Risk of major complications following thyroidectomy and parathyroidectomy: Utility of the NSQIP surgical risk calculator

Background

The primary objective of this study was to determine rates of reoperation, ED visits, and hospital readmission after thyroid and parathyroid surgery at a tertiary hospital. A secondary objective was to determine if scores from the American College of Surgeons Surgical Risk Calculator (ACS SRC) predicted these events.

Effect of Different Tube Feeding Methods on the Delivery of Docosahexaenoic and Arachidonic Acid: An In Vitro Pilot Study

Background: Arachidonic acid (AA) and docosahexaenoic acid (DHA) are crucial for neural and visual development after premature birth. Preterm infants usually require tube feeding (TF) until the achievement of adequate oral feeding skills; the impact of TF on DHA and AA delivery has not been investigated yet. This study aimed to evaluate the effect of different TF techniques on the delivery of AA and DHA contained in human milk (HM). Methods: HM samples (65 mL each) were collected and divided into three 20‐mL aliquots. The remaining 5 mL served as baseline. Three TF techniques were simulated (1 for each aliquot): gravity bolus feeding (BF), 3‐hour continuous feeding using a horizontal feeding pump, and 3‐hour continuous feeding with the feeding pump angled at 45°. For horizontal continuous feeding (HCF) and 45° angled continuous feeding (ACF), aliquots delivered between 0 and 90 minutes (T1) and 91 and 180 minutes (T2) were collected separately. AA and DHA concentration was analyzed by gas chromatography/mass spectrometry and compared among the TF methods. DHA and AA delivery at T1 and T2 was also evaluated. Results: Fifty‐one simulated feeds were performed. DHA and AA amounts after BF and ACF did not differ significantly compared with baseline, whereas HCF resulted in significantly lower DHA and AA concentration. During T2, ACF delivered almost twice the DHA and AA amounts compared with T1. Conclusion: The delivery of HM AA and DHA is significantly affected by TF, with potential clinical implications. When BF is not tolerated, ACF might represent a feasible alternative to reduce TF‐related DHA and AA loss.     

Disorders of swallowing

Disorders of swallowing are very common and, when looked for, occur regularly in most branches of surgery. Dysphagia is often not the patient's presenting complaint and can be easily missed. The consequences of missed or delayed diagnosis of dysphagia can be insidious but profound and, in some cases, fatal. The investigation and treatment of these patients is normally highly multidisciplinary, potentially involving gastroenterology, general surgery, otolaryngology, acute medicine, stroke medicine, paediatrics, speech and language therapy (SLT) and dietitians. While this article is aimed at surgeons and will thus concentrate mostly on those conditions seen by surgeons, it must be remembered that the most common cause of dysphagia is a neurological disturbance and is managed by physicians and SLT. That said, the incidence of these conditions rises with age, as does the incidence of many surgically treatable conditions. It is therefore common to assess a patient with a known neurological condition for the presence of a second pathology affecting their swallow. A basic knowledge of non-surgical conditions is therefore useful.     

Normal solid bolus swallowing erect position

Individuals with structural and functional abnormalities of the esophagus are frequently symptomatic when swallowing solids and have been reported to demonstrate delay during nuclide examinations. This study was performed in symptomatic individuals to determine how often a solid bolus (13 mm barium tablet or 10 mm bagel bread sphere) passed through the esophagus without delay and whether erect solid bolus swallowing occurred without significant bolus hesitation during fluoroscopic evaluation. All individuals referred for an upper gastrointestinal examination or barium swallow who complained of dysphagia, heartburn, or chest pain were evaluated with a solid bolus. Individuals demonstrating gastroesophageal reflux, a hiatal hernia, a Schatzki B ring, or any esophageal motility disturbance were given a solid bolus. Twenty-six (27%) of 98 symptomatic individuals given a barium tablet had no delay in its passage. Thirteen (8%) of 150 symptomatic individuals given a bagel sphere had an erect solid bolus swallow with no delay in its passage. Only one individual of 26 given both solids (4%) showed no delay in transit of either bolus. Solid bolus swallows without delay were noted to occur in two ways: (1) The entire solid bolus passed in less than 3 s without delay of any kind, and (2) some temporary delay (less than 5 s) occurred at regions of anatomic esophageal narrowing (circopharyngeus, thoracic inlet, transverse aorta, left mainstem bronchus, or diaphragm). These temporarily delayed swallows were assisted by coincidentally swallowed fluid or the following peristaltic wave. No additional swallows were required to complete passage into the stomach. Bolus passage was accomplished predominantly by oral thrust, gravitational pull, esophageal relaxation, and possibly because of intraluminal esophageal pressure differentials. Therefore, solid bolus erect swallowing can occur without significant delay of bolus passage into the stomach in a symptomatic population. Opinions and assertions contained herein are those of the authors and do not represent the official position of the U.S. Navy, Uniformed Services University of the Health Sciences, or the Department of Defense.     

Prandial-basal insulin regimens plus oral antihyperglycaemic agents to improve mealtime glycaemia: initiate and progressively advance insulin therapy in type 2 diabetes

Aims: To compare two progressive approaches [once‐daily insulin glargine plus ≤3 mealtime lispro (G+L) vs. insulin lispro mix 50/50 (LM50/50) progression once up to thrice daily (premix progression, PP)] of beginning and advancing insulin in patients with type 2 diabetes (T2D) and inadequate glycaemic control on oral therapy, with the aim of showing non‐inferiority of PP to G+L. Methods: Patients were randomized to PP (n = 242) or G+L (n = 242) in a 36‐week, multinational, open‐label trial. Dinnertime insulin LM 50/50 could be replaced with insulin lispro mix 75/25 if needed for fasting glycaemic control. Results: Baseline haemoglobin A1c (HbA1c) were 9.5% (PP) and 9.3% (G+L); p = 0.095. Change in A1C (baseline to endpoint) was ?1.76% (PP) and ?1.93% (G+L) (p = 0.097) [between‐group difference of 0.17 (95% confidence interval: ?0.03, 0.37)]. Non‐inferiority of PP to G+L was not shown based on the prespecified non‐inferiority margin of 0.3%. A1C was lower with G+L at weeks 12 (7.8 vs. 7.9%; p = 0.042), 24 (7.4 vs. 7.6%; p = 0.046), but not at week 36 (7.5 vs. 7.6%; p = 0.405). There were no significant differences in percentages of patients achieving A1C ≤7%, overall hypoglycaemia incidence and rate or weight change. Total daily insulin dosages at endpoint were higher with PP vs. G+L (0.57 vs. 0.51 U/kg; p = 0.017), likely due to more injections (1.98 vs. 1.79; p = 0.011). Conclusions: Both treatments progressively improved glycaemic control in patients with T2D on oral therapy, although non‐inferiority of PP to G+L was not shown. Higher insulin doses were observed with PP with no between‐treatment differences in overall hypoglycaemia or weight gain.     

推注与泵注舒芬太尼在腹腔镜胆囊切除术中的应用

随着腹腔镜下胆囊切除(LC)技术的不断提高,手术时间越来越短,手术连台情况越来越多,这就要求患者在停止给药后尽快苏醒。因此,寻求安全有效的药物和给药方式显得尤为重要。本研究将间断推注舒芬太尼和持续泵注舒芬太尼用于LC术,以观察两种方法对患者术中血流动力学和麻醉恢复的影响,从而为临床工作提供参考。     

Midazolam as a sole sedative for computed tomography imaging in pediatric patients

Objective: To evaluate the efficacy and adverse effects of i.v. midazolam as a sole agent for sedation in children for computed tomography (CT) imaging. Materials and Methods: Prospective clinical trial in which 516 children under ASA classification II–IV (273 boys and 243 girls) in the age group of 6 months to 6 years for elective CT scan were enrolled over a 17‐month period. Patients were administered i.v. midazolam 0.2 mg·kg^?1 and further boluses of 0.1 mg·kg^?1 (total 0.5 mg·kg^?1) if required. Measurements included induction time, efficacy, side effects, complications, and degree of sedation. Sedation was graded on the basis of Ramsay sedation score (RSS) as over sedated (RSS 5–6), adequately sedated (AS, RSS 3–4), under sedated (RSS 1–2), or failed if the procedure could not be completed or another agent had to be administered. Results: Of the 516 procedures, 483 brains, 16 chests, and 17 abdomens were scanned with a mean duration of 4.75 ± 1.75 min with a mean dose of 0.212 mg·kg^?1 of i.v. midazolam. Four hundred and sixty‐five (90.12%) patients were AS in 5.9 ± 0.7 min while 40 (7.75%) patients required additional boluses. Of these 40 patients, 24 (4.65%) required a single bolus, 12 (2.32%) required two boluses, whereas the remaining four (0.78%) required three boluses. In 11 (2.13%; P < 0.0001) patients, the scan could not be completed satisfactorily. Side effects were seen in 46 (9.11%) patients in the form of desaturation, hiccups (seven patients, 1.38%), and agitation (four patients, 0.79%). Desaturation (SpO₂ 90–95%) was seen in 35 (6.93%) patients, which was corrected by topical application of oxygen. None of the patients exhibited any complications such as pulmonary aspiration or need to maintain airway. The patients were kept under observation for 1 h after the procedure. Conclusion: The level of sedation achieved in children with midazolam 0.2 mg·kg^?1 is adequate for imaging with minimal side effects, no airway complications, and fast recovery. It can be recommended as the sole agent for sedation in pediatric patients for CT imaging.