Application of subretinal fluid to close refractory full thickness macular holes: treatment strategies and primary outcome: APOSTEL study

Graefe's Archive for Clinical and Experimental Ophthalmology - Persisting macular holes (PMH) after surgical release of any epiretinal traction of the vitreous and adjacent membrane may rely on...     

Tumor Size Predicts Vascular Invasion and Histologic Grade Among Patients Undergoing Resection of Intrahepatic Cholangiocarcinoma

The association between tumor size and survival in patients with intrahepatic cholangiocarcinoma (ICC) undergoing surgical resection is controversial. We sought to define the incidence of major and microscopic vascular invasion relative to ICC tumor size, and identify predictors of microscopic vascular invasion in patients with ICC ≥5 cm. A total of 443 patients undergoing surgical resection for ICC between 1973 and 2011 at one of 11 participating institutions were identified. Clinical and pathologic data were evaluated using uni- and multivariate analyses. As tumor sized increased, the incidence of microscopic vascular invasion increased: <3 cm, 3.6 %; 3–5 cm, 24.7 %; 5–7 cm, 38.3 %; 7–15 cm, 32.9 %, ≥15 cm, 55.6 %; (p?<?0.001). Increasing tumor size was also found to be associated with worsening tumor grade. The incidence of poorly differentiated tumors increased with increasing ICC tumor size: <3 cm, 9.7 %; 3–5 cm, 19.8 %; 5–7 cm, 24.2 %; 7–15 cm, 21.1 %; >15 cm, 31.6 % (p?=?0.04). The presence of perineural invasion (odds ratio [OR]?=?2.98) and regional lymph node metastasis (OR?=?4.43) were independently associated with an increased risk of microscopic vascular invasion in tumors ≥5 cm (both p?<?0.05). Risk of microscopic vascular invasion and worse tumor grade increased with tumor size. Large tumors likely harbor worse pathologic features; this information should be considered when determining therapy and prognosis of patients with large ICC.     

Diagnostic markers of postoperative morbidity after laparoscopic Roux-en-Y gastric bypass for obesity

Purpose

The main objective of this study was to detect subacute complications that can arise from laparoscopic Roux-en-Y gastric bypass and take a rational approach to manage these complications.

Methods

A prospective observational study was performed from November 2010 to December 2012. All patients undergoing gastric bypass surgery for morbid obesity were included in this study. Patients with complications before day 5 were excluded from the study. Clinical and laboratory data (C-reactive protein, leukocyte count) at postoperative day 5, 30-day morbidity, were recorded. The diagnostic value of C-reactive protein (CRP) and leukocytes were determined by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve.

Results

One hundred and twenty-six patients were included. The overall incidence of 30-day morbidity was 8.7 %, and anastomotic leakage rate was 3.2 %. C-reactive protein at postoperative day 5 was a good predictor of complications (AUC was 0.862 (95 % CI [0.76; 0.96]; p?<?0.001) and anastomotic leakage (AUC was 0.863 (95 % CI [0.66; 1]; p?=?0.014). A CRP cutoff level of 136 mg/l at postoperative day 5 yielded a specificity of 95.5 % and a sensitivity of 57.1 % for the detection of postoperative complications. The negative predictive value was 94.6 %. A CRP level of 136 mg/l at day 5 was significantly associated with postoperative morbidity.

Conclusions

C-reactive protein dosage at postoperative day 5 is a relevant predictor of postoperative complications permitting to select patients at risk. Radiological examination and close monitoring could be restricted to patients with CRP level exceeding 136 mg/l.     

Establishing a Role for Vancomycin Powder Application for Prosthetic Joint Infection Prevention—Results of a Wear Simulation Study

Topical vancomycin powder (VP) has shown efficacy and safety in decreasing post-operative spine infections. VP use in arthroplasty has not been established. Concerns remain for third-body wear with the addition of crystalline substrate at the implant interface. The study's purpose was to compare wear behavior of CoCr on UHMWPE to identical wear couples with VP. A six-station wear simulator was utilized and cyclic articulations were run for 10 million cycles (Mc). UHMWPE wear was measured using photography, stereomicroscopy, and gravimetric measurement. There were no differences in wear mark length (P = 0.43), width (P = 0.49), or gravimetric wear at 10 Mc (P = 0.98). VP and control groups lost 0.32 and 0.33 mg, respectively. VP may have a role in PJI prevention. A well-designed clinical study is needed.     

Anticoagulation and antiaggregation in cardiac patients

Aspirin treatment for primary prevention is safe and useful at an annual coronary event risk > or = 1.5%. Both aspirin and clopidogrel reduce the rate of cardiovascular events in patients with coronary disease. Clopidogrel in addition to aspirin further reduces cardiovascular events, but is associated with and increased bleeding risk. Recent studies in patients with myocardial infarction suggest that treatment with either coumadin or with coumadin and aspirin are both at least as effective than treatment with aspirin alone. Thromboembolism and bleeding during therapeutic anticoagulation are the major chronic risks for patients with native valvular heart disease and mechanical prosthetic valves. The recommendations for the prevention of thromboembolic events and bleeding complications are discussed and recommended intensity of antithrombotic therapy are outlined. Key points of the guidelines for managing patients with atrial fibrillation are summarised.     

Activity-dependent slowing of conduction velocity in uninjured L4 C fibers increases after an L5 spinal nerve injury in the rat

Growing evidence suggests that uninjured afferents may play an important role in neuropathic pain following nerve injury. The excitability of nociceptive neurons in the L4 spinal nerve appears to be enhanced following an injury to the adjacent L5 spinal nerve. In this study, we investigated whether the action-potential conduction properties of unlesioned, unmyelinated fibers are also altered. A teased-fiber technique was used to record from single C fibers from the L4 spinal nerve of the rat in vitro. Repeated electrical stimulation of the tibial nerve was used to investigate activity-dependent slowing of conduction velocity. Twin pulse stimulation at a 50 ms interpulse interval allowed investigation of supranormal conduction velocity. Blinded experiments were performed 8-10 days after sham surgery and after an L5 spinal nerve ligation (L5 SNL). Activity-dependent slowing revealed two populations of C fibers, a "nociceptor" population with a large degree of activity-dependent slowing and a "non-nociceptor" population with a smaller degree of activity-dependent slowing. Both populations showed enhanced activity-dependent slowing of conduction velocity and enhanced supranormal conduction velocities in lesioned animals compared to sham animals. Activity-dependent slowing was also enhanced after an L5 SNL in the mouse. These alterations in conduction velocity may reflect changes in expression of ion channels responsible for the membrane excitability. These data provide additional evidence that a nerve injury leads to persistent alterations in the properties of adjacent uninjured, unmyelinated fibers.     

Podocyte loss and progressive glomerular injury in type II diabetes.

Kidney biopsies from Pima Indians with type II diabetes were analyzed. Subjects were classified clinically as having early diabetes (n = 10), microalbuminuria (n = 17), normoalbuminuria, despite a duration of diabetes equal to that of the subjects with microalbuminuria (n = 12), or clinical nephropathy (n = 12). Subjects with microalbuminuria exhibited moderate increases in glomerular and mesangial volume when compared with those with early diabetes, but could not be distinguished from subjects who remained normoalbuminuric after an equal duration of diabetes. Subjects with clinical nephropathy exhibited global glomerular sclerosis and more prominent structural abnormalities in nonsclerosed glomeruli. Marked mesangial expansion was accompanied by a further increase in total glomerular volume. Glomerular capillary surface area remained stable, but the glomerular basement membrane thickness was increased and podocyte foot processes were broadened. Broadening of podocyte foot processes was associated with a reduction in the number of podocytes per glomerulus and an increase in the surface area covered by remaining podocytes. These findings suggest that podocyte loss contributes to the progression of diabetic nephropathy.     

警惕性-护理的要素

护理及其它卫生保健职业在其实践过程中基本的要求是照护,专业的警惕性是护理中照护的要素。本文运用历史学和理论学为基础结合专业的警惕性,探讨它的构成要素。介绍了护理诊断的两种形式(中心和监视诊断)。中心诊断是指护士对指定计划完成和实施措施的评估,北美护理诊断学会批准了这种类型的诊断。监视诊断是护士评估预期的患者的风险,为突发事件做准备。整体而言,职业和术语研究者要扩大护理诊断术语使其标准化,以利于护士对患者安全的警惕性进行有效的沟通和实践。     

Dietary fat and incidence of type 2 diabetes in older Iowa women

OBJECTIVE: To examine the associations between reported intakes of dietary fat and incident type 2 diabetes. RESEARCH DESIGN AND METHODS: We studied the relation between dietary fatty acids and diabetes in a prospective cohort study of 35,988 older women who initially did not have diabetes. Diet was assessed with a food frequency questionnaire at baseline, and 1,890 incident cases of diabetes occurred during 11 years of follow-up. RESULTS: After adjusting for age, smoking, alcohol consumption, BMI, waist-to-hip ratio, physical activity, demographic factors, and dietary magnesium and cereal fiber, diabetes incidence was negatively associated with dietary polyunsaturated fatty acids, vegetable fat, and trans fatty acids and positively associated with omega-3 fatty acids, cholesterol, and the Keys score. After simultaneous adjustment for other dietary fat, only vegetable fat remained clearly related to diabetes risk. Relative risks across quintiles of vegetable fat intake were 1.00, 0.90, 0.87, 0.84, and 0.82 (P = 0.02). Diabetes risk was also inversely related to substituting polyunsaturated fatty acids for saturated fatty acids and positively correlated to the Keys dietary score. CONCLUSIONS: These data support an inverse relation between incident type 2 diabetes and vegetable fat and substituting polyunsaturated fatty acids for saturated fatty acids and cholesterol.