胰十二指肠切除术后出血影响因素分析与处理

目的 探讨胰十二指肠切除术后出血的原因、诊断及防治方法.方法 回顾性分析2009年1月至2012年6月154例胰十二指肠切除术的临床资料.结果 154例胰十二指肠切除共发生术后出血16例,发生率10.4％.2例术后临床死亡,死亡率为12.5％.16例中腹腔出血7例,消化道出血9例,1例兼有腹腔出血和消化道出血.在7例腹腔出血中,早期和晚期出血分别有5例和2例;9例消化道出血中,早期出血3例,晚期出血6例.统计分析显示,术后感染(P=0.002,P＜0.01)和胰瘘(P=0.048,P＜0.05)为术后出血的相关因素.结论 胰十二指肠切除术后出血是严重并发症,术中确切止血、术后预防胰瘘、预防感染是减少术后出血的关键.应根据出血的部位、时间和严重程度及时、果断采取相应的治疗措施.     

Outcomes after cardiac arrest in an adult burn center

Objective

Adult burn patients who experience in-hospital cardiac arrest (CA) and undergo cardiopulmonary resuscitation (CPR) represent a unique patient population. We believe that they tend to be younger and have the added burden of the burn injury compared to other populations. Our objective was to determine the incidence, causes and outcomes following cardiac arrest (CA) and cardio-pulmonary resuscitation (CPR) within this population.

Methods

We conducted a retrospective review at the US Army Institute of Surgical Research (ISR) burn intensive care unit (BICU). Charts from 1st January 2000 through 31st August 2009 were reviewed for study. Data were collected all on adult burn patients who experienced in-hospital CA and CPR either in the BICU or associated burn operating room. Patients undergoing CPR elsewhere in our burn unit were excluded because we could not validate the time of CA since they are not routinely monitored with real-time rhythm strips. The study population included civilian burn patients from the local catchment area and burn casualties from the conflicts in Iraq and Afghanistan, but patients with do-not-resuscitate (DNR) orders were excluded.

Results

We found 57 burn patients who had in-hospital CA and CPR yielding an incidence of one or more in-hospital CA of 34 per 1000 admissions (0.34%). Fourteen of these patients (25%) survived to discharge while 43 (75%) died. The most common initial cardiac rhythm was pulseless electrical activity (50.9%). The most common etiology of CA among burn patients was respiratory failure (49.1%). The most significant variable affecting survival to discharge was duration of CPR (P < 0.01) with no patient surviving more than 7 min of CPR.

Conclusions

CPR in burn patients is sometimes effective, and those patients who survive are likely to have good neurological outcomes. However, prolonged CPR times are unlikely to result in return of spontaneous circulation and may be considered futile. Further, those who experience multiple CA are unlikely to survive to discharge.     

Mandatory reporting of oral injuries indicating possible child abuse

BackgroundThe dental professional may see pediatric patients who have signs of intraoral trauma, perioral trauma or both. Evaluation should include the possibility of nonaccidental, deliberately inflicted abuse. Reporting such injuries is mandated.MethodsThe authors reviewed the criminal and civil statutes in all 50 states to determine what role dental professionals are required to play in instances of abuse or neglect.ResultsMandates in all 50 states require that dental professionals be aware of and report instances of child abuse and neglect to the proper state authority. State laws also protect the reporting dental professional from civil retribution.ConclusionsState laws and dental ethical duties require all dental professionals to be aware of and to report instances of child abuse or neglect. These same laws protect clinicians in this duty. It is the clinician's responsibility to help prevent ongoing injury to people who are incapable of self-protection.Clinical ImplicationsClinicians should learn to recognize signs of abuse and neglect, which often involve injury to the mouth and dentition. Dental professionals are mandated to report such abuse to state child protection authorities.     

Undiagnosed and comorbid disorders in patients with presumed chronic fatigue syndrome

Objective

To assess undiagnosed and comorbid disorders in patients referred to a tertiary care center with a presumed diagnosis of chronic fatigue syndrome (CFS).

Methods

Patients referred for chronic unexplained fatigue entered an integrated diagnostic pathway, including internal medicine assessment, psychodiagnostic screening, physiotherapeutic assessment and polysomnography + multiple sleep latency testing. Final diagnosis resulted from a multidisciplinary team discussion. Fukuda criteria were used for the diagnosis of CFS, DSM-IV-TR criteria for psychiatric disorders, ICSD-2 criteria for sleep disorders.

Results

Out of 377 patients referred, 279 (74.0%) were included in the study [84.9% female; mean age 38.8 years (SD 10.3)].A diagnosis of unequivocal CFS was made in 23.3%. In 21.1%, CFS was associated with a sleep disorder and/or psychiatric disorder, not invalidating the diagnosis of CFS. A predominant sleep disorder was found in 9.7%, 19.0% had a psychiatric disorder and 20.8% a combination of both. Only 2.2% was diagnosed with a classical internal disease.In the total sample, a sleep disorder was found in 49.8%, especially obstructive sleep apnea syndrome, followed by psychophysiologic insomnia and periodic limb movement disorder. A psychiatric disorder was diagnosed in 45.2%; mostly mood and anxiety disorder.

Conclusions

A multidisciplinary approach to presumed CFS yields unequivocal CFS in only a minority of patients, and reveals a broad spectrum of exclusionary or comorbid conditions within the domains of sleep medicine and psychiatry. These findings favor a systematic diagnostic approach to CFS, suitable to identify a wide range of diagnostic categories that may be subject to dedicated care.     

Adding Value in Radiology Reporting

The major goal of the radiology report is to deliver timely, accurate, and actionable information to the patient care team and the patient. Structured reporting offers multiple advantages over traditional free-text reporting, including reduction in diagnostic error, comprehensiveness, adherence to national consensus guidelines, revenue capture, data collection, and research. Various technological innovations enhance integration of structured reporting into everyday clinical practice. This review discusses the benefits of innovations in radiology reporting to the clinical decision process, the patient experience, the cost of imaging, and the overall contributions to the health of the population. Future directions, including the use of artificial intelligence, are reviewed.     

Comparison of glenohumeral and humerothoracical range of motion in healthy controls,osteoarthritic patients and patients after total shoulder arthroplasty performing different activities of daily living

PurposeThe purpose of this study was to examine how total shoulder arthroplasty improves performance of activities of daily living compared to patients with glenohumeral osteoarthritis and how they perform compared to healthy controls.MethodsGlenohumeral and humerothoracical elevation used by patients with primary osteoarthritis (12 participants, 16 shoulders), after total shoulder arthroplasty (16 participants, 24 shoulders) and healthy controls (11 participants, 22 shoulders) for four different activities of daily living were assessed using 3D motion analysis. Analysis of range of motion and angle time series was performed.ResultsRange of motion used for activities of daily living was better in patients treated with anatomical total shoulder arthroplasty than in patients with primary glenohumeral osteoarthritis. Although it was still reduced compared to healthy individuals. Angle time series showed improved kinematics in patients with total shoulder arthroplasty compared to patients with glenohumeral osteoarthritis. Both glenohumeral and humerothoracical elevation kinematic time series were in almost all cases in between the control group’s and the osteoarthritis group’s.ConclusionTotal shoulder arthroplasty improves performance of activities of daily living in patients with primary glenohumeral osteoarthritis but cannot restore the full range of Motion compared to healthy controls. A prospective study with pre- and postoperative examinations is necessary to understand to understand how preoperative status influences the postoperative results.