Time to Administration of Antibiotics among Inpatients with Severe Sepsis or Septic Shock

Background

Current evidence suggests that administration of appropriate antibiotic therapy within 1 h after the onset of hypotension significantly improves mortality rates among patients with severe sepsis and septic shock.

Objectives:

To determine the interval from recognition of severe sepsis or septic shock in inpatients to initial administration of antibiotic and to assess institutional compliance with the Surviving Sepsis Campaign’s recommendation for early antibiotic therapy.

Methods:

A 6-month retrospective chart analysis was conducted to determine the interval from documented onset of hypotension to initial administration of antibiotic for patients with severe sepsis or septic shock. Patients who were admitted to a general medicine ward, a surgery ward, or the intensive care unit (ICU) of a 475-bed university-affiliated hospital and who met the criteria for severe sepsis or septic shock were eligible for inclusion. Patients who received antibiotics before meeting the criteria for severe sepsis or septic shock were excluded.

Results:

Charts for 100 patients with severe sepsis or septic shock were reviewed. The mean age was 69.0 years (standard deviation 18.7 years), and 56% were men. The median interval from onset of severe sepsis or septic shock to administration of antibiotic was 4.00 h (interquartile range [IQR] 1.80–6.45 h). The median interval from the time a physician ordered an antibiotic to administration of the drug was 1.28 h (IQR 0.57–3.05 h). The interval between ordering and administration differed significantly for patients on the wards (5.67 h), those with onset in the ICU (4.00 h), and those with onset in the emergency department (3.28 h) (p = 0.039). The overall survival rate was 56%.

Conclusion:

At the study hospital, the interval from onset of severe sepsis or septic shock to initial administration of antibiotic to inpatients exceeded the 1-h period recommended by the Surviving Sepsis Campaign. These results will be used as a baseline for future quality assurance and improvement initiatives aimed at minimizing the time to antibiotic administration for this group of patients, who are at high risk of death.     

扁桃体周围脓肿摘除扁桃体不同手术时机的疗效观察

目的观察扁桃体周围脓肿摘除扁桃体不同手术时机的疗效。方法将94例扁桃体周围脓肿患者分成3组,分别选择脓肿期、脓肿后期、择期手术等3种不同的手术时机,从术中出血量、手术时间、术后出血发生率、术中术后疼痛程度、平均住院时间等方面观察不同手术时机的疗效。结果脓肿期手术组、脓肿后期手术组及择期手术组患者的术中出血量分别为（25±5）、（10±3）、（35±5）ml;手术时间分别为（15±3）、（10±3）、（20±5）min;术后出血发生率分别为4．0％、0．0％、10．0％;术中疼痛程度（NRS）分别为（7．1±0．5）、（5．5±013）、（8．2±0．4）;术后24h疼痛程度（NRS）分别为（5．0±0．4）、（4．1±0．4）、（6．5±0．3）;术后48h疼痛程度（NRS）分别为（3．1±0．3）、（2．5±0．3）、（3．9±0．4）;平均住院时间分别为7．2、6．5、13．6d。脓肿后期手术组与另外两组比较,差异均有统计学意义（P〈0．05）。术后随访半年无复发病例。结论扁桃体周围脓肿患者在脓肿后期行扁桃体摘除术比在脓肿期或择期手术更加安全有效,目并发症少。     

Revision surgery for incidental gallbladder cancer: factors influencing operability and further evidence for T1b tumours

Background and aim. There is a need to increase the available data on revision radical surgery for incidental gallbladder cancer and to determine factors influencing operability. We aimed to assess the impact of stage of disease (pT) and the type of primary surgery (laparoscopy versus open) on resectability rates. Material and methods. The data of 90 consecutive patients referred to the Tata Memorial Hospital between 1 January 2003 and 30 April 2007 for revision radical surgery for incidental gallbladder cancer were reviewed retrospectively. Results. Of the 90 patients who underwent revision surgery, accurate data on T-stage was available in 76, and of these 76 patients, 44 (57.8%) had prior laparoscopic simple cholecystectomy, while 32 (42.2%) had undergone open surgery. The median time interval between the two surgeries was 2 months (range 4 weeks to 11 months). By T-stage, 23 patients had T1b disease, while 33 and 20 patients had T2 and T3 disease, respectively. Successful revision surgery could be undertaken in 71% of patients (54/76) and 29.6% of these had residual disease confirmed by histopathological examination. Conclusions. T-stage is an important factor in determining operability as confirmed by our study. As the T-stage of the disease increased, the chances of finding residual disease increased, while operability decreased. Furthermore, the case for revision surgery is strengthened because the incidence of lymph nodal disease is high even for pT1b cancers. The type of primary surgery does not affect operability in patients undergoing revision radical surgery for incidental gallbladder cancer.     

Binge Drinking Trajectories Across Adolescence: For Early Maturing Youth,Extra-Curricular Activities Are Protective

PurposeTo describe adolescent binge drinking trajectories across grades 8–11 and examine their associations with pubertal timing, socioeconomic status (SES), and structured activity and sport involvement.MethodsLongitudinal data were analyzed from the Youth Activity Participation Study (YAPS), an annual survey of youth in 39 schools across Western Australia (N = 1,342).ResultsLatent class growth analysis revealed four binge drinking trajectory groups: Accelerating (early onset, increased frequency), Steep Increase (delayed onset, rapid escalation), Slow Growth (delayed onset, gradual increase) and Stable Low (abstinence). Accelerating was characterized by early pubertal timing, low SES, and more sport involvement in grade 8, relative to Stable Low. The groups did not significantly differ in their grade 8 activity participation. However, for early maturers, greater grade 8 activity participation was associated with a decreased probability of belonging to Steep Increase relative to Stable Low.ConclusionsEarly pubertal timing and sports participation increased the odds of belonging to a problematic binge drinking trajectory. For youth at-risk due to early pubertal timing, structured activities appear to be protective against a problematic developmental course of binge drinking.     

Sleep timing,chronotype, mood,and behavior at an Arctic latitude (69°N)

ObjectiveDaylight is an important zeitgeber for entraining the circadian rhythm to a 24 h clock cycle, especially within the Polar circle, which has long Polar nights several months each year. Phase delays in sleep timing may occur, but the mean shift is normally small. However, the individual variation in phase shifts is large, implicating moderating factors. Here we examined the role of several self-regulatory variables (mood and fatigue, behavioral habits, and psychological self-regulation) as moderators of seasonality in sleep timing and chronotype.MethodsA sample of 162 young adults (76% females; mean age: females 23.4 years, males 24.3 years) participated in a prospective study across three seasons (September, December, March) in Tromsø/Norway at 69°39′N. Sleep diary and sleep/health-related questionnaire data were collected at each time-point.ResultsSleep timing and chronotype were delayed during the dark period (December) compared with brighter photoperiods (September and March). Comparable effects were observed for insomnia, fatigue, mood (depression and anxiety), subjective health complaints, physical activity, and school-related stress. Most importantly, depression and fatigue moderated the degree of seasonal shifting in sleep timing, whereas the other self-regulation indicators did not (ie eating habits, physical activity, and psychological self-regulation).ConclusionSeasonality in sleep timing and chronotype was confirmed, and it seems that depressive symptoms during the dark period exacerbate phase-shifting problems for people living in sub-Arctic regions.     

A comparative analysis of the efficacy of anterior cruciate ligament reconstruction with autologous ligament grafting at different time points

BackgroundThis study was performed to compare the clinical efficacies of anterior cruciate ligament (ACL) reconstruction with autologous ligament grafting at different time points.MethodsEighty‐five patients with ACL were categorized into two groups: Group A (GA, n = 45), who underwent early‐stage (≤3 weeks) surgery, and Group B (GB, n = 40), who underwent advanced‐stage (>3 weeks) surgery. Perioperative conditions, knee joint functions, activity and stability before and at 6 months postoperatively, changes in quality of life (QOL), good and excellent rates of knee joint functions, and incidence of complications were compared between the two groups.ResultsIn both groups, there was an increase in the International Knee Documentation Committee (IKDC) score, Lysholm score, and QOL and a decrease in the knee joint angle flexion limitation, angle of spread limitation, positive rates in the anterior drawer test (ADT), and Lachman test score (P < .05) after surgery. At 6 months postoperatively, the IKDC score, Lysholm score, and QOL were higher in GA than in GB (P < .05). The good and excellent rates of knee joint functions were higher in GA than in GB (93.33% vs. 77.50%) (P < .05).ConclusionAnterior cruciate ligament reconstruction with autologous ligament grafting can achieve good effects whether performed in the early or advanced stage; however, the improvements in patients'' knee joint functions and QOL are better in the early stage. Therefore, early ACL reconstruction with autologous ligament grafting is suggested.     

Professor YANG Yu-fei’s Experience on the Integrated Chinese and Western Medicine Treatment Strategy for Advanced Colorectal Cancer

Colorectal cancer is one of the common malignant tumors in China.It poses a serious threat to the national health of China.For advanced colorectal cancer, the main goal of treatment is to prolong survival and improve quality of life.It complements other advantages, showing good therapeutic results.However, how to grasp the timing of integrated Chinese and Western Medicine for the treatment of advanced colorectal cancer and use the integrated Chinese and Western Medicine treatment methods flexibly contains profound therapeutic art.Prof.YANG Yu-fei is an authoritative expert in the field of integrated Chinese and Western medicine for colorectal cancer.She is good at accurately grasping the timing of treatment of integrated Chinese and Western Medicine, and flexibly adjusts the treatment strategy according to the specific conditions.In this paper, we shared Professor YANG Yu-fei's strategy for treating advanced colorectal cancer with emphasis on integrated Chinese and Western Medicine and attached a typical case, with a view to provide reference for the treatment of advanced colorectal cancer with integrated Chinese and Western Medicine.     

Protective and Risk Factors for Humerus Head Necrosis After Proximal Humerus Fracture Treated with Internal Locking Plate

BackgroundProximal humerus fractures (PHF) are common and lead to post-traumatic humerus head necrosis (HHN) in 3–35% after ORIF with an internal locking plate. Few studies focus on this condition and risk factors remain a discussion topic. Hertel’s criteria for initial head ischemia right after fracture (fracture complexity, medial hinge displacement and short metaphyseal head extension) have recently been correlated to HHN, but there is still a clear lack of evidence on the topic. Due to its anatomical similarities to the proximal femur, some authors argue that PHF may as well benefit from early surgery to avoid head necrosis.MethodsIn this 10-year retrospective study, we assessed 305 patients from a single center. All cases were treated with a PHILOS plate through a deltopectoral approach. The mean follow-up time was 467 days. The primary endpoint was HHN.ResultsHHN was diagnosed in 12 patients (4%), 10 of which were diagnosed within the first year and one case 4 years after surgery. A positive correlation (p < 0.04) was found between HHN and fracture type (both in AO and Neer’s classification), initial neck-shaft-angle (NSA) and metaphyseal head extension (MHE). Medial hinge displacement (MHD) occurred in all HHN cases. Achieving perfect reduction (< 2 mm dislocation) was relevant to avoiding HHN (p = 0.035). Although HHN developed in 32% of the high risk cases (four-part fractures with a short MHE), it was completely avoided (0%) when perfect reduction was achieved. Time until surgery after admission was neither a protective nor a risk factor for HHN.ConclusionWe conclude that fracture complexity (four-part and C-fractures) as well as disruption of the medial hinge with a metaphyseal head extension smaller than 8 mm are relevant risk factors for humerus head necrosis. A combination of these criteria generated an high risk pattern with a 32% rate of HHN. Though often difficult to achieve, perfect reduction was a clear protective factor and reduced HHN to 0%. Perfect reduction may be key to inosculation and, therefore, salvage of the humerus head, especially in high risk cases. Surgery timing did not correlate with HHN.Level of EvidenceLevel 3, retrospective cohort study.