Systematic management of chyle fistula: the Southwestern experience and review of the literature.

Postoperative cervical chyle fistula after neck dissection is a complication with potentially serious morbidity. Once it is recognized, treatment decisions to optimize patient care can be difficult. Different management strategies have been advocated on the basis of institutional and personal experience. In this study we comprehensively review the published protocols and retrospectively review our experience in the management of 15 patients with chyle fistula. All patients in this study were given a trial of nonoperative management with nutritional modification, pressure dressings, and closed drainage. Medical management ultimately failed in 3 patients (20%). Two patients had prolonged courses of medical management with associated complications. An analysis of our data supports early operative intervention if the peak 24-hour drainage is greater than 1000 mL without a prompt response to medical management. Persistent low-output drainage after 10 days is associated with a prolonged management course and treatment-related complications. Optimal treatment of these patients is unclear.     

Leadership characteristics and business management in modern academic surgery

Background Management skills are necessary to successfully lead a surgical department in future. Objective This article focuses on practical aspects of surgical management, leadership and training. It demonstrates how the implementation of business management concepts changes workflow management and surgical training. Methods A systematic Medline search was performed and business management publications were analysed. Results Neither management nor leadership skills are inborn but acquired. Management is about planning, controlling and putting appropriate structures in place. Leadership is anticipating and coping with change and people, and adopting a visionary stance. More change requires more leadership. Changes in surgery occur with unprecedented speed because of a growing demand for surgical procedures with limited financial resources. Modern leadership and management theories have to be tailored to surgery. It is clear that not all of them are applicable but some of them are essential for surgeons. In business management, common traits of successful leaders include team orientation and communication skills. As the most important character, however, appears to be the emotional intelligence. Novel training concepts for surgeons include on-the-job training and introduction of improved workflow management systems, e.g. the central case management. Conclusion The need for surgeons with advanced skills in business, finance and organisational management is evident and will require systematic and tailored training.     

信息化管理在医院医保管理中的作用

近年来,随着科学技术的进步和时代的发展,中国医院医保管理的创新和改革带来了重大机 遇。在新时代,医院医保管理正逐步向信息化发展。在医院医保管理中有效利用信息技术,可以提高医院 的运行效率和管理水平,有助于促进医院医保管理模式的演变和发展。因此,有必要进一步探索提高医保 系统管理水平的途径,将信息技术网络与医院医保系统深度融合,改革医院信息化。本文旨在探讨信息化 管理在医院医保管理中的实践作用,以期为今后医院医保的健康管理提供科学依据,为下一阶段深入探索 和广泛应用高质量健康大数据奠定基础,从而进一步提高我国医保管理的信息化水平。     

Oligoanalgesia in the emergency setting – An Indian review

Pain is a result of nociceptive tissue injury and results in acute and chronic impact to patients. Acute pain management is the need of the hour as untreated or under-treated pain may progress to chronic pain. Pain irrespective of its temporality causes a negative impact on the quality of life of the patients. Many Indian emergency settings are not adequately equipped to handle pain due to the heavy load of patients and the lack of awareness about the pain management guidelines. This leads to undertreatment of pain or ‘oligoanalgesia’. A pain management protocol can help prevent oligoanalgesia in an emergency setting. Proper utilization of triage systems that incorporate pain as one of the vital signs is necessary. The categorization of pain with the help of a pain scale helps determine the severity of pain and its appropriate management. Pain management is an ongoing process that does not end with the discharge of the patient. Post discharge management of pain is also an important factor to prevent chronic pain. This may involve various modalities for pain management under the preview of multimodal management of pain.     

全国中老年骨质疏松症分级健康管理平台的设计与应用

目的 搭建全国中老年骨质疏松症分级健康管理平台,加强骨质疏松症患者档案的数字化管理。方法 制定全国中老年骨质疏松症患者基础档案和规范化诊疗的业务流程和数据管理规范,采用企业级应用的技术架构研发由用户层、表示层、应用层、数据层和存储层构成的全国中老年骨质疏松症分级健康管理平台,并进行应用示范。结果 搭建了由患者管理、样本管理、统计管理、参数管理、用户管理、日志管理、信息发布等功能模块组成的全国中老年骨质疏松症分级健康管理平台,并在中心医院和社区医院的应用示范过程中升级完善,为全国中老年骨质疏松症患者的规范化管理提供了技术支持。结论 全国中老年骨质疏松症分级健康管理平台实现了骨质疏松症患者档案的信息化管理,建立了中心医院与社区医院之间的双向转诊模式,有助于提高骨质疏松症患者的诊疗率和依从性,促进我国医疗资源的合理配置。     

A review of the management of tibial plateau fractures

Tibial plateau fractures form a wide spectrum of injuries presenting varying challenges to the trauma surgeon. The prognosis of this injury spectrum is largely dependent on the management of each particular configuration, and the literature is as a result littered with a number of management strategies with limited consensus. The aim of this review is to provide a concise guide to the trauma surgeon based on newer and classical peer-reviewed publications in international orthopaedic journals. A PubMed search was conducted to identify peer-reviewed publications within the last 10 years and expanded to identify classic papers pertaining to the Schatzker classification. The focus was on articles based on management techniques, controversies and recent developments. The management of specific injury patterns is based on the Schatzker classification which is a widely accepted traditional classification system. Whilst there is a general consensus on the ultimate goal of a stable anatomic reduction in this subset of fractures, there continues to be a number of controversies surrounding issues including pre-operative imaging, initial assessment and definitive management of specific injury patterns, some of which do not conform to the original Schatzker classification. The majority of fractures will require operative management, and with whatever management strategy employed, the main emphasis is on respecting the soft tissue envelope. There remains a paucity of prospective randomised controlled trials comparing the different available operative techniques.     

Using an Electronic Self‐Management Tool to Support Patients with Chronic Kidney Disease (CKD): A CKD Clinic Self‐Care Model

New healthcare delivery models are needed to enhance the patient experience and improve quality of care for individuals with chronic conditions such as kidney disease. One potential avenue is to implement self‐management strategies. There is growing evidence that self‐management interventions help optimize various aspects of chronic disease management. With the increasing use of information technology (IT) in health care, chronic disease management programs are incorporating IT solutions to support patient self‐management practices. IT solutions have the ability to promote key principles of self‐management, namely education, empowerment, and collaboration. Positive clinical outcomes have been demonstrated for a number of chronic conditions when IT solutions were incorporated into self‐management programs. There is a paucity of evidence for self‐management in chronic kidney disease (CKD) patients. Furthermore, IT strategies have not been tested in this patient population to the same extent as other chronic conditions (e.g., diabetes, hypertension). Therefore, it is currently unknown if IT strategies will promote self‐management behaviors and lead to improvements in overall patient care. We designed and developed an IT solution called My KidneyCare Centre to support self‐management strategies for patients with CKD. In this review, we discuss the rationale and vision of incorporating an electronic self‐management tool to support the care of patients with CKD.     

Cesárea urgente y craneotomía en una paciente con rotura de una malformación arteriovenosa cerebral

The intracerebral hemorrhage in pregnancy is a rare event, but can have catastrophic consequences for both mother and fetus. The management of non-ruptured arteriovenous malformations in pregnancy is not free of controversy in the current literature, as there is the possibility of spontaneous bleeding and becoming a true emergency. We report the case of a pregnant patient of 35 weeks with a diagnosis of a cerebral arteriovenous malformation, who developed a sudden onset of headache, generalized tonic-clonic seizures, loss of consciousness, and hemiparesis with radiological images of an intracranial hematoma with a mass effect, and signs of herniation. The multidisciplinary management is discussed, emphasizing perioperative cesarean approach plus craniotomy and drainage of the hematoma, and subsequent management in intensive care, and definitive management by neuroradiology, with a successful outcome.     

A systematic review of the safety and efficacy of non-operative management in patients with high grade liver injury

IntroductionThe liver is the most frequently damaged organ in blunt abdominal trauma. It is widely accepted that hemodynamically stable patients with low-grade liver trauma should be treated with non-operative management, however there is controversy surrounding its safety and efficacy in high-grade trauma. The purpose of this review is to investigate the role of non-operative management in patients with high-grade liver trauma.MethodsPubMed and reference lists of PubMed articles were searched to find studies that examined the efficacy of non-operative management in high-grade liver injury patients, and compare it to operative management. Non-operative management was considered successful if rescue surgery was avoided. Outcomes considered were success, mortality, and complication rates.ResultsThe electronic search revealed 2662 records, 8 of which met the inclusion criteria. All 8 studies contained results suggesting that non-operative management was safe and effective in hemodynamically stable patients with high-grade liver trauma. By combining the outcomes of the different studies, non-operative management had a high success rate of 92.4% (194/210) in high-grade liver trauma patients, which was near the overall 95.0% non-operative management success rate. Non-operative management also had mortality and complication rates of 4.6% (9/194) and 9.7% (7/72) in high-grade injury patients, respectively, compared to operative management's 17.6% (26/148) and 45.5% (5/11).ConclusionNon-operative management of liver trauma is safe and effective in hemodynamically stable patients with high-grade liver injury. It is associated with significantly lower mortality compared with operative management. More studies are required to evaluate complications of non-operative management in high-grade liver injury.     

Management of severe acute pancreatitis

BACKGROUND: Acute pancreatitis is still associated with significant morbidity and mortality. Current management guidelines are sometimes equivocal, particularly in relation to the surgical treatment of severe disease. This review assesses available investigative and treatment strategies to allow the development of a formalized management approach. METHODS: A literature review of diagnosis, staging and management of acute pancreatitis was performed. RESULTS AND CONCLUSION: Recent evidence has helped to clarify the roles of computed tomography, endoscopic retrograde cholangiopancreatography, prophylactic antibiotics, enteral feeding and fine-needle aspiration for bacteriology in the management of acute pancreatitis. Despite a relative shortage of prospective randomized trials there has been a significant change in the surgical management of acute pancreatitis over the past 20 years. This change has been away from early aggressive surgical intervention towards more conservative management, except when infected necrosis is confirmed. A formalized approach, with appropriate use of the various non-surgical and surgical options, is feasible in the management of severe acute pancreatitis.     

Retroperitoneal duodenal perforation and IVC injury in blunt abdominal trauma: Pushing the boundaries of non-operative management? Brief report and a review of the literature

IntroductionDuodenal injuries present a significant challenge for trauma management because of the associated injuries and its anatomical inaccessibility. Surgical management can range from simple repair, Roux-en-Y duodenojejunostomies, T-tube decompression, or even pancreaticoduodenectomy as a last resort. Conservative treatment is very rarely described in the literature and in this report we present a case of retroperitoneal duodenal perforation with IVC injury successfully managed conservatively.Case report and discussionWe reviewed other cases described in the literature and attempt to identify the common characteristics which indicate the circumstances where conservative management might be successful. The described case, along with the three other cases reported in the literature, point to the feasibility of conservative management under the following conditions. The patient was coherent with reliable clinical symptoms and signs, which were stable and non-progressive. The retroperitoneal location of the perforation of the duodenum, without pancreatic or biliary injuries, allowed the possibility of non-operative management.In this described case, we demonstrate the feasibility of non operative management with an associated contained IVC injury. Although there is at least a 20-day observation period required for these cases, obviation of considerable surgical morbidity is a significant benefit.ConclusionWhilst our case may not qualify to demonstrate proof-of-concept in conservative management of duodenal perforation and IVC injury, we believe that given the appropriate clinical context, level of monitoring, availability of expertise, and evolution of clinical picture in the positive direction, in highly selected cases, non-operative management of retroperitoneal duodenal and IVC trauma is a viable option.     

Does the use of pretreatment MRI change the management of patients with newly diagnosed breast cancer?

Breast MRI plays a critical role in the diagnosis and management of breast cancer. The purpose of this study is to evaluate the effect of preoperative breast MRI on the management of a large cohort of breast cancer patients at our institution. This study is a retrospective chart review of all newly diagnosed breast cancer patients who underwent preoperative breast MRI at our institution between January 1, 2004 and December 31, 2009. 1352 patients comprised the study population. 241 (17.8%) patients underwent a change in surgical management as a result of preoperative MRI. Patients with tumors in the lower inner quadrant and the central breast and those with pathology of invasive lobular carcinoma were significantly more likely to have their management changed by preoperative MRI. There was also a significant trend for larger tumors to be associated with a change in surgical management. No statistically significant association was found between breast density and change in management. This study supports the recommendation for the use of preoperative breast MRI in the majority of newly diagnosed breast cancer patients, especially those with larger tumors, pathology of invasive lobular carcinoma, and tumors in the lower inner quadrant. Preoperative breast MRI is a useful tool for the evaluation of additional disease that led to a change in the surgical management of 17.8% of patients.     

Montgomery T-tube: anesthetic management

The Montgomery T-tube is a device used as a combined tracheal stent and airway after laryngotracheoplasty. It is a valuable option in the management of upper and mid-tracheal lesions. Because its use is sporadic, many anesthesiologists may not be familiar with this device, and its anesthetic management may pose a challenge. Safe management of such patients requires careful planning. We describe different techniques of anaesthetic management in two cases of injuries to the throat, for which this tube was inserted as a tracheal stent.     

The perioperative management of children with phaeochromocytoma

The safe anaesthetic management of a child with a phaeochromocytoma requires an understanding of the pathophysiology of the disease, together with a thorough knowledge of its pharmacology, in order to avoid or minimize the potentially harmful cardiovascular changes that may occur during anaesthesia. Although there is a considerable amount of information on the management of the adult with phaeochromocytoma, much less has been written concerning children with the disease. Children differ significantly from adults in the incidence, location, presentation and management of this condition and these differences are discussed here together with some of the more controversial issues of management.     

Congenital complete heart block in the setting of severe pre-eclampsia requiring urgent cesarean section

Congenital complete heart block is a rare phenomenon that may be discovered during pregnancy in patients who were previously asymptomatic. Peripartum management of these patients mandates a multidisciplinary approach with careful planning regarding indications for pacing, appropriate anesthetic technique, and contingency planning. Approaches to anesthetic management for congenital complete heart block have been described, but management in association with severe pre-eclampsia has not been reported. We describe the anesthetic management of a parturient with complete heart block who presented with severe pre-eclampsia requiring urgent cesarean section.     

Congenital tylosis and the role of the plastic and reconstructive surgeon

Congenital tylosis or hereditary palmoplantar keratoderma is a group of heterogeneous diseases characterised by thickening of the skin on the palms and soles of feet. A case history of a patient with congenital tylosis is presented to highlight the involvement of plastic and reconstructive surgery in the management of this issue. The management of this condition is discussed and poses a difficult challenge requiring the corroborative efforts of many health care professionals. It appears that there is no single answer to the treatment of this condition, although topical and systemic treatments, in conjunction with surgical management of extensive disease and physiotherapy for contracture formation seem to be the appropriate management plan.     

Prophylactic cholecystectomy in transplant patients: a decision analysis

Prophylactic laparoscopic cholecystectomy should be performed in solid organ transplant patients with asymptomatic cholelithiasis. Modeled, decision analytic techniques were used to evaluate the different management strategies for asymptomatic cholelithiasis in cardiac and pancreas/renal transplant recipients. The clinical outcomes of expectant management, pretransplantation prophylactic cholecystectomy, and posttransplantation prophylactic cholecystectomy were analyzed for each population. The probabilities and outcomes were derived form a pooled analysis of published studies. One- and two-way sensitivity and cost analyses were performed. Prophylactic posttransplantation cholecystectomy is favored for cardiac transplant recipients with asymptomatic cholelithiasis, resulting in 5:1000 deaths versus 80:1000 for pretransplantation cholecystectomy and 44:1000 for expectant management. In distinction, expectant management for asymptomatic cholelithiasis is favored in pancreas/renal transplant patients, resulting in 2:1000 deaths compared with 5:1000 for prophylactic cholecystectomy. After heart transplantation, a strategy of routine, prophylactic cholecystectomy is anticipated to result in a cost savings of $17,779 per quality-adjusted life-year. Prophylactic posttransplantation cholecystectomy is the preferred management strategy for cardiac transplant patients with incidental gallstones, resulting in decreased mortality and significant cost savings per quality-adjusted life-year. Expectant management is the preferred strategy for pancreas and/or kidney transplant recipients with asymptomatic cholelithiasis.     

Acute epiglottitis in a 79-year-old man

A case of acute epiglottitis in a 79-year-old man is presented describing the airway and anaesthetic management. Early reports of adult epiglottitis advocated observation or tracheostomy for airway management. Recent reports stress early endotracheal intubation. Unlike the paediatric age group adults may present with differing degrees of airway obstruction, epiglottic abscess, and with a more diverse set of medical problems. This can make airway management more variable than in children. A discussion of airway management in adult epiglottitis is presented.     

Vesicoureteral reflux: A historical perspective

The management of vesicoureteral reflux is a mainstay of pediatric urology. This management however, has evolved considerably throughout the years due to a dynamic understanding of both pathology and the relationship between surgical and medical therapies. The purpose of this article is to provide the reader with a historical perspective on management and delineate how its past has shaped current therapies and guidelines.     

Anesthesia for patients with congenital insensitivity to pain and anhidrosis: a questionnaire study in Japan.

We investigated the anesthetic management of patients with congenital insensitivity to pain and anhidrosis (CIPA) in Japan. CIPA is a rare inherited disease characterized by a lack of pain sensation and thermoregulation. Although lacking pain sensation, some patients do have tactile hyperesthesia. Thus, anesthetics are a necessity during operations. We also determined that because patients with CIPA have problems with thermoregulation, temperature management is a concern during the perioperative period and sufficient sedation is necessary to avoid accidental fractures. Additionally, it was found that the use of muscle relaxants does not present a problem, malignant hyperthermia is not associated with CIPA, and that the possibility of abnormalities in the autonomic nervous system must be taken into consideration. Therefore, patients with CIPA can be safely managed with anesthesia. IMPLICATIONS: We investigated the anesthetic management of patients with congenital insensitivity to pain and anhidrosis. We clarified the following three important points: anesthesia is necessary, temperature management must be maintained, and there must be sufficient perioperative sedation in the anesthetic management of patients with congenital insensitivity to pain and anhidrosis.