BACKGROUND AND PURPOSE: CSP in patients with HNC presenting with CBS can provide immediate hemostasis to prevent exsanguination. We evaluated the safety and efficacy of CSP to control acute life-threatening hemorrhage in patients with HNC presenting with CBS.
Archibald (Archie) Cochrane's most influential mark on healthcare was his 1971 publication, "Effectiveness and Efficiency." This book strongly criticized the lack of reliable evidence behind many of the commonly accepted healthcare interventions at the time. His criticisms spurred rigorous evaluations of healthcare interventions and highlighted the need for evidence in medicine. His call for a collection of systematic reviews led to the creation of The Cochrane Collaboration. Archie Cochrane was a visionary person who helped lay down much of the foundation for evidence-based medicine. This paper will introduce evidence-based medicine to Plastic Surgery by tracing its history to the seminal efforts by Archie Cochrane.
KeywordsArchie Cochrane; Cochrane Collaboration; Evidence-based medicine; Archibald CochraneThe American healthcare system is at a crossroads. Healthcare costs are weighing heavily on the American people with costs totaling $2.1 trillion (or $7,026 per person) in 2006, and consuming approximating 16% of GDP. 1 It is particularly disturbing that healthcare costs are predicted to comprise 19.5% of American GDP by 2017. 2 In spite of these staggering expenditures, 15-20% of Americans remain uninsured and emergency rooms across the country are strained (Fig. 1). [3][4][5] It comes as no surprise that many Americans consider health care reform an issue of utmost priority. 6 As a result, the political arena has been dominated by discussions regarding health care reform, as legislators work with leading experts in the healthcare field to increase coverage and reduce health care costs. Recently, presidential hopefuls have proposed using evidence-based medicine (EBM) as a method to curb expenditure and improve health care delivery. 7,8 This movement towards using current evidence to guide medical decisions can be referred to as the "fourth revolution" of health care (the first three being the introduction of health insurance, the backlash of payers to reduce costs, and outcomes-based research). 9,10 To understand how EBM gained such a strong foothold in the American mind frame, it is important to understand its origins and to become familiar with the Cochrane Collaboration, a testament to the EBM revolution in today's society.
Purpose
Ulnar styloid fractures commonly occur in association with distal radius fractures. Ulnar styloid fractures that involve the insertion of the radioulnar ligaments can result in distal radioulnar joint (DRUJ) instability, and the literature suggests that these fractures should be treated with open reduction internal fixation (ORIF). However, in the absence of DRUJ instability, the effects of ulnar styloid fractures are not known. The purpose of this study is to evaluate the outcome of ulnar styloid fractures without DRUJ instability on patient-rated outcomes after distal radius fracture ORIF.
Materials and Methods
Between 2003 and 2008, a prospective cohort of distal radius fracture subjects treated with volar locking plating was enrolled. Patients with DRUJ instability treated at the time of distal radius ORIF were excluded. Radiographs were evaluated to identify ulnar styloid fractures, fracture size, amount of displacement, and evidence of healing. Patient-rated outcomes were measured at 6 weeks, 3 months, 6 months, and 12 months after surgery using the Michigan Hand Outcomes Questionnaire (MHQ). Physical examination, including a specific evaluation of the DRUJ, was performed at each postoperative visit. Regression analysis was performed to determine if the presence of an ulnar styloid fracture, the size or displacement of the ulnar styloid fracture, or the healing status of the ulnar styloid fracture (union versus non-union) was predictive of MHQ scores.
Results
One hundred forty-four patients were enrolled; 88 patients had associated ulnar styloid fractures, and 56 did not. During the collection period, three patients with ulnar styloid fractures had DRUJ instability found intraoperatively and underwent ulnar styloid ORIF. These patients were excluded. The remaining patients with a stable DRUJ after ORIF were included in the study, and maintained DRUJ stability postoperatively. The presence of an ulnar styloid fracture was not found to be an independent predictor of MHQ scores (p=0.55). In addition, neither the size of the ulnar styloid fracture (p=0.18), nor the degree of displacement (p=0.25) was found to be a significant independent predictor of MHQ scores. Furthermore, the healing status of the fracture (union versus non-union) was not predictive of MHQ scores (p=0.95).
Conclusion
In patients with a stable DRUJ after distal radius ORIF with a volar locking plate, the presence of an ulnar styloid fracture did not affect subjective outcomes as measured by the MHQ. Furthermore, neither the size of the ulnar styloid fracture, the degree of displacement, nor the presence or absence of radiographic union affected subjective outcomes as measured by the MHQ.
Our preliminary experience suggests that EVOH may offer a higher degree of devascularization when compared with other embolic agents. This may facilitate easier surgical resection with lower blood loss. EVOH seems to be safe when percutaneously injected as the sole embolic agent.
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