Predicting excessive hemorrhage in adolescent idiopathic scoliosis patients undergoing posterior spinal instrumentation and fusion

Background contextBlood loss in patients with adolescent idiopathic scoliosis (AIS) who are undergoing posterior spinal instrumentation and fusion (PSIF) varies greatly. The reason for this wide range is not clear. There are reports of unexpected massive hemorrhage during these surgeries. Many studies reflect authors' preferences for describing blood loss in terms of levels fused, weight, or percent blood volume.PurposeWe sought to define excessive blood loss clinically, determine its incidence in our study population, and identify associated variables. Results are intended to inform perioperative preparation for these cases. Results may be used to inform prospective study designs.Study designThis was a retrospective uncontrolled case series.Patient sampleA total of 311 consecutive AIS PSIF cases during the years 2005–2010 performed at Children's Hospital Colorado were studied.Outcome measuresWe measured estimated blood loss (EBL) and its association with multiple patient, surgical, and anesthetic variables.MethodsThirty-one variables potentially related to blood loss were collected retrospectively from electronic medical records for analysis. When no cases of clearly excessive blood loss were identified on the basis of visual examination of EBL distribution, we chose to use the top 10% of blood loss cases as an arbitrary determinant of excessive blood loss. Three cut-off strategies captured the top 10% of EBL cases with little variation in who was selected: 1) >1,700 mL of EBL, 2) >50% EBL/estimated blood volume, and 3) >150 mL/level fused EBL. Variables were compared with the χ² test, Fisher exact, or t-tests, when appropriate. A generalized linear mixed logistic model was used to determine the probability of excessive blood loss based on the number of levels fused.ResultsThe average EBL was 89.17 mL/level fused (range, 45–133 mL). EBL fit a progressively wider distribution as surgical complexity (number of levels fused) increased. Number of levels fused (p<.0001), operative time (p=.0139), number of screws (p<.0001), and maximal preoperative Cobb angle (p=.0491) were significantly associated with excessive blood loss. The variable that was most strongly associated with excessive blood loss was the number of levels fused, with ≥12 levels having a probability of >10% of excessive hemorrhage.ConclusionExcessive blood loss may be an arbitrary number until future research suggests otherwise. We show that the probability of exceeding one of our arbitrary definitions is approximately 10% when 12 or more levels are fused. If a 10% incidence of excessive blood loss is determined to be clinically relevant, teams might wish to pursue hematologic consultation and maximal blood conservation strategy when 12 or more levels are planned for fusion.     

Should art be integrated into cognitive behavioral therapy for anxiety disorders?

Although cognitive behavioral therapy (CBT) is the preferred treatment method for anxiety disorders, it is underutilized and has been critiqued for being too verbal or abstract. Due to the role of imagery in maintaining anxiety disorders, art may be a useful addition to CBT for anxiety disorders. Art was incorporated into a brief CBT model in two quantitative case studies: Case 1 for panic disorder with agoraphobia (PDA) and Case 2 for generalized anxiety disorder (GAD). The A-B, single-subject experimental design included a two-week baseline period and a seven-week intervention period in both cases. The participant with PDA recorded her symptoms of PDA and her level of general anxiety throughout the baseline and intervention periods using a panic diary, whereas the participant with GAD recorded her level of general anxiety. In Case 1 for PDA, the intervention resulted in statistically significant reductions in panic frequency and some features of panic anxiety and agoraphobia. In Case 2 for GAD, the decrease in general anxiety was marginally significant.     

Editorial Perspective: The importance of considering parent's preferences when planning treatment for their children – the case of childhood obsessive‐compulsive disorder

Assessing parental treatment preference is critical for maximizing alliance, adherence, and efficacy while minimizing patient attrition. Parents of youth with OCD report significantly higher preference for and acceptability of behavioral treatment over medication or combined treatment. Parents of younger children expressed lower acceptability of pharmacotherapy. Consistent concerns about medication safety were expressed.     

中青年高血压护理简况

生活节奏的加快,工作、学习压力让中青年人无暇顾及健康问题。由于缺乏对疾病的认识及不健康的生活方式,中年年高血压患者逐年增加。临床护理应加强健康教育,合理用药,干预生活方式,同时关注患者心理及家庭,有利于稳定病情,促进恢复。     

Reducing Psychological Distress in Patients with Inflammatory Bowel Disease by Cognitive-Behavioural Treatment: Exploratory Study of Effectiveness

Background: This prospective study aimed to determine whether cognitive-behavioural group treatment accompanying medical standard care is effective in reducing psychological distress in patients with inflammatory bowel disease. Methods: Twenty-eight outpatients with Crohn disease or ulcerative colitis completed the treatment programme. Psychological treatment consisting of 12 weekly sessions was conducted in a group setting. Medical and psychometric assessments were taken at the beginning of the 3-month pretreatment waiting period, at pretreatment, at post-treatment and at the 3, 6 and 9-month follow-ups. Results: During baseline, no change was observed in psychological distress. Disease-related worries and concerns decreased significantly from pretreatment to the follow-ups. The disease groups differed in the decline of concerns between pre- and post-treatment, with a significant reduction of concerns in patients with ulcerative colitis but not Crohn disease. This difference did not occur at the follow-ups, indicating long-term improvement for both disease groups. Depressive coping decreased significantly in women and remained stable at the follow-ups, whereas depressive coping did not change in men. The same gender difference was found for depressive symptoms. Conclusions: The exploratory findings suggest that psychological group treatment for outpatients is a feasible and effective approach for the short- and long-term reduction of psychological distress for patients with inflammatory bowel disease. However, the revealed gender differences on coping and depression might indicate the necessity to consider gender-specific aspects of inflammatory bowel disease when designing and evaluating psychological interventions.