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The purpose of this study was to examine the psychosocial and disease-specific factors that influence functional recovery in older adults newly diagnosed with cancer. Multivariate logistic regression models were estimated using panel data from a sample of community-residing adults older than 65 years surgically treated for lung, prostate, breast, or colorectal cancer (N = 172). Data were obtained between 1993 and 1997 during interviews 4 to 6 weeks after cancer surgery for Wave 1 and 14 to 16 weeks after hospital discharge for Wave 2. The outcome measure, functional recovery, was determined by comparing the physical function and physical role subscales of Medical Outcomes Study (MOS) SF-36 over time. Findings showed that prostatectomy patients were more likely to recover by Wave 2 when compared to individuals with lung, colon, or breast resections. Comorbidities and symptom severity were each significantly associated with a decreased probability of recovery. Pain and fatigue were the most common and most severe symptoms reported, regardless of primary site. Psychological well-being was a significant factor influencing functional recovery when age, comorbidities, site of disease, and symptom severity were controlled. The results clearly point to the need for psychological support following cancer surgery.

Background: Many patients believe prayer helps them recover from health problems. Benefits of spirituality on other illnesses and surgical procedures have been reported. It is unknown whether patients with strong spiritual beliefs have a greater propensity for successful recovery from spinal surgery., Methods: In this study, 188 patients having spinal surgery completed the visual analog pain scale (VAS) and the Oswestry functional capacity questionnaire (OSW) before and after operation, and the scores were used to assess surgical outcome. Degree of spirituality was assessed using the INSPIRIT survey., Results: Paired t test revealed significant improvements in both the VAS and OSW outcome measures. Linear regression analysis revealed no correlation between change in either VAS or OSW., Conclusions: These results suggest that recovery from spinal surgery may be more dependent on proper patient selection and surgical technique than on patient spiritual beliefs.

Surgery originates an inflammatory state which triggers an acute phase response (APR). In this study, variations in the acute phase reactant proteins (APRP) and their relationship with fatigue were assessed. A total of 58 candidate patients for elective abdominal surgery participated in this study. In the preoperative period (PRE) and in the post-operative period (9 days [9-P], 27 days [27-P] and 45 days [45-P]), variations in serum APRP and fatigue were analyzed. In the post-operative period (9-P), a significant decrease in PT, ALB, PAB, TRF, and an increase in CER were observed. In 27-P, significant decreases were observed in PAB and PBR, with increased PT and CER, and without significant variations in ALB ad TRF. In the 45-P day, a concomitant increase in PT and CER was observed. Dynamometric parameters also decreased significantly in the post-operative period (9-P). In conclusion, our results demonstrate the existence of changes in serum proteins and in APRP after an elective abdominal surgical intervention, which are associated with fatigue, evaluated both by subjective and objective (dynamometry) means and the use of a mathematical model that considers weight, proteins and APRP.

Objective: To evaluate the effect of modifying perioperative care in noncardiac surgical patients on morbidity, mortality, and other outcome measures., Background: New approaches in pain control, introduction of techniques that reduce the perioperative stress response, and the more frequent use of minimal invasive surgical access have been introduced over the past decade. The impact of these interventions, either alone or in combination, on perioperative outcome was evaluated., Methods: We searched Medline for the period of 1980 to the present using the key terms fast track surgery, accelerated care programs, postoperative complications and preoperative patient preparation; and we examined and discussed the articles that were identified to include in this review. This information was supplemented with our own research on the mediators of the stress response in surgical patients, the use of epidural anesthesia in elective operations, and pilot studies of fast track surgical procedures using the multimodality approach., Results: The introduction of newer approaches to perioperative care has reduced both morbidity and mortality in surgical patients. In the future, most elective operations will become day surgical procedures or require only 1 to 2 days of postoperative hospitalization. Reorganization of the perioperative team (anesthesiologists, surgeons, nurses, and physical therapists) will be essential to achieve successful fast track surgical programs., Conclusions: Understanding perioperative pathophysiology and implementation of care regimes to reduce the stress of an operation, will continue to accelerate rehabilitation associated with decreased hospitalization and increased satisfaction and safety after discharge. Developments and improvements of multimodal interventions within the context of "fast track" surgery programs represents the major challenge for the medical professionals working to achieve a "pain and risk free" perioperative course.

Objective: To assess the relationship of health status and functional status to key nursing home subacute rehabilitation program outcomes: motor function at discharge, discharge destination, and length of stay in the program., Design: Using a prospective cohort study design, 164 patients were assessed on entering the rehabilitation program for the first time after discharge from an acute hospital. Their median length of stay was 40 days., Results: The patients' motor function improved over time (P < 0.0001), and a large majority were discharged to the community. At admission, health status was positively associated with motor function (P < 0.05) and cognitive function (P < 0.01). Higher cognitive function and higher motor function at admission were correlated with higher motor function at discharge (rs = 0.386, P < 0.0001; rs = 0.563, P < 0.0001 respectively). Better health status was independently associated with discharge to the community (P < 0.01). Only motor function at admission was independently associated with length of stay (P < 0.01)., Conclusion: Health status and functional status are related, and both are independently associated with nursing home subacute rehabilitation program outcomes. Therefore, an improvement in one may result in an improvement in the other, and both aid in the attainment of positive subacute rehabilitation outcomes.

This paper presents the development and testing of an outcome-oriented quality management system for the inpatient rehabilitation of orthopaedic patients, with a special focus on the indication of knee-replacement. On the level of outcomes we describe the development of appropriate indication-specific outcome indicators, capable of being used to rank the performance of hospitals. With regard to the process-quality of the empirical analysis of the rehabilitative-therapeutic services possibilities and limitations are shown. Furthermore an inkling of the shape that an expert-consent-based base of evidence for identifying best practice--arrived at by using primary empirical findings--might assume is presented. The procedure for establishing the latter offers a methodical approach toward continuous quality development of orthopaedic inpatient rehabilitation, one that is characterised by guidelines and performance transparency. Development potentials are recognised in the formal and the content quality of the therapeutic services.

Relatively recent changes in health care have seen shorter hospital stays and a considerable increase in day-only admissions, anticipated to involve 60% of all patients admitted for surgery and/or investigations within the next couple of years. Surprisingly little is known about the experiences of the approximately 40% of patients who will begin to convalesce in hospital following illness, trauma or surgery. Findings from a qualitative study, briefly reported here, identified a sense of vulnerability in transition as a significant discomfort. By examining assumptions underlying the care of patients recovering in hospital, the nexus between system-determined care trajectories transition, and patient vulnerability can be identified and problems suitably addressed.

Background: Quality of life after surgical critical illness is an important measure of outcome. The Sickness Impact Profile Score (SIP) has been validated in critically ill patients, but the Modified Short-Form (MSF) has not been directly compared with it., Methods: The SIP and MSF-36 were coadministered to 127 patients (surrogates) with a prolonged surgical critical illness at baseline at 1, 3, 6, and 12 months. Reliability, validity, and acceptability were determined for overall and subscores at each time point., Results: The overall SIP and eight subscores, including physical health and psychosocial health, were all significantly improved at 1 year compared with baseline (p < 0.05). However, the MSF-36 was improved only in health perception (p < 0.05), but pain scores were higher (p < 0.05) than at baseline. Internal consistency of the MSF-36 was poor at 1 and 3 months. Correlation between the tools was excellent at baseline and 1 year but variable in overall and subscores at other time points., Conclusion: The SIP is more comprehensive, reliable, and acceptable in determining specific quality-of-life abnormalities, but the MSF-36 is easier to administer and correlates well at baseline and 1 year in patients with a prolonged critical illness.

Malnutrition and weight loss are associated with alterations in cellular physiology and organ function, which are of importance for the surgical patient. Pre-operative weight loss can lead to increased post-operative morbidity and mortality. This review addresses the following questions: (a) what effects can key nutrients have on the immune system, metabolism and wound healing in man, and which may be of potential benefit to the surgical patient? (b) can clinically beneficial effects be demonstrated if patients receive nutritional supplementation with one of these key nutrients? (c) what effects does nutritional supplementation with combinations of these nutrients have on clinical outcomes?

At the URIOP Department of Tumours of the Locomotor System, osseous plastic operations were performed with making use of hydroxilapatite-base porous ceramics in 60 patients with benign tumours of bone and tumour-like lesions of bone. Apart from surgery the patients underwent a complex of rehabilitative measures, such as remedial gymnastics, massage, designed to restore locomotor functions of the extremity. Time periods of medical rehabilitation of patients were found to have gotten reduced by 1 to 2 months on the average providing the multimodality treatments with remedial gymnastics and massage were administered.

This article describes the technique of elbow release and debridement using a lateral approach designed to spare the lateral collateral ligament complex and extensor tendon origins of the elbow. This exposure allows for complete exposure of the anterior and posterior ulnohumeral and radiocapitellar joints through a single incision. Advantages include simplified surgical dissection, minimal operative morbidity, and less potential for postoperative instability after release.

Perioperative nurses have acquired greater responsibility for patients' and family members' postoperative education. Recent nursing research indicates that patients may not be getting specific information about dealing with the everyday practical matters they encounter while recovering at home from their surgical procedures. This article addresses some of these issues (e.g., food, sex, driving, bathing, wound care, return to work, limits on activities). The authors answer questions most often asked by patients and their family members.

Peripheral nerve injuries are a major source of chronic disability. Advances in microsurgery and a better understanding of nerve healing have greatly improved the outcomes of nerve repair in the past two decades. This paper reviews the current thoughts on peripheral nerve regeneration and repair. Controversial topics such as the timing of nerve repair, new techniques of nerve repair (fibrin glue, lasers, and tubulization), nerve grafting, and the treatment of neuroma are discussed. A general approach to postoperative care is presented and shown to be governed by an understanding of not only nerve healing but tissue healing in general. A summary of current clinical results of upper extremity nerve repairs is given to provide benchmarks of practice for hand therapy units to achieve and supersede.

The authors' repeated measures experimental study at a 359-bed community medical center located in California compared the effect of preadmission structured education with postadmission unstructured education on the outcomes of patient satisfaction, postoperative recovery, and return to functional status. Power analysis for a large effect size was used to determine the sample size of 50 adult females scheduled for open abdominal surgery. The authors used valid and reliable tools to measure the dependent variables and their findings suggest that same-day admission surgical patients who receive preadmission structured education have improved clinical outcomes, are more satisfied, are more likely to meet the targeted discharge date, and return to prior functional status sooner.

Major surgery is still associated with undesirable sequelae such as pain, cardiopulmonary, infective and thromboembolic complications, cerebral dysfunction, nausea and gastrointestinal paralysis, fatigue and prolonged convalescence. The key pathogenic factor in postoperative morbidity, excluding failures of surgical and anaesthetic technique, is the surgical stress response with subsequent increased demands on organ function. These changes in organ function are thought to be mediated by trauma-induced endocrine metabolic changes and activation of several biological cascade systems (cytokines, complement, arachidonic acid metabolites, nitric oxide, free oxygen radicals, etc). To understand postoperative morbidity it is therefore necessary to understand the pathophysiological role of the various components of the surgical stress response and to determine if modification of such responses may improve surgical outcome. While no single technique or drug regimen has been shown to eliminate postoperative morbidity and mortality, multimodal interventions may lead to a major reduction in the undesirable sequelae of surgical injury with improved recovery and reduction in postoperative morbidity and overall costs.

The investigation of 86 children at the remote period after operations for developmental defects in their neonatal period enabled the criteria of the successful medico-rehabilitative treatment to be determined according to the indicators of quality of their life. It was found that the quality of life of such children remained quite satisfactory even without systematic rehabilitation. At the same time, the critical periods were determined in the physical and mental development of the children and the pathology with which the child's rehabilitation could be slower and less effective.

Age is often a marker for comorbid illnesses that may complicate attempts at surgical intervention. Careful selection is important in deciding to recommend surgery for geriatric patients, but selected elderly patients may even benefit from major surgery. Ancillary services, such as nutrition, nursing, and physical therapy, are particularly important components in the postoperative care of geriatric patients. Case series have shown the ability of geriatric patients to recover from major surgical procedures, including cardiac surgery, neurosurgery, and oncologic surgery. In general, advanced age is not a contraindication to surgery but it reinforces the need for careful preoperative evaluation and vigorous postoperative support of the patient.

An audit of surgery for acoustic neuroma was carried out to determine the frequency and nature of postoperative symptoms and their impact upon the patient's quality of life and vocation. Fifty-six patients were interviewed between 6 months and 5 years (mean 26 months) after surgical excision of an acoustic neuroma. The objective surgical results in these patients are good, with normal or near normal functional preservation rates of 80% for the facial nerve (House-Brackmann grade I/II), and 27.3% for a previously functioning acoustic nerve. Despite this there was no significant overall reduction in the reported occurrence of balance problems, tinnitus, headache and other neurological sequelae of the tumour after surgical excision. In 20% of the patients persistent symptoms, including deafness and facial weakness, had prevented the resumption of former social activities. As a result of these symptoms 8.6% of the patients were certified medically unfit for work, but of those employed preoperatively over 70% had returned to their jobs. The success of neuro-otological surgical management of acoustic neuroma is offset by some degree of chronic morbidity. Our patients expressed the need to know whether their symptoms would resolve, but were often too afraid to ask. Patients can be reassured that the majority resume their former social and vocational activities, but should be advised that some symptoms can persist or occur de novo after surgery. Our data suggest that early intervention would reduce the incidence of these troublesome sequelae.

Postoperative nausea and vomiting is one of the most common complications of inpatient and day case surgical procedures. In a climate where total cost of an illness is becoming increasingly important, postoperative nausea and vomiting is a major contributor to direct and indirect costs for both the hospital and patient. In patient terms, the impact of increased recovery room stays and extra nursing time required by PONV patients has been estimated to range from 96-576 more surgical procedures which may be performed in an 'average' day case surgery centre. Postoperative nausea and vomiting is perceived by patients to account for equal or more debilitation than surgery itself and may cause them to lose wages due to absence from work. Reducing the incidence of nausea and vomiting and its associated problems may therefore provide opportunities to improve patient care, decrease the size of waiting lists and improve utilisation of scarce healthcare resources.

A phenomenological study explored the experience of healing in nine post-surgical patients. Extensive interviews were conducted at one and four weeks after hospital discharge. A follow-up interview was conducted after participants reviewed descriptions of the experience. Healing included four overlapping themes: Active Participation (personal responsibility to assist in the healing process); Achieving Balance (reintegration of the whole system); Evolving Beyond (examination of goals, values and priorities); and Healing Process (change over time and connections between themes).

The concept of patients' quality of life is assuming increasing importance in modern medicine and surgery. Interventions are increasingly being assessed in terms of their impact on such areas of functioning as mobility, mood, cognitive function, ability to fulfil occupational and social roles, and general life satisfaction. This paper discusses the theoretical underpinnings of the quality-of-life paradigm and its practical relevance for modern surgery.

We are encouraged by the favorable preliminary results of ligamentous reconstruction using the porous Dacron tendon. It provides a stable construct in cases where there is insufficient local autogenous tissue, and obviates the need for a tendon graft. Early active range of motion is permitted. Current investigation for additional applications for the use of the porous Dacron tendon include volar plate reconstruction following disruption, capsuloligamentous reconstruction of the trapezial metacarpal joint (with trapezium implant arthroplasty as well as for isolated disruption of the volar oblique ligament), intercarpal ligament repair or augmentation, and distal radioulnar joint stabilization.

The article analyses the efficacy of rehabilitation measures after implantation of a REPTELA cava-filter in 750 patients in the immediate postimplantation period and in 400 patients in late-term periods of up to 8 years. The average duration of the hospital stage of rehabilitation was 45 days for patients with thromboembolism of the pulmonary artery and 22 days for those without this condition. The application of a complex of rehabilitation measures makes it possible to restore the working capacity of 78.5% of patients with an implanted REPTELA cava-filter.

Successful discharge planning, home care, and rehabilitation for surgical patients can be very satisfying. However, everyone involved should be aware that it can also be frustrating when, despite careful plans and organization, everything falls apart, often because the patient's disease course is different from that expected or the patient or family are not satisfied with the services. There are multiple other reasons for plans to fail, but with experience the failures should become less frequent. All too often in life we take success for granted and weigh failures twice as much. The danger of this type of thinking becomes especially important in discharge planning--successfully discharged patients may be "invisible" but the failures are back very quickly. Everyone involved in discharge planning should be made aware of the successes in order to prevent "burn out." Certain predictable complications can often be prevented or rapidly reversed, and rehabilitation is achieved by a team of varied health care providers. A home visit is often very helpful before discharge of an elderly surgical patient.

Mortality and morbidity of surgery in the very old patient is much less than generally accepted. Age on his own is never a good reason to refuse surgical intervention. Good assessment after extended interrogation of patient and family, clinical examination and eventually technical procedures will reveal a number of other diseases. The higher the number of other diseases the higher will be the risk of the operation. More attention is needed for the quality of life after the operation. The fact that the patient will remain independent for the activities of daily living is for the very old patient more important than his 5-year survival. I am wondering why the number of female who come to operation is relatively lower than the men. A possible explanation is the fact that to many very old people receive to much nursing care and not enough real medical care.

A quantitative review of 34 controlled studies demonstrates that, on the average, surgical or coronary patients who are provided information or emotional support to help them master the medical crisis do better than patients who receive only ordinary care. A review of 13 studies that used hospital days post-surgery or post-heart attack as outcome indicators showed that on the average psychological intervention reduced hospitalization approximately two days below the control group's average of 9.92 days. Most of the interventions were modest and, in most studies, were not matched in any way to the needs of particular patients or their coping styles. Beyond the intrinsic value of offering humane and considerate care, the evidence is that psychological care can be cost-effective.

Forty-six patients lived with kidney grafts for more than 10 years. The kidney function was excellent or good in 35 patients. Thirty-seven patients were in excellent physical and mental condition and were considered fully restored. Nine patients had disabling diseases of varying severity. Thirty-eight patients were employed and several had all their occupational education after transplantation. Nine of the 31 patients of fertile age at transplantation had born or fathered 15 normal children. Forty-six patients who lived with kidney grafts for more than 10 years were very well socially rehabilitated and had reached a quality of life quite comparable to that of people of the same age.