Portal vein thrombosis after laparoscopic splenectomy: an ongoing clinical challenge.

ObjectivesPortal vein thrombosis (PVT) following open splenectomy is a potentially lethal complication with an incidence of up to 6%. The objective of this report is to describe our management of a recent laparoscopic case, discuss current therapies, and consider antiplatelet therapy for prophylaxis.MethodsMedical records, laboratory studies, and imaging studies pertaining to a recent case of a laparoscopic splenectomy were examined. Current literature related to this topic was reviewed.ResultsA 16-year-old girl underwent laparoscopic splenectomy for idiopathic thrombocytopenic purpura. Her preoperative platelet count was 96K. She was discharged on postoperative day 1 after an uneventful operation including division of the splenic hilum with an endoscopic linear stapler. On postoperative day 20, she presented with a 5-day history of epigastric pain, nausea, and low-grade fevers without peritoneal signs. Her white blood cell count was 17.3; her platelets were 476K. Computed tomography demonstrated thrombosis of the splenic, superior mesenteric, and portal veins propagating into the liver. Heparinization was begun followed by an unsuccessful attempt at pharmacologic and mechanical thrombolysis by interventional radiology. Over the next 5 days, her pain resolved, she tolerated a full diet, was converted to oral anticoagulation and sent home. Follow-up radiographic studies demonstrated the development of venous collaterals and cavernous transformation of the portal vein.DiscussionNo standard therapy for PVT exists; several approaches have been described. These include systemic anticoagulation, systemic or regional medical thrombolysis, mechanical thrombolysis, and surgical thrombectomy. Unanswered questions exist about the most effective acute therapy, duration of anticoagulation, and the potential efficacy of routine prophylaxis with perioperative antiplatelet agents. PVT following splenectomy occurs with both the open and laparoscopic approach

Same-Day Discharge Following Laparoscopic Appendectomy for Uncomplicated Acute Appendicitis as a Measure of Quality in the Pediatric Population.

BACKGROUND: Acute appendicitis remains the most common surgical emergency in children, with laparoscopic appendectomy (LA) now the standard of care. Same-day discharge (SD) after LA is both feasible and safe in children treated for uncomplicated appendicitis. This study aims to determine if SD following LA for children with uncomplicated appendicitis would improve the quality of care with respect to cost of treatment, patient satisfaction, and complications when compared with a cohort admitted postoperatively. METHODS: An IRB-approved retrospective review of children, 1-18 years old, treated with LA for uncomplicated appendicitis and eligible for same-day discharge at our hospital from August 2012 to April 2015, was performed with telephone follow-up and satisfaction survey for SD patients. Children discharged the same day postoperatively (SD) were compared with those who were admitted postoperatively and discharged the next day (ND) for baseline characteristics, complications, length of stay (LOS), and hospital charges with Student\u27s t-test. Significance was set at P \u3c .05. RESULTS: Of 236 acute, uncomplicated appendicitis patients, 121 (51%) had SD and 115 (49%) had ND. Baseline characteristics and postoperative complications were similar, but SD was associated with shorter LOS, 11.8 ± 2.7 versus 24.8 ± 21.2 (P \u3c .001); lower costs, $10,551 ± 2165 versus$12,691 ± 3507 (P \u3c .0001); and good family satisfaction, with 25/32 (80%) of those surveyed opting for SD in the future. DISCUSSION: This study shows good patient/family satisfaction following discharge from the recovery room in addition to expected cost and LOS savings, without increasing complications or shifting costs. SD could become the standard of care, improving quality and value for these patients, and a benchmark for emerging therapies

Portal vein thrombosis after laparoscopic splenectomy: an ongoing clinical challenge.

ObjectivesPortal vein thrombosis (PVT) following open splenectomy is a potentially lethal complication with an incidence of up to 6%. The objective of this report is to describe our management of a recent laparoscopic case, discuss current therapies, and consider antiplatelet therapy for prophylaxis.MethodsMedical records, laboratory studies, and imaging studies pertaining to a recent case of a laparoscopic splenectomy were examined. Current literature related to this topic was reviewed.ResultsA 16-year-old girl underwent laparoscopic splenectomy for idiopathic thrombocytopenic purpura. Her preoperative platelet count was 96K. She was discharged on postoperative day 1 after an uneventful operation including division of the splenic hilum with an endoscopic linear stapler. On postoperative day 20, she presented with a 5-day history of epigastric pain, nausea, and low-grade fevers without peritoneal signs. Her white blood cell count was 17.3; her platelets were 476K. Computed tomography demonstrated thrombosis of the splenic, superior mesenteric, and portal veins propagating into the liver. Heparinization was begun followed by an unsuccessful attempt at pharmacologic and mechanical thrombolysis by interventional radiology. Over the next 5 days, her pain resolved, she tolerated a full diet, was converted to oral anticoagulation and sent home. Follow-up radiographic studies demonstrated the development of venous collaterals and cavernous transformation of the portal vein.DiscussionNo standard therapy for PVT exists; several approaches have been described. These include systemic anticoagulation, systemic or regional medical thrombolysis, mechanical thrombolysis, and surgical thrombectomy. Unanswered questions exist about the most effective acute therapy, duration of anticoagulation, and the potential efficacy of routine prophylaxis with perioperative antiplatelet agents. PVT following splenectomy occurs with both the open and laparoscopic approach

Post-Occupancy Evaluation of Facilities Change

This chapter discusses possible aims, tools and deliverables of Post-Occupancy Evaluations (POE) (otherwise known as building-in-use studies), with a focus on interventions in supporting facilities. POE has a long tradition and has been applied in different fields (e.g. offices, educational buildings, health care facilities, retail and leisure, as well as residential areas). The objectives of POE are various and can include; delivering input to an improvement plan; building up a generic body of knowledge by exploring and testing scientific theories; and developing practical design guidelines and decision support tools. Data collection tools are also varied, ranging from observations, interviews and web-based questionnaires to walk-throughs and use of narratives. A number of different data analysis techniques are available as well, including qualitative methods, such as content analysis, and quantitative methods, such as descriptive and inductive statistical analyses. A case study illustrates the application of different data collection tools. This case study seeks answers to the effects of new ways of working on employee satisfaction and perceived labour productivity. This study has been conducted by the Center for People and Buildings, Delft, the Netherlands, which specialises in research into the relations between people, working activities and the working environment. The case is an example of physical interventions including changing the office lay-out, new furniture, new information and communication technology (ICT) and document storage systems, as well as the flexible use of workplaces. A POE of three pilots has been conducted to test if the new environment performed well as perceived by the managers and employees. The research data has been used in the first instance in order to test if the organizational goals and objectives have been attained; and to support decisions with regard to the next steps in this change process. The research data has been used in the second instance more generically, as input to a database for cross-case analyses, exploring and testing hypotheses and benchmarking objectives.Accepted Author ManuscriptReal Estate Managemen

Multicomplex Wave Functions for Linear And Nonlinear Schrödinger Equations

We consider a multicomplex Schrödinger equation with general scalar potential, a generalization of both the standard Schrödinger equation and the bicomplex Schrödinger equation of Rochon and Tremblay, for wave functions mapping onto (Formula presented.). We determine the equivalent real-valued system in recursive form, and derive the relevant continuity equations in order to demonstrate that conservation of probability (a hallmark of standard quantum mechanics) holds in the multicomplex generalization. From here, we obtain the real modulus and demonstrate the generalized multicomplex version of Born’s formula for the probability densities. We then turn our attention to possible generalizations of the multicomplex Schrödinger equation, such as the case where the scalar potential is replaced with a multicomplex-valued potential, or the case where the potential involves the real modulus of the wave function, resulting in a multicomplex nonlinear Schrödinger equation. Finally, in order to demonstrate the solution methods for such equations, we obtain several particular solutions to the multicomplex Schrödinger equation. We interpret the generalized results in the context of the standard results from quantum mechanics