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Search Results: 1 - 10 of 329077 matches for " Ronald S. Chamberlain "
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Caudal and Penile Blocks Demonstrate Similar Reliability and Efficacy in Pediatric Patients Undergoing Circumcision: A Meta-Analysis  [PDF]
Kiran Malik, Ronald S. Chamberlain
International Journal of Clinical Medicine (IJCM) , 2016, DOI: 10.4236/ijcm.2016.75033
Abstract: Purpose: Circumcision is one of the most common surgeries performed in the pediatric population. Multiple regional analgesic techniques, including caudal (CB) and penile block (PB), have championed as offering optimal analgesia for circumcision in the post-neonatal pediatric population without clear consensus. This meta-analysis sought to investigate CB and PB’s analgesic efficacy and the impact on postoperative analgesic requirements in pediatric circumcisions. Methods: A comprehensive literature search of PubMed, Google Scholar, and Cochrane Library (1966-2016) was completed to identify all published randomized control trials (RCTs). Keywords searched included “circumcision”, “caudal block”, “penile block”, and “analgesia”. Inclusion criteria were limited to the comparison of PB versus CB in children less than 18 years of age and its efficacy towards circumcision. The efficacy, time to first additive analgesia, time to first micturition, duration of prolonged motor blockade, incidence of vomiting, and length of stay were analyzed. Results: 9 RCTs involving 574 children (N = 287 in CB and PB) were included. No differences in analgesic efficacy (relative risk (RR) = 0.983, 95% confidence interval (CI) = 0.95 to 1.02; p = 0.328) or time to first additive analgesia were observed (standardized difference in mean (SDM) = 0.438, 95% CI = -0.04 to 0.92; p = 0.073). Time to first micturition (SDM = 0.680, 95% CI = 0.40 to 0.96; p < 0.001) and motor block duration (SDM = 0.707, 95% CI = 0.19 to 1.22; p = 0.007) were significantly prolonged in patients receiving CB. No differences were observed between groups in regards to the incidence of vomiting (RR = 1.56, 95% CI = 0.91 to 2.67; p = 0.107) and length of stay (SDM = 0.741, 95% CI = -0.05 to 1.53; p = 0.066). Conclusion: CB and PB offer similar analgesic success rates for pediatric patients (age 18 months to 16 years) undergoing circumcision. CB is associated with a trend towards longer duration of analgesia, but is associated with prolonged urinary retention and delayed ambulation. CB use is recommended in non-ambulatory children, whereas PB is recommended in ambulatory children.
The World Health Organization Surgical Safety Checklist Improves Post-Operative Outcomes: A Meta-Analysis and Systematic Review  [PDF]
Christine S. M. Lau, Ronald S. Chamberlain
Surgical Science (SS) , 2016, DOI: 10.4236/ss.2016.74029
Abstract: Background: The incidence of in-hospital adverse events is about 10%, with a majority of these related to surgery, and nearly half considered preventable events. In attempts to improve patient safety, the World Health Organization (WHO) developed a checklist to be used at critical perioperative moments. This meta-analysis examines the impact of the WHO surgical safety checklist (SSC) on various patient outcomes. Methods: A comprehensive search of all published studies assessing the use of the WHO SSC in patients undergoing surgery was conducted. Studies using the WHO SSC in any surgical setting, with pre-implementation and post-implementation outcome data were included. The incidence of patient outcomes (total complications, surgical site infections, unplanned return to the operating room (OR) within 30 days, and overall mortality) and adherence to safety measures were analyzed. Results: 10 studies involving 51,125 patients (27,490 prior to implementation and 23,635 after implementation of the WHO SSC) were analyzed. The implementation of the WHO SSC significantly reduced the risk of total complications by 37.9%, surgical site infections by 45.5%, unplanned return to OR by 32.1%, and mortality by 15.3%. Increased adherence to safety measures including airway evaluation, use of pulse oximetry, prophylactic antibiotics when necessary, confirmation of patient name and surgical site, and sponge count was also observed. Conclusions: The use of the WHO SSC is associated with a significant reduction in post-operative complication rates and mortality. The WHO SSC is a valuable tool that should be universally implemented in all surgical centers and utilized in all surgical patients.
A Population-Based Outcomes Analysis of the Impact of Age on Morbidity and Mortality Following Gastrectomy: An Analysis of 13,799 Patients from the Nationwide Inpatient Sample Database  [PDF]
Ami Karkar, Sachin Patil, Ronald S. Chamberlain
Journal of Cancer Therapy (JCT) , 2013, DOI: 10.4236/jct.2013.41A012

Introduction: Gastric cancer is the 4th most common malignancy and second leading cause of cancer-related death worldwide, both its incidence and mortality have decreased over the past 70 years. Advancing life expectancy, as well as subtle change in the type and location of gastric cancer in the US, has resulted in an increased number of elderly patients requiring gastric surgery. By 2050, the population older than 85 years is projected to reach 20.9 million, and as a result, the need to assess the operative outcomes and mortality following gastrectomy in this group is imperative. This study sought to assess age-related clinical outcomes following gastric cancer surgery across all age groups to provide more precise data for pre-operative surgical risk stratification. Methods: Discharge data on 40,276,240 patients was collected from Nationwide Inpatient Sample Database (NIS) (2004-2008). Data on patients undergoing gastrectomy as the primary procedure was analyzed including age, gender, elective/non-elective admission, pre-operative length of stay (LOS), total LOS, and mortality. Eight age groups were compared for two procedures: total gastrectomy (TG) and partial gastrectomy (PG). Categorical data was compared using the Chi square test and continuous data using the Student’s t test. Univariate analysis and multivariate regression analysis were performed to assess independent variables. Results: 13,799 patients underwent gastrectomy surgery with 23.7% having TG and 76.3% PG. Gastric carcinoma was the most common indication for TG, while benign gastric disease was more common for PG, especially in years 51 - 70 (p < 0.001).The mean age for TG and PG groups were 63 ± 12.8 and 64 ± 15 years respectively. Males underwent twice the number of TGs (p < 0.001), whereas equal number of males and females underwent PG (p < 0.001). The number of TGs increased over the 5-year study period, with the highest % change noted in those 41 - 50 years (1500%). PGs performed decreased overall, especially in patients <60 years, however PGs increased in patients >81 years with the greatest % change in the oldest patients >91

Males at High Risk for Breast Cancer: Who Are They and How Should We Screen Them?  [PDF]
Natalie Swergold, Vijayashree Murthy, Ronald S. Chamberlain
Surgical Science (SS) , 2014, DOI: 10.4236/ss.2014.57054

Background: It is estimated that 2240 males in the United States will develop invasive breast cancer (BC) in 2013, resulting in 410 deaths. Overall, male breast cancers (MBCs) are diagnosed with larger tumor size, more frequent lymphatic invasion, and advanced tumor stage compared to their female counterparts. Several risk factors have been elucidated for the development of MBC, and this paper aims to critically review the existing literature on at-risk populations and provide screening recommendations. Methods: A comprehensive search for all published studies on populations at risk for MBC using PubMed, EBSCOhost, and Google Scholar was performed (1982- 2013). The search focused specifically on genetic and epidemiologic risk factors, and screening for MBC. Keywords searched included “male breast cancer risk factors”, “male breast cancer epidemiology”, and “male breast cancer genetics”. A total of 34 studies involving 4,865,819 patients were identified. Results: Five studies (N = 327,667) focused primarily on family history of breast cancer as a risk factor for MBC. 15% - 20% of men with BC have a family history of breast or ovarian cancer, and a family history of BC among first-degree relatives confers a 2-to 3-fold increase in MBC risk (odds ratio = 3.3). Seventeen studies (N = 5451) analyzed associations between several heritable genes and MBC. Lifetime MBC risk among BRCA1 mutation carriers is 1% - 5%, while MBC risk in BRCA2 mutation carriers is higher and varies between 4% - 40%. Less clear associations between MBC and PALB2, Androgen Receptor gene, CYP17, and CHEK2 mutations have also been documented. Five studies (N = 16,667) have addressed occupational risk factors for MBC. An 8-fold increase in MBC is reported in males working in the cosmetic cream manufacturing, and the motor vehicle industries. A meta-analysis of 18 trials also identified electromagnetic field exposure as a potential MBC risk, though causation remains undocumented. Eleven studies (N = 4,843,598) analyzed the role of abnormalities in the androgen-to-estrogen ratio as a risk factor for MBC. Conditions associated with increased MBC risk include Klinefelter’s syndrome (relative risk, RR = 29.64), obesity (RR = 1.98), orchitis/epididymitis (RR = 1.84), and gynecomastia (RR = 5.86). Conclusion: Routine screening for MBC should be considered in all high risk male populations, including those with a prior history of breast carcinoma, a strong family history of BC

Intensive Insulin Therapy Has No Effect on Mortality and Morbidity in Cardiac Surgery Patients: A Meta-Analysis  [PDF]
Kedar P. Kulkarni, Ronald S. Chamberlain
International Journal of Clinical Medicine (IJCM) , 2016, DOI: 10.4236/ijcm.2016.78057
Abstract: Introduction: Optimal glycemic control in cardiac surgery patients remains a laudable but confusing practice. Existing studies have primarily employed two maintenance strategies using either intensive insulin therapy (IIT) (maintain glucose < 120 mg/dl) or conventional insulin therapy (CIT) (<200 mg/dl) with conflicting outcomes. This meta-analysis evaluates the impact of IIT and CIT in regards to the incidence of mortality, length of stay (LOS), intensive care unit (ICU) LOS, atrial fibrillation (AF), and infections. Methods: A comprehensive literature search in PubMed, Google Scholar and the Cochrane Central Registry of Controlled Trials was completed between 1966 and 2016. Keywords searched were “insulin”, “bypass”, “coronary”, “CABG”, “glucose”, “artery”, “intensive”, “cardiac”, and “surgery”. Eligible studies were randomized control trials (RCTs) comparing IIT (BGL 80-120 mg/dL) and CIT (BGL < 200 mg/dL). Primary outcomes were mortality, ICU LOS, and hospital LOS. Results: 8 RCTs were included in this study. IIT strategies did not significantly affect overall mortality (RR = 0.905, 95% CI = 0.604 to 1.356; p = 0.628), ICU LOS (MD = -0.073 days, 95% CI = -0.324 to 0.178; p = 0.568), or hospital LOS (MD = 0.269, 95% CI = -2.158 to 2.696; p = 0.828). No difference in AF rates (RR = 0.887, 95% CI = 0.681 to 1.155; p = 0.375) or deep sternal infection (RR = 0.985, 95% CI = 0.357 to 2.720; p = 0.977) were observed. Conclusion: IIT targeting blood sugar levels of 80 - 120 mg/dl have no effect on perioperative outcomes in cardiac surgery patients. IIT is associated with similar mortality, ICU LOS, hospital LOS, AF rates, and deep sternal infection rates compared to more liberal glycemic strategies. IIT should not replace CIT as the standard of care in cardiac surgery patients.
Perioperative Adjunct Magnesium Decreases Postoperative Opioid Requirements—A Meta-Analysis  [PDF]
Sudha Arumugam, Christine S. M. Lau, Ronald S. Chamberlain
International Journal of Clinical Medicine (IJCM) , 2016, DOI: 10.4236/ijcm.2016.75032
Abstract: Objectives: Magnesium (Mg) is the fourth most common cation in the body and has numerous physiological activities and anti-nociceptive effects. The anti-nociceptive effects are primarily mediated by regulation of calcium influx into the cell and antagonism of the N-Methyl-D-aspartate glutamate receptors. Opioids are widely used as analgesics to minimize postoperative pain, but their use is associated with various side effects as well as the potential for addiction and tolerance. Systemic Mg has been proposed as an adjunct to minimize postoperative pain in numerous clinical studies. This meta-analysis aims to critically examine the ability of perioperative intravenous (IV) Mg to reduce opioid use and its’ side effects. Methods: A comprehensive literature search of Pub Med, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2016) was performed to identify all randomized control trials (RCTs) assessing the use of perioperative IV Mg in the reduction of postoperative opioid consumption. Keywords searched included combinations of “magnesium”, “pain”, “postoperative”, “preoperative”, “analgesia” and “opioid”. Inclusion criteria included RCTs comparing the use of perioperative IV Mg with a control group in adult patients (>18 yrs) undergoing elective surgery. Cumulative opioid consumption within the first 24 hours (hrs) postoperative period and the incidence of nausea and vomiting were analyzed. Results: 14 RCTs involving 910 patients were identified (455 patients received Mg and 455 patients received placebo or no therapy). Opioid consumption was significantly decreased in the systemic Mg group (standard mean difference [SMD]: 1.39, 95% CI 1.83 to -0.96; p < 0.001) at 24 hrs postoperatively. Subgroup analysis revealed a significant reduction in the morphine consumption (SMD: -1.37, 95% CI: -1.79 to -0.95; p < 0.001) with the use of IV Mg. There was a decrease in tramadol consumption; however, this did not reach statistical significance (SMD: -1.74, 95% CI: -4.62 to 1.13; p = 0.234). Systemic Mg adjunct had no significant effect on postoperative nausea and vomiting (RR = 0.63; 95% CI 0.38 to 1.04; p = 0.07). Conclusion: Perioperative IV Mg administration reduces opioid use in the first 24 hours postoperatively without any serious adverse events. The decreased need for postoperative opioids in the Mg group was not associated with a decrease in opioid-related side effects such as nausea and vomiting. Mg is an efficacious adjunct for postoperative analgesia and should be considered in multimodal analgesic
The Impact of Ethnicity on the Incidence, Tumor Characteristics and Treatment of Ductal Carcinoma in Situ—An 11-Year Clinical Experience at a High Volume Teaching Hospital  [PDF]
Lauren S. Sparber, Vijayashree Murthy, Ronald S. Chamberlain
Surgical Science (SS) , 2016, DOI: 10.4236/ss.2016.78050
Abstract: Introduction: Screening mammography has led to a marked increase in detection of in situ breast tumors in the United States. The University of Southern California/Van Nuys Prognostic Index (USC/VNPI) predicts the recurrence rates of ductal carcinoma in situ (DCIS); however variations in tumor characteristics, USC/VNPI scores, receptor and human epithelial growth factor receptor (HER)-2/neu status across different ethnicities/races have not been well studied. This study aimed to evaluate the racial trends in incidence, patient demographics, tumor characteristics and treatment variations for patients with DCIS at a high volume teaching hospital. Methods: 395 women underwent surgical intervention for DCIS between 2000 and 2011. Their race/ethnicity was divided into five mutually exclusive categories and demographic and clinicopathological data was collected. Multivariate analysis was performed to evaluate variations in patient and tumor factors with respect to age, size and surgical management among different ethnicities and races. Results: 82.1% of Caucasian women underwent simple mastectomy with sentinel lymph node biopsy (SLNB) while lumpectomy with SLNB was highest in Hispanics (40%, p = 0.005). Overall, there was no significant difference in the incidence of receptor or HER-2/neu
Lithium Associated Hyperparathyroidism: An Evidence Based Surgical Approach  [PDF]
Umashankar K Ballehaninna, Steven M. Nguyen, Ronald S. Chamberlain
Surgical Science (SS) , 2011, DOI: 10.4236/ss.2011.210103
Abstract: Background: Long-term lithium use in psychiatric patients may lead to lithium associated hyperparathyroidism (LAH). Although anecdotal case reports have appeared, an evidence based algorithm for management of LAH is lacking. Methods: A comprehensive literature search was performed (1973-2010) using PubMed with keywords; “lithium” “hypercalcemia” “hyperparathyroidism” “sestamibi” “intra-operative parathyroid hormone (IOPTH) monitoring” “parathyroidectomy” and “medical management”. All English language publications addressing etiology and clinical management issues concerning LAH were critically analyzed. Results: Lithium associated hyperparathyroidism occurs in 4.3% - 6.3% of chronic lithium users compared to the general population which has an incidence of 0.5% - 1%. 194 cases of LAH have been reported which includes 10 patients (5%) treated medically and 170 patients (88%) who underwent parathyroidectomy. No details were available for 14 patients (7%). Among parathyroidectomy patients, 104 (59%) had adenomatous disease and 66 (39%) had multiglandular hyperplasia. Preoperative localization studies were utilized in only 22 patients (13%) and IOPTH monitoring was reported in only 3 studies (32 patients, 19%). Among surgical patients, bilateral neck exploration (BNE) was the most common approach performed in 162 patients (95%); focused neck exploration was utilized in only 8 patients (5%). Parathyroidectomy normalized LAH biochemical changes in nearly all patients (90% - 97%) in the early post-operative period, but recurrent hyperparathyroidism occurred in 8% - 42% of patients. Conclusion: LAH is an under appreciated and poorly understood endocrine disorder. LAH has a higher incidence of multiglandular disease and bilateral neck exploration is mandatory in majority for disease control. Nonsurgical approaches may be useful in select patients on short-term lithium therapy.
Surgical Outcome Following Hip Fracture in Patients > 100 Years Old: Will They Ever Walk Again?  [PDF]
Sachin Patil, Bertrand Parcells, Alexis Balsted, Ronald S. Chamberlain
Surgical Science (SS) , 2012, DOI: 10.4236/ss.2012.311109
Abstract: Introduction: Advances in medicine have led to a growth in the centenarian population (>100 years old). Centenarians are a largely unstudied population but as longevity increases, so will the cost of providing care for this group. Methods: One hundred and ten patients were admitted to SBMC 195 times between 2000 and 2009. Thirteen patients were treated for hip fracture. Data abstracted from the charts of these patients including age, gender, ethnicity, co-morbidities, advance directives (ADRs), functional status, length of stay (LOS), pre-operative and post-operative residential status and ambulatory status, ASA grade, type of anesthesia, duration of surgery and for complications of surgery or anesthesia. Results: The mean age was 101.2 years (100 to 104 years) with an M:F ratio of 2:11. The most common co-morbidities were hypertension, anemia, congestive heart failure (CHF) and coronary artery disease. Among the 13 patients with hip fractures, 12 had operative intervention while one was treated conservatively. The mean ASA grade was 2.75 (1 - 4). Five patients had surgery under general anesthesia and seven received spinal anesthesia. Five patients received a bi-polar hip replacement and seven patients underwent internal fixation. The mean operative time was 47.6 min (27 - 90 min). Five (41.7%) patients required a peri-operative blood transfusion. The mean post-anesthesia recovery score was 9.42 (9 - 10). All patients, except two, were returned to their pre-operative ambulatory status. Advanced directives were held by only 30.8% of patients on admission. There were 2 post-operative morbidities and 1 mortality. Conclusions: Centenarians represent a high-risk-surgical population due to their age and associated comorbidities. Hip fracture is the cause of >10% of all admissions and accounts for 29% of all surgical procedures in this age group. Despite their age and comorbidities, surgery for hip fracture is well tolerated and nearly all patients were returned to their pre-hospital ambulatory status. Education on advanced directives is lacking.
A United States Population-Based Study on Clinical Outcomes Following Primary Carotid Endarterectomy: Who and When?  [PDF]
Shirali T. Patel, Sachin V. Patil, Ronald S. Chamberlain
Surgical Science (SS) , 2012, DOI: 10.4236/ss.2012.312117
Abstract: Introduction: Carotid Endarterectomy (CEA) is widely recognized as effective in significantly reducing the risk of recurrent stroke emanating from extracranial carotid atherosclerosis and approximately 140,000 carotid endarterectomies are performed annually in the United States (US). As such, data are scarce on the prevalence and clinical outcomes of CEA across different age groups. This study aimed to determine and analyze the prevalence, demographic and clinical outcomes of CEA across six decades of life. Methods: Data on 40,276,240 patients were abstracted from discharge data obtained from the Nationwide Inpatient Sample (NIS) database, a part of the Healthcare Cost and Utilization Project (HCUP) of the Agency for Healthcare Research and Quality (2004-2008). Demographic and clinical characteristics of patients undergoing CEA as the primary procedure were abstracted including age, gender, elective or non-elective admission, comorbidities, Length of Stay (LOS), secondary procedures, NIS severity of illness and risk of mortality class, complications and mortality. CEA outcomes were compared across six decades of life starting at age 41. Categorical variables were compared using the Chi-square test, and the Student’s t-test was used to compare continuous variables. Results: 118,947 patients who underwent CEA as their primary procedure were identified. Caucasians accounted for 67.1% of the population. The overall mean age was 71.2 ± 9.5 years, with a Male: Female ratio of 1.3:1. Nineteen percent of patients had non-elective admission, with the highest percentage (29.5%) in those >91 years old. Over three percent of patients had a prior stroke. The overall number of CEA performed peaked in the 8th decade of life (38.4%). The most common co-morbidities were hypertension, diabetes mellitus, and chronic pulmonary disease. Mean LOS was 3.3 days. Forty-two percent of all cases were performed in a teaching hospital, with the percentage increasing with advancing age. The overall mortality and stroke rates were 0.4% and 0.9%, respectively, and these rates were highest in the oldest patients (>91 years). The overall myocardial infarction rate was 0.8% which was highest incidence in the 7th and 9th decades (1.1%). On multivariate analysis, age >80 years (Odds Ratio (OR), 2.9; 95% Confidence Interval (CI), 1.1 - 8.0), Non-white race (OR, 1.7; CI, 1.1 - 2.7), Charlson co-morbidity index score of 1 - 5 (OR, 1.7; CI, 1.3 - 2.4), carotid artery stenosis with stroke at presentation (OR, 1.7; CI, 1.1 - 2.5), Congestive Heart Failure (CHF) (OR, 3.7; CI, 2.8 - 4.8)
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