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<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_402"
                     title="Minimally Invasive Surgery Takes Toll on MDs, Poll Shows (CME/CE)"
                     score="0.012"
                     href="http://www.medpagetoday.com/Surgery/GeneralSurgery/tb/18306?impressionId=1265815412504"
                     
      &lt;p&gt;Four out of five surgeons agree: Laparoscopic procedures cause substantial discomfort and pain for the surgeons who perform them.&lt;/p&gt;
&lt;p&gt;More than 80% of surgeons completing an online questionnaire reported pain or stiffness in the hands, neck, back, or legs after performing minimally invasive surgeries, according to Adrian Park, MD, of the University of Maryland Medical Center in Baltimore, and colleagues.&lt;/p&gt;
&lt;p&gt;For most symptoms, the strongest predictor was high case volume, the researchers reported online in the &lt;em&gt;Journal of the American College of Surgeons&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Park and colleagues warned of &quot;an impending epidemic&quot; of occupational injuries among clinicians specializing in minimally invasive surgeries, as such procedures become more common.&lt;/p&gt;
&lt;p&gt;&quot;Now, especially in the face of an impending shortage of general surgeons in the U.S., the last thing that we as a society can afford is surgical careers shortened by occupationally related symptoms and conditions,&quot; they asserted.&lt;/p&gt;
&lt;p&gt;The researchers recommended more research into the ergonomics of laparoscopic surgery, as well as better implementation of existing guidelines meant to reduce injuries associated with the awkward postures and long surgical times often required with these procedures.&lt;/p&gt;
&lt;p&gt;&quot;That research must more clearly and emphatically define the ergonomic impact of minimally invasive surgery on the practicing surgeon (then set about improving it) is now all too painfully clear,&quot; Park and colleagues concluded.&lt;/p&gt;
&lt;p&gt;The researchers invited some 2,000 board-certified members of the Society of American Gastrointestinal and Endoscopic Surgeons (of which Park is currently secretary) to complete the online survey.&lt;/p&gt;
&lt;p&gt;The response rate was 14.4%, with 317 surgeons identified as actively and regularly involved in laparoscopic practices participating.&lt;/p&gt;
&lt;p&gt;Of these, 272 reported experiencing physical symptoms or discomfort that they believed were the result of performing minimally invasive procedures.&lt;/p&gt;
&lt;p&gt;This rate of reported symptoms is markedly higher than that found in earlier studies and surveys, in which the prevalences were in the range of 15% to 60%, Park and colleagues noted.&lt;/p&gt;
&lt;p&gt;They speculated that the current survey, as the most recent, may better reflect the accumulation of injuries over time as surgeons&apos; careers doing minimally invasive surgery have grown longer.&lt;/p&gt;
&lt;p&gt;Fortunately, they found, symptoms were generally not persistent. Only 10.8% of respondents indicated that pain or discomfort continued beyond the immediate aftermath of surgery.&lt;/p&gt;
&lt;p&gt;The largest class of symptoms were those occurring during surgery, with 20.8% of surgeons saying they had symptoms only during procedures and 27.8% reporting symptoms both during and immediately after surgery.&lt;/p&gt;
&lt;p&gt;Another 22.4% indicated that symptoms occurred only immediately after surgery and not persistently.&lt;/p&gt;
&lt;p&gt;About 15% chose &quot;nothing bothers me&quot; in the questionnaire.&lt;/p&gt;
&lt;p&gt;Age appeared to be a factor in the incidence of some complaints, although the pattern was not what might be expected. In particular, hand pain was most common among surgeons younger than 40 and in those older than 60, whereas it was least frequent among surgeons in their 50s.&lt;/p&gt;
&lt;p&gt;Park and colleagues did not report specific hazard ratios or correlation coefficients for case volume as a predictor of symptoms, but they indicated that it was associated with complaints more strongly than other factors such as age, career duration, gender, and height.&lt;/p&gt;
&lt;p&gt;About three-quarters of respondents attributed symptoms to instrument design. Some 40% indicated that operating room table setup and the display monitor location were also contributing factors.&lt;/p&gt;
&lt;p&gt;On the other hand, more than 180 respondents said they had slight or no awareness of published recommendations on surgical ergonomics, such as guidelines published last year in the journal &lt;em&gt;Surgical Endoscopy&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Among those reporting any level of knowledge about the guidelines, only 60% indicated that they had applied it in their practices, Park and colleagues indicated. But more than 90% of surgeons who said they had high awareness of ergonomic guidelines reported putting it to use.&lt;/p&gt;
&lt;p&gt;The researchers said future studies should address other issues not covered adequately in the survey, such as the effects of different monitor positions and instrument designs, as well as whether surgeon discomfort during laparoscopic surgery leads to adverse patient outcomes.&lt;/p&gt;
&lt;p&gt;Park and colleagues also suggested that similar research be conducted on open surgery.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;No external funding for the study was reported.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_212"
                     title="No Need for Most Moms to Fast During Labor (CME/CE)"
                     score="-0.004"
                     href="http://www.medpagetoday.com/OBGYN/Pregnancy/tb/18059?impressionId=1265815412504"
                     
      &lt;p&gt;Although conventional wisdom has long held that women shouldn&apos;t eat or drink during labor, the scientific evidence suggests there&apos;s no reason for the prohibition, according to a new meta-analysis.&lt;/p&gt;
&lt;p&gt;&quot;Since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labor for women at low risk of complications,&quot; Mandisa Singata, MBA, RM, RN, of the University of the Witwatersrand in East London, South Africa, and colleagues concluded in a Cochrane review.&lt;/p&gt;
&lt;p&gt;They identified five studies involving 3,130 women that examined whether food and drink during labor affected outcomes such as rates of cesarean section, operative vaginal births, or Apgar scores. No significant advantage was found for restricting access to food or liquids on any outcome, Singata and colleagues found.&lt;/p&gt;
&lt;p&gt;Until the 1940s, women were generally encouraged to eat and drink during labor  --  often specific foods and fluids  --  to keep up their strength.&lt;/p&gt;
&lt;p&gt;But a 1946 paper and other publications by Curtis Lewis Mendelson suggested that access to food increased the risk that women under anesthesia would aspirate acidic stomach contents during labor, potentially causing serious lung injury and even death.&lt;/p&gt;
&lt;p&gt;Mendelson&apos;s work persuaded many obstetricians to urge that women fast until after delivery, according to Singata and colleagues.&lt;/p&gt;
&lt;p&gt;The researchers cited a 1988 survey of U.S. hospitals that found almost half allowed only ice chips, although more recent trends suggested that access to food and liquids had increased, at least in Great Britain.&lt;/p&gt;
&lt;p&gt;They noted that some women in labor don&apos;t feel like eating but others regard restrictions as &quot;unpleasant and sometimes harrowing.&quot;&lt;/p&gt;
&lt;p&gt;One reason for revisiting Mendelson&apos;s research is that anesthesia procedures have changed markedly since the 1940s, with regurgitation of stomach contents now considered very rare.&lt;/p&gt;
&lt;p&gt;&quot;The policy of routine restriction of foods and fluids in labor in many hospitals across the world generally does not reflect women&apos;s preferences or cultural expectations,&quot; Singata and colleagues wrote. &quot;It is critical that any policy should be based on evidence of overall benefit to women and babies.&quot;&lt;/p&gt;
&lt;p&gt;Searching the literature, Singata and colleagues found five randomized trials that had compared more versus less restrictive nutrition regimens.&lt;/p&gt;
&lt;p&gt;Only one of the trials tested free access to any kind of food and drink against restriction to ice chips or sips of water. The other four examined particular classes of nutritive foods or drinks.&lt;/p&gt;
&lt;p&gt;Two tested electrolyte-carbohydrate sports drinks and two others evaluated low-fat and/or low-residue foods, all against water or ice chips.&lt;/p&gt;
&lt;p&gt;Pooling data from the five studies, Singata and colleagues calculated relative risks for three major adverse outcomes for allowing access to nutrition, versus water or ice chips: &lt;ul&gt; &lt;li&gt;Cesarean section: RR 0.89, 95% CI 0.63 to 1.25&lt;/li&gt; &lt;li&gt;Operative vaginal birth: RR 0.98, 95% CI 0.88 to 1.10&lt;/li&gt; &lt;li&gt;Apgar scores &amp;lt;7 at five minutes: RR 1.43, 95% CI 0.77 to 2.68&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The meta-analysis also examined eight other outcomes, such as maternal ketosis and nausea and vomiting, infant admission to intensive care, and augmentation of labor. There were no significant differences in any of these outcomes between allowing and restricting access to nutrition.&lt;/p&gt;
&lt;p&gt;The sole study comparing unlimited access to food and drink to water or ice chips, which had 330 participants, also found no effects on either primary or secondary outcomes in either direction.&lt;/p&gt;
&lt;p&gt;None of the studies examined women&apos;s perceptions of the labor experience based on whether or not they had access to nutrition.&lt;/p&gt;
&lt;p&gt;Singata and colleagues called the overall quality of evidence &quot;reasonable.&quot; But they noted that none of the studies enrolled women at increased risk of needing general anesthesia, so the conclusions should be interpreted as applying only to women at low risk of complications.&lt;/p&gt;
&lt;p&gt;The studies also left some questions unanswered. For example, one of the two sports drink studies found that C-section rates were lower in participants who drank plain water, but no such result was seen in the other.&lt;/p&gt;
&lt;p&gt;&quot;It would be worth comparing the use of carbohydrate drinks ... with freedom to eat and drink at will during labour to see if this really is a problem,&quot; Singata and colleagues wrote.&lt;/p&gt;
&lt;p&gt;Moreover, they suggested, &quot;a better approach&quot; to the rare problem of inhaling regurgitated material while under anesthesia during labor may be to test treatments intended to reduce acidity and volume of stomach contents, now used during elective C-sections.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;External funding for the study came from the World Health Organization and the U.K. National Institute for Health Research.&lt;/p&gt;&lt;p&gt;One author of the review was principal author of one of the studies included in the meta-analysis, but did not participate in decisions regarding data from that study. No other potential conflicts were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_201"
                     title="Viral Cause of Appendicitis Called Unlikely (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Surgery/GeneralSurgery/tb/18048?impressionId=1265815412504"
                     
      &lt;p&gt;The cause of appendicitis remains a mystery, according to a study that discounts flu and intestinal infection as candidates.&lt;/p&gt;
&lt;p&gt;Influenza&apos;s distinctive seasonal variations don&apos;t match appendicitis hospitalization rates, according to researchers led by Edward H. Livingston, MD, of the University of Texas Southwestern Medical Center in Dallas.&lt;/p&gt;
&lt;p&gt;Enteric infections and rotavirus showed trends that were likewise dissimilar to those of perforating and nonperforating appendicitis, the researchers reported in the January issue of the &lt;em&gt;Archives of Surgery&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;Most theories regarding the underlying causes of appendicitis rely on the notion that the appendix becomes obstructed,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;However, a more complex explanation appears necessary, they said, citing studies suggesting that blockage by hard pieces of stool called fecaliths is rare and that intraluminal pressures become elevated only in late-stage disease as inflammation progresses.&lt;/p&gt;
&lt;p&gt;Viral infection has been proposed as one explanation.&lt;/p&gt;
&lt;p&gt;And apparent &quot;outbreaks&quot; of appendicitis have been described in epidemiologic studies, suggesting an infectious etiology, Livingston&apos;s group noted.&lt;/p&gt;
&lt;p&gt;&quot;Viral infection of the appendix could cause mucosal ulceration followed by secondary bacterial infection of the appendix,&quot; they wrote. &quot;Alternatively, viral disease could result in lymphoid hyperplasia of the appendix with resultant obstruction and mucosal injury followed by bacterial infection.&quot;&lt;/p&gt;
&lt;p&gt;To explore the viral etiology scenario, the researchers used the National Hospital Discharge Survey to measure disease incidence trends from 1970 to 2006 based on admissions for appendicitis, flu, rotavirus, and enteric infections.&lt;/p&gt;
&lt;p&gt;They found a decline in overall annual incidence of both nonperforating appendicitis and influenza until 1995, after which the incidence for both rose in parallel.&lt;/p&gt;
&lt;p&gt;Perforating appendicitis, on the other hand, slowly rose in incidence over the years without a U-shaped curve.&lt;/p&gt;
&lt;p&gt;The incidence of perforating appendicitis, in fact, did not correlate with that of nonperforating appendicitis or any infectious disease studied.&lt;/p&gt;
&lt;p&gt;This suggested that &quot;perforated appendicitis has causative factors that are more complex than the simple delay in treating acute appendicitis,&quot; the researchers said.&lt;/p&gt;
&lt;p&gt;Rebecca C. Britt, MD, of Eastern Virginia Medical School in Norfolk, Va., commented that this was perhaps the most important implication of the study  --  that perforating and nonperforating appendicitis may be separate entities.&lt;/p&gt;
&lt;p&gt;Her critique accompanying the &lt;em&gt;Archives&lt;/em&gt; paper cautioned that further investigation is &quot;definitely warranted.&quot;&lt;/p&gt;
&lt;p&gt;But if confirmed, management patterns could shift, the researchers said.&lt;/p&gt;
&lt;p&gt;&quot;This has important clinical ramifications since appendectomy is generally performed as an emergency operation for fear of causing a perforation if treatment is delayed,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;For nonperforating appendicitis, the year-to-year association with influenza was discounted by the lack of within-year correlation.&lt;/p&gt;
&lt;p&gt;Appendicitis occurred throughout the year, with a &quot;slight tendency&quot; to occur more often in summer months whereas the flu was largely limited to winter.&lt;/p&gt;
&lt;p&gt;Furthermore, appendicitis is predominantly a disease of the young, while influenza disproportionately affects the older population, &quot;which goes against influenza as a proximate agent,&quot; Britt added.&lt;/p&gt;
&lt;p&gt;&quot;While perhaps influenza plays a role in the development of appendicitis by sensitizing the immune system to another viral agent, there remains no clear evidence that it is a causative agent for appendicitis,&quot; she wrote.&lt;/p&gt;
&lt;p&gt;Rotavirus infection also peaked in the winter months, without an apparent association with appendicitis incidence.&lt;/p&gt;
&lt;p&gt;Intestinal infection incidence matched the fairly even distribution of appendicitis throughout the year, but had a propensity to be higher in winter months rather than during the summer as was the case with appendicitis.&lt;/p&gt;
&lt;p&gt;Overall and peak hospital admission rates for intestinal infection began a yearly rise in 1989 and have been steadily increasing, which also did not match trends in appendicitis.&lt;/p&gt;
&lt;p&gt;Britt cautioned that the study relied on hospital discharge data, which is not likely to be a complete picture of incidence for viral illness because the vast majority of cases do not require hospitalization and many are not treated at all.&lt;/p&gt;
&lt;p&gt;&quot;Certainly this makes comparison onerous,&quot; she said.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The researchers reported no conflicts of interest. Britt reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_2_280"
                     title="Surgery Increases Risk of Cognitive Decline Among Elderly"
                     score="-0.005"
                     href="