141-6-200409210-00109 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Altruism and trust lie at the heart of research on human subjects. Altruistic individuals volunteer for research because they trust that their participation will contribute to improved health for others and that researchers will minimize risks to participants. In return for the altruism and trust that make clinical research possible, the research enterprise has an obligation to conduct research ethically and to report it honestly. Honest reporting begins with revealing the existence of all clinical studies, even those that reflect unfavorably on a research sponsor's product.Unfortunately, selective reporting of trials does occur, and it distorts the body of evidence available for clinical decision making. Researchers (and journal editors) are generally most enthusiastic about the publication of trials that show either a large effect of a new treatment (positive trials) or equivalence of two approaches to treatment (noninferiority trials). Researchers (and journals) typically are less excited about trials that show that a new treatment is inferior to standard treatment (negative trials) and even less interested in trials that are neither clearly positive nor clearly negative, since inconclusive trials will not in themselves change practice. Irrespective of their scientific interest, trial results that place financial interests at risk are particularly likely to remain unpublished and hidden from public view. The interests of the sponsor or authors notwithstanding, anyone should be able to learn of any trial's existence and its important characteristics.The case against selective reporting is particularly compelling for research that tests interventions that could enter mainstream clinical practice. Rather than a single trial, it is usually a body of evidence, consisting of many studies, that changes medical practice. When research sponsors or investigators conceal the presence of selected trials, these studies cannot influence the thinking of patients, clinicians, other researchers, and experts who write practice guidelines or decide on insurance-coverage policy. If all trials are registered in a public repository at their inception, every trial's existence is part of the public record and the many stakeholders in clinical research can explore the full range of clinical evidence. We are far from this ideal at present, since trial registration is largely voluntary, registry data sets and public access to them vary, and registries contain only a small proportion of trials. In this editorial, published simultaneously in all member journals, the International Committee of Medical Journal Editors (ICMJE) proposes comprehensive trials registration as a solution to the problem of selective awareness and announces that all 11 ICMJE member journals will adopt a trials-registration policy to promote this goal.The ICMJE member journals will require, as a condition of consideration for publication, registration in a public trials registry. Trials must register at or before the onset of patient enrollment. This policy applies to any clinical trial starting enrollment after July 1, 2005. For trials that began enrollment prior to this date, the ICMJE member journals will require registration by September 13, 2005, before considering the trial for publication. We speak only for ourselves, but we encourage editors of other biomedical journals to adopt similar policies. For this purpose, the ICMJE defines a clinical trial as any research project that prospectively assigns human subjects to intervention or comparison groups to study the cause-and-effect relationship between a medical intervention and a health outcome. Studies designed for other purposes, such as to study pharmacokinetics or major toxicity (for example, phase I trials), would be exempt.The ICMJE does not advocate one particular registry, but its member journals will require authors to register their trial in a registry that meets several criteria. The registry must be accessible to the public at no charge. It must be open to all prospective registrants and managed by a not-for-profit organization. There must be a mechanism to ensure the validity of the registration data, and the registry should be electronically searchable. An acceptable registry must include at minimum the following information: a unique identifying number, a statement of the intervention (or interventions) and comparison (or comparisons) studied, a statement of the study hypothesis, definitions of the primary and secondary outcome measures, eligibility criteria, key trial dates (registration date, anticipated or actual start date, anticipated or actual date of last follow-up, planned or actual date of closure to data entry, and date trial data considered complete), target number of subjects, funding source, and contact information for the principal investigator. To our knowledge, at present, only www.clinicaltrials.gov, sponsored by the United States National Library of Medicine, meets these requirements; there may be other registries, now or in the future, that meet all these requirements.Registration is only part of the means to an end; that end is full transparency with respect to performance and reporting of clinical trials. Research sponsors may argue that public registration of clinical trials will result in unnecessary bureaucratic delays and destroy their competitive edge by allowing competitors full access to their research plans. We argue that enhanced public confidence in the research enterprise will compensate for the costs of full disclosure. Patients who volunteer to participate in clinical trials deserve to know that their contribution to improving human health will be available to inform health care decisions. The knowledge made possible by their collective altruism must be accessible to everyone. Required trial registration will advance this goal.Catherine De Angelis, MD, MPH, Editor-in-Chief, Journal of the American Medical AssociationJeffrey M. Drazen, MD, Editor-in-Chief, The New England Journal of MedicineProfessor Frank A. Frizelle, MBChB, MMedSc, FRACS, Editor, The New Zealand Medical JournalCharlotte Haug, MD, PhD, MSc, Editor-in-Chief, Norwegian Medical JournalJohn Hoey, MD, Editor, Canadian Medical Association JournalRichard Horton, FRCP, Editor, The LancetSheldon Kotzin, MLS, Executive Editor, MEDLINE; National Library of MedicineChristine Laine, MD, MPH, Senior Deputy Editor, Annals of Internal MedicineAna Marusic, MD, PhD, Editor, Croatian Medical JournalA. John P.M. Overbeke, MD, PhD, Executive Editor, Nederlands Tijdschrift voor Geneeskunde (Dutch Journal of Medicine)Torben V. Schroeder, MD, DMSc, Editor, Journal of the Danish Medical AssociationHarold C. Sox, MD, Editor, Annals of Internal MedicineMartin B. Van Der Weyden, MD, Editor, The Medical Journal of AustraliaCatherine De Angelis, MD, MPHEditor-in-Chief, Journal of the American Medical AssociationJeffrey M. Drazen, MDEditor-in-Chief, The New England Journal of MedicineProfessor Frank A. Frizelle, MBChB, MMedSc, FRACSEditor, The New Zealand Medical JournalCharlotte Haug, MD, PhD, MScEditor-in-Chief, Norwegian Medical JournalJohn Hoey, MDEditor, Canadian Medical Association JournalRichard Horton, FRCPEditor, The LancetSheldon Kotzin, MLSExecutive Editor, MEDLINE; National Library of MedicineChristine Laine, MD, MPHSenior Deputy Editor, Annals of Internal MedicineAna Marusic, MD, PhDEditor, Croatian Medical JournalA. John P.M. Overbeke, MD, PhDFrom Executive Editor, Nederlands Tijdschrift voor Geneeskunde.Torben V. Schroeder, MD, DMScEditor, Journal of the Danish Medical AssociationHarold C. Sox, MDEditor, Annals of Internal MedicineMartin B. Van Der Weyden, MDEditor, The Medical Journal of Australia Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Catherine De Angelis, MD, MPH; Jeffrey M. Drazen, MD; Frank A. Frizelle, MBChB, MMedSc, FRACS; Charlotte Haug, MD, PhD, MSc; John Hoey, MD; Richard Horton, FRCP; Sheldon Kotzin, MLS; Christine Laine, MD, MPH; Ana Marusic, MD, PhD; A. John P.M. Overbeke, MD, PhD; Torben V. Schroeder, MD, DMSc; Harold C. Sox, MD; Martin B. Van Der Weyden, MDAffiliations: Corresponding Author: Customer Service, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoRegistration of Clinical Trials Alain Braillon , Gérard Dubois , and Michel Slama Registration of Clinical Trials Christine Laine and Harold C. Sox International Committee of Medical Journal Editors' Definition of a Clinical Trial Christine Laine Metrics Cited byHas the degree of outcome reporting bias in surgical randomized trials changed? A meta‐regression analysisReporting and transparent research practices in sports medicine and orthopaedic clinical trials: a meta-research studyClinical trial registration was associated with lower risk of bias compared with non-registered trials among trials included in systematic reviewsStrategies for using topical corticosteroids in children and adults with eczemaProspective trial registration and publication rates of randomized clinical trials in digital health: A cross-sectional analysis of global trial registriesReferencesClinical trial registry searches are under-utilized in systematic reviews from critical care journals: A bibliometric analysisSelective outcome reporting in root coverage randomized clinical trialsPatient Participation in Clinical Trials of Oncology Drugs and Biologics Preceding Approval by the US Food and Drug AdministrationUse of corticoids and non-steroidal anti-inflammatories in the treatment of rheumatoid arthritis: Systematic review and network meta-analysisPoor compliance of clinical trial registration among trials included in systematic reviews: a cohort studyPublication Rate and Consistency of Registered Trials of Motor-Based Stroke RehabilitationRegistering your research: What's required?Proportion of Patients in Phase I Oncology Trials Receiving Treatments That Are Ultimately ApprovedCharacteristics of studies of pharmacist services registered in ClinicalTrials.govFrom registration to publication: A study on Dutch academic randomized controlled trialsEthical and Policy Issues for Seamless Phase I Oncology TrialsForensic science needs registered reportsComparison of Clinical Trial Changes in Primary Outcome and Reported Intervention Effect Size Between Trial Registration and PublicationDialysate temperature reduction for intradialytic hypotension for people with chronic kidney disease requiring haemodialysisAmerican College of Physicians Ethics Manual Seventh EditionLois Snyder Sulmasy, JD and Thomas A. Bledsoe, MD, for the ACP Ethics, Professionalism and Human Rights Committee*A Risk-Based Paradigm of Biomarkers in Clinical TrialsInteresting TimesThe enforcement of mandatory disclosure rulesAn observational analysis of discontinuation and non-publication of osteoarthritis trialsDifferences between protocols for randomized controlled trials and systematic reviewsA mapping of 115,000 randomized trials revealed a mismatch between research effort and health needs in non–high-income regionsPublication of Randomized Clinical Trials in Pediatric ResearchOpen season: positive changes for increased transparency in the biomedical literatureKeeping a watchful eye on the food giants and cleansing the temple of nutritional medicine and epidemiologyThe Role and Importance of Clinical Trial Registries and Results DatabasesClinical trial registry use in anaesthesiology systematic reviewsData Escrow and Clinical Trial TransparencyHarlan M. Krumholz, MD, SM and Jeanie Kim, JDPublication Rates of Abstracts Presented at the Society of General Internal Medicine Annual MeetingPhase-II trials in osteosarcoma recurrences: A systematic review of past experienceOn Fishing for Significance and Statistician's Degree of Freedom in the Era of Big Molecular DataThe method of systematic review for clinical guidelinesA metadata schema for data objects in clinical researchRandomized trials in top dermatological journals, 2009-13Compliance with prospective trial registration guidance remained low in high-impact journals and has implications for primary end point reportingApplication of an automated natural language processing (NLP) workflow to enable federated search of external biomedical content in drug discovery and developmentCONSORT and clinical trial reporting: room for improvementDeveloping timely insights into comparative effectiveness research with a text-mining pipelineThe Changing Geography of Clinical Research: A Critical Analysis of Its DriversManaging the incidence of selective reporting bias: a survey of Cochrane review groupsConsiderations from the risk of bias perspective for updating Cochrane reviewsRegistration status and outcome reporting of trials published in core headache medicine journalsPeer reviewDo surgery journals insist on reporting by CONSORT and PRISMA? A follow-up survey of 'instructions to authors'Investigation of publication bias in meta-analyses of diagnostic test accuracy: a meta-epidemiological studyStandardization of Patient Outcomes Reporting in Percutaneous NephrolithotomyDesign and execution of clinical trials in orthopaedic surgeryMaking Prospective Registration of Observational Research a RealityReplication and the Manufacture of Scientific Inferences: A Formal ApproachElectromagnetic fields for treating osteoarthritisHow Psychiatry Journals Support the Unbiased Translation of Clinical Research. A Cross-Sectional Study of Editorial PoliciesIntegrated disease management interventions for patients with chronic obstructive pulmonary diseaseEuropean Union Clinical Trials Register: on the way to more transparency of clinical trial dataPRAISE (Prospective Randomized Amlodipine Survival Evaluation) and Criticism ∗What If We Were Texas Sharpshooters? Predictor Reporting Bias in Regression AnalysisLearning from failure - rationale and design for a study about discontinuation of randomized trials (DISCO study)Lack of proportionality. Seven specifications of public interest that override post-approval commercial interests on limited access to clinical dataOpen-access clinical trial registries: the Italian scenarioPublishing Results of Clinical Trials and Reviewing Papers for PublicationTrial registration in Latin America and the Caribbean's: study of randomized trials published in 2010Normative arguments and new solutions for the unbiased registration and publication of clinical trialsThe Growth of Clinical Trials and Systematic Reviews in Informing Dermatological Patient CareAmerican College of Physicians Ethics Manual Sixth EditionLois Snyder, JD, for the American College of Physicians Ethics, Professionalism, and Human Rights Committee*The Role and Importance of Clinical Trial Registries and Results DatabasesRegistration and Reporting Guidelines for Clinical TrialsDisclosure of Investigators' Recruitment Performance in Multicenter Clinical Trials: A Further Step for Research TransparencyWalking the talk: the need for a trial registry for development interventionsLimited accessibility to designs and results of Japanese large-scale clinical trials for cardiovascular diseasesIntegrated disease management interventions for patients with chronic obstructive pulmonary diseaseRegistration of epidemiological studies: benefits and risksWorldwide Clinical Interventional Studies on Leading Causes of Death: A Descriptive AnalysisWorldwide Behavioral Research on Major Global Causes of MortalityZur Ethik einer restriktiven Regulierung der StudienregistrierungReporting of noninferiority trials was incomplete in trial registriesEarly phase drugs and biologicals clinical trials on worldwide leading causes of death: a descriptive analysisBest Practice in Systematic Reviews: The Importance of Protocols and RegistrationBotulinum toxin injection for tennis elbowObstacles to researching the researchers: A case study of the ethical challenges of undertaking methodological research investigating the reporting of randomised controlled trialsInfluence of trial registration on reporting quality of randomized trials: Study from highest ranked journalsRCT of urethral versus suprapubic catheterizationCONSORT 2010 Statement: Updated Guidelines for Reporting Parallel Group Randomized TrialsKenneth F. Schulz, PhD, MBA, Douglas G. Altman, DSc, and David Moher, PhD, for the CONSORT Group*Implementing registries and results databases of clinical trials: is there a side effect?Can Clinical Trial Results Databases and Manuscripts Coexist?ReferencesClinical Trial Overview and Enrollment«Conflict of Interest» oder Interesse am Konflikt? 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Survey of a Pubmed sampleReview of new regulations for the conduct of clinical trials of investigational medicinal productsRegistro dos ensaios clínicosPaliperidone: quo vadis?Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP panel: clinical trial designPeer review policies and theCanadian Journal of Anesthesia: an update for authors and readersReported Outcomes in Major Cardiovascular Clinical Trials Funded by For-Profit and Not-for-Profit Organizations: 2000–2005Clinical research design and reporting: always room for improvement!Quality assessment of randomized controlled trials in the treatment of hepatocellular carcinomaNew regulatory rules for clinical trials in the United States and the European Union: Key points and comparisonsThe Editor as umpire: clinical trial registration and dispute resolutionQuality of Trials in a Systematic Review of Powered Toothbrushes: Suggestions for Future Clinical TrialsThe need to register clinical trials in orthodonticsClinical trial data: to disclose or not to disclose?International Committee of Medical Journal Editors' Definition of a Clinical TrialChristine Laine, MD, MPH, Senior Deputy EditorIs This Clinical Trial Fully Registered? A Statement from the International Committee of Medical Journal Editors*Catherine D. De Angelis, MD, MPH, Jeffrey M. Drazen, MD, Frank A. Frizelle, MB, ChB, MMedSc, FRACS, Charlotte Haug, MD, PhD, MSc, John Hoey, MD, Richard Horton, FRCP, Sheldon Kotzin, MLS, Christine Laine, MD, MPH, Ana Marusic, MD, PhD, A. John P.M. Overbeke, MD, PhD, Torben V. Schroeder, MD, DMSc, Harold C. Sox, MD, and Martin B. Van Der Weyden, MDAnnals 2004–2005: A Peek Back and a Look ForwardThe EditorsRegistration of Clinical TrialsAlain Braillon, MD, Gérard Dubois, MD, and Michel Slama, MDRegistro (de ensayos clínicos) sin fronteras 21 September 2004Volume 141, Issue 6Page: 477-478KeywordsClinical trial reportingClinical trialsHealth careHeartInformation storage and retrievalLibrariesPharmacokineticsResearch ethicsToxicityTreatment guidelines ePublished: 21 September 2004 Issue Published: 21 September 2004 PDF downloadLoading ...
The Journal of Alternative and Complementary MedicineVol. 26, No. 5 CommentariesPublic Health Approach of Ayurveda and Yoga for COVID-19 ProphylaxisGirish Tillu, Sarika Chaturvedi, Arvind Chopra, and Bhushan PatwardhanGirish TilluAYUSH Center of Excellence, Center for Complementary and Integrative Health, Interdisciplinary School of Health Sciences, Savitribai Phule Pune University, Pune, India.Search for more papers by this author, Sarika ChaturvediDr. D.Y. Patil Vidyapeeth (DPU), Pune, India.Search for more papers by this author, Arvind ChopraCenter for Rheumatic Diseases, Pune, India.Search for more papers by this author, and Bhushan PatwardhanAddress correspondence to: Bhushan Patwardhan, AYUSH Center of Excellence, Center for Complementary and Integrative Health, Interdisciplinary School of Health Sciences, Savitribai Phule Pune University, Pune, India E-mail Address: [email protected]AYUSH Center of Excellence, Center for Complementary and Integrative Health, Interdisciplinary School of Health Sciences, Savitribai Phule Pune University, Pune, India.Search for more papers by this authorPublished Online:11 May 2020https://doi.org/10.1089/acm.2020.0129AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookXLinked InRedditEmail View articleFiguresReferencesRelatedDetailsCited byDNA metabarcoding uncovers fungal communities in Zingiberis RhizomaChinese Herbal Medicines, Vol. 6"We are adapting to it because it is within us": The co‐becoming of COVID‐19 in Malawi20 December 2023 | World Medical & Health Policy, Vol. 5COVID-19 Cases and Comorbidities: Complementary and Alternative Medicinal Systems (CAM) for Integrated Management of the PandemicJournal of Herbal Medicine, Vol. 42Traditional Formulations for Managing COVID-19: A Systematic Review Rudra B. 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Multiple randomized clinical trials have established the efficacy of standard heparin (SH) anticoagulation for venous thromboembolism prophylaxis. However, for high-risk populations, such as patients undergoing total hip or knee replacement, SH is relatively ineffective and may be associated with significant bleeding complications [1]. Initial animal model studies suggested that low molecular weight fractions of heparin, when administered at equivalent antithrombotic doses, caused less bleeding than SH [2]. These early studies raised the exciting possibility of separating the antithrombotic from the bleeding effects of heparin. The efficacy and safety of low molecular weight heparins (LMWH) as postoperative venous thromboembolism prophylaxis subsequently has been demonstrated in more than 60 clinical trials including more than 20,000 patients [3]. However, reports of spinal hematoma occurring spontaneously and in association with regional anesthesia [4,5] have generated concern regarding the safety of spinal or epidural anesthesia in patients receiving LMWH. In this review, we focus on the biochemistry and pharmacology of LMWH compared with SH, current LMWH prophylaxis regimens, and the implications of perioperative LMWH prophylaxis for anesthesia, particularly among patients receiving regional anesthesia and analgesia. Guidelines will be provided for minimizing the risk of spinal hematoma in patients undergoing regional anesthesia while receiving perioperative anticoagulant-based prophylaxis. Biochemistry and Pharmacology of SH and LMWH SH is a mixture of linear polysaccharide molecules of variable chain lengths (45-50 sugar units) and molecular weights (5,000-30,000 daltons). The mean molecular weight of SH ranges from 12,000 to 15,000 Daltons. Heparin acts as an anticoagulant by binding and catalyzing antithrombin III, a plasma serine protease inhibitor. The heparin-antithrombin III complex inhibits several procoagulant serine proteases, including factors IIa (thrombin), IXa, Xa, XIa, and XIIa (Figure 1).Figure 1: Schematic of the procoagulant system. Circulating procoagulants are shown in ellipses, and activated coagulation factors are shown in rectangles. Heparin catalyzes antithrombin III inhibition of all procoagulant factors enclosed in the rectangles except factor VIIa. Vitamin K-antagonist drugs reduce the plasma activities of factors II (prothrombin), VII, IX, and X. (Reproduced with permission from Horlocker TT, Wedel DJ. Anitcoagulants, antiplatelet therapy, and neuraxis blockade. In: Batra MS, ed. Anesthesiology clinics of North America. Vol 10. Philadelphia: WB Saunders, 1992:3.)Heparin catalytic activity is dependent on both the polysaccharide chain length as well as a specific pentasaccharide sequence within the heparin molecule, which is a high-affinity binding site for antithrombin III. Approximately 30% of SH molecules contain the pentasaccharide high-affinity binding sequence and can catalyze antithrombin III. Heparin chain length partially determines antithrombin III substrate specificity. For example, to efficiently catalyze antithrombin III inhibition of factor IIa (thrombin), a heparin molecule must contain both the pentasaccharide high-affinity binding sequence as well as a chain length of at least 13 additional sugars. Conversely, only the pentasaccharide high-affinity binding sequence is required for heparin to catalyze antithrombin III inhibition of factor Xa. Commercial LMWH is produced by either chemical or enzymatic depolymerization of SH and has a mean molecular weight of 4000-6500 Daltons and a chain length of 13-22 sugars. Consequently, LMWH retains full anti-Xa activity with relatively less anti-IIa (thrombin) activity. The concentration of LMWH is referenced to an international standard and usually expressed as anti-Xa U / mL. The bioavailability and anticoagulant effect of SH is reduced due to binding of SH by plasma and platelet proteins, endothelial cells, and vascular wall matrix proteins [5]. Many of these plasma proteins increase with illness as acute phase reactants (especially factor VIII and von Willebrand factor), which accounts in part for the large interpatient variability in the anticoagulant response to SH. In contrast, LMWH has a much lower affinity for plasma and matrix proteins [6], which results in greater than 90% bioavailability after subcutaneous administration and a very predictable and reproducible anticoagulant response when dosed on a weight-adjusted basis. Consequently, neither laboratory monitoring of the anticoagulant response to LMWH (anti-Xa levels) nor dose adjustment is necessary. Peak anti-Xa activity occurs 3-4 h after a subcutaneous LMWH injection, and 12-h anti-Xa levels are approximately 50% of peak levels. The clearance of SH is dose-dependent and occurs through a saturable mechanism due to binding by plasma proteins and endothelial cells, and a slower nonsaturable renal clearance. Because LMWH is not highly protein- or endothelial cell-bound, the saturable mechanism is minimal, and clearance is primarily renal. Therefore, the plasma half-life of LMWH is approximately 2-4 times longer than that of SH and increases in patients with renal failure [5,7]. A comparison of the biochemistry and pharmacology of SH and LMWH is shown in Table 1.Table 1: Biochemical and Pharmacologic Properties of Standard Heparin and Low Molecular Weight HeparinsFive LMWHs and one heparinoid (heparan and dermatan sulfate) are currently marketed or under development (Table 2). Low molecular weight heparin drugs vary both biochemically and pharmacologically, including molecular weight, anti-IIa and anti-Xa activities, and plasma half-life. Therefore, each drug must be administered based on the drug-specific dose and dosing schedule that have been determined in clinical trials to be safe and effective for the specific prophylaxis indication.Table 2: Commercially Available Low Molecular Weight HeparinsAdministration, Monitoring, and Reversal of LMWH Anticoagulant Effect To avoid bleeding and optimize convenience, most North American LMWH prophylaxis regimens for hip or knee replacement surgery administer the first dose from 12 to 24 h postoperatively and on a once- or twice-daily dosing schedule (dalteparin 5000 U once daily or enoxaparin 30 mg twice daily) [1]. In contrast, European regimens typically administer the first dose 6 h preoperatively and use a once-daily schedule (enoxaparin 40 mg once daily). Neither regimen requires laboratory monitoring or dose adjustment. Several additional issues regarding the optimal LMWH prophylaxis regimen are unresolved, including fixed versus weight-adjusted dosing and the duration of prophylaxis (inpatient versus extended outpatient prophylaxis) [8,9]. Because there are no adequate trials comparing the efficacy and safety of one LMWH with another, it is impossible to recommend one specific LMWH drug over another. When LMWH is administered at prophylaxis doses, the activated partial thromboplastin time is a relatively insensitive measure of LMWH activity. The anti-Xa level, as measured by either clot-based assays, such as the Heptest, or amidolytic assays, is a more sensitive measure of LMWH anticoagulant effect. Peak anti-Xa levels of 0.1-0.2 U / mL provide safe and effective venous thromboembolism prophylaxis after hip or knee replacement surgery [10,11]. The anticoagulant effects of SH are neutralized by an equimolar dose of protamine. Because of reduced protamine binding to LMWH fractions, only the anti-IIa activity of LMWH is completely reversed, whereas anti-Xa activity is not fully neutralized. A dose of 1 mg protamine / 100 LMWH anti-Xa units reverses 90% of anti-IIa and 60% of anti-Xa activity. The clinical significance of the residual anti-Xa effect is unknown. Both anti-IIa and anti-Xa activity may return up to 3 h after protamine reversal, possibly due to release of additional LMWH from the subcutaneous depot [12]. LMWH for Venous Thromboembolism Prophylaxis A comprehensive review of venous thromboembolism prophylaxis is beyond the scope of this article. We have restricted our review to the current Food and Drug Administration (FDA)-approved indications for LMWH as venous thromboembolism prophylaxis. For a more comprehensive review, the reader is referred to another publication [1]. Orthopedic Surgery Patients In the absence of prophylaxis, the prevalence of deep venous thrombosis as detected by venography among patients undergoing major orthopedic surgery ranges from 50% for total hip replacement to 80% for total knee replacement patients [1]. LMWH provides safe and effective prophylaxis in patients undergoing total knee or hip replacement. However, the efficacy varies by type of orthopedic procedure. For patients undergoing total hip replacement, LMWH is as effective as adjusted-dose subcutaneous SH and low-intensity oral anticoagulation (international normalized ratio 2.0-3.0) [13,14]. However, for patients undergoing total knee replacement, LMWH is significantly more effective than all other anticoagulant-based methods of prophylaxis [15-19]. The risk of major bleeding among patients receiving LMWH is similar to that with other anticoagulant-based methods of prophylaxis [20,21]. Currently, dalteparin and enoxaparin are FDA-approved and are marketed for prophylaxis after lower extremity joint replacement surgery, and ardeparin will be marketed for the same indication in the near future. LMWH prophylaxis is more effective and is as safe as low-dose SH prophylaxis after major trauma [22]. General Surgery Patients Several large studies and meta-analyses report a modest decrease in venous thromboembolism prevalence among general surgery patients receiving LMWH compared with low-dose SH prophylaxis [20,21,23,24]. In one study, the incidence of major bleeding was significantly less among LMWH patients compared with SH patients [24]. Prophylaxis with LMWH may be appropriate for general surgery patients at especially high risk, such as those patients undergoing abdominal or pelvic surgery for malignancy. However, due to the greater LMWH cost and lower risk for postoperative deep venous thrombosis, LMWH is unlikely to replace SH as standard prophylaxis for other general surgery patients. Currently, dalteparin and enoxaparin are FDA-approved and are marketed for prophylaxis after general surgery. Bleeding and heparin-induced thrombocytopenia and thrombosis (HITT) are the major complications associated with SH or LMWH prophylaxis. HITT, which is characterized by the presence of heparin-dependent, platelet-activating antibodies, typically occurs 7-10 days after initiation of heparin prophylaxis and may be associated with both venous and arterial thrombosis. In a clinical trial randomizing total hip replacement patients to either LMWH or SH prophylaxis, the incidence of HITT and heparin-dependent antibodies was significantly greater among patients receiving prophylaxis with SH (2.7%) compared with those receiving LMWH (0%) [25]. However, HITT associated with LMWH therapy has been reported [26]. Furthermore, antibody cross-reactivity between SH and LMWHs occurs in 40%-90% of patient sera with known heparin antibodies [27]. Therefore, LMWH should be avoided in patients with established HITT. Heparinoids such as danaparoid, which contain no heparin, have minimal cross-reactivity and have been used successfully in patients with HITT [28]. Spinal and Epidural Anesthesia in the Patient Receiving Standard or Low Molecular Weight Heparin Neurologic dysfunction due to bleeding after neuraxial blockade is rare, with an estimated incidence of less than 0.5 per 100,000 spinal anesthetics and less than 0.7 per 100,000 epidural anesthetics [29]. A review of clinical studies involving patients undergoing regional anesthesia while receiving anticoagulants, as well as case reports of spinal hematoma after neuraxial block, is helpful in evaluating potential risk factors for spinal bleeding. Vandermuelen et al. [4] reported 61 cases of spinal hematoma associated with spinal or epidural anesthesia. In 42 (68%) of the patients, there was evidence of a hemostatic abnormality. Twenty-five patients had received intravenous (IV) heparin (18 patients), subcutaneous heparin (3 patients), or LMWH (4 patients), whereas an additional 5 patients presumably received heparin during a vascular surgical procedure. Timing of needle placement relative to heparinization was not reported. A spinal anesthetic was performed in 15 patients, whereas the remaining 46 patients received an epidural anesthetic, including 32 patients with an indwelling catheter. In 15 of these 32 patients, the spinal hematoma occurred immediately after removal of the epidural catheter. These results are noteworthy, as they suggest that both catheter removal and the patient's coagulation status at the time of removal are critical factors in the development of spinal bleeding. A more recent investigation of 8501 spinal and 9232 epidural anesthetics performed from 1991 to 1994 reported three spinal hematomas, which all occurred in anticoagulated patients receiving postoperative epidural analgesia [30]. Two patients received an anticoagulant before catheter placement (one patient was chronically anticoagulated with dicoumarol and one patient received LMWH); the third patient received dextran intraoperatively and IV heparin postoperatively. IV and Subcutaneous Heparin Several large studies have demonstrated that spinal or epidural anesthesia followed by systemic heparinization is relatively safe [31,32]. Rao and El-Etr [31] reported no spinal hematomas in over 4000 patients undergoing lower extremity vascular surgery under continuous spinal or epidural anesthesia. However, patients with preexisting coagulation disorders were excluded, heparinization occurred at least 60 min after catheter placement, the level of anticoagulation was carefully monitored, and the indwelling catheters were removed at a time when heparin activity was low. Surgery in patients with frank blood noted in the needle was canceled and was performed the following day under general anesthesia. Subsequent investigations [4] of patients undergoing complete heparinization during cardiopulmonary bypass after subarachnoid or epidural needle / catheter placement typically followed the techniques described by Rao and El-Etr, including exclusion of patients with preexisting coagulapathies, a minimum of 1 h between needle placement and heparinization, close monitoring of clotting times, and postponement of surgery should a bloody tap occur. These methods were also substantiated in a subsequent report in the neurologic literature. Ruff and Dougherty [33] noted spinal hematomas in 7 of 342 (2%) patients who underwent lumbar puncture and subsequent heparinization for evaluation of cerebral ischemia. The presence of blood during needle or catheter placement, concomitant aspirin therapy, and heparinization within 1 h were identified as risk factors for spinal hematoma [33]. The safety of subcutaneous administration of SH also is well documented. A review by Schwander and Bachman [34] reported no spinal hematomas in more than 5000 patients undergoing spinal or epidural anesthesia while receiving varying doses of low-dose SH. Only three cases of spinal bleeding after subcutaneous SH have been reported in the literature, two of which involved a continuous epidural technique [4]. LMWH The administration of LMWH in patients undergoing spinal or epidural anesthesia was examined by Bergqvist et al. [35,36] in two reviews published in and These studies the European with LMWH no LMWH had been for general use in the at that Bergqvist et al. identified involving patients who had received the of LMWH and spinal or epidural anesthesia. of the studies were on the of anesthetic of the regional anesthetic technique are not with neurologic complications to spinal or epidural blockade are not The noted that estimated an additional several patients had received LMWH while undergoing regional anesthetic techniques with only one reported case of spinal hematoma on these Bergqvist et al. that neurologic complications after spinal or epidural anesthesia in patients receiving LMWH are rare, and that the However, an In a of the in we identified studies in which LMWH had been administered to surgical or patients. In of these spinal or epidural anesthesia had been used in with perioperative LMWH (Table These studies spinal or epidural A spinal was performed in a continuous spinal in and an epidural anesthetic in The placement of an indwelling epidural catheter was in it is impossible to the of continuous epidural The anesthetic technique was as or or in LMWH was preoperatively in 90% of cases and was typically administered once A of LMWH and doses are In more than of the the LMWH a were no spinal hematomas among the patients in these Because these studies were to and it is unlikely that neurologic complications to the anesthetic technique However, to those of the reports by Bergqvist et al. with of Low Molecular Weight Heparin (LMWH) and Spinal or Epidural trauma associated with the presence of an indwelling catheter was by et al. in the of and patients were patients received enoxaparin vascular patients of to aspirin received IV heparin 100 U / and 24 patients had no anticoagulant or antiplatelet administered and as of were immediately after catheter placement, 1 h after heparinization patients), or 3 h after catheter placement and patients), in the patients and before catheter removal 24 h A total of patients, 5 each in the and vascular patients and 7 patients had more than 100 and in at least one of the was no in among patient patient of spinal The that the indications for the placement of an catheter should be carefully the risk of spinal and that the perioperative administration of SH and LMWH not increase the risk of associated with continuous spinal anesthesia. have been published case reports of spinal hematoma in patients undergoing spinal or epidural anesthesia while receiving LMWH (Table The first were published in the patient to which LMWH was administered at that of patient and anesthetic factors associated with these cases subsequently to for the of regional anesthesia in patients receiving LMWH. that needle and catheter placement should be for at least h after the dose of LMWH. catheter removal should at least h after the with subsequent dosing of LMWH for at least h after catheter were by et al. [4] in These have been effective in the of spinal hematoma in patients receiving the of regional anesthesia and LMWH. However, it is that European have anesthetic of these patients, for by a spinal than a continuous epidural of Spinal with Low Molecular Weight Heparin (LMWH) and Spinal or Epidural was for general use by the in that there have been cases of spinal hematoma in the associated with LMWH reported to the (Table and Table Only one of these has been published as a case report (Table the of spinal hematoma in patients receiving enoxaparin while undergoing spinal or epidural anesthesia is to of the enoxaparin doses administered and the prevalence of regional anesthesia in orthopedic patients the between 1 in and 1 in regional is that the of spinal hematoma reported to European is significantly greater than provided by published and in that in the However, this is as by the of recent in the European of Spinal with and Spinal or Epidural Anesthesia to and anesthetic factors may for the in of spinal hematoma between the and the most factor is the in dosing of which is 30 mg twice daily in the and 40 mg once daily in The twice-daily dose regimen may provide a greater of anticoagulation and not in the same of heparin activity required for the safe placement and removal of spinal and epidural / The in dosing between the and results from of the clinical investigations at the time of drug review and Timing of the first dose of LMWH also LMWH therapy is preoperatively intraoperatively by the in In the that the first dose be administered h after surgery or when is is initiation of should the safety of regional anesthesia in patients receiving LMWH in the the regional anesthetic technique may the risk of spinal the patients with spinal hematomas associated with LMWH in the had indwelling epidural catheters for at least 24 of of the 24 spinal hematomas reported in Table and Table 5 several risk However, only a partial evaluation is only patients with spinal hematomas are and is reported on the anesthetic, and surgical factors of the several patients who received the of LMWH and spinal or epidural anesthesia the cases of spinal hematoma in which the regional anesthetic technique was involved epidural of which involved catheter In 7 of patients with indwelling epidural catheters within a of catheter which that catheter removal is a Conversely, the of spinal hematomas occurring in patients with epidural anesthesia and analgesia may the patient receiving LMWH and regional anesthetic surgical patients. Several other risk factors are In the patient received additional doses of LMWH or IV heparin and dextran were administered in an additional Bleeding complications in patients receiving antiplatelet therapy in with LMWH is not The of LMWH activity by antiplatelet has been reported in In in response to these the the to in the use of enoxaparin in patients with indwelling or epidural catheters or in patients with platelet Guidelines for the of Anesthesia in Patients Receiving Heparin The to neuraxial blockade on a patient receiving perioperative SH or LMWH must be on an the risk of spinal hematoma with the of regional anesthesia for a specific The following based on the of SH and as well as case reports and clinical studies involving patients undergoing spinal or epidural anesthesia while receiving these will the with this IV Heparin Spinal and epidural anesthesia may be performed in the patient undergoing subsequent heparinization provided heparinization occurs a minimum of 60 min after needle placement, the heparin effect is and within levels clotting time or activated partial thromboplastin time times and indwelling catheters are removed at a time when heparin activity is low or completely also recommend of surgery should bleeding during needle or catheter placement SH for the of regional anesthesia in patients receiving subcutaneous SH of needle placement or catheter removal within h of and monitoring of anticoagulant effect in patients with or to patients receiving LMWH is However, the in must be LMWH LMWH. Patients receiving LMWHs can be to have LMWHs are antithrombotic with a to half-life. Approximately 50% of peak anti-Xa activity is 12 h after administration of such as antiplatelet SH, or dextran an additional risk of complications including spinal A spinal anesthetic may be the neuraxial technique in patients receiving placement should at least h after the LMWH Subsequent dosing should be for at least h after needle The presence of blood during needle placement may an additional in initiation of postoperative LMWH. Patients with postoperative initiation of LMWH may and continuous catheter a continuous technique is the epidural catheter should be indwelling and removed the following with the first dose of LMWH administered h after catheter The to LMWH in the presence of an indwelling catheter must be with and of the patient's neurologic status is or anesthetic is in these patients to continuous monitoring of neurologic For LMWH prophylaxis the of catheter removal is of removal should be for at least h after a dose of LMWH. A of the patient's coagulation status be the dose of LMWH is not and the catheter is removed the following h after the subsequent dosing should not for h after catheter Patients be in the perioperative for early of such as of or and and was in our of patients. spinal hematoma is must be may to ischemia. The of is is unlikely surgery is more than h [4]. In regional anesthesia in association with perioperative heparin prophylaxis or systemic heparin anticoagulation is safe and effective with appropriate patient and anesthetic A of SH and LMWH biochemistry and pharmacology will optimal regional anesthesia while minimizing the risk of as well as venous of patients with spinal hematoma associated with LMWH (Table and Table is comprehensive through However, in the first of there have been additional cases reported to the and one published
The Journal of Bone and Joint Surgery. British volumeVol. 70-B, No. 4 ArticlesFree AccessDoes corrosion matter?J BlackJ BlackSearch for more papers by this authorPublished Online:1 Aug 1988https://doi.org/10.1302/0301-620X.70B4.3403590AboutSectionsPDF/EPUB ToolsAdd to FavouritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byPediatric fractures following implant removal: A systematic review10 November 2022 | Journal of Children's Orthopaedics, Vol. 6Effect of boron oxide on mechanical and thermal properties of bioactive glass coatings for biomedical applications7 March 2022 | Journal of the American Ceramic Society, Vol. 105, No. 6Titanium Wear of Dental Implants from Placement, under Loading and Maintenance Protocols21 January 2021 | International Journal of Molecular Sciences, Vol. 22, No. 3IN VITRO STUDY AND MECHANICAL CHARACTERISTICS OF DENTAL IMPLANTS MADE OF VARIOUS MATERIALS AND FABRICATION METHODS18 February 2021 | Journal of Mechanics in Medicine and Biology, Vol. 21, No. 01Coatings on orthopedic implants to overcome present problems and challenges: A focused reviewMaterials Today: Proceedings, Vol. 45Hardware removal rates after surgical treatment of proximal femur fractures21 January 2020 | Archives of Orthopaedic and Trauma Surgery, Vol. 140, No. 8Recent advancements in Fe-based biodegradable materials for bone repair19 October 2018 | Journal of Materials Science, Vol. 54, No. 3Mandibular Osteotomies1 August 2019Biodegradation of gold and platinum implants in rats studied by electron microscopy27 November 2019 | International Journal of Physics Research and Applications, Vol. 2, No. 1Artificial neural network based optimization of prerequisite properties for the design of biocompatible titanium alloysComputational Materials Science, Vol. 149Detection of Titanium Particles in Soft Tissues Adjacent to the Fixators in Patients with Facial Fractures and Bone Defects30 March 2018 | Journal of Diagnostics and Treatment of Oral and Maxillofacial Pathology, Vol. 2, No. 1Metal-on-Metal Hip Implants: Progress and Problems25 February 2018Dual-surface modification of titanium alloy with anodizing treatment and bioceramic particles for enhancing prosthetic devices21 April 2017 | Journal of Materials Science, Vol. 52, No. 15In Vivo Damage of the Head-Neck Junction in Hard-on-Hard Total Hip Replacements: Effect of Femoral Head Size, Metal Combination, and 12/14 Taper Design1 July 2017 | Materials, Vol. 10, No. 7Influence of process parameters on plasma electrolytic surface treatment of tantalum for biomedical applicationsApplied Surface Science, Vol. 407Fabrication and apatite inducing ability of different porous titania structures by PEO treatmentMaterials Science and Engineering: C, Vol. 66Inorganic characterizations and filler particles morphology of self-adhesive cementsInternational Journal of Adhesion and Adhesives, Vol. 68Study of the bioactivity, wettability and hardness behaviour of the bovine hydroxyapatite-diopside bio-nanocomposite coatingJournal of the Taiwan Institute of Chemical Engineers, Vol. 60Chapter 4 Immune Response12 June 2016Tribocorrosion and TMJ TJR DevicesAnodisation and Sol–Gel Coatings as Surface Modification to Promote Osseointegration in Metallic Prosthesis10 August 2016Corrosion at the Head-Neck Taper Interface Affects the Prognosis of Hip Revision Surgery29 January 2016Is Taper Fretting Corrosion a Threat to the Clinical Performance of Large-Diameter Hips with Highly Crosslinked Polyethylene Bearings?29 January 2016In vivo electrochemical corrosion study of a CoCrMo biomedical alloy in human synovial fluidsActa Biomaterialia, Vol. 21Metal Removal29 October 2014Do Ceramic Femoral Heads Reduce Taper Fretting Corrosion in Hip Arthroplasty? 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No AccessJournal of Speech and Hearing ResearchResearch Article1 Sep 1960Bekesy Audiometry in Analysis of Auditory Disorders James Jerger James Jerger Google Scholar https://doi.org/10.1044/jshr.0303.275 SectionsAboutPDF ToolsAdd to favoritesDownload CitationTrack Citations ShareFacebookTwitterLinked In Additional Resources FiguresReferencesRelatedDetailsCited by International Journal of Audiology61:3 (187-196)3 Mar 2022Distortion product otoacoustic mapping measured pre- and post-loud sound exposuresChris A. Brooks, Odile H. Clavier, Abigail M. Fellows, Catherine C. Rieke, Christopher E. Niemczak, Jiang Gui, Nina J. Pryor, Hilary L. Gallagher, Sara A. Murphy, Sean R. Wise, Claire Healy-Leavitt, Lindsay V. Allen and Jay C. 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SchlauchJournal of Speech and Hearing Disorders55:1 (67-74)1 Feb 1990A Descending Lot-Bekesy Screening Test for Functional Hearing LossJoseph B. Chaiklin The Journal of Laryngology & Otology101:4 (334-345)1 Apr 1987Auditory brain stem response and computed tomography in acoustic tumour investigationsS. J. Abramovich Scandinavian Audiology16:2 (101-108)1 Jan 1987 Quantitative Interpretation of Audiological Test Battery I. A Comparison with ABR in 97 Cases of Unilateral Sensorineural Hearing Loss Åke Reimer H. Hosoi, H. Abe, F. Ohta and S. Imaizumi Assessment of speech discrimination ability of hearing impaired subjects using FIR digital filter IEEE International Conference on Acoustics, Speech, and Signal Processing10.1109/ICASSP.1986.1169014 International Journal of Audiology23:6 (525-536)1 Jan 1984High-Frequency Békésy Audiometry V. Excursion WidthMaurice T. Gauz, Marshall M. Smith and Elizabeth Kocmond International Journal of Audiology23:2 (145-164)1 Jan 1984Auditory Deficits in Multiple Sclerosis: A ReviewPardo Mustillo E. Lehnhardt (1984) Klinik der Innenohrschwerhörigkeiten Verhandlungsbericht 1984 der Deutschen Gesellschaft für Hals- Nasen- Ohren-Heilkunde, Kopf- und Hals-Chirurgie10.1007/978-3-642-88067-4_2 Annals of the New York Academy of Sciences405:1 Cochlear Pros (412-420)1 Jun 1983COMPARISON OF PERCEPTS FOUND WITH COCHLEAR IMPLANT DEVICESCarl G. Müller International Journal of Audiology22:2 (144-161)1 Jan 1983Evaluation of Diagnostic Audiometric TestsSusan Jerger and James Jerger D. Plester and J. Poppendieck (1981) Audiological Findings in Retrocochlear Lesions The Cranial Nerves10.1007/978-3-642-67980-3_69 E. Harris Nober and Gerard L. Kupperman (1981) Physiogenic Hearing Impairment in Adults Communication Disorders10.1007/978-1-4757-9760-2_3 International Journal of Audiology19:6 (519-535)1 Jan 1980Pure-Tone Masking of TinnitusC. Formby and D. B. Gjerdingen Current Medical Research and Opinion6:sup10 (19-33)1 Jan 1980Audiological investigation in vertigoR. R.A. Coles R.S. Tyler, M. Fernandes and E.J. Wood (1980) MASKING, TEMPORAL INTEGRATION AND SPEECH INTELLIGIBILITY IN INDIVIDUALS WITH NOISE-INDUCED HEARING LOSS Disorders of Auditory Function10.1016/B978-0-12-684780-2.50025-9 K. Fleischer and J. Kießling (1980) Topodiagnostische Audiometrie HNO Praxis Heute10.1007/978-3-642-95369-9_1 Archives of Oto-Rhino-Laryngology222:4 (265-271)1 Dec 1979Zur Interpretation von B�k�sy-AudiogrammenOn the interpretation of B�k�sy audiogramsT. Harden and J. Kie�ling Acta Oto-Laryngologica87:3-6 (441-444)1 Jan 1979Békésy Audiometry in Evaluation of Hearing in Cases of Raised Intracranial PressureP. Y. John, S. K. Kacker and P. N. Tandon Otolaryngologic Clinics of North America11:3 (777-789)1 Oct 1978VertigoRobert J. Wolfson, Gene Del Polito and Uday Dave Otolaryngologic Clinics of North America11:3 (701-708)1 Oct 1978Automatic AudiometryLouis Siemiński The Journal of Laryngology & Otology92:1 (1-7)1 Jan 1978The diagnosis of acoustic neurinomaK. P. Singh, G. D. L. Smyth and D. S. Gordon DONALD D. DIRKS (1978) EFFECTS OF HEARING IMPAIRMENT ON THE AUDITORY SYSTEM Hearing10.1016/B978-0-12-161904-6.50020-8 D. Plester (1978) Otologische Diagnose der Kleinhirnbrückenwinkel-Tumoren Kleinhirnbrückenwinkel-Tumoren10.1007/978-3-642-66820-3_4 Annals of Otology, Rhinology & Laryngology86:3_suppl (40-48)1 May 1977Present Audiologic Status of Subjects Implanted with Auditory ProsthesesN. T. Hopkinson, R. C. Bilger and F. O. Black Annals of Otology, Rhinology & Laryngology86:3 (323-328)1 May 1977Hearing Loss from Acute Carbon Monoxide IntoxicationShan R. Baker and David J. Lilly Scandinavian Audiology6:4 (179-196)1 Jan 1977 Observations on Electric Brain-Stem Responses in Retrocochlear Hearing Loss A Preliminary Report H. J. Rosenhamer Archives of Oto-Rhino-Laryngology218:1-2 (27-35)Messung der Reaktionszeit und B�k�sy-AudiometrieReaction time and B�k�sy audiometryJ�rgen Kie�ling Archives of Otolaryngology102:11 (654)1 Nov 1976Special Audiometric Test Battery in 121 Proved Acoustic TumorsJack D. Clemis and Patricia G. Mastricola International Journal of Audiology15:3 (222-227)1 Jan 1976Comparison of Two Methods to Predict Cochlear Pathology from Beakeasy TracingsVincent W. Byers and David W. Granitz International Journal of Audiology15:3 (215-221)1 Jan 1976Typing of Beakeasy AudiogramsDavid W. Granitz and Vincent W. Byers International Journal of Audiology15:2 (152-162)1 Jan 1976Possibilities of Improving the Diagnosis of Noise-Induced Hearing Damage by Means of Directional Audiometry, the Dichotic Speech Discrimination Test, and the EEGH.-G. Dieroff Acta Oto-Laryngologica81:sup343 (67-77)1 Jan 1976Chapter VIII: Audiometric Evaluation C. S. Hallpike (1976) Sensori-Neural Deafness and Derangements of the Loudness Function: their Nature and Clinical Investigation Auditory System10.1007/978-3-642-66082-5_1 Indian Journal of Otolaryngology27:2 (76-84)1 Jun 1975Bekesy audiometry in diagnosis of sensori-neural deafnessP. S. Maiya, S. K. Kacker and A. K. Banerji Annals of Otology, Rhinology & Laryngology84:3 (384-390)1 May 1975Value of Special Auditory Tests in the Latero-Medial Inferior Pontine SyndromeDouglas Noffsinger, Sabina Kurdziel and Edward L. Applebaum Scandinavian Audiology4:3 (147-163)1 Jan 1975Clinical Validity of Central Auditory TestsI. Jerger and S. Jerger International Journal of Audiology14:2 (93-117)1 Jan 1975Extra- and Intra-Axial Brain Stem Auditory DisordersSusan Jerger and James Jerger Acta Oto-Laryngologica79:3-6 (378-383)1 Jan 1975Otological Studies in Patients with Deafness Due to Paget's Disease Before and After Treatment with Synthetic Human CalcitoninM. A. Menzies, P. B. Greenberg and G. F. Joplin Annals of Otology, Rhinology & Laryngology83:3 (275-285)1 May 1974Audiological Comparison of Cochlear & Eighth Nerve DisordersJames Jerger and Susan Jerger Otolaryngologic Clinics of North America6:1 (189-228)1 Feb 1973The Diagnosis and Evaluation of Acoustic NeuromasFelix Shiffman, Jess Dancer, Allan B. Rothballer, Arnold Berrett and Sheldon Baum Otolaryngologic Clinics of North America6:1 (53-71)1 Feb 1973Audiologie Tests in the Differential Diagnosis of VertigoJohn M. Page Scandinavian Audiology2:1 (29-40)1 Jan 1973Audiometric Manifestations of Retrocochlear LesionsG. Lidén and M. Korsan-Bengtsen International Journal of Audiology12:1 (21-27)1 Jan 1973Automatic versus Standard AudiometryO. Sala and G. Babighian Acta Oto-Laryngologica76:1-6 (328-330)1 Jan 1973Discrepancy Between The Loudness Function As Measured By The Ablb And The Metz MethodK. Terkildsen and J. Tingsgaard Archiv f�r klinische und experimentelle Ohren- Nasen- und Kehlkopfheilkunde203:3 (196-207)�ber die diagnostik von ponswinkeltumorenThe diagnosis of cerebellar-pontine angle tumorsA. Axelsson, N. Grebelius, C. Jensen and S. S�rne Occupational and Environmental Medicine29:2 (125-133)1 Apr 1972The meaning of modern audiological tests in relation to noise-induced deafness: a reviewT. J. Wilmot Archiv für klinische und experimentelle Ohren- Nasen- und Kehlkopfheilkunde199:2 (541-544)1 Feb 1972Der Hörschwellenschwund für Sinussignal und Rauschen bei Normalhörenden und LärmgeschädigtenR. Fischer and H. D. Gentz Scandinavian Audiology1:3 (115-118)1 Jan 1972Contralateral Masking Effect After Transsection of the Efferent Fibers to the CochleaB. Blegvad Acta Oto-Laryngologica74:sup303 (61-63)1 Jan 1972References The Laryngoscope82:1 (21-23)1 Jan 1972Change in type of bekesy audiogram in acoustic neuromaV. S. Dayal and T. Ruff British Journal of Audiology5:3 (62-64)1 Jan 1971A Re-Appraisal of Fixed Frequency Bekesy AudiometryR. H. Allen British Journal of Audiology5:1 (2-6)1 Jan 1971The Differential Detectability Index: A New Monaural Test for the Locus of Hearing Disorders?R. M. Barr-Hamilton, W. Tempest and M. E. Bryan Acta Oto-Laryngologica71:1-6 (212-216)1 Jan 1971Auditory Adaptation in HypoxiaG. von Schulthess Acta Oto-Laryngologica72:1-6 (413-420)1 Jan 1971 Viewpoints on the Management of Retrocochlear Lesions in Connection with a Case Report: A Tumour Originating from the Glossopharyngeal Nerve T. Lundborg Acta Oto-Laryngologica71:sup283 (43-45)1 Jan 1971References Physics in Medicine and Biology16:1 (1-24)1 Jan 1971A review of audiometryD W Robinson Annals of Otology, Rhinology & Laryngology79:1 (42-53)1 Feb 1970V Dominant Midfrequency Hearing LossBruce W. Konigsmark, Salah Salman, Harriet Haskins and Marvin Mengel International Audiology9:2-4 (149-155)1 Jan 1970Concerning BéKéSY Type V Audiograms as Evidence of Functional Hearing LossH. G. Dieroff Acta Oto-Laryngologica69:1-6 (324-328)1 Jan 1970Presbyacusis III. Perstimulatory Threshold AdaptationK. Jokinen The Journal of Laryngology & Otology83:10 (973-980)1 Oct 1969Electrogustometry III: Adaptation in electrical tasteM. Føns Journal of Speech and Hearing Research12:3 (594-606)1 Sep 1969Relationship of Auditory Distortion Test Results to Speech Discrimination Through Flat vs. Selective Amplifying SystemsGary Thompson and Frank Lassman The Journal of Laryngology & Otology83:6 (507-520)1 Jun 1969The scope and application of current audiometric testsGunnar Lidén Otolaryngologic Clinics of North America2:1 (191-197)1 Feb 1969Audiometric Profiles in Meniere's DiseaseCharles V. Anderson, David I. Huffman and Brian F. McCabe Acta Oto-Laryngologica68:sup258 (49-51)1 Jan 1969Refrences Acta Oto-Laryngologica67:1 (57-68)1 Jan 1969Hearing Loss And Caloric Response In Menière'a Disease: A Comparative StudyA. Enander and J. Stahle Annals of Otology, Rhinology & Laryngology77:6 (1042-1053)1 Dec 1968LXXXV Review of Diagnostic AudiometryJames Jerger Annals of Otology, Rhinology & Laryngology77:4 (686-705)1 Aug 1968LVI Assessment of the Newer Tests of Auditory FunctionD. Thane R. Cody, Terry Griffing and William F. Taylor The Journal of Laryngology & Otology82:8 (693-705)1 Aug 1968The Evaluation of Suspected Non-Organic Hearing LossH. A. Beagley and J. J. Knight Annals of Otology, Rhinology & Laryngology77:1 (78-87)1 Feb 1968VIII Retrocochlear Lesions: Problems in Early DiagnosisRobert F. Balas and Will P. Pirkey International Audiology7:1 (148-158)1 Jan 1968Hearing Impairment in Patients Having Multiple (Disseminated) SclerosisCurtis N Williams Acta Oto-Laryngologica66:1-6 (229-240)1 Jan 1968Beakeasy Audiometry and Clinical MaskingB. Blegvad Otolaryngologic Clinics of North America1:2 (489-497)1 Jan 1968Audiometric Findings in Meniere's DiseaseLeRoy D. Hedgecock Proceedings of the Royal Society of Medicine60:11P1 (1111-1117)1 Nov 1967Occupational DeafnessR Hinchcliffe Journal of Neurosurgery26:6 (598-602)Evaluation of the Auditory System Following Surgical Section of the Vestibular Division of the Eighth Cranial NerveWilliam R. Hodgson and Paul C. Bucy The Journal of Laryngology & Otology81:6 (613-617)1 Jun 1967A Further Study on the Temporary Effect of Industrial Noise on the Hearing of Stapedectomized Ears at 4,000 c.p.s.K. Ferris Annals of Otology, Rhinology & Laryngology76:1 (189-203)1 Mar 1967XIV Two Tests of Tone Decay: Their Contribution to Diagnostic DecisionsNorma T. Hopkinson and Sharon L. Thomas International Audiology6:2 (190-200)1 Jan 1967Critical Off-Time in Viiith-Nerve DisordersJames Jerger and Susan Jerger Acta Oto-Laryngologica64:1-6 (157-165)1 Jan 1967Contralateral Masking and Bfiklssy Audiometry in Normal ListenersB. Blegvad The Laryngoscope76:9 (1533-1539)1 Sep 1966Detection of cochlear overlay by full-range and discrete frequency bekesy audiometryRobert C. Bilger, Norma T. Hopkinson and Janet B. Richardson Journal of Neurosurgery24:3 (621-628)Audiological Aspects of the Diagnosis of Acoustic NeuromasE. W. Johnson and J. L. Sheehy Journal of Neurosurgery24:2 (483-492)Suboccipital Surgery for Acoustic Neurinomas: Advantages and DisadvantagesJ. Lawrence Pool Acta Oto-Laryngologica62:1-6 (453-458)1 Jan 1966 Békésy Audiometry, Sisi-Test and Contralateral Masking: Preliminary Report B. Blegvad and K. Terkildsen Journal of Neurosurgery22:4 (399-401)Translabyrinthine Microsurgery for Acoustic NeuromasErnest Sachs International Audiology4:2 (141-148)1 Jan 1965Békésy-Audiometry in Cases of Unstable Hearing and Preceeding Surgery to Improve HearingK. H. Hahlbrock Archiv für Ohren- Nasen- und Kehlkopfheilkunde183:2 (86-124)1 Nov 1964Störungen des Gehörs und des Geruchs bei endokraniellen ErkrankungenK. W. Hommerich The Laryngoscope74:10 (1391-1400)1 Oct 1964Atypical audiologic findings in a case of acoustic neurinomaOtto J. Menzelx, Louis A. Finney, Noble J. David and August Buermann New England Journal of Medicine271:12 (593-597)17 Sep 1964Congenital Laryngeal-Abductor Paralysis Due to Nucleus Ambiguus Dysgenesis in Three BrothersDwight Plott Clinical Pediatrics3:7 (414-417)1 Jul 1964Hearing and Related Problems in ChildhoodEthan A. Walker Annals of Otology, Rhinology & Laryngology73:1 (48-60)1 Mar 1964VI Threshold Auditory Adaptation Measured by Tone Decay Test and Békésy AudiometryF. Harbert and I. M. Young The Laryngoscope74:2 (171-185)1 Feb 1964A program of medical management for the adult with sensori-neural hearing lossH. A. Bailey Ted Acta Oto-Laryngologica57:1-2 (145-154)1 Jan 1964Audiologic Findings In Ménière's SyndromeF. Harbert and I. M. Young Acta Oto-Laryngologica58:1-6 (17-31)1 Jan 1964A Study of the Order Effects on Tracings Made with a Békésy-Type AudiometerLawrence J. Bradford and Cornelius P. Goetzinger Annals of Otology, Rhinology & Laryngology71:3 (744-758)1 Sep 1962LXIII Atypical Audiometric Configurations Associated with OtosclerosisRaymond Carhart Annals of Otology, Rhinology & Laryngology71:1 (124-133)1 Mar 1962XII Hemorrhagic Bullous Myringitis: Its Relation to Perceptive DeafnessDavid O. Merifield Volume 3Issue 3September 1960Pages: 275-287 Get Permissions Add to your Mendeley library History Published in issue: Sep 1, 1960 Metrics Topicsasha-topicsasha-article-typesCopyright & PermissionsCopyright © 1960 American Speech-Language-Hearing AssociationPDF downloadLoading ...
Academia and Clinic18 August 2009Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA StatementFREEDavid Moher, PhD, Alessandro Liberati, MD, DrPH, Jennifer Tetzlaff, BSc, and Douglas G. Altman, DSc, the PRISMA Group*David Moher, PhDFrom Ottawa Methods Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada; Università di Modena e Reggio Emilia, Modena, Italy; Centro Cochrane Italiano, Istituto Ricerche Farmacologiche Mario Negri, Milan, Italy; and Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom.Search for more papers by this author, Alessandro Liberati, MD, DrPHFrom Ottawa Methods Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada; Università di Modena e Reggio Emilia, Modena, Italy; Centro Cochrane Italiano, Istituto Ricerche Farmacologiche Mario Negri, Milan, Italy; and Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom.Search for more papers by this author, Jennifer Tetzlaff, BScFrom Ottawa Methods Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada; Università di Modena e Reggio Emilia, Modena, Italy; Centro Cochrane Italiano, Istituto Ricerche Farmacologiche Mario Negri, Milan, Italy; and Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom.Search for more papers by this author, and Douglas G. Altman, DScFrom Ottawa Methods Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada; Università di Modena e Reggio Emilia, Modena, Italy; Centro Cochrane Italiano, Istituto Ricerche Farmacologiche Mario Negri, Milan, Italy; and Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom.Search for more papers by this author, the PRISMA Group*Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-151-4-200908180-00135 SectionsSupplemental MaterialAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Editor's Note: In order to encourage dissemination of the PRISMA Statement, this article is freely accessible on the Annals of Internal Medicine Web site (www.annals.org) and will be also published in PLOS Medicine, BMJ, Journal of Clinical Epidemiology, and Open Medicine. The authors jointly hold the copyright of this article. For details on further use, see the PRISMA Web site (www.prisma-statement.org).Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field (1, 2), and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research (3), and some health care journals are moving in this direction (4). As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews.Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in four leading medical journals in 1985 and 1986 and found that none met all eight explicit scientific criteria, such as a quality assessment of included studies (5). In 1987, Sacks and colleagues (6) evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in six domains. Reporting was generally poor; between one and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement (7).In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized, controlled trials (8). In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1).Box 1. Conceptual Issues in the Evolution From QUOROM to PRISMA Download figure Download PowerPoint TerminologyThe terminology used to describe a systematic review and meta-analysis has evolved over time. One reason for changing the name from QUOROM to PRISMA was the desire to encompass both systematic reviews and meta-analyses. We have adopted the definitions used by the Cochrane Collaboration (9). A systematic review is a review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research, and to collect and analyze data from the studies that are included in the review. Statistical methods (meta-analysis) may or may not be used to analyze and summarize the results of the included studies. Meta-analysis refers to the use of statistical techniques in a systematic review to integrate the results of included studies.Developing the PRISMA StatementA three-day meeting was held in Ottawa, Ontario, Canada, in June 2005 with 29 participants, including review authors, methodologists, clinicians, medical editors, and a consumer. The objective of the Ottawa meeting was to revise and expand the QUOROM checklist and flow diagram, as needed.The executive committee completed the following tasks, prior to the meeting: a systematic review of studies examining the quality of reporting of systematic reviews, and a comprehensive literature search to identify methodological and other articles that might inform the meeting, especially in relation to modifying checklist items. An international survey of review authors, consumers, and groups commissioning or using systematic reviews and meta-analyses was completed, including the International Network of Agencies for Health Technology Assessment (INAHTA) and the Guidelines International Network (GIN). The survey aimed to ascertain views of QUOROM, including the merits of the existing checklist items. The results of these activities were presented during the meeting and are summarized on the PRISMA Web site (www.prisma-statement.org).Only items deemed essential were retained or added to the checklist. Some additional items are nevertheless desirable, and review authors should include these, if relevant (10). For example, it is useful to indicate whether the systematic review is an update (11) of a previous review, and to describe any changes in procedures from those described in the original protocol.Shortly after the meeting a draft of the PRISMA checklist was circulated to the group, including those invited to the meeting but unable to attend. A disposition file was created containing comments and revisions from each respondent, and the checklist was subsequently revised 11 times. The group approved the checklist, flow diagram, and this summary paper.Although no direct evidence was found to support retaining or adding some items, evidence from other domains was believed to be relevant. For example, Item 5 asks authors to provide registration information about the systematic review, including a registration number, if available. Although systematic review registration is not yet widely available (12, 13), the participating journals of the International Committee of Medical Journal Editors (ICMJE) (14) now require all clinical trials to be registered in an effort to increase transparency and accountability (15). Those aspects are also likely to benefit systematic reviewers, possibly reducing the risk of an excessive number of reviews addressing the same question (16, 17) and providing greater transparency when updating systematic reviews.The PRISMA StatementThe PRISMA Statement consists of a 27-item checklist (Table 1; see also Table S1, for a downloadable Word template for researchers to re-use) and a four-phase flow diagram (Figure 1; see also Figure S1, for a downloadable Word template for researchers to re-use). The aim of the PRISMA Statement is to help authors improve the reporting of systematic reviews and meta-analyses. We have focused on randomized trials, but PRISMA can also be used as a basis for reporting systematic reviews of other types of research, particularly evaluations of interventions. PRISMA may also be useful for critical appraisal of published systematic reviews. However, the PRISMA checklist is not a quality assessment instrument to gauge the quality of a systematic review.Table 1. Checklist of Items to Include When Reporting a Systematic Review or Meta-AnalysisFigure 1. Flow of information through the different phases of a systematic review. Download figure Download PowerPoint From QUOROM to PRISMAThe new PRISMA checklist differs in several respects from the QUOROM checklist, and the substantive specific changes are highlighted in Table 2. Generally, the PRISMA checklist “decouples” several items present in the QUOROM checklist and, where applicable, several checklist items are linked to improve consistency across the systematic review report.Table 2. Substantive Specific Changes Between the QUOROM Checklist and the PRISMA ChecklistThe flow diagram has also been modified. Before including studies and providing reasons for excluding others, the review team must first search the literature. This search results in records. Once these records have been screened and eligibility criteria applied, a smaller number of articles will remain. The number of included articles might be smaller (or larger) than the number of studies, because articles may report on multiple studies and results from a particular study may be published in several articles. To capture this information, the PRISMA flow diagram now requests information on these phases of the review process.EndorsementThe PRISMA Statement should replace the QUOROM Statement for those journals that have endorsed QUOROM. We hope that other journals will support PRISMA; they can do so by registering on the PRISMA Web site. To underscore to authors, and others, the importance of transparent reporting of systematic reviews, we encourage supporting journals to reference the PRISMA Statement and include the PRISMA Web address in their instructions to authors. We also invite editorial organizations to consider endorsing PRISMA and encourage authors to adhere to its principles.The PRISMA Explanation and Elaboration PaperIn addition to the PRISMA Statement, a supporting Explanation and Elaboration document has been produced (18) following the style used for other reporting guidelines (19–21). The process of completing this document included developing a large database of exemplars to highlight how best to report each checklist item, and identifying a comprehensive evidence base to support the inclusion of each checklist item. The Explanation and Elaboration document was completed after several face-to-face meetings and numerous iterations among several meeting participants, after which it was shared with the whole group for additional revisions and final approval. Finally, the group formed a dissemination subcommittee to help disseminate and implement PRISMA.DiscussionThe quality of reporting of systematic reviews is still not optimal (22–27). In a recent review of 300 systematic reviews, few authors reported assessing possible publication bias (22), even though there is overwhelming evidence both for its existence (28) and its impact on the results of systematic reviews (29). Even when the possibility of publication bias is assessed, there is no guarantee that systematic reviewers have assessed or interpreted it appropriately (30). Although the absence of reporting such an assessment does not necessarily indicate that it was not done, reporting an assessment of possible publication bias is likely to be a marker of the thoroughness of the conduct of the systematic review.Several approaches have been developed to conduct systematic reviews on a broader array of questions. For example, systematic reviews are now conducted to investigate cost-effectiveness (31), diagnostic (32) or prognostic questions (33), genetic associations (34), and policy making (35). The general concepts and topics covered by PRISMA are all relevant to any systematic review, not just those whose objective is to summarize the benefits and harms of a health care intervention. However, some modifications of the checklist items or flow diagram will be necessary in particular circumstances. For example, assessing the risk of bias is a key concept, but the items used to assess this in a diagnostic review are likely to focus on issues such as the spectrum of patients and the verification of disease status, which differ from reviews of interventions. The flow diagram will also need adjustments when reporting individual patient data meta-analysis (36).We have developed an explanatory document (18) to increase the usefulness of PRISMA. For each checklist item, this document contains an example of good reporting, a rationale for its inclusion, and supporting evidence, including references, whenever possible. We believe this document will also serve as a useful resource for those teaching systematic review methodology. We encourage journals to include reference to the explanatory document in their Instructions to Authors.Like any evidence-based endeavor, PRISMA is a living document. To this end we invite readers to comment on the revised version, particularly the new checklist and flow diagram, through the PRISMA Web site. We will use such information to inform PRISMA's continued development.References1. Oxman AD, Cook DJ, Guyatt GH. Users' guides to the medical literature. VI. How to use an overview. Evidence-Based Medicine Working Group. JAMA. 1994;272:1367-71. [PMID: 7933399] CrossrefMedlineGoogle Scholar2. Swingler GH, Volmink J, Ioannidis JP. Number of published systematic reviews and global burden of disease: database analysis. BMJ. 2003;327:1083-4. [PMID: 14604930] CrossrefMedlineGoogle Scholar3. Canadian Institutes of Health Research. Randomized controlled trials registration/application checklist. December 2006. Accessed at www.cihr-irsc.gc.ca/e/documents/rct_reg_e.pdf on 19 May 2009. Google Scholar4. Young C, Horton R. Putting clinical trials into context. Lancet. 2005;366:107-8. [PMID: 16005318] CrossrefMedlineGoogle Scholar5. Mulrow CD. 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[PMID: CrossrefMedlineGoogle In to A Article, and Disclosure From Ottawa Methods Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada; Università di Modena e Reggio Emilia, Modena, Italy; Centro Cochrane Italiano, Istituto Ricerche Farmacologiche Mario Negri, Milan, Italy; and Centre for Statistics in Medicine, University of Oxford, Oxford, United The following to the PRISMA Altman, DSc, Centre for Statistics in Medicine United PhD, University Hospital MD, Health Research & Health PLoS Medicine United PhD, Hospital of Ontario, A. & Research and PhD, PLoS Medicine the of United PhD, Cochrane Centre United and of and MD, of Medicine, Clinical Epidemiology and University Ontario, PhD, Università di Modena e Reggio and Centro Cochrane Italiano, Istituto Ricerche Farmacologiche Mario J. PhD, University of United MD, PhD, of Medicine, Clinical Epidemiology and University Ontario, PhD, of Health MD, of and Medicine, University of MD, PhD, Medical United MD, The Cochrane Centre PhD, Ottawa Hospital Research Institute Ontario, MD, of Medicine, Clinical Epidemiology and University Ontario, PhD, United MD, University of MD, PhD, Systematic Reviews United and for Health and University of the and Alessandro Liberati, MD, Università di Modena e Reggio and Centro Cochrane Italiano, Istituto Ricerche Farmacologiche Mario MD, Centre for the of the of Health PhD, The United MD, Centro Cochrane Italiano, Istituto Ricerche Farmacologiche Mario Moher, PhD, Ottawa Methods Centre, Ottawa Hospital Research Institute Ontario, MD, Annals of Internal Medicine for Medical MD, Health Research Centre Health and Technology Assessment Ontario, Canada; at the of the first meeting of the group, Ontario, MD, University of Hospital of Ontario, PhD, Health International G. MD, PhD, Evidence-Based Jennifer Tetzlaff, BSc, Ottawa Methods Centre, Ottawa Hospital Research Institute Ontario, The Cochrane Cochrane Collaboration United at the of the first meeting of the group, United and MD, Institute of University of Ottawa Ontario, PRISMA was by the Canadian Institutes of Health Università di Modena e Reggio Emilia, Italy; Research Clinical Evidence The Cochrane Collaboration; and Liberati is in through of the of University and Altman is by Research Moher is by a University of Ottawa Research of the any in the or of the PRISMA no a role in the Moher, PhD, Ottawa Methods Centre, Ottawa Hospital Research Institute, The Ottawa Ottawa, Canada; Moher and Ottawa Methods Centre, Ottawa Hospital Research Institute, The Ottawa Ottawa, Università di Modena e Reggio and Centro Cochrane Italiano, Istituto Ricerche Farmacologiche Mario Negri, Milan, Centre for Statistics in Medicine, University of Oxford, United of the PRISMA is in the PRISMA Statement for Reporting Systematic Reviews and of Studies Health Explanation and Elaboration Alessandro Liberati Douglas G. Altman Jennifer
No AccessJournal of Urology1 Feb 1958Congenital Patent Urachus J.T. Nix, J.G. Menville, M. Albert, and D.L. Wendt J.T. NixJ.T. Nix , J.G. MenvilleJ.G. Menville , M. AlbertM. Albert , and D.L. WendtD.L. Wendt View All Author Informationhttps://doi.org/10.1016/S0022-5347(17)66268-2AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail © 1958 by The American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited by Hirosawa T, Kaneko N, Kobayashi T, Sato J and Funayama Y (2022) Laparoscopic Resection of a Urachal Remnant in 19 Cases尿膜管遺残症19例に対する腹腔鏡下尿膜管摘除術の検討Nihon Gekakei Rengo Gakkaishi (Journal of Japanese College of Surgeons), 10.4030/jjcs.47.10, VOL. 47, NO. 1, (10-16), . Rove K and Wilcox D (2022) Bladder Diverticula, Urachal Anomalies, and Other Unusual Conditions of the Bladder Pediatric Surgery, 10.1007/978-3-642-38482-0_184-1, (1-8), . 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No AccessJournal of UrologyCLINICAL UROLOGY: ORIGINAL ARTICLES1 Sep 2002Laparoscopic and Robot Assisted Radical Prostatectomy: Establishment of a Structured Program and Preliminary Analysis of Outcomes Mani Menon, Alok Shrivastava, Ashutosh Tewari, Richard Sarle, Ashok Hemal, James O. Peabody, and Guy Vallancien Mani MenonMani Menon , Alok ShrivastavaAlok Shrivastava , Ashutosh TewariAshutosh Tewari , Richard SarleRichard Sarle , Ashok HemalAshok Hemal , James O. PeabodyJames O. Peabody , and Guy VallancienGuy Vallancien View All Author Informationhttps://doi.org/10.1016/S0022-5347(05)64548-XAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: The technique of laparoscopic radical prostatectomy is difficult to master and is associated with a steep learning curve. We hypothesized that a structured approach to establishing a laparoscopic prostatectomy program would diminish complications during the learning process and that robotic technology would be useful in learning the operation. Materials and Methods: A structured laparoscopic radical prostatectomy program was introduced at the Vattikuti Urology Institute on October 23, 2000. One of 2 surgeons with a combined experience of more than 500 laparoscopic radical prostatectomies performed or supervised the first prostatectomies, training a third surgeon with extensive "open" surgical skills but no laparoscopic experience. The "trained" surgeon then started performing the operation independently with robotic assistance. The results of this approach were analyzed at the end of 12 months. Results: We performed 48 laparoscopic radical prostatectomies and 50 robot assisted prostatectomies within the 12-month period. The preoperative and intraoperative demographical variables were comparable in both groups as were the operative times, changes in hemoglobin concentrations, durations of hospitalization, positive margin rates and overall complication rates. All measured parameters were comparable to the "best-in-class" values for laparoscopic radical prostatectomy reported in the literature. Conclusions: A structured approach minimizes complications during the establishment of laparoscopic radical prostatectomy program. Robotic assistance helps skilled "open" surgeons learn the technique of laparoscopic radical prostatectomy. References 1 : Laparoscopic radical prostatectomy: initial short-term experience. Urology1997; 50: 854. Crossref, Medline, Google Scholar 2 : Laparoscopic radical prostatectomy: the Montsouris technique. J Urol2000; 163: 1643. Link, Google Scholar 3 : Laparoscopic radical prostatectomy: preliminary results. Urology2000; 55: 630. 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Online publication date: X, Wang L, and Wang Comparison of and outcomes between standard laparoscopic and radical prostatectomy: a review and VOL. 31, NO. 3, Online publication date: Cole A, Trinh Sood A and Menon M The of Robotic Surgery in the New of Urology, VOL. NO. Online publication date: Abdollah F, T and Menon M (2017) Surgical in the Robotic Surgery The of Structured Urology Focus, VOL. 3, NO. 1, Online publication date: C, O, M, G, Mottrie A, Dasgupta P and K (2017) in Robot-assisted Urologic A Urology Focus, VOL. 3, NO. 1, Online publication date: A, P and P (2017) The Robotic Laparoscopic Radical Prostatectomy Management of Prostate . H, H, K, S, G and S (2017) A feasibility study of an for VOL. 44, NO. 1, Online publication date: F, R, S, F, G and A for the evaluation of robotic in and and Health VOL. NO. 6, Abdollah F, Dalela D, Sood A, J, Jeong W, B, N, Rogers C, M, Peabody J, A, F, M, A and Menon M control outcomes
You have accessJournal of UrologyAdult urology1 Dec 20072007 Guideline for the Management of Ureteral Calculi Glenn M. Preminger, Hans-Göran Tiselius, Dean G. Assimos, Peter Alken, Colin Buck, Michele Gallucci, Thomas Knoll, James E. Lingeman, Stephen Y. Nakada, Margaret Sue Pearle, Kemal Sarica, Christian Türk, and J. Stuart Wolf Glenn M. PremingerGlenn M. Preminger , Hans-Göran TiseliusHans-Göran Tiselius , Dean G. AssimosDean G. Assimos , Peter AlkenPeter Alken , Colin BuckColin Buck , Michele GallucciMichele Gallucci , Thomas KnollThomas Knoll , James E. LingemanJames E. Lingeman , Stephen Y. NakadaStephen Y. Nakada , Margaret Sue PearleMargaret Sue Pearle , Kemal SaricaKemal Sarica , Christian TürkChristian Türk , and J. Stuart WolfJ. Stuart Wolf View All Author Informationhttps://doi.org/10.1016/j.juro.2007.09.107AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction The American Urological Association Nephrolithiasis Clinical Guideline Panel was established in 1991. Since that time, the Panel has developed three guidelines on the management of nephrolithiasis, the most recent being a 2005 update of the original 1994 Report on the Management of Staghorn Calculi.1 The European Association of Urology began their nephrolithiasis guideline project in 2000, yielding the publication of Guidelines on Urolithiasis, with updates in 2001 and 2006.2 While both documents provide useful recommendations on the management of ureteral calculi, changes in shock-wave lithotripsy technology, endoscope design, intracorporeal lithotripsy techniques, and laparoscopic expertise have burgeoned over the past five to ten years. Under the sage leadership of the late Dr. Joseph W. Segura, the AUA Practice Guidelines Committee suggested to both the AUA and the EAU that they join efforts in developing the first set of internationally endorsed guidelines focusing on the changes introduced in ureteral stone management over the last decade. We therefore dedicate this report to the memory of Dr. Joseph W. Segura whose vision, integrity, and perseverance led to the establishment of the first international guideline project. This joint EAU/AUA Nephrolithiasis Guideline Panel (hereinafter the Panel) performed a systematic review of the English language literature published since 1997 and a comprehensively analyzed outcomes data from the identified studies. Based on their findings, the Panel concluded that when removal becomes necessary, SWL and ureteroscopy remain the two primary treatment modalities for the management of symptomatic ureteral calculi. Other treatments were reviewed, including medical expulsive therapy to facilitate spontaneous stone passage, percutaneous antegrade ureteroscopy, and laparoscopic and open surgical ureterolithotomy. In concurrence with the previously published guidelines of both organizations, open stone surgery is still considered a secondary treatment option. Blind basketing of ureteral calculi is not recommended. In addition, the Panel was able to provide some guidance regarding the management of pediatric patients with ureteral calculi. The Panel recognizes that some of the treatment modalities or procedures recommended in this document require access to modern equipment or presupposes a level of training and expertise not available to practitioners in many clinical centers. Those situations may require physicians and patients to resort to treatment alternatives. This article will be published simultaneously in European Urology and The Journal of Urology®. The Panel believes that future collaboration between the EAU and the AUA will serve to establish other internationally approved guidelines, offering physician and patient guidance worldwide. Methodology The Panel initially discussed the scope of the guideline and the methodology, which would be similar to that used in developing the previous AUA guideline. All treatments commonly employed in the United States and/or Europe were included in this report except for those that were explicitly excluded in the previous guideline or newer treatments for which insufficient literature existed. In the analysis, patient data were stratified by age (adult versus child), stone size, stone location, and stone composition. Later, however, the data were found to be insufficient to allow analysis by composition. The outcomes deemed by the Panel to be of particular interest to the patient included the following: stone-free rate, number of procedures performed, stone-passage rate or probability of spontaneous passage, and complications of treatment. The Panel did not examine economic effects, including treatment costs. Outcomes were stratified by stone location (proximal, mid, and distal ureter) and by stone size (dichotomized as ≤10 mm and >10 mm for surgical interventions, and ≤5 mm and >5 mm for medical interventions and observation where possible; exceptions were made when data were reported, for example as <10 mm and ≥10 mm). The mid ureter is the part of the ureter that overlies the bony pelvis, i.e., the position of the ureter that corresponds to the sacroiliac joint; the proximal ureter is above and the distal ureter is below. Treatments were divided into three broad groups: 1 Observation and medical therapy 2 Shock-wave lithotripsy and ureteroscopy 3 Open surgery, laparoscopic stone removal, or percutaneous antegrade ureteroscopy. The review of the evidence began with a literature search and data extraction. Articles were selected from a database of papers derived from MEDLINE® searches dealing with all forms of urinary tract stones. This database was maintained by a Panel chair. The abstract of each paper was independently reviewed by an American and a European Panel member, and articles were selected for data extraction if any panel member felt it might have useful data. Additional articles were suggested by Panel members or found as references in review articles. In total, 348 citations entered the extraction process. An American and a European Panel member each independently extracted data from each article onto a standardized form. The team members reconciled the extractions, and the data were entered into a Microsoft Access® (Microsoft, Redmond, WA) database. The Panel scrutinized the entries, reconciled the inconsistencies in recording, corrected the extraction errors, and excluded some articles from further analysis for the following reasons: 1 The article was included in the previous guideline. 2 The article did not provide usable data on the outcomes of interest. 3 Results for patients with ureteral stones could not be separated from results for those with renal stones. 4 The treatments used were not current or were not the focus of the analysis. 5 The article was a review article of data reported elsewhere. 6 The article dealt only with salvage therapy. A total of 244 of the 348 articles initially selected had extractable data. Articles excluded from evidence combination remained candidates for discussion in the text of the guideline. The goal was to generate outcomes tables comparing estimates of outcomes across treatment modalities. To generate an outcomes table, estimates of the probabilities and/or magnitudes of the outcomes are required for each intervention. Ideally, these are derived from a synthesis or combination of the evidence. Such a combination can be performed in a variety of ways depending on the nature and quality of the evidence. For this report, the Panel elected to use the Confidence Profile Method,3 which provides methods for analyzing data from studies that are not randomized controlled trials. The Fast*Pro computer software4 was used in the analysis. This program provides posterior distributions from meta-analyses from which the median can be used as a best estimate, and the central 95% of the distribution serves as a confidence interval. Statistical significance at the p <0.05 level (two-tailed) was inferred when zero was not included in the CI. Because of the paucity of controlled trials found on literature review, however, the outcome for each intervention was estimated by combining single arms from various clinical series. These clinical series frequently had very different outcomes, likely due to a combination of site-to-site variations in patient populations, in the performance of the intervention, in the skill of those performing the intervention, and different methods of determining stone-free status. Given these differences, a random-effects, or hierarchical, model was used to combine the studies. Evidence from the studies meeting the inclusion criteria and reporting a given outcome was combined within each treatment modality. Graphs showing the results for each modality were developed to demonstrate similarities and differences between treatments. The available data for procedures per patient would not permit a statistical analysis using these techniques. Unlike the binary outcome of stone-free status (the patient either is or is not stone free), the number of procedures per patient is a discrete rate. In some cases discrete rates can be approximated with a continuous rate, but in order to meta-analyze continuous rates, a measure of variance (e.g., standard deviation, standard error) is needed in addition to the mean. Unfortunately, measures of variance were rarely reported in the studies reviewed. As a result, numbers of procedures per patient were evaluated by calculating the average across studies weighted by the number of patients in each study. Procedures per patient were counted in three totals: primary procedures, secondary procedures, and adjunctive procedures. Primary procedures were all consecutive procedures of the same type aimed at removing the stone. Secondary procedures were all other procedures used to remove the stone. Adjunctive procedures were defined as additional procedures that do not involve active stone removal. One difficulty in estimating the total number of procedures per patient is that secondary and adjunctive procedures were not reported consistently. Since the Panel had decided to analyze primary, secondary, and adjunctive procedures separately, only studies that specifically reported data on a type of procedure were included in estimates for that procedure type. This approach may have overestimated numbers of secondary and adjunctive procedures because some articles may not have reported that procedures were not performed. It is important to note that, for certain outcomes, more data were reported for one or another treatment modality. While resulting CIs reflect available data, the probabilities for certain outcomes can vary widely within one treatment modality. In addition, the fact that data from only a few RCTs could be evaluated may have somewhat biased results. For example, differences in patient selection may have had more weight in analyses than differing treatment effects. Nevertheless, the results obtained reflect the best outcome estimates presently available. Studies that reported numbers of patients who were stone free after primary procedures were included in the stone-free analysis. Studies that reported only the combined number of patients who either were stone free or had "clinically insignificant fragments" were excluded. Many studies did not indicate how or when stone-free status was determined. The stone-free rate was considered at three time points: after the first procedure, after all consecutive procedures using the primary treatment, and after the total treatments. Initially, the Panel divided complications into three broad categories: acute, long-term, and medical; however, after examining the available evidence, the Panel determined that this breakdown was not useful. Several factors caused inaccuracy in the estimates, but did so in opposite directions, thereby reducing the magnitude of inaccuracy. For example, including studies that did not specifically mention that there were no occurrences of a specific complication may have led to overestimates of complication rates when meta-analyzed. By combining similar complications, the Panel also potentially mitigated the overestimate by making it more likely that a complication in the class was reported. The probability that a patient will have a complication may still be overstated slightly because some patients experienced multiple complications. Since the grouping of complications varies by study, the result of the meta-analysis is best interpreted as the mean number of complications that a patient may experience rather than as the probability of having a complication. Moreover, since reporting of complications is not consistent, the estimated rates given here are probably less accurate than the CIs would indicate. There were insufficient data to permit meaningful meta-analyses of patient deaths. Data analyses were conducted for two age groups. One analysis included studies of patients ages 18 or younger (or identified as pediatric patients in the article without specifying age ranges). The adult analysis included all other studies even if children were included. After the evidence was combined and outcome tables were produced, the Panel met to review the results and identify anomalies. From the evidence in the outcome tables and expert opinion, the Panel drafted the treatment guidelines. In this guideline the standard, recommendations, and options given were rated according to the levels of evidence published from the U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research:5 Ia Evidence obtained from meta-analysis of randomized trials Ib Evidence obtained from at least one randomized trial IIa Evidence obtained from at least one well-designed controlled study without randomization IIb Evidence obtained from at least one other type of well-designed quasi-experimental study III Evidence obtained from well-designed nonexperimental studies, such as comparative studies, correlation studies, and case reports IV Evidence obtained from expert committee reports, or opinions, or clinical experience of respected authorities As in the previous AUA guideline, the present statements are graded with respect to the degree of flexibility in application. Although the terminology has changed slightly, from the original AUA reports, the current three levels are essentially the same. A "standard" is the most rigid treatment policy. A "recommendation" has significantly less rigidity, and an "option" has the largest amount of flexibility. These terms are defined as follows: 1 Standard: A guideline statement is a standard if: (1) the health outcomes of the alternative interventions are sufficiently well known to permit meaningful decisions, and (2) there is virtual unanimity about which intervention is preferred. 2 Recommendation: A guideline statement is a recommendation if: (1) the health outcomes of the alternative interventions are sufficiently well known to permit meaningful decisions, and (2) an appreciable, but not unanimous majority agrees on which intervention is preferred. 3 Option: A guideline statement is an option if: (1) the health outcomes of the interventions are not sufficiently well known to permit meaningful decisions, or (2) preferences are unknown or equivocal. The draft was sent to 81 peer reviewers of whom 26 provided comments; the Panel revised the document based on the comments received. The guideline was submitted first for approval to the Practice Guidelines Committee of the AUA and the Guidelines Office of the EAU and then forwarded to the AUA Board of Directors and the EAU Executive Board for final approval. The guideline is posted on the American Urological Association website, www.auanet.org, and on the European Association of Urology website, www.uroweb.org. Chapter 1 will be published in The Journal of Urology and in European Urology. Results of the Outcomes Analysis The results of the analysis described in this chapter provide most of the evidentiary basis for the guideline statements. Further details and tables corresponding to the figures in this section are found in Chapter 3 and the Appendixes. The panel's attempt to differentiate results for pediatric patients from those for adults was not completely successful as most studies included both adults and children. Where possible, the panel performed two analyses, one including all studies regardless of patient age, and a second including only those studies or groups of patients that were comprised entirely of pediatric patients. Observation and Medical Therapies Stone-passage rates Only limited data were found on the topic of spontaneous passage by stone size. For stones ≤5 mm, meta-analysis of five patient groups (224 patients) yielded an estimate that 68% would pass spontaneously (95% CI: 46% to 85%). For stones >5 mm and ≤10 mm, analysis of three groups (104 patients) yielded an estimate that 47% would pass spontaneously (95% CI: 36% to 59%). Details of the meta-analysis are presented in Appendixes 8 and 9. Two medical therapies had sufficient analyzable data: the calcium channel blocker nifedipine and alpha-receptor antagonists. Analyses of stone-passage rates were done in three ways. The first combined all single arms evaluating the therapies. Using this approach, meta-analysis of four studies of nifedipine (160 patients) yielded an estimate of a 75% passage rate (95% CI: 63% to 84%). Six studies examined alpha blockers (280 patients); the meta-analysis yielded a stone-passage rate of 81% (95% CI: 72% to 88%). The second method was a standard Bayesian hierarchical meta-analysis of the available RCTs that compared either nifedipine or alpha blockers to control therapies. The results for nifedipine showed an absolute increase of 9% in stone-passage rates (95% CI: −7% to 25%), which was not statistically significant. Meta-analysis of alpha blockers versus control showed an absolute increase of 29% in the stone-passage rate (95% CI: 20% to 37%), which was statistically significant. The Panel also attempted to determine whether alpha blockers provide superior stone passage when compared to nifedipine. Two randomized controlled trials were identified. When hierarchical meta-analysis was performed on these two studies, tamsulosin provided an absolute increase in stone-passage rate of 14% (95% CI: −4% to 32%) which was not statistically significant. When nonhierarchical methods were used, the stone-passage improvement increased to 16% (95% CI: 7% to 26%) which was statistically significant. Finally, the Panel used the results of the meta-analyses versus controls (second method above) to determine the difference between alpha blockers and calcium channel blockers. This method allows the use of more data but is risky since it depends on the control groups having comparable results. The analysis yielded a 20% improvement in stone-passage rates with alpha blockers, and the 95% CI of 1% to 37% just reached statistical significance. Shock-wave Lithotripsy and Ureteroscopy Stone-free rates were analyzed for a number of variant methods of performing SWL and URS. The Panel attempted to differentiate between bypass, pushback, and in situ SWL as well as differences between lithotripters. Most differences were minimal and did not reach statistical significance. For that reason, the data presented in this Chapter compare the meta-analysis of all forms of SWL to the meta-analysis of all forms of URS. The Panel also attempted to differentiate between flexible and rigid ureteroscopes. Details of the breakdowns by type of SWL and URS are given in Chapter 3. Data were analyzed for both efficacy and complications. Two efficacy outcomes were analyzed: stone-free rate and procedure counts. Complications were grouped into classes. The most important classes are reported herein. The full complication results are in Appendix 10. Analyses were performed for the following patient groups where data were available. 1 Proximal stones ≤10 mm 2 Proximal stones >10 mm 3 Proximal stones regardless of size 4 Mid-ureteral stones ≤10 mm 5 Mid-ureteral stones >10 mm 6 Mid-ureteral stones regardless of size 7 Distal stones ≤10 mm 8 Distal stones >10 mm 9 Distal stones regardless of size Analyses of pediatric groups were attempted for the same nine groups, although data were lacking for many groups. Efficacy Outcomes Stone-free rates The Panel decided to analyze a single stone-free rate. If the study reported the stone-free rate after all primary procedures, that number was used. If not and the study reported the stone-free rate after the first procedure, then that number was used. The intention of the Panel was to provide an estimate of the number of primary procedures and the stone-free rate after those procedures. There is a lack of uniformity in the literature in reporting the time to stone-free status, thereby limiting the ability to comment on the timing of this parameter. The results of the meta-analysis of stone-free data are presented for the overall group in Table 1 and Figure 1. The results are presented as medians of the posterior distribution (best central estimate) with 95% credible intervals (Bayesian confidence intervals). Table 1. Stone-free rates for SWL and URS in the overall population Overall Population AUA/EAU Ureteral Stones Guideline Panel Stone Free Rate—Primary Treatments or SWL URS CI CI Distal Distal ureter mm Distal ureter mm 8 ureter mm 5 5 ureter mm 2 5 Proximal 81% Proximal ureter mm 9 Proximal ureter mm 68% 8 of arms of in those groups 1. Stone-free rates for SWL and URS in the overall This analysis that for stones in the proximal ureter there was no difference in stone-free rates between SWL and URS. for proximal ureteral stones <10 mm SWL had a stone-free rate than and for stones >10 mm URS had superior stone-free This difference because the stone-free rate for proximal ureteral stones with URS did not vary significantly with size, the stone-free rate following SWL with stone size. For all distal URS stone-free rates overall and in both size For all URS but the number of patients may have results from statistical significance. Unfortunately, RCTs comparing these treatments were making an accurate the posterior distributions resulting from the meta-analysis can be yielding a distribution for the difference between the treatments. If the CI of this result not then the results may be considered to be statistically significantly This is but if the patients different treatments are different or if outcome measures are results may be the Panel performed the and found that URS stone-free rates were significantly than SWL rates for distal ureteral stones ≤10 mm and >10 mm and for proximal ureteral stones >10 The stone-free rate for stones was not statistically significantly different between URS and The results with URS using a flexible for proximal ureteral stones than those with a rigid but not at a statistically Stone-free results for pediatric patients are in Table 2 and Figure The very number of patients in most groups, for treatments it that SWL may be more in the pediatric than in the overall in the mid and Table Stone-free rates for SWL and pediatric population Population AUA/EAU Ureteral Stones Guideline Panel Stone Free Rate—Primary Treatments or SWL URS CI CI Distal 8 9 Distal ureter mm 5 2 Distal ureter mm 2 26 6 3 ureter mm 4 ureter mm 1 1 6 5 Proximal 7 81% 5 18 Proximal ureter mm 5 Proximal ureter mm 3 63% of arms of in those groups Stone-free rates for SWL and pediatric were as three 1 Primary number of the procedure was performed. 2 Secondary number of an alternative stone removal was performed. 3 Adjunctive procedures performed at a time other than when the primary or secondary procedures were these could procedures to the procedures such as as well as procedures performed to with most adjunctive procedures in the data presented It is likely that many adjunctive procedures were and the adjunctive procedure may be As in Chapter it was not to a meta-analysis or to for statistically differences between treatments due to the lack of variance data, and only weighted could be The procedure results for the overall population are in Table 3 and Figure 3 results are presented as Table 3. for SWL and URS in the overall population Overall Population SWL URS Primary Secondary Adjunctive Primary Secondary Adjunctive Distal Distal ureter mm Distal ureter mm ureter mm ureter mm Proximal Proximal ureter mm Proximal ureter mm 3. for SWL and URS in the overall results for pediatric patients are in Table 4 and Figure the numbers of patients with available data were and did not meaningful treatments. Table for SWL and URS in the pediatric all Population SWL URS Primary Secondary Adjunctive Primary Secondary Adjunctive Distal Distal ureter mm
Gradenigo syndrome is a rare but potentially serious complication of suppurative otitis media, characterized by the classic triad of suppurative otorrhea, abducens nerve (VI) paralysis, and pain in the trigeminal nerve (V) territory. Although the advent of antibiotic therapy has significantly reduced its incidence, this condition remains relevant, particularly in children, requiring early recognition and appropriate multidisciplinary management. We report the case of a 13-year-old girl who presented with a painful swelling behind her right ear that had been developing for a year, accompanied by headaches, pain behind her right eye, and earache, along with a fever. Clinical examination revealed severe bulging of the right tympanic membrane, inflammatory retro auricular swelling, and decreased right ocular mobility in abduction with diplopia, suggestive of abducens nerve involvement. Imaging (CT scan of the temporal bone and brain) confirmed the diagnosis, showing a right mastoid subperiosteal abscess with complete opacification of the tympanic cavity, bone lysis of the external wall of the mastoid, and filling of the petrous apex. Treatment consisted of intravenous antibiotic therapy (third-generation cephalosporin (Ceftriaxone 50 mg/kg/day IV) and metronidazole (30 mg/kg/day IV)) for 15 days, short-term corticosteroid therapy, drainage of the collection, and drainage mastoidectomy due to persistent symptoms. This case perfectly illustrates the contemporary evolution of Gradenigo syndrome, where incomplete forms predominate. The pathophysiology involves the spread of infection from the middle ear to the petrous apex. Current microbiological data identify Fusobacterium necrophorum as the most common pathogen, justifying the systematic use of an anti-anaerobic agent. Modern management combines prolonged antibiotic therapy with surgery. Our patient's progress, marked by the disappearance of retro-orbital pain on the 5th postoperative day and complete recovery of ocular mobility on the 10th day, is consistent with the usual recovery times (median of 11 days after surgery). Gradenigo syndrome remains a serious complication of otitis media requiring early diagnosis and multidisciplinary management. The evolution of clinical presentations toward incomplete forms requires an adaptation of traditional diagnostic criteria. With appropriate management combining prolonged antibiotic therapy and surgery when necessary, the prognosis is generally favorable. This case highlights the importance of maintaining a high degree of clinical suspicion in the presence of any complicated otitis in children, particularly when associated neurological signs are present.
Splenic cysts are rare, with a reported incidence of 0.07-0.3%. Although most cases are benign and asymptomatic, some may grow large, rupture, become infected, or cause internal hemorrhage. Elevated serum carbohydrate antigen 19-9 (CA19-9) levels may also be observed, raising concerns regarding malignancy. Nonetheless, their diagnosis remains challenging because of their rarity, and the optimal treatment strategy remains controversial. Herein, we report a case of a giant splenic epithelial cyst with elevated serum CA19-9 levels that was successfully treated with laparoscopy-assisted splenectomy. We present the case of a 34-year-old female with a giant splenic epithelial cyst measuring >17 cm in diameter associated with elevated serum CA19-9 levels (122 U/mL). The cyst was initially discovered incidentally during imaging studies 3 years prior but had increased significantly in size. Recently, imaging revealed a multilocular cystic lesion with septations that prompted surgical resection owing to concerns of malignancy. Laparoscopic-assisted splenectomy was performed using a hand-assisted technique, following laparoscopic management of the splenic hilum. The cystic fluid CA19-9 level was markedly elevated at 10 832 U/mL; however, histopathology revealed a benign epithelial cyst. The postoperative recovery was uneventful, and the serum CA19-9 level normalized (8 U/mL) within 1 month. Three years after surgery, there were no signs of recurrence or complications. Splenic cysts are considered challenging to diagnose because splenic cysts are not common. However, proper management is needed. In cases of giant splenic cysts, pure laparoscopic surgery without rupture of the cyst presents challenges in accessing and dissecting the cranial side of the spleen owing to limited instrument maneuverability. In contrast, a planned hand-assisted approach may ensure safe and complete removal of the cyst without intraoperative rupture and spillage. Giant splenic cysts accompanied by elevated CA19-9 levels are rare and pose a diagnostic challenge. Laparoscopy-assisted splenectomy offers a safe and effective approach for complete resection while minimizing the risk of intraoperative rupture and spillage.
Metacarpal head fractures are rare intra-articular injuries categorized into 10 types by McElfresh and Dobyns. This report discusses the first reported case of simultaneous coronal head-split fractures of the fourth and fifth metacarpals, the unusual mechanism of injury, and our surgical management of this never-seen type of fracture. We describe the case of a coronal head split fracture of the fourth and fifth metacarpals in an 18-year-old male who presented with severe pain in the knuckles following a punch. Radiographs of the left hand showed intra-articular fractures of the heads of his fourth and fifth metacarpals step-off of 3 mm. Fixation was performed using two crossed 1.2-mm headless compression screws, each inserted dorsal to palmar to restore articular surface integrity and congruency. A full active range of motion was achieved at 8 weeks postoperatively without rotational deformity. We present our approach to patient management, comparing it to the existing literature. Given the articular step-off and the patient's young age, open reduction and internal fixation with headless compression screws was performed. To the best of our knowledge, this is the first documented case of surgical management for this specific fracture pattern, highlighting our successful approach in achieving anatomical reduction and stable fixation, which facilitated early mobilization and a favorable outcome. This report highlights a viable surgical approach and major take-away points for this rare intra-articular injury, namely fracture pattern recognition, adherence to surgical principles, and achieving appropriate anatomical reduction and stable fixation to promote faster and successful recovery.
Foramen of Winslow herniation is a rare type of internal hernia and an uncommon cause of intestinal obstruction. Early diagnosis is critical, as delayed recognition can lead to bowel ischemia and increased morbidity. This report contributes to the limited literature on large-bowel involvement and emphasises the value of prompt computed tomography (CT) imaging in reducing surgical morbidity. A 46-year-old woman presented with acute abdominal pain and vomiting. CT demonstrated the cecum and ascending colon entrapped within the lesser sac, highly suggestive of a foramen of Winslow hernia. Differential diagnoses included small-bowel obstruction and internal hernia. Emergency laparotomy confirmed herniation of the cecum, ascending colon, and terminal ileum without ischemic changes. Reduction was achieved via gentle traction and decompression, followed by colopexy and cecopexy to prevent recurrence. No bowel resection was required. Foramen of Winslow hernias represent fewer than 0.1% of all internal hernias and often present with nonspecific symptoms, making pre-operative diagnosis challenging. Cross-sectional imaging, particularly CT, is essential for early identification. Surgical management involves reduction of the herniated bowel, assessment of viability, and fixation procedures to prevent recurrence. This reinforces the need for early recognition to prevent ischemia and resection. Prompt recognition of foramen of Winslow hernia on CT enables timely surgery, often avoiding bowel resection. Awareness of this rare entity and its imaging characteristics facilitates early diagnosis and optimal patient outcomes. Fixation procedures such as colopexy or cecopexy may also help prevent recurrence and improve long-term outcomes.