Balanced resuscitative fluids (BF) have been associated with decreased incidence of hyperchloremic metabolic acidosis in sepsis. We hypothesized that higher proportions of BF during resuscitation would thus be associated with improved mortality in Emergency Department (ED) patients with sepsis.
Methods
This was a retrospective chart review of adult ED patients who presented with sepsis to a large, urban teaching hospital over one year. The choice of resuscitation fluid in the first 2 days of hospitalization was defined as either normal saline (NS) or balanced fluids (BF; Lactated Ringer's or Isolyte). The primary study outcome was in-hospital mortality, which was analyzed with multivariable logistic regression based on the proportion of BF received during the initial ED resuscitation.
Results
Of 149 patients screened, 33 were excluded, leaving 115 for analysis, of whom 18 died (16% overall mortality). Sixty-one (53%) patients received BF and NS, 6 (5%) patients received BF exclusively, while 48 (42%) patients received NS only. The mean number of liters administered was 5.4, and the mean percentage of BF administered was 29%. In univariate analysis, a higher proportion of BF was associated with lower odds of mortality (OR 0.973 [95% CI 0.961–0.986], p = 0.00003). This association held true in multivariable models controlling for comorbidities and admission lactate level.
Conclusions
We found that the proportion of BF during the initial ED resuscitation in septic patients was associated with a significant reduction in mortality. This association provides the necessary rationale for future randomized clinical trials of BF resuscitation in sepsis. 相似文献
Purpose: To demonstrate the success rate of three-snip punctoplasty (TSP) for the treatment of punctual stenosis and to evaluate the need for additional treatment after TSP.
Methods: A retrospective chart review was conducted of all patients undergoing TSP by a single surgeon at Bascom Palmer Eye Institute from January 1, 2006 to January 1, 2010. Outcome measures include the persistence of symptomatic epiphora, the need for additional surgical interventions, and postoperative time required until complete resolution of symptoms achieved.
Results: Primary TSP resulted in an 86% success rate with resolution of symptomatic epiphora without further surgical intervention. Seven eyes (14%) required secondary TSP with or without stent placement. All 6 eyes with TSP with stent placement achieved functional success within an average of 6.8 months (stdev 6.83) from the first TSP. The one eye that was not stented during secondary TSP required a tertiary TSP with stenting and achieved functional success within the 1 month of the final procedure.
Conclusion: Primary TSP showed an 86% success rate with the resolution of tearing by an average of 1.2 months post-operatively. Membrane formation or scarring over the surgical site required an additional TSP with stenting in 14% of patients. All 50 eyes eventually achieved functional success. TSP alone as a primary procedure is a safe, relatively simple, and effective treatment of epiphora caused by punctual stenosis. Stenting should be explored as an adjunct to this procedure if primary TSP alone does not produce resolution of symptoms. 相似文献
Osteoporosis is a major clinical problem in older women and men. Almost any bone can fracture as a result of the increased bone fragility of osteoporosis. These fractures are associated with higher health care costs, physical disability, impaired quality of life, and increased mortality. Because the incidence of osteoporotic fracture increases with advancing age, measures to diagnose and prevent osteoporosis and its complications assume a major public health concern. BMD is a valuable tool to identify patients at risk for fracture, to make therapeutic decisions, and to monitor therapy. Several other modifiable and nonmodifiable risk factors for osteoporosis have also been identified. Treatment of potentially modifiable risk factors along with exercise and calcium and vitamin D supplementation forms an important adjunct to pharmacologic management of osteoporosis. Improved household safety can reduce the risk of falls. Hip protectors have been found to be effective in nursing home population. The pharmacologic options include bisphosphonates, HRT, SERMs and calcitonin. PTH had received FDA advisory committee approval. Alendronate has been approved for treatment of osteoporosis in men, and other treatments for men are under evaluation. 相似文献
Combination therapy, the use of an anabolic agent with an antiresorptive agent in some sequence, has been evaluated in a number
of clinical trials. There is no fracture data on combination therapy except for a small trial using PTH and estrogen. It appears
that simultaneous use of a bisphosphonate (alendronate 10 mg per day) with PTH offers no advantage (and appears to blunt PTH's
effect) compared with the use of PTH alone based on bone density gains. Previous therapy with alendronate also blunts gains
in bone density with PTH therapy. Estrogen and raloxifene, whether given before or with PTH, do not blunt its anabolic effect.
Sequential therapy with PTH followed by an antiresorptive agent (alendronate) offers the greatest gains in bone mass. It is
possible that alendronate or other bisphosphonates given in a different dosing regimes may have different effects on PTH's
anabolic effect. More trial data on combination therapy is needed. 相似文献
Advances in myocardial perfusion imaging have firmly established the use of noninvasive techniques capable of providing useful
information over a broad range of diagnostic and therapeutic cardiovascular problems. Evaluating regional myocardial perfusion
abnormalities is a cornerstone for the diagnosis of coronary artery disease, risk assessment in those with known disease,
and determination of myocardial viability. The clinical use of myocardial perfusion imaging and the current limitations of
existing techniques continue to promote the development of new technologies capable of assessing microvascular and capillary
perfusion abnormalities on a global myocardial level. Myocardial contrast echocardiography is an emerging technique capable
of rapidly assessing myocardial perfusion at the capillary level in many different clinical settings. This article focuses
on myocardial contrast-enhanced ultrasound perfusion techniques, emphasizing the unique information this modality provides
compared with other noninvasive perfusion imaging techniques. 相似文献
Pancreatic fistula remains a major complication after pancreaticoduodenectomy (PD). Re-operation is generally considered only after exhaustion of non-surgical options. A variety of pancreas-preserving operations have been proposed, but completion pancreatectomy (CP) stands out in locally complicated cases as a universal approach. This study aims to provide a qualitative synthesis of the peer-reviewed literature regarding emergency CP for post-PD pancreatic fistula.
Methods
A systematic search of PubMed and EMBASE for all studies reporting clinical outcomes for CP in the acute treatment of pancreatic fistula following PD from January 1975 until May 2016.
Results
Eleven patient-series with a total of 5566 PD and 151 (3%) emergency CP were included. Median time from PD to CP ranged from 6 to 17 days (7 studies), and mean operative time and blood loss – reported in only two studies – were 197 min and 2173 mL respectively. Re-laparotomy following CP was required in 35% of patients. Median hospital length-of-stay varied from 21 to 64 days, and postoperative mortality was 42%.
Conclusions
Emergency surgery for postoperative pancreatic fistula should only be considered after expert consultation. CP carries a high risk of mortality, and it is most commonly recommended for a selected subgroup of patients with locally complicated fistula. 相似文献
Acute Myeloid Leukemia (AML) is a disorder affecting primarily elderly individuals and poses significant treatment challenges. Much has been learned about the underlying immunologic, cytogenetic and molecular features of AML in recent years, and many features have been identified that portend a poor prognosis for elderly patients with newly diagnosed AML. Despite this, treatment outcomes for elderly patients remain poor for both newly diagnosed and relapsed disease. While conventional treatment approaches may be appropriate for some elderly patients, the vast majority do not tolerate intensive chemotherapy well, thus alternative strategies have been investigated. Here we review both conventional and novel treatment approaches for elderly patients with AML, including agents in early clinical trials. Treatment options have been divided into several discussions, including conventional treatments, agents complementary to conventional treatments, alternatives to conventional induction therapies, post-induction treatment, and relapsed disease. Current and developing research focuses upon identifying subgroups of patients that benefit more from specific chemotherapeutic agents. Treating elderly patients with AML requires an organized, multidisciplinary approach, taking into account individual patient characteristics, preferences, and comorbidities when formulating treatment plans. 相似文献