Three-dimensional reconstructed images using multidetector computed tomography in evaluation of the biliary tract

The recent development of multidetector computed tomography (MDCT) and the parallel escalation in the capabilities of the workstation allow the use of high-quality multiplanar and three-dimensional reconstruction images. As a noninvasive technique, MDCT dedicated to the biliary tract represents an alternative to magnetic resonance cholangiography. The usefulness of three-dimensional reconstructed images using MDCT in evaluating biliary tract abnormality is illustrated.     

Best interests at end of life: A review of decisions made by the Consent and Capacity Board of Ontario

Purpose

When patients are unable to communicate their own wishes, surrogates are commonly used to aid in decision making. Although each jurisdiction has its own rules or legislation governing how surrogates are to make health care decisions, many rely on the notion of “best interests” when no prior expressed wishes are known.

Methods

We purposively sampled written decisions of the Ontario Consent and Capacity Board that focused on the best interests of patients at the end of life. Interpretive content analysis was performed independently by 2 reviewers, and themes that were identified by consensus as describing best interests were construed, as well as the characteristics of an end-of-life dispute that may be most appropriately handled by an application to the Consent and Capacity Board.

Results

We found that many substitute decision makers rely on an appeal to religion or God in their interpretation of best interests, whereas physicians focused narrowly on the clinical condition of the patient in their interpretations.

Conclusions

Several lessons are drawn for the benefit of health care teams engaged in end-of-life conflicts with substitute decision makers over the best interests of patients.     

Assessing Internet Addiction Using the Parsimonious Internet Addiction Components Model—A Preliminary Study

Internet usage has grown exponentially over the last decade. Research indicates that excessive Internet use can lead to symptoms associated with addiction. To date, assessment of potential Internet addiction has varied regarding populations studied and instruments used, making reliable prevalence estimations difficult. To overcome the present problems a preliminary study was conducted testing a parsimonious Internet addiction components model based on Griffiths’ addiction components (Journal of Substance Use, 10, 191–197, 2005), including salience, mood modification, tolerance, withdrawal, conflict, and relapse. Two validated measures of Internet addiction were used (Compulsive Internet Use Scale [CIUS], Meerkerk et al. in Cyberpsychology & Behavior, 12(1), 1–6, 2009, and Assessment for Internet and Computer Game Addiction Scale [AICA-S], Wölfling et al. 2010) in two independent samples (ns?=?3,105 and 2,257). The fit of the model was analysed using Confirmatory Factor Analysis. Results indicate that the Internet addiction components model fits the data in both samples well. The two sample/two instrument approach provides converging evidence concerning the degree to which the components model can organize the self-reported behavioural components of Internet addiction. Recommendations for future research include a more detailed assessment of tolerance as addiction component.     

Ileal pouch fistulas after restorative proctocolectomy: management and outcomes

Background

Fistula between an ileal pouch and the vagina, anus, or perineum is an uncommon complication of ileal pouch-anal anastomosis and is a cause of considerable morbidity. Its optimal management has not been determined because of its low incidence. The aim of this study was to review the outcomes of patients who presented with symptomatic ileal pouch-associated fistulas after restorative proctocolectomy (RPC) and to present a diagnostic and treatment algorithm.

Methods

Retrospective review of patients treated for symptomatic ileal pouch-associated fistulas after RPC from 1989 to 2011.

Results

Twenty-five patients (14 men, mean age 40 years) were presented with symptomatic ileal pouch-associated fistulas. Median time to pouch fistula following RPC was 6.9 years (range 1 month–20 years). Fistulas were classified as pouch-anal (n = 12, 48 %), pouch-vaginal (n = 7, 28 %), complex (n = 4, 16 %), and pouch-perineal (n = 2, 8 %). Etiology included Crohn’s disease (n = 15, 60 %), cryptoglandular (n = 6, 24 %), and anastomotic failure (n = 4, 16 %). Each patient underwent an average of 2.8 local procedures or repairs. Overall healing rate was 64 % at a median follow-up of 29 (range 2–108) months. None of the complex fistulas were healed. Postoperative pelvic sepsis, fecal diversion, anti-tumor necrosis factor therapy, and fistula etiology did not significantly impact fistula healing. Three patients required pouch excision with end ileostomy.

Conclusions

Operative treatment of pouch fistulas after RPC resulted in complete healing in 64 % of patients following a stepwise diagnostic and therapeutic approach.     

Early oral feeding after pancreatoduodenectomy enhances recovery without increasing morbidity

Objective

The aim of this study was to evaluate whether a change in the routine feeding strategy applied after pancreatoduodenectomy (PD) from nasojejunal tube (NJT) feeding to early oral feeding improved clinical outcomes.

Methods

An observational cohort study was performed in 102 consecutive patients undergoing PD. In period 1 (n = 51, historical controls), the routine postoperative feeding strategy was NJT feeding. This was changed to a protocol of early oral feeding with on-demand NJT feeding in period 2 (n = 51, consecutive prospective cohort). The primary outcome was time to resumption of adequate oral intake.

Results

The baseline characteristics of study subjects in both periods were comparable. In period 1, 98% (n = 50) of patients received NJT feeding, whereas in period 2, 53% (n = 27) of patients did so [for delayed gastric empting (DGE) (n = 20) or preoperative malnutrition (n = 7)]. The time to resumption of adequate oral intake significantly decreased from 12 days in period 1 to 9 days in period 2 (P = 0.015), and the length of hospital stay shortened from 18 days in period 1 to 13 days in period 2 (P = 0.015). Overall, there were no differences in the incidences of complications of Clavien–Dindo Grade III or higher, DGE, pancreatic fistula, postoperative haemorrhage and mortality between the two periods.

Conclusions

The introduction of an early oral feeding strategy after PD reduced the time to resumption of adequate oral intake and length of hospital stay without negatively impacting postoperative morbidity.     

Aktuelle Epidemiologie der Tuberkulose weltweit,in Europa und in Deutschland

Background

Tuberculosis remains one of the most important infectious diseases worldwide. For 2011 the World Health Organization estimated that there were 8.7 million new cases of tuberculosis and 1.4 million deaths from tuberculosis.

Objectives

This article gives an overview on the current tuberculosis (TB) situation worldwide, in Europe as well as in Germany. Special attention is given to drug resistance and the HIV and tuberculosis coepidemic as they strongly impact on the epidemiology of tuberculosis.

Methods

International and national epidemiological reports on tuberculosis as well as selected epidemiological studies were considered. Challenges for tuberculosis control in Germany are discussed.

Results

Globally, a slight decline in tuberculosis incidence is currently being observed. This is partly attributed to improvements in diagnostic and therapeutic care and also for HIV infected patients. However, drug resistance rates are causing concern, especially in several newly independent states of the former Soviet Union. Although tuberculosis case numbers and incidences in the European Union and the European Economic Area (EU/EEA) are comparably low, tuberculosis still represents a considerable burden of disease. In Germany, as in several other western European countries with a low incidence of tuberculosis, case numbers are stagnating and childhood tuberculosis is slightly increasing. Therefore, efforts to ensure an effective tuberculosis control cannot be allowed to wane.