The clinical quandary of counseling the moribund critical care patient—a registry analysis of postsurgical outcomes

Purpose

To provide outcomes data to intensivists and surgeons for counseling patients and family members when considering a surgical intervention in a moribund patient.

Materials and Methods

Retrospective analysis of prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program database in moribund patients undergoing general surgical procedures.

Results

Out of 633,262 patients available in the national registry, 2063 (0.3%) were of moribund status. Post-operative mortality was 52.8% for moribund patients. Those who died had higher rates of compromised respiratory, renal and cognitive dysfunction, were older, less independent prior to surgery and had generally longer surgeries. 83% of patients experienced a major complication including mortality and 17 % of patients experienced minor complications.

Conclusion

The moribund patient is not as grave as once thought and surgery on these patients may not be futile given the 47% survival rate at 30 days. Postoperative complication rates are high. The data presented provide a meaningful tool for the clinicians in counseling patients and families on the expectations when considering a surgical intervention for moribund patients.     

原发性小肠肿瘤41例诊治体会

目的总结原发性小肠(空、回肠)肿瘤的临床特点及诊疗经验。方法对1999年至2012年收治的经手术治疗、病理确诊的41例原发性空、回肠肿瘤进行回顾性分析。结果本组病例良性11例、恶性30例,发生在空肠16例,回肠25例。主要临床表现为腹痛、腹部包块、消化道出血、肠梗阻等,术前确诊率低,但近来有所提高,CT、胶囊内镜、小肠镜检查、PET-CT等对小肠肿瘤诊断有意义。结论小肠肿瘤无特异性临床特征。CT、PET-CT、胶囊内镜、小肠镜检查有助于早期诊断。     

实施临床路径对终末病历病案质量的影响

目的通过对终末病历病案质量的评价分析,研究实施临床路径对病历病案质量影响。方法选择2010年8月至2012年8月实施临床路径管理的病例1436例作为观察组,随机选择同时期未实施临床路径的病例1430例作为对照组。所有病历均经病历质量专家小组评审并确定甲级、乙级、丙级;记录"单项否决项"和"单项扣分5分"的病历数及核查出院病历3日归档率、病案首页完整规范率和病历完整性。结果观察组终末病历的甲级率比对照组明显提高,乙级和丙级率比对照组明显降低(P<0.001);观察组"单项否决"和"单项扣分5分"的发生率低于对照组(P<0.05);观察组出院病历3日归档率、病案首页填写完整规范率和病历完整性高于对照组(P<0.05)。结论实施临床路径不仅对提高医疗质量和保障医疗安全有重要作用,而且有助于提高病案质量和完善病案管理。     

Human leumorphin is a potent, kappa opioid receptor agonist

The opioid activity and opioid receptor type specificity of synthetic human leumorphin were studied in vitro. Human leumorphin inhibited the contraction of the myenteric plexus-longitudinal muscle preparation of the guinea pig ileum and was similar in opioid potency to porcine leumorphin. This action of human leumorphin was antagonized less effectively by naloxone than by the opiate antagonist Mr 2266. Human leumorphin also inhibited the contraction of the rabbit vas deferens which has only the -type opioid receptor. It is concluded that human leumorphin has potent opioid activity and acts as an agonist at the -type opioid receptor, like porcine leumorphin and other peptides derived from preproenkephalin B.     

A reinterpretation of schedule-induced behaviors based on a systematic analysis of behavior

Confusion exists regarding the criteria to be used in determining whether or not particular behaviors are schedule-induced. Four critical characteristics of schedule-induced behaviors are suggested and a comparison made of the complete range of behaviors exhibited by body weight-reduced rats drinking in response to one of three stimuli. These were (1) a fixed-time food reinforcement schedule, (2) a meal of dry food, and (3) 24 hour water deprivation. Drinking, locomotion, rearing and oral and perioral behaviors occurred in accordance with the defining characteristics of schedule-induced behaviors. Rats in the fixed-time reinforcement condition also deposited significantly greater numbers of fecal boli. Sniffing and food bowl related behaviors occurred as terminal responses for this group. It is concluded that animals which receive reinforcers intermittently maintain high levels of arousal for extended periods, and that the presence of the schedule may mimic conditions experienced by wild rats in non-laboratory settings. In such conditions ambulatory behaviors may be particularly adaptive. In contrast, reinforcing sensory feedback and a stress reducing role may be particularly important in the mediation of oral behaviors (such as drinking) which occur during intermittent reinforcement.     

COMPARISON OF THE AFFINITY OF SECOVERINE FOR SOME MUSCARINIC RECEPTORS

The selective muscarinic receptor antagonist secoverine was found to have a similar affinity for muscarinic receptors in the guinea-pig left atrium and ileal longitudinal muscle as well as in the rat urinary bladder and ileum.     

Lobular Involvement in Human Breast Carcinoma

One hundred twenty-nine cases of breast carcinoma were examined in order to clarify the occurrence of lobular involvement with regard to stromal invasion. Lobular involvement was clearly recognized in 56 cases (43%) having discernible portions of intraductal carcinoma components. The process of lobular involvement was first recognizable as an extension of a few carcinoma cells from intralobular ducts into the acinar lumina. Progressive accumulation of the carcinoma cells resulted in marked swelling and distortion of the involved lobules. During the process, perilobular myoepithelial cells (actin positive cells) were stretched and disappeared. Subsequently, breaks in the basement membranes were also observed, resulting in stromal invasion of carcinoma cells. The lobular involvement was classified into common and round varieties, possibly reflecting different growth activities of the carcinoma cells. The stromal invasion was initiated by peripheral budding or focal necrosis of the involved lobules. The latter pattern was often observed in comedo carcinoma. It was thus revealed that in breast carcinomas the terminal ductal-lobular units are quite often involved and can become sites of extraductal invasion.