Gastric Antral Web in a 103-Year-Old Patient

Copyright © 2011 Waheed Gul et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1

Intracranial Pressure is a Better Predictor of Mortalitythan Cerebral Perfusion Pressure

Objective: To evaluate whether elevated intracranial pressure (ICP) or depressed cerebral perfusion pressure (CPP) is a better predictor of intracranial compartment syndrome and long-term functional outcomes in blunt traumatic brain injury. Methods: This was a retrospective evaluation of data collected on 203 patients with blunt traumatic brain injury who were admitted to Miami Valley Hospital, a Level I trauma center, over a 2 years period, whose initial hospital management required an intracranial pressure monitor. Serial measurements of ICP and CPP were recorded during the patients’ hospital stay. These patients were then evaluated at 3,6,12 and 24 months post-injury to assess their outcome based on functional status, as defined by death vegetative state, severe disability, moderate disability and good recovery. Results: Utilizing an ICP cut-off value of 25 or greater and a CPP value of less than 60 at any point during the patients’ hospital course, ICP elevation consistently correlated with a higher percentage of deaths and persistent vegetative state than a depression in CPP value. Outcomes as measured by severe or moderate disability where similar in both groups. However, neither measure approached statistical significance. Conclusion: ICP appears to be a better predictor of intracranial compartment syndrome and extent of brain injury, predicting better than CPP values, the outcome of death or persistent vegetative state. This may help to predict prognosis, change management strategies and guide discussions with family, especially in the early phase of injur

Laparoscopic Cholecystectomy in the Acute Care Surgery Model: Risk Factors for Complications

Background: The Acute Care Surgery (ACS) model developed during the last decade fuses critical care, trauma, and emergency general surgery. ACS teams commonly perform laparoscopic cholecystectomy (LC) for acute biliary disease. This study reviewed LCs performed by an ACS service focusing on risk factors for complications in the emergent setting. Methods: All patients who underwent LC on an ACS service during a 26-month period were identified. Demographic, perioperative, and complication data were collected and analyzed with Fisher\u27s exact test, χ 2 test, and Mann-Whitney U Test. Results: During the study period, 547 patients (70.2% female, mean age 46.1±18.1, mean body mass index 32.4±7.8 kg/m 2 ) had LC performed for various acute indications. Mean surgery time was 77.9±50.2 minutes, and 5.7% of cases were performed after hours. Rate of conversion to open procedure was 6%. Complications seen included minor bile leaks (3.8%), infection (3.8%), retained gallstones (1.1%), organ injury (1.1%), major duct injury (0.9%), and postoperative bleeding (0.9%). Statistical analysis demonstrated significant relationships between conversion, length of surgery, age, gender, and intraoperative cholangiogram with various complications. No significant relationships were detected between complications and BMI, pregnancy, attending experience, and time of operation. Discussion: Although several statistically significant relationships were identified between several risk factors and complications, these findings have limited clinical significance. Factors including attending years in practice and time of the operation were not associated with increased complications. ACS services are capable of performing a high volume of LCs for emergent indications with low complication and conversion rates.-Level of evidence:IV. Competing Interests: Competing interests: None declared

Thymus transplantation for complete DiGeorge syndrome: European experience

Background: Thymus transplantation is a promising strategy for the treatment of athymic complete DiGeorge syndrome (cDGS). Methods: Twelve patients with cDGS were transplanted with allogeneic cultured thymus. Objective: To confirm and extend the results previously obtained in a single centre. Results: Two patients died of pre-existing viral infections without developing thymopoeisis and one late death occurred from autoimmune thrombocytopaenia. One infant suffered septic shock shortly after transplant resulting in graft loss and the need for a second transplant. Evidence of thymopoeisis developed from 5-6 months after transplantation in ten patients. The median (range) of circulating naïve CD4 counts (x10663 /L) were 44(11-440) and 200(5-310) at twelve and twenty-four months post-transplant and T-cell receptor excision circles were 2238 (320-8807) and 4184 (1582 -24596) per106 65 T-cells. Counts did not usually reach normal levels for age but patients were able to clear pre-existing and later acquired infections. At a median of 49 months (22-80), eight have ceased prophylactic antimicrobials and five immunoglobulin replacement. Histological confirmation of thymopoeisis was seen in seven of eleven patients undergoing biopsy of transplanted tissue including five showing full maturation through to the terminal stage of Hassall body formation. Autoimmune regulator (AIRE) expression was also demonstrated. Autoimmune complications were seen in 7/12 patients. In two, early transient autoimmune haemolysis settled after treatment and did not recur. The other five suffered ongoing autoimmune problems including: thyroiditis (3); haemolysis (1), thrombocytopaenia (4) and neutropenia (1). Conclusions: This study confirms the previous reports that thymus transplantation can reconstitute T cells in cDGS but with frequent autoimmune complications in survivors

Knee Range of Motion: Reliability and Agreement of 3 Measurement Methods

We conducted a study to compare 3 methods of measuring knee range of motion: visual estimation by physicians, hand goniometry by physical therapists, and radiographic goniometry. We hypothesized that reliability would be high within and across all techniques. We found intrarater and interrater reliability to be satisfactory for visual estimation, hand goniometry, and radiographic goniometry. Interrater reliability across methods did not agree satisfactorily. Between-methods differences in estimating knee range of motion may result from variations in technique among physicians and physical therapists

Selecting and interpreting diagnostic tests

Dijagnostički testovi uključuju sve od simptoma bolesti opisanih u bolesnikovoj anamnezi i uočenih fizičkim pregledom do sofisticiranih laboratorijskih pretraga i slikovnih tehnika široke upotrebe u današnjoj praksi. Dijagnostičkim testom uspoređuje se klinička informacija dobivena manje invazivnim i/ili jeftinijim testom s takozvanim „zlatnim standardom". U ovom članku najprije definiramo osnovne odrednice dijagnostičkog testiranja, primjerice, specifičnost i osjetljivost testa te pozitivnu i negativnu prediktivnu vrijednost kao mjeru učinkovitosti testa. Također raspravljamo o korisnosti ovih odrednica u odabiru testa i tumačenju dobivenih rezultata. Isto tako, objašnjavamo i Bayesov pristup dijagnostičkom ispitivanju kroz raspravu 0 vjerojatnosti neke dijagnoze prije i poslije učinjenog testa te o pozitivnom i negativnom omjeru vjerojatnosti. Potom tumačimo sva pitanja koja se tiču sažimanja mjera učinkovitosti testa, s osobitim naglaskom na površinu ispod ROC krivulje, dijagnostičku točnost 1 dijagnostički omjer izgleda. Također se pojašnjava i učinak prevalencije na dijagnostičku točnost i prediktivne vrijednosti. Na kraju, predstavljamo dijagnostički omjer izgleda kao mjeru učinkovitosti testa koja udružuje osjetljivost i specifičnost, ali ne ovisi o prevalenciji. Prije nego što liječnik zatraži neki dijagnostički test, mora procijeniti njegovu moguću dobrobit i rizike te kako će rezultat testa utjecati na skrb o bolesniku. Osnovni preduvjet za postavljanje dijagnoze temeljene na dokazima je dobro poznavanje i ispravno tumačenje svih dostupnih mjera diskriminacijske učinkovitosti testa.Diagnostic tests range from the signs and symptoms obtained from the patient\u27s history and physical examination to the sophisticated laboratory and imaging tests widely used in medical practice today. The typical diagnostic test compares clinical information gathered in a less invasive and/or less costly manner to the so-called gold standard. First, we define the basic components of diagnostic testing - i.e., the test characteristics of sensitivity and specificity and the test performance measures of positive predictive value and negative predictive value. We discuss the traditional use of these components in selecting and interpreting diagnostic test results. We then explain the Bayesian model for diagnostic testing through a discussion of pre-test probability and post-test probability and positive and negative likelihood ratios. We discuss the issue of integrating indicators of a test\u27s characteristics and performance, highlighting the area under the ROC curve, diagnostic accuracy and the diagnostic odds ratio. The impact of prevalence on accuracy and predictive values is clarified. And lastly, the diagnostic odds ratio is presented as a measure of test performance that combines sensitivity and specificity but is independent of test prevalence. Before ordering a diagnostic test, the clinician must evaluate the potential benefits and risks of the test and how the results will alter patient management. Familiarity with the available measurement options for evaluating a test and how to interpret the results are the first steps toward making evidence-based diagnostic decisions

Acute inflammatory responses to high-intensity functional training programming: An observational study

Effects of varying types of short duration workouts in high-intensity functional training (HIFT) on inflammatory biomarkers have not been adequately characterized. Objectives: The purpose of this descriptive study was to examine the acute effects of HIFT workouts on biomarkers of inflammation, over time, in two HIFT bouts. Materials and Methods: Ten apparently healthy males (28.1 ± 5 yrs) completed two HIFT sessions (“short bout:” sub-5-minute vs. “long bout:” 15-minute) in a randomized crossover design. Blood was drawn pre and post-exercise, and 1 hour, 3 hours, and 6 hours post-exercise, centrifuged, and plasma frozen for analysis. Inflammation was assessed through plasma interleukin-6 (IL-6), interleukin-10 (IL-10), and tumour necrosis factor alpha (TNF-α). Results: Repeated measures ANOVA revealed a single trial-dependent difference (IL-6, p≤ 0.05), and while statistically significant, this difference may not be biologically significant. The biomarkers IL-6, IL-10, and TNF-α all follow a similar pattern of peaking post-exercise and returning to baseline within 6 hours in both trials. Conclusions: Both temporal responses and concentrations were similar in the short and long bout. A practical implication is that both bouts of a HIFT elicit certain specific physiologic inflammatory responses

Conversations with Faculty About Research

O this learning, what a thing it is. William Shakespeare, The Taming of the Shrew My introduction to research and statistics started during my graduate school days at Michigan State University in 1969. I was blessed with formative course work, outstanding teachers, and practical opportunities to learn the skills of investigation. In the 40 plus years, since first learning about experimental and quasi-experimental designs and that multivariable statistics were now available (thanks to IBM mainframe computers), I have conducted, collaborated, and advised on many university-based research studies. My work has been primarily with medical school faculty, a population that spans the continuum of researchers, from those with keen acumen to those who have little training but who have an interest in research or who are externally motivated (read chairperson, tenure, promotion, etc.)

A Research Methods and Statistics Journal Club for Residents

A monthly journal club for residents that focuses on research methods and statistics is described. Detaileddiscussions and analyses of clinical research articles by the residents are used to teach the important conceptsand principles of medical research in a manner useful to the practicing physician. Discussion of research articlesis structured by a guide for presenting the research articles to the group and by stimulus questions that addressspecific methodological issues related to the study being examined. Residents have been enthusiastic in theirevaluation of the journal club; the experience has stimulated some of them to conduct their own research studies