Value of "Second-look laparotomy" in peritoneal sepsis

Background: Evaluation of the post-laparotomy patient, particularly if still on a ventilator, is difficult and assessment of resolution of sepsis controversial.Methods: A retrospective study of all cases of severe peritonitis seen over a 14-year period in Bulawayo on one surgical firm from 1989 to 2003 was carried out. Patients studied included cases of sepsis de novo and septic complications of semi-elective or emergency abdominal surgery.Results: Out of a total of 691 cases of generalized septic peritonitis seen between 1989 and 2003, 170 patients met the criteria and formed the basis of this study. Their ages ranged from 3 days to 90 years. Cases of severe generalized septic peritonitis in which the Acute Physiology and Chronic Health Evaluation (APACHE) II score was over 16 were analyzed. Fifty-four patients died within 48 hours of surgery. Thirty-nine patients survived after a second laparotomy; three of these had two re-laparotomies. There were 24 patients who underwent a second laparotomy, but succumbed nonetheless. Benefits of single or multiple laparotomies for intra-abdominal sepsis were computed where the predicted mortality was 20-30% (APACHE II 12-16) the actual mortality was reduced to zero; where the predicted mortality was 30-45% (APACHE II 16-20) the actual mortality came down to <10%; where the predicted mortality was 45-60% (APACHE II 20-25) the actual mortality dropped to <30%

Duplex ventral pancreas

Complete duplication of the ventral pancreatic ductal system in 2 patients is reported. Both patients, during evaluation for recurrent abdominal pain, underwent endoscopic retrograde cholangiopancreatography that revealed typical changes of chronic pancreatitis and pseudocysts confined to 1 ductal system with the other ductal system completely normal. Both ductal systems filled with contrast medium via a common opening at the major papilla. A rudimentary minor papilla was present, but cannulations were unsuccessful. This unusual anomaly of the ventral pancreas with its embryologic basis, diagnosis, and clinical implications is discussed.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/48132/1/261_2005_Article_BF01885095.pd

Statistical machines for trauma hospital outcomes research: Application to the PRospective, Observational, Multi-center Major trauma Transfusion (PROMMTT) study

Improving the treatment of trauma, a leading cause of death worldwide, is of great clinical and public health interest. This analysis introduces flexible statistical methods for estimating center-level effects on individual outcomes in the context of highly variable patient populations, such as those of the PRospective, Observational, Multi-center Major Trauma Transfusion study. Ten US level I trauma centers enrolled a total of 1,245 trauma patients who survived at least 30 minutes after admission and received at least one unit of red blood cells. Outcomes included death, multiple organ failure, substantial bleeding, and transfusion of blood products. The centers involved were classified as either large or small-volume based on the number of massive transfusion patients enrolled during the study period. We focused on estimation of parameters inspired by causal inference, specifically estimated impacts on patient outcomes related to the volume of the trauma hospital that treated them. We defined this association as the change in mean outcomes of interest that would be observed if, contrary to fact, subjects from large-volume sites were treated at small-volume sites (the effect of treatment among the treated). We estimated this parameter using three different methods, some of which use data-adaptive machine learning tools to derive the outcome models, minimizing residual confounding by reducing model misspecification. Differences between unadjusted and adjusted estimators sometimes differed dramatically, demonstrating the need to account for differences in patient characteristics in clinic comparisons. In addition, the estimators based on robust adjustment methods showed potential impacts of hospital volume. For instance, we estimated a survival benefit for patients who were treated at large-volume sites, which was not apparent in simpler, unadjusted comparisons. By removing arbitrary modeling decisions from the estimation process and concentrating on parameters that have more direct policy implications, these potentially automated approaches allow methodological standardization across similar comparativeness effectiveness studies

Change in depressive symptoms over higher education and professional establishment - a longitudinal investigation in a national cohort of Swedish nursing students

<p>Abstract</p> <p>Background</p> <p>There are indications of a high prevalence of psychological distress among students in higher education and also that distress increases over the course of study. However, not all studies on student distress controlled for sociodemographic differences and few followed development of distress over an extended period through professional establishment. We investigated if there is an independent effect of time in education and the first two years in the profession on depressive symptoms and mapped change over the period in a national cohort of students.</p> <p>Methods</p> <p>Data came from LANE, a nation-wide longitudinal panel survey of Swedish nursing students (N = 1700) who responded to annual questionnaires over five years from 2002 to 2007. Depressive symptoms were measured by the Major Depression Inventory and change over time analysed in a linear mixed effects model for repeated measures.</p> <p>Results</p> <p>There was a significant change in level of depressive symptoms over time: an increase from the first to later years in education and a decrease to levels similar to baseline after graduation and a year in the profession. The change in symptoms remained significant after adjustment for sociodemographic factors (p < 0.01). Symptom levels differed due to age, gender, household composition and prior nurse assistant training but change over time was similar in all groups. The correlation among the repeated measures, representing within individual correlation over time, varied between 0.44-0.60.</p> <p>Conclusions</p> <p>The findings indicate an independent but transitional effect of time in education and professional establishment on depressive symptoms. We think heightened distress over education abates as the graduate accommodates to the profession. Nevertheless, within education, the differences in depressive symptoms associated to demographic factors can help identify student groups more vulnerable to distress. Also, as individual differences in distress seem to persist over time, perhaps students highly distressed in the beginning of education can be helped by awareness among educators of the elevated levels of distress in late education.</p

Feasibility study of computed tomography colonography using limited bowel preparation at normal and low-dose levels study

The purpose was to evaluate low-dose CT colonography without cathartic cleansing in terms of image quality, polyp visualization and patient acceptance. Sixty-one patients scheduled for colonoscopy started a low-fiber diet, lactulose and amidotrizoic-acid for fecal tagging 2 days prior to the CT scan (standard dose, 5.8–8.2 mSv). The original raw data of 51 patients were modified and reconstructed at simulated 2.3 and 0.7 mSv levels. Two observers evaluated the standard dose scan regarding image quality and polyps. A third evaluated the presence of polyps at all three mSv levels in a blinded prospective way. All observers were blinded to the reference standard: colonoscopy. At three times patients were given questionnaires relating to their experiences and preference. Image quality was sufficient in all patients, but significantly lower in the cecum, sigmoid and rectum. The two observers correctly identified respectively 10/15 (67%) and 9/15 (60%) polyps ≥10 mm, with 5 and 8 false-positive lesions (standard dose scan). Dose reduction down to 0.7 mSv was not associated with significant changes in diagnostic value (polyps ≥10 mm). Eighty percent of patients preferred CT colonography and 13% preferred colonoscopy (P<0.001). CT colonography without cleansing is preferred to colonoscopy and shows sufficient image quality and moderate sensitivity, without impaired diagnostic value at dose-levels as low as 0.7 mSv

A Dutch guideline for the treatment of scoliosis in neuromuscular disorders

<p>Abstract</p> <p>Background</p> <p>Children with neuromuscular disorders with a progressive muscle weakness such as Duchenne Muscular Dystrophy and Spinal Muscular Atrophy frequently develop a progressive scoliosis. A severe scoliosis compromises respiratory function and makes sitting more difficult. Spinal surgery is considered the primary treatment option for correcting severe scoliosis in neuromuscular disorders. Surgery in this population requires a multidisciplinary approach, careful planning, dedicated surgical procedures, and specialized after care.</p> <p>Methods</p> <p>The guideline is based on scientific evidence and expert opinions. A multidisciplinary working group representing experts from all relevant specialties performed the research. A literature search was conducted to collect scientific evidence in answer to specific questions posed by the working group. Literature was classified according to the level of evidence.</p> <p>Results</p> <p>For most aspects of the treatment scientific evidence is scarce and only low level cohort studies were found. Nevertheless, a high degree of consensus was reached about the management of patients with scoliosis in neuromuscular disorders. This was translated into a set of recommendations, which are now officially accepted as a general guideline in the Netherlands.</p> <p>Conclusion</p> <p>In order to optimize the treatment for scoliosis in neuromuscular disorders a Dutch guideline has been composed. This evidence-based, multidisciplinary guideline addresses conservative treatment, the preoperative, perioperative, and postoperative care of scoliosis in neuromuscular disorders.</p

Preoperative biliary drainage for periampullary tumors causing obstructive jaundice; DRainage vs. (direct) OPeration (DROP-trial)

BACKGROUND: Surgery in patients with obstructive jaundice caused by a periampullary (pancreas, papilla, distal bile duct) tumor is associated with a higher risk of postoperative complications than in non-jaundiced patients. Preoperative biliary drainage was introduced in an attempt to improve the general condition and thus reduce postoperative morbidity and mortality. Early studies showed a reduction in morbidity. However, more recently the focus has shifted towards the negative effects of drainage, such as an increase of infectious complications. Whether biliary drainage should always be performed in jaundiced patients remains controversial. The randomized controlled multicenter DROP-trial (DRainage vs. Operation) was conceived to compare the outcome of a 'preoperative biliary drainage strategy' (standard strategy) with that of an 'early-surgery' strategy, with respect to the incidence of severe complications (primary-outcome measure), hospital stay, number of invasive diagnostic tests, costs, and quality of life. METHODS/DESIGN: Patients with obstructive jaundice due to a periampullary tumor, eligible for exploration after staging with CT scan, and scheduled to undergo a "curative" resection, will be randomized to either "early surgical treatment" (within one week) or "preoperative biliary drainage" (for 4 weeks) and subsequent surgical treatment (standard treatment). Primary outcome measure is the percentage of severe complications up to 90 days after surgery. The sample size calculation is based on the equivalence design for the primary outcome measure. If equivalence is found, the comparison of the secondary outcomes will be essential in selecting the preferred strategy. Based on a 40% complication rate for early surgical treatment and 48% for preoperative drainage, equivalence is taken to be demonstrated if the percentage of severe complications with early surgical treatment is not more than 10% higher compared to standard treatment: preoperative biliary drainage. Accounting for a 10% dropout, 105 patients are needed in each arm resulting in a study population of 210 (alpha = 0.95, beta = 0.8). DISCUSSION: The DROP-trial is a randomized controlled multicenter trial that will provide evidence whether or not preoperative biliary drainage is to be performed in patients with obstructive jaundice due to a periampullary tumor