Management and outcomes of small bowel obstruction in older adult patients: a prospective cohort study

Background

The purpose of this research was to examine the morbidity, mortality and rate of recurrent bowel obstruction associated with the treatment of small bowel obstruction (SBO) in older adults.

Methods

We prospectively enrolled all patients 70 years or older with an SBO who were admitted to a tertiary care teaching centre between Jul. 1, 2011, and Sept. 30, 2012. Data regarding presentation, investigations, treatment and outcomes were collected.

Results

Of the 104 patients admitted with an SBO, 49% were managed nonoperatively and 51% underwent surgery. Patients who underwent surgery experienced more complications (64% v. 27%, p = 0.002) and stayed in hospital longer (10 v. 3 d, p < 0.001) than patients managed nonoperatively. Nonoperative management was associated with a high rate of recurrent SBO: 31% after a median follow-up of 17 months. Of the patients managed operatively, 60% underwent immediate surgery and 40% underwent surgery after attempted nonoperative management. Patients in whom nonoperative management failed underwent surgery after a median of 2 days, and 89% underwent surgery within 5 days. The rate of bowel resection was high (29%) among those who underwent delayed surgery. Surgery after failed nonoperative management was associated with a mortality of 14% versus 3% for those who underwent immediate surgery; however, this difference was not significant.

Conclusion

These data suggest that some elderly patients with SBO may be waiting too long for surgery.     

Predictors of ovarian malignancy in children: Overcoming clinical barriers of ovarian preservation

Background/Purpose

Ovarian preservation is desirable in girls with benign ovarian masses. We aimed to 1) identify clinical predictors of malignant ovarian masses, 2) investigate how often ovarian tissue is present to preserve in benign masses, and 3) identify factors associated with successful ovarian preservation.

Methods

Retrospective analysis (1997–2012) of girls age 1–18 years with an ovarian mass managed operatively. Data on presenting symptoms, imaging, biochemical markers, treatment, outcome, and pathology were extracted.

Results

We identified 150 patients. Large mass size, solid components, and elevated tumor markers (AFP, βHCG, and/or LDH) were significantly predictive of malignancy. All masses < 10 cm, predominantly cystic, and with negative tumor markers were benign. Masses with all three of these characteristics would decrease a 20% malignancy pretest probability to a posttest probability of 0.25%. Benign masses managed by oophorectomy contained normal ovarian tissue in 76% of the specimens. For benign masses, successful ovarian preservation was significantly associated with size < 10 cm, predominantly cystic, laparoscopy, and absence of torsion or calcifications.

Conclusion

Ovarian masses that are < 10 cm, primarily cystic, and have negative tumor markers are most likely benign. Viable ovarian tissue is frequently present in benign masses, so significant efforts should be made for ovarian preservation.     

Trends in community violence in England and Wales 2005–2009

Purpose

Injury records from Emergency Departments (EDs) have been studied over the last decade as part of the work of the National Violence Surveillance Network (NVSN) and provide information about local, regional and national violence levels and trends in England and Wales. The purpose of the current study is to evaluate overall, gender, age-specific and regional trends in community violence in England and Wales from an ED perspective from January 2005 to December 2009.

Methods

Violence-related injury data were collected prospectively in a stratified sample of 77 EDs (Types 1, 3 and 4) in the nine Government Office Regions in England and in Wales. All 77 EDs were recruited on the basis that they had implemented and continued to comply with the provisions of the 1998 Data Protection Act and Caldicott guidance. Attendance date, age and gender of patients who reported injury in violence were identified using assault-related attendance codes, specified at the local level. Time series statistical methods were used to detect both regional and national trends.

Results

In total 221,673 (163,384 males: 74%) violence-related attendances were identified. Overall estimated annual injury rate was 6.5 per 1000 resident population (males 9.8 and females 3.4 per 1000). Violence affecting males and females decreased significantly in England and Wales over the 5-year period, with an overall estimated annual decrease of 3% (95% CI: 1.8–4.1%, p < 0.05). Attendances decreased significantly for both genders across four out of the five age groups studied. Attendances were found to be highest during the months of May and July and lowest in February. Substantial differences in violence-related ED attendances were identified at the regional level.

Conclusions

From this ED perspective overall violence in England and Wales decreased over the period 2005–2009 but increased in East Midlands, London and South West regions. Since 2006, overall trends according to Crime Survey for England and Wales (CSEW), police and ED measures were similar, though CSEW and ED measures reflect far greater numbers of violent incidents than police data. Causes of decreases in violence in regions need to be identified and shared with regions where violence increased.