Decisions to Transfer Nursing Home Residents to Emergency Departments: A Scoping Review of Contributing Factors and Staff Perspectives.

PubMed

Trahan, Lisa M; Spiers, Jude A; Cummings, Greta G

2016-11-01

Nursing home (NH) residents are a frail and vulnerable population often faced with iatrogenic effects of hospital stays when transferred to emergency departments for acute changes in health status. Avoidable or unnecessary transfers of care need to be identified and defined to prevent unintended harm. The aim of this scoping review was to identify characteristics of avoidable or unnecessary transitions of NH residents to emergency departments, and examine factors influencing decision-making by NH staff, residents, and their family members to transfer nursing home residents to emergency departments. The search strategy began with 5 electronic databases, and a hand search of gray literature. Published qualitative and quantitative studies were included that examined the definition of avoidable or unnecessary transfers, and/or reported factors associated with decision-making to transfer NH residents to emergency departments. Methods included quality assessments, data extraction, and synthesis using content analysis. A total of 783 titles and abstracts were retrieved and screened resulting in 19 included studies. Results describing "avoidable" or "unnecessary" transfers were grouped into 3 dimensions of factors: management of early-acute or low-acuity symptoms and chronic disease management in NHs, ambulatory care-sensitive indicators, and use of post hoc assessments. Five categories of factors contributing to decision-making to transfer were identified: nursing factors, physician factors, facility/resource factors, NH resident/family factors, and health system factors. A consensus on the definition of "avoidable" or "unnecessary" transfers was not found. Findings suggest that transfers of NH residents to emergency departments may be avoided with increased care capacity within NHs. The decision-making process involved in the transfer is influenced by many factors, with intentions of both improving clinical outcomes and maintaining quality of life for the NH resident. Acute changes in health status are contextually specific and decisions must consider not only the resident's acute condition, but also resources available in the NH, and resident and family members' preferences for care. A definition of "avoidable" or "unnecessary" transfer must include reliable measurement, yet remain flexible enough to be generalizable to various care facilities to meet the needs of NH residents and manage required care safely within the NH. Robust research aimed at improving the primary care of NH residents is essential to informing health policy reform and education of those providing care in NHs. Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Voltage control on a train system

DOEpatents

Gordon, Susanna P.; Evans, John A.

2004-01-20

The present invention provides methods for preventing low train voltages and managing interference, thereby improving the efficiency, reliability, and passenger comfort associated with commuter trains. An algorithm implementing neural network technology is used to predict low voltages before they occur. Once voltages are predicted, then multiple trains can be controlled to prevent low voltage events. Further, algorithms for managing inference are presented in the present invention. Different types of interference problems are addressed in the present invention such as "Interference During Acceleration", "Interference Near Station Stops", and "Interference During Delay Recovery." Managing such interference avoids unnecessary brake/acceleration cycles during acceleration, immediately before station stops, and after substantial delays. Algorithms are demonstrated to avoid oscillatory brake/acceleration cycles due to interference and to smooth the trajectories of closely following trains. This is achieved by maintaining sufficient following distances to avoid unnecessary braking/accelerating. These methods generate smooth train trajectories, making for a more comfortable ride, and improve train motor reliability by avoiding unnecessary mode-changes between propulsion and braking. These algorithms can also have a favorable impact on traction power system requirements and energy consumption.

Method of managing interference during delay recovery on a train system

DOEpatents

Gordon, Susanna P.; Evans, John A.

2005-12-27

The present invention provides methods for preventing low train voltages and managing interference, thereby improving the efficiency, reliability, and passenger comfort associated with commuter trains. An algorithm implementing neural network technology is used to predict low voltages before they occur. Once voltages are predicted, then multiple trains can be controlled to prevent low voltage events. Further, algorithms for managing inference are presented in the present invention. Different types of interference problems are addressed in the present invention such as "Interference During Acceleration", "Interference Near Station Stops", and "Interference During Delay Recovery." Managing such interference avoids unnecessary brake/acceleration cycles during acceleration, immediately before station stops, and after substantial delays. Algorithms are demonstrated to avoid oscillatory brake/acceleration cycles due to interference and to smooth the trajectories of closely following trains. This is achieved by maintaining sufficient following distances to avoid unnecessary braking/accelerating. These methods generate smooth train trajectories, making for a more comfortable ride, and improve train motor reliability by avoiding unnecessary mode-changes between propulsion and braking. These algorithms can also have a favorable impact on traction power system requirements and energy consumption.

Efficient high density train operations

DOEpatents

Gordon, Susanna P.; Evans, John A.

2001-01-01

The present invention provides methods for preventing low train voltages and managing interference, thereby improving the efficiency, reliability, and passenger comfort associated with commuter trains. An algorithm implementing neural network technology is used to predict low voltages before they occur. Once voltages are predicted, then multiple trains can be controlled to prevent low voltage events. Further, algorithms for managing inference are presented in the present invention. Different types of interference problems are addressed in the present invention such as "Interference. During Acceleration", "Interference Near Station Stops", and "Interference During Delay Recovery." Managing such interference avoids unnecessary brake/acceleration cycles during acceleration, immediately before station stops, and after substantial delays. Algorithms are demonstrated to avoid oscillatory brake/acceleration cycles due to interference and to smooth the trajectories of closely following trains. This is achieved by maintaining sufficient following distances to avoid unnecessary braking/accelerating. These methods generate smooth train trajectories, making for a more comfortable ride, and improve train motor reliability by avoiding unnecessary mode-changes between propulsion and braking. These algorithms can also have a favorable impact on traction power system requirements and energy consumption.

7 CFR 1780.70 - Owner's procurement regulations.

Code of Federal Regulations, 2010 CFR

2010-01-01

... practices between firms; organizational conflicts of interest; and unnecessary experience and bonding... avoid the purchase of unnecessary or duplicate items. Consideration should be given to consolidation or separation of procurement items to obtain a more economical purchase. Where appropriate, an analysis shall be...

Screening for genital tuberculosis in a limited resource country: case report.

PubMed

Namani, Sadie; Qehaja-Buçaj, Emine; Namani, Diellëza

2017-02-07

Screening for benign or malignant process of pelvis in young females is a challenge for a physician in a limited resource country. Tuberculosis should be always considered in the differential diagnosis of a pelvic mass in countries with high prevalence of tuberculosis. Negative results of analysis of peritoneal fluid for acid-fast staining, late cultures, and unavailability of new diagnostics methods such as polymerase chain reaction and adenosine deaminase of the aspirated fluid from peritoneal cavity can often result in invasive diagnostic procedures such as laparotomy. We report a case of a 24 year old Albanian unemployed female living in urban place in Kosovo who presented with abdominal pain, loss of appetite, fever, headache, a weight loss, nonproductive cough and menstrual irregularity for three weeks. In this example case, the patient with cystic mass in tubo-ovarial complex and elevated serum cancer antigen 125 levels was diagnosed for genital tuberculosis after performing laparotomy. Caseose mass found in left tubo-ovarial complex and histopathological examination of biopsied tissue were the fastest diagnostic tools for confirming pelvis TB. The Lowenstein-Jensen cultures were positive after six weeks and her family history was positive for tuberculosis. Young females with abdominopelvic mass, ascites, a positive family history for tuberculosis and high serum cancer antigen 125, should always raise suspicion of tuberculosis especially in a limited resource country. A laparoscopy combined with peritoneal biopsy should be performed to confirm the diagnosis as this could lead to a prevention of unnecessary laparotomies.

Lymphocyte proliferation in mice after a full laparotomy is the same whether performed in a sealed carbon dioxide chamber or in room air.

PubMed

Lee, S W; Southall, J C; Gleason, N R; Huang, E H; Bessler, M; Whelan, R L

2000-03-01

Our laboratory has demonstrated that significantly more cell-mediated immunosuppression occurs after full laparotomy than after either anesthesia control or carbon dioxide (CO2) pneumoperitoneum. We further demonstrated that the postoperative immunosuppression is related to the length of the incision. Other investigators believe that the immunosuppression observed after laparotomy is caused by peritoneal exposure to small amounts of lipopolysaccharide found in circulating air. They believe that the better-preserved immune function associated with laparoscopic surgery results from the avoidance of air contamination of the peritoneal cavity. To investigate this hypothesis, we determined and compared postoperative lymphocyte proliferation rates after (a) laparotomy in room air, (b) laparotomy in a CO2 chamber, (c) CO2 insufflation in a murine model, and (d) anesthesia alone. Female C3H/He mice (n = 21) were divided randomly into four groups: (a) anesthesia control, (b) air laparotomy, (c) CO2 laparotomy, and (d) CO2 insufflation. The control mice underwent no procedure. The group 2 animals underwent a full midline incision (xiphoid to pubis) and exposure to room air for 20 min and then were clipped closed. The group 3 mice underwent a full midline incision in a sealed CO2 chamber for 20 min, and the group 4 mice insufflation with CO2 gas at 4 to 6 mm Hg for 20 min. Splenocytes were harvested from all the animals on day 2 after the interventions. Lymphocyte proliferation then was assessed using the nonradioactive colorimetric MTS/PMS system 72 h after concanavalin-A stimulation. There was no significant difference in lymphocyte proliferation between the air and CO2 laparotomy groups. Lymphocyte proliferation in the anesthesia control and CO2 insufflation groups was significantly higher than in both the air laparotomy (p<0.05) and CO2 laparotomy (p<0.05) groups (p values by Tukey-Kramer test). There was no significant difference between the anesthesia control and CO2 pneumoperitoneum groups. Our results suggest that full laparotomy performed in a sealed CO2 chamber compared to room air laparotomy resulted in similar suppression of lymphocyte proliferation. Furthermore, no significant suppression of lymphocyte proliferation was observed in the CO2 pneumoperitoneum group. These results, with regard to lymphocyte proliferation rates, refute the hypothesis that postoperative immunosuppression is related to air exposure and support the alternative hypothesis that immunosuppression is related to incision length.

Morphometrical differences between resectable and non-resectable pancreatic cancer: a fractal analysis.

PubMed

Vasilescu, Catalin; Giza, Dana Elena; Petrisor, Petre; Dobrescu, Radu; Popescu, Irinel; Herlea, Vlad

2012-01-01

Pancreatic cancer is a highly aggressive cancer with a rising incidence and poor prognosis despite active surgical treatment. Candidates for surgical resection should be carefully selected. In order to avoid unnecessary laparotomy it is useful to identify reliable factors that may predict resectability. Nuclear morphometry and fractal dimension of pancreatic nuclear features could provide important preoperative information in assessing pancreas resectability. Sixty-one patients diagnosed with pancreatic cancer were enrolled in this retrospective study between 2003 and 2005. Patients were divided into two groups: one resectable cancer group and one with non-resectable pancreatic cancer. Morphometric parameters measured were: nuclear area, length of minor axis and length of major axis. Nuclear shape and chromatin distribution of the pancreatic tumor cells were both estimated using fractal dimension. Morphometric measurements have shown significant differences between the nuclear area of the resectable group and the non-resectable group (61.9 ± 19.8µm vs. 42.2 ± 15.6µm). Fractal dimension of the nuclear outlines and chromatin distribution was found to have a higher value in the non-resectable group (p<0.05). Objective measurements should be performed to improve risk assessment and therapeutic decisions in pancreatic cancer. Nuclear morphometry of the pancreatic nuclear features can provide important pre-operative information in resectability assessment. The fractal dimension of the nuclear shape and chromatin distribution may be considered a new promising adjunctive tool for conventional pathological analysis.

Enterobius Vermicularis as a Cause of Intestinal Occlusion: How To Avoid Unnecessary Surgery.

PubMed

Adorisio, Ottavio; De Peppo, Francesco; Rivosecchi, Massimo; Silveri, Massimiliano

2016-04-01

Enterobius vermicularis may cause infections of the gastrointestinal tract and occurs approximately in 4% to 28% of children worldwide. It is most common in children aged 5 to 14 years.The most commonly reported symptoms are pruritus in the perianal region, abdominal pain, urinary tract infection, insomnia, irritability, salpingitis, and appendicitis, whereas intestinal obstruction is a very rare but would be considered to perform the right instrumental examination avoiding unnecessary surgical exploration.We report a case of an 8-year-old boy with an intestinal occlusion due to a colonic intussusception by Enterobius vermicularis managed conservatively.

Minimally Invasive Surgery in Pediatric Trauma: One Institution's 20-Year Experience

PubMed Central

Xu, Min Li; Lopez, Joseph

2016-01-01

Background: Minimally invasive surgery (MIS) for trauma in pediatric cases remains controversial. Recent studies have shown the validity of using minimally invasive techniques to decrease the rate of negative and nontherapeutic laparotomy and thoracotomy. The purpose of this study was to evaluate the diagnostic accuracy and therapeutic options of MIS in pediatric trauma at a level I pediatric trauma center. Methods: We reviewed cases of patients aged 15 years and younger who had undergone laparoscopy or thoracoscopy for trauma in our institution over the past 20 years. Each case was evaluated for mechanism of injury, computed tomographic (CT) scan findings, operative management, and patient outcomes. Results: There were 23 patients in the study (16 boys and 7 girls). Twenty-one had undergone diagnostic laparoscopy and 2 had had diagnostic thoracoscopy. In 16, there were positive findings in diagnostic laparoscopy. Laparoscopic therapeutic interventions were performed in 6 patients; the remaining 10 required conversion to laparotomy. Both patients who underwent diagnostic thoracoscopy had positive findings. One had a thoracoscopic repair, and the other underwent conversion to thoracotomy. There were 5 negative diagnostic laparoscopies. There was no mortality among the 23 patients. Conclusions: The use of laparoscopy and thoracoscopy in pediatric trauma helps to reduce unnecessary laparotomy and thoracotomy. Some injuries can be repaired by a minimally invasive approach. When conversion is necessary, the use of these techniques can guide the placement and size of surgical incisions. The goal is to shift the paradigm in favor of using MIS in the treatment of pediatric trauma as the first-choice modality in stable patients. PMID:26877626

Rectus sheath haematoma: a rare masquerader for abdominal pain.

PubMed

Changal, Khalid Hamid; Saleem, Saad; Ghous, Ghulam

2017-04-13

Rectus sheath haematoma is a rare cause of abdominal pain. It can be easily confused for other causes of acute abdomen and may even lead to unnecessary laparotomies. Our patient has the rectus sheath haematoma because of violent coughing and on presentation had no obvious clinical sign pointing to the same. Diagnosis was made by a CT scan of the abdomen, and patient was treated conservatively. Rectus sheath haematomas are usually present on the posterior aspect of the rectus muscles and thus may not be clinically appreciable. © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Primary hepatic artery embolization in pediatric blunt hepatic trauma.

PubMed

Ong, Caroline C P; Toh, Luke; Lo, Richard H G; Yap, Te-Lu; Narasimhan, Kannan

2012-12-01

Non-operative management of isolated blunt hepatic trauma is recommended except when hemodynamic instability requires immediate laparotomy. Hepatic artery angioembolization is increasingly used for hepatic injuries with ongoing bleeding as demonstrated by contrast extravasation on the CT scan. It is used primarily or after laparotomy to control ongoing hemorrhage. Hepatic angioembolization as part of multimodality management of hepatic trauma is reported mainly in adults, with few pediatric case reports. We describe our institution experience with primary pediatric hepatic angioembolization and review the literature with regard to indications and complications. Two cases (3 and 8 years old), with high-grade blunt hepatic injuries with contrast extravasation on the CT scan were successfully managed by emergency primary hepatic angioembolization with minimal morbidity and avoided laparotomy. To date, the only reports of pediatric hepatic angioembolization for trauma are 5 cases for acute bleeding and 15 delayed cases for pseudoaneurysm. The role of hepatic angioembolization in the presence of an arterial blush on CT in adults is accepted, but contested in a pediatric series, despite higher transfusion rate and mortality rate. We propose that hepatic angioembolization should be considered adjunct treatment, in lieu of, or in addition to emergency laparotomy for hemostasis in pediatric blunt hepatic injury. Copyright © 2012 Elsevier Inc. All rights reserved.

Hernioscopy: a useful technique for the evaluation of incarcerated hernias that retract under anaesthesia.

PubMed

Morris-Stiff, G; Hassn, A

2008-04-01

The diagnosis of strangulation within an incarcerated abdominal-wall hernia is not always possible preoperatively. In approximately 1% of cases of incarcerated hernias, a strangulated viscus will reduce spontaneously following administration of muscle relaxants during induction of anaesthesia, and the surgeon has to perform an exploratory laparotomy. The aim of this study was to report the use of hernioscopy to inspect intra-abdominal contents and thus prevent unnecessary laparotomy. The case notes of all patients undergoing hernioscopy for incarcerated hernias that reduced spontaneously during induction of anaesthesia, skin incision, or prior to evaluation of sac contents were reviewed. Hernioscopy is performed following insertion of a 10-mm port through the hernia sac. Standard insufflation with carbon dioxide is performed, maintaining an intra-abdominal pressure of 10-12 mmHg following which the laparoscope is inserted and a diagnostic examination performed. Following completion of hernioscopy, the laparoscope is withdrawn, the pneumoperitoneum released, and the hernia repaired in a conventional manner using a tension-free technique. Five patients underwent hernioscopy for the evaluation of incarcerated hernias that had reduced spontaneously prior to inspection of sac contents. There were four men with indirect inguinal hernias and one woman with an incarcerated femoral hernia. The hernioscopy of the four men was unremarkable and they went home the following day. The female patient had blood within the peritoneal cavity arising from the upper abdomen and underwent laparotomy and splenectomy. She made an unremarkable recovery and was discharged on postoperative day 7. Hernioscopy is a simple and useful technique that can be performed by surgeons familiar with laparoscopic procedures such as appendicectomy and cholecystectomy.

Surgery in ovarian cancer - Brazilian Society of Surgical Oncology consensus.

PubMed

Tsunoda, Audrey Tieko; Ribeiro, Reitan; Reis, Rosilene Jara; Andrade, Carlos Eduardo Mattos da Cunha; Marques, Renato Moretti; Baiocchi, Glauco; Fin, Fabio; Zanvettor, Paulo Henrique; Falcao, Deraldo; Batista, Thales Paulo; Azevedo, Bruno Roberto Braga; Guitmann, Gustavo; Pessini, Suzana Arenhart; Nunes, João Soares; Campbell, Leonardo Martins; Linhares, José Clemente; Coimbra, Felipe José Fernandez

2018-06-14

Surgical management in epithelial ovarian cancer (EOC) has a significant impact in overall survival (OS) and progression free survival (PFS). Brazilian Society of Surgical Oncology (BSSO) supported a taskforce with experts for consensus: experienced and specialized trained surgeons, in cancer centers, provide the best EOC surgery. Laparoscopic and/or radiological staging prognosticate the possibility of complete cytoreduction (CC0) and help to reduce unnecessary laparotomies. Surgical techniques were reviewed. Multidisciplinary input is essential for treatment planning. Quality assurance criteria are proposed and need national consensus. Genetic testing is mandatory. This consensus states the final recommendations from BSSO for management of EOC. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Selection Bias in Colorectal Surgery in a Non-Tertiary Hospital: Laparoscopic Versus Open Surgery.

PubMed

Verzaro, Roberto; Mattia, Simona; Rago, Teresa; Casella, Francesco; Ferroni, Andrea; Gianfreda, Valeria; Cofini, Vincenza; Necozione, Stefano

2018-03-01

Laparoscopy is used increasingly to treat malignant and benign colorectal surgical diseases. However, this practice is still not offered to all patients. Many barriers halt the widespread use of laparoscopic colorectal surgery. Both surgeon's and patient's factors contribute to limit a wider use of laparoscopy in colorectal surgery. We retrospectively analyzed 408 consecutive colorectal resections in a 4-year period, to find out if a selection bias exists in using laparotomy or laparoscopy for colorectal surgical diseases, and which factors are associated with a poor use of laparoscopy or to a preferred laparotomy. In our practice, advanced disease, American Society of Anesthesiologist class III and IV, and emergency status are all patient-related factors associated with laparotomy. Surgeon's age more than 52 years and lack of laparoscopic training are surgeon-related factors that negatively affect the chance of being operated on with the laparoscopic technique. An extensive laparoscopic colorectal training and a supporting environment, especially during the night shift, are needed to facilitate the use of laparoscopy in colorectal surgery avoiding a bias in selecting surgical candidates to one technique or another.

Not Another Budget Cut! Money-Saving Ideas for Campus Organizations.

ERIC Educational Resources Information Center

Oxendine, W. H. "Butch," Jr.

1997-01-01

Twenty ideas for reducing program costs are offered to campus activities programmers. They include using technology wisely, avoiding excess outlay of funds, trading for services, seeking donations and sponsors, co-sponsoring events, buying supplies in bulk, requesting discounts, avoiding unnecessary sales taxes, using telephone services…

[Convenience clinic redefine polycystic ovary syndrome (Stein-Leventhal)].

PubMed

Zárate-Treviño, Arturo; Hernández-Valencia, Marcelino; Morán, Carlos; Manuel, Leticia; Saucedo, Renata

2014-04-01

In 1935 during a medical meeting behalf in New Orleans was presents a study that included seven cases of women that suffered menstrual dysfunctions, hirsutism and sterility, for laparotomy the description of the ovaries had a pearly white color and it was hypertrophic, the cuneiform resection in both ovaries resulted in correction of the menstrual dysfunction and two of them got pregnancy later on, receiving the name of polycystic ovary syndrome (PCOS). The technological advance facilitates the hormonal analyses demonstrating the hyperandrogenism existence and the mechanism of the anovulation, the PCOS showed to be heterogeneous, reason why it was hindered to define it, this advanced the current trend to question the existence of the PCOS and to accept the convenience, either to change the name or to redefine it, leaving it as a simple syndrome with several phenotypes. The endocrine component includes abnormal secretion of insulin and consequently outlying resistance to this hormone, likewise is hyperandrogenism, dislipoproteinemia and obesity. The hormonal exams are unnecessary for the diagnostic and treatment; it is convenient to demonstrate for sonography the ovarian growth. Other dysfunctions like the congenital suprarenal hyperplasia, hyperprolactinemia and hypotiroidism should be discarded. The treatment should be individualized with relationship to the reason of the consultation and the patients age. It has not been demonstrated that the sensibilitizers use to the insulin avoids long term cardiovascular illness and diabetes. Therefore, the phenotype is heterogeneous with a fickle metabolic component and for it has arisen the restlessness of a better definition of the SPO.

The contribution of laparoscopy in evaluation of penetrating abdominal wounds.

PubMed

Ahmed, Naveed; Whelan, Jim; Brownlee, John; Chari, Vedantum; Chung, Raphael

2005-08-01

Penetrating abdominal wounds are traditionally explored by laparotomy. We investigated prospectively the role of laparoscopy within a defined protocol for management of penetrating abdominal wounds to determine its safety and advantages over traditional operative management. The study inclusion criteria were: stab and gun shot abdominal wounds, including junction zone injuries; stable vital signs; and absence of contraindications for laparoscopy. Diagnostic end points included detection of peritoneum or diaphragm violation, visceral injuries, and other indications for laparotomy. Systematic examination was undertaken using a multiport technique whenever the peritoneum or diaphragm had been violated. All repairs were done by open operation. A total of 40.6% of patients with penetrating trauma fulfilled study criteria (52 patients). Of these, 33% had no peritoneal penetration; 29% had no visceral injuries despite violation of peritoneum or diaphragm; 38% had visceral injuries, of which 40% (mainly liver and omentum) required no intervention. Twelve patients (23% of total) had open repairs. No missed injuries or death occurred in the study. Overall, 77% of penetrating injuries with stable vital signs avoided exploratory laparotomy. Compared with National Trauma Data Bank information for patients with the same Injury Severity Scores, hospitalization was reduced by more than 55% for the entire series. Laparoscopy for penetrating abdominal injuries in a defined set of conditions was safe and accurate, effectively eliminating nontherapeutic laparotomy and shortening hospitalization.

Adverse events related to blood transfusion

PubMed Central

Sahu, Sandeep; Hemlata; Verma, Anupam

2014-01-01

The acute blood transfusion reactions are responsible for causing most serious adverse events. Awareness about various clinical features of acute and delayed transfusion reactions with an ability to assess the serious reactions on time can lead to a better prognosis. Evidence-based medicine has changed today's scenario of clinical practice to decrease adverse transfusion reactions. New evidence-based algorithms of transfusion and improved haemovigilance lead to avoidance of unnecessary transfusions perioperatively. The recognition of adverse events under anaesthesia is always challenging. The unnecessary blood transfusions can be avoided with better blood conservation techniques during surgery and with anaesthesia techniques that reduce blood loss. Better and newer blood screening methods have decreased the infectious complications to almost negligible levels. With universal leukoreduction of red blood cells (RBCs), selection of potential donors such as use of male donors only plasma and restriction of RBC storage, most of the non-infectious complications can be avoided. PMID:25535415

75 FR 5241 - Maritime Communications

Federal Register 2010, 2011, 2012, 2013, 2014

2010-02-02

... effective and efficient use of the spectrum available for maritime communications, accommodate technological innovation, avoid unnecessary regulatory burdens, and maintain consistency with international maritime...

The Exercise–Affect–Adherence Pathway: An Evolutionary Perspective

PubMed Central

Lee, Harold H.; Emerson, Jessica A.; Williams, David M.

2016-01-01

The low rates of regular exercise and overall physical activity (PA) in the general population represent a significant public health challenge. Previous research suggests that, for many people, exercise leads to a negative affective response and, in turn, reduced likelihood of future exercise. The purpose of this paper is to examine this exercise–affect–adherence relationship from an evolutionary perspective. Specifically, we argue that low rates of physical exercise in the general population are a function of the evolved human tendency to avoid unnecessary physical exertion. This innate tendency evolved because it allowed our evolutionary ancestors to conserve energy for physical activities that had immediate adaptive utility such as pursuing prey, escaping predators, and engaging in social and reproductive behaviors. The commonly observed negative affective response to exercise is an evolved proximate psychological mechanism through which humans avoid unnecessary energy expenditure. The fact that the human tendencies toward negative affective response to and avoidance of unnecessary physical activities are innate does not mean that they are unchangeable. Indeed, it is only because of human-engineered changes in our environmental conditions (i.e., it is no longer necessary for us to work for our food) that our predisposition to avoid unnecessary physical exertion has become a liability. Thus, it is well within our capabilities to reengineer our environments to once again make PA necessary or, at least, to serve an immediate functional purpose. We propose a two-pronged approach to PA promotion based on this evolutionary functional perspective: first, to promote exercise and other physical activities that are perceived to have an immediate purpose, and second, to instill greater perceived purpose for a wider range of physical activities. We posit that these strategies are more likely to result in more positive (or less negative) affective responses to exercise, better adherence to exercise programs, and higher rates of overall PA. PMID:27610096

Anagrelide

MedlinePlus

... platelet-reducing agents. It works by slowing the production of platelets in the body. ... plan to avoid unnecessary or prolonged exposure to sunlight and to wear protective clothing, sunglasses, and sunscreen. ...

Outcomes of laparoscopic resection of Meckel's diverticulum are equivalent to open laparotomy.

PubMed

Ezekian, Brian; Leraas, Harold J; Englum, Brian R; Gilmore, Brian F; Reed, Christopher; Fitzgerald, Tamara N; Rice, Henry E; Tracy, Elisabeth T

2018-03-15

Meckel's diverticulum (MD) is a common congenital anomaly caused by failure of involution of the omphalomesenteric duct. Enthusiasm for minimally invasive surgery (MIS) in children has burgeoned as technologies have advanced, but the outcomes of laparoscopic resection in comparison to open laparotomy for MD remain poorly defined. We queried a large national database to compare current practice patterns and clinical outcomes between surgical approaches for MD in the pediatric population. The National Surgical Quality Improvement Program-Pediatric (NSQIP-Ped) database was queried for patients undergoing surgical intervention for MD (2011-2014). Patients were stratified by surgical approach. Baseline characteristics, intraoperative variables, and perioperative complications were compared by univariate analysis using Pearson's χ 2 test for categorical variables and Kruskall-Wallis test for continuous variables. Primary outcomes of interest were length of stay (LOS), rate of readmission, and 30-day mortality. Secondary outcomes included operative time, anesthesia time, postoperative complications, and rates of reoperation. A total of 148 cases of MD were identified, of which 73 (49.3%) were initially managed with a laparoscopic approach and 75 (50.7%) were managed with an open approach. We found a high rate of conversion from laparoscopy to an open approach (20/73 or 27.4%). The median age of the laparoscopic group was higher than the open group (8.3 vs. 2.5years, p<0.001). Operative and anesthesia time, LOS, 30-day mortality, post-operative complications, and rates of reoperation and readmission were similar between groups (all p>0.05). Nearly half of all resections for MD in children are now approached laparoscopically. This approach has equivalent outcomes to traditional open laparotomy. More widespread use of a hybrid approach with laparoscopy and exteriorization of the small bowel through an extended port site may facilitate avoiding open laparotomy. Routine conversion to open for palpation of the MD or segmental small bowel resection should be avoided in the absence of compelling intra-operative findings or operative complications. Level III (retrospective comparative study). Copyright © 2018 Elsevier Inc. All rights reserved.

Laparoscopic Management of Sclerosing Stromal Tumors of the Ovary Combined with Ectopic Pregnancy.

PubMed

Liu, Hua-Qian; Liu, Qiang; Sun, Xue-Bing; Chang, Wen-Min

2015-01-01

Like other stromal-derived gynecological tumors, a sclerosing stromal tumor of the ovary (SSTO) is a rare benign tumor that is difficult to distinguish from a malignant ovarian tumor in clinical practice. An SSTO is routinely treated with laparotomy. Here, we present two extremely rare cases of SSTO with contralateral and ipsilateral tubal pregnancies, in which laparoscopic surgery was performed to remove the tumors. After surgery, one patient (case 1) became pregnant twice within 29 months, and the other patient (case 2) did not become pregnant within 6 months postoperatively. These two cases suggest that laparoscopic management is not only useful in treating SSTO and complicating diseases, but it may also help to reduce unnecessary surgical injury to the ovary. © 2015 S. Karger AG, Basel.

Nabumetone

MedlinePlus

... called NSAIDs. It works by stopping the body's production of a substance that causes pain, fever, and ... plan to avoid unnecessary or prolonged exposure to sunlight and to wear protective clothing, sunglasses, and sunscreen. ...

The hospital based staffing agency.

PubMed

Manion, J; Reid, S B

1989-01-01

Before a hospital considers creating an internal staffing agency, a detailed business plan must be developed. By addressing marketing and operational issues in advance, nurse executives can avoid unnecessary business problems.

Fluorouracil Topical

MedlinePlus

... caused by years of too much exposure to sunlight). Fluorouracil cream and topical solution are also used ... plan to avoid unnecessary or prolonged exposure to sunlight and UV light (such as tanning booths) and ...

Up-front systemic chemotherapy is a feasible option compared to primary tumor resection followed by chemotherapy for colorectal cancer with unresectable synchronous metastases.

PubMed

Niitsu, Hiroaki; Hinoi, Takao; Shimomura, Manabu; Egi, Hiroyuki; Hattori, Minoru; Ishizaki, Yasuyo; Adachi, Tomohiro; Saito, Yasufumi; Miguchi, Masashi; Sawada, Hiroyuki; Kochi, Masatoshi; Mukai, Shoichiro; Ohdan, Hideki

2015-04-24

In stage IV colorectal cancer (CRC) with unresectable metastases, whether or not resection of the primary tumor should be indicated remains controversial. We aim to determine the impact of primary tumor resection on the survival of stage IV CRC patients with unresectable metastases. We retrospectively investigated 103 CRC patients with stage IV colorectal cancer with metastases, treated at Hiroshima University Hospital between 2007 and 2013. Of these, those who had resectable primary tumor but unresectable metastases and received any chemotherapy were included in the study. We analyzed the overall survival (OS) and short-term outcomes between the patients who received up-front systemic chemotherapy (USC group) and those who received primary tumor resection followed by chemotherapy (PTR group). Of the 57 included patients, 15 underwent USC and 42 PTR. The median survival times were 13.4 and 23.9 months in the USC and PTR groups, respectively (P = 0.093), but multivariate analysis for the overall survival showed no significant difference between the two groups (hazard ratio, 1.30; 95% confidence interval (CI), 0.60 to 2.73, P = 0.495). In the USC group, the disease control rate of primary tumor was observed in 12 patients (80.0%), but emergency laparotomy was required for 1 patient. Morbidity in the PTR group was observed in 18 cases (42.9%). The overall survival did not differ significantly between the USC and PTR groups. USC may help avoid unnecessary resection and consequently the high morbidity rate associated with primary tumor resection for stage IV CRC with unresectable metastases.

Rectus sheath hematoma: three case reports

PubMed Central

Kapan, Selin; Turhan, Ahmet N; Alis, Halil; Kalayci, Mustafa U; Hatipoglu, Sinan; Yigitbas, Hakan; Aygun, Ersan

2008-01-01

Introduction Rectus sheath hematoma is an uncommon cause of acute abdominal pain. It is an accumulation of blood in the sheath of the rectus abdominis, secondary to rupture of an epigastric vessel or muscle tear. It could occur spontaneously or after trauma. They are usually located infraumblically and often misdiagnosed as acute abdomen, inflammatory diseases or tumours of the abdomen. Case presentation We reported three cases of rectus sheath hematoma presenting with a mass in the abdomen and diagnosed by computerized tomography. The patients recovered uneventfully after bed rest, intravenous fluid replacement, blood transfusion and analgesic treatment. Conclusion Rectus sheath hematoma is a rarely seen pathology often misdiagnosed as acute abdomen that may lead to unnecessary laparotomies. Computerized tomography must be chosen for definitive diagnosis since ultrasonography is subject to error due to misinterpretation of the images. Main therapy is conservative management. PMID:18221529

Are You Overworked . . . or Underorganized?

ERIC Educational Resources Information Center

Stegman, Wayne G.; Mackenzie, R. Alec

1985-01-01

Successful administrators practice time management by delegating effectively and scheduling blocks of time to work without interruption. In addition, they set clear goals for meetings, avoid unnecessary meetings, and use weekly and monthly calendars. (MLF)

International Research: Its Role in Environmental Biology

ERIC Educational Resources Information Center

Higginson, John

1970-01-01

Proposes an international research laboratory to investigate environmental factors in human health. By international cooperation unnecessary duplication and waste of resources can be avoided and long-term studies can examine various world-wide environments. (JM)

48 CFR 6302.16 - Prehearing conference (Rule 16).

Code of Federal Regulations, 2010 CFR

2010-10-01

... case is to be submitted on the written record or be heard under any hearing procedure, the Board, upon..., understandings on matters already of record, or similar agreements which will avoid unnecessary proof; (3) The...

Making planes plain.

PubMed

O'Rahilly, R

1997-01-01

The major anatomical planes (horizontal, coronal, and sagittal, including the median plane) are discussed from a historical perspective, and their correct usage is clarified. Unofficial and unnecessary terms to be avoided (for reasons explained) include midsagittal, parasagittal, and midline.

Format conversion between CAD data and GIS data based on ArcGIS

NASA Astrophysics Data System (ADS)

Xie, Qingqing; Wei, Bo; Zhang, Kailin; Wang, Zhichao

2015-12-01

To make full use of the data resources and realize a sharing for the different types of data in different industries, a method of format conversion between CAD data and GIS data based on ArcGIS was proposed. To keep the integrity of the converted data, some key steps to process CAD data before conversion were made in AutoCAD. For examples, deleting unnecessary elements such as title, border and legend avoided the appearance of unnecessary elements after conversion, as layering data again by a national standard avoided the different types of elements to appear in a same layer after conversion. In ArcGIS, converting CAD data to GIS data was executed by the correspondence of graphic element classification between AutoCAD and ArcGIS. In addition, an empty geographic database and feature set was required to create in ArcGIS for storing the text data of CAD data. The experimental results show that the proposed method avoids a large amount of editing work in data conversion and maintains the integrity of spatial data and attribute data between before and after conversion.

Lateral repair of parastomal hernia.

PubMed Central

Amin, S. N.; Armitage, N. C.; Abercrombie, J. F.; Scholefield, J. H.

2001-01-01

INTRODUCTION: Parastomal hernia is a common complication of stoma construction. Although the majority of patients are asymptomatic, about 10% require surgical correction. AIMS: We describe a new surgical approach for the repair of parastomal hernias, which avoids both the need for laparotomy and stoma mobilization. PATIENTS AND METHODS: Nine patients (4 female) with parastomal hernia underwent surgical repair. Median age was 55 years (range 38-73 years). There were 8 para-ileostomy herniae and one paracolostomy hernia. A lateral incision was made approximately 10 cm from the stoma, and carried down to the rectus sheath. The dissection was carried medially towards the stoma, and around the defect in the abdominal musculature. The hernia sac was excised when possible and the fascial defect closed with non-absorbable, monofilament suture. A polyprolene mesh was placed round the stoma by making a slit in the mesh. The skin was closed with subcuticular monofilament absorbable suture. RESULTS: All patients returned to normal diet on the first postoperative day, and were discharged from hospital within 72 h. There were no wound infections, and no recurrences after a median follow up of 6 months (range 3-12 months). DISCUSSION: The technique we describe is simple and avoids the need of laparotomy. The mucocutaneous junction of the stoma is not disturbed, reducing the risk of contamination of the mesh, stenosis or retraction of the stoma. Grooving of the stoma and difficulty in fitting appliances is avoided because the wound is not placed near the mucocutaneous junction. This approach may be superior to other mesh repairs for parastomal hernia. Images Figure 1 Figure 2 PMID:11432142

Supply Chain Management in Disaster Response

DOT National Transportation Integrated Search

2009-09-01

In todays society that disasters seem to be striking all corners of the United States and the globe, the importance of emergency management is undeniable. Much human loss and unnecessary destruction of infrastructure can be avoided with more fores...

[Abdominal trauma].

PubMed

Sido, B; Grenacher, L; Friess, H; Büchler, M W

2005-09-01

Blunt abdominal trauma is much more frequent than penetrating abdominal trauma in Europe. As a consequence of improved quality of computed tomography, even complex liver injuries are increasingly being treated conservatively. However, missed hollow viscus injuries still remain a problem, as they considerably increase mortality in multiply injured patients. Laparoscopy decreases the rate of unnecessary laparotomies in perforating abdominal trauma and helps to diagnose injuries of solid organs and the diaphragm. However, the sensitivity in detecting hollow viscus injuries is low and the role of laparoscopy in blunt abdominal injury has not been defined. If intra-abdominal bleeding is difficult to control in hemodynamically unstable patients, damage control surgery with packing of the liver, total splenectomy, and provisional closure of hollow viscus injuries is of importance. Definitive surgical treatment follows hemodynamic stabilization and restoration of hemostasis. Injuries of the duodenum and pancreas after blunt abdominal trauma are often associated with other intra-abdominal injuries and the treatment depends on their location and severity.

Dapsone

MedlinePlus

... are pregnant, plan to become pregnant, or are breast-feeding. If you become pregnant while taking dapsone, call your doctor.plan to avoid unnecessary or prolonged exposure to sunlight and to wear protective clothing, sunglasses, and sunscreen. Dapsone may make your skin sensitive to sunlight.

76 FR 18817 - Self-Regulatory Organizations; NASDAQ OMX PHLX LLC; Order Granting Approval of Proposed Rule...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-04-05

... investors the ability to more closely tailor investment strategies to the precise movement of the underlying... array of investment opportunities and the need to avoid unnecessary proliferation of options series and...

Carcinoma of the pancreatic head and periampullary region. Tumor staging with laparoscopy and laparoscopic ultrasonography.

PubMed Central

John, T G; Greig, J D; Carter, D C; Garden, O J

1995-01-01

OBJECTIVE: The authors performed a prospective evaluation of staging laparoscopy with laparoscopic ultrasonography in predicting surgical resectability in patients with carcinomas of the pancreatic head and periampullary region. SUMMARY BACKGROUND DATA: Pancreatic resection with curative intent is possible in a select minority of patients who have carcinomas of the pancreatic head and periampullary region. Patient selection is important to plan appropriate therapy and avoid unnecessary laparotomy in patients with unresectable disease. Laparoscopic ultrasonography is a novel technique that combines the proven benefits of staging laparoscopy with high resolution intraoperative ultrasound of the liver and pancreas, but which has yet to be evaluated critically in the staging of pancreatic malignancy. METHODS: A cohort of 40 consecutive patients referred to a tertiary referral center and with a diagnosis of potentially resectable pancreatic or periampullary cancer underwent staging laparoscopy with laparoscopic ultrasonography. The diagnostic accuracy of staging laparoscopy alone and in conjunction with laparoscopic ultrasonography was evaluated in predicting tumor resectability (absence of peritoneal or liver metastases; absence of malignant regional lymphadenopathy; tumor confined to pancreatic head or periampullary region). RESULTS: "Occult" metastatic lesions were demonstrated by staging laparoscopy in 14 patients (35%). Laparoscopic ultrasonography demonstrated factors confirming unresectable tumor in 23 patients (59%), provided staging information in addition to that of laparoscopy alone in 20 patients (53%), and changed the decision regarding tumor resectability in 10 patients (25%). Staging laparoscopy with laparoscopic ultrasonography was more specific and accurate in predicting tumor resectability than laparoscopy alone (88% and 89% versus 50% and 65%, respectively). CONCLUSIONS: Staging laparoscopy is indispensable in the detection of "occult" intra-abdominal metastases. Laparoscopic ultrasonography improves the accuracy of laparoscopic staging in patients with potentially resectable pancreatic and periampullary carcinomas. Images Figure 1. Figure 2. Figure 3. Figure 4. PMID:7857143

Introduction of staging laparoscopy in the management of advanced epithelial ovarian, tubal and peritoneal cancer: impact on prognosis in a single institution experience.

PubMed

Fagotti, A; Vizzielli, G; Fanfani, F; Costantini, B; Ferrandina, G; Gallotta, V; Gueli Alletti, S; Tortorella, L; Scambia, G

2013-11-01

To evaluate the prognostic impact of routinely use of staging laparoscopy (S-LPS) in patients with primary advanced epithelial ovarian cancer (AEOC). All women were submitted to S-LPS before receiving primary debulking surgery (PDS) or neoadjuvant treatment (NACT). The surgical and survival outcome were evaluated by univariate and multivariate analysis. Among 300 consecutive patients submitted to S-LPS no complications related to the surgical procedure were registered. The laparoscopic evaluation showed that almost half of the patients (46.3%) had a high tumor load. One-hundred forty-eight (49.3%) women were considered suitable for PDS and the remaining 152 (50.7%) were submitted to NACT. The percentages of complete (residual tumor, RT=0) and optimal (RT<1cm) cytoreduction of PDS and interval debulking surgery (IDS) were 62.1% and 57.5%, 22.5% and 27.7%, respectively, p=0.07. The post-operative complications of NACT/IDS group were lower than PDS group (p=0.01). The median progression free survival in women with RT=0 at PDS was 25 months (95% CI, 15.1-34.8), which was statistically significant longer than in all other patients, irrespective of the type of treatment they received (p=0.0001). At multivariate analysis, residual disease (p=0.011) and performance status (p=0.016) maintained an independent association with the PFS. Including S-LPS in a tertiary referral center for the management AEOC does not appear to have a negative impact in terms of survival and it may be helpful to individualize the treatment avoiding unnecessary laparotomies and surgical complications. © 2013.

Improved load rating of reinforced concrete slab bridges.

DOT National Transportation Integrated Search

2007-09-01

In New Mexico, many reinforced concrete slab (RCS) bridges provide service on interstates I-10, I-25, and I-40. An accurate strength evaluation of interstate bridges is essential to avoid unnecessary load restrictions. The AASHTO load rating factor f...

Systematic Review of Economic Evaluation of Laparotomy versus Laparoscopy for Patients Submitted to Roux-en-Y Gastric Bypass

PubMed Central

Sussenbach, Samanta Pereira; Silva, Everton Nunes; Pufal, Milene Amarante; Casagrande, Daniela Shan; Padoin, Alexandre Vontobel; Mottin, Cláudio Corá

2014-01-01

Background Because of the high prevalence of obesity, there is a growing demand for bariatric surgery worldwide. The objective of this systematic review was to analyze the difference in relation to cost-effectiveness of access route by laparoscopy versus laparotomy of Roux en-Y gastric bypass (RYGB). Methods A systematic review was conducted in the electronic databases MEDLINE, Embase, Scopus, Cochrane and Lilacs in order to identify economic evaluation studies that compare the cost-effectiveness of laparoscopic and laparotomic routes in RYGB. Results In a total of 494 articles, only 6 fulfilled the eligibility criteria. All studies were published between 2001 and 2008 in the United States (USA). Three studies fulfilled less than half of the items that evaluated the results quality; two satisfied 5 of the required items, and only 1 study fulfilled 7 of 10 items. The economic evaluation of studies alternated between cost-effectiveness and cost-consequence. Five studies considered the surgery by laparoscopy the dominant strategy, because it showed greater clinical benefit (less probability of post-surgical complications, less hospitalization time) and lower total cost. Conclusion This review indicates that laparoscopy is a safe and well-tolerated technique, despite the costs of surgery being higher when compared with laparotomy. However, the additional costs are compensated by the lower probability of complications after surgery and, consequently, avoiding their costs. PMID:24945704

The contemporary management of penetrating splenic injury.

PubMed

Berg, Regan J; Inaba, Kenji; Okoye, Obi; Pasley, Jason; Teixeira, Pedro G; Esparza, Michael; Demetriades, Demetrios

2014-09-01

Selective non-operative management (NOM) is standard of care for clinically stable patients with blunt splenic trauma and expectant management approaches are increasingly utilised in penetrating abdominal trauma, including in the setting of solid organ injury. Despite this evolution of clinical practice, little is known about the safety and efficacy of NOM in penetrating splenic injury. Trauma registry and medical record review identified all consecutive patients presenting to LAC+USC Medical Center with penetrating splenic injury between January 2001 and December 2011. Associated injuries, incidence and nature of operative intervention, local and systemic complications and mortality were determined. During the study period, 225 patients experienced penetrating splenic trauma. The majority (187/225, 83%) underwent emergent laparotomy. Thirty-eight clinically stable patients underwent a deliberate trial of NOM and 24/38 (63%) were ultimately managed without laparotomy. Amongst patients failing NOM, 3/14 (21%) underwent splenectomy while an additional 6/14 (42%) had splenorrhaphy. Hollow viscus injury (HVI) occurred in 21% of all patients failing NOM. Forty percent of all NOM patients had diaphragmatic injury (DI). All patients undergoing delayed laparotomy for HVI or a splenic procedure presented symptomatically within 24h of the initial injury. No deaths occurred in patients undergoing NOM. Although the vast majority of penetrating splenic trauma requires urgent operative management, a group of patients does present without haemodynamic instability, peritonitis or radiologic evidence of hollow viscus injury. Management of these patients is complicated as over half may remain clinically stable and can avoid laparotomy, making them potential candidates for a trial of NOM. HVI is responsible for NOM failure in up to a fifth of these cases and typically presents within 24h of injury. Delayed laparotomy, within this limited time period, did not appear to increase mortality nor preclude successful splenic salvage. In clinically stable patients, diagnostic laparoscopy remains essential to evaluate and repair occult DI. As NOM for penetrating abdominal trauma becomes more common, multi-centre data is needed to more accurately define the principles of patient selection and the limitations and consequences of this approach in the setting of splenic injury. Copyright © 2014 Elsevier Ltd. All rights reserved.

19 CFR 354.11 - Prehearing conference.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 19 Customs Duties 3 2011-04-01 2011-04-01 false Prehearing conference. 354.11 Section 354.11 Customs Duties INTERNATIONAL TRADE ADMINISTRATION, DEPARTMENT OF COMMERCE PROCEDURES FOR IMPOSING...) Obtaining stipulations of fact and of documents to avoid unnecessary proof; (iii) Settlement of the matter...

19 CFR 354.11 - Prehearing conference.

Code of Federal Regulations, 2012 CFR

2012-04-01

... 19 Customs Duties 3 2012-04-01 2012-04-01 false Prehearing conference. 354.11 Section 354.11 Customs Duties INTERNATIONAL TRADE ADMINISTRATION, DEPARTMENT OF COMMERCE PROCEDURES FOR IMPOSING...) Obtaining stipulations of fact and of documents to avoid unnecessary proof; (iii) Settlement of the matter...

19 CFR 354.11 - Prehearing conference.

Code of Federal Regulations, 2013 CFR

2013-04-01

... 19 Customs Duties 3 2013-04-01 2013-04-01 false Prehearing conference. 354.11 Section 354.11 Customs Duties INTERNATIONAL TRADE ADMINISTRATION, DEPARTMENT OF COMMERCE PROCEDURES FOR IMPOSING...) Obtaining stipulations of fact and of documents to avoid unnecessary proof; (iii) Settlement of the matter...

19 CFR 354.11 - Prehearing conference.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 19 Customs Duties 3 2010-04-01 2010-04-01 false Prehearing conference. 354.11 Section 354.11 Customs Duties INTERNATIONAL TRADE ADMINISTRATION, DEPARTMENT OF COMMERCE PROCEDURES FOR IMPOSING...) Obtaining stipulations of fact and of documents to avoid unnecessary proof; (iii) Settlement of the matter...

19 CFR 354.11 - Prehearing conference.

Code of Federal Regulations, 2014 CFR

2014-04-01

... 19 Customs Duties 3 2014-04-01 2014-04-01 false Prehearing conference. 354.11 Section 354.11 Customs Duties INTERNATIONAL TRADE ADMINISTRATION, DEPARTMENT OF COMMERCE PROCEDURES FOR IMPOSING...) Obtaining stipulations of fact and of documents to avoid unnecessary proof; (iii) Settlement of the matter...

9 CFR 3.116 - Care in transit.

Code of Federal Regulations, 2010 CFR

2010-01-01

... such methods as intermittent spraying of water or application of a nontoxic emollient; (2) Assuring... related stress; and (5) Calming the marine mammals to avoid struggling, thrashing, and other unnecessary.../or warmed sufficiently to prevent overheating, hypothermia, or temperature related stress; and (2...

9 CFR 3.116 - Care in transit.

Code of Federal Regulations, 2011 CFR

2011-01-01

... such methods as intermittent spraying of water or application of a nontoxic emollient; (2) Assuring... related stress; and (5) Calming the marine mammals to avoid struggling, thrashing, and other unnecessary.../or warmed sufficiently to prevent overheating, hypothermia, or temperature related stress; and (2...

45 CFR 672.12 - Prehearing conference.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Public Welfare Regulations Relating to Public Welfare (Continued) NATIONAL SCIENCE FOUNDATION ENFORCEMENT... consider: (1) The settlement of the case; (2) The simplification of issues and stipulation of facts not in..., documents, prepared testimony, and admissions or stipulations of fact which will avoid unnecessary proof; (5...

45 CFR 672.12 - Prehearing conference.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Public Welfare Regulations Relating to Public Welfare (Continued) NATIONAL SCIENCE FOUNDATION ENFORCEMENT... consider: (1) The settlement of the case; (2) The simplification of issues and stipulation of facts not in..., documents, prepared testimony, and admissions or stipulations of fact which will avoid unnecessary proof; (5...

45 CFR 672.12 - Prehearing conference.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Public Welfare Regulations Relating to Public Welfare (Continued) NATIONAL SCIENCE FOUNDATION ENFORCEMENT... consider: (1) The settlement of the case; (2) The simplification of issues and stipulation of facts not in..., documents, prepared testimony, and admissions or stipulations of fact which will avoid unnecessary proof; (5...

45 CFR 672.12 - Prehearing conference.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Public Welfare Regulations Relating to Public Welfare (Continued) NATIONAL SCIENCE FOUNDATION ENFORCEMENT... consider: (1) The settlement of the case; (2) The simplification of issues and stipulation of facts not in..., documents, prepared testimony, and admissions or stipulations of fact which will avoid unnecessary proof; (5...

45 CFR 672.12 - Prehearing conference.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Public Welfare Regulations Relating to Public Welfare (Continued) NATIONAL SCIENCE FOUNDATION ENFORCEMENT... consider: (1) The settlement of the case; (2) The simplification of issues and stipulation of facts not in..., documents, prepared testimony, and admissions or stipulations of fact which will avoid unnecessary proof; (5...

Radiotherapy for early infradiaphragmatic Hodgkin's disease: the Australasian experience.

PubMed

Barton, M; Boyages, J; Crennan, E; Davis, S; Fisher, R J; Hook, C; Johnson, N; Joseph, D; Khoo, V; Liew, K H; Morgan, G; O'Brien, P; Pendlebury, S; Pratt, G; Quong, G; Roos, D E; Thornton, D; Trotter, G; Walker, Q; Wallington, M

1996-04-01

To review the Australasian results of Stage I and IIA Infradiaphragmatic Hodgkin's Disease (IHD) treated solely by irradiation. Eligible patients had IHD only and were treated by irradiation with curative intent over the period of 1969 to 1988. Ten radiation oncology centres from within Australia and New Zealand were surveyed for patient, tumour and treatment variables. Disease free rates, survival and complications were analysed. 106 patients with IHD were studied. The average potential follow up was 9.4 years. The male to female ratio was 3.3:1. The median age was 37.5 years. Histological subgroups were as follows; lymphocyte predominant 43%, mixed cellularity 21%, lymphocyte depleted 5%, nodular sclerosing 27% and unclassifiable 4%. Fifty nine patients had laparotomy of which 22 (37%) were positive for tumour. Nine laparotomies were performed for diagnosis and the remainder for staging. One patient was up-staged by laparotomy and three were down-staged. Sixty-eight patients presented with inguinal disease alone, five with abdominal disease alone, 19 with two sites of involvement and 12 with inguinal, pelvic and abdominal disease. In two patients the site was unknown. There was no correlation between site of involvement, age, sex or histological subtype. Forty seven cases were clinically staged (CS) as follows: CS IA-23, CS IIA-24. The other 59 were pathologically staged (PS) as follows: PS IA-37, PS IB-1, PS IIA-21. Treatment consisted of involved field alone (16), inverted Y (68), inverted Y and spleen (13), para-aortic irradiation only (3), or total nodal irradiation (6). Mean dose was 37 Gy. There were 30 recurrences to give an acturial 10-year disease-free rate of 70%. In multivariate analysis lower number of tumour sites, lymphocyte predominant histology and higher dose were all significantly correlated with higher disease free rates. Eight patients died of Hodgkin's disease and 19 of other causes. The 10-year overall survival rate was 71%. Older age and higher number of disease sites were significantly correlated with shorter survival. Fourteen of 30 relapses may have been avoidable by the use of total nodal irradiation. In particular ten of 21 patients with abdominal disease relapsed in nodal sites which would have been covered by total nodal irradiation. The rate of control in IHD could perhaps be improved by avoiding involved field irradiation or by aggressive therapy with total nodal irradiation or combined modality chemo-irradiation in Stage II disease. Staging laparotomy does not appear to be indicated.

49 CFR 1.25 - Relationships.

Code of Federal Regulations, 2010 CFR

2010-10-01

... are staff and advisory in nature. In performing their functions, the Assistant Secretaries are...: (1) Avoid unnecessary duplication of effort by or in conflict with the performance of similar... operational character may be delegated to an Assistant Secretary when the nature of the function or its stage...

Reorientation from Altered States: Please, More Carefully.

ERIC Educational Resources Information Center

Heikkinen, Charles A.

1989-01-01

Claims counselors too often appear to forget to reorient clients from altered states of consciousness used in counseling and that failure to reorient can result in unnecessary discomfort for clients. Provides suggestions for when and how to reorient to avoid unwanted, lingering aftereffects. (Author/ABL)

49 CFR 19.44 - Procurement procedures.

Code of Federal Regulations, 2011 CFR

2011-10-01

...)(1), (2) and (3) of this section apply. (1) Recipients avoid purchasing unnecessary items. (2) Where appropriate, an analysis is made of lease and purchase alternatives to determine which would be the most... timeframes for purchases and contracts to encourage and facilitate participation by small businesses...

43 CFR 3480.0-1 - Purpose.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Federal coal; ensure production practices that prevent wasting or loss of coal or other resources; avoid unnecessary damage to coal-bearing or mineral-bearing formations; ensure MER of Federal coal; ensure that... regulation of surface and underground coal mining operations; require an accurate record and accounting of...

43 CFR 3480.0-1 - Purpose.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Federal coal; ensure production practices that prevent wasting or loss of coal or other resources; avoid unnecessary damage to coal-bearing or mineral-bearing formations; ensure MER of Federal coal; ensure that... regulation of surface and underground coal mining operations; require an accurate record and accounting of...

43 CFR 3480.0-1 - Purpose.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Federal coal; ensure production practices that prevent wasting or loss of coal or other resources; avoid unnecessary damage to coal-bearing or mineral-bearing formations; ensure MER of Federal coal; ensure that... regulation of surface and underground coal mining operations; require an accurate record and accounting of...

43 CFR 3480.0-1 - Purpose.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Federal coal; ensure production practices that prevent wasting or loss of coal or other resources; avoid unnecessary damage to coal-bearing or mineral-bearing formations; ensure MER of Federal coal; ensure that... regulation of surface and underground coal mining operations; require an accurate record and accounting of...

Savvy Spending

ERIC Educational Resources Information Center

Kennedy, Mike

2009-01-01

In the last several years, the growing demand that education institutions incorporate sustainable design and construction concepts in school facility plans has created a greater emphasis on using life-cycle costing. The use of long-lasting materials and equipment enables schools and universities to avoid the unnecessary consumption of energy and…

[The art of saying 'no': is it important inside or outside the consulting room?].

PubMed

Cals, Jochen W L

2015-01-01

This commentary discusses a report by the Health Council of the Netherlands on 'The art of saying no: factors contributing to the delivery of unnecessary health care'. In this report the Health Council identifies and discusses contributing factors in the areas of society, the organisation of health care and doctor-patient consultations. In its recommendations the Health Council calls upon doctors to avoid delivering unnecessary care and to set boundaries by using risk communication and decision aids. Yet again, this commentary argues that the current complex health system as created by the government and health insurance companies severely restricts health professionals' ability to do so.

Optimal Implantable Cardioverter Defibrillator Programming.

PubMed

Shah, Bindi K

Optimal programming of implantable cardioverter defibrillators (ICDs) is essential to appropriately treat ventricular tachyarrhythmias and to avoid unnecessary and inappropriate shocks. There have been a series of large clinical trials evaluating tailored programming of ICDs. We reviewed the clinical trials evaluating ICD therapies and detection, and the consensus statement on ICD programming. In doing so, we found that prolonged ICD detection times, higher rate cutoffs, and antitachycardia pacing (ATP) programming decreases inappropriate and painful therapies in a primary prevention population. The use of supraventricular tachyarrhythmia discriminators can also decrease inappropriate shocks. Tailored ICD programming using the knowledge gained from recent ICD trials can decrease inappropriate and unnecessary ICD therapies and decrease mortality.

New scoring system for intra-abdominal injury diagnosis after blunt trauma.

PubMed

Shojaee, Majid; Faridaalaee, Gholamreza; Yousefifard, Mahmoud; Yaseri, Mehdi; Arhami Dolatabadi, Ali; Sabzghabaei, Anita; Malekirastekenari, Ali

2014-01-01

An accurate scoring system for intra-abdominal injury (IAI) based on clinical manifestation and examination may decrease unnecessary CT scans, save time, and reduce healthcare cost. This study is designed to provide a new scoring system for a better diagnosis of IAI after blunt trauma. This prospective observational study was performed from April 2011 to October 2012 on patients aged above 18 years and suspected with blunt abdominal trauma (BAT) admitted to the emergency department (ED) of Imam Hussein Hospital and Shohadaye Hafte Tir Hospital. All patients were assessed and treated based on Advanced Trauma Life Support and ED protocol. Diagnosis was done according to CT scan findings, which was considered as the gold standard. Data were gathered based on patient's history, physical exam, ultrasound and CT scan findings by a general practitioner who was not blind to this study. Chi-square test and logistic regression were done. Factors with significant relationship with CT scan were imported in multivariate regression models, where a coefficient (β) was given based on the contribution of each of them. Scoring system was developed based on the obtained total β of each factor. Altogether 261 patients (80.1% male) were enrolled (48 cases of IAI). A 24-point blunt abdominal trauma scoring system (BATSS) was developed. Patients were divided into three groups including low (score<8), moderate (8≤score<12) and high risk (score≥12). In high risk group immediate laparotomy should be done, moderate group needs further assessments, and low risk group should be kept under observation. Low risk patients did not show positive CT-scans (specificity 100%). Conversely, all high risk patients had positive CT-scan findings (sensitivity 100%). The receiver operating characteristic curve indicated a close relationship between the results of CT scan and BATSS (sensitivity=99.3%). The present scoring system furnishes a high precision and reproducible diagnostic tool for BAT detection and has the potential to reduce unnecessary CT scan and cut unnecessary costs.

50 CFR 37.13 - Group participation.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 50 Wildlife and Fisheries 9 2014-10-01 2014-10-01 false Group participation. 37.13 Section 37.13 Wildlife and Fisheries UNITED STATES FISH AND WILDLIFE SERVICE, DEPARTMENT OF THE INTERIOR (CONTINUED) THE... NATIONAL WILDLIFE REFUGE, ALASKA General Requirements § 37.13 Group participation. (a) To avoid unnecessary...

50 CFR 37.13 - Group participation.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 50 Wildlife and Fisheries 9 2012-10-01 2012-10-01 false Group participation. 37.13 Section 37.13 Wildlife and Fisheries UNITED STATES FISH AND WILDLIFE SERVICE, DEPARTMENT OF THE INTERIOR (CONTINUED) THE... NATIONAL WILDLIFE REFUGE, ALASKA General Requirements § 37.13 Group participation. (a) To avoid unnecessary...

50 CFR 37.13 - Group participation.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 50 Wildlife and Fisheries 9 2013-10-01 2013-10-01 false Group participation. 37.13 Section 37.13 Wildlife and Fisheries UNITED STATES FISH AND WILDLIFE SERVICE, DEPARTMENT OF THE INTERIOR (CONTINUED) THE... NATIONAL WILDLIFE REFUGE, ALASKA General Requirements § 37.13 Group participation. (a) To avoid unnecessary...

40 CFR 164.50 - Prehearing conference and primary discovery.

Code of Federal Regulations, 2012 CFR

2012-07-01

... possibility of obtaining stipulations of fact and documents which will avoid unnecessary delay; (4) Matters of... any party desires that questions of scientific fact be referred to a committee designated by the National Academy of Sciences. (2) Preparation of questions. On determining an affirmative intent, the...

40 CFR 164.50 - Prehearing conference and primary discovery.

Code of Federal Regulations, 2011 CFR

2011-07-01

... possibility of obtaining stipulations of fact and documents which will avoid unnecessary delay; (4) Matters of... any party desires that questions of scientific fact be referred to a committee designated by the National Academy of Sciences. (2) Preparation of questions. On determining an affirmative intent, the...

40 CFR 164.50 - Prehearing conference and primary discovery.

Code of Federal Regulations, 2010 CFR

2010-07-01

... possibility of obtaining stipulations of fact and documents which will avoid unnecessary delay; (4) Matters of... any party desires that questions of scientific fact be referred to a committee designated by the National Academy of Sciences. (2) Preparation of questions. On determining an affirmative intent, the...

40 CFR 164.50 - Prehearing conference and primary discovery.

Code of Federal Regulations, 2013 CFR

2013-07-01

... possibility of obtaining stipulations of fact and documents which will avoid unnecessary delay; (4) Matters of... any party desires that questions of scientific fact be referred to a committee designated by the National Academy of Sciences. (2) Preparation of questions. On determining an affirmative intent, the...

40 CFR 164.50 - Prehearing conference and primary discovery.

Code of Federal Regulations, 2014 CFR

2014-07-01

... possibility of obtaining stipulations of fact and documents which will avoid unnecessary delay; (4) Matters of... any party desires that questions of scientific fact be referred to a committee designated by the National Academy of Sciences. (2) Preparation of questions. On determining an affirmative intent, the...

32 CFR 2103.12 - Level of original classification.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 32 National Defense 6 2010-07-01 2010-07-01 false Level of original classification. 2103.12... DECLASSIFIED Original Classification § 2103.12 Level of original classification. Unnecessary classification, and classification at a level higher than is necessary, shall be avoided. If there is reasonable doubt...

A resolution to permit the Senate to avoid unnecessary delay and vote on matters for which floor debate has ceased.

THOMAS, 113th Congress

Sen. Lautenberg, Frank R. [D-NJ

2013-01-03

Senate - 01/03/2013 Submitted in the Senate. Placed on Senate Legislative Calendar under Over, Under the Rule. (All Actions) Tracker: This bill has the status IntroducedHere are the steps for Status of Legislation:

Telehealth for paediatric burn patients in rural areas: a retrospective audit of activity and cost savings.

PubMed

McWilliams, Tania; Hendricks, Joyce; Twigg, Di; Wood, Fiona; Giles, Margaret

2016-11-01

Since 2005, the Western Australian paediatric burn unit has provided a state-wide clinical consultancy and support service for the assessment and management of acute and rehabilitative burn patients via its telehealth service. Since then, the use of this telehealth service has steadily increased as it has become imbedded in the model of care for paediatric burn patients. Primarily, the service involves acute and long term patient reviews conducted by the metropolitan-located burn unit in contact with health practitioners, advising patients and their families who reside outside the metropolitan area thereby avoiding unnecessary transfers and inpatient bed days. A further benefit of the paediatric burn service using telehealth is more efficient use of tertiary level burn unit beds, with only those patients meeting clinical criteria for admission being transferred. To conduct a retrospective audit of avoided transfers and bed days in 2005/06-2012/13 as a result of the use of the paediatric Burns Telehealth Service and estimate their cost savings in 2012/13. A retrospective chart audit identified activity, avoided unnecessary acute and scar review patient transfers, inpatient bed days and their associated avoided costs to the tertiary burn unit and patient travel funding. Over the period 2005/06-2012/13 the audit identified 4,905 avoided inpatient bed days, 364 avoided acute patient transfers and 1,763 avoided follow up review transfers for a total of 1,312 paediatric burn patients as a result of this telehealth service. This paper presents the derivation of these outcomes and an estimation of their cost savings in 2012/13 of AUD 1.89million. This study demonstrates avoided patient transfers, inpatient bed days and associated costs as the result of an integrated burns telehealth service. Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.

Choosing the right diagnostic imaging modality in musculoskeletal diagnosis.

PubMed

Aagesen, Andrea L; Melek, Maged

2013-12-01

Radiological studies can confirm or rule out competing diagnoses for musculoskeletal injuries and pain. Obtaining a detailed history and physical examination is pivotal for localizing the pain generator and choosing the most appropriate imaging studies, based on the suspected injured tissue. Judicious use of imaging is important to avoid unnecessary radiation exposure, minimize cost, and avoid therapy targeting asymptomatic imaging abnormalities. This article compares and contrasts the diagnostic imaging commonly used for detecting musculoskeletal injuries. Copyright © 2013 Elsevier Inc. All rights reserved.

Scanning and War: Utility of FAST and CT in the Assessment of Battlefield Abdominal Trauma.

PubMed

Smith, Iain M; Naumann, David N; Marsden, Max E R; Ballard, Mark; Bowley, Douglas M

2015-08-01

To determine utilization and accuracy of focused assessment with sonography for trauma (FAST) and computed tomography (CT) in a mature military trauma system to inform service provision for future conflicts. FAST and CT scans undertaken by attending radiologists contribute to surgical decision making for battlefield casualties at the Joint Force, Role 3 Medical Treatment Facility at Camp Bastion (R3), Afghanistan. Registry data for abdominally injured casualties treated at R3 from July to November 2012 were matched to radiological and surgical records to determine diagnostic accuracy for FAST and CT and their influence on casualty management. A total of 468 casualties met inclusion criteria, of whom 85.0% underwent FAST and 86.1% abdominal CT; 159 (34.0%) had abdominal injuries. For detection of intra-abdominal injury, FAST sensitivity (Sn) was 0.56, specificity (Sp) 0.98, positive predictive value (PPV) 0.87, negative predictive value (NPV) 0.90, and accuracy (Acc) 0.89. For CT, Sn was 0.99, Sp 0.99, PPV 0.96, NPV 1.00, and Acc 0.99. Forty-six solid organ injuries were identified in 38 patients by CT; 17 were managed nonoperatively. A further 61 patients avoided laparotomy after CT confirmed extra-abdominal wounds only. The negative laparotomy rate was 3.9%. FAST and CT contribute to triage, guide surgical management, and reduce nontherapeutic laparotomy. When imaging is available, these data challenge current doctrine about inadvisability of nonoperative management of abdominal injury after combat trauma.

[Massive haemoperitoneum due to traumatic rupture of multifocal hepatocarcinoma in the right hepatic lobe. Case report].

PubMed

Spaziani, E; Briganti, M; Saltarelli, A; Iozzino, M; Notarianni, E; Cianni, R; Di Filippo, A; Picchio, M; Ceci, F; Gammardella, P; De Angelis, F; Nardecchia, G; Cipriani, B; Nicodemi, S; Stagnitti, F

2009-01-01

Abdominal blunt trauma is the main cause of death in people younger than 40 years old. The liver injury still represents a challenging problem. Isolated hepatic injury is rare and it occurs more frequentely in polytraumatizated patients and causes massive haemoperitoneum. The Authors report a case of a 83 years-old woman admitted to Emergency Department for syncope due to an active bleeding arising from a rupture of a right hepatic lobe unsuspected tumor. The computer tomography (CT) scans showed a clear pattern of liver laceration of the VI segment with contrast enhancement spreading in the surrounding tissues, and detected a multifocal hepatocarcinoma located in the VI, VII and VIII segments. Patient's haemodinamically unstable conditions suggested an urgent laparotomy. An accurate perihepatic packing with sterile-drape were successfully employed to control liver hemorrage. Temporary abdominal closure, followed by hepatic arteriography and the right hepatic artery embolization, completed the damage control. Re-exploration laparotomy after 72 hours confirmed the definitive haemostasis and the pack removal was performed without complications. CT plays a leading role in the diagnosis of liver damage. The patient's haemodynamic status is the principal criterion determining conservative or operative therapy in blunt liver injury. The early perihepatic packing followed by artheriographic embolization to stop liver hemorrhage showed efficacy and safety for the patient. The packing performed with sterile-drape is able to avoid removal complications and 72 hours timing for the pack removal is effective to avoid re-bleeding.

40 CFR 305.26 - Prehearing conference.

Code of Federal Regulations, 2011 CFR

2011-07-01

... testimony, and admissions or stipulations of fact which will avoid unnecessary proof; (5) The limitation of... at the conference and shall serve that summary on all parties in the manner provided in § 305.5(b)(2... together with the conditions and terms thereof. (5) The Presiding Officer shall order depositions upon oral...

Quantitative Indicators for Behaviour Drift Detection from Home Automation Data.

PubMed

Veronese, Fabio; Masciadri, Andrea; Comai, Sara; Matteucci, Matteo; Salice, Fabio

2017-01-01

Smart Homes diffusion provides an opportunity to implement elderly monitoring, extending seniors' independence and avoiding unnecessary assistance costs. Information concerning the inhabitant behaviour is contained in home automation data, and can be extracted by means of quantitative indicators. The application of such approach proves it can evidence behaviour changes.

Student Rights, Safety, and Codes of Conduct

ERIC Educational Resources Information Center

Mawdsley, Ralph D.

2004-01-01

Community college students, like students in all of higher education, find their relationship with the college defined by contract. However, this contract is shaped and influenced by rights granted under state and federal constitutions and statutes. Knowing what these rights are can assist college officials in avoiding unnecessary litigation.

43 CFR 30.223 - What is a prehearing conference?

Code of Federal Regulations, 2011 CFR

2011-10-01

... 43 Public Lands: Interior 1 2011-10-01 2011-10-01 false What is a prehearing conference? 30.223... PROCEDURES Formal Probate Proceedings Depositions, Discovery, and Prehearing Conference § 30.223 What is a..., understandings on matters already of record, or similar agreements that will avoid unnecessary proof; (c) Limit...

12 CFR 19.5 - Authority of the administrative law judge.

Code of Federal Regulations, 2010 CFR

2010-01-01

... powers necessary to conduct a proceeding in a fair and impartial manner and to avoid unnecessary delay. (b) Powers. The administrative law judge shall have all powers necessary to conduct the proceeding in accordance with paragraph (a) of this section, including the following powers: (1) To administer oaths and...

12 CFR 509.5 - Authority of the administrative law judge.

Code of Federal Regulations, 2011 CFR

2011-01-01

... administrative law judge shall have all powers necessary to conduct a proceeding in a fair and impartial manner and to avoid unnecessary delay. (b) Powers. The administrative law judge shall have all powers... following powers: (1) To administer oaths and affirmations; (2) To issue subpoenas, subpoenas duces tecum...

Ask These Key Questions When You Review Child Abuse Reporting Policies.

ERIC Educational Resources Information Center

Rogers, Joy J.

1988-01-01

Urges policymakers to examine and update their school system's child abuse reporting policy. Such policies must be adequate to help endangered children, protect their right to privacy, and avoid overprotection. Advises on ways to protect staff against unnecessary accusations and develop inservice training programs discussing child abuse, state…

School Board Attorney: Friend in Need.

ERIC Educational Resources Information Center

Stover, Kermit M.

To keep abreast of newly enacted legislation and court opinions affecting school policies and regulation, school officials need prompt, competent, and reliable legal advice, and should be prepared to pay for it. By consulting a competent attorney, school officials can avoid unnecessary and costly delays resulting from litigation over procedural…

Determination of zilpaterol in sheep urine and tissues using immunochromatographic assay

USDA-ARS?s Scientific Manuscript database

Introduction: Zilpaterol is a feed additive used to increase weight gain, improve feed efficiency, and increase carcass leanness in cattle. An on-site analytical method is needed to determine zilpaterol exposure in animals to assist producer and trade groups in avoiding un-necessary animal or carca...

Assessing Patient and Caregiver Intent to Use Mobile Device Videoconferencing for Remote Mechanically-Ventilated Patient Management

ERIC Educational Resources Information Center

Smith, Brian R.

2017-01-01

The Michigan Medicine adult Assisted Ventilation Clinic (AVC) supports patients with neuromuscular disorders and spinal cord injuries and their caregivers at home, helping them avoid expensive emergency department visits, hospitalization, and unnecessary or excessive treatments. Mobile device videoconferencing provides an effective capability for…

43 CFR 30.223 - What is a prehearing conference?

Code of Federal Regulations, 2010 CFR

2010-10-01

... Section 30.223 Public Lands: Interior Office of the Secretary of the Interior INDIAN PROBATE HEARINGS... prehearing conference? Before a hearing, the judge may order the parties to appear for a conference to: (a..., understandings on matters already of record, or similar agreements that will avoid unnecessary proof; (c) Limit...

Indoor Air vs. Indoor Construction: A New Beginning.

ERIC Educational Resources Information Center

Manicone, Santo

2000-01-01

Identifies the steps that can be taken to lessen the impact of indoor air pollution created from indoor renovation projects, including project management tips to help contractors avoid creating unnecessary air pollution. Final comments address air pollution control when installing new furniture, smoking restrictions, occupant relations, and the…

Goddard Laboratory for Atmospheric Science, collected reprints 1978-1979, volume 1

NASA Technical Reports Server (NTRS)

Skillman, W. C. (Editor); Kreins, E. R. (Editor)

1981-01-01

A ready reference is presented to 61 papers by members of the Laboratory published between January 1, 1978 and December 31, 1979. To avoid unnecessary duplication, only abstracts or introductions of NASA reports and conference proceedings are included with reprints of articles from various journals.

[The effect of neoplastic disease and systemic disease of connective tissue on the occurrence of dehiscence laparotomy].

PubMed

Paunović, Milorad

2013-01-01

Dehiscence after laparotomy is one of the major complications of laparotomy. This is a partial or complete wound with disruption and evisceratio abdominal organs and require urgent reintervention. The aim of this study was to determine the impact of neoplastic disease and systemic disease of connective tissue on the occurrence of dehiscence laparotomy. A prospective study were included 612 patients operated at the Clinic for General Surgery in Nis in the period from January 2009 to December 2010. The effect of neoplastic disease and the presence of systemic disease of connective tissue on the occurrence of dehiscence laparotomy. Results are displayed numerically and in percentages. Of the total 24 patients with dehiscence laparotomy, 15 patients were male or 62.5% and 9 female patients, or 37.5%. There was a statistically significant association between dehiscence laparotomy and neoplastic diseases (c2 = 42,196; p < 0.01). There was no statistically significant association between dehiscence laparo-tomy and systemic disease of connective tissue (c2 = 0,028; p > 0.05). In patients with neoplastic diseases dehis-cence laparotomy is common, and in patients suffering from systemic disease of connective tissue dehiscence laparotomy occurs less frequently.

Faith community nursing demonstrates good stewardship of community benefit dollars through cost savings and cost avoidance.

PubMed

Brown, Ameldia R; Coppola, Patricia; Giacona, Marian; Petriches, Anne; Stockwell, Mary Ann

2009-01-01

Health systems seeking responsible stewardship of community benefit dollars supporting Faith Community Nursing Networks require demonstration of positive measurable health outcomes. Faith Community Nurses (FCNs) answer the call for measurable outcomes by documenting cost savings and cost avoidances to families, communities, and health systems associated with their interventions. Using a spreadsheet tool based on Medicare reimbursements and diagnostic-related groupings, 3 networks of FCNs have together shown more than 600 000 (for calendar year 2008) healthcare dollars saved by avoidance of unnecessary acute care visits and extended care placements. The cost-benefit ratio of support dollars to cost savings and cost avoidance demonstrates that support of FCNs is good stewardship of community benefit dollars.

Emergency treatment of violent trauma: clinical cases and surgical treatment of penetrating thoracoabdominal, perineal and anorectal trauma.

PubMed

Zuccon, William; Paternollo, Roberto; Del Re, Luca; Cordovana, Andrea; De Murtas, Giovanni; Gaverini, Giacomo; Baffa, Giulia; Lunghi, Claudio

2013-01-01

The authors analyse clinical cases of penetrating thoracic, abdominal, perineal and anorectal injury and describe the traumatic event and type of lesion, the principles of surgical treatment, the complication rate and follow up. In the last 24 months, we analyzed 10 consecutive cases of penetrating thoracic and abdominal wounds [stab wound (n=7), with evisceration (n=4), gunshot wound (n=1)], and penetrating perineal and anorectal wounds (impalement n=4). In addition, we report an unusual case of neck injury from a stab wound. All the patients underwent emergency surgery for the lesions reported. In 7 cases of perforating vulnerant thoracoabdominal trauma from stab wounds there was hemoperitoneum due to bleeding from the abdominal wall (n=3), the omentum (n=1), the vena cava (n=1) and the liver (n=2). Evisceration of the omentum was observed in 4 cases. In 2 cases laparoscopy was performed. In one case laparotomy and thoracoscopy was performed. In a patient with an abdominoperineal gunshot wound, exploration was extraperitoneal. The 4 cases of perineal and anorectal impalement were treated with primary reconstruction, while in one case a laparotomy was needed to suture the rectum and fashion a temporary colostomy. In one case of anorectal injury rehabilitation resulted in a gradual improvement of fecal continence, while in the patient with the colostomy follow up at 2 months was scheduled to plan colostomy closure. Based on the our clinical experience and the literature, in penetrating abdominal trauma laparotomy may be required if patients are hemodynamically unstable (or in hemorrhagic shock), in patients with evisceration and peritonitis, or for exploration of penetrating thoracoabdominal and epigastric lesions. In anterior injuries of the abdominal wall from gunshot or stab wounds, laparotomy is indicated when there is peritoneal violation and significant intraperitoneal damage. In patients with actively bleeding wounds of the abdominal wall muscles minimal laparotomy is often necessary for control of hemorrhage and abdominal wall reconstruction to avoid herniation. If patients are asymptomatic, in cases of anterior lesions the indications for diagnostic laparoscopy are uncertain. Selective conservative treatment is reserved for asymptomatic patients who are hemodynamically stable. Further controlled studies are needed. Early surgery for perineal and anorectal trauma, and also for complex injuries, is the gold standard for treatment.

Conservative treatment of idiopathic spontaneous pneumoperitoneum in a bedridden patient: a case report.

PubMed

Tanaka, Ryo; Kameyama, Hitoshi; Nagahashi, Masayuki; Kanda, Tatsuo; Ichikawa, Hiroshi; Hanyu, Takaaki; Ishikawa, Takashi; Kobayashi, Takashi; Sakata, Jun; Kosugi, Shin-Ichi; Wakai, Toshifumi

2015-01-01

Idiopathic spontaneous pneumoperitoneum is a rare condition that is characterized by intraperitoneal gas for which no clear etiology has been identified. We report here a case of idiopathic spontaneous pneumoperitoneum, which was successfully managed by conservative treatment. A 77-year-old woman who was bedridden with speech disability as a sequela of brain hemorrhage presented at our hospital with a 1-day history of abdominal distention. On physical examination, she had stable vital signs and slight epigastric tenderness on deep palpation without any other signs of peritonitis. A chest radiograph and computed tomography showed that a large amount of free gas extended into the upper abdominal cavity. Esophagogastroduodenoscopy revealed no perforation of the upper gastrointestinal tract. The patient was diagnosed with idiopathic spontaneous pneumoperitoneum, and conservative treatment was selected. The abdominal distension rapidly disappeared, and the patient resumed oral intake on the 5th hospital day without deterioration of symptoms. Knowledge of this rare disease and accurate diagnosis with findings of clinical imaging might contribute towards refraining from unnecessary laparotomy.

MRI facilitated a diagnosis of endometriosis of the rectum.

PubMed

Eguchi, S; Komuta, K; Haraguchi, M; Furui, J; Kanematsu, T

2000-01-01

A 51-year-old pre-menopausal Japanese woman suffering from chronic lower abdominal pain was referred to our hospital. A barium enema showed a stenotic lesion in the recto-sigmoid region, and a pelvic computed axial tomography (CAT) scan revealed a thickened rectal wall. A colonoscopic examination showed the rectum to be constrictive, but the mucosa appeared to be intact. Magnetic resonance imaging (MRI) with T1 high-intensity revealed a cystic lesion in the thickened wall of the rectum, which led us to suspect possible bowel endometriosis. Part of the biopsy specimen showed endometrial epithelium within the interstitial layer of histologically normal mucosa; finally, endometriosis of the rectum was diagnosed. The patient became asymptomatic after the initiation of hormonal treatment and later experienced spontaneous menopause. MRI was effective for diagnosis and the patient did not undergo unnecessary laparotomy. Although bowel endometriosis is generally diagnosed by means of resected specimens, in our patient, diagnosis was made using MRI and biopsy, and hormonal therapy had an effective role as a bridge to menopause.

The value of laparoscopy in acute pelvic pain.

PubMed Central

Anteby, S O; Schenker, J G; Polishuk, W Z

1975-01-01

Laparoscopy was performed in 223 patients with acute pelvic pain but without a definite diagnosis. The clinically suspected diagnosis was confirmed by laparoscopy in only 57 patients (25%). Laparotomy was thus avoided in 145 patients (65%). The endoscopic findings in the three clinical entities included here are presented: tubal pregnancy, acute appendicitis or torsion of adnexal mass. This study emphasizes the poor correlation between the clinical diagnosis based on history, pelvic examination and physical signs, and the final laparoscopic findings. The value of laparoscopy in evaluation of acute pelvic disease is stressed. PMID:124158

The Noncommissioned Officer and Petty Officer: Backbone of the Armed Forces

DTIC Science & Technology

2014-01-01

cherish, and others may envy. The patriotic flame that burns within every Servicemember is sometimes threatened and can occasionally flicker from the...their crews. “You Have to Go Out but You Don’t Have to Come Back.” Coast- guardsmen are taught to avoid or mitigate unnecessary risk, but this historic

Less Heat, More Light: Resolving Our Differences in the Community. Handbook on Religion in the Public Schools.

ERIC Educational Resources Information Center

Indiana Civil Liberties Union, Inc., Indianapolis.

This handbook assists teachers, administrators, and other members of the educational community in avoiding inappropriate religious activities in the public schools as well as unnecessary interference with legitimate private religious expression by clarifying existing law. Participants in the Task Force on Religion and the Constitution represented…

Re-Using Today's Metadata for Tomorrow's Research: Five Practical Examples for Enhancing Access to Digital Collections

ERIC Educational Resources Information Center

Tzoc, Elias

2011-01-01

According to the "Framework of Guidance for Building Good Digital Collections," a good collection is broadly available and avoids unnecessary impediments to use. Two challenges, however, are the constant change in users' expectations and the increasing volume of information in local repositories. Therefore, as academic and research…

Sonographic Spectrum of Tunica Albuginea Cyst

PubMed Central

Alvarez, Daniel M.; Bhatt, Shweta; Dogra, Vikram S.

2011-01-01

Tunica albuginea (TA) cyst is the most common extratesticular benign mass, which is usually palpable. Ultrasound examination is the imaging modality of choice to characterize palpable testicular lesions. This pictorial essay presents the spectrum of sonographic features of TA cysts in order to assist radiologists in making the correct diagnosis and avoid unnecessary surgeries. PMID:21915386

Unnecessary roughness? Testing the hypothesis that predators destined for molecular gut-content analysis must be hand-collected to avoid cross-contamination

USDA-ARS?s Scientific Manuscript database

Molecular gut-content analysis enables direct detection of arthropod predation with minimal disruption of on-going ecosystem processes. Mass-collection methods, such as sweep-netting, vacuum sampling, and foliage beating, could lead to regurgitation or even rupturing of predators along with uneaten ...

Mental health crisis and respite services: service user and carer aspirations.

PubMed

Lyons, C; Hopley, P; Burton, C R; Horrocks, J

2009-06-01

There is emerging evidence that crisis resolution services can provide alternatives to hospital admission, reducing demand on inpatient beds. Following a public consultation exercise in Lancashire (England), a team of nurses undertook a study, using interactive research methodology, to gain an understanding of how users and carers define a crisis and what range of crisis services, resources and interventions service users and carers thought would help avoid unnecessary hospital admission. Data collection comprised postal questionnaires and 24 group meetings with service users and carers, which were held during 2006. Data were analysed, and seven themes were identified: (1) definitions of a crisis; (2) access to services; (3) interventions; (4) range of services required (before, during and after crisis); (5) place of treatment; (6) recovery and rehabilitation; and (7) community support. We conclude that expressed preferences of service users and carers for pre-emptive services that are delivered flexibly will present a challenge for service commissioners and providers, particularly where stringent access criteria are used. Home-based pre-emptive services that reduce the need for unnecessary hospital treatment may avoid progression to social exclusion of service users.

Antibiotics may not decrease prostate-specific antigen levels or prevent unnecessary prostate biopsy in patients with moderately increased prostate-specific antigen levels: A meta-analysis.

PubMed

Yang, Lu; Zhu, Yuchun; Tang, Zhuang; Chen, Yongji; Gao, Liang; Liu, Liangren; Han, Ping; Li, Xiang; Wei, Qiang

2015-05-01

To evaluate the effect of empiric antibiotics on decreasing prostate-specific antigen (PSA) levels and the possibility of avoiding unnecessary prostate biopsies (PBs). A systematic search of PubMed, Embase, and the Cochrane Library was performed to identify all randomized controlled trials (RCTs) that compared effects of empiric antibiotics with no treatment or placebo on lowering PSA levels and minimizing unnecessary PBs in patients with moderately increased PSA levels. The Cochrane Collaboration Review Manager software (RevMan 5.1.4) was used for statistical analysis. The inclusion criteria for the study were met by 6 RCTs (1 placebo controlled and 5 no treatment controlled) involving 656 patients. The synthesized data from these RCTs indicated that there were no significant differences between the antibiotic and control groups in the PSA levels after treatment (mean difference [MD] = 0.15, 95% CI:-0.50 to 0.81, P = 0.65], number of patients with decreased PSA levels after treatment (relative risk [RR] = 1.22, 95% CI: 0.90-1.65, P = 0.20], prostate-specific antigen density levels after treatment (MD =-0.04, 95% CI:-0.15 to 0.07, P = 0.47), f/t% PSA after treatment (MD =-1.47, 95% CI:-4.65 to 1.71, P = 0.37), number of patients with responsive PSA (RR = 1.02, 95% CI: 0.58-1.81, P = 0.94), and individual Pca-positiverate in these patients (RR = 1.07, 95% CI: 0.53-2.16, P = 0.86), and Pca-positiverates (RR = 0.85, 95% CI: 0.48-1.50, P = 0.57). However, the antibiotic group had a significant change in the net PSA decrease after treatment compared with the control group (MD = 1.44, 95% CI: 0.70-2.17, P = 0.0001). The use of empiric antibiotics may not significantly decrease PSA levels or avoid unnecessary PBs. Copyright © 2015 Elsevier Inc. All rights reserved.

Early laparotomy wound failure as the mechanism for incisional hernia formation

PubMed Central

Xing, Liyu; Culbertson, Eric J.; Wen, Yuan; Franz, Michael G.

2015-01-01

Background Incisional hernia is the most common complication of abdominal surgery leading to reoperation. In the United States, 200,000 incisional hernia repairs are performed annually, often with significant morbidity. Obesity is increasing the risk of laparotomy wound failure. Methods We used a validated animal model of incisional hernia formation. We intentionally induced laparotomy wound failure in otherwise normal adult, male Sprague-Dawley rats. Radio-opaque, metal surgical clips served as markers for the use of x-ray images to follow the progress of laparotomy wound failure. We confirmed radiographic findings of the time course for mechanical laparotomy wound failure by necropsy. Results Noninvasive radiographic imaging predicts early laparotomy wound failure and incisional hernia formation. We confirmed both transverse and craniocaudad migration of radio-opaque markers at necropsy after 28 d that was uniformly associated with the clinical development of incisional hernias. Conclusions Early laparotomy wound failure is a primary mechanism for incisional hernia formation. A noninvasive radiographic method for studying laparotomy wound healing may help design clinical trials to prevent and treat this common general surgical complication. PMID:23036516

Impaired Laparotomy Wound Healing in Obese Rats

PubMed Central

Xing, Liyu; Culbertson, Eric J.; Wen, Yuan; Robson, Martin C.

2015-01-01

Background Obesity increases the risk of laparotomy dehiscence and incisional hernia. The aim of this study was to measure the biological effect of obesity on laparotomy wound healing and the formation of incisional hernias. Methods Normal-weight Sprague–Dawley (SD) and obese Zucker rats were used in an established laparotomy wound healing and incisional ventral hernia model. Mechanical testing was performed on abdominal wall strips collected from laparotomy wounds. Hernia size was measured by digital imaging. Picrosirius staining for collagen isoforms was observed with polarized microscopy. Abdominal wall fibroblasts were cultured to measure collagen matrix remodeling and proliferation. Results Laparotomy wound healing was significantly impaired in obese rats. Mechanical strength was lower than in normal-weight rats. Yield load was reduced in the obese group at all time points. Picrosirius red staining showed increased immature type III collagen content and disorganized type I collagen fibers within laparotomy wounds of obese rats. Wound size was significantly larger in the obese group. Collagen matrix remodeling was impaired with fibroblasts from obese rats, but there was no difference in fibroblast proliferation between the obese and normal-weight groups. Conclusions We observed for the first time that laparotomy wound healing is impaired in obese rats. The recovery of laparotomy wound strength is delayed due to abnormal collagen maturation and remodeling, possibly due to a defect in fibroblast function. Strategies to improve outcomes for laparotomy wound healing in obese patients should include correcting the wound healing defect, possibly with growth factor or cell therapy. PMID:21347822

A case of isolated abducens nerve paralysis in maxillofacial trauma

PubMed Central

Keskin, Elif Seda; Keskin, Ekrem; Atik, Bekir; Koçer, Abdülkadir

2015-01-01

Nervus abducens is a pure motor nerve located in the pons. It retracts the eyeball laterally by stimulating rectus lateralis muscle. In case of their paralysis, diplopia and restriction in the eye movements while looking sideways, are seen. Since the same signs are seen due to the muscle entrapment in blowout fractures, its differential diagnosis has importance in terms of the treatment protocol and avoiding unnecessary operations. In this article, we present a 22-year-old male patient who was referred to our department due to the prediagnosis of blowout fracture following maxillofacial trauma. However, he was diagnosed with abducens nerve paralysis after the consultations and analysis and his restriction of movement was resolved via systemic steroid treatment instead of unnecessary operation. PMID:26981484

Value of diagnostic imaging for the symptomatic male breast: Can we avoid unnecessary biopsies?

PubMed

Foo, Eric T; Lee, Amie Y; Ray, Kimberly M; Woodard, Genevieve A; Freimanis, Rita I; Joe, Bonnie N

To review the use of diagnostic breast imaging and outcomes for symptomatic male patients. We retrospectively evaluated 122 males who underwent diagnostic imaging for breast symptoms at our academic center. The majority (94%) of cases had negative or benign imaging, with gynecomastia being the most common diagnosis (78%). There were two malignancies, both of which had positive imaging. Fifteen patients underwent percutaneous biopsy, and over half (53%) were palpation-guided biopsies initiated by the referring clinician despite negative imaging. Diagnostic imaging demonstrated 100% sensitivity and 96% specificity for identifying cancer. Malignancy is rarely a cause of male breast symptoms. Diagnostic breast imaging is useful to establish benignity and avert unnecessary biopsies. Copyright © 2017 Elsevier Inc. All rights reserved.

Rib fractures induced by coughing: an unusual cause of acute chest pain.

PubMed

De Maeseneer, M; De Mey, J; Debaere, C; Meysman, M; Osteaux, M

2000-03-01

We report three patients with stress fractures of the ribs induced by coughing. Standard radiographs of the chest and ribs did not reveal evidence of rib fractures in any of the patients. Bone scintigraphy, performed 1 to 2 weeks after initial onset of symptoms, showed a focal area of increased uptake along the chest wall in all cases. Thin section angulated helical CT directly visualized the subtle rib fractures. Initial diagnosis of a cough-induced fracture of the rib may be difficult because of the associated underlying disorder, and unnecessary examinations are commonly performed. Identification of a cough-induced fracture of the rib using helical CT may be clinically important to avoid unnecessary concern and additional examinations.

Inguinal Hernia and Airport Scanners: An Emerging Indication for Repair?

PubMed Central

Cawich, Shamir O.; Maharaj, Ravi; Dan, Dilip

2013-01-01

The use of advanced imaging technology at international airports is increasing in popularity as a corollary to heightened security concerns across the globe. Operators of airport scanners should be educated about common medical disorders such as inguinal herniae in order to avoid unnecessary harassment of travelers since they will encounter these with increasing frequency. PMID:24368923

An Empirical Study on Non-English Majors' Ability to Express Chinese Culture in English

ERIC Educational Resources Information Center

Zhang, Min

2014-01-01

Cross-cultural communicative ability is an important ability that college students should have in modern society. A successful cross-cultural communication is based on several factors. The basic one is the understanding of the target language culture. In order to avoid unnecessary misunderstandings it is necessary for college students to know…

Teaching CAD at the University: Specifically Written or Commercial Software?

ERIC Educational Resources Information Center

Garcia, Ramon Rubio; Quiros, Javier Suarez; Santos, Ramon Gallego; Penin, Pedro I. Alvarez

2007-01-01

At most universities throughout the world Computer Aided Design is taught using commercial programs more suitable for business and industry than for teaching. This led us to write our own design program (GIcad) starting from the best-known standards on the market, but always avoiding unnecessary commands in the first steps of the learning process.…

Superior herniation of the mediastinum presenting as an anterior neck mass on straining.

PubMed

McDougall, Catherine M; Culham, Gordon; Seear, Michael D; Chilvers, Mark A

2012-07-01

We report an infant with an anterior neck mass present only on straining. Airway fluoroscopy revealed this to be due to superior mediastinal herniation. Neck masses apparent only during Valsalva maneuver are rare and awareness of the differential diagnosis is important to avoid unnecessary investigation or surgery. Copyright © 2012 Wiley Periodicals, Inc.

Therapeutic risk management of clinical-legal dilemmas: should it be a core competency?

PubMed

Simon, Robert I; Shuman, Daniel W

2009-01-01

Therapeutic risk management of clinical-legal dilemmas achieves an optimal alignment between clinical competence and an understanding of legal concerns applicable to psychiatric practice. Understanding how psychiatry and law interact in frequently occurring clinical situations is essential for effective patient care. Successful management of clinical-legal dilemmas also avoids unnecessary, counterproductive defensive practices.

Long-term performance of minimum-input oak restoration plantings

Treesearch

Elizabeth Bernhardt; Tedmund J. Swiecki

2015-01-01

Starting in 1989, we used minimum-input methods to restore native oaks to parts of their former ranges in Vacaville, California. Each restoration site was analyzed, and only those inputs deemed necessary to overcome expected limiting factors for oak establishment were used. We avoided unnecessary inputs that added to cost and could have unintended negative consequences...

Inguinal hernia and airport scanners: an emerging indication for repair?

PubMed

Naraynsingh, Vijay; Cawich, Shamir O; Maharaj, Ravi; Dan, Dilip

2013-01-01

The use of advanced imaging technology at international airports is increasing in popularity as a corollary to heightened security concerns across the globe. Operators of airport scanners should be educated about common medical disorders such as inguinal herniae in order to avoid unnecessary harassment of travelers since they will encounter these with increasing frequency.

Better Federal Program Administration Can Contribute to Improving State Foster Care Programs.

ERIC Educational Resources Information Center

Comptroller General of the U.S., Washington, DC.

The Adoption Assistance and Child Welfare Act of 1980 provides for annual federal incentive payments to states if they improve foster care programs by (1) avoiding unnecessary removal of children from their homes; (2) preventing extended stays in foster care; and (3) reunifying children with their families or placing them for adoption. To be…

Urine Culture Follow-up and Antimicrobial Stewardship in a Pediatric Urgent Care Network.

PubMed

Saha, Dipanwita; Patel, Jimisha; Buckingham, Don; Thornton, David; Barber, Terry; Watson, Joshua R

2017-04-01

Empiric antibiotic therapy for presumed urinary tract infection (UTI) leads to unnecessary antibiotic exposure in many children whose urine culture results fail to confirm the diagnosis. The objective of this quality improvement study was to improve follow-up management of negative urine culture results in the off-campus urgent care network of Nationwide Children's Hospital to reduce inappropriate antibiotic exposure in children. A multidisciplinary task force developed and implemented a protocol for routine nurse and clinician follow-up of urine culture results, discontinuation of unnecessary antibiotics, and documentation in the electronic medical record. Monthly antibiotic discontinuation rates were tracked in empirically treated patients with negative urine culture results from July 2013 through December 2015. Statistical process control methods were used to track improvement over time. Fourteen-day return visits for UTIs were monitored as a balancing measure. During the study period, 910 patients received empiric antibiotic therapy for UTIs but had a negative urine culture result. The antibiotic discontinuation rate increased from 4% to 84%, avoiding 3429 (40%) of 8648 antibiotic days prescribed. Among patients with discontinued antibiotics, none was diagnosed with a UTI within 14 days of the initial urgent care encounter. Implementation of a standard protocol for urine culture follow-up and discontinuation of unnecessary antibiotics was both effective and safe in a high-volume pediatric urgent care network. Urine culture follow-up management is an essential opportunity for improved antimicrobial stewardship in the outpatient setting that will affect many patients by avoiding a substantial number of antibiotic days. Copyright © 2017 by the American Academy of Pediatrics.

Incidental pT2-T3 gallbladder cancer after a cholecystectomy: outcome of staging at 3 months prior to a radical resection

PubMed Central

Ausania, Fabio; Tsirlis, Theodoris; White, Steven A; French, Jeremy J; Jaques, Bryon C; Charnley, Richard M; Manas, Derek M

2013-01-01

Introduction Patients with incidental pT2-T3 gallbladder cancer (IGC) after a cholecystectomy may benefit from a radical re-resection although their optimal treatment strategy is not well defined. In this Unit, such patients undergo delayed staging at 3 months after a cholecystectomy to assess the evidence of a residual tumour, extra hepatic spread and the biological behaviour of the tumour. The aim of this study was to evaluate the outcome of patients who had delayed staging at 3 months after a cholecystectomy. Methods From July 2003 to July 2011, 56 patients with T2-T3 gallbladder cancer were referred to this Unit of which 49 were diagnosed incidentally on histology after a cholecystectomy. All 49 patients underwent delayed pre-operative staging using multi-detector computed tomography (MDCT) followed selectively by laparoscopy at 3 months after a cholecystectomy. Data were collected from a prospectively held database. The peri-operative and long-term outcomes of patients were analysed. SPSS software was used for statistical analysis. Results There were 38 pT2 and 11 pT3 tumours. After delayed staging, 24/49 (49%) patients underwent a radical resection, 24/49 (49%) were found to be inoperable on pre-operative assessment and 1/49 (2%) patient underwent an exploratory laparotomy and were found to be unresectable. The overall median survival from referral was 20.7 months (54.8 months for the group who had a radical re-resection versus 9.7 months for the group who had unresectable disease, P < 0.001). These results compare favourably with the reported outcome of fast-track management for incidental pT2-T3 gallbladder cancer from other major series in the literature. Conclusion Delayed staging in patients with incidental T2-T3 gallbladder cancer after a cholecystectomy is a useful strategy to select patients who will benefit from a resection and avoid unnecessary major surgery. PMID:23458168

Probe Measures Fouling As In Heat Exchangers

NASA Technical Reports Server (NTRS)

Marner, Wilbur J.; Macdavid, Kenton S.

1990-01-01

Combustion deposits reduce transfer of heat. Instrument measures fouling like that on gas side of heat exchanger in direct-fired boiler or heat-recovery system. Heat-flux probe includes tube with embedded meter in outer shell. Combustion gases flow over probe, and fouling accumulates on it, just as fouling would on heat exchanger. Embedded heat-flow meter is sandwich structure in which thin Chromel layers and middle alloy form thermopile. Users determine when fouling approaches unacceptable levels so they schedule cleaning and avoid decreased transfer of heat and increased drop in pressure fouling causes. Avoids cost of premature, unnecessary maintenance.

A Case of Munchausen Syndrome Presenting with Hematemesis: A Case Report

PubMed Central

Aadil, Muhammad; Faraz, Aniqa; Anwar, Muhammad Jahanzaib; Nasir, Usama; Akhlaq, Anum

2017-01-01

Munchausen syndrome (MS) was first reported in 1951 by Richard Alan John Asher as a factitious disorder. It is a condition in which the patient intentionally produces symptoms to assume a sick role and gain medical attention. Underdiagnosis of this disorder results in the unnecessary use of medical resources, i.e. unnecessary medical tests and evaluations. This makes it one of the most challenging diagnosis in any medical set up. We present this rare case of a patient with chronic factitious disorder who presented to the emergency with hematemesis. The patient was successfully treated with psychotherapy with no recurrence. It is the need of the hour to create awareness amongst the medical and nonmedical population about factitious disorders so that they can easily be diagnosed and treated with efficiency. Further research is needed to find the risks leading to this syndrome and discover the cultural and social aspects of this disease, which may help us explore treatment strategies and avoid unnecessary tests and treatment.​ PMID:28979830

Peritoneal drainage or laparotomy for neonatal bowel perforation? A randomized controlled trial.

PubMed

Rees, Clare M; Eaton, Simon; Kiely, Edward M; Wade, Angie M; McHugh, Kieran; Pierro, Agostino

2008-07-01

To determine whether primary peritoneal drainage improves survival and outcome of extremely low birth weight (ELBW) infants with intestinal perforation. Optimal surgical management of ELBW infants with intestinal perforation is unknown. An international multicenter randomized controlled trial was performed between 2002 and 2006. Inclusion criteria were birthweight >or=1000 g and pneumoperitoneum on x-ray (necrotizing enterocolitis or isolated perforation). Patients were randomized to peritoneal drain or laparotomy, minimizing differences in weight, gestation, ventilation, inotropes, platelets, country, and on-site surgical facilities. Patients randomized to drain were allowed to have a delayed laparotomy after at least 12 hours of no clinical improvement. Sixty-nine patients were randomized (35 drain, 34 laparotomy); 1 subsequently withdrew consent. Six-month survival was 18/35 (51.4%) with a drain and 21/33 (63.6%) with laparotomy (P = 0.3; difference 12% 95% CI, -11, 34%). Cox regression analysis showed no significant difference between groups (hazard ratio for primary drain 1.6; P = 0.3; 95% CI, 0.7-3.4). Delayed laparotomy was performed in 26/35 (74%) patients after a median of 2.5 days (range, 0.4-21) and did not improve 6-month survival compared with primary laparotomy (relative risk of mortality 1.4; P = 0.4; 95% CI, 0.6-3.4). Drain was effective as a definitive treatment in only 4/35 (11%) surviving neonates, the rest either had a delayed laparotomy or died. Seventy-four percent of neonates treated with primary peritoneal drainage required delayed laparotomy. There were no significant differences in outcomes between the 2 randomization groups. Primary peritoneal drainage is ineffective as either a temporising measure or definitive treatment. If a drain is inserted, a timely "rescue" laparotomy should be considered. Trial registration number ISRCTN18282954; http://isrctn.org/

Focusing a Transition: A Report by the Defense Business Board

DTIC Science & Technology

2009-01-01

2. NEAR-TERM OBSTACLES THAT COULD HAMPER LONG -TERM SUCCESS .................................................................25 Lowering the Overhead...requiring immediate att ention, (2) near-term obstacles that could hamper long -term success, (3) organizational issues for the Department to address for...begin early – long before January 20th - to avoid major leadership gaps (see Figure 1-2) and unnecessary vulnerabilities to the Department. Department

How to Handle Difficult Parents: Proven Solutions for Teachers. Second Edition

ERIC Educational Resources Information Center

Tingley, Suzanne Capek

2012-01-01

"How to Handle Difficult Parents" is a funny, but practical, guide to working effectively with parents and avoiding unnecessary conflict. Whether you're a teacher (regular or special education) or a coach, this book will give you practical suggestions regarding what to say and how to say it to parents who question your lesson plans, challenge your…

Alternative Fuels Data Center: Techniques for Drivers to Conserve Fuel

Science.gov Websites

techniques to save fuel and money. The amount of fuel your vehicle consumes depends heavily on how you drive and money. Vehicles use the most energy when accelerating. Using cruise control on the highway can trips can save you time and money by avoiding unnecessary stopping and starting of your vehicle, which

[Herpes zoster infection with acute urinary retention].

PubMed

Jakab, G; Komoly, S; Juhász, E

1990-03-11

The history of a young female patient is presented. She developed urine retention of sudden onset as a complication of herpes zoster infection manifested in the sacral dermatomes. Symptomatic and antiviral treatments were introduced with full recovery of bladder function. The correct diagnosis of this rare and benign complication of herpes zoster infection can help to avoid unnecessary and invasive examinations.

Laparotomy findings in lymphangiogram-staged I and non-Hodgkin's lymphomas.

PubMed

Heifetz, L J; Fuller, L M; Rodgers, R W; Martin, R G; Butler, J J; North, L B; Gamble, J F; Shullenberger, C C

1980-06-01

Ninety patients with Stage I or II, including extranodal (E), presentations of non-Hodkin's lymphoma were investigated by laparotomy, either for the definitive staging of patients with peripheral presentations or for diagnosis of abdominal disease. Sixty-eight patients had staging laparotomies after extensive work-up, which included lymphangiography and bone marrow biopsy. The remaining 22 patients had laparotomies for diagnosis of abdominal symptoms or for management of unrelated surgical problems, with lyphoma being found incidentally. The incidence of positive abdominal findings in the 68 patients who had staging laparotomies depended on histologic subtype. In nodular lymphoma patients, abdominal disease was found in 17 of 28 (61%) and in diffuse lymphoma patients, in 9 of 40 (22.5%). For patients with nodular lymphomas upstaged by laparotomy, the positive findings tended to cluster around an axis consisting of the celiac, porta-hepatic, para-aortic, and root of the mesentery lymph nodes. In addition, 64% of these patients had splenic involvement. For the diffuse lymphoma upstaged by laparotomy, the distribution of positive findings was similar to that of the nodular lymphoma group; however, only 1 patient had splenic involvement. By contrast, in approximately half of the diffuse lymphoma patients who had laparotomies for diagnosis, the gastrointestinal tract was found to be involved in addition to the previously cited lymph nodes.

The Hundred Person Wellness Project and Google's Baseline Study: medical revolution or unnecessary and potentially harmful over-testing?

PubMed

Diamandis, Eleftherios P

2015-01-09

The Hundred Person Wellness Project is an ambitious pilot undertaking, which aims to intensely monitor 100 individuals over 10 months. Patients with abnormal findings will be treated, in hopes that this early intervention will avoid, or delay, symptomatic disease. Google's "Baseline Study" is of similar scope and will enroll 10,000 people over 2 to 3 years. I here speculate that these approaches will likely not be effective in preventing disease, but instead, lead to unnecessary and potentially harmful interventions. Examples from the cancer screening experience over the last 30 years are provided, which show that intensive testing may uncover indolent disease or incidental findings which, when treated, may cause more harm than good. Additional examples show that aggressive treatments for cancer and other diseases do not always lead to better patient outcomes. I conclude that the recent advances in omics provide us with unprecedented opportunities for high content clinical testing, but such testing should be used with caution to avoid the harmful consequences of over-diagnosis and over-treatment. Despite the detailed rebuttals by Hood and colleagues in another commentary in BMC Medicine, time will show the actual benefits and harms of these ambitious initiatives.

Costs and benefits of rapid screening of methicillin-resistant Staphylococcus aureus carriage in intensive care units: a prospective multicenter study

PubMed Central

2012-01-01

Introduction Pre-emptive isolation of suspected methicillin-resistant Staphylococcus aureus (MRSA) carriers is a cornerstone of successful MRSA control policies. Implementation of such strategies is hampered when using conventional cultures with diagnostic delays of three to five days, as many non-carriers remain unnecessarily isolated. Rapid diagnostic testing (RDT) reduces the amount of unnecessary isolation days, but costs and benefits have not been accurately determined in intensive care units (ICUs). Methods Embedded in a multi-center hospital-wide study in 12 Dutch hospitals we quantified cost per isolation day avoided using RDT for MRSA, added to conventional cultures, in ICUs. BD GeneOhm™ MRSA PCR (IDI) and Xpert MRSA (GeneXpert) were subsequently used during 17 and 14 months, and their test characteristics were calculated with conventional culture results as reference. We calculated the number of pre-emptive isolation days avoided and incremental costs of adding RDT. Results A total of 163 patients at risk for MRSA carriage were screened and MRSA prevalence was 3.1% (n = 5). Duration of isolation was 27.6 and 21.4 hours with IDI and GeneXpert, respectively, and would have been 96.0 hours when based on conventional cultures. The negative predictive value was 100% for both tests. Numbers of isolation days were reduced by 44.3% with PCR-based screening at the additional costs of €327.84 (IDI) and €252.14 (GeneXpert) per patient screened. Costs per isolation day avoided were €136.04 (IDI) and €121.76 (GeneXpert). Conclusions In a low endemic setting for MRSA, RDT safely reduced the number of unnecessary isolation days on ICUs by 44%, at the costs of €121.76 to €136.04 per isolation day avoided. PMID:22314204

Rectus sheath hematoma caused by non-contact strenuous exercise mimicking acute appendicitis.

PubMed

Oh, Je Hyeok; Kim, Tae Han; Cha, Sung Jae; Kim, Seung Ho

2010-09-01

A healthy 26-year-old man visited the Emergency Department due to right lower quadrant pain of 2 days' duration that developed after wakeboarding. There was no history of direct trauma to the abdomen. Physical examination revealed tenderness and rebound tenderness on the right lower quadrant area. There was no palpable abdominal mass. Computed tomography (CT) of the abdomen was undertaken to discern the causes of acute abdomen, including acute appendicitis. CT revealed a small-size rectus sheath hematoma beneath the lower end of the right rectus muscle. The patient was admitted for supportive care including pain control and was discharged with improvement after 5 days. Rectus sheath hematoma can be caused by not only a direct blow but also non-contact strenuous exercise, for example, wakeboarding in this case. Although the majority of rectus sheath hematomas are self-limiting, some can cause peritoneal irritation signs, mimicking acute abdomen, and eventually lead to unnecessary laparotomy without clinical suspicion and ancillary tests including CT scan and ultrasonography. Copyright © 2010 Elsevier Inc. All rights reserved.

Amnion-Derived Multipotent Progenitor Cells Increase Gain of Incisional Breaking Strength and Decrease Incidence and Severity of Acute Wound Failure

PubMed Central

Xing, Liyu; Franz, Michael G.; Marcelo, Cynthia L.; Smith, Charlotte A.; Marshall, Vivienne S.; Robson, Martin C.

2007-01-01

Objective: Acute wound failure is a common complication following surgical procedures and trauma. Laparotomy wound failure leads to abdominal dehiscence and incisional hernia formation. Delayed recovery of wound-breaking strength is one mechanism for laparotomy wound failure. Early fascial wounds are relatively acellular, and there is a delay in the appearance of acute wound growth factors and cytokines. The objective of this study was to accelerate and improve laparotomy wound healing using amnion-derived multipotent cells (AMPs). AMPs' nonimmunogenic phenotype and relative abundance support its role as a cell therapy. Methods: AMPs were injected into the load-bearing layer of rat abdominal walls prior to laparotomy, and cell viability was confirmed. Wound mechanical properties were measured over 28 days. The incidence and severity of laparotomy wound failure was measured in an incisional hernia model. Results: AMP cells were viable in laparotomy wounds for at least 28 days and did not migrate to other tissues. Laparotomy wound-breaking strength was increased by postoperative day 7 following AMP therapy. AMP therapy reduced the incidence of hernia formation and the size of hernia defects. Histology suggested stimulated wound fibroplasia and angiogenesis. Conclusions: AMP cell therapy reduces the incidence of laparotomy wound failure by accelerating the recovery of wound-breaking strength. This results in fewer incisional hernias and smaller hernia defects. PMID:18091982

Treatment philosophy and retreatment rates following piezoelectric lithotripsy.

PubMed

Fegan, J; Camp, L A; Wilson, W T; Miller, G L; Preminger, G M

1993-01-01

Second generation lithotriptors offer the advantage of anesthesia-free fragmentation of renal and ureteral calculi but they frequently require multiple treatments to attain a stone-free status. However, excessive single lithotripsy sessions or multiple treatments may be associated with significant damage to the kidney. For some clinicians a common treatment philosophy involves evaluation of serial plain abdominal films every 24 hours after lithotripsy and immediate retreatment of all patients with incomplete fragmentation. To avoid unnecessary retreatments and, thus, minimize potential renal damage, we prospectively evaluated 100 patients undergoing lithotripsy on a Wolf Piezolith 2300 device. Patients were routinely treated with 4,000 shocks at 1,100 bar. Serial plain abdominal films were obtained at 1 day and 2 weeks after lithotripsy. The need for retreatment was determined by the plain abdominal film results. Additional therapy was considered necessary if there was no stone fragmentation or if residual fragments measured greater than 4 mm. Of the patients whose plain abdominal film at 24 hours indicated the need for a repeat treatment 43% were stone-free on the 2-week film. Thus, these patients were spared an unnecessary treatment by allowing adequate time for the stone fragments to pass spontaneously. Our data suggest that repeat treatments on second generation lithotriptors should not be performed within 24 hours. Rather, the patient should be reevaluated at least 1 to 2 weeks later to avoid unnecessary retreatment with the attendant potential for renal injury. In addition, when comparing the retreatment rates of various lithotriptors, one should also consider the treatment philosophy used at the particular institution and the timing of the radiographic studies used to determine the stone-free status.

Age-Specific Cutoff Value for the Application of Percent Free Prostate-Specific Antigen (PSA) in Chinese Men with Serum PSA Levels of 4.0-10.0 ng/ml.

PubMed

Chen, Rui; Huang, Yiran; Cai, Xiaobing; Xie, Liping; He, Dalin; Zhou, Liqun; Xu, Chuanliang; Gao, Xu; Ren, Shancheng; Wang, Fubo; Ma, Lulin; Wei, Qiang; Yin, Changjun; Tian, Ye; Sun, Zhongquan; Fu, Qiang; Ding, Qiang; Zheng, Junhua; Ye, Zhangqun; Ye, Dingwei; Xu, Danfeng; Hou, Jianquan; Xu, Kexin; Yuan, Jianlin; Gao, Xin; Liu, Chunxiao; Pan, Tiejun; Sun, Yinghao

2015-01-01

The influence of age on the performance of percent free prostate-specific antigen (%fPSA) in diagnosing prostate cancer (PCa) in East Asians is controversial. We tested the diagnostic performance of %fPSA in a multi-center biopsy cohort in China and identified the proper age-specific cutoff values to avoid unnecessary biopsies. Consecutive patients with a prostate-specific antigen (PSA) level of 4.0-10.0 ng/ml or 10.1-20.0 ng/ml who underwent transrectal ultrasound-guided or transperineal prostate biopsy were enrolled from 22 Chinese medical centers from Jan 1, 2010 to Dec 31, 2013. The diagnostic accuracy of PSA and %fPSA was determined using the area under the receiver operating characteristic (ROC) curve (AUC). Age-specific cutoff values were calculated using ROC curve analysis. The median %fPSA was much lower in younger patients compared with older patients with a PSA level of 4.0-10.0 ng/ml or 10.1-20.0 ng/ml. The AUC of %fPSA was higher than PSA only in older patients. In patients aged 50 to 59 years, %fPSA failed to improve the diagnosis compared with PSA in these two PSA ranges. Age-specific cutoff values were 24%, 27% and 32% for patients aged 60-69, 70-79 and ≥80 years, respectively, to reduce unnecessary biopsies in men with PSA levels of 4.0-10.0 ng/ml to detect 90% of all PCa. The effectiveness of %fPSA is correlated with age in the Chinese population. Age-specific cutoff values would help avoid unnecessary biopsies in the Chinese population.

Age-Specific Cutoff Value for the Application of Percent Free Prostate-Specific Antigen (PSA) in Chinese Men with Serum PSA Levels of 4.0–10.0 ng/ml

PubMed Central

Xie, Liping; He, Dalin; Zhou, Liqun; Xu, Chuanliang; Gao, Xu; Ren, Shancheng; Wang, Fubo; Ma, Lulin; Wei, Qiang; Yin, Changjun; Tian, Ye; Sun, Zhongquan; Fu, Qiang; Ding, Qiang; Zheng, Junhua; Ye, Zhangqun; Ye, Dingwei; Xu, Danfeng; Hou, Jianquan; Xu, Kexin; Yuan, Jianlin; Gao, Xin; Liu, Chunxiao; Pan, Tiejun; Sun, Yinghao

2015-01-01

Objective The influence of age on the performance of percent free prostate-specific antigen (%fPSA) in diagnosing prostate cancer (PCa) in East Asians is controversial. We tested the diagnostic performance of %fPSA in a multi-center biopsy cohort in China and identified the proper age-specific cutoff values to avoid unnecessary biopsies. Methods Consecutive patients with a prostate-specific antigen (PSA) level of 4.0–10.0 ng/ml or 10.1–20.0 ng/ml who underwent transrectal ultrasound-guided or transperineal prostate biopsy were enrolled from 22 Chinese medical centers from Jan 1, 2010 to Dec 31, 2013. The diagnostic accuracy of PSA and %fPSA was determined using the area under the receiver operating characteristic (ROC) curve (AUC). Age-specific cutoff values were calculated using ROC curve analysis. Results The median %fPSA was much lower in younger patients compared with older patients with a PSA level of 4.0–10.0 ng/ml or 10.1–20.0 ng/ml. The AUC of %fPSA was higher than PSA only in older patients. In patients aged 50 to 59 years, %fPSA failed to improve the diagnosis compared with PSA in these two PSA ranges. Age-specific cutoff values were 24%, 27% and 32% for patients aged 60–69, 70–79 and ≥80 years, respectively, to reduce unnecessary biopsies in men with PSA levels of 4.0–10.0 ng/ml to detect 90% of all PCa. Conclusions The effectiveness of %fPSA is correlated with age in the Chinese population. Age-specific cutoff values would help avoid unnecessary biopsies in the Chinese population. PMID:26091007

Autoimmune pancreatitis associated with renal lesions mimicking metastatic tumours

PubMed Central

Rudmik, Lucas; Trpkov, Kiril; Nash, Carla; Kinnear, Susan; Falck, Vincent; Dushinski, John; Dixon, Elijah

2006-01-01

Autoimmune pancreatitis is a chronic inflammatory disorder that is often misdiagnosed as pancreatic cancer. Since autoimmune pancreatitis is benign and responds to steroid management, it is important to diagnose it to avoid unnecessary surgical intervention. We describe a novel case of IgG4-associated autoimmune pancreatitis presenting with tubulointerstitial nephritis as renal lesions mimicking metastatic tumours but with no change in renal function. PMID:16908897

Endobronchial Ultrasound (EBUS) - Update 2017.

PubMed

Darwiche, Kaid; Özkan, Filiz; Wolters, Celina; Eisenmann, Stephan

2018-02-01

Endobronchial ultrasound (EBUS) has revolutionized the diagnosis of lung cancer over the last decade. This minimally invasive diagnostic method has also become increasingly important in the case of other diseases such as sarcoidosis, thereby helping to avoid unnecessary diagnostic interventions. This review article provides an update regarding EBUS and discusses current and future developments of this method. © Georg Thieme Verlag KG Stuttgart · New York.

[Prevention and multimodal therapy of hyperthyroidism].

PubMed

Palitzsch, K-D

2008-12-01

Subclinical and overt hyperthyroidism have been associated with various negative clinical outcomes as for example an increased risk of atrial fibrillation or increased cardiovascular mortality, especially in old age. In order to avoid hyperthyroidism it is strongly recommended not to start any iodine containing drug therapy or to avoid application of contrast agents unless the patient presents with an unremarkable clinical course. TSH suppressive therapy for the treatment of endemic goiter or differentiated low risk thyroid carcinoma is unnecessary, since it favours the development of subclinical hyperthyroidism. Overt hyperthyroidism is treated with antithyroid drugs and/or radioiodine therapy or surgery according to the underlying disease (toxic nodular goiter, Graves' disease).

Correcting prominent ears with the island technique.

PubMed

DeMoura, L F

1977-01-01

A surgical procedure is described which corrects the ansiform ear by repositioning and reconstructing the anthelix and the anterior crus with the formation of the triangular fossa. This corrects the scaphoconchal angle and improves the cephaloauricular angle, overcoming the problem of prominent ears. Correction in early childhood is recommended in order to avoid personality problems that may result from the deformity, particularly in boys. The technique employed yields important advantages: (1) prolonged use of the helmet-type of surgical dressing is unnecessary; (2) scars are less conspicuous; (3) the outcome is attractive and normal; (4) bleeding and inflammatory complications are avoided; and (5) recurrence of the malformation is unlikely.

A Case of Familial Mediterranean Fever Having Intermittent Leukopenia.

PubMed

Beyitler, Ilke; Kavukcu, Salih

2018-03-01

Familial Mediterranean fever (FMF) is a genetically inherited autoinflammatory disorder characterized by inflammatory attacks and may result in amyloidosis as a severe complication. Elevation of acute phase reactants, including leukocytosis, is seen during attack periods. Here we describe a 13-year-old female patient with a very rare clinical presentation of FMF, who would experience FMF attacks when she did not regularly take her colchicine. During these attacks she had leukopenia and neutropenia instead of leukocytosis. The leukocyte count returned to normal when she continued the medication and avoided attacks. Ethnicity and clinical signs are important in leukopenic patientsand should be investigated for FMF to avoid unnecessary procedures and complications.

Current UK practice in emergency laparotomy

PubMed Central

Barrow, E; Varley, S; Pichel, AC; Peden, CJ; Saunders, DI; Murray, D

2013-01-01

Introduction Emergency laparotomy is a common procedure, with 30,000–50,000 performed annually in the UK. This large scale study reports the current spectrum of emergency laparotomies, and the influence of the surgical procedure, underlying pathology and subspecialty of the operating surgeon on mortality. Methods Anonymised data on consecutive patients undergoing an emergency laparotomy were submitted for a three-month period. The primary outcome measure was unadjusted 30-day mortality. Appendicectomy and cholecystectomy were among the procedures excluded. Results Data from 1,708 patients from 35 National Health Service hospitals were analysed. The overall 30-day mortality rate was 14.8%. ‘True’ emergency laparotomies (ie those classified by the National Confidential Enquiry into Patient Outcome and Death as immediate or urgent) comprised 86.5% of cases. The mortality rate rose from 8.0% among expedited cases to 14.3% among urgent cases and to 25.7% among laparotomies termed immediate. Among the most common index procedures, small bowel resection exhibited the highest 30-day mortality rate of 21.1%. The presence of abdominal sepsis was associated with raised 30-day mortality (17.5% in the presence of sepsis vs 12.6%, p=0.027). Colorectal procedures comprised 44.3% and within this group, data suggest that mortality from laparotomy may be influenced by surgical subspecialisation. Conclusions This report of a large number of patients undergoing emergency laparotomy in the UK confirms a remarkably high mortality by modern standards across the range. Very few pathologies or procedures can be considered anything other than high risk. The need for routine consultant involvement and critical care is evident, and the case distribution helps define the surgical skill set needed for a modern emergency laparotomy service. Preliminary data relating outcomes from emergency colonic surgery to surgical subspecialty require urgent further study. PMID:24165345

Current UK practice in emergency laparotomy.

PubMed

Barrow, E; Anderson, I D; Varley, S; Pichel, A C; Peden, C J; Saunders, D I; Murray, D

2013-11-01

Emergency laparotomy is a common procedure, with 30,000-50,000 performed annually in the UK. This large scale study reports the current spectrum of emergency laparotomies, and the influence of the surgical procedure, underlying pathology and subspecialty of the operating surgeon on mortality. Anonymised data on consecutive patients undergoing an emergency laparotomy were submitted for a three-month period. The primary outcome measure was unadjusted 30-day mortality. Appendicectomy and cholecystectomy were among the procedures excluded. Data from 1,708 patients from 35 National Health Service hospitals were analysed. The overall 30-day mortality rate was 14.8%. 'True' emergency laparotomies (ie those classified by the National Confidential Enquiry into Patient Outcome and Death as immediate or urgent) comprised 86.5% of cases. The mortality rate rose from 8.0% among expedited cases to 14.3% among urgent cases and to 25.7% among laparotomies termed immediate. Among the most common index procedures, small bowel resection exhibited the highest 30-day mortality rate of 21.1%. The presence of abdominal sepsis was associated with raised 30-day mortality (17.5% in the presence of sepsis vs 12.6%, p=0.027). Colorectal procedures comprised 44.3% and within this group, data suggest that mortality from laparotomy may be influenced by surgical subspecialisation. This report of a large number of patients undergoing emergency laparotomy in the UK confirms a remarkably high mortality by modern standards across the range. Very few pathologies or procedures can be considered anything other than high risk. The need for routine consultant involvement and critical care is evident, and the case distribution helps define the surgical skill set needed for a modern emergency laparotomy service. Preliminary data relating outcomes from emergency colonic surgery to surgical subspecialty require urgent further study.

LAPAROSCOPY AFTER PREVIOUS LAPAROTOMY

PubMed Central

Godinjak, Zulfo; Idrizbegović, Edin; Begić, Kerim

2006-01-01

Following the abdominal surgery, extensive adhesions often occur and they can cause difficulties during laparoscopic operations. However, previous laparotomy is not considered to be a contraindication for lap-aroscopy. The aim of this study is to present that an insertion of Veres needle in the region of umbilicus is a safe method for creating a pneumoperitoneum for laparoscopic operations after previous laparotomy. In the last three years, we have performed 144 laparoscopic operations in patients that previously underwent one or two laparotomies. Pathology of digestive system, genital organs, Cesarean Section or abdominal war injuries were the most common causes of previous laparotomy. During those operations or during entering into abdominal cavity we have not experienced any complications, while in 7 patients we performed conversion to laparotomy following the diagnostic laparoscopy. In all patients an insertion of Veres needle and trocar insertion in the umbilical region was performed, namely a technique of closed laparoscopy. Not even in one patient adhesions in the region of umbilicus were found, and no abdominal organs were injured. PMID:17177649

Triple ectopic thyroid: A rare entity

PubMed Central

Nilegaonkar, Sujit; Naik, Chetna; Sonar, Sameer; Hirawe, Deepti

2011-01-01

Ectopic thyroid tissue is an uncommon congenital aberration. It is extremely rare to have three ectopic foci at three different sites. The thyroid scan has been used successfully to diagnose ectopic thyroid tissue. We report a case of ectopic thyroid tissue at base of tongue, another at the level of hyoid and third one as aberrant tissue at suprahyoid location in a 16 year old female who presented with swelling in front of neck. This patient was clinically diagnosed as thyroglossal cyst and was being planned for surgery. Preoperative thyroid scan helped in establishing diagnosis of ectopic thyroid which was the only functioning thyroid tissue. Thus, it prevented unnecessary surgery. Therefore it is suggested that thyroid scan and USG/CT scan must be done as routine work up in neck swellings pre operatively to avoid unnecessary surgeries. PMID:23559716

A space efficient flexible pivot selection approach to evaluate determinant and inverse of a matrix.

PubMed

Jafree, Hafsa Athar; Imtiaz, Muhammad; Inayatullah, Syed; Khan, Fozia Hanif; Nizami, Tajuddin

2014-01-01

This paper presents new simple approaches for evaluating determinant and inverse of a matrix. The choice of pivot selection has been kept arbitrary thus they reduce the error while solving an ill conditioned system. Computation of determinant of a matrix has been made more efficient by saving unnecessary data storage and also by reducing the order of the matrix at each iteration, while dictionary notation [1] has been incorporated for computing the matrix inverse thereby saving unnecessary calculations. These algorithms are highly class room oriented, easy to use and implemented by students. By taking the advantage of flexibility in pivot selection, one may easily avoid development of the fractions by most. Unlike the matrix inversion method [2] and [3], the presented algorithms obviate the use of permutations and inverse permutations.

Prevention of healthcare-associated infections in neonates: room for improvement.

PubMed

Legeay, C; Bourigault, C; Lepelletier, D; Zahar, J R

2015-04-01

Infants in neonatal intensive care units (NICUs) are highly susceptible to infection due to the immaturity of their immune systems. Healthcare-associated infections (HCAIs) are associated with prolonged hospital stay, and represent a significant risk factor for neurological development problems and death. Improving HCAI control is a priority for NICUs. Many factors contribute to the occurrence of HCAIs in neonates such as poor hand hygiene, low nurse-infant ratios, environmental contamination and unnecessary use of antibiotics. Prevention is based on improving neonatal management, avoiding unnecessary use of central venous catheters, restricting use of antibiotics and H2 blockers, and introducing antifungal prophylaxis if necessary. Quality improvement interventions to reduce HCAIs in neonates seem to be the cornerstone of infection control. Copyright © 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

The trephine colostomy: a permanent left iliac fossa end colostomy without recourse to laparotomy.

PubMed Central

Senapati, A.; Phillips, R. K.

1991-01-01

An operative technique for performing a permanent end sigmoid colostomy without recourse to laparotomy is presented. The results from 16 patients have shown a very low morbidity. The technique was unsuccessful in three patients, each needing a formal laparotomy. PMID:1929133

Is laparoscopy equal to laparotomy in detecting and treating small bowel injuries in a porcine model?

PubMed Central

Shan, Cheng-Xiang; Ni, Chong; Qiu, Ming; Jiang, Dao-Zhen

2012-01-01

AIM: To evaluate the safety and effectiveness of laparoscopy compared with laparotomy for diagnosing and treating small bowel injuries (SBIs) in a porcine model. METHODS: Twenty-eight female pigs were anesthetized and laid in the left recumbent position. The SBI model was established by shooting at the right lower quadrant of the abdomen. The pigs were then randomized into either the laparotomy group or the laparoscopy group. All pigs underwent routine exploratory laparotomy or laparoscopy to evaluate the abdominal injuries, particularly the types, sites, and numbers of SBIs. Traditional open surgery or therapeutic laparoscopy was then performed. All pigs were kept alive within the observational period (postoperative 72 h). The postoperative recovery of each pig was carefully observed. RESULTS: The vital signs of all pigs were stable within 1-2 h after shooting and none of the pigs died from gunshot wounds or SBIs immediately. The SBI model was successfully established in all pigs and definitively diagnosed with single or multiple SBIs either by exploratory laparotomy or laparoscopy. Compared with exploratory laparotomy, laparoscopy took a significantly longer time for diagnosis (41.27 ± 12.04 min vs 27.64 ± 13.32 min, P = 0.02), but the time for therapeutic laparoscopy was similar to that of open surgery. The length of incision was significantly reduced in the laparoscopy group compared with the laparotomy group (5.27 ± 1.86 cm vs 15.73 ± 1.06 cm, P < 0.01). In the final post-mortem examination 72 h after surgery, both laparotomy and laparoscopy offered a definitive diagnosis with no missed injuries. Postoperative complications occurred in four cases (three following laparotomy and one following laparoscopy, P = 0.326). The average recovery period for bowel function, vital appearance, and food re-intake after laparoscopy was 10.36 ± 4.72 h, 14.91 ± 3.14 h, and 15.00 ± 7.11 h, respectively. All of these were significantly shorter than after laparotomy (21.27 ± 10.17 h, P = 0.004; 27.82 ± 9.61 h, P < 0.001; and 24.55 ± 9.72 h, respectively, P = 0.016). CONCLUSION: Compared with laparotomy, laparoscopy offers equivalent efficacy for diagnosing and treating SBIs, and reduces postoperative complications as well as recovery period. PMID:23239924

The health fraud battle. Education is the best defense.

PubMed

Johnson, G C; Gottesman, R A

1989-06-01

Despite the regulatory and educational efforts of the Food and Drug Administration and other agencies and organizations, large numbers of American consumers continue to be fooled by unsubstantiated "miracle cure" claims made by manufacturers of fraudulent medical products. Physicians who are familiar with the language of health fraud advertising and product labels may be able to help patients avoid unnecessary expense, false hope, and physical and emotional harm.

Potential applications of prefield land use and canopy cover data: Examples from nonforest and nonsampled forest inventory plots

Treesearch

Sara A. Goeking

2012-01-01

The Forest Inventory and Analysis (FIA) prefield workflow involves interpreting aerial imagery to determine whether each plot in a given inventory year may meet FIA’s definition of forest land. The primary purpose of this determination is to minimize inventory costs by avoiding unnecessary ground surveys of plots that are obviously in nonforest areas. Since the...

Avoiding emergency department visits for COPD, pneumonia, and heart failure: when should patients go to the emergency department?

PubMed

Fritz, Deborah; McKenzie, Patricia

2014-01-01

Patients with pneumonia, chronic obstructive pulmonary disease (COPD), and heart failure make frequent visits to the emergency department. Heart failure alone is the reason for more than 1 million emergency department visits annually in the United States. This article describes strategies home care clinicians can use to prevent unnecessary emergency department visits for patients with pneumonia, COPD and heart failure.

MRI of the knee.

PubMed

Skinner, Sarah

2012-11-01

Magnetic resonance imaging (MRI) is the gold standard in noninvasive investigation of knee pain. It has a very high negative predictive value and may assist in avoiding unnecessary knee arthroscopy; its accuracy in the diagnosis of meniscal and anterior cruciate ligament (ACL) tears is greater than 89%; it has a greater than 90% sensitivity for the detection of medial meniscal tears; and it is probably better at assessing the posterior horn than arthroscopy.

Application of Optical Disc Databases and Related Technology to Public Access Settings

DTIC Science & Technology

1992-03-01

users to download and retain data. A Video Graphics Adapter (VGA) monitor was included. No printer was provided. 2. CD-ROM Product Computer Select, a...download facilities, without printer support, satisfy user needs? 38 A secondary, but significant, objective was avoidance of unnecessary Reader...design of User Log sheets and mitigated against attachment of a printer to the workstation. F. DATA COLLECTION This section describes the methodology

[Imaging center - optimization of the imaging process].

PubMed

Busch, H-P

2013-04-01

Hospitals around the world are under increasing pressure to optimize the economic efficiency of treatment processes. Imaging is responsible for a great part of the success but also of the costs of treatment. In routine work an excessive supply of imaging methods leads to an "as well as" strategy up to the limit of the capacity without critical reflection. Exams that have no predictable influence on the clinical outcome are an unjustified burden for the patient. They are useless and threaten the financial situation and existence of the hospital. In recent years the focus of process optimization was exclusively on the quality and efficiency of performed single examinations. In the future critical discussion of the effectiveness of single exams in relation to the clinical outcome will be more important. Unnecessary exams can be avoided, only if in addition to the optimization of single exams (efficiency) there is an optimization strategy for the total imaging process (efficiency and effectiveness). This requires a new definition of processes (Imaging Pathway), new structures for organization (Imaging Center) and a new kind of thinking on the part of the medical staff. Motivation has to be changed from gratification of performed exams to gratification of process quality (medical quality, service quality, economics), including the avoidance of additional (unnecessary) exams. © Georg Thieme Verlag KG Stuttgart · New York.

America's Opioid Epidemic: Supply and Demand Considerations.

PubMed

Clark, David J; Schumacher, Mark A

2017-11-01

America is in the midst of an opioid epidemic characterized by aggressive prescribing practices, highly prevalent opioid misuse, and rising rates of prescription and illicit opioid overdose-related deaths. Medical and lay public sentiment have become more cautious with respect to prescription opioid use in the past few years, but a comprehensive strategy to reduce our reliance on prescription opioids is lacking. Addressing this epidemic through reductions in unnecessary access to these drugs while implementing measures to reduce demand will be important components of any comprehensive solution. Key supply-side measures include avoiding overprescribing, reducing diversion, and discouraging misuse through changes in drug formulations. Important demand-side measures center around educating patients and clinicians regarding the pitfalls of opioid overuse and methods to avoid unnecessary exposure to these drugs. Anesthesiologists, by virtue of their expertise in the use of these drugs and their position in guiding opioid use around the time of surgery, have important roles to play in reducing patient exposure to opioids and providing education about appropriate use. Aside from the many immediate steps that can be taken, clinical and basic research directed at understanding the interaction between pain and opioid misuse is critical to identifying the optimal use of these powerful pain relievers in clinical practice.

Value of percutaneous needle biopsy of small renal tumors in patients referred for cryoablation.

PubMed

Iguchi, Toshihiro; Hiraki, Takao; Gobara, Hideo; Fujiwara, Hiroyasu; Sakurai, Jun; Matsui, Yusuke; Araki, Motoo; Nasu, Yasutomo; Kanazawa, Susumu

2017-04-01

To retrospectively evaluate the safety and diagnostic yield of needle biopsy of small renal tumors, and the clinical consequences of performing needle biopsy in patients referred for percutaneous cryoablation before their treatment. Biopsy was performed for 120 tumors (mean diameter, 2.2 cm) in 119 patients. All procedures were divided into diagnostic and non-diagnostic biopsies. Various variables were compared between the two groups. All cryoablation procedures were divided into two groups: procedures with or without simultaneous biopsy. The rates of benign or non-diagnostic tumors in each group were compared. After performing 120 initial and eight repeat biopsies, Grade 1 bleedings occurred in 44 cases. Six tumors were non-diagnostic and 114 were pathologically diagnosed. There were no significant variables between the diagnostic and non-diagnostic biopsies. Unnecessary cryoablation was avoided in nine benign lesions by performing biopsy in advance. Cryoablation performed simultaneously with biopsy included significantly more benign or non-diagnostic tumors than cryoablation performed after biopsy (15.2% vs. 1.4%; p = .01). Percutaneous biopsy of small renal tumors referred for cryoablation was a safe procedure with high diagnostic yield. The confirmation of pathological diagnosis prior to cryoablation is necessary because patients with benign tumors can avoid unnecessary treatment.

Measuring Outcomes of Clinical Care: Victorian Emergency Laparotomy Audit Using Quality Investigator.

PubMed

Stevens, Claire L; Brown, Christopher; Watters, David A K

2018-07-01

The Australian and New Zealand Audit of Surgical Mortality (ANZASM) National Report 2015 found that within the cohort of audited deaths, 85% were emergencies with acute life-threatening conditions, and by far, the most common procedures were laparotomy and colorectal procedures. Emergency laparotomy outcomes have shown improvement through audit and reporting in the UK. The purpose of this study was to determine the outcome of emergency laparotomy in the state of Victoria, Australia. The Dr Foster Quality Investigator (DFQI) database was interrogated for a set of Australian Classification of Health Intervention (ACHI) codes defined by the authors as representing an emergency laparotomy. The dataset included patients who underwent emergency laparotomy from July 2007 to July 2016 in all Victorian hospitals. There were 23,115 emergency laparotomies conducted over 9 years in 66 hospitals. Inpatient mortality was 2036/23,115 (8.8%). Mortality in the adult population increased with age and reached 18.1% in those patients that were 80 years or older. 51.3% were females, and there was no significant difference in survival between genders. Patients with no recorded comorbidities had a mortality of 4.3%, whereas those with > 5 comorbidities had 19.3% mortality. Administrative data accessed via a tool such as DFQI can provide useful population data to guide further evidence-based improvement strategies. The mortality for emergency laparotomy within Victorian hospitals is comparable, if not better than that seen in overseas studies. There is a need to continue routine audit of mortality rates and implement systems improvement where necessary.

Multimodal analgesia in abdominal sepsis: a case report of liposome bupivacaine in ultrasound-guided rectus sheath blocks after unexpected open hemi-colectomy.

PubMed

Patzkowski, Michael S; Stevens, Gregory

2015-06-01

Contrasted with open laparotomy, the risk-benefit ratio of epidural anesthesia in laparoscopic surgery frequently disfavors its use. The presence of abdominal sepsis also affects utilization with concerns about the risks of epidural abscess and hypotension. In the unplanned conversion to open laparotomy, postoperative pain control becomes more difficult. We discuss utilization of rectus sheath blocks with liposome bupivacaine as a component of multimodal analgesia in a patient with abdominal sepsis from a perforated appendix. A 33-year-old healthy male Soldier presented with a perforated appendix. Treatment consisted of urgent laparoscopic appendectomy that was subsequently converted to an open right hemicolectomy. Bilateral rectus sheath blocks were performed with liposome bupivacaine before awakening to mitigate postoperative pain. The patient reported mild postoperative pain scores, was able to ambulate comfortably on the day of surgery, and had early return of bowel function. This case describes rectus sheath blocks with liposomal bupivacaine for postoperative pain control and to hasten functional recovery following an unplanned conversion to open hemicolectomy. This application provided many of the benefits of epidural analgesia while avoiding some of its most serious risks, making it a valuable analgesic option for the patient with abdominal sepsis. Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.

[Risk management for endoscopic surgery].

PubMed

Kimura, Taizo

2010-05-01

The number of medical accidents in endoscopic surgery has recently increased. Surgical complications caused by inadequate preparation or immature technique or those resulting in serious adverse outcomes may be referred to as medical accidents. The Nationwide Survey of Endoscopic Surgery showed that bile duct injury and uncontrollable bleeding were seen in 0.68% and in 0.58%, respectively, of cholecystectomy patients; interoperative and postoperative complications in 0.84% and in 3.8%, respectively, of gastric cancer surgery patients; and operative complications in 6.74% of bowel surgery patients. Some required open repair, and 49 patients died. The characteristic causes of complications in endoscopic surgery are a misunderstanding of anatomy, handling of organs outside the visual field, burn by electrocautery, and injuries caused by forceps. Bleeding that requires a laparotomy for hemostasis is also a complication. Furthermore, since the surgery is usually videorecorded, immature techniques resulting in complications are easily discovered. To decrease the frequency of accidents, education through textbooks and seminars, training using training boxes, simulators, or animals, proper selection of the surgeon depending on the difficulty of the procedure, a low threshold for conversion to laparotomy, and use of the best optical equipment and surgical instruments are important. To avoid malpractice lawsuits, informed consent obtained before surgery and proper communication after accidents are necessary.

Comparison of perioperative outcomes and cost of robotic-assisted laparoscopy, laparoscopy and laparotomy for endometrial cancer.

PubMed

Coronado, Pluvio J; Herraiz, Miguel A; Magrina, Javier F; Fasero, María; Vidart, Jose A

2012-12-01

To analyze the perioperative outcomes and cost of three surgical approaches in the treatment of endometrial cancer: robotic, laparoscopy and laparotomy. We studied 347 patients with endometrial cancer treated in a single institution: 71 patients were operated by robotics, 84 by conventional laparoscopy and 192 by laparotomy. All patients underwent total hysterectomy, bilateral salpingoophorectomy and pelvic and para-aortic lymphadenectomy depending on the pathological features. Operative time was longer in the laparoscopy group as compared to robotics and laparotomy (218.2 min, 189.2 min, and 157.4 min respectively, p=0.000). The estimated blood loss was lower in the robotic group relative to the other groups (99.4 ml in robotic, 190.0 ml in laparoscopy and 231.5 ml in laparotomy, p=0.000). Similar findings were observed for the pre- and post-operative mean hemoglobin levels (-1.3g/dl, -2.3g/dl and -2.5 g/dl respectively, p=0.000), and transfusion rate (4.2%, 7.1% and 14.1% respectively, p=0.036). The length of hospital stay was higher in the laparotomy group compared to robotics and laparoscopy (8.1, 3.5 and 4.6 days respectively; p=0.000). The conversion rate to laparotomy was lower for robotics (2.4% for robotics and 8.1% for laparoscopy, p=0.181). Overall complications were similar for robotics and laparoscopy (21.1%, 28.5%) (p=0.079). Robotic complications were significantly lower as compared to laparotomy (21.2 vs 34.9% (p=0.036). No differences were found relative to disease-free or overall survival among the three groups. The global costs were similar for the three approaches (p=0.566). Robotics is a safe alternative to laparoscopy and laparotomy for endometrial cancer patients, offering improved perioperative outcomes and similar cost as compared to the other two surgical approaches. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

An Efficient Two-Tier Causal Protocol for Mobile Distributed Systems

PubMed Central

Dominguez, Eduardo Lopez; Pomares Hernandez, Saul E.; Gomez, Gustavo Rodriguez; Medina, Maria Auxilio

2013-01-01

Causal ordering is a useful tool for mobile distributed systems (MDS) to reduce the non-determinism induced by three main aspects: host mobility, asynchronous execution, and unpredictable communication delays. Several causal protocols for MDS exist. Most of them, in order to reduce the overhead and the computational cost over wireless channels and mobile hosts (MH), ensure causal ordering at and according to the causal view of the Base Stations. Nevertheless, these protocols introduce certain disadvantage, such as unnecessary inhibition at the delivery of messages. In this paper, we present an efficient causal protocol for groupware that satisfies the MDS's constraints, avoiding unnecessary inhibitions and ensuring the causal delivery based on the view of the MHs. One interesting aspect of our protocol is that it dynamically adapts the causal information attached to each message based on the number of messages with immediate dependency relation, and this is not directly proportional to the number of MHs. PMID:23585828

Not all pustules are infective in nature: acute generalised exanthematous pustulosis causing pustular eruptions in an elderly woman.

PubMed

Kwah, Y C; Leow, Y H

2005-07-01

Acute generalised exanthematous pustulosis (AGEP) is an adverse drug reaction that can occur in any age group. It is commonly mistaken as pustular psoriasis or cutaneous infection, resulting in unnecessary commencement of medications such as methotrexate and antibiotics that can cause harm to the patient or interact and adversely affect the efficacy of other medications. Early diagnosis of AGEP avoids unnecessary investigations and treatment, which not only can harm the patient but also escalate health care, as the condition is self-limiting. This case report illustrates AGEP secondary to Cefaclor occurring in a 72-year-old Chinese woman. Although the literature has documented the occurrence of AGEP with Cefaclor, the unique feature of this case is the occurrence of AGEP following repeated uneventful courses of Cefaclor. This case highlights that AGEP must never be forgotten in the work-up for pustular eruptions in an elderly patient.

Primary and repeated surgeries for ectopic pregnancies and distribution by patient age, surgeon age, and hospital levels: an 11-year nationwide population-based descriptive study in Taiwan.

PubMed

Hsu, Ming-I; Tang, Chao-Hsiun; Hsu, Pei-Yang; Huang, Yu-Tung; Long, Cheng-Yu; Huang, Kuan-Hui; Wu, Ming-Ping

2012-01-01

To describe the changing trend, repeat operation rate, and distribution of laparoscopy, as compared with laparotomy, in treating ectopic pregnancy, according to patient age, preoperative conditions, surgeon age, and hospital accreditation level, in Taiwan over 11-years. Retrospective cohort study (Canadian Task Force classification II-2). Population-based nationwide insurance database. Women who underwent either laparotomy or laparoscopy because of ectopic pregnancy. Women who had National Health Insurance (NHI) underwent various surgical procedures to treat ectopic pregnancy. Data for this study were obtained from the Inpatient Expenditures by Admissions files of the NHI Research Database, released by the NHI program in Taiwan between 1997 and 2007. A total of 43 170 women with 44 928 operations were identified. Only the primary surgeries, via either laparotomy or laparoscopy, performed because of ectopic pregnancy were included for analysis. The annual number of procedures to treat ectopic pregnancies decreased in the later years of the 11-year study. Laparotomy decreased significantly, from 81.2% in 1997 to 26.2% in 2007, whereas laparoscopic procedures increased significantly, from 18.8% in 1997 to 73.8% in 2007, as evidenced at log-linear regression analysis (p < .001). The rate of repeat operations because of persistent ectopic pregnancy was higher in the laparoscopy group than in the laparotomy group (0.38% vs 0.14 %; p < .001). Patients were more likely to undergo the same type of operation for the repeated surgery (i.e., laparotomy to laparotomy in 73.1% or laparoscopy to laparoscopy in 80.2%; p = 0.43). Use of laparoscopy (58.1%) and laparotomy (41.9%) differed according to patient age, preoperative comorbidities, surgeon age, and hospital accreditation level and ownership type. With older patients, those with preoperative anemia or shock, and elder surgeons, there was a greater chance that laparotomy would be performed. The probability of undergoing laparotomy was greater in patients in regional hospitals, local hospitals, and office-based clinics compared with those in medical centers. There has been considerable change in the type of surgical approach used to treat ectopic pregnancy in Taiwan over the past 11 years. Laparoscopy is preferred to laparotomy, and has become the standard surgical approach to treating ectopic pregnancies in Taiwan. However, laparoscopy is associated with a higher rate of repeat operations. The laparoscopic approach signifies a profound change in treating ectopic pregnancies among patients, surgeons, and hospital types. Copyright © 2012 AAGL. Published by Elsevier Inc. All rights reserved.

Time to first take-back operation predicts successful primary fascial closure in patients undergoing damage control laparotomy.

PubMed

Pommerening, Matthew J; DuBose, Joseph J; Zielinski, Martin D; Phelan, Herb A; Scalea, Thomas M; Inaba, Kenji; Velmahos, George C; Whelan, James F; Wade, Charles E; Holcomb, John B; Cotton, Bryan A

2014-08-01

Failure to achieve primary fascial closure (PFC) after damage control laparotomy is costly and carries great morbidity. We hypothesized that time from the initial laparotomy to the first take-back operation would be predictive of successful PFC. Trauma patients managed with open abdominal techniques after damage control laparotomy were prospectively followed at 14 Level 1 trauma centers during a 2-year period. Time to the first take-back was evaluated as a predictor of PFC using hierarchical multivariate logistic regression analysis. A total of 499 patients underwent damage control laparotomy and were included in this analysis. PFC was achieved in 327 (65.5%) patients. Median time to the first take-back operation was 36 hours (interquartile range 24-48). After we adjusted for patient demographics, resuscitation volumes, and operative characteristics, increasing time to the first take-back was associated with a decreased likelihood of PFC. Specifically, each hour delay in return to the operating room (24 hours after initial laparotomy) was associated with a 1.1% decrease in the odds of PFC (odds ratio 0.989; 95% confidence interval 0.978-0.999; P = .045). In addition, there was a trend towards increased intra-abdominal complications in patients returning after 48 hours (odds ratio 1.80; 95% confidence interval 1.00-3.25; P = .05). Data from this prospective, multicenter study demonstrate that delays in returning to the operating room after damage control laparotomy are associated with reductions in PFC. These findings suggest that emphasis should be placed on returning to the operating room within 24 hours after the initial laparotomy if possible (and no later than 48 hours). Copyright © 2014 Mosby, Inc. All rights reserved.

Ensuring Interoperability between UAS Detect-and-Avoid and Manned Aircraft Collision Avoidance

NASA Technical Reports Server (NTRS)

Thipphavong, David; Cone, Andrew; Lee, Seung Man; Santiago, Confesor

2017-01-01

The UAS community in the United States has identified the need for a collision avoidance region in which UAS Detect-and-Avoid (DAA) vertical guidance is restricted to preclude interoperability issues with manned aircraft collision avoidance system vertical resolution advisories (RAs). This paper documents the process by which the collision avoidance region was defined. Three candidate definitions were evaluated on 1.3 million simulated pairwise encounters between UAS and manned aircraft covering a wide range of horizontal and vertical closure rates, angles, and miss distances. They were evaluated with regard to UAS DAA interoperability with manned aircraft collision avoidance systems in terms of: 1) the primary objective of restricting DAA vertical guidance before RAs when the aircraft are close, and 2) the secondary objective of avoiding unnecessary restrictions of DAA vertical guidance at a DAA alert when the aircraft are further apart. The collision avoidance region definition that fully achieves the primary objective and best achieves the secondary objective was recommended to and accepted by the UAS community in the United States. By this definition, UAS and manned aircraft are in the collision avoidance region--during which DAA vertical guidance is restricted--when the time to closest point of approach is less than 50 seconds and either the time to co-altitude is less than 50 seconds or the current vertical separation is less than 800 feet.

Ensuring Interoperability Between Unmanned Aircraft Detect-and-Avoid and Manned Aircraft Collision Avoidance

NASA Technical Reports Server (NTRS)

Thipphavong, David; Cone, Andrew; Lee, Seungman

2017-01-01

The Unmanned Aircraft Systems (UAS) community in the United States has identified the need for a collision avoidance region in which UAS Detect-and-Avoid (DAA) vertical guidance is restricted to preclude interoperability issues with manned aircraft collision avoidance system vertical resolution advisories (RAs). This paper documents the process by which the collision avoidance region was defined. Three candidate definitions were evaluated on 1.3 million simulated pairwise encounters between UAS and manned aircraft covering a wide range of horizontal and vertical closure rates, angles, and miss distances. Each definition was evaluated with regard to UAS DAA interoperability with manned aircraft collision avoidance in terms of how well it achieved: 1) the primary objective of restricting DAA vertical guidance prior to RAs when the aircraft are close, and 2) the secondary objective of avoiding unnecessary restrictions of DAA vertical guidance at DAA alerts when the aircraft are further apart. The collision avoidance region definition that fully achieves the primary objective and best achieves the secondary objective was recommended to and accepted by the UAS community in the United States. By this definition, UAS and manned aircraft are in the collision avoidance region where DAA vertical guidance is restricted when the time to closest point of approach (CPA) is less than 50 seconds and either the time to co-altitude is less than 50 seconds or the current vertical separation is less than 800 feet.

Worldwide Report, Epidemiology, No. 332

DTIC Science & Technology

1983-09-14

Patients Die, by Arne Soderlund ANIMAL DISEASES COLOMBIA New Foot-and-Mouth Foci Detected; Vaccination Campaign Discussed (EL TIEMPO, 23 Jul 83... Vaccination "Therefore it is so important for those who are homosexuals with many partners to go to the public health service and be thoroughly checked even...unnecessary anguish can be avoided." Geo von Krogh regards mass vaccination of all homosexual men against B-hepa- titis as one of the many measures to

Sources of avoidance motivation: Valence effects from physical effort and mental rotation.

PubMed

Morsella, Ezequiel; Feinberg, Giles H; Cigarchi, Sepeedeh; Newton, James W; Williams, Lawrence E

2011-09-01

When reaching goals, organisms must simultaneously meet the overarching goal of conserving energy. According to the law of least effort, organisms will select the means associated with the least effort. The mechanisms underlying this bias remain unknown. One hypothesis is that organisms come to avoid situations associated with unnecessary effort by generating a negative valence toward the stimuli associated with such situations. Accordingly, merely using a dysfunctional, 'slow' computer mouse causes participants to dislike ambient neutral images (Study 1). In Study 2, nonsense shapes were liked less when associated with effortful processing (135° of mental rotation) versus easier processing (45° of rotation). Complementing 'fluency' effects found in perceptuo-semantic research, valence emerged from action-related processing in a principled fashion. The findings imply that negative valence associations may underlie avoidance motivations, and have practical implications for educational/workplace contexts in which effort and positive affect are conducive to success.

Effects of laparotomy vs pneumoperitoneum on the hepatic catabolic stress response in ambulatory and stationary settings in pigs.

PubMed

Lausten, S B; Grøfte, T; Andreasen, F; Vilstrup, H; Jensen, S L

1999-04-01

We recently demonstrated that laparoscopic cholecystectomy is followed by a much smaller hepatic catabolic stress response than conventional cholecystectomy. It is not known what is responsible for this difference. Thirty pigs were randomly allocated to the following five treatment groups: (1) laparotomy, (2) pneumoperitoneum, (3) pneumoperitoneum with insertion of four trocars, (4) laparotomy, (5) pneumoperitoneum. Groups 1-3 were operated on in an ambulatory setting, whereas groups 4 and 5 were operated on in a stationary setting. Urea synthesis, as quantified by functional hepatic nitrogen clearance, and the response of stress hormones and cytokines were assessed. Laparotomy increased the functional hepatic nitrogen clearance by 195% (p < 0.001); pneumoperitoneum and trocars increased it by 145% (p < 0.001); and pneumoperitoneum alone increased it by 113% (p < 0. 001). The difference between laparotomy and both pneumoperitoneum groups was significant. If the stress factor of ambulatory surgery was eliminated, the increase in functional hepatic nitrogen clearance was reduced to 87% (p < 0.01) after laparotomy and 38% (NS) for animals subject to pneumoperitoneum. There were significant differences in concentrations of stress hormones, tumor necrosis factor alpha, and interleukin 8 among groups intra- and postoperatively. The magnitude of the postoperative hepatic stress response after laparotomy compared to pneumoperitoneum with and without insertion of trocars seems to be caused by the greater trauma to the abdominal wall. Furthermore, an ambulatory setting seems to be an important postoperative stress factor in itself.

Agenesis of the gallbladder: A dangerously misdiagnosed malformation

PubMed Central

Peloponissios, Nicolas; Gillet, Michel; Cavin, René; Halkic, Nermin

2005-01-01

Isolated agenesis of the gallbladder is a rare anomaly, often asymptomatic. However, one patient out of four presented with right upper abdominal pain, nausea, and fatty food intolerance. The condition is frequently mistaken with an excluded or sclero-atrophic gallbladder, regardless of the imaging modality used. Consequently, AG often leads to unnecessary and potentially dangerous laparoscopic surgery as described in a few case reports over the last 10 years. The aim of this study is to clarify the diagnostic and therapeutic approach of this unusual pathology. Two cases seen in our institutions were retrospectively reviewed, together with a review of the American and European literature. During laparoscopy, the absence of normal anatomical structures and the impossibility of pulling on the gallbladder to expose and dissect the triangle of Callot increases the risk of iatrogenic injury to biliary or portal structures. Depending on the experiment of the surgeon in laparoscopic procedure, this has to be taken into account to decide a conversion to laparotomy. A high index of suspicion is necessary when interpreting the radiological images. In case of doubt, a MRI-cholangiography is mandatory. Because of possible inherited transmission, relatives with a history of biliary symptoms should be investigated. PMID:16273658

[Abdominal wall actinomycosis. A report of a case].

PubMed

Rojas Pérez-Ezquerra, Beatriz; Guardia-Dodorico, Lorena; Arribas-Marco, Teresa; Ania-Lahuerta, Aldonza; González Ballano, Isabel; Chipana-Salinas, Margot; Carazo-Hernández, Belén

2015-01-01

Abdominal wall Actinomycosis is a rare disease associated with the use of intrauterine device and as a complication of abdominal surgery. Diagnosis is difficult because it is unusual and behaves like a malignant neoplasm. A case report is presented of a patient who had used an intrauterine device for four years and developed a stony tumour in the abdominal wall associated with a set of symptoms that, clinically and radiologically, was simulating a peritoneal carcinomatosis associated with paraneoplastic syndrome, even in the course of an exploratory laparotomy. The patient attended our hospital with a two-month history of abdominal pain and symptoms that mimic a paraneoplastic syndrome. The diagnosis of abdominal actinomycosis was suspected by the finding of the microorganism in cervical cytology together with other cultures and Actinomyces negative in pathological studies, confirming the suspicion of a complete cure with empirical treatment with penicillin. Actinomycosis should be considered in patients with pelvic mass or abdominal wall mass that mimics a malignancy. Antibiotic therapy is the first treatment choice and makes a more invasive surgical management unnecessary. Copyright © 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. All rights reserved.

Comparison between laparotomy first versus angiographic embolization first in patients with pelvic fracture and hemoperitoneum: a nationwide observational study from the Japan Trauma Data Bank

PubMed Central

2013-01-01

Background A common dilemma in the management of pelvic fractures is recognizing the presence of associated abdominal injury. The purpose of this study was to determine the association between initial therapeutic intervention (laparotomy or transcatheter arterial embolization (TAE)) and mortality. Methods This was a cohort study using the Japan Trauma Data Bank between 2004 and 2010, including blunt trauma patients with pelvic fractures and positive Focused Assessment with Sonography in Trauma (FAST) results. Eligible patients were restricted to those who underwent laparotomy or TAE/angiography as the initial therapeutic intervention. Crude and adjusted odds ratio (AOR) for in-hospital mortality were compared between the laparotomy first and TAE first groups (reference group). Multiple logistic regression analysis and propensity score adjusted analysis were used to adjust for clinically relevant confounders, including the severity of injury. Results Of the 317 participants, 123 patients underwent laparotomy first and 194 patients underwent TAE first. The two groups were similar in terms of age, although the laparotomy first group had higher mean Injury Severity Scores (ISS) and higher mean scores based on the abdominal Abbreviated Injury Scale (AIS), as well as lower mean pelvic AIS and systolic blood pressure (SBP). Half of the patients who were hypotensive (SBP < 90 mmHg) on arrival underwent TAE first. The laparotomy first group had a significantly higher crude in-hospital mortality (41% vs. 27%; P < 0.01). After adjusting for confounders, the choice of initial therapeutic intervention did not affect the in-hospital mortality (AOR, 1.20; 95% Confidence Interval (CI), 0.61-2.39). Even in the limited subgroup of hypotensive patients (SBP 66–89 mmHg and SBP < 65 mmHg subgroup), the effect was similar (AOR, 1.50; 95% CI, 0.56-4.05 and AOR, 1.05; 95% CI, 0.44-3.03). Conclusions In Japan, laparotomy and TAE are equally chosen as the initial therapeutic intervention regardless of hemodynamic status. No significant difference was seen between the laparotomy first and TAE first groups regarding in-hospital mortality. PMID:24299060

Failure of third-generation implantable cardioverter defibrillators to abort shock therapy for nonsustained ventricular tachycardia due to shortcomings of the VF confirmation algorithm.

PubMed

Grimm, W; Menz, V; Hoffmann, J; Maisch, B

1998-04-01

Unnecessary shocks by ICDs for rhythms other than sustained VT or VF have been described as the most frequent adverse event in ICD patients. To avoid unnecessary shocks for self-terminating arrhythmias, the third-generation Jewel PCD defibrillators 7202, 7219, and 7220 Plus use a specially designed VF confirmation algorithm after charge end. The purpose of this study was to determine the ability of this VF confirmation algorithm to recognize nonsustained VT, and to analyze the reasons for failure of the PCD device to abort shock therapy for nonsustained VT despite use of this VF confirmation algorithm. Analysis of stored electrograms of electrical events triggering high voltage capacitor charging in the programmed VF zone of the device showed 36 spontaneous episodes of nonsustained VT (227 +/- 21 beats/min) during 18 +/- 7 months follow-up in 15 patients who had a Jewel PCD implanted at our hospital. Intracardiac electrogram recordings and simultaneously retrieved marker channels demonstrated that the ICD shock was appropriately aborted according to the VF confirmation algorithm in 24 (67%) of 36 episodes of nonsustained VT. Twelve episodes (33%) of nonsustained VT, however, were followed by spontaneous ICD shock in 6 (40%) of the 15 study patients. The only reason for all 12 shocks for sustained VT was the inability of the device to recognize the absence of VT after charge end due to shortcomings of the VF confirmation algorithm: 11 of the 12 shocks for nonsustained VT were triggered by the occurrence of paced beats during the VF confirmation period and 1 shock for nonsustained VT was triggered by the occurrence of 2 premature beats after charge end. Thus, better VF confirmation algorithms need to be incorporated in future PCD devices to avoid unnecessary shocks for nonsustained VT.

Volvo and Infiniti drivers' experiences with select crash avoidance technologies.

PubMed

Braitman, Keli A; McCartt, Anne T; Zuby, David S; Singer, Jeremiah

2010-06-01

Vehicle-based crash avoidance systems can potentially reduce crashes, but success depends on driver acceptance and understanding. This study gauged driver use, experience, and acceptance among early adopters of select technologies. Telephone interviews were conducted in early 2009 with 380 owners of Volvo vehicles equipped with forward collision warning with autobrake, lane departure warning, side-view assist, and/or active bi-xenon headlights and 485 owners of Infiniti vehicles with lane departure warning/prevention. Most owners kept systems turned on most of the time, especially forward collision warning with autobrake and side-view assist. The exception was lane departure prevention; many owners were unaware they had it, and the system must be activated each time the vehicle is started. Most owners reported being safer with the technologies and would want them again on their next vehicles. Perceived false or unnecessary warnings were fairly common, particularly with side-view assist. Some systems were annoying, especially lane departure warning. Many owners reported safer driving behaviors such as greater use of turn signals (lane departure warning), increased following distance (forward collision warning), and checking side mirrors more frequently (side-view assist), but some reported driving faster at night (active headlights). Despite some unnecessary or annoying warnings, most Volvo and Infiniti owners use crash avoidance systems most of the time. Among early adopters, the first requirement of effective warning systems (that owners use the technology) seems largely met. Systems requiring activation by drivers for each trip are used less often. Owner experience with the latest technologies from other automobile manufacturers should be studied, as well as for vehicles on which technologies are standard (versus optional) equipment. The effectiveness of technologies in preventing and mitigating crashes and injuries, and user acceptance of interfaces, should be examined as more vehicles with advanced technologies penetrate the fleet.

Clinical anophthalmos.

PubMed Central

O'Keefe, M; Webb, M; Pashby, R C; Wagman, R D

1987-01-01

We report on 15 patients (10 boys, 5 girls) with clinical anophthalmos. Two of them had bilateral anophthalmos, 10 had systemic anomalies, and six had abnormalities of their remaining eye. Only two appeared to have an associated underlying aetiology. Fourteen patients underwent orbital reconstruction or socket enlargement with varying degrees of success. Our own experience suggests that unnecessary lid procedures should be avoided, but we recommend early prosthetic fittings. We feel that a multidisciplinary approach is necessary to attain useful rehabilitation. Images PMID:3651379

Empowering Physicians with Financial Literacy.

PubMed

Bar-Or, Yuval

2015-01-01

Most doctors complete their medical training without sufficient knowledge of business and finance. This leads to inefficient financial decisions, avoidable losses, and unnecessary anxiety. A big part of the problem is that the existing options for gaining financial knowledge are flawed. The ideal solution is to provide a simple framework of financial literacy to all students: one that can be adapted to their specific circumstances. That framework must be delivered by an objective expert to young physicians before they complete medical training.

High Velocity Firings of Slug Projectiles in a Double-Travel 120-MM Gun System

DTIC Science & Technology

1991-04-01

constraints presented by TBD. This charge configuration was then tested using aluminium slug projectiles to avoid the unnecessary expenditure of APFSDS...test projectile was a depleted uranium alloy (U-.75Ti) rod with a standard, four piece, aluminum sabot assembly. The launch package had a nominal...the rod is shown in Figure 2. Figure 2. Scaled, Long Rod Penetrator. Figure 3. Aluminium Slug Projectile. The aluminium slug rounds, fired at Range 18

Three dimensional PNS solutions of hypersonic internal flows with equilibrium chemistry

NASA Technical Reports Server (NTRS)

Liou, May-Fun

1989-01-01

An implicit procedure for solving parabolized Navier-Stokes equations under the assumption of a general equation of state for a gas in chemical equilibrium is given. A general and consistent approach for the evaluation of Jacobian matrices in the implicit operator avoids the use of unnecessary auxiliary quantities and approximations, and leads to a simple expression. Applications to two- and three-dimensional flow problems show efficiency in computer time and economy in storage.

Nipple piercing may be contraindicated in male patients with chest implants.

PubMed

de Kleer, N; Cohen, M; Semple, J; Simor, A; Antonyshyn, O

2001-08-01

The authors present a man who underwent chest augmentation and nipple piercing. The patient developed chronic nipple infection, which led to unnecessary invasive diagnostic procedures, serious implant infection, and eventually urgent explantation. This unfavorable scenario illustrates the distinct features of the procedure in men, which includes close proximity of the nipple to the implant and reduced awareness by health care providers. Based on this case the authors recommend avoiding nipple piercing in men with chest implants.

Diagnostic accuracy of fine-needle aspiration cytology of thyroid gland lesions: A study of 200 cases in Himalayan belt.

PubMed

Sharma, Reetika; Verma, Neelam; Kaushal, Vijay; Sharma, Dev Raj; Sharma, Dhruv

2017-01-01

The study is undertaken to correlate the fine-needle aspiration cytology (FNAC) findings with histopathology in a spectrum of thyroid lesions and to find the diagnostic accuracy of fine-needle aspiration (FNA) so that unnecessary thyroidectomies can be avoided in benign lesions. This study was carried out over the period of 1-year (May 1, 2012-April, 30 2013). FNA specimens obtained from 200 patients were analyzed. Of these, only 40 patients underwent surgery and their thyroid specimens were subjected to histopathological examination. The age of the patients ranged from 9 to 82 years with mean age being 43 years. There was female preponderance, with male to female ratio being 1:7. On cytology out of 200 cases, 148 (74%) were benign, 25 (12.5%) were malignant, 16 (8%) were indeterminate, and 11 (5.5%) were nondiagnostic. Only 40 patients underwent surgery. On histopathology, 21 (52.5%) cases were benign and 19 (47.5%) were malignant. The statistical analysis of cytohistological correlation for both benign and malignant lesions revealed sensitivity, specificity, and diagnostic accuracy of 84%, 100% and 90%, respectively. FNAC is a minimally invasive, highly accurate and cost-effective procedure for the assessment of patients with thyroid lesions and has high -sensitivity and specificity. It acts as a good screening test and avoids unnecessary thyroidectomies.

Localized primary amyloidosis of the breast: a case report and review of the literature.

PubMed

Tsuji, Wakako; Takeuchi, Eiji; Oka, Satoshi; Yamashita, Taro; Yotsumoto, Fumiaki

2016-09-13

Primary amyloidosis of the breast is an unusual benign disease that mostly occurs in postmenopausal elderly women. Amyloidosis is the deposition of amorphous protein within tissues. Breast biopsy is necessary to make a definite diagnosis in order to avoid unnecessary surgical methods. Localized primary amyloidosis of the breast has a good prognosis. However, secondary amyloidosis is a systemic disease and has a poor prognosis. We report the case of a 77-year-old female with primary amyloidosis of the breast. She noticed a lump in her left breast. Mammographic and ultrasonographic examinations indicated breast cancer. However, core needle biopsy showed amyloidosis, not cancer of the breast. For further examinations, the patient visited the outpatient clinics of the hematology, dermatology, and gastroenterology departments. She underwent bone marrow aspiration, computed tomography, cardiac ultrasonography, random skin biopsy, gastrofiberscopy, and colonofiberscopy. Plasma cell myeloma and systemic amyloidosis were ruled out, and localized breast amyloidosis was highly suspected. Lumpectomy was performed to make a definite diagnosis, and histological evaluations revealed that this patient had localized amyloidosis of the breast, and the deposited amyloid protein was of the amyloid light chain kappa type. Breast biopsy is necessary in order to avoid unnecessary surgical technique. A diagnosis should be achieved only through a histological evaluation. The main treatment of localized primary amyloidosis of the breast is surgical removal.

A maneuver for improved positioning of a tourniquet in the obese patient.

PubMed

Krackow, K A

1982-08-01

Proximal positioning of an arterial tourniquet will be greatly facilitated by having an assistant firmly draw the skin and subcutaneous tissue distally prior to positioning the cast padding and tourniquet. This simple maneuver is clearly not part of current practice or training, despite the simplicity and effectiveness. Excessive tourniquet tightening should be avoided prior to fixing the Velcro fasteners, a practice which is commonly employed and is not only ineffective in maintaining proximal tourniquet positioning, but also deleterious in that it creates a "venous tourniquet" effect. Loosening of the restraining adhesive tapes and unnecessary traction of adhesive tape on sensitive skin can be avoided by bringing the extremity to its resting position before fastening the tape proximal to the tourniquet.

Hyalinizing Trabecular Tumor of the Thyroid Gland, a Diagnostic Challenge in Fine-Needle Aspiration Cytology: Case Report.

PubMed

Rhee, Ye-Young; Jung, Hong Kyu; Kim, Se Hoon; Kim, Soo Hee

2018-06-11

Hyalinizing trabecular tumor (HTT) is a rare thyroid tumor with low to minimal malignant potential. HTT is often misinterpreted as other thyroid tumors, including papillary thyroid carcinoma (PTC) and medullary thyroid carcinoma (MTC), on fine-needle aspiration (FNA) cytology, because of its overlapping cytologic features, such as nuclear grooves and intranulcear pseudoinclusions. Although cytopathologists cannot definitely conclude HTT by FNA cytology, suspicion of HTT is necessary to avoid misdiagnosing HTT as PTC or MTC and to avoid unnecessary aggressive treatment. Here, we report a case of HTT with novel cytologic features in CellPrep liquid based cytology that was diagnosed as suspicious for papillary carcinoma by FNA and finally diagnosed as HTT in the surgical specimen.

Assessment of light stability of drugs in blood and plasma.

PubMed

de Vries, Ronald; Diels, Luc; Dillen, Lieve; Sips, Luc; Van Roosbroek, Dirk; Verhaeghe, Tom; Timmerman, Philip

2016-10-01

A procedure was developed for the assessment of photochemical stability of drugs in blood and plasma under standardized conditions. The procedure avoids a variable outcome of photochemical stability experiments and tests relevant worst case conditions so that unnecessary light protection is avoided. Results/methodology: Blood and plasma were spiked with a mixture of drugs and incubated in a Suntest CPS(+), in the laboratory on the bench and near the window on a sunny summer day. The results were compared. No protection from light, limited protection from light and full protection from light are advised for drugs that are stable in plasma in the Suntest CPS(+) at 250 W/m(2) for at least 30 min, for 5-30 min and for <5 min, respectively.

Incidence and clinical characteristics of unexpected uterine sarcoma after hysterectomy and myomectomy for uterine fibroids: a retrospective study of 10,248 cases.

PubMed

Zhao, Wan-Cheng; Bi, Fang-Fang; Li, Da; Yang, Qing

2015-01-01

Uterine fibroids often require a hysterectomy or myomectomy via laparotomy or laparoscopy. Morcellation is often necessary to perform a laparoscopic surgery. The objective of this study is to determine the incidence of unexpected uterine sarcomas (UUSs) after hysterectomy and myomectomy for uterine fibroids and to reduce the occurrence and avoid the morcellation of UUSs by analyzing their characteristics. Women who had a hysterectomy or myomectomy for uterine fibroids in Shengjing Hospital of China Medical University between November 2008 and November 2014 were selected for the study, and their clinical characteristics were analyzed. During the period, 48 UUSs were found in 10,248 cases, and the overall incidence was 0.47%. There was no statistical difference (P=0.449) regarding the incidence (0.50% vs 0.33%) between 42 UUSs in 8,456 cases undergoing laparotomy and six UUSs in 1,792 cases undergoing laparoscopy. Most of the UUSs were stage I (89.58%), which occurred more commonly (56.25%) in women aged 40-49. Abnormal uterine bleeding (39.58%) was the main clinical manifestation. Rapidly growing pelvic masses (12.5%), rich blood flow signals (18.75%), and degeneration of uterine fibroids (18.75%) prompted by ultrasonography may suggest the possibility of UUSs. The margins of most UUSs (93.75%) were regular, which may cause UUSs to be misdiagnosed as uterine fibroids. Fifteen cases underwent magnetic resonance imaging examinations. Approximately 73.33% showed heterogeneous and hypointense signal intensity on T1-weighted images, and 80% showed intermediate-to-high signal intensity on T2-weighted images, with necrosis and hemorrhage in 40% of cases. After contrast administration, 80% presented early heterogeneous enhancement. The incidence of UUSs after hysterectomy and myomectomy for uterine fibroids was low, and their clinical characteristics are atypical. It is necessary and very critical to make a complete and cautious preoperative evaluation to reduce the occurrence and avoid the morcellation of UUSs.

Can Teamwork and High-Volume Experience Overcome Challenges of Lymphadenectomy in Morbidly Obese Patients (Body Mass Index of 40 kg/m2 or Greater) with Endometrial Cancer?: A Cohort Study of Robotics and Laparotomy and Review of Literature.

PubMed

Fornalik, Hubert; Zore, Temeka; Fornalik, Nicole; Foster, Todd; Katschke, Adrian; Wright, Gary

2018-06-01

This study aimed to compare surgical outcomes and the adequacy of surgical staging in morbidly obese women with a body mass index (BMI) of 40 kg/m or greater who underwent robotic surgery or laparotomy for the staging of endometrioid-type endometrial cancer. This is a retrospective cohort study of patients who underwent surgical staging between May 2011 and June 2014. Patients' demographics, surgical outcomes, intraoperative and postoperative complications, and pathological outcomes were compared. Seventy-six morbidly obese patients underwent robotic surgery, and 35 underwent laparotomy for surgical staging. Robotic surgery was associated with more lymph nodes collected with increasing BMI (P < 0.001) and decreased chances for postoperative respiratory failure and intensive care unit admissions (P = 0.03). Despite a desire to comprehensively stage all patients, we performed successful pelvic and paraaortic lymphadenectomy in 96% versus 89% (P = 0.2) and 75% versus 60% (P = 0.12) of robotic versus laparotomy patients, respectively. In the robotic group, with median BMI of 47 kg/m, no conversions to laparotomy occurred. The robotic group experienced less blood loss and a shorter length of hospital stay than the laparotomy group; however, the surgeries were longer. In a high-volume center, a high rate of comprehensive surgical staging can be achieved in patients with BMI of 40 kg/m or greater either by laparotomy or robotic approach. In our experience, robotic surgery in morbidly obese patients is associated with better quality staging of endometrial cancer. With a comprehensive approach, a professional bedside assistant, use of a monopolar cautery hook, and our protocol of treating morbidly obese patients, robotic surgeries can be safely performed in the vast majority of patients with a BMI of 40 kg/m or greater, with lymph node counts being similar to nonobese patients, and with conversions to laparotomy reduced to a minimum.

The effect of laparotomy and external fixator stabilization on pelvic volume in an unstable pelvic injury.

PubMed

Ghanayem, A J; Wilber, J H; Lieberman, J M; Motta, A O

1995-03-01

Determine if laparotomy further destabilizes an unstable pelvic injury and increases pelvic volume, and if reduction and stabilization restores pelvic volume and prevents volume changes secondary to laparotomy. Cadaveric pelvic fracture model. Unilateral open-book pelvic ring injuries were created in five fresh cadaveric specimens by directly disrupting the pubic symphysis, left sacroliac joint, and sacrospinous and sacrotuberous ligaments. Pelvic volume was determined using computerized axial tomography for the intact pelvis, disrupted pelvis with both a laparotomy incision opened and closed, and disrupted pelvis stabilized and reduced using an external fixator with the laparotomy incision opened. The average volume increase in the entire pelvis (from the top of the iliac crests to the bottom of the ischial tuberosities) between a nonstabilized injury with the abdomen closed and then subsequently opened was 15 +/- 5% (423 cc). The average increase in entire pelvic volume between a stabilized and reduced pelvis and nonstabilized pelvis, both with the abdomen open, was 26 +/- 5% (692 cc). The public diastasis increased from 3.9 to 9.3 cm in a nonstabilized pelvis with the abdomen closed and then subsequently opened. Application of a single-pin anterior-frame external fixator reduced the pubic diastasis anatomically and reduced the average entire and true (from the pelvic brim to the ischeal tuberosities) pelvic volumes to within 3 +/- 4 and 8 +/- 6% of the initial volume, respectively. We believe that the abdominal wall provides stability to an unstable pelvic ring injury via a tension band effect on the iliac wings. Our results demonstrate that a laparotomy further destabilized an open-book pelvic injury and subsequently increased pelvic volume and pubic diastasis. This could potentially increase blood loss from the pelvic injury and delay the tamponade effect of reduction and stabilization. A single-pin external fixator prevents the destabilizing effect of the laparotomy and effectively reduces pelvic volume. These data support reduction and temporary stabilization of unstable pelvic injuries before or concomitantly with laparotomy.

Does the emergency surgery score accurately predict outcomes in emergent laparotomies?

PubMed

Peponis, Thomas; Bohnen, Jordan D; Sangji, Naveen F; Nandan, Anirudh R; Han, Kelsey; Lee, Jarone; Yeh, D Dante; de Moya, Marc A; Velmahos, George C; Chang, David C; Kaafarani, Haytham M A

2017-08-01

The emergency surgery score is a mortality-risk calculator for emergency general operation patients. We sought to examine whether the emergency surgery score predicts 30-day morbidity and mortality in a high-risk group of patients undergoing emergent laparotomy. Using the 2011-2012 American College of Surgeons National Surgical Quality Improvement Program database, we identified all patients who underwent emergent laparotomy using (1) the American College of Surgeons National Surgical Quality Improvement Program definition of "emergent," and (2) all Current Procedural Terminology codes denoting a laparotomy, excluding aortic aneurysm rupture. Multivariable logistic regression analyses were performed to measure the correlation (c-statistic) between the emergency surgery score and (1) 30-day mortality, and (2) 30-day morbidity after emergent laparotomy. As sensitivity analyses, the correlation between the emergency surgery score and 30-day mortality was also evaluated in prespecified subgroups based on Current Procedural Terminology codes. A total of 26,410 emergent laparotomy patients were included. Thirty-day mortality and morbidity were 10.2% and 43.8%, respectively. The emergency surgery score correlated well with mortality (c-statistic = 0.84); scores of 1, 11, and 22 correlated with mortalities of 0.4%, 39%, and 100%, respectively. Similarly, the emergency surgery score correlated well with morbidity (c-statistic = 0.74); scores of 0, 7, and 11 correlated with complication rates of 13%, 58%, and 79%, respectively. The morbidity rates plateaued for scores higher than 11. Sensitivity analyses demonstrated that the emergency surgery score effectively predicts mortality in patients undergoing emergent (1) splenic, (2) gastroduodenal, (3) intestinal, (4) hepatobiliary, or (5) incarcerated ventral hernia operation. The emergency surgery score accurately predicts outcomes in all types of emergent laparotomy patients and may prove valuable as a bedside decision-making tool for patient and family counseling, as well as for adequate risk-adjustment in emergent laparotomy quality benchmarking efforts. Copyright © 2017 Elsevier Inc. All rights reserved.

Thrombolysis with intravenous recombinant tissue plasminogen activator during early postpartum period: a review of the literature.

PubMed

Akazawa, Munetoshi; Nishida, Makoto

2017-05-01

Thromboembolic events are one of the leading causes of maternal death during the postpartum period. Postpartum thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) is controversial because the treatment may lead to massive bleeding. Data centralization may be beneficial for analyzing the safety and effectiveness of systemic thrombolysis during the early postpartum period. We performed a computerized MEDLINE and EMBASE search. We collected data for 13 cases of systemic thrombolytic therapy during the early postpartum period, when limiting the early postpartum period to 48 hours after delivery. Blood transfusion was necessary in all cases except for one (12/13; 92%). In seven cases (7/13; 54%), a large amount of blood was required for transfusion. Subsequent laparotomy to control bleeding was required in five cases (5/13; 38%), including three cases of hysterectomy and two cases of hematoma removal, all of which involved cesarean delivery. In cases of transvaginal delivery, there was no report of laparotomy. The occurrence of severe bleeding was high in relation to cesarean section, compared with vaginal deliveries. Using rt-PA in relation to cesarean section might be worth avoiding. However, the paucity of data in the literature makes it difficult to assess the ultimate outcomes and safety of this treatment. © 2017 Nordic Federation of Societies of Obstetrics and Gynecology.

Perioperative haemostatic management of haemophilic mice using normal mouse plasma.

PubMed

Tatsumi, K; Ohashi, K; Kanegae, K; Shim, I K; Okano, T

2013-11-01

Intense haemostatic interventions are required to avoid bleeding complications when surgical procedures are performed on haemophilia patients. The objective of this study was to establish an appropriate protocol for perioperative haemostatic management of haemophilic mice. We assessed the prophylactic haemostatic effects of normal mouse plasma (NMP) on haemophilia B (HB) mice for both a skin flap procedure and a laparotomy. When 500 μL of NMP was administered to the mice, plasma factor IX (FIX:C) levels peaked at 15.1% immediately after intravenous (IV) administration, at 6.1% 2 h after intraperitoneal (IP) administration and at 2.7% 6 h after subcutaneous administration. Administering 500 μL of NMP via IP or IV 30 min in advance enabled the skin flap procedure to be performed safely without any complications. After the laparotomy procedure, several mice in the IP administration group exhibited lethal bleeding, but all mice survived in the IV administration group. Anti-mouse FIX inhibitors did not develop, even after repetitive administrations of NMP. However, human FIX concentrates, especially plasma-derived concentrates, elicited the anti-human FIX inhibitors. The results show that administering 500 μL of NMP via IV or IP 30 min in advance enables surgical procedures to be safely performed on HB mice, and that IV administration is more desirable than IP if the procedure requires opening of the abdominal wall. © 2013 John Wiley & Sons Ltd.

Paediatric and adolescent traumatic gastrointestinal injuries: results of a European multicentre analysis.

PubMed

Fischerauer, E E; Zötsch, S; Capito, C; Bonnard, A; Sárközy, S; Berndt, J; Hosie, S; Beltra Pico, R; Steinau, G; Wiejek, A; Czauderna, P; Çelik, A; Lain Fernandez, A; Ibanez, V M; Esposito, C; Saxena, A K

2013-10-01

Paediatric gastrointestinal injuries (GIIs) are rare, and the aim of this multicentre study was to evaluate their outcomes in a large cohort. Hospital databases of 10 European paediatric surgical centres were reviewed for paediatric traumatic GIIs managed between 2000-2010. Ninety-seven patients with a median age of 9 years (0-17 years) were identified, with 72 blunt and 25 penetrating GIIs. Initial diagnostics in 90 patients led to correct diagnosis in 71%. Diagnostics were delayed in 26 patients (median 24 h). Eighty-two patients required surgery (67 laparotomy, 12 laparoscopy and three other approaches). There was a 50% conversion in the laparoscopic group. Median hospital stay was 10 days (range 1-137 days), with longer duration influenced by associated injuries (n = 41). Diagnosis <24 h was associated with significantly shorter hospital stay compared to more than 24 h (p = 0.011). In one-third of patients, morbidities were not related to a diagnostic delay or type of injury. There were five lethal outcomes, four due to associated injuries. Initial diagnostics in traumatic paediatric GIIs provide false negatives in one-third of patients. Diagnostic delay <24 h is associated with a significantly shorter hospital stay. Although laparoscopy is associated with a conversion rate of 50%, it can be used for diagnosis in suspected cases to avoid nontherapeutic laparotomy. ©2013 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.

The Air Force Mobile Forward Surgical Team (MFST): Using the Estimating Supplies Program to Validate Clinical Requirement

DTIC Science & Technology

2004-12-01

conducted in an abbreviated, staged manner, such as laparotomies, decompression craniotomies , vascular shunts, or amputations. The FRSS provides...Performed at MFST Abbreviated laparotomy 36.29 Vascular shunt/ligate 32.84 Amputation 12.32 Decompression craniotomy 8.98 Thoracotomy 6.35...Vascular shunt/ligations 6 33 Abbreviated laparotomy 4 22 Amputation 3 16 Decompression craniotomy 3 16 Thoracotomy 2 10 Other 3 Total 18 100

Optimization of Lyophilized Plasma for Use in Combat Casualties

DTIC Science & Technology

2016-03-01

during which a baseline MAP was recorded and pre-weighed laparotomy sponges were placed in both paracolic gutters and in the pelvis for blood...period, the liver was packed tightly with laparotomy sponges . Swine were randomized to receive either LP reconstituted to 50% (50%LP, n=10) or 100...continuously recorded throughout the study. Blood loss following liver injury was carefully recorded with the use of pre-weighed laparotomy sponges and

Brain–immune interactions and the neural basis of disease-avoidant ingestive behaviour

PubMed Central

Pacheco-López, Gustavo; Bermúdez-Rattoni, Federico

2011-01-01

Neuro–immune interactions are widely manifested in animal physiology. Since immunity competes for energy with other physiological functions, it is subject to a circadian trade-off between other energy-demanding processes, such as neural activity, locomotion and thermoregulation. When immunity is challenged, this trade-off is tilted to an adaptive energy protecting and reallocation strategy that is identified as ‘sickness behaviour’. We review diverse disease-avoidant behaviours in the context of ingestion, indicating that several adaptive advantages have been acquired by animals (including humans) during phylogenetic evolution and by ontogenetic experiences: (i) preventing waste of energy by reducing appetite and consequently foraging/hunting (illness anorexia), (ii) avoiding unnecessary danger by promoting safe environments (preventing disease encounter by olfactory cues and illness potentiation neophobia), (iii) help fighting against pathogenic threats (hyperthermia/somnolence), and (iv) by associative learning evading specific foods or environments signalling danger (conditioned taste avoidance/aversion) and/or at the same time preparing the body to counteract by anticipatory immune responses (conditioning immunomodulation). The neurobiology behind disease-avoidant ingestive behaviours is reviewed with special emphasis on the body energy balance (intake versus expenditure) and an evolutionary psychology perspective. PMID:22042916

Laparotomy for blunt abdominal trauma in a civilian trauma service.

PubMed

Howes, N; Walker, T; Allorto, N L; Oosthuizen, G V; Clarke, D L

2012-03-29

This report looks at the group of patients who required a laparotomy for blunt torso trauma at a busy metropolitan trauma service in South Africa. Methods. A prospective trauma registry is maintained by the surgical services of the Pietermaritzburg metropolitan complex. This registry is interrogated retrospectively. All patients who required admission for blunt torso trauma over the period September 2006 - September 2007 were included for review. Proformas documenting mechanism of injury, age, vital signs, blood gas, delay in presentation, length of hospital stay, intensive care unit stay and operative details were completed. Results. A total of 926 patients were treated for blunt trauma by the Pietermaritzburg metropolitan services during the period under consideration. A cohort of 65 (8%) required a laparotomy for blunt trauma during this period. There were 17 females in this group. The mechanisms of injury were motor vehicle accident (MVA) (27), pedestrian vehicle accident (PVA) (21), assault (5), fall from a height (3), bicycle accident (6), quad bike accident (1) and tractor-related accident (2). The following isolated injuries were discovered at laparotomy: liver (9), spleen (5), diaphragm (1), duodenum (2), small bowel (8), mesentery (8) bladder (10), gallbladder (1), stomach (2), colon/rectum (2) and retrohepatic vena cava (1). The following combined injuries were discovered: liver and diaphragm (2), spleen and pancreas (1), spleen and liver (2), spleen, aorta and diaphragm (1), spleen and bladder (1) and small bowel and bladder (2). Eighteen patients in the series (26%) required relaparotomy. In 10 patients temporary abdominal containment was needed. The mortality rate was 26% (18 patients). There were 6 deaths from massive bleeding, all within 6 hours of operation, and 3 deaths from renal failure; the remaining 9 patients died of multiple organ failure. There were 8 negative laparotomies (7%). In the negative laparotomy group false-positive computed tomography (CT) scan findings were a problem in 3 cases, in 1 case hypotension and a fractured pelvis on admission prompted laparotomy, and in the other cases clinical findings prompted laparotomy. All patients who underwent negative laparotomy survived. There were 10 pelvic fractures, 5 lower limb fractures, 2 spinal injuries, 4 femur fractures and 2 upper limb fractures. CT scans were done in 25 patients. In 20 patients the systolic blood pressure on presentation was <90 mmHg and in 41 the pulse rate was >110 beats/min. In 16 patients there was a base excess of <-4 on presentation. Conclusion. Laparotomy is needed in less than 10% of patients who sustain blunt abdominal trauma. Solid visceral injury requiring laparotomy presents with haemodynamic instability. Hollow visceral injury has a more insidious presentation and is associated with a delay in diagnosis. CT scan is the most widely used investigation in blunt abdominal trauma. It is both sensitive and specific for solid visceral injury, but its accuracy for the diagnosis of hollow visceral injury is less well defined. Clinical suspicion must be high, and hollow visceral injury needs to be actively excluded.

Patient outcome of emergency laparotomy improved with increasing "number of surgeons on-call" in a university hospital: Audit loop.

PubMed

Hussain, Anwar; Mahmood, Fahad; Teng, Chui; Jafferbhoy, Sadaf; Luke, David; Tsiamis, Achilleas

2017-11-01

Emergency laparotomy is a commonly performed high-mortality surgical procedure. The National Emergency Laparotomy Network (NELA) published an average mortality rate of 11.1% and a median length of stay equivalent to 16.3 days in patients undergoing emergency laparotomy. This study presents a completed audit loop after implementing the change of increasing the number of on-call surgeons in the general surgery rota of a university hospital. The aim of this study was to evaluate the outcomes of emergency laparotomy in a single UK tertiary centre after addition of one more consultant in the daily on-call rota. This is a retrospective study involving patients who underwent emergency laparotomy between March to May 2013 (first audit) and June to August 2015 (second audit). The study parameters stayed the same. The adult patients undergoing emergency laparotomy under the general surgical take were included. Appendicectomy, cholecystectomy and simple inguinal hernia repair patients were excluded. Data was collected on patient demographics, ASA, morbidity, 30-day mortality and length of hospital stay. Statistical analysis including logistic regression was performed using SPSS. During the second 3-month period, 123 patients underwent laparotomy compared to 84 in the first audit. Median age was 65(23-93) years. 56.01% cases were ASA III or above in the re-audit compared to 41.9% in the initial audit. 38% patients had bowel anastomosis compared to 35.7% in the re-audit with 4.2% leak rate in the re-audit compared to 16.6% in the first audit. 30-day mortality was 10.50% in the re-audit compared to 21% and median length of hospital stay 11 days in the re-audit compared to 16 days. The lower ASA grade was significantly associated with increased likelihood of being alive, as was being female, younger age and not requiring ITU admission post-operatively. However, having a second on-call consultant was 2.231 times more likely to increase the chances of patients not dying (p = 0.031). Our audit-loop suggests that adding a second consultant to the daily on-call rota significantly reduces postoperative mortality and morbidity. Age, ASA and ITU admission are other independent factors affecting patient outcomes. We suggest this change be applied to other high volume centres across the country to improve the outcomes after emergency laparotomy.

A Comparison of Mortality Following Emergency Laparotomy Between Populations From New York State and England.

PubMed

Tan, Benjamin H L; Mytton, Jemma; Al-Khyatt, Waleed; Aquina, Christopher T; Evison, Felicity; Fleming, Fergal J; Griffiths, Ewen; Vohra, Ravinder S

2017-08-01

The aim of this study was to compare mortality following emergency laparotomy between populations from New York State and England. Mortality following emergency surgery is a key quality improvement metric in both the United States and UK. Comparison of the all-cause 30-day mortality following emergency laparotomy between populations from New York State and England might identify factors that could improve care. Patient demographics, in-hospital, and 30-day outcomes data were extracted from Hospital Episode Statistics (HES) in England and the New York Statewide Planning and Research Cooperative System (SPARCS) administrative databases for all patients older than 18 years undergoing laparotomy for emergency open bowel surgery between April 2009 and March 2014. The primary outcome measure was all-cause mortality within 30 days of the index laparotomy. Mixed-effects logistic regression was performed to model independent demographic variables against mortality. A one-to-one propensity score matched dataset was created to compare the odd ratios of mortality between the 2 populations. Overall, 137,869 patient records, 85,286 (61.9%) from England and 52,583 (38.1%) from New York State, were extracted. Crude 30-day mortality for patients was significantly higher in the England compared with New York State [11,604 (13.6%) vs 3633 (6.9%) patients, P < 0.001]. Patients undergoing emergency laparotomy in England had significantly higher risk of mortality compared with those in New York State (odds ratio 2.35, confidence interval 2.24-2.46, P < 0.001). The risk of mortality at 30 days is higher following emergency laparotomy in England as compared with New York State despite similar patient groups.

A laparoscopic intraperitoneal onlay mesh technique for the repair of an indirect inguinal hernia.

PubMed Central

Fitzgibbons, R J; Salerno, G M; Filipi, C J; Hunter, W J; Watson, P

1994-01-01

OBJECTIVE: This study was done (1) to determine whether congenital indirect inguinal hernias in male pigs could be repaired by placing a polypropylene mesh prosthesis over the defect intra-abdominally, (2) to measure the incidence of adhesions between intra-abdominal viscera and the prosthesis with and without the adhesion barrier oxidized regenerated cellulose, (3) to determine the incidence of other complications, and (4) to assess the effect on fertility. SUMMARY BACKGROUND DATA: Several techniques for laparoscopic inguinal herniorrhaphy are currently being evaluated to determine whether there are advantages over conventional inguinal herniorrhaphy. Perhaps the most controversial is the intraperitoneal onlay mesh procedure (IPOM). Its advantage is its simplicity (in that the repair is accomplished by placing a prosthesis over the hernia defect intra-abdominally, avoiding a groin dissection). Its disadvantage is the potential for complications because the prosthesis is in contact with the intra-abdominal viscera. METHODS: In male pigs, polypropylene mesh alone or polypropylene mesh plus the adhesion barrier oxidized regenerated cellulose (composite prosthesis) was fixed to the peritoneum surrounding the hernia defect. In phase 1 (6-week follow-up), two groups of 13 pigs each underwent herniorrhaphy at laparotomy or laparoscopy. In phase 2 (7.1-month follow-up), 21 pigs underwent laparoscopic herniorrhaphy. RESULTS: All IPOM herniorrhaphies were successful. The prostheses adhered most frequently to the bladder, followed by small bowel, peritoneum, and cord structures. Prosthetic erosion into these organs was not observed. Laparoscopically placed prostheses in phases 1 and 2 had significantly less surface covered by adhesions (13% +/- 13% and 19% +/- 27%, respectively) and a lower adhesion tenacity grade (1.5 +/- 0.9 and 1.3 +/- 1.1, respectively) than those placed at laparotomy (44% +/- 27% and 2.5 +/- 0.7, respectively; p < 0.01). In phase 1, a histologic evaluation of laparoscopically placed specimens demonstrated significantly thinner above-mesh fibrotic tissue compared with the prostheses implanted at laparotomy (p < 0.04). In either phase, the use of the adhesion barrier did not produce any histologic difference between the polypropylene alone and the composite prosthesis. Fertility studies were performed in phase 2 and showed no adverse effects caused by either prosthesis. CONCLUSIONS: This study demonstrated that the intraperitoneal placement of a polypropylene prosthesis was an effective technique for indirect inguinal herniorrhaphy in a pig. Furthermore, with laparotomy, the addition of oxidized regenerated cellulose significantly decreased the rate of adhesion formation to the prosthesis. However, oxidized regenerated cellulose would appear to have no value when used with a prosthesis placed laparoscopically. Images Figure 1. Figure 2. Figure 5. Figure 5. PMID:8129485

Outcome of Blunt Abdominal Traumas with Stable Hemodynamic and Positive FAST Findings.

PubMed

Behboodi, Firooz; Mohtasham-Amiri, Zahra; Masjedi, Navid; Shojaie, Reza; Sadri, Peyman

2016-01-01

Focused assessment with sonography for trauma (FAST) is a highly effective first screening tool for initial classification of abdominal trauma patients. The present study was designed to evaluate the outcome of patients with blunt abdominal trauma and positive FAST findings. The present prospective cross-sectional study was done on patients over 7 years old with normal abdominal examination, positive FAST findings, and available abdominopelvic computed tomography (CT) scan findings. The frequency of need for laparotomy as well as its probable risk factors were calculated. 180 patients were enrolled (mean age: 28.0 ± 11.5 years; 76.7% male). FAST findings were confirmed by abdominopelvic CT scan in only 124 (68.9%) cases. Finally, 12 (6.6%) patients needed laparotomy. Mean age of those in need of laparotomy was significantly higher than others (36.75 ± 11.37 versus 27.34 ± 11.37, p = 0.006). Higher grading of spleen (p = 0.001) and hepatic (p = 0.038) ruptures increased the probability of need for laparotomy. 68.9% of the positive FAST findings in patients with blunt abdominal trauma and stable hemodynamics was confirmed by abdominopelvic CT scan and only 6.6% needed laparotomy. Simultaneous presence of free fluid and air in the abdominal area, old age, and higher grading o solid organ injuries were factors that had a significant correlation with need for laparotomy.

Computer-Aided Structural Engineering (CASE) Project: Investigation and Design of U-Frame Structures Using Program CUFRBC. Volume C. User’s Guide for Channels

DTIC Science & Technology

1990-05-01

1988) or ACI 318-83 (1983). Actual calculations for section strength are made using subroutines taken from the CASE program CSTR (Hamby and Price...validity of the design of their par- ticular structure. Thus, it is essential that the user of the program under- stand the design algorithm included...modes. However, several restrictions were placed on the design mode to avoid unnecessary com- plications of the design algorithm for cases rarely

Round pneumonia in an adult.

PubMed

Zhang, Yi; Yu, Yong-Sheng; Tang, Zheng-Hao; Chen, Xiao-Hua; Zang, Guo-Qing

2014-01-01

Round pneumonia is an uncommon form of pulmonary infection usually found in children. It may resemble pulmonary neoplasm on radiographs. We present a case of round pneumonia in a 43-year-old male with a history of smoking and a family history of lung cancer. The patient was treated with antibiotics for more than two weeks, after which the infection resolved completely both clinically and radiologically. Clinicians should consider this uncommon type of pneumonia in the differential diagnosis of spherical pulmonary masses to avoid unnecessary diagnostic tests.

[Practical approach to management of gynecomastia: six questions to be answered by the paediatrician regarding a patient with gynecomastia].

PubMed

2011-08-01

Pubertal gynecomastia is a common concern in the consultation of the adolescent. Usually, it is accompanied by an emotional component that can lead to changes in everyday attitudes of youth. The responsability of the pediatrician is to rule out other etiologies, to avoid unnecessary additional studies, to limit active therapeutic attitudes, and to reaffirm the variation of normality. We briefly describe six eminently practical questions to be answered by the physician.

Harlequin color change after abdominal paracentesis in a newborn with neonatal hemochromatosis.

PubMed

Cizmeci, Mehmet N; Alagoz, Demet; Avsar, Mehmet I; Alis, Gulten; Tutanc, Murat

2014-01-01

Harlequin color change is a distinctive cutaneous phenomenon presenting as a well-demarcated color change, with half of the body displaying erythema and the other half pallor. Only a few cases have been reported, possibly because of under-recognition. Recognition of this benign, self-limited condition may enable physicians to avoid unnecessary interventions. Herein we describe a neonate with nonimmune hydrops fetalis due to neonatal hemochromatosis who developed Harlequin color change after abdominal paracentesis. © 2014 Wiley Periodicals, Inc.

An interdisciplinary assessment of regional-scale nonpoint source ground-water vulnerability; theory and application

USGS Publications Warehouse

Bernknopf, Richard L.; Dinitz, Laura B.; Loague, Keith

2001-01-01

An integrated earth science-economics model, developed within a geographic information system (GIS), combines a regional-scale nonpoint source vulnerability assessment with a specific remediation measure to avoid unnecessary agricultural production costs associated with the use of agrochemicals in the Pearl Harbor basin on the island of Oahu, Hawaii. This approach forms the core of a risk-based regulation for the application of agrochemicals and estimates the benefits of an information-based approach to decisionmaking.

Avoidable interruptions during drug administration in an intensive rehabilitation ward: improvement project.

PubMed

Buchini, Sara; Quattrin, Rosanna

2012-04-01

To record the frequency of interruptions and their causes, to identify 'avoidable' interruptions and to build an improvement project to reduce 'avoidable' interruptions. In Italy each year 30,000-35,000 deaths per year are attributed to health-care system errors, of which 19% are caused by medication errors. The factors that contribute to drug management error also include interruptions and carelessness during treatment administration. A descriptive study design was used to record the frequency of interruptions and their causes and to identify 'avoidable' interruptions in an intensive rehabilitation ward in Northern Italy. A data collection grid was used to record the data over a 6-month period. A total of 3000 work hours were observed. During the study period 1170 interruptions were observed. The study identified 14 causes of interruption. The study shows that of the 14 cases of interruptions at least nine can be defined as 'avoidable'. An improvement project has been proposed to reduce unnecessary interruptions and distractions to avoid making errors. An additional useful step to reduce the incidence of treatment errors would be to implement the use of a single patient medication sheet for the recording of drug prescription, preparation and administration and also the incident reporting. © 2011 Blackwell Publishing Ltd.

Double-blind placebo-controlled food challenges in children with alleged cow's milk allergy: prevention of unnecessary elimination diets and determination of eliciting doses.

PubMed

Dambacher, Wendy M; de Kort, Ellen H M; Blom, W Marty; Houben, Geert F; de Vries, Esther

2013-02-08

Children with cow's milk allergy (CMA) need a cow's milk protein (CMP) free diet to prevent allergic reactions. For this, reliable allergy-information on the label of food products is essential to avoid products containing the allergen. On the other hand, both overzealous labeling and misdiagnosis that result in unnecessary elimination diets, can lead to potentially hazardous health situations. Our objective was to evaluate if excluding CMA by double-blind placebo-controlled food challenge (DBPCFC) prevents unnecessary elimination diets in the long term. Secondly, to determine the minimum eliciting dose (MED) for an acute allergic reaction to CMP in DBPCFC positive children. All children with suspected CMA under our care (Oct'05-Jun'09) were prospectively enrolled in a DBPCFC. Placebo and verum feedings were administered on two randomly assigned separate days. The MED was determined by noting the 'lowest observed adverse effect level' (LOAEL) in DBPCFC-positive children. Based on the outcomes of the DBPCFC a dietary advice was given. Parents were contacted by phone several months later about the diet of their child. 116 children were available for analysis. In 76 children CMA was rejected. In 60 of them CMP was successfully reintroduced, in 2 the parents refused introduction, in another 3 the parents stopped reintroduction. In 9 children CMA symptoms reappeared. In 40 children CMA was confirmed. Infants aged ≤ 12 months in our study group have a higher cumulative distribution of MED than older children. Excluding CMA by DBPCFC successfully stopped unnecessary elimination diets in the long term in most children. The MEDs form potential useful information for offering dietary advice to patients and their caretakers.

Genetically-Adjusted PSA Values May Prevent Delayed Biopsies in African-American Men

PubMed Central

Donin, Nicholas; Loeb, Stacy; Cooper, Phillip R.; Roehl, Kimberly A.; Baumann, Nikola A.; J.Catalona, William; Helfand, Brian T.

2014-01-01

Purpose Genetic variants called PSA-single nucleotide polymorphisms (PSA-SNPs) have been associated with serum PSA levels. We previously demonstrated that genetic correction of serum PSA in Caucasian men could reduce both potentially unnecessary biopsies by 15% to 20% and potentially delayed biopsies by 3%. Our objective was to evaluate whether genetic correction with the PSA-SNPs could reduce potentially unnecessary and/or delayed biopsies in African-American (AA) men. Materials and Methods We compared the genotypes of 4 PSA-SNPs between 964 Caucasian and 363 AA men without known PC. We adjusted PSA values based upon an individual's PSA-SNP carrier status, and calculated the percentage of men that would meet commonly used PSA thresholds for biopsy (≥2.5 or ≥4.0ng/mL) before and after genetic correction. Potentially unnecessary and delayed biopsies were defined as those men who went below and above the biopsy threshold after genetic correction, respectively. Results Overall, 349 (96.1%) and 354 (97.5%) AA men had measured PSA levels <2.5 and <4.0 ng/mL. Genetic correction in AA men did not avoid any potentially unnecessary biopsies, but resulted in a significant (p<0.001) reduction in potentially delayed biopsies by 2.5% and 3.9% based upon the biopsy threshold cutoff. Conclusions There are significant differences in the influence of the PSA-SNPs between AA and Caucasian men without known PC, as genetic correction resulted in an increased proportion of AA men crossing the threshold for biopsy. These results raise the question whether genetic differences in PSA might contribute to delayed PC diagnosis in AA patients. PMID:24712975

Cervical adenopathy secondary to toxoplasmosis.

PubMed

Rafaty, F M

1977-09-01

Toxoplasmosis is not a rare disease. Infestation occurs in 75% of the general world population and in 35% of the US population. Lymphadenopathy, primarily of the cervical type, is one of the most common signs of acquired toxoplasmosis. During the past 15 years a great number of reports have appeared in the medical literature regarding toxoplasmosis. However, it seems that most clinicians do not consider this disease as a possibility when they encounter patients with unexplained cervical adenopathy in whom the usual tests for infectious mononucleosis are negative. In fact, the majority of such patients come to the operating room with a suspected diagnosis of malignant neoplasm, particularly of malignant lymphoma. Thus, a great deal of unnecessary anxiety is generated and, at times, unnecessary surgery is performed. These may be avoidable. A total of 38 cases of acquired toxoplasmosis manifested by lymphadenopathy (82% in the cervical region) are analyzed with respect to symptomatology, differential diagnosis, clinical and laboratory diagnosis, and treatment. Toxoplasmosis should be included in the differential diagnosis of patients with cervical tumors.

Committee Opinion No. 723 Summary: Guidelines for Diagnostic Imaging During Pregnancy and Lactation.

PubMed

2017-10-01

Imaging studies are important adjuncts in the diagnostic evaluation of acute and chronic conditions. However, confusion about the safety of these modalities for pregnant and lactating women and their infants often results in unnecessary avoidance of useful diagnostic tests or the unnecessary interruption of breastfeeding. Ultrasonography and magnetic resonance imaging are not associated with risk and are the imaging techniques of choice for the pregnant patient, but they should be used prudently and only when use is expected to answer a relevant clinical question or otherwise provide medical benefit to the patient. With few exceptions, radiation exposure through radiography, computed tomography scan, or nuclear medicine imaging techniques is at a dose much lower than the exposure associated with fetal harm. If these techniques are necessary in addition to ultrasonography or magnetic resonance imaging or are more readily available for the diagnosis in question, they should not be withheld from a pregnant patient. Breastfeeding should not be interrupted after gadolinium administration.

Committee Opinion No. 723: Guidelines for Diagnostic Imaging During Pregnancy and Lactation.

PubMed

2017-10-01

Imaging studies are important adjuncts in the diagnostic evaluation of acute and chronic conditions. However, confusion about the safety of these modalities for pregnant and lactating women and their infants often results in unnecessary avoidance of useful diagnostic tests or the unnecessary interruption of breastfeeding. Ultrasonography and magnetic resonance imaging are not associated with risk and are the imaging techniques of choice for the pregnant patient, but they should be used prudently and only when use is expected to answer a relevant clinical question or otherwise provide medical benefit to the patient. With few exceptions, radiation exposure through radiography, computed tomography scan, or nuclear medicine imaging techniques is at a dose much lower than the exposure associated with fetal harm. If these techniques are necessary in addition to ultrasonography or magnetic resonance imaging or are more readily available for the diagnosis in question, they should not be withheld from a pregnant patient. Breastfeeding should not be interrupted after gadolinium administration.

[Food allergy in children: recommendations for diagnosis and treatment].

PubMed

2018-02-01

Food allergy arises from a specific immune response induced by food exposure. It is the first cause of anaphylaxis in childhood. Its prevalence increased exponentially in western countries. The proteins most frequently involved in infants are cow's milk and hen's egg; and in adults, seafood. Peanuts have the same frequency in both groups. The clinical manifestations and methodology of study are directly related to the pathophysiology of the disease. Clinical history, skin prick test, patch test, and food oral challenge are essential to arrive at a correct diagnosis, that will avoid unnecessary exclusions or exposures that carry life risk. The treatment is based on the correct avoidance of responsible food (considering hidden allergens), besides patient and their care giver's education, to maintain a good quality of life. Sociedad Argentina de Pediatría.

Justice and health care: When “ordinary” is extraordinary†

PubMed Central

McTavish, James

2016-01-01

In some Asian countries, the poor are often denied access to health care. In the Philippines, we have thousands of Catholic doctors, Catholic nurses, even Catholic administrators, but not a Catholic, understood as “universal,” healthcare system available to all. This is a scandal and places heavy emotional and financial burdens on many families who need to pay the healthcare costs of sick loved ones. The Church teaches the principles of ordinary and extraordinary care, with only the former being morally obligatory. Extraordinary care, that involving excessive burden or cost may be foregone. Many families and healthcare professionals are uncertain about these principles and their application in practice. It would be helpful to more widely disseminate the Catholic Church teaching regarding ordinary and extraordinary care, especially in poor countries, to also avoid unnecessary or futile treatments, especially in critical or end-of-life situations. Lay Summary: The poor have limited access to health care in many countries. Even one episode of sickness often places the patient and their family under considerable financial strain. Many times they simply cannot afford even basic treatments. This is a scandal and an injustice which is the concern of us all. The Church teaches that when a treatment becomes very expensive it may be considered “extraordinary care” and not morally obligatory. It would be helpful to more widely disseminate this Catholic Church teaching, helping families to avoid unnecessary treatments especially in critical or end-of-life situations. PMID:27833180

Choosing Wisely: The Top-5 Recommendations from the Italian Panel of the National Guidelines for the Management of Acute Pharyngitis in Children.

PubMed

Chiappini, Elena; Bortone, Barbara; Di Mauro, Giuseppe; Esposito, Susanna; Galli, Luisa; Landi, Massimo; Novelli, Andrea; Marchisio, Paola; Marseglia, Gian Luigi; Principi, Nicola; de Martino, Maurizio

2017-03-01

With the aim to reduce waste in the health care system and avoid risks associated with unnecessary treatment, the Italian Panel of the National Guidelines for the Management of Acute Pharyngitis in Children joined the Choosing Wisely initiative. An ad hoc Choosing Wisely task force was selected to develop a candidate list of items for the top-5 list on pharyngitis medicine. Through a process of literature review and consensus, the final list of 5 items was chosen. Drafted recommendations were formulated and then reviewed by the task force members until a final consensus was reached. The 5 recommendations approved are: blood exams should not be performed; antibiotics should not be administrated unless microbiologic confirmation of streptococcal infection has been carried out; if a throat culture is performed, susceptibility tests on isolates should not be executed; antibiotic course should not be shortened; because penicillin V is not available in Italy, amoxicillin (50 mg/kg/d in 2-3 doses orally) for 10 days is the first choice treatment; and steroids should not be administered for the risk of masking possible underlying severe condition. This top-5 list can be a novel tool to spread the key messages of guidelines and to avoid unnecessary diagnostic procedures, and to promote a rational use of antibiotics in children. Copyright © 2017 Elsevier HS Journals, Inc. All rights reserved.

Concomitant hollow viscus injuries in patients with blunt hepatic and splenic injuries: an analysis of a National Trauma Registry database.

PubMed

Swaid, Forat; Peleg, Kobi; Alfici, Ricardo; Matter, Ibrahim; Olsha, Oded; Ashkenazi, Itamar; Givon, Adi; Kessel, Boris

2014-09-01

Non-operative management has become the standard approach for treating stable patients sustaining blunt hepatic or splenic injuries in the absence of other indications for laparotomy. The liberal use of computed tomography (CT) has reduced the rate of unnecessary immediate laparotomies; however, due to its limited sensitivity in the diagnosis of hollow viscus injuries (HVI), this may be at the expense of a rise in the incidence of missed HVI. The aim of this study was to assess the incidence of concomitant HVI in blunt trauma patients diagnosed with hepatic and/or splenic injuries, and to evaluate whether a correlation exists between this incidence and the severity of hepatic or splenic injuries. A retrospective cohort study involving blunt trauma patients with splenic and/or liver injuries, between the years 1998 and 2012 registered in the Israel National Trauma Registry. The association between the presence and severity of splenic and/or liver injuries and the incidence of HVI was examined. Of the 57,130 trauma victims identified as suffering from blunt torso injuries, 2335 (4%) sustained hepatic injuries without splenic injuries (H group), 3127 (5.4%) had splenic injuries without hepatic injuries (S group), and 564 (1%) suffered from both hepatic and splenic injuries (H+S group). Overall, 957 patients sustained 1063 HVI. The incidence of HVI among blunt torso trauma victims who sustained neither splenic nor hepatic injuries was 1.5% which is significantly lower than in the S (3.1%), H (3.1%), and H+S (6.7%) groups. In the S group, there was a clear correlation between the severity of the splenic injury and the incidence of HVI. This correlation was not found in the H group. The presence of blunt splenic and/or hepatic injuries predicts a higher incidence of HVI, especially if combined. While in blunt splenic injury patients there is a clear correlation between the incidence of HVI and the severity of splenic injury, such a correlation does not exist in patients with blunt hepatic injury. Copyright © 2014 Elsevier Ltd. All rights reserved.

[Comparison of the results of laparotomy and laparoscopic surgery in patients with Crohn's disease].

PubMed

Horváth, Gyula; Simonka, Zsolt; Lázár, György

2014-01-05

Crohn's disease is an inflammatory bowel disease which may affect different parts of the gastrointestinal tract. To compare retrospectively the results of laparotomy and laparoscopic surgery performed in patients with Crohn's disease between January 1, 2005 and October 31, 2012 in the Department of Surgery, University of Szeged, Hungary. Patients were divided into two groups based on the types of surgery; 103 patients underwent laparotomy and 30 patients had laparoscopic surgery programmed. 22 patients had 24 primary acute interventions. The mean age was significantly lower in the laparoscopic surgery group (p = 0.042). The laparoscopic ileocecal resections have been found significantly shorter than laparotomies (p = 0.033). When ileocecal resection was performed the operation time was significantly longer (p = 0.033) while hospitalization time (p = 0.025) and intensive care unit treatment time (p<0.001) were shorter and the bowel passage also started earlier in the laparoscopic group as compared to the laparotomy group. Laparoscopic surgery results in smaller surgical trauma, better cosmetic outcome, shorter hospitalization time and not higher complication- and morbidity-rate as well as shorter operation time in certain cases. However, it requires more qualified surgical team and the operation expenses are higher.

Reduction of uterine prolapse in a sow by laparotomy.

PubMed

Raleigh, P J

1977-01-29

In the past, total uterine prolapse in the sow has been regarded as a grave condition because manipulative reposition through the vulva and vagina is extremely difficult, if not impossible, and amputation is merely a salvage procedure with a mortality rate approaching 100 percent. Laparotomy as a means of facilitating reduction of the prolapse in the sow appears to have been overlooked although it is a standard procedure in dogs and cats. This report describes a case of uterine prolapse in a sow successfully treated by laparotomy.

Assessing the cost of laparotomy at a rural district hospital in Rwanda using time‐driven activity‐based costing

PubMed Central

Odhiambo, J.; Riviello, R.; Lin, Y.; Nkurunziza, T.; Shrime, M.; Maine, R.; Omondi, J. M.; Mpirimbanyi, C.; de la Paix Sebakarane, J.; Hagugimana, P.; Rusangwa, C.; Hedt‐Gauthier, B.

2018-01-01

Background In low‐ and middle‐income countries, the majority of patients lack access to surgical care due to limited personnel and infrastructure. The Lancet Commission on Global Surgery recommended laparotomy for district hospitals. However, little is known about the cost of laparotomy and associated clinical care in these settings. Methods This costing study included patients with acute abdominal conditions at three rural district hospitals in 2015 in Rwanda, and used a time‐driven activity‐based costing methodology. Capacity cost rates were calculated for personnel, location and hospital indirect costs, and multiplied by time estimates to obtain allocated costs. Costs of medications and supplies were based on purchase prices. Results Of 51 patients with an acute abdominal condition, 19 (37 per cent) had a laparotomy; full costing data were available for 17 of these patients, who were included in the costing analysis. The total cost of an entire care cycle for laparotomy was US$1023·40, which included intraoperative costs of US$427·15 (41·7 per cent) and preoperative and postoperative costs of US$596·25 (58·3 per cent). The cost of medicines was US$358·78 (35·1 per cent), supplies US$342·15 (33·4 per cent), personnel US$150·39 (14·7 per cent), location US$89·20 (8·7 per cent) and hospital indirect cost US$82·88 (8·1 per cent). Conclusion The intraoperative cost of laparotomy was similar to previous estimates, but any plan to scale‐up laparotomy capacity at district hospitals should consider the sizeable preoperative and postoperative costs. Although lack of personnel and limited infrastructure are commonly cited surgical barriers at district hospitals, personnel and location costs were among the lowest cost contributors; similar location‐related expenses at tertiary hospitals might be higher than at district hospitals, providing further support for decentralization of these services.

Can Teamwork and High-Volume Experience Overcome Challenges of Lymphadenectomy in Morbidly Obese Patients (Body Mass Index of 40 kg/m2 or Greater) with Endometrial Cancer?

PubMed Central

Fornalik, Hubert; Zore, Temeka; Fornalik, Nicole; Foster, Todd; Katschke, Adrian; Wright, Gary

2018-01-01

Objective This study aimed to compare surgical outcomes and the adequacy of surgical staging in morbidly obese women with a body mass index (BMI) of 40 kg/m2 or greater who underwent robotic surgery or laparotomy for the staging of endometrioid-type endometrial cancer. Methods This is a retrospective cohort study of patients who underwent surgical staging between May 2011 and June 2014. Patients' demographics, surgical outcomes, intraoperative and postoperative complications, and pathological outcomes were compared. Results Seventy-six morbidly obese patients underwent robotic surgery, and 35 underwent laparotomy for surgical staging. Robotic surgery was associated with more lymph nodes collected with increasing BMI (P < 0.001) and decreased chances for postoperative respiratory failure and intensive care unit admissions (P = 0.03). Despite a desire to comprehensively stage all patients, we performed successful pelvic and paraaortic lymphadenectomy in 96% versus 89% (P = 0.2) and 75% versus 60% (P = 0.12) of robotic versus laparotomy patients, respectively. In the robotic group, with median BMI of 47 kg/m2, no conversions to laparotomy occurred. The robotic group experienced less blood loss and a shorter length of hospital stay than the laparotomy group; however, the surgeries were longer. Conclusions In a high-volume center, a high rate of comprehensive surgical staging can be achieved in patients with BMI of 40 kg/m2 or greater either by laparotomy or robotic approach. In our experience, robotic surgery in morbidly obese patients is associated with better quality staging of endometrial cancer. With a comprehensive approach, a professional bedside assistant, use of a monopolar cautery hook, and our protocol of treating morbidly obese patients, robotic surgeries can be safely performed in the vast majority of patients with a BMI of 40 kg/m2 or greater, with lymph node counts being similar to nonobese patients, and with conversions to laparotomy reduced to a minimum. PMID:29621128

Laparoscopic surgery for endometrial cancer: increasing body mass index does not impact postoperative complications.

PubMed

Helm, C William; Arumugam, Cibi; Gordinier, Mary E; Metzinger, Daniel S; Pan, Jianmin; Rai, Shesh N

2011-09-01

To determine the effect of body mass index on postoperative complications and the performance of lymph node dissection in women undergoing laparoscopy or laparotomy for endometrial cancer. Retrospective chart review of all patients undergoing surgery for endometrial cancer between 8/2004 and 12/2008. Complications graded and analyzed using Common Toxicity Criteria for Adverse Events ver. 4.03 classification. 168 women underwent surgery: laparoscopy n=65, laparotomy n=103. Overall median body mass index 36.2 (range, 18.1 to 72.7) with similar distributions for age, body mass index and performance of lymph node dissection between groups. Following laparoscopy vs. laparotomy the percent rate of overall complications 53.8:73.8 (p=0.01), grade ≥3 complications 9.2:34.0 (p<0.01), ≥3 wound complications 3.1:22.3 (p<0.01) and ≥3 wound infection 3.1:20.4 (p=0.01) were significantly lower after laparoscopy. In a logistic model there was no effect of body mass index (≥36 and<36) on complications after laparoscopy in contrast to laparotomy. Para-aortic lymph node dissection was performed by laparoscopy 19/65 (29%): by laparotomy 34/103 (33%) p=0.61 and pelvic lymph node dissection by laparoscopy 21/65 (32.3%): by laparotomy 46/103 (44.7%) p=0.11. Logistic regression analysis revealed that for patients undergoing laparoscopy for stage I disease there was an inverse relationship between the performance of both para-aortic lymph node dissection and pelvic lymph node dissection and increasing body mass index (p=0.03 and p<0.01 respectively) in contrast to the laparotomy group where there was a trend only (p=0.09 and 0.05). For patients undergoing laparoscopy, increasing body mass index did not impact postoperative complications but did influence the decision to perform lymph node dissection.

Diagnostic accuracy of ultrasonography in detection of blunt abdominal trauma and comparison of early and late ultrasonography 24 hours after trauma.

PubMed

Feyzi, Ali; Rad, Masoud Pezeshki; Ahanchi, Navid; Firoozabadi, Jalil

2015-01-01

Despite the advantages of ultrasound scan, its use as a screening tool in blunt abdominal trauma is controversial. The aim of this study was to evaluate the diagnostic value of early and late ultrasound in patients with blunt abdominal trauma (BAT). In this study which was performed in a level I trauma center, firstly, 2418 patients with BAT had ultrasound (US) examination by two trauma expert radiologists. Results were compared with the best available gold standards such as laparotomy, CT, repeated ultrasound or clinical course follow-up. Then, 400 patients with BAT were examined by a trained residency student. In the first phase, sensitivity, specificity, negative predictive value, positive predictive value and accuracy of ultrasound were 97%, 98.1%, 99.7%, 83% and 98% respectively. In the second phase, they were 97.3%, 97.2%, 97.7%, 96.8% and 97.3% for the early and 98.5%, 97.6%, 98.5%, 97.5% and 98% for the late ultrasound respectively. Results obtained from this study indicate that negative ultrasound findings associated with negative clinical observation virtually exclude abdominal injury, and confirmation by performing other tests is unnecessary. High sensitivity and negative predictive value is achieved if ultrasound is performed by expert trauma radiologist.

Surgical management of breast cancer liver metastases

PubMed Central

Cassera, Maria A; Hammill, Chet W; Ujiki, Michael B; Wolf, Ronald F; Swanström, Lee L; Hansen, Paul D

2011-01-01

Introduction Selected patients with isolated breast cancer liver metastases (BCLM) may benefit from surgical management; however, indications remain unclear and the risks may outweigh the benefits in patients with a generally poor prognosis. Methods Between 1998 and 2006, 17 patients diagnosed with BCLM were considered for surgical management (<4 tumours, tumour <4 cm in diameter and no/stable extrahepatic metastases). Peri-operative and outcomes data were analysed and compared. Results Eight patients were found to have extensive or untreatable disease on staging laparoscopy and intra-operative ultrasound (SL/IOUS). The remaining nine patients underwent surgical management [seven laparoscopic radiofrequency ablations (RFA) and two hepatic resections]. Median length of follow-up for patients treated surgically was 40.0 months, median disease-free survival (DFS) was 32.2 months and median time to disease progression was 17.7 months. Of the eight patients not amenable to surgery, median length of follow-up was 21.8 months. Conclusion SL/IOUS prevented unnecessary laparotomy in half of the patients taken to the operating room for surgical treatment of BCLM. In patients with BCLM, SL/IOUS should be considered standard of care before surgical intervention. The small number of patients and short follow-up may be inadequate to determine the true value of surgical management in this group of patients with BCLM. PMID:21418133

[Factitious fevers as a cause of prolonged fevers. Apropos of 5 clinical cases].

PubMed

Potin, M; Regamey, C; Glauser, M P

1983-10-22

Among the numerous causes of prolonged fever of unknown origin, the factitious fevers are frequently considered last after much diagnostic and therapeutic effort. Five observations of factitious fever are presented including 2 cases of thermometer manipulation in men aged 45 and 80. The latter patient is the oldest in whom such a case has been reported. In the first case the prolonged fever led to exploratory laparotomy with splenectomy followed by antilymphoma chemotherapy before the thermometer manipulation was discovered. This patient had previously been treated successfully for stage Ib Hodgkin lymphoma. In the other case hospitalization had lasted several weeks, and much antibiotic and steroid treatment had been administered, before the manipulation was suspected. A third case of thermometer manipulation was observed in a 57-year-old woman who had been presenting with factitious symptoms for over 10 years. Two other cases of factitious fever due to self-induced infections have been observed in two young women aged 23 and 27, both in paramedical professions. These self-induced infections led to polymicrobial bacteremia, exploratory laparotomy and hemicolectomy in one case, and to probable bacterial meningitis in the other. Certain aspects of these cases agree well with the diagnostic criteria of factitious fever described in the literature. We feel it is important to recognize this cause of febrile states, even if there is an apparent etiology, in order to avoid much vain investigation and prolonged hospitalization.

Closed-incision negative-pressure therapy in high-risk general surgery patients following laparotomy: a retrospective study.

PubMed

Zaidi, A; El-Masry, S

2017-03-01

Surgical site infection (SSI) and wound dehiscence are dreaded complications following laparotomy in general surgical patients, and can potentially occur more often in various comorbid states. Negative-pressure wound therapy (NPWT) has a positive effect of on open and complicated wounds and so has been used for at-risk surgical incisions with the aim of redistributing lateral tension and holding incision edges together. The aim of the present study was to compare the rate of wound complications following laparotomy in high-risk general surgical patients with a clean incision treated with closed-incision negative-pressure therapy (ciNPT) with those receiving conventional care. A retrospective review was performed of the hospital medical records of patients who underwent laparotomy between 1 October 2010 and 31 March 2012. Records of 69 patients who received ciNPT and 112 who were managed by adherent gauze dressings were included in the final analysis. Two (2.9%) patients in the ciNPT group and 23 (20.5%) in the non-NPWT group developed a wound complication following laparotomy (P < 0.0009). The relative risk (RR) was 0.14 (0.03-0.58), suggesting that infection is less likely to occur in ciNPT-treated incisions, compared with gauze dressings. ciNPT was associated with a positive clinical outcome and was a safe and effective method of postsurgical management in our general surgery patients considered to have risk of developing wound complications following laparotomy. © 2016 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.

Clinical application of 'Justification' and 'Optimization' principle of ALARA in pediatric CT imaging: "How many children can be protected from unnecessary radiation?".

PubMed

Sodhi, Kushaljit S; Krishna, Satheesh; Saxena, Akshay K; Sinha, Anindita; Khandelwal, Niranjan; Lee, Edward Y

2015-09-01

Practice of ALARA (as low as reasonably achievable) principle in the developed world is currently well established. However, there is striking lack of published data regarding such experience in the developing countries. Therefore, the goal of this study is to prospectively evaluate CT request forms to assess how many children could be protected from harmful radiation exposure if 'Justification' and 'Optimization' principles of ALARA are applied before obtaining CT imaging in a developing country. This can save children from potential radiation risks including development of brain cancer and leukemia. Consecutive CT request forms over a six month study period (May 16, 2013 to November 15, 2013) in a tertiary pediatric children's hospital in India were prospectively reviewed by two pediatric radiologists before obtaining CT imaging. First, 'Justification' of CT was evaluated and then 'Optimization' was applied for evaluation of appropriateness of the requested CT studies. The number (and percentage) of CT studies avoided by applying 'Justification' and 'Optimization' principle of ALARA were calculated. The difference in number of declined and optimized CT requests between CT requests from inpatient and outpatient departments was compared using Chi-Square test. A total of 1302 consecutive CT request forms were received during the study period. Some of the request forms (n=86; 6.61%) had requests for more than one (multiple) anatomical regions, hence, a total of 1392 different anatomical CT requests were received. Based on evaluation of the CT request forms for 'Justification' and 'Optimization' principle of ALARA by pediatric radiology reviewers, 111 individual anatomic part CT requests from 105 pediatric patients were avoided. Therefore, 8.06% (105 out of 1302 pediatric patients) were protected from unnecessary or additional radiation exposure.The rates of declined or optimized CT requests from inpatient department was significantly higher than that from outpatient departments (p<0.05). A substantial number of pediatric patients, particularly coming from outpatient departments, can be protected from unnecessary or additional radiation exposure from CT imaging when 'Justification' and 'Optimization' principle of ALARA are applied before obtaining CT imaging in a developing country. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Inadvertent transposition of defibrillator coil terminal pins causing inappropriate ICD therapies.

PubMed

Issa, Ziad F

2008-06-01

We report the case of a 65-year-old man with chronic atrial fibrillation (AF) and severe ischemic cardiomyopathy who underwent implantation of a prophylactic single-chamber implantable cardioverter-defibrillator (ICD). The patient experienced inappropriate ICD therapies due to oversensing of pectoral muscle myopotential secondary to reversal of the defibrillator coil terminal pins in the ICD header. Recognizing this possibility is important to avoid misinterpretation of spontaneous oversensing as hardware failure (e.g., lead fracture or insulation breech) and potentially unnecessary ICD system surgical intervention, including lead extraction.

Human Cell Line Activation Test of the Novel Energetics 2,6-pyrazinediamine 3,5-dinitro 1 -oxide (LLM-105) and 2,4,6-trinitro-3-bromoanisole (TNBA)

DTIC Science & Technology

2017-11-06

substances early in the RDT&E process to avoid unnecessary costs, conserve physical resources, and sustain the health of those potentially exposed. The SERDP...pyrazinediamine 3,5-dinitro 1 –oxide (LLM-105) and 2,4,6-trinitro-3-bromoanisole (TNBA) Prepared by: Emily Reinke, Ph.D. Health Effects Division...Toxicology Directorate Army Public Health Center ARIMS designation: 500c Use of trademarked name(s) does not imply endorsement by the U.S

SAPHO: What radiologists should know.

PubMed

Depasquale, R; Kumar, N; Lalam, R K; Tins, B J; Tyrrell, P N M; Singh, J; Cassar-Pullicino, V N

2012-03-01

SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) is an umbrella acronym for inflammatory clinical conditions whose common denominator is aseptic osteoarticular involvement with characteristic skin lesions. It involves all ages, can involve any skeletal site, and has variable imaging appearances depending on the stage/age of the lesion and imaging method. It mimics important differentials including infection and neoplasia. Awareness of the imaging features, especially in the spine, facilitates early diagnosis, prevents repeated biopsies, and avoids unnecessary surgery, while initiating appropriate treatment. Copyright © 2011 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Tattoo pigment in axillary lymph node mimicking calcification of breast cancer

PubMed Central

Matsika, Admire; Srinivasan, Bhuvana; Gray, Janet Meryl; Galbraith, Christine Ruth

2013-01-01

A tattoo is defined as the intentional or accidental deposit of pigment into the skin. The phenomenon of skin tattooing is on the rise worldwide and complications of tattooing are increasingly being recognised in diagnostic and clinical medicine. We describe a case of calcification-like changes on mammography resembling that of breast malignancy as a result of tattoo pigment deposition in an axillary lymph node. Recognition of such changes in routine breast screening is crucial to avoid further unnecessary invasive investigations and surgery in such patients. PMID:23929611

Retrorectal Tumors

PubMed Central

Neale, Jeffrey A.

2011-01-01

Tumors that arise in the retrorectal (presacral) space are uncommon lesions that present with nonspecific signs and symptoms, which lead to difficult diagnoses. For complete evaluation of the lesion, cross-sectional imaging is required to determine the extent of resection and the appropriate surgical approach. Surgical removal leads to favorable outcomes for patients with benign purely cystic retrorectal tumors. Preoperative tissue diagnosis with transperineal and transsacral biopsies of solid or heterogeneous cystic lesions, are essential to determine the necessity of neoadjuvant therapy, which may decrease local recurrence after surgery and avoid an unnecessary delay in systemic therapy. PMID:22942797

Manufacturing of polylactic acid nanocomposite 3D printer filaments for smart textile applications

NASA Astrophysics Data System (ADS)

Hashemi Sanatgar, R.; Cayla, A.; Campagne, C.; Nierstrasz, V.

2017-10-01

In this paper, manufacturing of polylactic acid nanocomposite 3D printer filaments was considered for smart textile applications. 3D printing process was applied as a novel process for deposition of nanocomposites on PLA fabrics to introduce more flexible, resourceefficient and cost effective textile functionalization processes than conventional printing process like screen and inkjet printing. The aim is to develop an integrated or tailored production process for smart and functional textiles which avoid unnecessary use of water, energy, chemicals and minimize the waste to improve ecological footprint and productivity.

Toward Reliable and Energy Efficient Wireless Sensing for Space and Extreme Environments

NASA Technical Reports Server (NTRS)

Choi, Baek-Young; Boyd, Darren; Wilkerson, DeLisa

2017-01-01

Reliability is the critical challenge of wireless sensing in space systems operating in extreme environments. Energy efficiency is another concern for battery powered wireless sensors. Considering the physics of wireless communications, we propose an approach called Software-Defined Wireless Communications (SDC) that dynamically decide a reliable channel(s) avoiding unnecessary redundancy of channels, out of multiple distinct electromagnetic frequency bands such as radio and infrared frequencies.We validate the concept with Android and Raspberry Pi sensors and pseudo extreme experiments. SDC can be utilized in many areas beyond space applications.

Laser treatment for retinopathy of prematurity through the incubator wall.

PubMed

Dogra, Mangat R; Vinekar, Anand; Viswanathan, Kavitha; Sangtam, Tiakumzuk; Das, Pranab; Gupta, Amod; Dutta, Sourab

2008-01-01

In this era of early treatment for retinopathy of prematurity, sick infants who develop aggressive diseases or remain oxygen and temperature dependent may be treated while they are inside the incubator itself, thus avoiding unnecessary delays. This article describes the treatment of eight infants with retinopathy of prematurity who were dependent on an incubator by using a laser indirect ophthalmoscope delivery system through the slanting transparent wall of the incubator. In this series, which is the largest to date, the relative advantages and disadvantages of the procedure are discussed.

Factitious Disorders and Cardiothoracic Surgery: The Ongoing Multidisciplinary Challenges of a Complex Case

PubMed Central

Firstenberg, Michael S.; Sirak, John H.; Sun, Benjamin; Kasick, David P.

2009-01-01

Chronic factitious disorder, Munchausen's syndrome, can be challenging to manage—particularly when complaints and symptoms suggest medical or surgical emergencies. We present a patient whose problems have spanned many years and a great distance. Hopefully, with a greater awareness of this disease, as this patient continues to seek health care in many different hospitals, the implications of timely access to information, good histories and physical exams, and an index of suspicion can assist in potentially avoiding unnecessary, expensive, and invasive evaluations. PMID:20029640

Electrocardiogram artifact caused by rigors mimicking narrow complex tachycardia: a case report.

PubMed

Matthias, Anne Thushara; Indrakumar, Jegarajah

2014-02-04

The electrocardiogram (ECG) is useful in the diagnosis of cardiac and non-cardiac conditions. Rigors due to shivering can cause electrocardiogram artifacts mimicking various cardiac rhythm abnormalities. We describe an 80-year-old Sri Lankan man with an abnormal electrocardiogram mimicking narrow complex tachycardia during the immediate post-operative period. Electrocardiogram changes caused by muscle tremor during rigors could mimic a narrow complex tachycardia. Identification of muscle tremor as a cause of electrocardiogram artifact can avoid unnecessary pharmacological and non-pharmacological intervention to prevent arrhythmias.

Through the looking glass: Basics and principles of reflectance confocal microscopy.

PubMed

Que, Syril Keena T; Fraga-Braghiroli, Naiara; Grant-Kels, Jane M; Rabinovitz, Harold S; Oliviero, Margaret; Scope, Alon

2015-08-01

Reflectance confocal microscopy (RCM) offers high-resolution, noninvasive skin imaging and can help avoid obtaining unnecessary biopsy specimens. It can also increase efficiency in the surgical setting by helping to delineate tumor margins. Diagnostic criteria and several RCM algorithms have been published for the differentiation of benign and malignant neoplasms. We provide an overview of the basic principles of RCM, characteristic RCM features of normal skin and cutaneous neoplasms, and the limitations and future directions of RCM. Copyright © 2015 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.

Re: Madsen et al. "Unnecessary work tasks and mental health: a prospective analysis of Danish human service workers".

PubMed

Durand-Moreau, Quentin; Loddé, Brice; Dewitte, Jean-Dominique

2015-03-01

Madsen et al (1) recently published a secondary analysis on data provided by the Project on Burnout, Motivation and Job Satisfaction (PUMA). The aim of their study, published in the Scandinavian Journal of Work, Environment & Health was to examine the associations between unnecessary work tasks and a decreased level of mental health. Though the topic was quite novel, reading this work proved disturbing and raised issues. Based on the results of this study, the authors stated that there is an association between unnecessary work tasks (assessed by a single question) and a decreased level of mental health, idem [assessed by the Mental Health Inventory (MHI-5)], in the specific population included in this PUMA survey. The authors point out a limitation of the study, namely that unnecessary work tasks were evaluated using one single question: "Do you sometimes have to do things in your job which appear to be unnecessary?". Semmer defines unnecessary work task as "tasks that should not be carried out at all because they do not make sense or because they could have been avoided, or could be carried out with less effort if things were organized more efficiently" (2). De facto, qualifying what an unnecessary task is requires stating or explaining whether the task makes sense. Making sense or not is not an objective notion. It is very difficult for either a manager or an employee to say if a task is necessary or not. Most important is that it makes sense from the worker's point of view. Making sense and being necessary are not synonyms. Some tasks do not make sense but are economically necessary (eg, when, as physicians, we are reporting our activity using ICD-10 on computers instead of being at patients' bedsides or reading this journal). Thus, there is a wide gap between Semmer's definition and the question used by the authors to evaluate his concept. A secondary analysis based on a single question is not adequate to evaluate unnecessary tasks. Nowadays, the general trend is to reduce the size of questionnaires because they are too long and cannot be used in a routine practice. But an analysis performed on a single question is quite risky: in psychometrics, redundancy is used to confirm a measurement. We lose precision on what exactly we are testing by asking a single question. Madsen et al's results show that among workers saying they are always or often performing unnecessary tasks, the MHI mean score was 74.00 versus 78.20 for people who never or almost never perform unnecessary tasks (P=0.0038). Even though it is a statistically significant result, its clinical relevance is never questioned. What is the impact of losing 4.20 points at MHI test instead of losing 20 points for instance? Statistical difference does not mean clinical relevance. These results show a statistical association, not a causality relationship. The authors did not show that performing unnecessary tasks lowers the level of mental health. It may be the exact opposite. Maybe having poorer mental health (eg, depression, with anhedonia) may make the workers think that what they're doing is useless. In their conclusion, Madsen et al suggest that the elimination of unnecessary work tasks may be beneficial for employees' mental health. To our mind, on the contrary, it may increase psychic suffering. If we suggest to fight unnecessary tasks in workplaces, this may encourage reduction of the margin of manoeuvre (3). The principle of removing unnecessary tasks is part of a Taylorized organization. Some tasks may seem unnecessary or bothersome, but may correspond to work periods that allow for temporary rest. Concretely, in the workplace, managers rather than the employee will be the ones to decide whether a task is useless or not. To improve well-being in the workplace, a global vision of work organization is required. From our point of view, the conclusion drawn from this study should not be that we must eliminate unnecessary tasks, but that we should focus on what makes sense for the worker, with a global view on his work and - as usual - the aim of carrying out further studies on this subject. Conflicts of interest The authors declare no conflict of interest. References 1. Madsen IEH, Tripathi M, Borritz M, Rugulies R, Unnecessary work tasks and mental health: a prospective analysis of Danish human service workers, Scand J Work Environ Health. 2014;40(6):631-8. http://dx.doi.org/10.5271/sjweh.3453.  2. Semmer NK, Tschan F, Meier LL, Facchin S, Jacobshagen N, Illegitimate tasks and counterproductive work behavior, Appl Psychol. 2010;59:70-96. http://dx.doi.org/10.1111/j.1464-0597.2009.00416.x.  3. Durand MJ, Vézina N, Baril R, Loisel P, Richard MC, Ngomo S, Margin of manoeuvre indicators in the workplace during the rehabilitation process: a qualitative analysis, J Occup Rehab. 2009;19:194-202. http://dx.doi.org/10.1007/s10926-009-9173-4.

Food protein-induced enterocolitis syndrome by fish: Not necessarily a restricted diet.

PubMed

Infante, S; Marco-Martín, G; Sánchez-Domínguez, M; Rodríguez-Fernández, A; Fuentes-Aparicio, V; Alvarez-Perea, A; Cabrera-Freitag, P; Morales-Cabeza, C; Zubeldia, J M; Zapatero, L

2018-03-01

Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated gastrointestinal food hypersensitivity usually due to cow's milk or soy. Recent researches show that fish is 1 of the most important triggers of FPIES in the Mediterranean countries. Due to the risk of multiple-food FPIES, avoiding foods in the same category or that often occur together may be reasonable. The aim of this study was to evaluate the evolution and follow-up of FPIES related to fish over a period of 20 years. We describe the clinical features of our population, discuss different approaches to oral food challenges, and analyze the possibility of introducing the culprit fish or other nonrelated fish to avoid unnecessary restricted diets. © 2017 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.

Implementation of Telemedicine Consultation to Assess Unplanned Transfers in Rural Long-Term Care Facilities, 2012-2015: A Pilot Study.

PubMed

Hofmeyer, Joshua; Leider, Jonathon P; Satorius, Jennifer; Tanenbaum, Erin; Basel, David; Knudson, Alana

2016-11-01

Public and private entities in the United States spend billions of dollars each year on potentially avoidable hospitalizations. This is a common occurrence in long-term care (LTC) facilities, especially in rural jurisdictions. This article details the creation of a telemedicine approach to assess residents from rural LTC facilities for potential transfer to hospitals. An electronic LTC (eLTC) pilot was conducted in 20 pilot LTC facilities from 2012-2015. Each site underwent technologic assessment and upgrading to ensure that 2-way video communication was possible. A new central "hub" was staffed with advanced practice providers and registered nurses. Long-term care pilot sites were trained and rolled out over 3 years. This article reports development and implementation of the pilot, as well as descriptive statistics associated with provider assessments and averted transfers. Over 3 years, 736 eLTC consultations occurred in pilot sites. One-quarter of consultations occurred between 10 pm and 9 am. Overall, approximately 31% of cases were transferred. This decreased from 54% of cases in 2013 to 17% in 2015. Rural pilot facilities had an average of 23 eLTC consults per site per year. Averted transfers represent a dramatic benefit to the residents, as potentially avoidable hospitalizations cause undue stress and allow for nosocomial infections, among other risks. In addition, averting these unnecessary transfers likely saved the taxpayers of the United States over $5 million in admission-related charges to Centers for Medicare and Medicaid Services (511 avoided transfers × $11,000 per average hospitalization from a LTC facility). Overall, the eLTC pilot showed promise as a proof-of-concept. The pilot's implementation resulted in increasing utilization and promising reductions in unnecessary transfers to emergency departments and hospitalizations. Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. All rights reserved.

Abdominal Trauma Revisited.

PubMed

Feliciano, David V

2017-11-01

Although abdominal trauma has been described since antiquity, formal laparotomies for trauma were not performed until the 1800s. Even with the introduction of general anesthesia in the United States during the years 1842 to 1846, laparotomies for abdominal trauma were not performed during the Civil War. The first laparotomy for an abdominal gunshot wound in the United States was finally performed in New York City in 1884. An aggressive operative approach to all forms of abdominal trauma till the establishment of formal trauma centers (where data were analyzed) resulted in extraordinarily high rates of nontherapeutic laparotomies from the 1880s to the 1960s. More selective operative approaches to patients with abdominal stab wounds (1960s), blunt trauma (1970s), and gunshot wounds (1990s) were then developed. Current adjuncts to the diagnosis of abdominal trauma when serial physical examinations are unreliable include the following: 1) diagnostic peritoneal tap/lavage, 2) surgeon-performed ultrasound examination; 3) contrast-enhanced CT of the abdomen and pelvis; and 4) diagnostic laparoscopy. Operative techniques for injuries to the liver, spleen, duodenum, and pancreas have been refined considerably since World War II. These need to be emphasized repeatedly in an era when fewer patients undergo laparotomy for abdominal trauma. Finally, abdominal trauma damage control is a valuable operative approach in patients with physiologic exhaustion and multiple injuries.

Conversion of laparoscopic surgery for perforated peptic ulcer: a single-center study.

PubMed

Zimmermann, Markus; Hoffmann, Martin; Laubert, Tilman; Jung, Carlo; Bruch, Hans-Peter; Schloericke, Erik

2015-11-01

A perforated peptic ulcer can be managed laparoscopically in selected patients. The purpose of this study was to evaluate whether conversion of emergency laparoscopy is inferior to primary median laparotomy in terms of postoperative morbidity and mortality. We analyzed patients who underwent laparoscopic or open surgery for a perforated peptic ulcer at the Department of Surgery, University of Schleswig-Holstein, Campus Luebeck between January, 1996 and December, 2010. Perforations were graded according to the Boey classification, a preoperative risk-scoring system. Conversion to laparotomy was necessary in 20 of the 45 patients who underwent laparoscopic surgery (CG); therefore, laparoscopic operations were completed in 25 patients (LG). The third patient cohort comprised 139 patients who underwent primary laparotomy (OG). Overall minor morbidity was significantly lower (p = 0.048) in the LG patients than in the OG patients, whereas no significant differences were found in major morbidity and mortality, particularly between the OG and CG. Patients' suitability for laparoscopic management should be decided on according to Boey's clinical scoring system. Our findings demonstrated that conversion from laparoscopy to laparotomy was not associated with elevated postoperative morbidity or mortality versus initial laparotomy. Therefore, emergency operations may be commenced laparoscopically in selected patients, especially considering the postoperative advantages of this approach.

Professional perspectives on systemic barriers to admission avoidance: learning from a system dynamics study of older people's admission pathways.

PubMed

Walsh, Bronagh; Lattimer, Valerie; Wintrup, Julie; Brailsford, Sally

2015-06-01

There is debate worldwide about the best way to manage increased healthcare demand within ageing populations, particularly rising rates of unplanned and avoidable hospital admissions. To understand health and social care professionals' perspectives on barriers to admission avoidance throughout the admissions journey, in particular: the causes of avoidable admissions in older people; drivers of admission and barriers to use of admission avoidance strategies; and improvements to reduce unnecessary admissions. A qualitative framework analysis of interview data from a System dynamics (SD) modelling study. Semi-structured interviews were conducted with twenty health and social care professionals with experience of older people's admissions. The interviews were used to build understanding of factors facilitating or hindering admission avoidance across the admissions system. Data were analysed using framework analysis. Three overarching themes emerged: understanding the needs of the patient group; understanding the whole system; and systemwide access to expertise in care of older people. There were diverse views on the underlying reasons for avoidable admissions and recognition of the need for whole-system approaches to service redesign. Participants recommended system redesign that recognises the specific needs of older people, but there was no consensus on underlying patient needs or specific service developments. Access to expertise in management of older and frailer patients was seen as a barrier to admission avoidance throughout the system. Providing access to expertise and leadership in care of frail older people across the admissions system presents a challenge for service managers and nurse educators but is seen as a prerequisite for effective admission avoidance. System redesign to meet the needs of frail older people requires agreement on causes of avoidable admission and underlying patient needs. © 2014 John Wiley & Sons Ltd.

International consensus conference on open abdomen in trauma.

PubMed

Chiara, Osvaldo; Cimbanassi, Stefania; Biffl, Walter; Leppaniemi, Ari; Henry, Sharon; Scalea, Thomas M; Catena, Fausto; Ansaloni, Luca; Chieregato, Arturo; de Blasio, Elvio; Gambale, Giorgio; Gordini, Giovanni; Nardi, Guiseppe; Paldalino, Pietro; Gossetti, Francesco; Dionigi, Paolo; Noschese, Giuseppe; Tugnoli, Gregorio; Ribaldi, Sergio; Sgardello, Sebastian; Magnone, Stefano; Rausei, Stefano; Mariani, Anna; Mengoli, Francesca; di Saverio, Salomone; Castriconi, Maurizio; Coccolini, Federico; Negreanu, Joseph; Razzi, Salvatore; Coniglio, Carlo; Morelli, Francesco; Buonanno, Maurizio; Lippi, Monica; Trotta, Liliana; Volpi, Annalisa; Fattori, Luca; Zago, Mauro; de Rai, Paolo; Sammartano, Fabrizio; Manfredi, Roberto; Cingolani, Emiliano

2016-01-01

A part of damage-control laparotomy is to leave the fascial edges and the skin open to avoid abdominal compartment syndrome and allow further explorations. This condition, known as open abdomen (OA), although effective, is associated with severe complications. Our aim was to develop evidence-based recommendations to define indications for OA, techniques for temporary abdominal closure, management of enteric fistulas, and methods of definitive wall closure. The literature from 1990 to 2014 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-analyses] protocol. Seventy-six articles were reviewed by a panel of experts to assign grade of recommendations (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development, and Evaluation] system, and an international consensus conference was held. OA in trauma is indicated at the end of damage-control laparotomy, in the presence of visceral swelling, for a second look in vascular injuries or gross contamination, in the case of abdominal wall loss, and if medical treatment of abdominal compartment syndrome has failed (GoR B, LoE II). Negative-pressure wound therapy is the recommended temporary abdominal closure technique to drain peritoneal fluid, improve nursing, and prevent fascial retraction (GoR B, LoE I). Lack of OA closure within 8 days (GoR C, LoE II), bowel injuries, high-volume replacement, and use of polypropylene mesh over the bowel (GoR C, LoE I) are risk factors for frozen abdomen and fistula formation. Negative-pressure wound therapy allows to isolate the fistula and protect the surrounding tissues from spillage until granulation (GoR C, LoE II). Correction of fistula is performed after 6 months to 12 months. Definitive closure of OA has to be obtained early (GoR C, LoE I) with direct suture, traction devices, component separation with or without mesh. Biologic meshes are an option for wall reinforcement if bacterial contamination is present (GoR C, LoE II). OA and negative-pressure techniques improve the care of trauma patients, but closure must be achieved early to avoid complications.

The effect of laparotomy on hydroxyl radicals, singlet oxygen and antioxidants measured by EPR method in the tails of rats.

PubMed

Fricova, Jitka; Stopka, Pavel; Krizova, Jana; Yamamotova, Anna; Rokyta, Richard

2009-01-01

The aim of the study was to demonstrate that direct measurement of hydroxyl radicals and singlet oxygen in the tail of living rats is possible. The basic level of hydroxyl radicals and singlet oxygen were measured and the effects of antioxidants on their levels were studied in the tail of living anaesthetized rats after acute postoperative pain. Laparotomy was performed as the source of acute abdominal pain. After closure of the abdominal cavity, the animals began to awaken within 30-60 minutes. They were left to recover for 2-3 hours; then they were reanesthetized and the effect of antioxidants was measured on the numbers of hydroxyl radicals and singlet oxygen via blood in the tail. The laparotomy was preformed under general anesthesia (Xylazin and Ketamin) using Wistar rats. After recovery and several hours of consciousness they were reanaesthetized and free radicals and singlet oxygen were measured. An antioxidant mixture (vitamins A, C, D and Selenium) was administered intramuscularly prior to the laparotomy. All measurements were done on the tail of anaesthetized animals. In this particular article, the effect of antioxidants is only reported for hydroxyl radicals. After laparotomy, which represented both somatic and visceral pain, hydroxyl radicals and singlet oxygen were increased. Antioxidant application prior to laparotomy decreased the numbers of hydroxyl radicals. Results are in agreement with our previous finding regarding the increase in hydroxyl free radicals and singlet oxygen following nociceptive stimulation, in this case a combination of both somatic and visceral pain. The administered antioxidants mitigated the increase. This is further confirmation that direct measurement of free radicals and singlet oxygen represents a very useful method for the biochemical evaluation of pain and nociception.

Postoperative intra-abdominal collections using a sodium hyaluronate-carboxymethylcellulose (HA-CMC) barrier at the time of laparotomy for uterine or cervical cancers.

PubMed

Leitao, Mario M; Byrum, Graham V; Abu-Rustum, Nadeem R; Brown, Carol L; Chi, Dennis S; Sonoda, Yukio; Levine, Douglas A; Gardner, Ginger J; Barakat, Richard R

2010-11-01

A prior analysis of patients undergoing laparotomy for ovarian malignancies at our institution revealed an increased rate of intra-abdominal collections using HA-CMC film during debulking surgery. The primary objective of the current study was to determine whether the use of HA-CMC is associated with the development of postoperative intra-abdominal collections in patients undergoing laparotomy for uterine or cervical malignancies. We retrospectively identified all laparotomies performed for these malignancies from 3/1/05 to 12/31/07. We identified cases involving the use of HA-CMC via billing records and operative reports. Intra-abdominal collections were defined as localized intraperitoneal fluid accumulations in the absence of re-accumulating ascites. We noted incidences of intra-abdominal collections, as well as other complications. Appropriate statistical tests were applied using SPSS 15.0. We identified 169 laparotomies in which HA-CMC was used and 347 in which HA-CMC was not used. The following were statistically similar in both cohorts: age, body mass index (BMI), primary site, surgery for recurrent disease, prior intraperitoneal surgery, and extent of current surgery. Intra-abdominal collections were seen in 6 (3.6%) of 169 HA-CMC cases compared to 10 (2.9%) of 347 non-HA-CMC cases (p=0.7). The rate of infected collections was similar in both groups (1.2% vs. 1.4%). In the subgroup that underwent tumor debulking, intra-abdominal collections were seen in 3 (11.5%) of 26 HA-CMC cases compared to 2 (5.4%) of 37 non-HA-CMC cases (p=0.6). HA-CMC use does not appear to be associated with postoperative intra-abdominal collections in patients undergoing laparotomy for uterine or cervical cancer. Copyright © 2010 Elsevier Inc. All rights reserved.

[Diagnostic and therapeutic activity moderation. Quaternary and genetic prevention].

PubMed

Gérvas, Juan

2006-03-01

Medical activities have more positive than negative outcomes. Because this balance, medicine has a great social recognition. But with new technology and more aggressive diagnostic and therapeutic interventions, there is a decreasing gap in between benefits and harms. Risk increases because more interventions, and because placing patients in more technology environments. As a consecuence, patient safety decreases. Quantity becomes as important as quality, and the place of care is crucial for patient safety. Medical activities should be of , performed in the low level of care possible. Then, quaternary prevention (to avoid unnecessary use and risk of medical interventions) should be a continuous parallel clinical activity. I consider four examples of needed quaternary prevention, with Spanish data: 1) cardiovascular prevention (where there is an inverse use of resources, as patients who need more receive less); 2) use of new antidepressants (which has provoke an artificial epidemic of

Sonographic Appearance of Testicular Adrenal Rest Tumour in a Patient with Congenital Adrenal Hyperplasia.

PubMed

Deshpande, Saurabh S; Shetty, Devdas; Saifi, Shenaz

2017-01-01

Testicular adrenal rest tumours (TARTs) are benign testicular masses that are found in inadequately treated patients with congenital adrenal hyperplasia (CAH). Recognizing this association and identifying characteristic ultrasound features of TARTs is important so as to avoid misdiagnosing them as malignancies, which can lead to unnecessary interventions. We describe a case of a 9-year-old boy, with a diagnosis of CAH and precocious puberty, who was referred to our department for an ultrasound evaluation of the abdomen and scrotum. On ultrasound, there were well-defined, heterogeneous, predominantly hypoechoic, round-to-oval masses in both testes. Taking into account the presence of CAH and a typical sonographic appearance of bilateral testicular masses, a diagnosis of testicular adrenal rest tumour was made; biopsy was deferred and hormonal treatment was modified. Prompt diagnosis of testicular adrenal rest tumours is essential, as it only indicates inadequate hormonal control. Moreover, it can prevent unnecessary biopsies and orchidectomies, and can maintain fertility. TARTs have a typical imaging appearance that every radiologist must be aware of.

Sonographic Appearance of Testicular Adrenal Rest Tumour in a Patient with Congenital Adrenal Hyperplasia

PubMed Central

Shetty, Devdas; Saifi, Shenaz

2017-01-01

Summary Background Testicular adrenal rest tumours (TARTs) are benign testicular masses that are found in inadequately treated patients with congenital adrenal hyperplasia (CAH). Recognizing this association and identifying characteristic ultrasound features of TARTs is important so as to avoid misdiagnosing them as malignancies, which can lead to unnecessary interventions. Case Report We describe a case of a 9-year-old boy, with a diagnosis of CAH and precocious puberty, who was referred to our department for an ultrasound evaluation of the abdomen and scrotum. On ultrasound, there were well-defined, heterogeneous, predominantly hypoechoic, round-to-oval masses in both testes. Taking into account the presence of CAH and a typical sonographic appearance of bilateral testicular masses, a diagnosis of testicular adrenal rest tumour was made; biopsy was deferred and hormonal treatment was modified. Conclusions Prompt diagnosis of testicular adrenal rest tumours is essential, as it only indicates inadequate hormonal control. Moreover, it can prevent unnecessary biopsies and orchidectomies, and can maintain fertility. TARTs have a typical imaging appearance that every radiologist must be aware of. PMID:29662583

Optimization of Multiple Related Negotiation through Multi-Negotiation Network

NASA Astrophysics Data System (ADS)

Ren, Fenghui; Zhang, Minjie; Miao, Chunyan; Shen, Zhiqi

In this paper, a Multi-Negotiation Network (MNN) and a Multi- Negotiation Influence Diagram (MNID) are proposed to optimally handle Multiple Related Negotiations (MRN) in a multi-agent system. Most popular, state-of-the-art approaches perform MRN sequentially. However, a sequential procedure may not optimally execute MRN in terms of maximizing the global outcome, and may even lead to unnecessary losses in some situations. The motivation of this research is to use a MNN to handle MRN concurrently so as to maximize the expected utility of MRN. Firstly, both the joint success rate and the joint utility by considering all related negotiations are dynamically calculated based on a MNN. Secondly, by employing a MNID, an agent's possible decision on each related negotiation is reflected by the value of expected utility. Lastly, through comparing expected utilities between all possible policies to conduct MRN, an optimal policy is generated to optimize the global outcome of MRN. The experimental results indicate that the proposed approach can improve the global outcome of MRN in a successful end scenario, and avoid unnecessary losses in an unsuccessful end scenario.

[Shall all lobular intraepithelial neoplasia diagnosed on image-guided biopsy require a surgical management?].

PubMed

Fischer-Hunsinger, Maeva; Guinebretière, Jean-Marc; Lasry, Serge; Langer, Adriana; Berment, Hélène; Nekka, Ibtissem; Nodiot, Philippe; Cherel, Pascal

2016-05-01

Lobular intraepithelial neoplasia (LIN) diagnosed on image-guided biopsy may be associated with an undiagnosed cancer. This is called under-diagnosis. The consequence is that management of these lesions is often surgical. But many surgeries finally are unnecessary. The aim of our study was to define criteria to avoid unnecessary surgery. This is a single-center, retrospective after a database collected prospectively study. Fourteen thousand biopsies were analyzed, including 456 diagnosed NLI. Under-diagnosis rates were analyzed according to many criteria. The average duration of following was 45 months. For atypical lobular hyperplasia (ALH), we obtained 7.6% under-diagnosis and combining several criteria, we got a low risk of cancer (2%). For LCIS, this rate was 23% and any low-risk group could be identified. ALH with calcifications≤20 mm, without any atypical lesion associated, histologically focal and whose removal is representative may be safely observed. For other LIN, surgery remains indicated. Copyright © 2016 Société Française du Cancer. Published by Elsevier Masson SAS. All rights reserved.

Consequences of following the new American Academy of Pediatrics guidelines for imaging children with urinary tract infection.

PubMed

Ristola, Marko Tapani; Hurme, Timo

2015-01-01

Urinary tract infections (UTIs) and vesicoureteral reflux (VUR) are assumed to predispose children to renal damage. Awareness of the significance of VUR and the possibility of reducing UTI recurrence and renal damage has warranted guidelines on which patients should undergo imaging after UTI. An authoritative guideline has been issued by the American Academy of Pediatrics (AAP). This study assessed the applicability of the AAP guidelines to a subpopulation of patients with UTI, 2-24-month-old children with febrile UTI. The records of 394 children aged 2-24 months with their first UTI were reviewed. Data were recorded on the indications for renal and bladder ultrasonography (RBUS) and voiding cystourethrography (VCUG) according to the AAP guidelines, RBUS results, VCUG results, use of antimicrobial prophylaxis, antireflux procedures and other urological treatment, and UTI recurrence. An indication for RBUS was seen in 344 patients. RBUS results were abnormal in 87, including 53 with urinary tract dilatation. An unnecessary RBUS would have been avoided in 43 patients. Seven patients with an abnormal RBUS would not have undergone RBUS. An indication for VCUG was seen in 126 patients. VCUG was performed in 206 patients; VUR was found in 72 patients, including 36 with high-grade VUR. An unnecessary VCUG would have been avoided in 82 patients. High-grade VUR would have been missed in six patients. Five patients would not have undergone surgery. The AAP guidelines for imaging studies in children aged 2-24 months with febrile UTI seem applicable to clinical practice.

Mobile phone-based telemedicine system for the home follow-up of patients undergoing ambulatory surgery.

PubMed

Martínez-Ramos, Carlos; Cerdán, María Teresa; López, Rodrigo S

2009-01-01

A pilot study was done to address the efficacy of a General Packet Radio Service mobile phone-based telemedicine system used to improve follow-up after ambulatory surgery. The method involves sending images of surgical wounds or other areas from the patient's home, to assess local complications and avoid unnecessary hospital visits. Ninety-six (N = 96) patients were enrolled in the study. The phone used was a Nokia 6600, which provides images in Joint Photographic Experts Group format. These images were sent via e-mail and visualized on a standard 17-inch screen of a personal computer. After the follow-up period, self-reported patient satisfaction was assessed by analyzing the replies to a 9-item questionnaire. Thirty of the 96 patients (31.3%) reported local problems including: hematoma in 20 (66.7%) patients, surgical bandage blood-stained in 7 (23.3%), exudates in 1 (3.3%), allergic skin reactions in 1 (3.3%), and bandage too tight in 1 (3.3%). In total, 225 photographs were evaluated by 3 physicians. In all cases, it was possible to identify and assess the postoperative problem with consensus among the 3 physicians. Images served to resolve patients' concerns in 20 individuals (66.7%). In 10 patients (33.3%), concerns were satisfied but it was suggested that follow-up images be sent in the following days. Only 1 patient (3.3%) was asked to visit the hospital. The telemedicine system proposed increases the efficiency of home follow-up to ambulatory surgery, avoids unnecessary hospital visits, and clearly improves patient satisfaction.

Abdominal injuries in a major Scandinavian trauma center – performance assessment over an 8 year period

PubMed Central

2014-01-01

Introduction Damage control surgery and damage control resuscitation have reduced mortality in patients with severe abdominal injuries. The shift towards non-operative management in haemodynamically stable patients suffering blunt abdominal trauma has further contributed to the improved results. However, in many countries, low volume of trauma cases and limited exposure to trauma laparotomies constitute a threat to trauma competence. The aim of this study was to evaluate the institutional patient volume and performance for patients with abdominal injuries over an eight-year period. Methods Data from 955 consecutive trauma patients admitted in Oslo University Hospital Ulleval with abdominal injuries during the eight-year period 2002-2009 were retrospectively explored. A separate analysis was performed on all trauma patients undergoing laparotomy during the same period, whether abdominal injuries were identified or not. Variable life-adjusted display (VLAD) was used in order to describe risk-adjusted survival trends throughout the period and the patients admitted before (Period 1) and after (Period 2) the institution of a formal Trauma Service (2005) were compared. Results There was a steady increase in admitted patients with abdominal injuries, while the number of patients undergoing laparotomy was constant exposing the surgical trauma team leaders to an average of 8 trauma laparotomies per year. No increase in missed injuries or failures of non-operative management was detected. Unadjusted mortality rates decreased from period 1 to period 2 for all patients with abdominal injuries as well as for the patients undergoing laparotomy. However, this apparent decrease was not confirmed as significant in TRISS-based analysis of risk-adjusted mortality. VLAD demonstrated a steady performance throughout the study period. Conclusion Even in a high volume trauma center the exposure to abdominal injuries and trauma laparotomies is limited. Due to increasing NOM, an increasing number of patients with abdominal injuries was not accompanied by an increase in number of laparotomies. However, we have demonstrated a stable performance throughout the study period as visualized by VLAD without an increase in missed injuries or failures of NOM. PMID:25097664

Rationale and design of the Clinical Evaluation of Magnetic Resonance Imaging in Coronary heart disease 2 trial (CE-MARC 2): A prospective, multicenter, randomized trial of diagnostic strategies in suspected coronary heart disease

PubMed Central

Ripley, David P.; Brown, Julia M.; Everett, Colin C.; Bijsterveld, Petra; Walker, Simon; Sculpher, Mark; McCann, Gerry P.; Berry, Colin; Plein, Sven; Greenwood, John P.

2015-01-01

Background A number of investigative strategies exist for the diagnosis of coronary heart disease (CHD). Despite the widespread availability of noninvasive imaging, invasive angiography is commonly used early in the diagnostic pathway. Consequently, approximately 60% of angiograms reveal no evidence of obstructive coronary disease. Reducing unnecessary angiography has potential financial savings and avoids exposing the patient to unnecessary risk. There are no large-scale comparative effectiveness trials of the different diagnostic strategies recommended in international guidelines and none that have evaluated the safety and efficacy of cardiovascular magnetic resonance. Trial Design CE-MARC 2 is a prospective, multicenter, 3-arm parallel group, randomized controlled trial of patients with suspected CHD (pretest likelihood 10%-90%) requiring further investigation. A total of 1,200 patients will be randomized on a 2:2:1 basis to receive 3.0-T cardiovascular magnetic resonance–guided care, single-photon emission computed tomography–guided care (according to American College of Cardiology/American Heart Association appropriate-use criteria), or National Institute for Health and Care Excellence guidelines–based management. The primary (efficacy) end point is the occurrence of unnecessary angiography as defined by a normal (>0.8) invasive fractional flow reserve. Safety of each strategy will be assessed by 3-year major adverse cardiovascular event rates. Cost-effectiveness and health-related quality-of-life measures will be performed. Conclusions The CE-MARC 2 trial will provide comparative efficacy and safety evidence for 3 different strategies of investigating patients with suspected CHD, with the intension of reducing unnecessary invasive angiography rates. Evaluation of these management strategies has the potential to improve patient care, health-related quality of life, and the cost-effectiveness of CHD investigation. PMID:25497243

Hepatocellular carcinoma in Riedel's lobe.

PubMed

Zamfir, R; Braşoveanu, V; Boroş, M; Herlea, V; Popescu, I

2008-01-01

We present a rare case of 65-year female with right abdominal mass and abdominal discomfort; a combination of Doppler ultrasonography, computed tomography and laparotomy was utilized to make a diagnosis of tumoral Riedel's lobe. In our case, laparotomy with resection of Riedel's lobe was the proper therapeutical solution.

The spectrum of injuries resulting from posterior abdominal stab wounds: a South African experience

PubMed Central

Oosthuizen, GV; Clarke, DL

2015-01-01

Introduction The spectrum of injury associated with anterior abdominal stab wounds (SWs) is well established. The literature on the spectrum of organ injury associated with SWs to the posterior abdomen, however, is limited. Methods We reviewed our experience of 105 consecutive patients who had established indications for laparotomy managed over a 4-year period in a high volume trauma service in South Africa. Results Of the 105 patients, 97 (92%) were male and the overall mean age was 24 years. Fifty-seven patients (54%) had immediate indications for laparotomy. The remaining 48 patients (46%) initially underwent active clinical observation and the indications for laparotomy became apparent during the observation period. Of the 105 laparotomies performed, 94 (90%) were positive and 11 (10%) were negative. Of the 94 positive laparotomies, 92 were therapeutic and 2 were non-therapeutic. A total of 176 organ injuries were identified: 50 (53%) of the 94 patients sustained a single organ injury while the remaining 44 (47%) sustained multiple organ injuries. The most commonly injured organs were the colon (n=63), spleen (n=21) and kidney (n=19). Conclusions The pattern of intra-abdominal injuries secondary to SWs to the posterior abdomen is different to that seen with the anterior abdomen. Colonic injury is most commonly encountered, followed by injuries to the spleen and kidney. Clinicians must remain vigilant because of the potential for occult injuries. PMID:26263933

The spectrum of injuries resulting from posterior abdominal stab wounds: a South African experience.

PubMed

Kong, V Y; Oosthuizen, G V; Clarke, D L

2015-05-01

The spectrum of injury associated with anterior abdominal stab wounds (SWs) is well established. The literature on the spectrum of organ injury associated with SWs to the posterior abdomen, however, is limited. We reviewed our experience of 105 consecutive patients who had established indications for laparotomy managed over a 4-year period in a high volume trauma service in South Africa. Of the 105 patients, 97 (92%) were male and the overall mean age was 24 years. Fifty-seven patients (54%) had immediate indications for laparotomy. The remaining 48 patients (46%) initially underwent active clinical observation and the indications for laparotomy became apparent during the observation period. Of the 105 laparotomies performed, 94 (90%) were positive and 11 (10%) were negative. Of the 94 positive laparotomies, 92 were therapeutic and 2 were non-therapeutic. A total of 176 organ injuries were identified: 50 (53%) of the 94 patients sustained a single organ injury while the remaining 44 (47%) sustained multiple organ injuries. The most commonly injured organs were the colon (n=63), spleen (n=21) and kidney (n=19). The pattern of intra-abdominal injuries secondary to SWs to the posterior abdomen is different to that seen with the anterior abdomen. Colonic injury is most commonly encountered, followed by injuries to the spleen and kidney. Clinicians must remain vigilant because of the potential for occult injuries.

Analysis of secondary cytoreduction for recurrent ovarian cancer by robotics, laparoscopy and laparotomy.

PubMed

Magrina, Javier F; Cetta, Rachel L; Chang, Yu-Hui; Guevara, Gregory; Magtibay, Paul M

2013-05-01

Analysis of perioperative outcomes and survival of patients with recurrent ovarian cancer undergoing secondary cytoreduction by robotics, laparoscopy, or laparotomy. Retrospective analysis of 52 selected patients with recurrent ovarian cancer undergoing secondary cytoreduction by laparoscopy (9), laparotomy (33) or robotics (10) between January 2006 and December 2010. Comparison was made by a total of 21 factors including age, BMI, number of previous surgeries, tumor type and grade, number of procedures, and 15 types of procedures performed at secondary cytoreduction. For all patients, the mean operating time was 213.8 min, mean blood loss 657.4 ml; and mean hospital stay 7.5 days. Complete debulking was achieved in 75% of patients. Postoperative complications were noted in 36.5% of patients. Overall and progression-free survival at 3-years were 58.8% and 34.1%, respectively. Laparoscopy and robotics had reduced blood loss and hospital stay, while no differences were observed among the three groups for operating time, complications, complete debulking, and survival. Selected patients with recurrent ovarian cancer benefit from a laparoscopic or robotic secondary cytoreduction without compromising survival. Robotics and laparoscopy provide similar perioperative outcomes, and reduced blood loss and shorter hospital stay as compared to laparotomy. Laparotomy seems preferable for patients with widespread peritoneal implants, multiple sites of recurrence, and/or extensive adhesions. Copyright © 2013 Elsevier Inc. All rights reserved.

Low-Cost Avoidance Behaviors are Resistant to Fear Extinction in Humans

PubMed Central

Vervliet, Bram; Indekeu, Ellen

2015-01-01

Elevated levels of fear and avoidance are core symptoms across the anxiety disorders. It has long been known that fear serves to motivate avoidance. Consequently, fear extinction has been the primary focus in pre-clinical anxiety research for decades, under the implicit assumption that removing the motivator of avoidance (fear) would automatically mitigate the avoidance behaviors as well. Although this assumption has intuitive appeal, it has received little scientific scrutiny. The scarce evidence from animal studies is mixed, while the assumption remains untested in humans. The current study applied an avoidance conditioning protocol in humans to investigate the effects of fear extinction on the persistence of low-cost avoidance. Online danger-safety ratings and skin conductance responses documented the dynamics of conditioned fear across avoidance and extinction phases. Anxiety- and avoidance-related questionnaires explored individual differences in rates of avoidance. Participants first learned to click a button during a predictive danger signal, in order to cancel an upcoming aversive electrical shock (avoidance conditioning). Next, fear extinction was induced by presenting the signal in the absence of shocks while button-clicks were prevented (by removing the button in Experiment 1, or by instructing not to click the button in Experiment 2). Most importantly, post-extinction availability of the button caused a significant return of avoidant button-clicks. In addition, trait-anxiety levels correlated positively with rates of avoidance during a predictive safety signal, and with the rate of pre- to post-extinction decrease during this signal. Fear measures gradually decreased during avoidance conditioning, as participants learned that button-clicks effectively canceled the shock. Preventing button-clicks elicited a sharp increase in fear, which subsequently extinguished. Fear remained low during avoidance testing, but danger-safety ratings increased again when button-clicks were subsequently prevented. Together, these results show that low-cost avoidance behaviors can persist following fear extinction and induce increased threat appraisal. On the other hand, fear extinction did reduce augmented rates of unnecessary avoidance during safety in trait-anxious individuals, and instruction-based response prevention was more effective than removal of response cues. More research is needed to characterize the conditions under which fear extinction might mitigate avoidance. PMID:26733837

Is Exercise Really Medicine? An Evolutionary Perspective.

PubMed

Lieberman, Daniel E

2015-01-01

An evolutionary perspective helps evaluate the extent to which exercise is medicine and to explain the exercise paradox: why people tend to avoid exercise despite its benefits. Many lines of evidence indicate that humans evolved to be adapted for regular, moderate amounts of endurance physical activity into late age. However, because energy from food was limited, humans also were selected to avoid unnecessary exertion, and most anatomical and physiological systems evolved to require stimuli from physical activity to adjust capacity to demand. Consequently, selection never operated to cope with the long-term effects of chronic inactivity. However, because all adaptations involve trade-offs, there is no evolutionary-determined dose or type of physical activity that will optimize health. Furthermore, because humans evolved to be active for play or necessity, efforts to promote exercise will require altering environments in ways that nudge or even compel people to be active and to make exercise fun.

Nodular fasciitis of the external auditory canal in six Egyptian children.

PubMed

Abdel-Aziz, Mosaad; Khattab, Hany; El-bosraty, Hussam; El-hoshy, Hassan; Hesham, Ahmed; Al-taweel, Hayam W

2008-05-01

Nodular fasciitis of external auditory canal may mimic a malignant tumor due to its progressive course, so it was the aim of this study to focus on a new etiology for aural masses to avoid unnecessary aggressive treatment. Retrospective study on six children presented with aural masses that were diagnosed pathologically to have nodular fasciitis. Presentation of the cases clinically, radiologically and pathologically was carried out. Surgical excision of the lesions was done through the external canal with follow up of the cases for 1 year. Recurrence was detected in two cases, one after 2 months and the other after 4 months. Re-excision was carried out without recurrence till the end of the follow up period. Proper diagnosis of this lesion is mandatory to avoid aggressive treatment (radical surgery and/or radiotherapy) as the disease has favorable prognosis with local excision.

Can the Ottawa and Pittsburgh rules reduce requests for radiography in patients referred to acute knee clinics?

PubMed Central

Zang, TT; Tamimi, N; Haddad, FS

2013-01-01

Our aim was to study the role of the Ottawa and Pittsburgh rules to reduce the unnecessary use of radiographs following knee injury. We prospectively reviewed 106 patients who were referred to our clinic over a 3-month period. The Ottawa and Pittsburgh rules were applied to individual patients to evaluate the need for radiography. One hundred and one patients (95%) had radiography of their knee. Five patients (5%) had a fracture of their knee and in all cases, the Ottawa and Pittsburgh knee rules were fulfilled. Using the Ottawa rules, 27 radiographs (25%) could have been avoided without missing a fracture. Using the Pittsburgh rules, 32 radiographs (30%) could have been avoided. The Ottawa and Pittsburgh rules have a high sensitivity for the detection of knee fractures. Their use can aid efficient clinical evaluation without adverse clinical outcome and may reduce healthcare costs. PMID:23827289

Can the Ottawa and Pittsburgh rules reduce requests for radiography in patients referred to acute knee clinics?

PubMed

Konan, S; Zang, T T; Tamimi, N; Haddad, F S

2013-04-01

Our aim was to study the role of the Ottawa and Pittsburgh rules to reduce the unnecessary use of radiographs following knee injury. We prospectively reviewed 106 patients who were referred to our clinic over a 3-month period. The Ottawa and Pittsburgh rules were applied to individual patients to evaluate the need for radiography. One hundred and one patients (95%) had radiography of their knee. Five patients (5%) had a fracture of their knee and in all cases, the Ottawa and Pittsburgh knee rules were fulfilled. Using the Ottawa rules, 27 radiographs (25%) could have been avoided without missing a fracture. Using the Pittsburgh rules, 32 radiographs (30%) could have been avoided. The Ottawa and Pittsburgh rules have a high sensitivity for the detection of knee fractures. Their use can aid efficient clinical evaluation without adverse clinical outcome and may reduce healthcare costs.

How to educate prescribers in antimicrobial stewardship practices

PubMed Central

Pulcini, Céline; Gyssens, Inge C.

2013-01-01

Widespread antimicrobial use has compromised its value, leading to a crisis of antimicrobial resistance. A major cause of misuse is insufficient knowledge of prescribing of antimicrobials in many categories of professionals. An important principle of antimicrobial stewardship is avoiding selection pressure in the patient, both on pathogen and commensal by avoiding unnecessary use, choosing the least broad-spectrum antibiotic, adequate doses, a good timing and the shortest possible duration. Up to now, most educational efforts have been targeted at professionals (mostly medical doctors) after their training and at the adult public. In the past few years, progress has been made in educating children. It is now crucial that academia and ministries of Health and Education jointly focus on an adapted undergraduate medical/professional curriculum that teaches all necessary principles of microbiology, infectious diseases and clinical pharmacology, with emphasis on the principles of prudent prescribing. PMID:23361336

Brucella taxonomy and evolution

PubMed Central

Ficht, Thomas

2010-01-01

Taxonomy and nomenclature represent man-made systems designed to enhance understanding of the relationship between organisms by comparison of discrete sets of properties. Initial efforts at bacterial taxonomy were flawed as a result of the previous use of nonsystematic approaches including common names resulting in confusing and inaccurate nomenclature. A decision was made to start afresh with bacterial nomenclature and to avoid the hazards experienced in the taxonomic classification of higher organisms. This was achieved by developing new rules designed to simplify classification and avoid unnecessary and confusing changes. This article reviews the work of a number of scientists attempting to reconcile new molecular data describing the phylogenetic relationship between Brucella organisms and a broader family of organisms with widely variant phenotypes that include human virulence and host range against a backdrop of strict regulatory requirements that fail to recognize significant differences between organisms with similar nomenclature. PMID:20521932

[Doctor shopping: the difficult-to-manage patient].

PubMed

de Zwaan, Martina; Müller, Astrid

2006-08-01

Medically unexplained symptoms and bodily dysfunctions are the single most prevalent class of symptoms in primary care. Differences in opinion as to the cause of the illness between the patients and the health care professionals make somatoform disorders a challenge for the patient-doctor relationship, and frequently produce negative feelings in health care professionals. The patients are usually reluctant to consider psychosocial aspects of their illness to be a factor. Early recognition of patients with somatization tendencies would be beneficial so that more effective treatment could begin sooner and unnecessary treatment be avoided. In order not to reinforce the patient's symptomatology, physicians should schedule appointments in a time contingent rather than a symptom contingent manner. Repetition of different tests should be avoided despite patients' demands in order not to further exacerbate the disorder. In many patients, psychotherapy should be recommended, although motivational work should already be initiated at the primary care stage.

Diagnosis of a sigmoid volvulus in pregnancy: ultrasonography and magnetic resonance imaging findings

PubMed Central

Palmucci, Stefano; Lanza, Maria Letizia; Gulino, Fabrizio; Scilletta, Beniamino; Ettorre, Giovanni Carlo

2014-01-01

Sigmoid volvulus complicating pregnancy is a rare, non-obstetric cause of abdominal pain that requires prompt surgical intervention (decompression) to avoid intestinal ischemia and perforation. We report the case of a 31-week pregnant woman with abdominal pain and subsequent development of constipation. Preoperative diagnosis was achieved using magnetic resonance imaging and ultrasonography: the large bowel distension and a typical whirl sign - near a sigmoid colon transition point - suggested the diagnosis of sigmoid volvulus. The decision to refer the patient for emergency laparotomy was adopted without any ionizing radiation exposure, and the pre-operative diagnosis was confirmed after surgery. Imaging features of sigmoid volvulus and differential diagnosis from other non-obstetric abdominal emergencies in pregnancy are discussed in our report, with special emphasis on the diagnostic capabilities of ultrasonography and magnetic resonance imaging. PMID:24967020

Diagnosis of a sigmoid volvulus in pregnancy: ultrasonography and magnetic resonance imaging findings.

PubMed

Palmucci, Stefano; Lanza, Maria Letizia; Gulino, Fabrizio; Scilletta, Beniamino; Ettorre, Giovanni Carlo

2014-02-01

Sigmoid volvulus complicating pregnancy is a rare, non-obstetric cause of abdominal pain that requires prompt surgical intervention (decompression) to avoid intestinal ischemia and perforation. We report the case of a 31-week pregnant woman with abdominal pain and subsequent development of constipation. Preoperative diagnosis was achieved using magnetic resonance imaging and ultrasonography: the large bowel distension and a typical whirl sign - near a sigmoid colon transition point - suggested the diagnosis of sigmoid volvulus. The decision to refer the patient for emergency laparotomy was adopted without any ionizing radiation exposure, and the pre-operative diagnosis was confirmed after surgery. Imaging features of sigmoid volvulus and differential diagnosis from other non-obstetric abdominal emergencies in pregnancy are discussed in our report, with special emphasis on the diagnostic capabilities of ultrasonography and magnetic resonance imaging.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Inagawa, Shoichi, E-mail: sinagawa@med.niigata-u.ac.j; Unno, Naoki; Yamashita, Shuhei

A 28-year-old woman was referred to our institution with hope for another child after having an abortion several months previously to avoid a potential risk of catastrophic hemorrhage from a retroperitoneal arteriovenous fistula (AVF) with enlarged and twisted draining veins in the pelvis. Multiple branches coming from the right lumbar arteries and the right iliac arteries fed fistulae converging on an enlarged venous pouch anterior to the psoas major muscle in the right retroperitoneal space. It seemed impossible to achieve complete occlusion of the lesion in a single session by either transarterial or transvenous approach. A laparotomy and direct puncturemore » of the enlarged draining vein immediately downstream of the venous pouch was performed and embolization was done with n-butyl cyanoacrylate and the aid of coils. Complete occlusion of the retroperitoneal AVF was achieved and confirmed in control angiography 5 months later.« less

Laparoscopic management of cholecystocolic fistula

PubMed Central

CONDE, Lauro Massaud; TAVARES, Pedro Monnerat; QUINTES, Jorge Luiz Delduque; CHERMONT, Ronny Queiroz; PEREZ, Mario Castro Alvarez

2014-01-01

Introduction Cholecystocolic fistula is a rare complication of gallbladder disease. Its clinical presentation is variable and nonspecific, and the diagnosis is made, mostly, incidentally during intraoperative maneuver. Cholecystectomy with closure of the fistula is considered the treatment of choice for the condition, with an increasingly reproducible tendency to the use of laparoscopy. Aim To describe the laparoscopic approach for cholecystocolic fistula and ratify its feasibility even with the unavailability of more specific instruments. Technique After dissection of the communication and section of the gallbladder fundus, the fistula is externalized by an appropriate trocar and sutured manually. Colonic segment is reintroduced into the cavity and cholecystectomy is performed avoiding the conversion procedure to open surgery. Conclusion Laparoscopy for resolution of cholecystocolic fistula isn't only feasible, but also offers a shorter stay at hospital and a milder postoperative period when compared to laparotomy. PMID:25626940

Enhanced Avoidance Habits in Obsessive-Compulsive Disorder

PubMed Central

Gillan, Claire M.; Morein-Zamir, Sharon; Urcelay, Gonzalo P.; Sule, Akeem; Voon, Valerie; Apergis-Schoute, Annemieke M.; Fineberg, Naomi A.; Sahakian, Barbara J.; Robbins, Trevor W.

2014-01-01

Background Obsessive-compulsive disorder (OCD) is a psychiatric condition that typically manifests in compulsive urges to perform irrational or excessive avoidance behaviors. A recent account has suggested that compulsivity in OCD might arise from excessive stimulus-response habit formation, rendering behavior insensitive to goal value. We tested if OCD patients have a bias toward habits using a novel shock avoidance task. To explore how habits, as a putative model of compulsivity, might relate to obsessions and anxiety, we recorded measures of contingency knowledge, explicit fear, and physiological arousal. Methods Twenty-five OCD patients and 25 control subjects completed a shock avoidance task designed to induce habits through overtraining, which were identified using goal-devaluation. The relationship between habitual behavior, erroneous cognitions, and physiological arousal was assessed using behavior, questionnaires, subjective report, and skin conductance responses. Results A devaluation sensitivity test revealed that both groups could inhibit unnecessary behavioral responses before overtraining. Following overtraining, OCD patients showed greater avoidance habits than control subjects. Groups did not differ in conditioned arousal (skin conductance responses) at any stage. Additionally, groups did not differ in contingency knowledge or explicit ratings of shock expectancy following the habit test. Habit responses were associated with a subjective urge to respond. Conclusions These data indicate that OCD patients have a tendency to develop excessive avoidance habits, providing support for a habit account of OCD. Future research is needed to fully characterize the causal role of physiological arousal and explicit fear in habit formation in OCD. PMID:23510580

Local repair of stoma prolapse: Case report of an in vivo application of linear stapler devices.

PubMed

Monette, Margaret M; Harney, Rodney T; Morris, Melanie S; Chu, Daniel I

2016-11-01

One of the most common late complications following stoma construction is prolapse. Although the majority of prolapse can be managed conservatively, surgical revision is required with incarceration/strangulation and in certain cases laparotomy and/or stoma reversal are not appropriate. This report will inform surgeons on safe and effective approaches to revising prolapsed stomas using local techniques. A 58 year old female with an obstructing rectal cancer previously received a diverting transverse loop colostomy. On completion of neoadjuvant treatment, re-staging found new lung metastases. She was scheduled for further chemotherapy but incarcerated a prolapsed segment of her loop colostomy. As there was no plan to resect her primary rectal tumor at the time, a local revision was preferred. Linear staplers were applied to the prolapsed stoma in step-wise fashion to locally revise the incarcerated prolapse. Post-operative recovery was satisfactory with no complications or recurrence of prolapse. We detail in step-wise fashion a technique using linear stapler devices that can be used to locally revise prolapsed stoma segments and therefore avoid a laparotomy. The procedure is technically easy to perform with satisfactory post-operative outcomes. We additionally review all previous reports of local repairs and show the evolution of local prolapse repair to the currently reported technique. This report offers surgeons an alternative, efficient and effective option for addressing the complications of stoma prolapse. While future studies are needed to assess long-term outcomes, in the short-term, our report confirms the safety and effectiveness of this local technique.

The use of JJ stent in the management of deep endometriosis lesion, affecting or potentially affecting the ureter: a review of our practice.

PubMed

Weingertner, A S; Rodriguez, B; Ziane, A; Gibon, E; Thoma, V; Osario, F; Haddad, C; Wattiez, A

2008-08-01

With the increasing number of operative laparoscopies performed for the treatment of deep pelvic endometriosis, technical difficulties and risk of complications inevitably increase. We report our experience using JJ stents, in women treated for deep pelvic endometriosis, with regard to prevention and management of ureteral lesions. Descriptive retrospective analysis between March 2004 and March 2007. Department of Obstetrics and Gynaecology, University Hospital, Strasbourg, France. Cases of women who underwent laparoscopic surgery for severe endometriosis and who needed a JJ stent in their management were recorded. Laparoscopic surgery was performed at the Department of Obstetrics and Gynaecology at CMCO-SIHCUS and Hautepierre Hospitals, Strasbourg, which are referral centres in the treatment of deep endometriosis. To evaluate the contribution of JJ stent in the prevention and management of ureteral lesions from endometriotic origin and/or iatrogenic origin in women treated for deep pelvic endometriosis. A total of 145 women had surgery for deep pelvic endometriosis. Seventeen (11.7%) women had a JJ ureteral stent inserted. In 82.4% of women, the stent was inserted pre- or peroperatively. We noted three ureteral complications, of which only one needed management by laparotomy. Except in extreme cases, management of ureteral endometriosis should be performed laparoscopically. Ureteral lesions whether iatrogenic, or secondary to endometriotic disease, can be treated by cystoscopy, JJ stent and laparoscopy. The combination of these three elements is the optimal management and is unlikely to cause subsequent complications. Laparotomy and its associated morbidity should be avoided.

Bone tumor mimickers: A pictorial essay

PubMed Central

Mhuircheartaigh, Jennifer Ni; Lin, Yu-Ching; Wu, Jim S

2014-01-01

Focal lesions in bone are very common and many of these lesions are not bone tumors. These bone tumor mimickers can include numerous normal anatomic variants and non-neoplastic processes. Many of these tumor mimickers can be left alone, while others can be due to a significant disease process. It is important for the radiologist and clinician to be aware of these bone tumor mimickers and understand the characteristic features which allow discrimination between them and true neoplasms in order to avoid unnecessary additional workup. Knowing which lesions to leave alone or which ones require workup can prevent misdiagnosis and reduce patient anxiety. PMID:25114385

Gas Bubbles in the Bone: A Case Report

PubMed Central

Abbasi, Bita; Seilanian-Toosi, Farrokh; Nekooei, Sirous; Kakhki, Behrang Rezvani

2016-01-01

Intraosseous pneumatocysts are benign gas-filled cavities within bones which are most commonly found in ilium, sacrum and vertebrae. The lesions are asymptomatic and found incidentally while evaluating for other injuries. Here, we present an intraosseous pneumatocyst of ilium in a 23-year-old male patient. Although once thought to be rare, intraossseous pneumatocyst are now believed to be more common. Thus, familiarity with their appearance is essential to avoid unnecessary workup. Intraosseous pneumatocysts are differentiated from more clinically significant differential diagnoses like osteonecrosis and osteomyelitis by their characteristic appearance of intraosseous air collections with sclerotic rim. PMID:27630918

Diagnosis of Food Allergy.

PubMed

Gupta, Malika; Cox, Amanda; Nowak-Węgrzyn, Anna; Wang, Julie

2018-02-01

Food allergy diagnosis remains challenging. Most standard methods are unable to differentiate sensitization from clinical allergy. Recognizing food allergy is of utmost importance to prevent life-threatening reactions. On the other hand, faulty interpretation of tests leads to overdiagnosis and unnecessary food avoidances. Highly predictive models have been established for major food allergens based on skin prick testing and food-specific immunoglobulin E but are lacking for most other foods. Although many newer diagnostic techniques are improving the accuracy of food allergy diagnostics, an oral food challenge remains the only definitive method of confirming a food allergy. Copyright © 2017 Elsevier Inc. All rights reserved.

[A CASE OF DEXTRANOMER-HYALURONIC ACID COPOLYMER (Deflux®) IMPLANTS CALCIFICATION MIMICKING DISTAL URETERAL CALCULI].

PubMed

Matsumoto, Fumi; Matsui, Futoshi; Yazawa, Koji; Shimada, Kenji

2017-01-01

Since 2011, endoscopic correction of vesicoureteral reflux using dextranomer-hyaluronic acid copolymer (Deflux ® ) has been widely accepted in Japan due to its safety and minimally invasive nature. However, long-term complications are unknown. We present a case of Deflux ® implants calcification mimicking distal ureteral calculi in a 12-year-old boy with a history of Deflux ® injection performed at three years of age for primary VUR. We should be aware of this complication to avoid misdiagnosis and unnecessary invasive examination such as radiological imaging or endoscopy.

Male tawny dragons use throat patterns to recognize rivals.

PubMed

Osborne, Louise; Umbers, Kate D L; Backwell, Patricia R Y; Keogh, J Scott

2012-10-01

The ability to distinguish between familiar and unfamiliar conspecifics is important for many animals, especially territorial species since it allows them to avoid unnecessary interactions with individuals that pose little threat. There are very few studies, however, that identify the proximate cues that facilitate such recognition in visual systems. Here, we show that in tawny dragons (Ctenophorus decresii), males can recognize familiar and unfamiliar conspecific males based on morphological features alone, without the aid of chemical or behavioural cues. We further show that it is the colour pattern of the throat patches (gular) that facilitates this recognition.

International Conference on Harmonisation; guidance on S7A safety pharmacology studies for human pharmaceuticals; availability. Notice.

PubMed

2001-07-13

The Food and Drug Administration (FDA) is announcing the availability of a guidance entitled "S7A Safety Pharmacology Studies for Human Pharmaceuticals." The guidance was prepared under the auspices of the International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH). The guidance provides a definition, general principles, and recommendations for the nonclinical safety pharmacology studies. The guidance is intended to help protect clinical trial participants and patients receiving marketed products from potential adverse effects of pharmaceuticals, while avoiding unnecessary use of animals and other resources.

Accelerating Drug Development: Antiviral Therapies for Emerging Viruses as a Model.

PubMed

Everts, Maaike; Cihlar, Tomas; Bostwick, J Robert; Whitley, Richard J

2017-01-06

Drug discovery and development is a lengthy and expensive process. Although no one, simple, single solution can significantly accelerate this process, steps can be taken to avoid unnecessary delays. Using the development of antiviral therapies as a model, we describe options for acceleration that cover target selection, assay development and high-throughput screening, hit confirmation, lead identification and development, animal model evaluations, toxicity studies, regulatory issues, and the general drug discovery and development infrastructure. Together, these steps could result in accelerated timelines for bringing antiviral therapies to market so they can treat emerging infections and reduce human suffering.

Sources of variation in an enzyme-linked immunoassay of bluetongue virus in Culicoides variipennis (Diptera: Ceratopogonidae).

PubMed

Tabachnick, W J; Mecham, J O

1991-03-01

An enzyme-linked immunoassay for detecting bluetongue virus in infected Culicoides variipennis was evaluated using a nested analysis of variance to determine sources of experimental error in the procedure. The major source of variation was differences among individual insects (84% of the total variance). Storing insects at -70 degrees C for two months contributed to experimental variation in the ELISA reading (14% of the total variance) and should be avoided. Replicate assays of individual insects were shown to be unnecessary, since variation among replicate wells and plates was minor (2% of the total variance).

Eosinophilic pustular folliculitis in infancy: report of a new case.

PubMed

Alonso-Castro, L; Pérez-García, B; González-García, C; Jaén-Olasolo, P

2012-10-15

We report a new case of eosinophilic pustular folliculitis in a 23-month-old boy. He presented with a seven-month history of recurrent episodes of pustular lesions on the scalp after having been treated with oral antifungal and topic antibiotics without response. The diagnosis was based on the clinical course and typical histopathological findings. Eosinophilic pustular folliculitis in infancy is an idiopathic and rare inflammatory disease characterized by recurrent crops of sterile pustules involving mainly the scalp. Because it is a benign, self-limiting condition an accurate diagnosis is essential to avoid unnecessary therapies.

Spontaneous ovarian hyperstimulation syndrome and pituitary hyperplasia mimicking macroadenoma associated with primary hypothyroidism

PubMed Central

Kanza, Rene Epunza; Gagnon, Sylvain; Villeneuve, Helene; Laverdiere, David; Rousseau, Isabelle; Bordeleau, Edith; Berube, Michel

2013-01-01

We report an unusual case of spontaneous ovarian hyperstimulation syndrome and pituitary hyperplasia mimicking macroadenoma in an adult, non-pregnant woman. Her condition was triggered by unrecognized primary hypothyroidism, which regressed after thyroid hormone replacement therapy. This case highlights the need for clinicians and radiologists to familiarize themselves with the clinical and imaging features detected in case of these complications of primary hypothyroidism, which are not well known in the medical and radiological profession. Such improved knowledge will help avoid delays in diagnosis, progression to life-threatening complications, and unnecessary surgery. PMID:23494012

Biological Effects and Safety in Magnetic Resonance Imaging: A Review

PubMed Central

Hartwig, Valentina; Giovannetti, Giulio; Vanello, Nicola; Lombardi, Massimo; Landini, Luigi; Simi, Silvana

2009-01-01

Since the introduction of Magnetic Resonance Imaging (MRI) as a diagnostic technique, the number of people exposed to electromagnetic fields (EMF) has increased dramatically. In this review, based on the results of a pioneer study showing in vitro and in vivo genotoxic effects of MRI scans, we report an updated survey about the effects of non-ionizing EMF employed in MRI, relevant for patients’ and workers’ safety. While the whole data does not confirm a risk hypothesis, it suggests a need for further studies and prudent use in order to avoid unnecessary examinations, according to the precautionary principle. PMID:19578460

Gold(I)-Catalysed Direct Thioetherifications Using Allylic Alcohols: an Experimental and Computational Study

PubMed Central

Herkert, Lorena; Green, Samantha L J; Barker, Graeme; Johnson, David G; Young, Paul C; Macgregor, Stuart A; Lee, Ai-Lan

2014-01-01

A gold(I)-catalysed direct thioetherification reaction between allylic alcohols and thiols is presented. The reaction is generally highly regioselective (SN2′). This dehydrative allylation procedure is very mild and atom economical, producing only water as the by-product and avoiding any unnecessary waste/steps associated with installing a leaving or activating group on the substrate. Computational studies are presented to gain insight into the mechanism of the reaction. Calculations indicate that the regioselectivity is under equilibrium control and is ultimately dictated by the thermodynamic stability of the products. PMID:25080400

Research of improved banker algorithm

NASA Astrophysics Data System (ADS)

Yuan, Xingde; Xu, Hong; Qiao, Shijiao

2013-03-01

In the multi-process operating system, resource management strategy of system is a critical global issue, especially when many processes implicating for the limited resources, since unreasonable scheduling will cause dead lock. The most classical solution for dead lock question is the banker algorithm; however, it has its own deficiency and only can avoid dead lock occurring in a certain extent. This article aims at reducing unnecessary safety checking, and then uses the new allocation strategy to improve the banker algorithm. Through full analysis and example verification of the new allocation strategy, the results show the improved banker algorithm obtains substantial increase in performance.

Nonpalpable testes: Ultrasound and contralateral testicular hypertrophy predict the surgical access, avoiding unnecessary laparoscopy.

PubMed

Berger, Christoph; Haid, Bernhard; Becker, Tanja; Koen, Mark; Roesch, Judith; Oswald, Josef

2018-04-01

In up to 20% of patients presenting with undescended testes, one or both are non-palpable. Whereas the most reliable means to exclude an abdominal testis is laparoscopy, there has been a lot of debate about the role of inguinal ultrasound (US) in detecting non-palpable inguinal testis. While we do not aim to add another paper claiming the benefits of US, we wanted to determine the excess capability of US to determine the correct surgical approach - inguinal or laparoscopy. In the light of avoiding unnecessary diagnostic laparoscopies, even the cost-effectiveness raised in many current papers might be called into question. Of a total of 684 boys who underwent surgery for undescended testes at our department between 2011 and 2014, in 58 (8.5%), one or both testes were neither palpable preoperatively nor under general anesthesia. These boys were examined by two experienced pediatric urologists clinically as well as by US. Besides the size of the contralateral testis, the presence of a testis in the inguinal channel was investigated. The additional impact of US over clinical exam and consideration of the size of the contralateral testis was assessed by means of intra-individual comparisons using Cochran-Q as well as McNemar tests. Clinical exam without considering the size of the contralateral testis had a sensitivity of 9% (95% CI 2-24%) and a specificity of 100% (95% CI 86-100%) to accurately predict the surgical approach deemed appropriate postoperatively. The consideration of the size of the contralateral testis - taken as an isolated factor - accurately predicted the surgical approach with a sensitivity of 21% (95% CI 9-38%) and a specificity of 88% (95% CI 68-97%). Ultrasound accounted for a sensitivity of 53% (95% CI 35-70%) and a specificity of 100% (95% CI 86-100%). The addition of US increased the sensitivity to correctly predict an inguinal incision from 29% to 71% and specificity slightly increased from 88% to 92%. This difference is significant (p = 0.008) in the bilateral McNemar test (Figure). Inguinal US of non-palpable testes and measurement of the contralateral testis are synergistic in predicting the surgical approach. The addition of ultrasound to a clinical exam, performed also under general anesthesia and by an experienced pediatric urologist significantly increases the prediction of the correct surgical approach. Our results translate into five boys needing an US of the NPT to prevent one laparoscopy. Whereas cost-effectiveness of US might be debatable in regard to different healthcare systems, it is proven to be an effective, non-harmful tool to avoid unnecessary diagnostic laparoscopies. Copyright © 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

A rare indication for liver resection.

PubMed

Popescu, I; Zamfir, R; Braşoveanu, V; Boroş, M; Herlea, V

2005-01-01

We present the rare case of a young female with a right upper abdomen tumoral mass and suffering abdominal discomfort. A combination of ultrasonography, computed tomography, magnetic resonance imaging and laparotomy was utilized to conclude a diagnosis of Riedel's lobe. Laparotomy and a resection of Riedel's lobe were selected as the correct therapeutic solutions.

Role of 3D power Doppler ultrasound in the further characterization of suspicious breast masses.

PubMed

Kupeli, Ali; Kul, Sibel; Eyuboglu, Ilker; Oguz, Sukru; Mungan, Sevdegul

2016-01-01

To investigate effectiveness of vascular indices obtained with 3D power Doppler ultrasound in the further characterization of breast masses and prevention of unnecessary biopsies. Between April 2013 and March 2014, 109 patients (age range, 17-85 years; mean age, 47 years) with 117 radiologically or clinically suspicious breast masses were prospectively evaluated with 3DPDUS before biopsy. Mass volume (MV), vascularization index (VI), flow index (FI) and vascularization flow index (VFI) were calculated using Virtual Organ Computer-aided Analysis (VOCAL) software and they were correlated with the final diagnosis. Cutoff values of vascular indices were determinated and diagnostic efficacy was calculated with receiver operating curve (ROC) analysis. All vascular indices, age of patients and tumor volume were significantly lower in benign masses compared with malignant ones (p<0.001). AUCs were 0.872, 0.867 and 0.789 for VI, VFI and FI, respectively. The diagnostic efficacy of VI (for cutoff 1.1; 83% sensitivity, 82% specificity and 82% accuracy) and VFI (for cutoff 0.4; 80% sensitivity, 83% specificity and 80% accuracy) were significantly higher than FI (for cutoff 33,9; 73% sensitivity, 69% specificity and 71% accuracy). It was found that with the use of vascular indices of 3DPDUS in the further characterization of suspicious breast masses between 24% to 37% of unnecessary biopsies could have been avoided. The vascular indices obtained with 3DPDUS seem reliable in the further characterization of suspicious breast masses and might be used to decrease unnecessary biopsies. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Incidence of post-operative adhesions following Misgav Ladach caesarean section--a comparative study.

PubMed

Fatusić, Zlatan; Hudić, Igor

2009-02-01

To evaluate the incidence of peritoneal adhesions as a post-operative complication after caesarean section following the Misgav Ladach method and compare it with peritoneal adhesions following traditional caesarean section methods (Pfannenstiel-Dörffler, low midline laparotomy-Dörffler). The analysis is retrospective and is based on medical documentation of the Clinic for Gynecology and Obstetrics, University Clinical Centre, Tuzla, Bosnia and Herzegovina (data from 1 January 2001 to 31 December 2005). We analysed previous caesarean section dependent on caesarean section method (200 by Misgav Ladach method, 100 by Pfannenstiel-Dörffler method and 100 caesarean section by low midline laparotomy-Dörffler). Adhesion scores were assigned using a previously validated scoring system. We found statistically significant difference (p < 0.05) in incidence of peritoneal adhesions in second and third caesarean section between Misgav Ladach method and the Pfannestiel-Dörffler and low midline laparotomy-Dörffler method. Difference in incidence of peritoneal adhesions between low midline laparotomy-Dörffler and Pfannenstiel-Dörffler method was not statistically different (p > 0.05). The mean pelvic adhesion score was statistically lower in Misgav Ladach group (0.43 +/- 0.79) than the mean score in the Pfannestiel-Dörffler (0.71 +/- 1.27) and low midline laparotomy-Dörffler groups (0.99 +/- 1.49) (p < 0.05). Our study showed that Misgav Ladach method of caesarean section makes possible lower incidence of peritoneal adhesions as post-operative complication of previous caesarean section.

Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network.

PubMed

Saunders, D I; Murray, D; Pichel, A C; Varley, S; Peden, C J

2012-09-01

Emergency laparotomy is a common intra-abdominal procedure. Outcomes are generally recognized to be poor, but there is a paucity of hard UK data, and reports have mainly been confined to single-centre studies. Clinicians were invited to join an 'Emergency Laparotomy Network' and to collect prospective non-risk-adjusted outcome data from a large number of NHS Trusts providing emergency surgical care. Data concerning what were considered to be key aspects of perioperative care, including thirty-day mortality, were collected over a 3 month period. Data from 1853 patients were collected from 35 NHS hospitals. The unadjusted 30 day mortality was 14.9% for all patients and 24.4% in patients aged 80 or over. There was a wide variation between units in terms of the proportion of cases subject to key interventions that may affect outcomes. The presence of a consultant surgeon in theatre varied between 40.6% and 100% of cases, while a consultant anaesthetist was present in theatre for 25-100% of cases. Goal-directed fluid management was used in 0-63% of cases. Between 0% and 68.9% of the patients returned to the ward (level one) after surgery, and between 9.7% and 87.5% were admitted to intensive care (level three). Mortality rates varied from 3.6% to 41.7%. This study confirms that emergency laparotomy in the UK carries a high mortality. The variation in clinical management and outcomes indicates the need for a national quality improvement programme.

Postoperative intra-abdominal collections using a sodium hyaluronate-carboxymethylcellulose (HA-CMC) barrier at the time of laparotomy for ovarian, fallopian tube, or primary peritoneal cancers.

PubMed

Leitao, Mario M; Natenzon, Anna; Abu-Rustum, Nadeem R; Chi, Dennis S; Sonoda, Yukio; Levine, Douglas A; Gardner, Ginger J; Barakat, Richard R

2009-11-01

To determine whether HA-CMC was associated with the development of postoperative intra-abdominal collections in patients undergoing laparotomy for ovarian, fallopian tube, or primary peritoneal malignancies. We retrospectively identified all laparotomies performed for these malignancies from March 1, 2005 to December 31, 2007. The use of HA-CMC was identified. Laparotomies for malignant bowel obstruction or repair of fistulae were excluded. Intra-abdominal collections, non-infected and infected, were defined as localized intraperitoneal fluid accumulations in the absence of re-accumulating ascites. All other complications were also captured. Appropriate statistical tests were applied using SPSS 15.0. We identified 219 laparotomies with HA-CMC and 204 without HA-CMC. Upper abdominal resections were performed in 65/219 (30%) HA-CMC cases compared to 39/204 (19%) cases without HA-CMC (P=0.01). The rates of large bowel and/or rectal resections were similar in both cohorts. Intra-abdominal collections were seen in 18/219 (8.2%) HA-CMC cases compared to 5/204 (2.5%) cases without HA-CMC (P=0.009). HA-CMC was independently associated with the diagnosis of a postoperative intra-abdominal collection (P=0.01). All but 2 collections developed in patients undergoing debulking procedures. HA-CMC appears to be associated with a higher rate of postoperative intra-abdominal collections. This seems to be greatest in patients who are undergoing a debulking procedure.

Benchmarking against the National Emergency Laparotomy Audit recommendations.

PubMed

Ho, Yiu Ming; Cappello, Julie; Kousary, Ramin; McGowan, Brian; Wysocki, Arkadiusz P

2018-05-01

The Royal College of Anaesthetists published the National Emergency Laparotomy Audit (NELA) to describe and compare inpatient care and outcomes of major emergency abdominal surgery in England and Wales in 2015 and 2016. The purpose of this article is to compare emergency abdominal surgical care and mortality in a regional hospital (Logan Hospital, Queensland, Australia) with NELA results. Data were extracted from two databases. All deaths from May 2010 to April 2015 were reviewed and patients who had an emergency abdominal operation within 30 days of death were identified. The health records of all patients who underwent abdominal surgery were extracted and those who had an emergency laparotomy were identified for analysis. Three hundred and fifty patients underwent emergency laparotomy and were included in the analysis. The total 30-day mortality during this 5-year period was 9.7%. Factors affecting mortality included age, Portsmouth-Physiological and Operative Severity Score (P-POSSUM) and admission source. Timing of antibiotic administration, use of perioperative medical service and frequency of intensive care admission were the same in patients who died and survived. Mortality in patients following emergency laparotomy at Logan Hospital compares favourably with 11.1% reported by NELA. This may be partly attributable to case mix distribution as for each P-POSSUM risk Logan Hospital mortality was at the upper end of that reported by NELA. Further Australia data are required. Improved compliance with NELA recommendations may improve outcomes. © 2017 Royal Australasian College of Surgeons.

Glove perforations during open surgery for gynaecological malignancies.

PubMed

Manjunath, A P; Shepherd, J H; Barton, D P J; Bridges, J E; Ind, T E J

2008-07-01

To audit glove perforations at laparotomies for gynaecological cancers. Gynaecological oncology unit, cancer centre, London. Prospective audit. Twenty-nine laparotomies for gynaecological cancers over 3 months. Gloves used during laparotomies for gynaecological cancer were tested for perforations by the air inflation and water immersion technique. Parameters recorded were: type of procedure, localisation of perforation, type of gloves, seniority of surgeon, operation time and awareness of perforations. Glove perforation rate. Perforations were found in gloves from 27/29 (93%) laparotomies. The perforation rate was 61/462 (13%) per glove. The perforation rate was three times higher when the duration of surgery was more than 5 hours. The perforation rate was 63% for primary surgeons, 54.5% for first assistant, 4.7% for second assistant and 40.5% for scrub nurses. Clinical fellows were at highest risk of injury (94%). Two-thirds of perforations were on the index finger or thumb. The glove on the nondominant hand had perforations in 54% of cases. In 50% of cases, the participants were not aware of the perforations. There were less inner glove perforations in double gloves compared with single gloves (5/139 versus 26/154; P = 0.0004, OR = 5.4, 95% CI 1.9-16.7). The indicator glove system failed to identify holes in 44% of cases. Glove perforations were found in most (93%) laparotomies for gynaecological malignancies. They are most common among clinical fellows, are often unnoticed and often not detected by the indicator glove system.

Rectus sheath hematoma in a single secondary care institution: a retrospective study.

PubMed

Anyfantakis, D; Kastanakis, M; Petrakis, G; Bobolakis, E

2015-06-01

Rectus sheath hematoma (RSH) represents an unusual abdominal wall pathology, frequently confounded as acute abdomen, with high mortality rates reported especially among elderly patients. The purpose of this retrospective study was to delineate characteristics of the patients diagnosed with RSH at the First Surgery Department of the Saint George General Hospital of Chania, Greece over a 5-year period. Seven patients with a median age of 62 years (range 51–85) were included in the study. Clinical features, demographics, management and outcome are summarized. The most common predisposing risk factor was anticoagulation. Acute onset abdominal pain and painful palpable abdominal mass, located more often on the right lower abdominal quadrant, were the most frequent initial symptoms. Management was mostly conservative [6 (85.7 %)] with disruption of anticoagulation, analgesia and bed rest. Blood transfusion was performed in hemodynamic compromised patients [2 (28.5 %)]. One patient was not appropriately diagnosed. On admission, the patient presented severe hemodynamic compromise and for this reason underwent emergency explorative laparotomy. The majority of the patients [6 (85.7 %)] experienced an uncomplicated clinical recovery and were discharged home after a mean hospital stay of 10 days (range 7–12). Surgeons as well as primary care physicians have to be aware of the clinical diagnostic tests and include the condition in the differential diagnosis of acute onset abdominal pain. Prompt recognition will prevent unnecessary surgical intervention and potential complications.

Laparoscopic Excision of an Unusual Presentation of a Nabothian Cyst: Case Report and Review of the Literature.

PubMed

Nassif, Joseph; Nahouli, Hasan; Mourad, Ali; Yammine, Ryan; Khoury, Sally; Khalil, Ali

2017-12-22

Nabothian cysts are mucinous retention cysts formed through the accumulation of cervical mucus inside blocked cervical crypts leading to non-neoplastic mucinous cystic lesion in relation to the uterine cervix. The formation of Nabothian cysts is a common gynecological benign condition in women of reproductive age. While the presence of small-sized Nabothian cysts is usually clinically asymptomatic and requires no treatment or intervention, the diagnosis of larger Nabothian cysts can be mistaken with malignant tumors, including mucin producing carcinomas such as Adenoma malignum. In this study, we report the case of a large Nabothian cyst that was correctly diagnosed preoperatively using ultrasonography and magnetic resonance imaging (MRI), and successfully treated through laparoscopic excision, avoiding the performance of unnecessary hysterectomy. A 44-year old Lebanese patient presented with chronic dyspareunia and pelvic pain. An ultrasound was performed and revealed an 8cm multiloculated anechoic pelvic cystic lesion with no solid components. An MRI was performed and showed an 8cm mass lateral to the right vaginal wall, suggestive of a Nabothian cyst. The patient was scheduled for laparoscopic removal of the Nabothian cyst. The patient tolerated the procedure well and was discharged under stable condition a few hours after the operation. Careful preoperative examination, including the use of imaging methods such as ultrasonogoraphy and MRI, is crucial for diagnosis and differentiation of atypical presentation of benign, but large and complex, Nabothian cysts from other differential conditions of malignancies, consequently avoiding unnecessary hysterectomy. Use of laparoscopy as a minimally-invasive technique to excise such cysts is considered a valid option, allowing for a fast recovery for the patients.

An evaluation of the relationship between Enterobius vermicularis infestation and acute appendicitis in a paediatric population--A retrospective cohort study.

PubMed

Fleming, C A; Kearney, D E; Moriarty, P; Redmond, H P; Andrews, E J

2015-06-01

Enterobius vermicularis is an often unexpected finding in appendectomy specimen, most commonly seen in paediatric cases. Predicting the presence of E. vermicularis in the setting of appendectomy is important to avoid unnecessary appendectomy and associated morbidity. We sought to identify the incidence of E. vermicularis in a paediatric population undergoing appendectomy for clinically suspected acute appendicitis and identify predictive factors for E. vermicularis. This study was performed in an 800-bed University Teaching Hospital, in the Republic of Ireland. We identified all paediatric appendectomies performed at our institute from January to December 2012 using prospectively maintained operating theatre logbooks. In-hospital Histopathology database, medical notes and operative findings were reviewed for each patient and relevant data recorded. Statistical analysis was performed using IBM SPSS, version 21. In total 182 paediatric appendectomies were performed during the year 2012 for clinically suspected acute appendicitis. Demographics included: Mean age 11.14 years (3-16), gender 1M: 1F. 58.8% of procedures were completed laparoscopically, 39% open and 2.2% were converted. The negative appendectomy rate was 22.5%. The annual incidence of E. vermicularis in acute appendicitis specimen from a paediatric cohort at our institute was 7% (1 in 14). In specimen containing E. vermicularis, 69% had no evidence of appendicitis and of those that had, no gangrene or perforation was seen. The presence of E. vermicularis in paediatric patients with RIF pain may be predicted by Eosinophilia (p = 0.016), normal WCC (p = 0.034) and normal Neutrophil count (p = 0.014). E. vermicularis is responsible for 7% of acute appendicitis. It is responsible for a significantly higher negative appendectomy rate which if predicted may avoid unnecessary appendectomy and associated morbidity. Copyright © 2015. Published by Elsevier Ltd.

The Prostate Health Index in predicting initial prostate biopsy outcomes in Asian men with prostate-specific antigen levels of 4-10 ng/mL.

PubMed

Ng, C F; Chiu, Peter K F; Lam, N Y; Lam, H C; Lee, Kim W M; Hou, Simon S M

2014-04-01

To investigate the role of the Prostate Health Index (phi) in prostate cancer (PCa) detection in patients with a prostate-specific antigen (PSA) level of 4-10 ng/mL receiving their first prostatic biopsy in an Asian population. This was a retrospective study of archived serum samples from patients enlisted in our tissue bank. Patients over 50 years old, with PSA level of 4-10 ng/mL, a negative digital rectal examination, and received their first prostatic biopsy between April 2008 and April 2013, were recruited. The serum sample collected before biopsy was retrieved for the measurement of various PSA derivatives and the phi value was calculated for each patient. The performance of these parameters in predicting the prostatic biopsy results was assessed. Two hundred and thirty consecutive patients, with 21 (9.13 %) diagnosed with PCa, were recruited for this study. Statistically significant differences between PCa patients and non-PCa patients were found for total PSA, PSA density, [-2]proPSA (p2PSA), free-to-total PSA ratio (%fPSA), p2PSA-to-free PSA ratio (%p2PSA), and phi. The areas under the curve of the receiver operating characteristic curve for total PSA, PSA density, %fPSA, %p2PSA, and phi were 0.547, 0.634, 0.654, 0.768, and 0.781, respectively. The phi was the best predictor of the prostatic biopsies results. At a sensitivity of 90 %, the use of the phi could have avoided unnecessary biopsies in 104 (45.2 %) patients. Use of the phi could improve the accuracy of PCa detection in patients with an elevated PSA level and thus avoid unnecessary prostatic biopsies.

A NEW CLINICAL PREDICTION CRITERION ACCURATELY DETERMINES A SUBSET OF PATIENTS WITH BILATERAL PRIMARY ALDOSTERONISM BEFORE ADRENAL VENOUS SAMPLING.

PubMed

Kocjan, Tomaz; Janez, Andrej; Stankovic, Milenko; Vidmar, Gaj; Jensterle, Mojca

2016-05-01

Adrenal venous sampling (AVS) is the only available method to distinguish bilateral from unilateral primary aldosteronism (PA). AVS has several drawbacks, so it is reasonable to avoid this procedure when the results would not affect clinical management. Our objective was to identify a clinical criterion that can reliably predict nonlateralized AVS as a surrogate for bilateral PA that is not treated surgically. A retrospective diagnostic cross-sectional study conducted at Slovenian national endocrine referral center included 69 consecutive patients (mean age 56 ± 8 years, 21 females) with PA who underwent AVS. PA was confirmed with the saline infusion test (SIT). AVS was performed sequentially during continuous adrenocorticotrophic hormone (ACTH) infusion. The main outcome measures were variables associated with nonlateralized AVS to derive a clinical prediction rule. Sixty-seven (97%) patients had a successful AVS and were included in the statistical analysis. A total of 39 (58%) patients had nonlateralized AVS. The combined criterion of serum potassium ≥3.5 mmol/L, post-SIT aldosterone <18 ng/dL, and either no or bilateral tumor found on computed tomography (CT) imaging had perfect estimated specificity (and thus 100% positive predictive value) for bilateral PA, saving an estimated 16% of the patients (11/67) from unnecessary AVS. The best overall classification accuracy (50/67 = 75%) was achieved using the post-SIT aldosterone level <18 ng/dL alone, which yielded 74% sensitivity and 75% specificity for predicting nonlateralized AVS. Our clinical prediction criterion appears to accurately determine a subset of patients with bilateral PA who could avoid unnecessary AVS and immediately commence with medical treatment.

Abdominal Complications after Severe Burns

DTIC Science & Technology

2009-05-01

abdominal compartment syndrome, schemic bowel, biliary disease, peptic ulcer disease and astritis requiring laparotomy, small bowel obstruction, rimary fungal...abdominal complications was 25%, with Curl- ng’s ulcer the most common malady (54% of the total), ollowed by esophageal lesions (17%), hemorrhagic...complications in- luded trauma exploratory laparotomy, abdominal com- artment syndrome, ischemic bowel, biliary disease, peptic lcer disease and gastritis, large

CT of abdominal tuberculosis

DOE Office of Scientific and Technical Information (OSTI.GOV)

Epstein, B.M.; Mann, J.H.

1982-11-01

Intraabdominal tuberculosis (TB) presents with a wide variety of clinical and radiologic features. Besides the reported computed tomographic (CT) finding of high-density ascites in tuberculous peritonitis, this report describes additional CT features highly suggestive of abdominal tuberculosis in eight cases: (1) irregular soft-tissue densities in the omental area; (2) low-density masses surrounded by thick solid rims; (3) a disorganized appearance of soft-tissue densities, fluid, and bowel loops forming a poorly defined mass; (4) low-density lymph nodes with a multilocular appearance after intravenous contrast administration; and (5) possibly high-density ascites. The differential diagnosis of these features include lymphoma, various forms ofmore » peritonitis, peritoneal carcinomatosis, and peritoneal mesothelioma. It is important that the CT features of intraabdominal tuberculosis be recognized in order that laparotomy be avoided and less invasive procedures (e.g., laparoscopy, biopsy, or a trial of antituberculous therapy) be instituted.« less

Innovative non-surgical management of pelvic and anterior vaginal wall abscess following vaginal surgery.

PubMed

Singh, Nisha; Negi, Neha; Kumar, Namrata

2016-08-29

Surgical site infections remain a common cause of morbidity following gynaecological surgery. The widespread implementation of antibiotic prophylaxis prior to surgery, as well as cognizance of modifiable risk factors for postoperative infection, has led to a significant reduction in postoperative infection rates. However, in low resource settings where sepsis and infections are common, surgical site infections following vaginal hysterectomy are sometimes encountered. It is a challenge to treat these infections with minimal intervention avoiding repeat surgery. We report here a unique situation following vaginal hysterectomy and then laparotomy; where a pelvic abscess communicated with the vesicovaginal space and drained through an opening into the anterior vaginal wall. An innovative technique was used to drain this anterior vaginal wall abscess connecting to pelvic cavity using a 40 cm long disposable urinary catheter (made of polyvinyl chloride), which was inserted into the vaginal opening under ultrasound guidance. 2016 BMJ Publishing Group Ltd.

Two similar cases of elderly women with moderate abdominal pain and pneumoperitoneum of unknown origin: a surgeon's successful conservative management.

PubMed

Vinzens, Fabrizio; Zumstein, Valentin; Bieg, Christian; Ackermann, Christoph

2016-05-26

Patients presenting with abdominal pain and pneumoperitoneum in radiological examination usually require emergency explorative laparoscopy or laparotomy. Pneumoperitoneum mostly associates with gastrointestinal perforation. There are very few cases where surgery can be avoided. We present 2 cases of pneumoperitoneum with unknown origin and successful conservative treatment. Both patients were elderly women presenting to our emergency unit, with moderate abdominal pain. There was neither medical intervention nor trauma in their medical history. Physical examination revealed mild abdominal tenderness, but no clinical sign of peritonitis. Cardiopulmonary examination remained unremarkable. Blood studies showed only slight abnormalities, in particular, inflammation parameters were not significantly increased. Finally, obtained CTs showed free abdominal gas of unknown origin in both cases. We performed conservative management with nil per os, nasogastric tube, total parenteral nutrition and prophylactic antibiotics. After 2 weeks, both were discharged home. 2016 BMJ Publishing Group Ltd.

Oxygen in the critically ill: friend or foe?

PubMed

Damiani, Elisa; Donati, Abele; Girardis, Massimo

2018-04-01

To examine the potential harmful effects of hyperoxia and summarize the results of most recent clinical studies evaluating oxygen therapy in critically ill patients. Excessive oxygen supplementation may have detrimental pulmonary and systemic effects because of enhanced oxidative stress and inflammation. Hyperoxia-induced lung injury includes altered surfactant protein composition, reduced mucociliary clearance and histological damage, resulting in atelectasis, reduced lung compliance and increased risk of infections. Hyperoxemia causes vasoconstriction, reduction in coronary blood flow and cardiac output and may alter microvascular perfusion. Observational studies showed a close relationship between hyperoxemia and increased mortality in several subsets of critically ill patients. In absence of hypoxemia, the routine use of oxygen therapy in patients with myocardial infarction, stroke, traumatic brain injury, cardiac arrest and sepsis, showed no benefit but rather it seems to be harmful. In patients admitted to intensive care unit, a conservative oxygen therapy aimed to maintain arterial oxygenation within physiological range has been proved to be well tolerated and may improve outcome. Liberal O2 use and unnecessary hyperoxia may be detrimental in critically ill patients. The current evidence supports the use of a conservative strategy in O2 therapy to avoid patient exposure to unnecessary hyperoxemia.

Improving outcome of trauma patients by implementing patient blood management.

PubMed

Füllenbach, Christoph; Zacharowski, Kai; Meybohm, Patrick

2017-04-01

Patient blood management aims to improve patient outcome and safety by reducing the number of unnecessary red blood cell transfusions and vitalizing patient-specific anemia reserves. While this is increasingly recognized as best clinical practice in elective surgery, the implementation in the setting of trauma is restrained because of typically nonelective (emergency) surgery and, in specific circumstances, allogeneic blood transfusions as life-saving therapy. Viscoelastic diagnostics allow a precise identification of trauma-induced coagulopathy. A coagulation factor concentrate-based therapy is increasingly recognized as a fast and effective concept to correct coagulopathy and minimize blood loss. Using smaller tubes has a great potential to reduce the severity of phlebotomy-induced anemia. Washed cell salvage may reduce the number of allogeneic blood transfusions. Intravenous iron (with or without erythropoietin) may result in an increase of hemoglobin levels and reduced red blood cell transfusion requirements. Although a restrictive transfusion strategy is recommended in general, a target hemoglobin level of 7-9 g/dl is recommended in acute bleeding patients. In the setting of trauma, options to avoid unnecessary blood loss and reduce blood transfusion are manifold. These are likely to improve safety and outcome of trauma patients while potentially reducing therapeutic costs.

[What is the potential for acute laparoscopy in penetrating abdominal injuries?].

PubMed

Petrás, D; Javora, J

2004-03-01

The aim of this work was to show current opinions on performing acute laparoscopic exploration in penetrating injuries of the abdomen and to assess the authors' own experience in performing the above operation in conditions of the regional hospital. The authors present 17 patients treated between the years 1997-2002 for penetrating injuries of the abdomen or suspected for a penetrating injury. Acute laparotomy was performed in 11 cases, acute laparoscopy in 6 patients. The authors specify certain indications which lead to the acute laparoscopy, the method performed and its diagnostic value. In the group observed, an intraabdominal injury was diagnosed in 41% of the patients, in 59% of cases findings were negative. When the intraabdominal injuries were assessed, the group of the acute laparotomies had 54% of negative findings, the group of the acute laparoscopies had 66.6% of negative findings. Laparoscopy decreased the total number of all negative laparotomies from 59% down to 35%. Diagnostic laparotomy fits to complement a spectrum of examination methods. Especially in equivocal cases, when a penetrating injury is suspected, it decreases the number of so called "necessary" non-therapeutic laparotomies to a minimum. It is most efficient, compared to other diagnostic methods, in verifying injuries of the peritoneum and diaphragm. However, acute laparoscopy should be always performed by an experienced surgeon. A therapeutic potential of the acute laparoscopy depend on proficiency of the operating surgeon and on the technical potential of each hospital. However, they, mostly, still remain restricted to caring for minor, isolated intraabdominal injuries.

Damage control laparotomy for abdominal trauma in children.

PubMed

Polites, Stephanie F; Habermann, Elizabeth B; Glasgow, Amy E; Zielinski, Martin D

2017-05-01

Damage control laparotomy (DCL) is not well studied in the pediatric trauma population. The purpose of this study was to develop a surrogate definition of DCL compatible with national and administrative data sources so that the rate and outcomes of DCL in pediatric trauma patients could be determined. Using the 2010-2014 National Trauma Data Bank, children ≤18 with an abdominal AIS ≥ 3 who underwent a laparotomy within 3 h of arrival were identified (n = 2989). DCL was defined as occurring in children who underwent a second laparotomy within 5-48 h from the index laparotomy (n = 360). Children meeting these criteria were compared to those children who had the initial definitive operative management (n = 2174) and those who died prior to 48 h (n = 455). DCL occurred in 12% of children with operative abdominal trauma. Children who underwent DCL had a greater median ISS (25 vs 18) and heart rate (112 vs 100), lower systolic blood pressure (104 vs 113), and GCS (12 vs 13), and were more likely to receive a preoperative blood transfusion (19 vs 11%) than those who had definitive initial operative management (all p < .05). Median length of stay (17 vs 8 days) and mortality (9 vs 2%) were greater following DCL than definitive initial operative management (p < .001). No differences in rate of DCL were seen based on ACS pediatric verification (p = .07). Few children with operative abdominal trauma undergo DCL. DCL was associated with worse physiology rather than anatomic injury severity in this study. As expected, outcomes were worse following DCL.

Prospective multi-center study for quantification of chemotherapies and CTX-related direct medication costs avoided by use of biomarkers uPA and PAI-1 in primary breast cancer.

PubMed

Jacobs, Volker R; Augustin, Doris; Wischnik, Arthur; Kiechle, Marion; Höss, Cornelia; Steinkohl, Oliver; Rack, Brigitte; Kapitza, Thomas; Krase, Peter

2013-08-01

Biomarkers uPA/PAI-1 as recommended by ASCO and AGO are used in primary breast cancer to avoid unnecessary CTX in medium risk-recurrence patients. This study verified how many CTX cycles and CTX-related direct medication costs can be avoided by uPA/PAI-1 testing. A prospective, non-interventional, multi-center study was performed among six Certified Breast Centers to analyze application of uPA/PAI-1 and consecutive decision-making. CTX avoided were identified and direct costs for CTX, CTX-related concomitant medication and febrile neutropenia (FN) prophylaxis with G-CSF calculated. In n = 93 breast cancers n = 35 CTX (37.6%) with 210 CTX cycles were avoided according to uPA/PAI-1 test result. uPA/PAI-1 testing saved direct medication costs for CTX of 177,453 €, CTX-related concomitant medication of 27,482 € and FN prophylaxis of 20,599 €, overall 225,534 €. At test costs at 287.50 € uPA/PAI-1 testing resulted in additional costs of 26,737.50 €. uPA/PAI-1 has proven to be cost-effective at a return-on-investment ratio of 8.4:1. Indirect cost savings further increase this ROI. These results support decision-making for cost-effective diagnostics and therapy in breast cancer. Copyright © 2013 Elsevier Ltd. All rights reserved.

Analgesic effects of tramadol, carprofen or multimodal analgesia in rats undergoing ventral laparotomy.

PubMed

Zegre Cannon, Coralie; Kissling, Grace E; Goulding, David R; King-Herbert, Angela P; Blankenship-Paris, Terry

2011-03-01

In this study, the authors evaluated the analgesic efficacy of tramadol (an opioid-like analgesic), carprofen (a nonsteroidal anti-inflammatory drug) and a combination of both drugs (multimodal therapy) in a rat laparotomy model. The authors randomly assigned rats to undergo either surgery (abdominal laparotomy with visceral manipulation and anesthesia) or anesthesia only. Rats in each group were treated with tramadol (12.5 mg per kg body weight), carprofen (5 mg per kg body weight), a combination of tramadol and carprofen (12.5 mg per kg body weight and 5 mg per kg body weight, respectively) or saline (anesthesia control group only; 5 mg per kg body weight). The authors administered analgesia 10 min before anesthesia, 4 h after surgery or (for the rats that received anesthesia only) anesthesia and 24 h after surgery or anesthesia. They measured locomotor activity, running wheel activity, feed and water consumption, body weight and fecal corticosterone concentration of each animal before and after surgery. Clinical observations were made after surgery or anesthesia to evaluate signs of pain and distress. The authors found that carprofen, tramadol and a combination of carprofen and tramadol were all acceptable analgesia regimens for a rat laparotomy model.

Effects of platelet rich plasma on fascial healing in rats with fecal peritonitis

PubMed

Girgin, Mustafa; Binnetoglu, Kenan; Duman, Kazim; Kanat, Burhan Hakan; Cetinkaya, Ziya; Ayten, Refik; Ilhan, Yavuz Selim; Ilhan, Necip; Seker, Ibrahim; Timurkaan, Necati

2016-05-01

To evaluate the effects of platelet rich plasma (PRP) on the healing of fascia wherein peritonitis has been created. Twenty eight Wistar Albino rats were divided into four groups. Only a primary fascial repair following laparotomy was performed on Group 1, a primary fascial repair performed and PRP treatment applied following laparotomy on Group 2, and a fecal peritonitis created following laparotomy and a primary fascial repair carried out on Group 3. A fecal peritonitis was created following laparotomy and primary fascial repair and PRP treatment on the fascia was carried out on Group 4. TNF-α was found to be significantly lower in the control group (Group 1). It was detected at the highest level in the group in which fecal peritonitis was created and PRP applied (Group 4). TGF-β was determined as being significantly higher only in Group 4. Histopathologically, the differences between the groups in terms of cell infiltration and collagen deposition were not found to be significant. When platelet rich plasma was given histologically and biochemicaly as wound healing parameters cellular infiltration, collagen accumulation, and tissue hydroxyiproline levels were not increased but neovascularization, fibroblast activation and TNF Alfa levels were increased and PRP accelerated wound healing.

Doctor, my child is bullied: food allergy management in schools.

PubMed

Egan, Maureen; Sicherer, Scott

2016-06-01

Studies suggest that food allergies have increased in prevalence, resulting in most school classrooms having more than one child affected. Children with food allergies are vulnerable for experiencing potentially life-threatening allergic reactions, as well as social consequences such as bullying. Management recommendations for food allergies in schools should incorporate knowledge of both issues. Current recommendations for food allergy management in schools focus on appropriate avoidance measures and prompt recognition and treatment of allergic reactions. Guidelines focus upon a school-wide approach, with comprehensive involvement of many stakeholders, but individual students require specific emergency action plans. Special risk groups include young children who need additional supervision and adolescents who may take risks. Based on the observation that anaphylaxis can occur in persons without a prior diagnosis, having epinephrine available for prompt first-aid management of any student in need is now recommended. To promote socialization, avoidance measures should minimize separation of children with food allergies from their peers. Parents and schools need to be aware of bullying and implement intervention and prevention measures. Management recommendations for food allergies in schools should ensure the safety of the child, address bullying, and avoid unnecessary isolation.

Ventilator-associated pneumonia management in critical illness.

PubMed

Albertos, Raquel; Caralt, Berta; Rello, Jordi

2011-03-01

Ventilator-associated pneumonia (VAP) is a frequent adverse event in the intensive care unit.We review recent publications about the management and prevention of VAP. The latest care bundles introduced standard interventions to facilitate implementation of evidence-based clinical guidelines and to improve the outcome of patients. Recent studies find that prevention management of ventilated patients decreases the risk of VAP. Enteral feeding, considered a risk factor for VAP, currently has been recommended, with appropriate administration, for all critical ill patients if no contraindications exist. In view of the recently available data, it can be concluded that the implementation of care bundles on the general management of ventilated patients in daily practice has reduced the VAP rates. The main pharmacological measures to prevent VAP are proper hands hygiene, high nurse-to-patient ratio, avoid unnecessary transfer of ventilated patients, use of noninvasive mechanical ventilation, shortening weaning period, avoid the use of nasal intubation, prevent bio-film deposition in endotracheal tube, aspiration of subglottic secretions, maintenance of adequate pressure of endotracheal cuffs, avoid manipulation of ventilator circuits, semi-recumbent position and adequate enteral feeding.In addition, updated guidelines incorporate more comprehensive diagnostic protocols to the evidence-based management of VAP.

Pharmacokinetic-pharmacodynamic (PK-PD) modeling and the rational selection of dosage regimes for the prudent use of antimicrobial drugs.

PubMed

Papich, Mark G

2014-07-16

One of the strategies to decrease inappropriate antimicrobial use in veterinary medicine is to apply pharmacokinetic-pharmacodynamic (PK-PD) principles to dosing regimens. If antimicrobials are used appropriately by applying these principles to attain targets for area-under-the-curve to MIC ratio (AUC/MIC), peak concentration to MIC ratio (CMAX/MIC), and time above MIC (T>MIC), more effective antibiotic therapy is possible, thus avoiding ineffective administration. Another mechanism whereby inappropriate antibiotic administration can be avoided is to use accurate Interpretive Criteria established by the Clinical Laboratory Standards Institute (CLSI) for breakpoint selection. Inaccurate breakpoints will encourage antibiotic administration that is likely to be ineffective. For newly approved antimicrobials, three criteria are used for determining breakpoints: PK-PD criteria, MIC distributions, and clinical response. For older (often generic drugs) evaluated by the CLSI, recent clinical data may not be available and breakpoints are derived from PK-PD principles, wild-type distributions, and Monte Carlo simulations. It is the goal of the CLSI subcommittee that these revised breakpoints will encourage more effective antimicrobial use and avoid unnecessary antimicrobial administration. Copyright © 2014 Elsevier B.V. All rights reserved.

Cytological Diagnosis of Primary Thyroid Tuberculosis.

PubMed

Goyal, P; Mittal, D; Ghosh, S; Agrawal, D; Sehgal, S; Singh, S

2015-01-01

Primary thyroid tuberculosis is an extremely rare disease, even in countries where other forms of tuberculosis are abundant. TT has no age bar but usually affects women in fourth and fifth decade. Hereby, we report a case of 16-years-old girl presented with complaint of progressively increasing, painful thyroid swelling. Diagnosis of TT was made on cytology and there was no evidence of involvement of any other organ by tuberculosis. Despite of its rarity, TT is usually misdiagnosed. So, a clinician should always consider this entity in the differential diagnosis of thyroid swelling. Fine needle aspiration cytology is the best diagnostic method and can result in the avoidance of unnecessary thyroid surgeries.

Delayed diagnosis of Alport syndrome without hematuria.

PubMed

Yin-Yin, Chen; You-Ming, Peng; Yu-Mei, Liang

2014-05-01

Alport syndrome is a progressive hereditary disease caused by mutations in the genes encoding type IV collagen. Persistent microscopic hematuria is the hallmark of Alport syndrome, occurring in almost all boys according to previous reports. We report the case of a 20-year-old man presented with proteinuria but no hematuria that was initially misdiagnosed with refractory nephrotic syndrome and was eventually diagnosed with Alport syndrome following kidney and skin biopsy. During the follow-up period, he experienced a rapid progression to end-stage renal disease. Timely diagnosis of Alport syndrome is important, because patients may benefit from early intervention and avoid suffering from unnecessary nephrotoxic drug use.

FORMATOMATIC: a program for converting diploid allelic data between common formats for population genetic analysis.

PubMed

Manoukis, Nicholas C

2007-07-01

There has been a great increase in both the number of population genetic analysis programs and the size of data sets being studied with them. Since the file formats required by the most popular and useful programs are variable, automated reformatting or conversion between them is desirable. formatomatic is an easy to use program that can read allelic data files in genepop, raw (csv) or convert formats and create data files in nine formats: raw (csv), arlequin, genepop, immanc/bayesass +, migrate, newhybrids, msvar, baps and structure. Use of formatomatic should greatly reduce time spent reformatting data sets and avoid unnecessary errors.

Two Cases of Transiently Elevated Serum CEA Levels in Severe Hypothyroidism without Goiter.

PubMed

Sekizaki, Tomonori; Yamamoto, Chiho; Nomoto, Hiroshi

2018-04-27

Carcinoembryonic antigen (CEA), the level of which is known to increase in both patients with gastrointestinal cancers and those with non-neoplastic conditions, is one of the most widely-used tumor markers. Hypothyroidism is a common endocrinological disorder in which CEA levels can rise, and is sometimes overlooked as a diagnosis in the absence of typical symptoms or thyroid enlargement. We report the cases of two patients with non-goiterous severe hypothyroidism with markedly elevated CEA levels that effectively decreased with levothyroxine replacement therapy alone. Hypothyroidism should be considered as an important cause of unexplained high serum CEA levels in order to avoid unnecessary medical examination.

Aberrant hepatic arterial anatomy and the whipple procedure: lessons learned.

PubMed

Chamberlain, Ronald S; El-Sedfy, Abraham; Rajkumar, Dhiraj

2011-05-01

Appreciation and study of hepatic arterial anatomical variability is essential to the performance of a pancreaticoduodenectomy to avoid surgical complications such as bleeding, hepatic ischemia/failure, and anastomotic leak/stricture. Awareness of this variability permits the surgeon to adapt the surgical technique to deal with anomalies identified preoperatively or intraoperatively thereby preventing unnecessary surgical morbidity and mortality. The objective of our study is to provide a comprehensive review of the anatomic arterial anomalies and discuss surgical strategies that will equip the surgeon to deal with all anomalies that may be encountered a priori or en passant during the course of a Whipple procedure.

Collagenous spherulosis presenting as a mass of the breast.

PubMed

Jan, Yee-Jee; Li, Mu-Chun; Ho, William L

2002-10-01

Collagenous spherulosis (CS) is a rare benign lesion which typically presents as an incidental microscopic finding accompanying other breast lesions. Pathologists who are not familiar with this entity occasionally misdiagnose CS as adenoid cystic carcinoma (ACC), cribriform ductal carcinoma in situ (C-DCIS), or atypical intraductal hyperplasia (AIH), especially when it presents as a mass. It is of utmost importance to differentiate benign CS from its malignant mimics in order to avoid unnecessary treatment. We report an unusual case of CS manifested as a mass in the right breast of a 45-year-old female and discuss the problems of differential diagnosis and histogenesis.

Bilateral optic disc drusen mimicking papilledema.

PubMed

Sahin, Alparslan; Cingü, Abdullah Kürşat; Ari, Seyhmus; Cinar, Yasin; Caça, Ihsan

2012-06-01

Optic disc drusen, which are calcified deposits that form anterior to the lamina cribrosa in the optic nerve, may mimic papilledema. We report herein three cases referred to us with suspicion of disc swelling and papilledema. Following ophthalmologic evaluation with B-scan ultrasound, red-free fundus photography, and computed tomography, the diagnosis of papilledema was excluded in all cases and optic disc drusen was diagnosed. Clinical suspicion of optic disc drusen in cases presenting with swelling of the optic nerve head is important in order to avoid unnecessary interventions and anxiety. The reported cases highlight the commonly encountered clinical presentations and the practical aspects of diagnosis and management of optic disc drusen.

Prenatal Diagnosis of Congenital Adrenal Hyperplasia.

PubMed

Yau, Mabel; Khattab, Ahmed; New, Maria I

2016-06-01

Congenital adrenal hyperplasia (CAH) owing to 21-hydroxylase deficiency is a monogenic disorder of adrenal steroidogenesis. To prevent genital ambiguity, in girls, prenatal dexamethasone treatment is administered early in the first trimester. Prenatal genetic diagnosis of CAH and fetal sex determination identify affected female fetuses at risk for genital virilization. Advancements in prenatal diagnosis are owing to improved understanding of the genetic basis of CAH and improved technology. Cloning of the CYP21A2 gene ushered in molecular genetic analysis as the current standard of care. Noninvasive prenatal diagnosis allows for targeted treatment and avoids unnecessary treatment of males and unaffected females. Copyright © 2016 Elsevier Inc. All rights reserved.

Teledermatology via a social networking web site: a pilot study between a general hospital and a rural clinic.

PubMed

Garcia-Romero, Maria Teresa; Prado, Fernanda; Dominguez-Cherit, Judith; Hojyo-Tomomka, Maria Teresa; Arenas, Roberto

2011-10-01

Teledermatology via a free public social networking Web site is a practical tool to provide attention to patients who do not have access to dermatologic care. In this pilot study, a general practitioner sent consults to a dermatology department at a general hospital via Facebook(®). Forty-four patients were seen and treatment was installed. We identified both simple-to-treat, common skin diseases and rare congenital diseases that require genetic counseling and more complex treatment. The majority of patients (75%) benefited with the diagnoses and treatments offered, thus avoiding unnecessary expenses or transportation to urban areas.

Obstructive internal hernia caused by mesodiverticular bands in children

PubMed Central

Bertozzi, Mirko; Melissa, Berardino; Magrini, Elisa; Di Cara, Giuseppe; Esposito, Susanna; Apignani, Antonino

2017-01-01

Abstract Introduction: The mesodiverticular band (MDB) is an embryologic remnant of the vitelline circulation, which carries the arterial supply to the Meckel diverticulum. In the event of an error of involution, a patent or nonpatent arterial band persists and extends from the mesentery to the apex of the antimesenteric diverticulum. This creates a snare-like opening through which bowel loops may herniate and become obstructed. This report describes 2 rare cases of small bowel occlusion owing to an internal hernia caused by a MDB. Cases: Case 1 was a 5-year-old boy who presented to our Emergency Department with colicky abdominal pain diffused to all abdominal quadrants. He also had 5 episodes of emesis, the last with bilious vomiting. Case 2, a 12-year-old boy, presented to our Emergency Department complaining of colicky abdominal pain. He had 2 episodes of nonbilious emesis. On physical examination, both children showed distension and tenderness of the abdomen and abdominal x-ray and ultrasound confirmed an occlusive picture without an apparent etiology. In case 1, an urgent laparotomy was performed and the MDB was ligated and cut, whereas in case 2 diagnosis and excision were performed in laparotomy. In both patients, there was a positive clinical evolution. Conclusion: Although MDB causing internal hernia is very rare, it should be considered in patients with a clinical picture of small bowel obstruction. In these cases, early surgery is important to prevent strangulation and gangrene of the bowel and to avoid dramatic events. Moreover, laparoscopy seems a safe and effective technique in these patients, especially in children with mild abdominal distention without surgical or trauma history, highlighting that further studies on the value of laparoscopy for the treatment of small bowel obstruction in pediatric patients are urgently needed. PMID:29145243

Standardized laparoscopic NOSE-colectomy is feasible with low morbidity.

PubMed

Wolthuis, Albert M; de Buck van Overstraeten, Anthony; Fieuws, Steffen; Boon, Katrien; D'Hoore, André

2015-05-01

In laparoscopic colorectal surgery, extraction site laparotomy can be avoided by natural orifice specimen extraction (NOSE) resulting in less postoperative pain, shorter length of stay, and less morbidity such as wound complications. To date, short-term outcome of a large prospective cohort of patients has not been studied. The aim of this prospective cohort study was to assess short-term outcome of laparoscopic left-sided NOSE-colectomy. Prospectively collected data of patients who had undergone elective laparoscopic NOSE-colectomy between July 2009 and December 2013 were analyzed retrospectively. Primary endpoint was short-term morbidity. A total of 110 patients were included in this study. Median age was 38 years (IQR: 32-56), median BMI was 23 kg/m(2) (IQR: 21-25), and 88% of the patients were female. Sixty-three patients (57%) underwent resection for endometriosis, 29 patients (26%) for diverticular disease, 16 patients (15%) for a tumor, and 2 patients for other indications. Median operating time was 85 min (IQR: 70-100) and median length of the extracted specimen was 20 cm (IQR: 16-25). Overall, 14 patients had a postoperative complication (13%), of which 9 were Clavien-Dindo grade 1 or 2 (8%). Four patients (3.6%) had an intraluminal bleeding from the anastomosis, which was treated endoscopically. There was 1 anastomotic leak (1%), treated by emergency laparotomy and creation of a new colorectal anastomosis (grade 3b). The median hospital stay was 5 days (IQR: 4-6). Laparoscopic NOSE-colectomy is safe and feasible with good short-term outcome. This study concerning a standardized operative technique is the first in literature reporting on a large group of patients.

Another Setting for Stewardship: High Rate of Unnecessary Antimicrobial Use in a VA Long-Term Care Facility

PubMed Central

Peron, Emily P.; Hirsch, Amy A.; Jury, Lucy A.; Jump, Robin L.P.; Donskey, Curtis J.

2015-01-01

BACKGROUND/OBJECTIVE Antimicrobials are frequently prescribed in long-term care facilities (LTCFs). In order to develop effective stewardship interventions, there is a need for data on current patterns of unnecessary antimicrobial prescribing among LTCF residents. The objective of this study was to examine the frequency of, reasons for, and adverse effects of unnecessary antimicrobial use in our Veterans Affairs (VA) LTCF. DESIGN Retrospective chart review. SETTING Cleveland VA Medical Center LTCF. PARTICIPANTS Randomly selected patients receiving antimicrobial therapy from October 1, 2008 to March 31, 2009. MEASUREMENTS Days of necessary and unnecessary antimicrobial therapy determined using Infectious Diseases Society of America guidelines, syndromes treated with unnecessary antimicrobials, and the frequency of development of Clostridium difficile infection (CDI), colonization or infection with antimicrobial resistant pathogens, and other adverse effects. RESULTS Of 1351 days of therapy prescribed in 100 regimens, 575 days (42.5%) were deemed unnecessary. Of the 575 unnecessary days of therapy, 334 (58%) were for antimicrobial regimens that were entirely unnecessary (n=42). Asymptomatic bacteriuria was the most common reason for entirely unnecessary regimens (n=21), resulting in 173 days of unnecessary therapy. Regimens that were partially unnecessary resulted in 241 (42%) days of unnecessary therapy, with longer than recommended treatment duration accounting for 226 (94%) unnecessary days of therapy. Within 30 days of completing the antimicrobial regimens, 5 patients developed CDI, 5 had colonization or infection with antimicrobial-resistant pathogens, and 10 experienced other adverse drug events. CONCLUSIONS In our VA LTCF, 43% of all days of antimicrobial therapy were unnecessary. Our findings suggest that antimicrobial stewardship interventions in LTCFs should focus on improving adherence to recommended treatment durations and eliminating inappropriate treatment of asymptomatic bacteriuria. PMID:23405923

Men's preferences and trade-offs for prostate cancer screening: a discrete choice experiment.

PubMed

Howard, Kirsten; Salkeld, Glenn P; Patel, Manish I; Mann, Graham J; Pignone, Michael P

2015-12-01

Prostate cancer screening using prostate-specific antigen (PSA) remains controversial. In deciding about screening, men must weigh the benefits and harms: little is known about benefit: harm trade-offs men are willing to accept. The objective of this study was to assess men's preferences for PSA screening, and the trade-offs between benefits and harms men are willing to accept when deciding about screening. Preferences of 662 men aged 40-69 were assessed using a discrete choice experiment. PSA screening was described by six attributes: prostate cancer deaths, prostate cancer diagnoses, unnecessary biopsies from false-positive PSA tests, impotence, urinary incontinence/bowel problems and cost. A mixed logit model was used to examine the influence of attributes on men's preferences for PSA testing; benefit: harm trade-offs were also calculated. Men's preferences were significantly influenced by test characteristics, particularly potential mortality benefit, unnecessary biopsies and likelihood of urinary incontinence or bowel problems; preferences were also influenced by age, prior PSA testing experience and perceived risk of prostate cancer. Men were willing to accept between 65 and 233 of 10 000 extra men with unnecessary biopsies, and between 31 and 72 of 10 000 extra men with incontinence/bowel problems to avoid one prostate cancer death. Differences in valuations of attributes and trade-offs acceptable to men of different ages suggest a one size fits all approach to PSA testing, regardless of age, may not reflect men's preferences. Our results can be used by policymakers to ensure screening programmes are in line with men's preferences and by clinicians and patients to facilitate informed discussions of the most relevant benefits and downsides of PSA screening for an individual man. © 2014 John Wiley & Sons Ltd.

Nontherapeutic Laparotomy in American Combat Casualties: A 10-year Review

DTIC Science & Technology

2014-09-10

for selective nonoperative management (SNOM) for abdominal trauma to minimize morbidity from nontherapeutic laparotomies (NTLs); however, this treatment...credited for introducing selective nonoperative management (SNOM) for penetrating abdominal trauma.2 SNOM, which now encompasses both penetrating and...BAT), 30% of anterior and 67% of back abdominal gunshot wounds, as well as 50% of anterior and 85% of back stab wounds can be managed using SNOM

Ratio-driven resuscitation predicts early fascial closure in the combat wounded.

PubMed

Glaser, Jacob; Vasquez, Matthew; Cardarelli, Cassandra; Dunne, James; Elster, Eric; Hathaway, Emily; Bograd, Benjamin; Safford, Shawn; Rodriguez, Carlos

2015-10-01

Operation Iraqi Freedom and Operation Enduring Freedom have seen the highest rates of combat casualties since Vietnam. These casualties often require massive transfusion (MT) and immediate surgical attention to control hemorrhage. Clinical practice guidelines dictate ratio-driven resuscitation (RDR) for patients requiring MT. With the transition from crystalloid to blood product resuscitation, we have seen fewer open abdomens in combat casualties. We sought to determine the effect RDR has on achieving early definitive abdominal fascial closure in combat casualties undergoing exploratory laparotomy. Records of 1,977 combat casualties admitted to a single US military hospital from April 2003 to December 2011 were reviewed. Patients receiving an MT and laparotomy in theater constituted the study cohort. The cohort was divided into RDR, defined as a ratio of 0.8-U to 1.2-U packed red blood cells to 1-U fresh frozen plasma, and No-RDR groups. Age, injury patterns, mechanism of injury, injury severity, blood products, number of laparotomies, and days to fascial closure were collected. Assessed outcomes were number of days (early ≤ 2 days) and number of laparotomies to achieve fascial closure. The mean age of the study cohort (n = 172) was 24.0 years, and mean Injury Severity Score (ISS) was 24.8. Improvised explosive device blast was the most common mechanism of injury (74.4%). The cohort was divided into RDR patients (n = 73) and no RDR (n = 99). There was no difference in mean age, mean ISS, or rate of nontherapeutic exploratory laparotomies between the groups. RDR patients had a significantly lower abdominal injury rate (34.2% vs. 72.7%, p < 0.01), had fewer laparotomies (2.7 vs. 4.3, p = 0.003), and achieved primary fascial closure faster (2.4 days vs. 7.2 days, p = 0.004). On multivariate analysis, RDR (2.74; 95% confidence interval, 1.44-5.2) was an independent predictor for early fascial closure. Adherence to RDR guidelines resulted in significantly decreased number of abdominal operations and was identified as an independent predictor for early fascial closure. Further investigation is warranted to validate these findings. Therapeutic study, level III.

Region-Based Collision Avoidance Beaconless Geographic Routing Protocol in Wireless Sensor Networks.

PubMed

Lee, JeongCheol; Park, HoSung; Kang, SeokYoon; Kim, Ki-Il

2015-06-05

Due to the lack of dependency on beacon messages for location exchange, the beaconless geographic routing protocol has attracted considerable attention from the research community. However, existing beaconless geographic routing protocols are likely to generate duplicated data packets when multiple winners in the greedy area are selected. Furthermore, these protocols are designed for a uniform sensor field, so they cannot be directly applied to practical irregular sensor fields with partial voids. To prevent the failure of finding a forwarding node and to remove unnecessary duplication, in this paper, we propose a region-based collision avoidance beaconless geographic routing protocol to increase forwarding opportunities for randomly-deployed sensor networks. By employing different contention priorities into the mutually-communicable nodes and the rest of the nodes in the greedy area, every neighbor node in the greedy area can be used for data forwarding without any packet duplication. Moreover, simulation results are given to demonstrate the increased packet delivery ratio and shorten end-to-end delay, rather than well-referred comparative protocols.

Region-Based Collision Avoidance Beaconless Geographic Routing Protocol in Wireless Sensor Networks

PubMed Central

Lee, JeongCheol; Park, HoSung; Kang, SeokYoon; Kim, Ki-Il

2015-01-01

Due to the lack of dependency on beacon messages for location exchange, the beaconless geographic routing protocol has attracted considerable attention from the research community. However, existing beaconless geographic routing protocols are likely to generate duplicated data packets when multiple winners in the greedy area are selected. Furthermore, these protocols are designed for a uniform sensor field, so they cannot be directly applied to practical irregular sensor fields with partial voids. To prevent the failure of finding a forwarding node and to remove unnecessary duplication, in this paper, we propose a region-based collision avoidance beaconless geographic routing protocol to increase forwarding opportunities for randomly-deployed sensor networks. By employing different contention priorities into the mutually-communicable nodes and the rest of the nodes in the greedy area, every neighbor node in the greedy area can be used for data forwarding without any packet duplication. Moreover, simulation results are given to demonstrate the increased packet delivery ratio and shorten end-to-end delay, rather than well-referred comparative protocols. PMID:26057037

Teaching high-value, cost-conscious care to residents: the Alliance for Academic Internal Medicine–American College of Physicians Curriculum.

PubMed

Smith, Cynthia D

2012-08-21

Health care expenditures are projected to reach nearly 20% of the U.S. gross domestic product by 2020. Up to $765 billion of this spending has been identified as potentially avoidable; many of the avoidable costs have been attributed to unnecessary services. Postgraduate trainees have historically received little specific training in the stewardship of health care resources and minimal feedback on resource utilization and its effect on the cost of care. This article describes a new curriculum that was developed collaboratively by the Alliance for Academic Internal Medicine and the American College of Physicians to address this training gap. The curriculum introduces a simple, stepwise framework for delivering high-value care and focuses on teaching trainees to incorporate high-value, cost-conscious care principles into their clinical practice. It consists of ten 1-hour, case-based, interactive sessions designed to be flexibly incorporated into the existing conference structure of a residency training program.

Analysis of Compression Algorithm in Ground Collision Avoidance Systems (Auto-GCAS)

NASA Technical Reports Server (NTRS)

Schmalz, Tyler; Ryan, Jack

2011-01-01

Automatic Ground Collision Avoidance Systems (Auto-GCAS) utilizes Digital Terrain Elevation Data (DTED) stored onboard a plane to determine potential recovery maneuvers. Because of the current limitations of computer hardware on military airplanes such as the F-22 and F-35, the DTED must be compressed through a lossy technique called binary-tree tip-tilt. The purpose of this study is to determine the accuracy of the compressed data with respect to the original DTED. This study is mainly interested in the magnitude of the error between the two as well as the overall distribution of the errors throughout the DTED. By understanding how the errors of the compression technique are affected by various factors (topography, density of sampling points, sub-sampling techniques, etc.), modifications can be made to the compression technique resulting in better accuracy. This, in turn, would minimize unnecessary activation of A-GCAS during flight as well as maximizing its contribution to fighter safety.

Transcranial Doppler ultrasound in the diagnosis of brain death. Is it useful or does it delay the diagnosis?

PubMed

Escudero, D; Otero, J; Quindós, B; Viña, L

2015-05-01

Transcranial Doppler ultrasound is able to demonstrate cerebral circulatory arrest associated to brain death, being especially useful in sedated patients, or in those in which complete neurological exploration is not possible. Transcranial Doppler ulstrasound is a portable, noninvasive and high-availability technique. Among its limitations, mention must be made of the absence of acoustic windows and false-negative cases. In patients clinically diagnosed with brain death, with open skulls or with anoxia as the cause of death, cerebral blood flow can be observed by ultrasound, since cerebral circulatory arrest is not always synchronized to the clinical diagnosis. The diagnostic rate is therefore time-dependent, and this fact that must be recognized in order to avoid delays in death certification. Despite its limitations, transcranial Doppler ulstrasound helps solve common diagnostic problems, avoids the unnecessary consumption of resources, and can optimize organ harvesting for transplantation. Copyright © 2014 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.

On the Choice of Adequate Randomization Ranges for Limiting the Use of Unwanted Cues in Same-Different, Dual-Pair, and Oddity Tasks

PubMed Central

Dai, Huanping; Micheyl, Christophe

2010-01-01

A major concern when designing a psychophysical experiment is that participants may use another stimulus feature (“cue”) than that intended by the experimenter. One way to avoid this involves applying random variations to the corresponding feature across stimulus presentations, to make the “unwanted” cue unreliable. An important question facing experimenters who use this randomization (“roving”) technique is: How large should the randomization range be to ensure that participants cannot achieve a certain proportion correct (PC) by using the unwanted cue, while at the same time avoiding unnecessary interference of the randomization with task performance? Previous publications have provided formulas for the selection of adequate randomization ranges in yes-no and multiple-alternative, forced-choice tasks. In this article, we provide figures and tables, which can be used to select randomization ranges that are better suited to experiments involving a same-different, dual-pair, or oddity task. PMID:20139466

Network architecture for global biomedical monitoring service.

PubMed

Lopez-Casado, Carmen; Tejero-Calado, Juan; Bernal-Martin, Antonio; Lopez-Gomez, Miguel; Romero-Romero, Marco; Quesada, Guillermo; Lorca, Julio; Garcia, Eugenia

2005-01-01

Most of the patients who are in hospitals and, increasingly, patients controlled remotely from their homes, at-home monitoring, are continuously monitored in order to control their evolution. The medical devices used up to now, force the sanitary staff to go to the patients' room to control the biosignals that are being monitored, although in many cases, patients are in perfect conditions. If patient is at home, it is he or she who has to go to the hospital to take the record of the monitored signal. New wireless technologies, such as BlueTooth and WLAN, make possible the deployment of systems that allow the display and storage of those signals in any place where the hospital intranet is accessible. In that way, unnecessary displacements are avoided. This paper presents a network architecture that allows the identification of the biosignal acquisition device as IP network nodes. The system is based on a TCP/IP architecture which is scalable and avoids the deployment of a specific purpose network.

Vesico-vaginal fistula -- a major cause of unnecessary and avoidable suffering.

PubMed

1999-01-01

Vesico-vaginal fistula is a serious disability that can be experienced by women after childbirth. It is defined as a hole that develops between the vagina and the bladder, resulting in uncontrollable leaking of urine through the vagina. The most common cause of vesico-vaginal fistula is obstructed labor, early marriage, poverty, and women's limited control over the use of family resources. Women and girls with this disability are often abandoned by their husbands and isolated from the community due to the smell and associated shame of urine leakage. However, this type of disability can be avoided by changing the attitudes of the community to women. Better nutrition, delaying first pregnancy, using a partograph during labor, and the availability of emergency obstetric care can also reduce the likelihood of having the disability. But for those who already have this condition, understanding and support of husbands and the community is needed in order for them to be restored to good health.

Fallopian tube cancer. The Roswell Park experience.

PubMed

Rose, P G; Piver, M S; Tsukada, Y

1990-12-15

Sixty-four patients with primary fallopian tube cancer treated at Roswell Park Memorial Institute from 1964 to 1987 underwent retrospective clinicopathologic review. In 40 patients fallopian tube cancer was the only primary, but in 24 patients primary fallopian tube cancer was part of a multifocal upper genital tract malignancy. Of the 40 patients with unifocal fallopian disease, the median survival was 28 months. Only 15% of patients were alive and disease free with follow-up ranging from 22 to 141 months (median, 90.5 months). Survival was not associated with stage of disease, tumor histology, grade, or depth of invasion in this series. Fourteen patients who received cisplatin-based chemotherapy were evaluable for response. Three patients (21%) responded; two complete and one partial. Twelve patients without clinical evidence of disease underwent second-look procedures, ten laparotomy and two laparoscopy. Four of ten second-look laparotomies were negative. Secondary debulking was done in three of four patients with gross disease, one of which had a negative third-look laparotomy. Negative laparotomy, second-look or third-look, was associated with improved survival (P = 0.016). One of the two laparoscopies was negative, but the patient recurred. In the remaining 24 patients cancer of the fallopian tube was part of a multifocal upper genital tract malignancy. In 12 patients tubal disease was invasive, and in 12, it was in situ. Separate primaries occurred in the ovaries (n = 20); uterus (n = 7); and cervix (n = 2). This represents 1.3% of ovarian malignancies treated at Roswell Park Memorial Institute during the study period. Fallopian tube cancer seems as virulent as ovarian cancer with few long-term survivors. It is frequently associated with other sites of upper genital tract malignancy. Second-look laparotomy is an important predictor of survival. Second-look laparoscopy may be useful if positive.

Complications of nonoperative management of high-grade blunt hepatic injuries.

PubMed

Kozar, Rosemary A; Moore, John B; Niles, Sarah E; Holcomb, John B; Moore, Ernest E; Cothren, C Clay; Hartwell, Elizabeth; Moore, Frederick A

2005-11-01

Nonoperative management of blunt hepatic injuries is highly successful. Complications associated with high-grade injuries, however, have not been well characterized. The purpose of the present study was therefore to define hepatic-related complications and associated treatment modalities in patients undergoing nonoperative management of high-grade blunt hepatic injuries. Three hundred thirty-seven patients from two regional Level I trauma centers with grade 3 to 5 blunt hepatic injuries during a 40-month period were reviewed. Complications and treatment of hepatic-related complications in patients not requiring laparotomy in the first 24 hours were identified. Of 337 patients with a grade 3 to 5 injury, 230 (68%) were managed nonoperatively. There were 37 hepatic-related complications in 25 patients (11%); 63% (5 of 8) of patients with grade 5 injuries developed complications, 21% (19 of 92) of patients with grade 4 injuries, but only 1% (1 of 130) of patients with grade 3 injuries. Complications included bleeding in 13 patients managed by angioembolization (n = 12) and laparotomy (n = 1), liver abscesses in 2 patients managed with computed tomography-guided drainage (n = 2) and subsequent laparotomy (n = 1). In one patient with bleeding, hepatic necrosis followed surgical ligation of the right hepatic artery and required delayed hepatic lobectomy. Sixteen biliary complications were managed with endoscopic retrograde cholangiopancreatography and stenting (n = 7), drainage (n = 5), and laparoscopy (n = 4). Three patients had suspected abdominal sepsis and underwent a negative laparotomy, whereas an additional three patients underwent laparotomy for abdominal compartment syndrome. Nonoperative management of high-grade liver injuries can be safely accomplished. Mortality is low; however, complications in grade 4 and 5 injuries should be anticipated and may require a combination of operative and nonoperative management strategies.

Applicability of an established management algorithm for destructive colon injuries after abbreviated laparotomy: a 17-year experience.

PubMed

Sharpe, John P; Magnotti, Louis J; Weinberg, Jordan A; Shahan, Charles P; Cullinan, Darren R; Marino, Katy A; Fabian, Timothy C; Croce, Martin A

2014-04-01

For more than a decade, operative decisions (resection plus anastomosis vs diversion) for colon injuries, at our institution, have followed a defined management algorithm based on established risk factors (pre- or intraoperative transfusion requirements of more than 6 units packed RBCs and/or presence of significant comorbid diseases). However, this management algorithm was originally developed for patients managed with a single laparotomy. The purpose of this study was to evaluate the applicability of this algorithm to destructive colon injuries after abbreviated laparotomy (AL) and to determine whether additional risk factors should be considered. Consecutive patients over a 17-year period with colon injuries after AL were identified. Nondestructive injuries were managed with primary repair. Destructive wounds were resected at the initial laparotomy followed by either a staged diversion (SD) or a delayed anastomosis (DA) at the subsequent exploration. Outcomes were evaluated to identify additional risk factors in the setting of AL. We identified 149 patients: 33 (22%) patients underwent primary repair at initial exploration, 42 (28%) underwent DA, and 72 (49%) had SD. Two (1%) patients died before re-exploration. Of those undergoing DA, 23 (55%) patients were managed according to the algorithm and 19 (45%) were not. Adherence to the algorithm resulted in lower rates of suture line failure (4% vs 32%, p = 0.03) and colon-related morbidity (22% vs 58%, p = 0.03) for patients undergoing DA. No additional specific risk factors for suture line failure after DA were identified. Adherence to an established algorithm, originally defined for destructive colon injuries after single laparotomy, is likewise efficacious for the management of these injuries in the setting of AL. Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Octreotide inhibits hepatic fibrosis, bile duct proliferation and bacterial translocation in obstructive jaundice.

PubMed

Türkçapar, Nuran; Bayar, Sancar; Koyuncu, Ayhan; Ceyhan, Koray

2003-01-01

The protective effect of octreotide on bacterial translocation, bile duct epithelial proliferation and hepatic fibrosis was studied in an experimental obstructive jaundice model. Forty-five healthy Wistar albino rats were randomly divided into three groups. Group I (n = 15): Median laparotomy and common bile duct manipulation performed (Sham group). Group II (n = 15): Laparotomy and common bile duct ligation performed. Group III (n = 15): After laparotomy and common bile duct ligation octreotide (Sandostatin, sandoz) was given. Simultaneously group I and II received 3 cc 0.9% NaCl and group III received 20 micrograms/kg/daily octreotide subcutaneously every 8 hours during 9 days. Two days after the procedure all rats were opened under ether anesthesia and sterile conditions. Group I had simple laparotomy but group II and III also had common bile duct ligation by 5/0 prolene. Seven days after the surgery (9th day after treatment) all rats underwent laparotomy and tests for bacterial translocation, liver biochemical tests and histopathologic analysis of liver and small bowel were carried out. In group II cecal population levels of bacteria were significantly higher than group I and group III (p < 0.05). In group II there was also statistically significant bacterial translocation to the mesenteric lymph nodes. Pathological changes were found in terminal ileum samples in group II which seemed to improve in group III. Hepatocyte function was preserved with octreotide treatment which also significantly decreased bile duct proliferation and periportal fibrosis in response to biliary obstruction. This experimental study showed that octreotide is effective in preventing bacterial translocation, bile duct proliferation and hepatic fibrosis in obstructive jaundice.

Outcomes of hospitalized patients undergoing emergency general surgery remote from admission.

PubMed

Sharoky, Catherine E; Bailey, Elizabeth A; Sellers, Morgan M; Kaufman, Elinore J; Sinnamon, Andrew J; Wirtalla, Christopher J; Holena, Daniel N; Kelz, Rachel R

2017-09-01

Emergency general surgery during hospitalization has not been well characterized. We examined emergency operations remote from admission to identify predictors of postoperative 30-day mortality, postoperative duration of stay >30 days, and complications. Patients >18 years in The American College of Surgeons National Surgical Quality Improvement Program (2011-2014) who had 1 of 7 emergency operations between hospital day 3-18 were included. Patients with operations >95th percentile after admission (>18 days; n = 581) were excluded. Exploratory laparotomy only (with no secondary procedure) represented either nontherapeutic or decompressive laparotomy. Multivariable logistic regression was used to identify predictors of study outcomes. Of 10,093 patients with emergency operations, most were elderly (median 66 years old [interquartile ratio: 53-77 years]), white, and female. Postoperative 30-day mortality was 12.6% (n = 1,275). Almost half the cohort (40.1%) had a complication. A small subset (6.8%) had postoperative duration of stay >30 days. Postoperative mortality after exploratory laparotomy only was particularly high (>40%). In multivariable analysis, an operation on hospital day 11-18 compared with day 3-6 was associated with death (odds ratio 1.6 [1.3-2.0]), postoperative duration of stay >30 days (odds ratio 2.0 [1.6-2.6]), and complications (odds ratio 1.5 [1.3-1.8]). Exploratory laparotomy only also was associated with death (odds ratio 5.4 [2.8-10.4]). Emergency general surgery performed during a hospitalization is associated with high morbidity and mortality. A longer hospital course before an emergency operation is a predictor of poor outcomes, as is undergoing exploratory laparotomy only. Copyright © 2017 Elsevier Inc. All rights reserved.

Assessment of post-laparotomy pain in laboratory mice by telemetric recording of heart rate and heart rate variability

PubMed Central

Arras, Margarete; Rettich, Andreas; Cinelli, Paolo; Kasermann, Hans P; Burki, Kurt

2007-01-01

Background Pain of mild to moderate grade is difficult to detect in laboratory mice because mice are prey animals that attempt to elude predators or man by hiding signs of weakness, injury or pain. In this study, we investigated the use of telemetry to identify indicators of mild-to-moderate post-laparotomy pain. Results Adult mice were subjected to laparotomy, either combined with pain treatment (carprofen or flunixin, 5 mg/kg s/c bid, for 1 day) or without pain relief. Controls received anesthesia and analgesics or vehicle only. Telemetrically measured locomotor activity was undisturbed in all animals, thus confirming that any pain experienced was of the intended mild level. No symptoms of pain were registered in any of the groups by scoring the animals' outer appearance or spontaneous and provoked behavior. In contrast, the group receiving no analgesic treatment after laparotomy demonstrated significant changes in telemetry electrocardiogram recordings: increased heart rate and decreased heart rate variability parameters pointed to sympathetic activation and pain lasting for 24 hours. In addition, core body temperature was elevated. Body weight and food intake were reduced for 3 and 2 days, respectively. Moreover, unstructured cage territory and destroyed nests appeared for 1–2 days in an increased number of animals in this group only. In controls these parameters were not affected. Conclusion In conclusion, real-time telemetric recordings of heart rate and heart rate variability were indicative of mild-to-moderate post-laparotomy pain and could define its duration in our mouse model. This level of pain cannot easily be detected by direct observation. PMID:17683523

A Prospective, Comparative Study for the Evaluation of Postoperative Pain and Quality of Recovery in Patients Undergoing Robotic Versus Open Hysterectomy for Staging of Endometrial Cancer.

PubMed

Cohn, David E; Castellon-Larios, Karina; Huffman, Laura; Salani, Ritu; Fowler, Jeffrey M; Copeland, Larry J; O'Malley, David M; Backes, Floor J; Eisenhauer, Eric L; Abdel-Rasoul, Mahmoud; Puente, Erika G; Bergese, Sergio D

2016-01-01

To measure and compare postoperative pain and patient satisfaction in patients undergoing either robotic or open laparotomy for surgical staging of endometrial cancer. Prospective, comparative study (Canadian Task Force classification II). University hospital. A total of 142 patients undergoing either robotic or open laparotomy for surgical staging of endometrial cancer. Patients scheduled for surgical staging of endometrial cancer at a single institution were identified. The patients underwent either robotic or open hysterectomy for staging of endometrial cancer. The choice of operative approach (robotic vs laparotomy) was made by the faculty physician before enrollment. Patients participated in the study for up to 48 hours for pain assessments and up to 10 ± 3 days postoperatively for quality of recovery assessments. The following measurements were performed: postoperative pain with the visual analog scale (VAS), 24-hour opioid consumption, and quality of recovery using the Quality of Recovery Questionnaire (QoR-40). The study was terminated owing to futility, given the lack of open procedures at our institution. Despite that lack of statistically significant difference between VAS scores at rest and with leg extension, there was a significant decrease in 24-hour opioid consumption in the robotic group. In addition, the QoR-40 showed an increased perception of recovery in patients within the robotic group compared with the laparotomy group. Patients with endometrial cancer who underwent robotic surgery had decreased postoperative opioid consumption and improved quality of recovery compared with those who underwent surgery via laparotomy. Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.

Rates of intraoperative complications and conversion to laparotomy during laparoscopic ovariectomy performed by veterinary students: 161 cases (2010-2014).

PubMed

Nylund, Adam M; Drury, Adam; Weir, Heather; Monnet, Eric

2017-07-01

OBJECTIVE To assess rates of intraoperative complications and conversion to laparotomy associated with supervised veterinary students performing laparoscopic ovariectomy in dogs. DESIGN Retrospective case series. ANIMALS 161 female shelter dogs for which elective laparoscopic ovariectomy had been performed by supervised senior (fourth-year) veterinary students from 2010 through 2014. PROCEDURES Medical records of all dogs were reviewed and data collected regarding duration of surgery, surgical complications and other characteristics, and whether conversion to laparotomy was required. RESULTS Laparoscopic ovariectomy was performed with a 2-cannula technique and a 10-mm vessel-sealing device for hemostasis in all dogs. A Veress needle was used for initial insufflation in 144 (89.4%) dogs; method of insufflation was not reported for the remaining 17 (10.6%) dogs. Mean ± SD duration of surgery was 114.90 ± 33.40 minutes. Surgical complications, all classified as minor blood loss, occurred in 24 (14.9%) dogs. These included splenic puncture during insertion of the Veress needle (n = 20 [12.4%]) and minor bleeding from the ovarian pedicle (4 [2.5%]). Splenic puncture required no intervention, and ovarian pedicle bleeding required application of the vessel-sealing device an additional time to control the bleeding. Two ovaries were dropped in the abdominal cavity at the time of removal. Both were retrieved without complication. Conversion to laparotomy was not required for any dog. All dogs were discharged from the hospital within 24 hours after surgery. CONCLUSIONS AND CLINICAL RELEVANCE Laparoscopic ovariectomy in dogs was performed safely by closely supervised novice surgeons, with only minor intraoperative complications encountered and no need for conversion to laparotomy.

Laparotomy and proximal gastric vagotomy in Zollinger-Ellison syndrome: results of a 16-year prospective study.

PubMed

McArthur, K E; Richardson, C T; Barnett, C C; Eshaghi, N; Smerud, M J; McClelland, R N; Feldman, M

1996-06-01

Pharmacological control of gastric acid hypersecretion in the Zollinger-Ellison syndrome has steadily improved, but medical treatment does not address the underlying tumor. The objective of this study was to evaluate the long-term effectiveness of a surgical approach to both tumor and acid hypersecretion in 22 patients with the Zollinger-Ellison syndrome. Patients underwent laparotomy to resect tumors, combined with vagotomy to reduce acid secretion, followed by postoperative antisecretory therapy, if necessary. No surgical mortality or serious morbidity occurred. Tumor was found at laparotomy in nine patients (41%) and during long-term follow-up in an additional two patients (9%). Ten-year survival is 81%, with a long-term cure rate of at least 14%. Most patients (86%) have had long-term inhibition of acid secretion. Eight patients have discontinued regular use of acid-inhibiting medications. Patients requiring medication need less of it, and they have an improved acid inhibitory response to medication for up to 16 yr after surgery. Cure of the Zollinger-Ellison syndrome is possible in a minority of patients. Acid secretion can be safely reduced in almost all patients with laparotomy/vagotomy, usually allowing discontinuation, or reduced dose, of acid-inhibiting drugs. Long-term survival and quality of life are generally excellent.

Computed Tomography Evaluation of Esophagogastric Necrosis After Caustic Ingestion.

PubMed

Chirica, Mircea; Resche-Rigon, Matthieu; Zagdanski, Anne Marie; Bruzzi, Matthieu; Bouda, Damien; Roland, Eric; Sabatier, François; Bouhidel, Fatiha; Bonnet, Francine; Munoz-Bongrand, Nicolas; Marc Gornet, Jean; Sarfati, Emile; Cattan, Pierre

2016-07-01

Endoscopy is the standard of care for emergency patient evaluation after caustic ingestion. However, the inaccuracy of endoscopy in determining the depth of intramural necrosis may lead to inappropriate decision-making with devastating consequences. Our aim was to evaluate the use of computed tomography (CT) for the emergency diagnostic workup of patients with caustic injuries. In a prospective study, we used a combined endoscopy-CT decision-making algorithm. The primary outcome was pathology-confirmed digestive necrosis. The respective utility of CT and endoscopy in the decision-making process were compared. Transmural endoscopic necrosis was defined as grade 3b injuries; signs of transmural CT necrosis included absence of postcontrast gastric/ esophageal-wall enhancement, esophageal-wall blurring, and periesophageal-fat blurring. We included 120 patients (59 men, median age 44 years). Emergency surgery was performed in 24 patients (20%) and digestive resection was completed in 16. Three patients (3%) died and 28 patients (23%) experienced complications. Pathology revealed transmural necrosis in 9/11 esophagectomy and 16/16 gastrectomy specimens. Severe oropharyngeal injuries (P = 0.015), increased levels of blood lactate (P = 0.007), alanine aminotransferase (P = 0.027), bilirubin (P = 0.005), and low platelet counts (P > 0.0001) were predictive of digestive necrosis. Decision-making relying on CT alone or on a combined CT-endoscopy algorithm was similar and would have spared 19 unnecessary esophagectomies and 16 explorative laparotomies compared with an endoscopy-alone algorithm. Endoscopy did never rectify a wrong CT decision. Emergency decision-making after caustic injuries can rely on CT alone.

An Experience in the Management of the Open Abdomen in Severely Injured Burn Patients

DTIC Science & Technology

2012-07-01

laparotomy was ACS in 31 patients (82%), abdominal trauma in 6 patients (16%), and a perforated gastric ulcer in 1 patient (3%). The abdominal...and other primary intra-abdominal pathology resulting in an abdominal catastrophe. Decompres- sive laparotomy for the treatment of ACS has been...presence of burns involving abdominal skin. • Treatment characteristics: method of temporary abdominal closure, number of days to closure, and number

A United Kingdom national survey of trends in ectopic pregnancy management.

PubMed

Taheri, M; Bharathan, R; Subramaniam, A; Kelly, T

2014-08-01

Our national survey demonstrates increased use of medical and laparoscopic management of ectopic pregnancy in the UK. In the UK in 2000, 35% of cases were managed by laparoscopy, 63% by laparotomy and 1% with medication. A recent review in the USA revealed increasing rates of medical management and decreasing rates of laparotomy; a trend driven by both cost-effectiveness and patient choice. A total of 119 early pregnancy units were surveyed regarding the nature and management of the three most recent cases of ectopic pregnancy; in addition, feasibility of training residents was also requested. Participants reported on 124 cases with a median of five cases per month per department. A total of 57% of cases were managed laparoscopically, 31% medically, 5% by laparotomy and 6% conservatively. Out of 44 centres, 29 have the facilities for training in both intermediate laparoscopic surgery and early pregnancy ultrasound.

Evaluation of the effects of laparotomy and laparoscopy on the immune system in intra-abdominal sepsis--a review.

PubMed

Karantonis, Fotios-Filippos; Nikiteas, Nikolaos; Perrea, Despina; Vlachou, Antonia; Giamarellos-Bourboulis, Evangelos J; Tsigris, Christos; Kostakis, Alkiviadis

2008-01-01

This review portrays the most common experimental models of intra-abdominal sepsis. Additionally, it outlines the facts that distinguish laparotomy from laparoscopy, in respect to the immune response, when comparing these two techniques in experimental models of intra-abdominal sepsis. It describes the consequences of pneumoperitoneum and trauma produced by laparoscopy or laparotomy, respectively, on bacterial translocation and immunity. Furthermore, we report the few efforts that have been made in clinical settings, where surgeons have attempted to utilize laparoscopy as a therapeutic module when treating peritonitis or sepsis of abdominal origin. Certainly there is a need for more research in order to fortify the role of pneumoperitoneum in sepsis of abdominal origin. It seems that minimally invasive surgery will inevitably gain acceptance by surgeons, as evidence points that by inflicting less trauma the healing response is expected to be more efficient, especially in septic patients.

Allergic contact dermatitis to acrylates in disposable blue diathermy pads.

PubMed Central

Sidhu, S. K.; Shaw, S.

1999-01-01

We report 2 cases of elicitation of allergic contact dermatitis to acrylates from disposable blue diathermy pads used on patients who underwent routine surgery. Their reactions were severe, and took approximately 5 weeks to resolve. Both patients gave a prior history of finger tip dermatitis following the use of artificial sculptured acrylic nails, which is a common, but poorly reported, cause of acrylate allergy. Patch testing subsequently confirmed allergies to multiple acrylates present in both the conducting gel of disposable blue diathermy pads, and artificial sculptured acrylic nails. We advocate careful history taking prior to surgery to avoid unnecessary exposure to acrylates in patients already sensitized. Images Figure 1 Figure 2 PMID:10364952

Recurrence of primary extramedullary plasmacytoma in breast both simulating primary breast carcinoma

PubMed Central

Kaviani, Ahmad; Djamali-zavareie, Mansoor; Noparast, Maryam; Keyhani-Rofagha, Sedigheh

2004-01-01

Background Extramedullary myelomas (plasmacytoma) are malignant proliferations of plasma cells in the absence of bone involvement. When they occur in the soft tissue they usually involve the upper respiratory tract and oral cavity. Extramedullary plasmacytomas of breast are uncommon. Case presentation A 70 year-old woman with bilateral breast masses underwent excisional biopsy for suspected primary carcinoma that subsequently proved to be a recurrence from extramedullary plasmacytoma of the mediastinum. This was diagnosed and treated 5-years prior to appearance of breast lumps. Conclusion Though uncommon, considering the possibility of metastatic carcinoma and primary, secondary or recurrent lymphoproliferative disease presenting as a breast mass may avoid unnecessary surgeries. PMID:15339332

Pinworm infection masquerading as colorectal liver metastasis.

PubMed

Roberts, K J; Hubscher, S; Mangat, K; Sutcliffe, R; Marudanayagam, R

2012-09-01

Enterobius vermicularis is responsible for a variety of diseases but rarely affects the liver. Accurate characterisation of suspected liver metastases is essential to avoid unnecessary surgery. In the presented case, following a diagnosis of rectal cancer, a solitary liver nodule was diagnosed as a liver metastasis due to typical radiological features and subsequently resected. At pathological assessment, however, a necrotic nodule containing E. vermicularis was identified. Solitary necrotic nodules of the liver are usually benign but misdiagnosed frequently as malignant due to radiological features. It is standard practice to diagnose colorectal liver metastases solely on radiological evidence. Without obtaining tissue prior to liver resection, misdiagnosis of solitary necrotic nodules of the liver will continue to occur.

Pinworm infection masquerading as colorectal liver metastasis

PubMed Central

Roberts, KJ; Hubscher, S; Mangat, K; Sutcliffe, R; Marudanayagam, R

2012-01-01

Enterobius vermicularis is responsible for a variety of diseases but rarely affects the liver. Accurate characterisation of suspected liver metastases is essential to avoid unnecessary surgery. In the presented case, following a diagnosis of rectal cancer, a solitary liver nodule was diagnosed as a liver metastasis due to typical radiological features and subsequently resected. At pathological assessment, however, a necrotic nodule containing E vermicularis was identified. Solitary necrotic nodules of the liver are usually benign but misdiagnosed frequently as malignant due to radiological features. It is standard practice to diagnose colorectal liver metastases solely on radiological evidence. Without obtaining tissue prior to liver resection, misdiagnosis of solitary necrotic nodules of the liver will continue to occur. PMID:22943320

Enterobius Vermicularis-Associated Pelvic Inflammatory Disease in a Child.

PubMed

Mentessidou, Anastasia; Theocharides, Constantine; Patoulias, Ioannis; Panteli, Christina

2016-04-01

Enterobius vermicularis is the most highly prevalent intestinal worm in childhood and is generally considered of low pathogenicity. Little is known about the inflammatory complications of the female genital tract induced by E. vermicularis in childhood. A case of E. vermicularis-associated pelvic inflammatory disease with right salpingitis mimicking acute abdomen due to appendicitis in an 11-year-old girl is presented. E. vermicularis-related pelvic inflammatory disease should be included in the differential diagnosis of abdominal pain in children. Increased awareness is necessary to avoid an unnecessary surgery and to choose the correct antibiotic treatment. Copyright © 2016 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.

Beyond the Golden Hours: Caring for Septic Patients After the Initial Resuscitation.

PubMed

Gelinas, Jean P; Walley, Keith R

2016-06-01

Recognition and management of agitation, delirium, and pain are key areas. Reduced use of sedatives is an important measure that must be coupled with increased patient engagement, mobilization, and exercise. Use of low tidal volumes and low mean airway pressures during mechanical ventilation is helpful. A key hemodynamic principle following early aggressive volume resuscitation is subsequent careful assessment to avoid unnecessary additional volume administration and adverse consequences of frank volume overload. Substantial evidence now supports a lower hemoglobin transfusion threshold of 7 g/dL. A rush to initiate enteral or parenteral feeds is not clearly supported by the current evidence. Copyright © 2016 Elsevier Inc. All rights reserved.

Practical pulse engineering: Gradient ascent without matrix exponentiation

NASA Astrophysics Data System (ADS)

Bhole, Gaurav; Jones, Jonathan A.

2018-06-01

Since 2005, there has been a huge growth in the use of engineered control pulses to perform desired quantum operations in systems such as nuclear magnetic resonance quantum information processors. These approaches, which build on the original gradient ascent pulse engineering algorithm, remain computationally intensive because of the need to calculate matrix exponentials for each time step in the control pulse. In this study, we discuss how the propagators for each time step can be approximated using the Trotter-Suzuki formula, and a further speedup achieved by avoiding unnecessary operations. The resulting procedure can provide substantial speed gain with negligible costs in the propagator error, providing a more practical approach to pulse engineering.

Recognition of Similar Shaped Handwritten Marathi Characters Using Artificial Neural Network

NASA Astrophysics Data System (ADS)

Jane, Archana P.; Pund, Mukesh A.

2012-03-01

The growing need have handwritten Marathi character recognition in Indian offices such as passport, railways etc has made it vital area of a research. Similar shape characters are more prone to misclassification. In this paper a novel method is provided to recognize handwritten Marathi characters based on their features extraction and adaptive smoothing technique. Feature selections methods avoid unnecessary patterns in an image whereas adaptive smoothing technique form smooth shape of charecters.Combination of both these approaches leads to the better results. Previous study shows that, no one technique achieves 100% accuracy in handwritten character recognition area. This approach of combining both adaptive smoothing & feature extraction gives better results (approximately 75-100) and expected outcomes.

Fluorescence-Guided Surgery

PubMed Central

Nagaya, Tadanobu; Nakamura, Yu A.; Choyke, Peter L.; Kobayashi, Hisataka

2017-01-01

Surgical resection of cancer remains an important treatment modality. Despite advances in preoperative imaging, surgery itself is primarily guided by the surgeon’s ability to locate pathology with conventional white light imaging. Fluorescence-guided surgery (FGS) can be used to define tumor location and margins during the procedure. Intraoperative visualization of tumors may not only allow more complete resections but also improve safety by avoiding unnecessary damage to normal tissue which can also reduce operative time and decrease the need for second-look surgeries. A number of new FGS imaging probes have recently been developed, complementing a small but useful number of existing probes. In this review, we describe current and new fluorescent probes that may assist FGS. PMID:29312886

Pseudo-hemothorax at computed tomography due to residual contrast media.

PubMed

Romero, Matías; Bächler, Pablo

2014-01-01

Pleural effusion is a clinical problem that has many causes, with hemothorax being one of them. Computed tomography readily characterizes pleural fluid with determination of the attenuation value, helping to distinguish hemothorax from other types of effusion. Herein, we report the case of a 67-year-old man with end-stage renal disease in which a high-density pleural effusion due to residual contrast media was misinterpreted as hemothorax. Radiologists should consider the possibility of contrast media retention when interpreting a high-density pleural effusion in patients with end-stage renal disease. Recognition of this entity is crucial to avoid misdiagnosis, which might lead to unnecessary testing or procedures. Copyright © 2014 Elsevier Inc. All rights reserved.

[Fever, atrial fibrillation, and angina pectoris in a 58-year-old man].

PubMed

Groebner, M; Südhoff, T; Doering, M; Kirmayer, M; Nitsch, T; Prügl, L; Römer, W; Wolf, H; Tacke, J; Massoudy, P; Nüsse, T; Elsner, D

2014-05-01

Primary cardiac lymphoma (PCL) respresents a very rare type of cardiac tumour. This report illustrates a case of PCL in an immunocompetent 58-year-old man presenting with atrial fibrillation and febrile syndrome. Comprehensive imaging [computer tomography (CT), cardiac magnetic resonance imaging (cMRI), 3-dimensional transesophageal echocardiography (3D-TEE)] identified a large right atrial tumour, leading to pericardial effusion. Isolated cardiac involvement was confirmed by positron emission tomography (PET)-CT. A diffuse large B-cell lymphoma (DLBCL) was diagnosed based on the results of a TEE-guided biopsy. A normalized PET scan (PETAL study) indicated complete remission following R-CHOP 14 immunochemotherapy. Thus, an interdisciplinary and multimodal approach avoided unnecessary cardiac surgery.

Diaphragmatic Myopotential Oversensing Caused by Change in Implantable Cardioverter Defibrillator Sensing Bandpass Filter.

PubMed

Ploux, Sylvain; Swerdlow, Charles D; Eschalier, Romain; Monteil, Benjamin; Ouali, Sana; Haïssaguerre, Michel; Bordachar, Pierre

2016-07-01

Diaphragmatic myopotential oversensing (DMO) causes inhibition of pacing and inappropriate detection of ventricular fibrillation in implantable cardioverter defibrillators (ICDs). It occurs almost exclusively with integrated bipolar leads and is extremely rare with dedicated bipolar leads. If DMO cannot be corrected by reducing programmed sensitivity, ventricular lead revision is often required. The new Low Frequency Attenuation (LFA) filter in St. Jude Medical ICDs (St. Jude Medical, Sylmar, CA, USA) alters the sensing bandpass to reduce T-wave oversensing. This paper aims to present the LFA filter as a reversible cause of DMO. Unnecessary lead revision can be avoided by the simple programming solution of deactivating this LFA filter. ©2016 Wiley Periodicals, Inc.

Circumventing photodamage in live-cell microscopy

PubMed Central

Magidson, Valentin; Khodjakov, Alexey

2013-01-01

Fluorescence microscopy has become an essential tool in cell biology. This technique allows researchers to visualize the dynamics of tissue, cells, individual organelles and macromolecular assemblies inside the cell. Unfortunately, fluorescence microscopy is not completely ‘non-invasive’ as the high-intensity excitation light required for excitation of fluorophores is inherently toxic for live cells. Physiological changes induced by excessive illumination can lead to artifacts and abnormal responses. In this chapter we review major factors that contribute to phototoxicity and discuss practical solutions for circumventing photodamage. These solutions include the proper choice of image acquisition parameters, optimization of filter sets, hardware synchronization, and the use of intelligent illumination to avoid unnecessary light exposure. PMID:23931522

Two models for identification and predicting behaviour of an induction motor system

NASA Astrophysics Data System (ADS)

Kuo, Chien-Hsun

2018-01-01

System identification or modelling is the process of building mathematical models of dynamical systems based on the available input and output data from the systems. This paper introduces system identification by using ARX (Auto Regressive with eXogeneous input) and ARMAX (Auto Regressive Moving Average with eXogeneous input) models. Through the identified system model, the predicted output could be compared with the measured one to help prevent the motor faults from developing into a catastrophic machine failure and avoid unnecessary costs and delays caused by the need to carry out unscheduled repairs. The induction motor system is illustrated as an example. Numerical and experimental results are shown for the identified induction motor system.

When should computed tomography angiography of pulmonary vessels be done in patients with low clinical probability of acute pulmonary embolism?

PubMed

Ródenas Quiñonero, I; Plasencia Martínez, J M; García Santos, J M

2018-02-24

When the probability of pulmonary embolism is low, the decision to do a computed tomography angiography (CTA) of the pulmonary vessels is based on the D-dimer concentration. However, excessive dependence on this parameter can result in unnecessary imaging studies, inappropriate treatment, or an inappropriate increase in the estimated probability of venous thromboembolism developing. The main objective of this study was to determine when CTA of pulmonary vessels could be avoided in patients with low clinical probability of pulmonary embolism through an efficient literature search of studies published about this question. Copyright © 2018 SERAM. Publicado por Elsevier España, S.L.U. All rights reserved.

Summary of lightning activities by NASA for the Apollo Soyuz test project: Supplement no. 1 to Apollo Soyuz mission evaluation report

NASA Technical Reports Server (NTRS)

1976-01-01

To avoid the possibility of an unnecessary launch delay, a special program was initiated to provide aircraft measurement of electric fields at various altitudes over the Apollo vehicle launch pad. Eight aircraft, each equipped with electric field meters, were used in the program. This program and some of the more important findings are discussed. Also included is a summary of the history of manned space vehicle involvement with lightning, a brief description of the lightning instrumentation in use at KSC (Kennedy Space Center) at the time of the Apollo Soyuz mission and a discussion of the airborne instrumentation and related data.

A Fast MAC-Layer Handover for an IEEE 802.16e-Based WMAN

NASA Astrophysics Data System (ADS)

Ray, Sayan K.; Pawlikowski, Krzysztof; Sirisena, Harsha

We propose a modification of the IEEE 802.16e hard handover (HHO) procedure, which significantly reduces the handover latency constraint of the original HHO procedure in IEEE 802.16e networks. It allows a better handling of the delay-sensitive traffic by avoiding unnecessary time-consuming scanning and synchronization activity as well as simplifies the network re-entry procedure. With the help of the backhaul network, it reduces the number of control messages in the original handover policy, making the handover latency acceptable also for real-time streaming traffic. Preliminary performance evaluation studies show that the modified handover procedure is able to reduce the total handover latency by about 50%.

Bilateral Optic Disc Drusen Mimicking Papilledema

PubMed Central

Cingü, Abdullah Kürşat; Ari, Şeyhmus; Çinar, Yasin; Çaça, İhsan

2012-01-01

Background Optic disc drusen, which are calcified deposits that form anterior to the lamina cribrosa in the optic nerve, may mimic papilledema. Case Report We report herein three cases referred to us with suspicion of disc swelling and papilledema. Following ophthalmologic evaluation with B-scan ultrasound, red-free fundus photography, and computed tomography, the diagnosis of papilledema was excluded in all cases and optic disc drusen was diagnosed. Conclusions Clinical suspicion of optic disc drusen in cases presenting with swelling of the optic nerve head is important in order to avoid unnecessary interventions and anxiety. The reported cases highlight the commonly encountered clinical presentations and the practical aspects of diagnosis and management of optic disc drusen. PMID:22787500

IgG4-related disease presenting with destructive sinonasal lesion mimicking malignancy.

PubMed

Chen, Bo-Nien

2016-11-01

IgG4-related disease is a newly recognized systemic fibroinflammatory disorder. We report a 36-year-old man who presented with intractable right nasal pain and frontal headache for 1 month. Computed tomography revealed an ill-defined lesion with bony erosion over the right anterior ethmoid sinus and middle turbinate. The lesion was resected through endoscopic anterior ethmoidectomy and middle turbinectomy. IgG4-related disease was definitively diagnosed according to histopathological features. Prednisolone was administered postoperatively. IgG4-related disease presenting with destructive sinonasal lesion mimicking malignancy is rare. Awareness is essential to avoid delayed diagnosis or unnecessary invasive intervention, because the disorder responds to glucocorticoid and immunosuppressant therapy.

[Up-to-date research for clinical application in breast cancer].

PubMed

Koyama, Hiroki

2006-03-01

Breast cancer is still increasing in number of patients affected annually, with a peak incidence between 40-50 years of age. Various researches to control the disease have been attracting much attention scientifically and socially. Clinical application of trastuzumab (Herceptin), sentinel node biopsy to avoid unnecessary axillary dissection and individualized use of chemo-endocrine therapy as indicated by large scale clinical trials are among the recent successful results by pre-clinical and early clinical studies. In this context, the present special edition deals with articles on recent progress in breast cancer researches by leading scientists in this field. Hoping readers to understand, digest, and also to be stimulated by the updates for daily clinical practice.

Generalized likelihood ratios for quantitative diagnostic test scores.

PubMed

Tandberg, D; Deely, J J; O'Malley, A J

1997-11-01

The reduction of quantitative diagnostic test scores to the dichotomous case is a wasteful and unnecessary simplification in the era of high-speed computing. Physicians could make better use of the information embedded in quantitative test results if modern generalized curve estimation techniques were applied to the likelihood functions of Bayes' theorem. Hand calculations could be completely avoided and computed graphical summaries provided instead. Graphs showing posttest probability of disease as a function of pretest probability with confidence intervals (POD plots) would enhance acceptance of these techniques if they were immediately available at the computer terminal when test results were retrieved. Such constructs would also provide immediate feedback to physicians when a valueless test had been ordered.

Flux splitting algorithms for two-dimensional viscous flows with finite-rate chemistry

NASA Technical Reports Server (NTRS)

Shuen, Jian-Shun; Liou, Meng-Sing

1989-01-01

The Roe flux difference splitting method was extended to treat 2-D viscous flows with nonequilibrium chemistry. The derivations have avoided unnecessary assumptions or approximations. For spatial discretization, the second-order Roe upwind differencing is used for the convective terms and central differencing for the viscous terms. An upwind-based TVD scheme is applied to eliminate oscillations and obtain a sharp representation of discontinuities. A two-state Runge-Kutta method is used to time integrate the discretized Navier-Stokes and species transport equations for the asymptotic steady solutions. The present method is then applied to two types of flows: the shock wave/boundary layer interaction problems and the jet in cross flows.

Flux splitting algorithms for two-dimensional viscous flows with finite-rate chemistry

NASA Technical Reports Server (NTRS)

Shuen, Jian-Shun; Liou, Meng-Sing

1989-01-01

The Roe flux-difference splitting method has been extended to treat two-dimensional viscous flows with nonequilibrium chemistry. The derivations have avoided unnecessary assumptions or approximations. For spatial discretization, the second-order Roe upwind differencing is used for the convective terms and central differencing for the viscous terms. An upwind-based TVD scheme is applied to eliminate oscillations and obtain a sharp representation of discontinuities. A two-stage Runge-Kutta method is used to time integrate the discretized Navier-Stokes and species transport equations for the asymptotic steady solutions. The present method is then applied to two types of flows: the shock wave/boundary layer interaction problems and the jet in cross flows.

Using quantum theory to simplify input-output processes

NASA Astrophysics Data System (ADS)

Thompson, Jayne; Garner, Andrew J. P.; Vedral, Vlatko; Gu, Mile

2017-02-01

All natural things process and transform information. They receive environmental information as input, and transform it into appropriate output responses. Much of science is dedicated to building models of such systems-algorithmic abstractions of their input-output behavior that allow us to simulate how such systems can behave in the future, conditioned on what has transpired in the past. Here, we show that classical models cannot avoid inefficiency-storing past information that is unnecessary for correct future simulation. We construct quantum models that mitigate this waste, whenever it is physically possible to do so. This suggests that the complexity of general input-output processes depends fundamentally on what sort of information theory we use to describe them.

Splenic syndrome in patients at high altitude with unrecognized sickle cell trait: splenectomy is often unnecessary.

PubMed

Sheikha, Anwar

2005-10-01

The health risks associated with sickle cell trait are minimal in this sizable sector of the world's population, and many of these patients have no information about their sickle cell status. Splenic syndrome at high altitude is well known to be associated with sickle cell trait, and unless this complication is kept in mind these patients may be subjected to unnecessary surgery when they present with altitude-induced acute abdomen. Four patients were admitted to the surgical ward with a similar complaint of acute severe left upper abdominal pain after arrival to the mountainous resort city of Abha, Saudi Arabia. All were subjected to splenectomy because of lack of suspicion regarding sickle cell status. Histologic examination of the spleen showed all patients had sickle cells in the red pulp. On further assessment all were found to have sickle cell trait with splenic infarction. In a similar study of 6 patients with known sickle cell disease who had comparable problems when they travelled to the Colorado mountains, all made an uncomplicated recovery with conservative management. In ethnically vulnerable patients with splenic syndrome, sickle cell trait should be ruled out before considering splenectomy. These patients could respond well to supportive management, and splenectomy would be avoided.

The self-adjusting file (SAF) system: An evidence-based update.

PubMed

Metzger, Zvi

2014-09-01

Current rotary file systems are effective tools. Nevertheless, they have two main shortcomings: They are unable to effectively clean and shape oval canals and depend too much on the irrigant to do the cleaning, which is an unrealistic illusionThey may jeopardize the long-term survival of the tooth via unnecessary, excessive removal of sound dentin and creation of micro-cracks in the remaining root dentin. The new Self-adjusting File (SAF) technology uses a hollow, compressible NiTi file, with no central metal core, through which a continuous flow of irrigant is provided throughout the procedure. The SAF technology allows for effective cleaning of all root canals including oval canals, thus allowing for the effective disinfection and obturation of all canal morphologies. This technology uses a new concept of cleaning and shaping in which a uniform layer of dentin is removed from around the entire perimeter of the root canal, thus avoiding unnecessary excessive removal of sound dentin. Furthermore, the mode of action used by this file system does not apply the machining of all root canals to a circular bore, as do all other rotary file systems, and does not cause micro-cracks in the remaining root dentin. The new SAF technology allows for a new concept in cleaning and shaping root canals: Minimally Invasive 3D Endodontics.

Looking for trouble? Diagnostics expanding disease and producing patients.

PubMed

Hofmann, Bjørn

2018-05-23

Novel tests give great opportunities for earlier and more precise diagnostics. At the same time, new tests expand disease, produce patients, and cause unnecessary harm in overdiagnosis and overtreatment. How can we evaluate diagnostics to obtain the benefits and avoid harm? One way is to pay close attention to the diagnostic process and its core concepts. Doing so reveals 3 errors that expand disease and increase overdiagnosis. The first error is to decouple diagnostics from harm, eg, by diagnosing insignificant conditions. The second error is to bypass proper validation of the relationship between test indicator and disease, eg, by introducing biomarkers for Alzheimer's disease before the tests are properly validated. The third error is to couple the name of disease to insignificant or indecisive indicators, eg, by lending the cancer name to preconditions, such as ductal carcinoma in situ. We need to avoid these errors to promote beneficial testing, bar harmful diagnostics, and evade unwarranted expansion of disease. Accordingly, we must stop identifying and testing for conditions that are only remotely associated with harm. We need more stringent verification of tests, and we must avoid naming indicators and indicative conditions after diseases. If not, we will end like ancient tragic heroes, succumbing because of our very best abilities. © 2018 John Wiley & Sons, Ltd.

An evaluation of the benefits and challenges of video consulting between general practitioners and residential aged care facilities.

PubMed

Wade, Victoria; Whittaker, Frank; Hamlyn, Jeremy

2015-12-01

This research evaluated a project that provided video consultations between general practitioners (GPs) and residential aged care facilities (RACFs), with the aim of enabling faster access to medical care and avoidance of unnecessary hospital transfers. GPs were paid for video consultations at a rate equivalent to existing insurance reimbursement for supporting telehealth services. Evaluation data were gathered by direct observation at the project sites, semi-structured interviews and video call data from the technical network. Three pairs of general practices and RACFs were recruited to the project. 40 video consultations eligible for payment occurred over a 6 month period, three of which were judged to have avoided hospital attendance. The process development and change management aspects of the project required substantially more effort than was anticipated. This was due to problems with RACF technical infrastructure, the need for repeated training and awareness raising in RACFs, the challenge of establishing new clinical procedures, the short length of the project and broader difficulties in the relationships between GPs and RACFs. Video consulting between GPs and RACFs was clinically useful and avoided hospital attendance on a small scale, but further focus on process development is needed to embed this as a routine method of service delivery. © The Author(s) 2015.

Laparoscopic staging for apparent stage I epithelial ovarian cancer.

PubMed

Melamed, Alexander; Keating, Nancy L; Clemmer, Joel T; Bregar, Amy J; Wright, Jason D; Boruta, David M; Schorge, John O; Del Carmen, Marcela G; Rauh-Hain, J Alejandro

2017-01-01

Whereas advances in minimally invasive surgery have made laparoscopic staging technically feasible in stage I epithelial ovarian cancer, the practice remains controversial because of an absence of randomized trials and lack of high-quality observational studies demonstrating equivalent outcomes. This study seeks to evaluate the association of laparoscopic staging with survival among women with clinical stage I epithelial ovarian cancer. We used the National Cancer Data Base to identify all women who underwent surgical staging for clinical stage I epithelial ovarian cancer diagnosed from 2010 through 2012. The exposure of interest was planned surgical approach (laparoscopy vs laparotomy), and the primary outcome was overall survival. The primary analysis was based on an intention to treat: all women whose procedures were initiated laparoscopically were categorized as having had a planned laparoscopic procedure, regardless of subsequent conversion to laparotomy. We used propensity methods to match patients who underwent planned laparoscopic staging with similar patients who underwent planned laparotomy based on observed characteristics. We compared survival among the matched cohorts using the Kaplan-Meier method and Cox regression. We compared the extent of lymphadenectomy using the Wilcoxon rank-sum test. Among 4798 eligible patients, 1112 (23.2%) underwent procedures that were initiated laparoscopically, of which 190 (17%) were converted to laparotomy. Women who underwent planned laparoscopy were more frequently white, privately insured, from wealthier ZIP codes, received care in community cancer centers, and had smaller tumors that were more frequently of serous and less often of mucinous histology than those who underwent staging via planned laparotomy. After propensity score matching, time to death did not differ between patients undergoing planned laparoscopic vs open staging (hazard ratio, 0.77, 95% confidence interval, 0.54-1.09; P = .13). Planned laparoscopic staging was associated with a slightly higher median lymph node count (14 vs 12, P = .005). Planned laparoscopic staging was not associated with time to death after adjustment for receipt of adjuvant chemotherapy, histological type and grade, and pathological stage (hazard ratio, 0.82, 95% confidence interval, 0.57-1.16). Surgical staging via planned laparoscopy vs laparotomy was not associated with worse survival in women with apparent stage I epithelial ovarian cancer. Copyright © 2016 Elsevier Inc. All rights reserved.

Postoperative Outcomes of Extremely Low Birth-Weight Infants With Necrotizing Enterocolitis or Isolated Intestinal Perforation

PubMed Central

Blakely, Martin L.; Lally, Kevin P.; McDonald, Scott; Brown, Rebeccah L.; Barnhart, Douglas C.; Ricketts, Richard R.; Thompson, W Raleigh; Scherer, L R.; Klein, Michael D.; Letton, Robert W.; Chwals, Walter J.; Touloukian, Robert J.; Kurkchubasche, Arlett G.; Skinner, Michael A.; Moss, R Lawrence; Hilfiker, Mary L.

2005-01-01

Objective: Purposes of this study were: 1) to compare mortality and postoperative morbidities (intra-abdominal abscess, wound dehiscence, and intestinal stricture) in extremely low birth weight (ELBW) infants who underwent initial laparotomy or drainage for necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP); 2) to determine the ability to distinguish NEC from IP preoperatively and the importance of this distinction on outcome measures; and 3) to evaluate the association between extent of intestinal disease determined at operation and outcome measures. Background: ELBW infants who undergo operation for NEC or IP have a postoperative, in-hospital mortality rate of approximately 50%. Whether to perform laparotomy or drainage initially is controversial. Also unknown is the importance of distinguishing NEC from IP and the current ability to make this distinction based on objective data available prior to operation. Methods: A prospective, multicenter cohort study of 156 ELBW infants at 16 neonatal intensive care units (NICU) within the NICHD Neonatal Research Network. Results: Among the 156 enrolled infants, 80 underwent initial peritoneal drainage and 76 initial laparotomy. Mortality rate was 49% (76 of 156). Ninety-six patients had a preoperative diagnosis of NEC and 60 had presumed IP. There was a high level of agreement between the presumed preoperative diagnosis and intraoperative diagnosis in patients undergoing initial laparotomy (kappa = 0.85). The relative risk for death with a preoperative diagnosis of NEC (versus IP) was 1.4 (95% confidence interval, 0.99–2.1, P = 0.052). The overall incidence of postoperative intestinal stricture was 10.3%, wound dehiscence 4.4%, and intra-abdominal abscess 5.8%, and did not significantly differ between groups undergoing initial laparotomy versus initial drainage. Conclusions: Survival to hospital discharge after operation for NEC or IP in ELBW neonates remains poor (51%). Patients with a preoperative diagnosis of NEC have a relative risk for death of 1.4 compared with those with a preoperative diagnosis of IP. A distinction can be made preoperatively between NEC and IP based on abdominal radiographic findings and the patient's age at operation. Future randomized trials that compare laparotomy versus drainage would likely benefit from stratification of treatment assignment based on preoperative diagnosis. PMID:15912048

Independent predictors of enteric fistula and abdominal sepsis after damage control laparotomy: results from the prospective AAST Open Abdomen registry.

PubMed

Bradley, Matthew J; Dubose, Joseph J; Scalea, Thomas M; Holcomb, John B; Shrestha, Binod; Okoye, Obi; Inaba, Kenji; Bee, Tiffany K; Fabian, Timothy C; Whelan, James F; Ivatury, Rao R

2013-10-01

Enterocutaneous fistula (ECF), enteroatmospheric fistula (EAF), and intra-abdominal sepsis/abscess (IAS) are major challenges for surgeons caring for patients undergoing damage control laparotomy after trauma. To determine independent predictors of ECF, EAF, or IAS in patients undergoing damage control laparotomy after trauma, using the AAST Open Abdomen Registry. The AAST Open Abdomen registry of patients with an open abdomen following damage control laparotomy was used to identify patients who developed ECF, EAF, or IAS and to compare these patients with those without these complications. Univariate analyses were performed to compare these groups of patients. Variables from univariate analyses differing at P < .20 were entered into a stepwise logistic regression model to identify independent risk factors for ECF, EAF, or IAS. Fourteen level I trauma centers. A total of 517 patients with an open abdomen following damage control laparotomy. Complication of ECF, EAF, or IAS. More patients in the ECF/EAF/IAS group than in the group without these complications underwent bowel resection (63 of 111 patients [57%] vs 133 of 406 patients [33%]; P < .001). Within the first 48 hours after surgery, the ECF/EAF/IAS group received more colloids (P < .03) and total fluids (P < .03) than did the group without these complications. The ECF/EAF/IAS group underwent almost twice as many abdominal reexplorations as did the group without these complications (mean [SD] number, 4.1 [4.1] vs 2.2 [3.4]; P < .001). After multivariate analysis, the independent predictors of ECF/EAF/IAS were a large bowel resection (adjusted odds ratio [AOR], 3.56 [95% CI, 1.88-6.76]; P < .001), a total fluid intake at 48 hours of between 5 and 10 L (AOR, 2.11 [95% CI, 1.15-3.88]; P = .02) or more than 10 L (AOR, 1.93 [95% CI, 1.04-3.57]; P = .04), and an increasing number of reexplorations (AOR, 1.14 [95% CI, 1.06-1.21]; P < .001). Large bowel resection, large-volume fluid resuscitation, and an increasing number of abdominal reexplorations were statistically significant predictors of ECF, EAF, or IAS in patients with an open abdomen after damage control laparotomy.

Risk Factors for Hepatic Morbidity Following Nonoperative Management: Multicenter Study

DTIC Science & Technology

2006-05-01

with a primary bile duct leak at ERCP. The last patient underwent laparotomy for a biliary -venous fistula that failed to resolve by ERCP and stenting ...the patient with a biliary -venous fistula underwent laparotomy and ERCP with stenting to manage this complication and then later, IR drainage of a...peritonitis,17 and stenting rather than sphincter- otomy is felt to expedite healing of biliary leaks.18 Al- though we had relatively few bile duct

A comparison of alcohol positive and alcohol negative trauma patients requiring an emergency laparotomy.

PubMed

Benson, Cedric; Weinberg, Janice; Narsule, Chaitan K; Brahmbhatt, Tejal S

2018-07-01

The effect of alcohol exposure on patients undergoing a laparotomy for trauma is unknown. The purpose of this study was to compare outcomes of morbidity and mortality between alcohol positive and alcohol negative trauma patients who required emergent laparotomies using the National Trauma Data Bank (NTDB). A retrospective database analysis was performed using 28,354 NTDB incident trauma cases, from 2007 through 2012, who had been tested for alcohol and who required abdominal operations (using ICD-9-CM procedure codes) within 24h of presentation. Variables used: age, gender, admission year, alcohol presence, ISS, GCS, injury type & mechanism, discharge status, hospital LOS, ICU stay, ventilator use, and hospital complications. In adjusted analyses, there were no statistically significant differences between the alcohol positive and alcohol negative cohorts when evaluating in-hospital mortality (OR, 0.93; 95% CI: 0.84-1.03), likelihood of earlier hospital discharge (HR, 1.02; 95% CI: 0.99-1.05), and the all-inclusive category of in-hospital complications (OR, 1.04; 95% CI: 0.97-1.12). After adjusting for age, gender, admission year, ISS, GCS, and injury mechanism, there were no major differences between the alcohol positive and alcohol negative cohorts when it came to in-hospital mortality, likelihood of earlier hospital discharge, and most of the in-hospital complications measured among adult trauma patients requiring emergency laparotomies. Copyright © 2017 Elsevier Inc. All rights reserved.

The utility of focused assessment with sonography for trauma as a triage tool in multiple-casualty incidents during the second Lebanon war.

PubMed

Beck-Razi, Nira; Fischer, Doron; Michaelson, Moshe; Engel, Ahuva; Gaitini, Diana

2007-09-01

The purpose of this study was to evaluate the role of focused assessment with sonography for trauma (FAST) as a triage tool in multiple-casualty incidents (MCIs) for a single international conflict. The charts of 849 casualties that arrived at our level 1 trauma referral center were reviewed. Casualties were initially triaged according to the Injury Severity Score at the emergency department gate. Two-hundred eighty-one physically injured patients, 215 soldiers (76.5%) and 66 civilians (23.5%), were admitted. Focused assessment with sonography for trauma was performed in 102 casualties suspected to have an abdominal injury. Sixty-eight underwent computed tomography (CT); 12 underwent laparotomy; and 28 were kept under clinical observation alone. We compared FAST results against CT, laparotomy, and clinical observation records. Focused assessment with sonography for trauma results were positive in 17 casualties and negative in 85. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of FAST were 75%, 97.6%, 88.2%, 94.1%, and 93.1%, respectively. A strong correlation between FAST and CT results, laparotomy, and clinical observation was obtained (P < .05). In a setting of a war conflict-related MCI, FAST enabled immediate triage of casualties to laparotomy, CT, or clinical observation. Because of its moderate sensitivity, a negative FAST result with strong clinical suspicion demands further evaluation, especially in an MCI.

The impact of robotics on practice management of endometrial cancer: transitioning from traditional surgery.

PubMed

Hoekstra, Anna V; Jairam-Thodla, Arati; Rademaker, Alfred; Singh, Diljeet K; Buttin, Barbara M; Lurain, John R; Schink, Julian C; Lowe, M Patrick

2009-12-01

Evaluation of the impact of a new robotic surgery programme on perioperative outcomes for endometrial cancer A prospective database of all patients undergoing staging for endometrial cancer during July 2007-July 2008 was collected and analysed. Demographic data and perioperative outcomes were compared between cases performed via laparotomy, laparoscopy and robotics. Sixty-five patients underwent staging during the time of data collection (LAP-26, LSC-7, ROB-32). No difference in surgical volume in the year before vs. after robotics was identified. Median operative time for robotics and laparotomy was significantly less than for laparoscopy (p = 0.023). There was no significant difference in lymph node yields between the three groups (p = 0.92). Robotics was associated with significantly less blood loss (p < 0.0001). Complication rates were significantly lower in the robotic group compared to the laparotomy group (p = 0.05). Median hospital stay was 1 day for the minimally invasive groups. Total number of perioperative inpatient days decreased from 331 to 150 in one year. Practice management of endometrial cancer transitioned from a predominantly open approach (5.6% LSC) to robotics (11% LSC, 49% ROB) within 12 months. Robotic surgery dramatically altered our management of endometrial cancer and was associated with a significant improvement in several perioperative outcomes when compared to laparotomy and laparoscopy. Copyright (c) 2009 John Wiley & Sons, Ltd.

Mini-Laparotomy for Superior Mesenteric Artery Aneurysm Due to Takayasu's Arteritis.

PubMed

Matsumoto, Takatsugu; Ishizuka, Mitsuru; Iso, Yukihiro; Kita, Junji; Kubota, Keiichi

2015-04-01

Superior mesenteric artery aneurysm (SMAA) is reported to be the third-most common type of visceral aneurysm (VA), accounting for 5% of all VAs. The etiology of SMAA is commonly thought to be infection, and it usually exists in the proximal part of the superior mesenteric artery, which is suitable for endovascular treatment. We herein report an extremely rare case of the distal part of SMAA caused by Takayasu's arteritis (TA), which was successfully resected using a mini-laparotomy method without impairing the intestinal blood supply. A 51-year-old woman was admitted to our hospital with sustained fever and lower back pain. Physical examination showed that she had a discrepancies in blood pressure between both arms. Contrast-enhanced whole-body computed tomography showed stenosis of the thoracic aorta and an aneurysm located in the distal part of the superior mesenteric artery. The diameter of the aneurysm was 4.5 cm. The aneurysm was resected via 4-cm mini-laparotomy, and the vascularity of the intestine was successfully preserved. The postoperative course was uneventful, and the patient was diagnosed as having TA based on both clinical and pathologic findings. Additional corticosteroid therapy was started to treat the arteritis, and at 3-month follow-up she was without critical incidents. Mini-laparotomy is a safe and less-invasive approach to treat SMAA, especially when the lesion is located in the distal part of the artery.

Minimalism through intraoperative functional mapping.

PubMed

Berger, M S

1996-01-01

Intraoperative stimulation mapping may be used to avoid unnecessary risk to functional regions subserving language and sensori-motor pathways. Based on the data presented here, language localization is variable in the entire population, with only certainty existing for the inferior frontal region responsible for motor speech. Anatomical landmarks such as the anterior temporal tip for temporal lobe language sites and the posterior aspect of the lateral sphenoid wing for the frontal lobe language zones are unreliable in avoiding postoperative aphasias. Thus, individual mapping to identify essential language sites has the greatest likelihood of avoiding permanent deficits in naming, reading, and motor speech. In a similar approach, motor and sensory pathways from the cortex and underlying white matter may be reliably stimulated and mapped in both awake and asleep patients. Although these techniques require an additional operative time and equipment nominally priced, the result is often gratifying, as postoperative morbidity has been greatly reduced in the process of incorporating these surgical strategies. The patients quality of life is improved in terms of seizure control, with or without antiepileptic drugs. This avoids having to perform a second costly operative procedure, which is routinely done when extraoperative stimulation and recording is done via subdural grids. In addition, an aggressive tumor resection at the initial operation lengthens the time to tumor recurrence and often obviates the need for a subsequent reoperation. Thus, intraoperative functional mapping may be best alluded to as a surgical technique that results in "minimalism in the long term".

Re-evaluating the relationships among filtering activity, unnecessary storage, and visual working memory capacity.

PubMed

Emrich, Stephen M; Busseri, Michael A

2015-09-01

The amount of task-irrelevant information encoded in visual working memory (VWM), referred to as unnecessary storage, has been proposed as a potential mechanism underlying individual differences in VWM capacity. In addition, a number of studies have provided evidence for additional activity that initiates the filtering process originating in the frontal cortex and basal ganglia, and is therefore a crucial step in the link between unnecessary storage and VWM capacity. Here, we re-examine data from two prominent studies that identified unnecessary storage activity as a predictor of VWM capacity by directly testing the implied path model linking filtering-related activity, unnecessary storage, and VWM capacity. Across both studies, we found that unnecessary storage was not a significant predictor of individual differences in VWM capacity once activity associated with filtering was accounted for; instead, activity associated with filtering better explained variation in VWM capacity. These findings suggest that unnecessary storage is not a limiting factor in VWM performance, whereas neural activity associated with filtering may play a more central role in determining VWM performance that goes beyond preventing unnecessary storage.

Clinical outcomes in endometrial cancer care when the standard of care shifts from open surgery to robotics.

PubMed

Mok, Zhun Wei; Yong, Eu Leong; Low, Jeffrey Jen Hui; Ng, Joseph Soon Yau

2012-06-01

In Singapore, the standard of care for endometrial cancer staging remains laparotomy. Since the introduction of gynecologic robotic surgery, there have been more data comparing robotic surgery to laparoscopy in the management of endometrial cancer. This study reviewed clinical outcomes in endometrial cancer in a program that moved from laparotomy to robotic surgery. A retrospective review was performed on 124 consecutive endometrial cancer patients. Preoperative data and postoperative outcomes of 34 patients undergoing robotic surgical staging were compared with 90 patients who underwent open endometrial cancer staging during the same period and in the year before the introduction of robotics. There were no significant differences in the mean age, body mass index, rates of diabetes, hypertension, previous surgery, parity, medical conditions, size of specimens, histologic type, or stage of cancer between the robotic and the open surgery groups. The first 20 robotic-assisted cases had a mean (SD) operative time of 196 (60) minutes, and the next 14 cases had a mean time of 124 (64) minutes comparable to that for open surgery. The mean number of lymph nodes retrieved during robot-assisted staging was smaller than open laparotomy in the first 20 cases but not significantly different for the subsequent 14 cases. Robot-assisted surgery was associated with lower intraoperative blood loss (110 [24] vs 250 [83] mL, P < 0.05), a lower rate of postoperative complications (8.8% vs 26.8%, P = 0.032), a lower wound complication rate (0% vs 9.9%, P = 0.044), a decreased requirement for postoperative parenteral analgesia (5.9% vs 51.1, P < 0.001), and shorter length of hospitalization (2.0 [1.1] vs 6.0 [4.5] days, P < 0.001) compared to patients in the open laparotomy group. Our series shows that outcomes traditionally associated with laparoscopic endometrial cancer staging are achievable by laparoscopy-naive gynecologic cancer surgeons moving from laparotomy to robot-assisted endometrial cancer staging after a relatively small number of cases.

Is sarcopenia a useful predictor of outcome in patients after emergency laparotomy? A study using the NELA database.

PubMed

Trotter, John; Johnston, Judith; Ng, Alvin; Gatt, Marcel; MacFie, John; McNaught, Clare

2018-05-01

Introduction Studies have reported on the use of frailty as a prognostic indicator in patients undergoing elective surgery. Similar data do not exist for patients undergoing emergency surgery. The aim of this study was to evaluate the effect of preoperative sarcopenia measured by computed tomography (CT) on outcome following emergency laparotomy. Materials and methods Data from the National Emergency Laparotomy Audit database were retrieved for patients who had undergone an emergency laparotomy over 12 months at York NHS Foundation Trust. Sarcopenia was assessed by psoas density and area on preoperative CT. Mortality rates at 30 days and 1 year were recorded. Secondary outcomes included discharge rates to non-independent living. Results A total of 259 patients were included. Overall cohort 30-day and 1-year mortality was 13.9% (36/259) and 28.2% (73/259), respectively. Sarcopenia measured by psoas density was associated with increased mortality compared with patients who did not develop sarcopenia at 30 days (29.7%, 19/64, vs. 8.7%, 17/195; P < 0.001; odds ratio, OR, 4.42; 95% confidence interval, CI 2.13-9.26) and at 1 year (57.8%, 37/64, vs. 18.5%, (36/195; P < 0.001; OR 6.05; 95%CI 3.28-11.18). An increase in mortality was seen in patients with sarcopenia measured by psoas area at 30 days (21.3%, 13/61, vs. 9.1%, 17/187; OR 2.71; 95%CI 1.23-5.96, P = 0.013) and at 1 year (42.6%, 26/61, vs. 20.9%, 39/187; OR 2.82; 95% CI 1.52-5.23, P < 0.001). Conclusions Sarcopenia assessed by measurement of psoas density and area on CT is associated with increased mortality following emergency laparotomy. The use of sarcopenia as a predictive tool merits further attention and may be useful in patients undergoing emergency surgery.

Kaolin-based hemostatic dressing improves hemorrhage control from a penetrating inferior vena cava injury in coagulopathic swine.

PubMed

Koko, Kiavash R; McCauley, Brian M; Gaughan, John P; Nolan, Ryan S; Fromer, Marc W; Hagaman, Ashleigh L R; Choron, Rachel L; Brown, Spencer A; Hazelton, Joshua P

2017-07-01

Retrohepatic inferior vena cava (RIVC) injuries are often lethal due to challenges in obtaining hemorrhage control. We hypothesized that packing with a new kaolin-based hemostatic dressing (Control+; Z-Medica, Wallingford, CT) would improve hemorrhage control from a penetrating RIVC injury compared with packing with standard laparotomy sponges alone. Twelve male Yorkshire pigs received a 25% exchange transfusion of blood for refrigerated normal saline to induce a hypothermic coagulopathy. A laparotomy was performed and a standardized 1.5 cm injury to the RIVC was created which was followed by temporary abdominal closure and a period of uncontrolled hemorrhage. When the mean arterial pressure reached 70% of baseline, demonstrating hemorrhagic shock, the abdomen was re-entered, and the injury was treated with perihepatic packing using standard laparotomy sponges (L; n = 6) or a new kaolin-based hemostatic dressing (K; n = 6). Animals were then resuscitated for 6 hours with crystalloid solution. The two groups were compared using the Wilcoxon rank sum test and Fisher exact test. A p value of 0.05 or less was considered statistically significant. There was no difference in the animal's temperature, heart rate, mean arterial pressure, cardiac output, and blood loss at baseline or before packing was performed (all p > 0.05). In the laparotomy sponge group, five of six pigs survived the entire study period, whereas all six pigs treated with kaolin-based D2 hemostatic dressings survived. Importantly, there was significantly less blood loss after packing with the new hemostatic kaolin-based dressing compared with packing with laparotomy sponge (651 ± 180 mL vs. 1073 ± 342 mL; p ≤ 0.05). These results demonstrate that the use of this new hemostatic kaolin-based dressing improved hemorrhage control and significantly decreased blood loss in this penetrating RIVC model. This is basic science research based on a large animal model, level V.

Model-based high-throughput design of ion exchange protein chromatography.

PubMed

Khalaf, Rushd; Heymann, Julia; LeSaout, Xavier; Monard, Florence; Costioli, Matteo; Morbidelli, Massimo

2016-08-12

This work describes the development of a model-based high-throughput design (MHD) tool for the operating space determination of a chromatographic cation-exchange protein purification process. Based on a previously developed thermodynamic mechanistic model, the MHD tool generates a large amount of system knowledge and thereby permits minimizing the required experimental workload. In particular, each new experiment is designed to generate information needed to help refine and improve the model. Unnecessary experiments that do not increase system knowledge are avoided. Instead of aspiring to a perfectly parameterized model, the goal of this design tool is to use early model parameter estimates to find interesting experimental spaces, and to refine the model parameter estimates with each new experiment until a satisfactory set of process parameters is found. The MHD tool is split into four sections: (1) prediction, high throughput experimentation using experiments in (2) diluted conditions and (3) robotic automated liquid handling workstations (robotic workstation), and (4) operating space determination and validation. (1) Protein and resin information, in conjunction with the thermodynamic model, is used to predict protein resin capacity. (2) The predicted model parameters are refined based on gradient experiments in diluted conditions. (3) Experiments on the robotic workstation are used to further refine the model parameters. (4) The refined model is used to determine operating parameter space that allows for satisfactory purification of the protein of interest on the HPLC scale. Each section of the MHD tool is used to define the adequate experimental procedures for the next section, thus avoiding any unnecessary experimental work. We used the MHD tool to design a polishing step for two proteins, a monoclonal antibody and a fusion protein, on two chromatographic resins, in order to demonstrate it has the ability to strongly accelerate the early phases of process development. Copyright © 2016 Elsevier B.V. All rights reserved.

Gaia-GOSA: An interactive service for coordination of asteroid observation campaigns

NASA Astrophysics Data System (ADS)

Santana-Ros, Toni; Bartczak, Przemyslaw; Michalowski, Tadeusz; Marciniak, Anna; Butkiewicz-Bak, Magda; Dudziński, Grzegorz

2016-10-01

We describe the Gaia-Ground-based Observational Service for Asteroids (www.gaiagosa.eu), which is a website aiming to facilitate asteroid observers in contributing to the Gaia mission by gathering lightcurves of selected targets.There are many asteroids which lightcurves cannot be covered during one observing run, like slow rotators,with periods longer than 12 hours. There are also targets with periods commensurate with the Earth's day, sotheir lightcurves cannot be covered by observing from one site only. There are also targets of special interest,like binary objects, where a large amount of data is needed. For all targets like those mentioned above, acoordination of observers is needed, also to avoid unnecessary duplication of data gathering.To that end we have created Gaia-GOSA, a web service which allows coordination between observers, focuseson interesting targets and may avoid observers to unnecessary gather data of the same object at the sametime. Furthermore, it is not necessary to be an advanced observer to contribute to the project. The websiteprepares the observing plan, providing all the necessary information to point your telescope. Thesubscription is free and observers with any level of experience are welcome.All the data gathered by Gaia-GOSA users will be reduced and analyzed by astronomers from the Astronomical Observatory of Adam Mickiewicz University in Poznan (AO AMU). The resulting catalogue, containing all the lightcurves obtained, will be used to enhance the results of the Gaia (cornerstone European Space Agency's mission) inversion algorithm.The project has been developed under funding from the European Space Agency (ESA) and initially was only devoted to help users in planning photometric observations of asteroids. However, in this poster we also present an extended version of the website, which also aims to publish predictions of stellar occultations for selected targets. This work has been done in the framework of the Small Bodies: Near and Far (SBNAF) research project, which has received funding from the European Union's Horizon 2020 Research and Innovation Programme, under Grant Agreement no 687378.

Humanised care and a change in practice in a hospital in Benin.

PubMed

Fujita, Noriko; Perrin, Xavier R; Vodounon, Joséf A; Gozo, Michel K; Matsumoto, Yasuyo; Uchida, Sanae; Sugiura, Yasuo

2012-08-01

to describe the process of introduction and implementation of humanised care (humanised childbirth); to determine how the practice of humanised care affects midwives, obstetricians, and other service providers in the hospital; and to determine the factors influencing the change in practice. a qualitative study with grounded theory approach. A semi-structured, in-depth individual interview was conducted for data collection with open coding and a constant comparative analysis until the saturation of concepts. mothers' and children's hospital functioning as a top referral centre in Benin. 16 hospital staff, including 6 midwives. humanised care was initiated by midwives with hesitation and difficulties. Midwives and obstetricians learned that a supportive environment for women could produce a positive birth outcome without medication. Communication between the midwives and women and their families improved with a higher level of appreciation of the care provided by the midwives among the women and their families. Humanised care appears to affect the professional value of midwives, their levels of job satisfaction, and their personal motivation for work towards improving their performance. A positive influence on obstetricians and other staff was observed. These individuals were inspired to make changes in hospital culture to improve care, to avoid unnecessary interventions, and to improve communication. Important factors in achieving favourable results were the leadership and commitment of the hospital management team and the recognition and support they extended towards the hospital staff, especially the midwives. a system of humanised care that stresses improved communication between the women giving birth, their families, and care providers, based on respect for women's dignity and liberty, and avoidance of unnecessary intervention can be promoted with proper managerial support. This system can promote favourable changes in hospital practice, which are helpful in motivating midwives in resource-limited settings. Copyright © 2011 Elsevier Ltd. All rights reserved.

Comparison of Various Methods in the Diagnosis of Entamoeba histolytica in Stool and Serum Specimens

PubMed Central

Uslu, Hakan; Aktas, Osman; Uyanik, Muhammet Hamidullah

2016-01-01

Objective: Entamoeba histolytica is indistinguishable from Entamoeba dispar in direct microscopic examination. A definitive diagnosis of E. histolytica is important in terms of the treatment of the patient and to avoid unnecessary costs. This study’s aim is to determine the prevalence of E. histolytica and to make a comparison of the different diagnostic tests in the patients specimens defined as E. histolytica/E. dispar infection. Materials and Methods: Faecal and serum specimens of 90 patients defined as E. histolytica/E. dispar with microscopy (wet mount examination with 0.85% saline and Lugol’s iodine) were examined. Stool samples were examined by trichrome staining for trophozoites and cysts and by immunoassay methods for specific adhesin antigens (Wampole ® E. histolytica II antigen testing) and for specific serine-rich 30 kD membrane protein (Serazym® E. histolytica antigen testing). Anti-E. histolytica antibodies were investigated using a latex slide test and indirect hemagglutination methods in serum specimens. Results: Presence of E. histolytica was not confirmed in 31.1% cases with trichrome staining, 62.2% of the Wampole antigen test, 64.4%, of the Serazym antigen test, 73.3% of the indirect hemagglutination test and 75.6%. of the latex agglutination. Considering the common results from Wampole and Serazym antigen testing as a reference standard, the specificity/sensitivity is 100/53.85% for trichrome staining, 75.00/98.11% for the latex agglutination test and 78.57/96.77% for the indirect hemagglutination test. Conclusion: It has been shown that investigation of E. histolytica in stools by direct wet-smear microscopy alone can cause significant false positive results. To obtain a reliable diagnosis for E. histolytica and to avoid unnecessary treatment for this parasite, at least one more specific assay, particularly an antigen testing and microscopy, is required. PMID:27551176

A Rare Case of Splenic Torsion with Sigmoid Volvulus in a 14-Year-Old Girl.

PubMed

Ahmadi, Hamid; Tehrani, Mahdieh Mohammad Khan

2016-01-01

Wandering spleen is an uncommon entity in adults and has been described only rarely with sigmoid volvulus, that rarely affects children and adolescents. It is usually described in adults.Wandering spleen characterized by the abnormal location of the spleen, caused by incomplete fusion of the four primary splenic ligaments, allowing the spleen to be mobile within the abdomen.The wandering spleen can lead to torsion and subsequent splenic infarction or rupture. Clinical suspicion plus urgent investigation and intervention are important. We present a rare clinical case of acute abdomen due to torsion of wandering spleen and volvulus of sigmoid in a 14-year-old girl presented with painful periumbilical mass. Detorsion of sigmoid occurred while undergoing exploratory laparotomy and splenectomy was performed. The possibility of torsion and its complication like gastric, pancreas tail and colon volvulus should be kept in mind in the differential diagnosis of the acute abdomen to avoid serious complications.

Delayed diaphragmatic herniation masquerading as a complicated parapneumonic effusion.

PubMed

Tsang, J; Ryan, F

1999-01-01

Injury to the diaphragm following blunt or penetrating thoracoabdominal trauma is not uncommon. Recognition of this important complication of trauma continues to be a challenge because of the lack of specific clinical and plain radiographic features, the frequent presence of other serious injuries and the potential for delayed presentation. Delayed diaphragmatic herniation often presents with catastrophic bowel obstruction or strangulation. Early recognition of diaphragmatic injury is required to avoid this potentially lethal complication. The case of a 35-year-old man with a history of a knife wound to the left flank 15 years previously, who presented with unexplained acute hypoxemic respiratory failure and a unilateral exudative pleural effusion that was refractory to tube thoracostomy drainage, is reported. After admission to hospital, he developed gross dilation of his colon; emergency laparotomy revealed an incarcerated colonic herniation into the left hemithorax. Interesting clinical features of this patient's case included the patient's hobby of weightlifting, a persistently deviated mediastinum despite drainage of the pleural effusion and deceptive pleural fluid biochemical indices.

Duodenal ulcer perforation: a district hospital experience.

PubMed

Durai, R; Razvi, A; Uzkalnis, A; Ng, Ph C H

2011-01-01

Duodenal ulcer perforation still occurs frequently in the 21st century inspite of the wide availability of proton pump inhibitors. During 2005-2008, 34 patients underwent treatment of duodenal ulcer perforation at the University Hospital Lewisham, London. Laparoscopic or open repair of the perforation was used. In this study, we analysed the outcome of treatment in terms of complications, mortality and hospital stay with relevant to laparoscopy and open approach. Ten patients underwent laparoscopic closure and the remaining 24 patients underwent laparotomy. The mean hospital stay for the laparoscopic group was 6.6 days and for open repair group was 12.8 days. There were two wound infection related to open approach and four patients died during the post operative period however the cause of death was not related to the procedure. Laparoscopy has the advantage of avoiding a big incision and will enable the patient to get discharged home early. However, the only limiting factor is availability of expertise and competency of the surgeon.

[Type IV paraesophageal hernia with 60% of gastric necrosis. Case report].

PubMed

Navarro-Tovar, Fernando; Juárez-de La Torre, Juan Carlos; Pérez-Ayala, Luis Carlos; Quintero-Cabrera, Eduardo

2014-01-01

Paraesophageal hernias are rare and, when associated with symptoms, the risk of complications increases, becoming a surgical emergency. We report a case of a 53 year-old female with 3 weeks of clinical evolution including abdominal pain, nausea and occasional vomiting; 24 h prior to admission she presented intestinal occlusion. Radiographic and tomographic findings showed a paraesophageal hernia, requiring exploratory laparotomy, which demonstrated a 9 cm paraesophageal diaphragmatic defect with a hernia sac containing transverse colon, omentum, fundus and body of the stomach (this last one presented ~60% of necrosis), performing nonanatomic gastrectomy and simple diaphragmatic reconstruction. The patient had a complicated postoperative period requiring two additional surgeries attempting to correct gastrectomy dehiscence and ending with a third procedure for cervical esophagostomy and Witzel jejunostomy. Elective repair is recommended in all patients with asymptomatic paraesophageal hernia in order to avoid possible complications. The approach method is dependent on the surgeon's experience and the conditions of the hernia and involved structures at the time of diagnosis.

True trilineage haematopoiesis in excised heterotopic ossification from a laparotomy scar: report of a case and literature review.

PubMed

Christofi, Theodoros; Raptis, Dimitri A; Kallis, Andreas; Ambasakoor, Faisal

2008-07-01

We report a case of true trilineage haematopoiesis in an excised area of heterotopic ossification from an upper mid-line laparotomy scar. Heterotopic ossification is a rare complication of abdominal surgery and usually occurs when upper mid-line incisions are utilised. Whereas cases of heterotopic ossification in abdominal incisions are not exceedingly rare, true trilineage haematopoiesis in such an area of heterotopic ossification, to our knowledge, has only been previously reported once in the English literature.

Clinics in diagnostic imaging (7). Omental caking due to ovarian carcinoma.

PubMed

Helpert, C; Peh, W C; Ng, T Y

1995-12-01

A 52-year-old Chinese woman with previously resected ovarian carcinoma was found to have ascites and a mass in the Pouch of Douglas on follow-up examination. A large omental cake was detected on computerised tomography (CT), and subsequently confirmed during laparotomy. After completion of four cycles of chemotherapy, a near complete resolution of omental metastases was demonstrated on both CT and laparotomy. The role of CT in ovarian cancer is discussed and the CT appearances of omental tumour are described.

Caring for critically injured children: An analysis of 56 pediatric damage control laparotomies.

PubMed

Villalobos, Miguel A; Hazelton, Joshua P; Choron, Rachel L; Capano-Wehrle, Lisa; Hunter, Krystal; Gaughan, John P; Ross, Steven E; Seamon, Mark J

2017-05-01

Injury is the leading cause of death in children under 18 years. Damage control principles have been extensively studied in adults but remain relatively unstudied in children. Our primary study objective was to evaluate the use of damage control laparotomy (DCL) in critically injured children. An American College of Surgeons-verified Level 1 trauma center review (1996-2013) of pediatric trauma laparotomies was undertaken. Exclusion criteria included: age older than 18 years, laparotomy for abdominal compartment syndrome or delayed longer than 2 hours after admission. Demographics, mechanism, resuscitation variables, injuries, need for DCL, and outcomes were evaluated. Independent t test, Mann-Whitney U test, Fisher's exact test, and single-factor analysis of variance assessed statistical significance. Study endpoints were hospital survival and DCL complications. Of 371 children who underwent trauma laparotomy, the median age (IQR; LQ-UQ) age was 16 (5; 11-17) years. Most (73%) were male injured by blunt mechanism (65%). Fifty-six (15%) children (Injury Severity Score [ISS], 33 (25; 17-42), pediatric trauma score 5 (6; 2-8), penetrating abdominal trauma index score [PATI] 29 (32; 12-44)) underwent DCL after major solid organ (63%), vascular (36%), thoracic (38%) and pelvic (36%) injury. DCL patients were older (16.5 (4; 14-18) vs. 16 (7; 10-17)) and were more severely injured (ISS, 33 [25; 17-42] vs. 16 [16; 9-25]), requiring greater intraoperative packed red blood cell transfusion (8 [13; 3.5-16.5] vs. 1 (0; [0-1] units) than definitive laparotomy counterparts. Nonsurvivors arrived in severe physiologic compromise (base deficit, 17 [17; 8-25] vs. 7 [4; 4-8]), requiring more frequent preoperative blood product transfusion (67% vs. 10%) after comparable injury (ISS survivors, 36 [23; 18-41] vs. nonsurvivors 26 (7; 25-32), p = 0.8880). Fifty-five percent of DCL patients survived (length of stay, 26 [21; 18-39] days) requiring 3 (2; 2-4) laparotomies during 4 (6; 2-8) days until closure (fascial, 90%; vicryl/split thickness skin grafting, 10%). DCL complications (surgical site infection, 18%; dehiscence, 2%; enterocutaneous fistula, 2%) were analyzed. When stratified by age (<15 years vs. 15-18 years) and period (1996-2006 vs. 2007-2013), no differences were found in injury severity or DCL outcomes (p > 0.05). After controlling for DCL, age, and gender, multivariate analysis indicated only ISS (odds ratio, 1.10 [95% confidence interval, 1.01 - 1.19], p = 0.0218) and arrival systolic blood pressure (odds ratio, 0.96 [95% confidence interval, 0.93-0.99], p = 0.0254) predicted mortality after severe injury. DCL is a proven, lifesaving surgical technique in adults. This report is the first to analyze the use of DCL in children with critical abdominal injuries. With similar survival and morbidity rates as critically injured adults, DCL merits careful consideration in children with critical abdominal injuries. Therapeutic study, level IV.

Unusual food allergy: Alioidea allergic reactions overview.

PubMed

Cantisani, Carmen; Visconti, Bianca; Paolino, Giovanni; Frascani, Federica; Tofani, Sonia; Fazia, Gilda; Calvieri, Stefano

2014-01-01

Allergic reactions can cause by several aliments and foods. Symptoms usually appear after ingestion, several hours after consumption or even almost immediately. Various food allergies can lead to serious diseases and in some cases to death, so the priority for people suffering from them should be prevention and completely avoiding foods that cause this kind of reactions. Allergy to Alioidea is one of the probable causes of contact dermatitis, gingival and oculonasal diseases and asthma. In this review, we will focus on the increasing incidence of allergy to foods of common use like onions and garlic. In the last ten years, the world production of onions and garlic has increased of at least 25%. People make large use of them, not only in cookery but also from a therapeutic point of view. Their growing use is producing more and more specific, insidious and sometimes serious medical conditions, which highly influence the quality of life of patients. Medical practitioners should be able to recognize immediately these disorders in order to diagnose them quickly and accurately, avoiding unnecessary tests and treatments. We will also describe new patents for detecting food allergens.

Identifying opportunities to improve management of autoimmune hepatitis: evaluation of drug adherence and psychosocial factors.

PubMed

Sockalingam, Sanjeev; Blank, Diana; Abdelhamid, Nour; Abbey, Susan E; Hirschfield, Gideon M

2012-12-01

Recognizing the importance of adherence to therapy in autoimmune hepatitis (AIH) is critical for patient care and avoidance of unnecessary intervention. The influence of psychosocial factors on treatment adherence needs better understanding and prominence. We sought to determine the association between anxiety, depressive symptoms, and avoidant relationship style on self-reported immunosuppressant medication adherence and treatment response in patients with AIH. Fifty two patients with AIH were assessed using the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, the Experiences in Close Relationship Scale (ECR) and a visual analogue scale to measure self-reported adherence. Laboratory markers of adherence and immunosuppressant treatment response were recorded. Chi-square Fisher's exact or Wilcox rank sum tests were used for comparison between groups. Treatment responders compared to non-responders were older (p=0.035), had normal or mild score ranges for anxiety and depression (p=0.025) and were significantly more likely to report >80% treatment adherence (p=0.007). Non-responders had higher anxiety symptoms (p=0.025), and significantly higher ECR-avoidance scores (p=0.023), suggestive of a tendency towards a more avoidant relationship style. We formally document that patients with AIH who have higher depressive and anxiety symptoms and avoidant relationship styles are more likely to be non-adherent to AIH therapy. We reiterate the need for early recognition and treatment of anxiety and depression in patients with AIH, stress the need for treatment adherence and highlight the need for formal evaluation of these factors in trials of therapy targeting apparent treatment non-responders. Copyright © 2012 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

The value of sequential bone marrow biopsy and laparotomy and splenectomy in a series of 127 consecutive untreated patients with non-Hodgkin's lymphoma.

PubMed Central

Rosenberg, S. A.; Dorfman, R. F.; Kaplan, H. S.

1975-01-01

The information derived from sequential routine bone marrow biopsies and exploratory laparotomy with splenectomy in 127 consecutive untreated protocol patients with malignant lymphomata other than Hodgkin's disease is reviewed. Of the 61 patients with diffuse lymphomata, 36% changed stage after these diagnostic procedures, usually to a more advanced stage. Of the 66 patients with nodular lymphomata, 62% had a change in stage, almost all to more advanced stages, usually as a result of bone marrow biopsy. The correlation of pathological stages to clinical stages is presented for each of the Rappaport classification subgroups and for several age groups. The precise indications for exploratory laparotomy with splenectomy cannot yet be defined. These will have to await the results of current clinical trials, which may reveal to what degree an improvement in therapeutic results has been achieved as a result of a better knowledge of the extent of disease. PMID:1237307

A palm-sized high-sensitivity near-infrared fluorescence imager for laparotomy surgery.

PubMed

Dorval, Paul; Mangeret, Norman; Guillermet, Stephanie; Atallah, Ihab; Righini, Christian; Barabino, Gabriele; Coll, Jean-Luc; Rizo, Philippe; Poulet, Patrick

2016-01-01

In laparotomy surgery guided by near-infrared fluorescence imaging, the access to the field of operation is limited by the illumination and/or the imaging field. The side of cavities or organs such as the liver or the heart cannot be examined with the systems available on the market, which are too large and too heavy. In this article, we describe and evaluate a palm sized probe, whose properties, weight, size and sensitivity are adapted for guiding laparotomy surgery. Different experiments have been performed to determine its main characteristics, both on the illumination and imaging sides. The device has been tested for fluorescent molecular probe imaging in preclinical procedures, to prove its ability to be used in cancer nodule detection during surgery. This system is now CE certified for clinical procedures and Indocyanine Green imaging has been performed during clinical investigations: lymphedema and surgical resection of liver metastases of colorectal cancers. Copyright © 2015 Associazione Italiana di Fisica Medica. Published by Elsevier Ltd. All rights reserved.

[Low transverse laparotomy with rectus abdominus section in gynecology and obstetrics. Apropos of 1,000 cases].

PubMed

Querleu, D; Delahousse, G; Turpin, D; Leblanc, P; Debodinance, P; Boutteville, C; Meurette, J; Laurent, J C; Crépin, G

1987-11-01

The authors report 1,000 cases (357 cesarean sections, 230 hysterectomies for benign lesions, 157 conservative utero-adnexal procedures, 128 tubal plasties, 58 prolapse or incontinence procedures, 70 cancers) ,of laparotomies performed according to the technique described by Mouchel in 1980, i.e. strictly supra-pubic and transverse, from skin to peritoneum, including section of the rectus abdominis. This incision enables to perform in ideal technical conditions, with a minimal complication rate (3 hematomas, 2 incisional hernias for 1,000), and satisfactory esthetic results, almost all of the gynecological and obstetrical surgical procedures (90% of two among the authors' practice). The only contra-indications are, except for cases of previous median laparotomy, ovarian tumors. Neither the high risk of infection, nor obesity, extended hysterectomy, nor fetal distress, represent contra-indications, which is a definite advantage over the Pfannenstiel incision. As compared with the median incision which at some time offered similar results, the esthetics and mainly the strength of the abdominal wall are markedly superior.

Unnecessary surgery.

PubMed Central

Leape, L L

1989-01-01

The extent of unnecessary surgery has been the object of considerable speculation and occasional wild accusation in recent years. Most evidence of the existence of unnecessary surgery, such as information from studies of geographic variations and the results of second surgical opinion programs, is circumstantial. However, results from the few studies that have measured unnecessary surgery directly indicate that for some highly controversial operations the fraction that are unwarranted could be as high as 30 percent. Most unnecessary surgery results from physician uncertainty about the effectiveness of an operation. Elimination of this uncertainty requires more efficient production and dissemination of scientific information about clinical effectiveness. In the absence of adequate data from scientific studies, the use of a consensus of expert opinion, disseminated by means of comprehensive practice guidelines, offers the best opportunity to identify and eliminate unnecessary surgery. PMID:2668237

Primary epiploic appendagitis and successful outpatient management

PubMed Central

Schnedl, Wolfgang J.; Krause, Robert; Wallner-Liebmann, Sandra J.; Tafeit, Erwin; Mangge, Harald; Tillich, Manfred

2012-01-01

Summary Background Primary epiploic appendagitis (PEA) is a rare cause of abdominal acute or subacute complaints. Diagnosis of PEA is made with ultrasonography (US) or when computed tomography (CT) reveals a characteristic lesion. Case Report We report on two patients with PEA. In one patient PEA was first seen with US and confirmed with contrast enhanced CT, and in the second patient CT without contrast enhancement demonstrated PEA. In both patients an outpatient recovery with conservative non-surgical treatment is described. Conclusions Medical personnel should be aware of this rare disease, which mimics many other intra-abdominal acute and subacute conditions. A correct diagnosis of PEA with imaging procedures enables conservative and successful outpatient management avoiding unnecessary surgical intervention and additional costs. PMID:22648258

Global case management: Scotland. Real-time monitoring of patient flow as an instrument to optimize quality of care in acute receiving units.

PubMed

Thuemmler, Christoph; Morris, Carole

2005-01-01

Recent audits within our hospital suggest that especially during peak phases the patient flow from our acute admission units downstream into hospital beds is not directed in the most efficient way and patients may be placed inappropriately. This inevitably causes time delays and potentially increases the risk of malpractice as patients have to spend an extended period of time in admission areas with a high workload and very busy staff. Using latest information technology, such as wireless local area networks and handheld devices, can improve the efficiency of patient management and can increase the quality of care by helping to avoid unnecessary treatment delays in overcrowded admission areas.

What Instills Trust? A Qualitative Study of Phishing

NASA Astrophysics Data System (ADS)

Jakobsson, Markus; Tsow, Alex; Shah, Ankur; Blevis, Eli; Lim, Youn-Kyung

This paper reports the highlights of a user study which gauges reactions to a variety of common "trust indicators" - such as logos, third party endorsements, and padlock icons - over a selection of authentic and phishing stimuli. In the course of the think-aloud protocol, participants revealed different sensitivities to email messages and web pages. Our principal result is the analysis of what makes phishing emails and web pages appear authentic. This is not only of interest from a pure scientific point of view, but can also guide the design of legitimate material to avoid unnecessary risks. A second result of ours are observations of what makes legitimate content appear dubious to consumers. This is a result with obvious applications to online advertising.

Spasm of the near reflex: A case report.

PubMed

Rhatigan, Maedbh; Byrne, Caroline; Logan, Patricia

2017-06-01

Spasm of the near reflex (SNR) is a triad of miosis, excess accommodation and excess convergence. Primary SNR is most often functional in origin We aim to highlight the clinical features which distinguish primary convergence from other conditions with a similar presentation but more sinister underlying aetiology, for example bilateral abducens nerve palsy. There is a paucity of published data on SNR, in particular diagnostic criteria and treatment. We report a case of SNR of functional origin in an otherwise healthy young female and discuss the clinical features that differentiate this condition from similar conditions with underlying neurological origin. SNR is predominantly a clinical diagnosis, and often leads to patients undergoing unnecessary investigations and sometimes treatment. Recognising the salient features that differentiate it could potentially avoid this.

Cerebral Fat Embolism: Recognition, Complications, and Prognosis.

PubMed

Godoy, Daniel Agustín; Di Napoli, Mario; Rabinstein, Alejandro A

2017-09-20

Fat embolism syndrome (FES) is a rare syndrome caused by embolization of fat particles into multiple organs including the brain. It typically manifests with petechial rash, deteriorating mental status, and progressive respiratory insufficiency, usually occurring within 24-48 h of trauma with long-bone fractures or an orthopedic surgery. The diagnosis of FES is based on clinical and imaging findings, but requires exclusion of alternative diagnoses. Although there is no specific treatment for FES, prompt recognition is important because it can avoid unnecessary interventions and clarify prognosis. Patients with severe FES can become critically ill, but even comatose patients with respiratory failure may recover favorably. Prophylactic measures, such as early stabilization of fractures and certain intraoperative techniques, may help decrease the incidence and severity of FES.

Unreliable numbers: error and harm induced by bad design can be reduced by better design

PubMed Central

Thimbleby, Harold; Oladimeji, Patrick; Cairns, Paul

2015-01-01

Number entry is a ubiquitous activity and is often performed in safety- and mission-critical procedures, such as healthcare, science, finance, aviation and in many other areas. We show that Monte Carlo methods can quickly and easily compare the reliability of different number entry systems. A surprising finding is that many common, widely used systems are defective, and induce unnecessary human error. We show that Monte Carlo methods enable designers to explore the implications of normal and unexpected operator behaviour, and to design systems to be more resilient to use error. We demonstrate novel designs with improved resilience, implying that the common problems identified and the errors they induce are avoidable. PMID:26354830

Pregnancy Luteoma in Ectopic Pregnancy: A Case Report.

PubMed

Brar, Rupinder Kaur; Bharti, Jyotsna Naresh; Nigam, Jitendra Singh; Sehgal, Sahil; Singh, Hena Paul; Ojha, Pushpanjali

2017-01-01

Pregnancy luteoma is a rare non neoplastic condition of the ovary. It is usually asymptomatic and found incidentally during imaging in pregnancy or during cesarean section. Pregnancy luteoma can also occur after ectopic pregnancy. A 30 year old female presented to G.B. Pant Hospital, Andaman and Nicobar Islands institute of Medical Sciences, Port Blair in October 2015 with abdominal pain. After initial investigations, exploratory laporotomy was done for ruptured ectopic pregnancy. Enlarged ovary was removed along with the ruptured portion of fallopian tube. Histopathological examination revealed solid aggregates of large cells with abundant eosinophilic cytoplasm; diagnosis of pregnancy luteoma was given. It must be considered in the differential diagnosis of ovarian masses in pregnant females that early diagnosis of this entity may avoid unnecessary radical surgery.

Practical Unitary Simulator for Non-Markovian Complex Processes

NASA Astrophysics Data System (ADS)

Binder, Felix C.; Thompson, Jayne; Gu, Mile

2018-06-01

Stochastic processes are as ubiquitous throughout the quantitative sciences as they are notorious for being difficult to simulate and predict. In this Letter, we propose a unitary quantum simulator for discrete-time stochastic processes which requires less internal memory than any classical analogue throughout the simulation. The simulator's internal memory requirements equal those of the best previous quantum models. However, in contrast to previous models, it only requires a (small) finite-dimensional Hilbert space. Moreover, since the simulator operates unitarily throughout, it avoids any unnecessary information loss. We provide a stepwise construction for simulators for a large class of stochastic processes hence directly opening the possibility for experimental implementations with current platforms for quantum computation. The results are illustrated for an example process.

Challenges for allergy diagnosis in regions with complex pollen exposures.

PubMed

Barber, Domingo; Díaz-Perales, Araceli; Villalba, Mayte; Chivato, Tomas

2015-02-01

Over the past few decades, significant scientific progress has influenced clinical allergy practice. The biological standardization of extracts was followed by the massive identification and characterization of new allergens and their progressive use as diagnostic tools including allergen micro arrays that facilitate the simultaneous testing of more than 100 allergen components. Specific diagnosis is the basis of allergy practice and is always aiming to select the best therapeutic or avoidance intervention. As a consequence, redundant or irrelevant information might be adding unnecessary cost and complexity to daily clinical practice. A rational use of the different diagnostic alternatives would allow a significant improvement in the diagnosis and treatment of allergic patients, especially for those residing in complex pollen exposure areas.

Integrated billing and accounts receivable management system needed to maximize payments and cope with managed care.

PubMed

Sanders, J; Wold, D; Sullivan, T

1999-01-01

The billing and accounts receivable management process in medical practices today has evolved into a multidisciplinary function. This function requires efficient, coordinated performance by physicians and all staff members, from the point of initial patient contact through aggressive follow-up on delinquent payments for services rendered. Offices with deficient or nonexistent billing and accounts receivable management systems typically experience collection ratios that are less than industry norms. They also experience poor cash flow and unnecessary overhead costs. To avoid costly inefficiencies and ensure that it maximizes payments from third-party payors and patients, a medical practice must have an integrated billing and accounts receivable management system that includes components outlined in this article.

Anti-claudin 18.2 antibody as new targeted therapy for advanced gastric cancer.

PubMed

Singh, Prabhsimranjot; Toom, Sudhamshi; Huang, Yiwu

2017-05-12

Targeted therapy and immunotherapy have revolutionized treatment of various cancers in the past decade. Despite targeted therapy with trastuzumab in Her2-positive gastric cancer patients, survival has been dismal, mostly due to disease progression and toxicity related to the treatments. One area of active development is looking for ideal monoclonal antibodies (IMAB) specific to the proteins only on the tumor and hence avoiding unnecessary side effects. Claudin proteins with isoform 2 are one such protein, specific for several cancers, particularly gastric cancer and its metastases, leading to the development of anti-claudin 18.2 specific antibody, claudiximab. This review will highlight the latest development of claudiximab as first in class IMAB for the treatment of gastric cancer.

Apparent mineralcorticoid excess syndrome, an often forgotten or unrecognized cause of hypokalemia and hypertension: case report and appraisal of the pathophysiology.

PubMed

Bisogni, Valeria; Rossi, Gian Paolo; Calò, Lorenzo A

2014-06-01

The glicyrrhizic acid, contained in licorice, has a mineralcorticoid-like effect. Chronic excess intake of licorice induces the rare syndrome of "apparent mineralcorticoid excess", due to the inhibitory effect of glicyrrhizic acid on 11 β-hydroxysteroid dehydrogenase type 2 determining clinical/biochemical manifestations as resistant hypertension, metabolic alkalosis and severe hypokalemia. We report a typical clinical case of licorice abuse to emphasize the importance of a detailed anamnesis, which is essential for the diagnosis, avoid unnecessary and expensive investigations, and reduce the duration of hospitalization. We also provide an appraisal of the pathophysiology of "apparent mineralcorticoid excess" syndrome, still an often forgotten or unrecognized cause of hypokalemia and hypertension.

Do event horizons exist?

NASA Astrophysics Data System (ADS)

Baccetti, Valentina; Mann, Robert B.; Terno, Daniel R.

Event horizons are the defining feature of classical black holes. They are the key ingredient of the information loss paradox which, as paradoxes in quantum foundations, is built on a combination of predictions of quantum theory and counterfactual classical features: neither horizon formation nor its crossing by a test body can be detected by a distant observer. Furthermore, horizons are unnecessary for the production of Hawking-like radiation. We demonstrate that when this radiation is taken into account, it can prevent horizon crossing/formation in a large class of models. We conjecture that horizon avoidance is a general feature of collapse. The nonexistence of event horizons dispels the paradox, but opens up important questions about thermodynamic properties of the resulting objects and correlations between different degrees of freedom.

Traumatic bone cyst suggestive of a chronic periapical abscess: a case report.

PubMed

Kahler, Bill

2011-08-01

Traumatic bone cysts can mimic the signs and symptoms of an endodontic lesion. This case reports on a 19-year-old male patient who was referred for endodontic assessment of a symptomatic tooth with a gingival swelling and a draining sinus at the furcation of a mandibular second molar. Radiographically, a periradicular radiolucency is evident. A prior history of trauma as well as removal of the wisdom teeth was determined. After careful diagnosis unnecessary endodontic intervention was avoided. Surgical exploration, curettage and the generation of a blood clot resulted in healing at the 6 month review appointment. The tooth remained responsive to pulp sensibility testing at that time. © 2010 The Author. Australian Endodontic Journal © 2010 Australian Society of Endodontology.

Zoster-associated segmental paresis in a patient with cervical spinal stenosis.

PubMed

Kang, Sung-Hee; Song, Ho-Kyung; Jang, Yeon

2013-06-01

Segmental zoster paresis is a rare complication of herpes zoster, characterized by focal motor weakness that does not always present simultaneously with skin lesions. Zoster paresis can be easily confused with other neuromuscular or spinal diseases. This case report describes the case of a 72-year-old woman with herpes zoster and cervical spinal stenosis at the same spinal level, where it was difficult to distinguish segmental zoster paresis from cervical radiculopathy combined with motor neuropathy. Although segmental zoster paresis in the upper extremity is rare, it should be included in the differential diagnosis of segmental pain and weakness in the extremities, especially in older or immunocompromised patients. Correct diagnosis is required, to avoid unnecessary surgery and allow timely antiviral treatment.

The Prophylactic Extraction of Third Molars: A Public Health Hazard

PubMed Central

Friedman, Jay W.

2007-01-01

Ten million third molars (wisdom teeth) are extracted from approximately 5 million people in the United States each year at an annual cost of over $3 billion. In addition, more than 11 million patient days of “standard discomfort or disability”—pain, swelling, bruising, and malaise—result postoperatively, and more than 11000 people suffer permanent paresthesia—numbness of the lip, tongue, and cheek—as a consequence of nerve injury during the surgery. At least two thirds of these extractions, associated costs, and injuries are unnecessary, constituting a silent epidemic of iatrogenic injury that afflicts tens of thousands of people with lifelong discomfort and disability. Avoidance of prophylactic extraction of third molars can prevent this public health hazard. PMID:17666691

Malakoplakia mimics urinary bladder cancer: a case report.

PubMed

Ristić-Petrović, Ana; Stojnev, Slavica; Janković-Velicković, Ljubinka; Marjanović, Goran

2013-06-01

Malakoplakia is an unusual and very rare chronic inflammatory disease. In bladder especially it can mimic malignancy and lead to serious misdiagnosis. We presented a case of a middle-aged woman with persistent macrohematuria and cystoscopically polypoid bladder mass that resembled a neoplastic process. The final diagnosis was based on cystoscopic biopsy and microscopic findings of acidophilic, foamy histiocytes with the presence of Michaelis-Gutmann inclusions which are characteristic for diagnosis of malakoplakia. Immunohistochemistry confirmed diagnosis by demonstrating CD68-positive macrophages. Urinary bladder malakoplakia should be considered in patients with persistent urinary tract infections and tumor mass at cystoscopy. Early identification with prompt antibiotic treatment can be helpful in avoiding unnecessary surgical interventions and in preventing development of possible complications.

"Turn laterally to the left!". The need for uniform C-arm communication terminology during orthopaedic trauma surgery.

PubMed

De Muinck Keizer, R-J; Klei, D S; Van Koperen, P J; Van Dijk, C N; Goslings, J C

2017-03-01

To avoid disturbed teamwork, unnecessary radiation exposure, and procedural delays, we designed and tested a uniform communication language for use in fluoroscopy-assisted surgical procedures. Input of surgeons and radiographers was used to create a set of commands. The potential benefit of this terminology was explored in an experimental setting. There was a tremendous diversity in the currently used terminology. Use of the newly designed terminology showed a reduction of procedural time and amount of images needed. Our first standardized Dutch language terminology can reduce total fluoroscopy time, number of images acquired, and potentially radiation exposure. For Dutch speaking colleagues, the developed terminology is freely available for use in their OR.

Strategies for maximizing your chances for weaning success. Limitations--and advantages--of common predictive indices.

PubMed

Patel, R G; Petrini, M F; Norman, J R

1995-06-01

Using indices to predict weaning outcome can avoid premature extubation and unnecessary prolongation of ventilatory support. Unfortunately, none of the indices is consistently able to predict outcome. The key to successful weaning is to assess respiratory function repeatedly with several indices, not just one. The patient should be able to sustain spontaneous breathing for at least 24 hours on minimal partial ventilatory support (a pressure support or a continuous positive airway pressure of 5 cm H2O or a T piece, for example). Indices of maximal inspiratory pressure; work of breathing; and rapid, shallow breathing are useful in evaluating a patient's respiratory muscle performance; airway occlusion pressure is helpful as well when increased neuromuscular drive is a problem.

Aspiration cytology of extramammary tumours metastatic to the breast.

PubMed

Handa, Uma; Chhabra, Seema; Mohan, Harsh

2007-10-01

This study was undertaken to highlight the use of fine needle aspiration cytology (FNAC) to distinguish tumours metastatic to the breast from primary breast malignancies. A total of 1866 fine needle aspirates of the breast were performed during a period of 7 years. Three hundred and fourteen cases of breast malignancies were diagnosed and 5 (1.5%) out of these cases were metastatic in origin. The metastatic tumors included, 2 cases of malignant melanoma (chest wall and left arm), 1 case each of haematolymphoid malignancy, adenocarcinoma of the ovary, and squamous cell carcinoma (left leg). FNA diagnosis of metastasis to the breast is essential in order to avoid unnecessary mastectomy and to ensure appropriate chemotherapy and/or irradiation treatment.

Tubular sigmoid duplication in an adult man: an interesting incidental finding.

PubMed

Asour, Amani; Kim, Hyun-Kyung; Arya, Shobhit; Hepworth, Clive

2017-11-12

A 61-year-old man attended an outpatient colorectal clinic for a chronic, non-specific abdominal pain, associated with rectal bleeding. He underwent a number of investigations including a CT pneumocolon, which revealed an incidental finding of 20 cm of additional sigmoid colon. This case is interesting because tubular sigmoid duplication is an extremely unusual condition, rarely diagnosed in adults; only a few cases have been reported of this condition in the adult population. Our team chose to treat this patient conservatively, in order to avoid putting the patient at risk of an unnecessary surgery. © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Basal cell carcinoma of the nipple-areola complex: a case report.

PubMed

Huang, Ching-Wen; Pan, Ching-Kuen; Shih, Teng-Fu; Tsai, Cheng-Chien; Juan, Chung-Chou; Ker, Chen-Guo

2005-10-01

Basal cell carcinoma (BCC) of the nipple-areola complex is very rare. Only 24 cases were reported in the literature and 17 (70.8%) of these cases arose in men. Most of the cases were treated with simple excision. We report on a case of BCC of the nipple-areola complex in a 46-year-old woman, treated with partial mastectomy. Metastasis to the axillary lymph nodes had been noted in 3 (12.5%) of the 24 reported cases of BCC of the nipple-areola complex. Thus, we applied the concept of the sentinel lymph node to detect possible metastases of axillary lymph nodes, letting us avoid the unnecessary axillary lymph node dissection and possible future morbidity.

The effect of incentive spirometry on postoperative pulmonary function following laparotomy: a randomized clinical trial.

PubMed

Tyson, Anna F; Kendig, Claire E; Mabedi, Charles; Cairns, Bruce A; Charles, Anthony G

2015-03-01

Changes in pulmonary dynamics following laparotomy are well documented. Deep breathing exercises, with or without incentive spirometry, may help counteract postoperative decreased vital capacity; however, the evidence for the role of incentive spirometry in the prevention of postoperative atelectasis is inconclusive. Furthermore, data are scarce regarding the prevention of postoperative atelectasis in sub-Saharan Africa. To determine the effect of the use of incentive spirometry on pulmonary function following exploratory laparotomy as measured by forced vital capacity (FVC). This was a single-center, randomized clinical trial performed at Kamuzu Central Hospital, Lilongwe, Malawi. Study participants were adult patients who underwent exploratory laparotomy and were randomized into the intervention or control groups (standard of care) from February 1 to November 30, 2013. All patients received routine postoperative care, including instructions for deep breathing and early ambulation. We used bivariate analysis to compare outcomes between the intervention and control groups. Adult patients who underwent exploratory laparotomy participated in postoperative deep breathing exercises. Patients in the intervention group received incentive spirometers. We assessed pulmonary function using a peak flow meter to measure FVC in both groups of patients. Secondary outcomes, such as hospital length of stay and mortality, were obtained from the medical records. A total of 150 patients were randomized (75 in each arm). The median age in the intervention and control groups was 35 years (interquartile range, 28-53 years) and 33 years (interquartile range, 23-46 years), respectively. Men predominated in both groups, and most patients underwent emergency procedures (78.7% in the intervention group and 84.0% in the control group). Mean initial FVC did not differ significantly between the intervention and control groups (0.92 and 0.90 L, respectively; P=.82 [95% CI, 0.52-2.29]). Although patients in the intervention group tended to have higher final FVC measurements, the change between the first and last measured FVC was not statistically significant (0.29 and 0.25 L, respectively; P=.68 [95% CI, 0.65-1.95]). Likewise, hospital length of stay did not differ significantly between groups. Overall postoperative mortality was 6.0%, with a higher mortality rate in the control group compared with the intervention group (10.7% and 1.3%, respectively; P=.02 [95% CI, 0.01-0.92]). Education and provision of incentive spirometry for unmonitored patient use does not result in statistically significant improvement in pulmonary dynamics following laparotomy. We would not recommend the addition of incentive spirometry to the current standard of care in this resource-constrained environment. clinicaltrials.gov Identifier: NCT01789177.

Demonstration of Sensor Data Integration Across Naval Aviation Maintenance

DTIC Science & Technology

2018-02-01

With expedited fault detection, fewer unnecessary parts would need to be ordered, saving time and money . Recommendations Based on our findings...level maintainer. These notes were included in every MAF in the “corrective action” block and were unformatted free -text. Out of the 70 repairs, only...translates to fewer unnecessary parts ordered, a reduction in the money spent on unnecessary parts, and a reduction of unnecessary logistic delays

T cell lymphomatoid contact dermatitis: a challenging case and review of the literature.

PubMed

Knackstedt, Thomas J; Zug, Kathryn A

2015-02-01

Lymphomatoid contact dermatitis is a pseudolymphoma with clinical and histological features of allergic contact dermatitis and cutaneous T cell lymphoma. Incorrect diagnosis may lead to unnecessary testing, unnecessary treatment, or patient harm. The objective of this study is to present a case to demonstrate the diagnostic challenge and overlap between allergic contact dermatitis and cutaneous T cell lymphoma in a patient with lymphomatoid contact dermatitis caused by methylchoroisothiazolinone/methylisothiazolinone and paraben mix, and to review the existing literature in order to summarize the demographics, clinical features, allergens and treatments reported for lymphomatoid contact dermatitis. A search of major scientific databases was conducted for English-language articles reporting cases of lymphomatoid contact dermatitis or additional synonymous search headings. Nineteen articles with a total of 23 patients were analysed. Lymphomatoid contact dermatitis was more common in men, with an average age of 58.5 years. Fourteen unique allergens were identified and confirmed by patch testing. However, no single test or study was diagnostic of lymphomatoid contact dermatitis. Allergen avoidance was the most useful management tool, but selected patients required topical or systemic immunosuppression. In conclusion, without specific diagnostic features, evaluation for lymphomatoid contact dermatitis should include a thorough history and examination, patch testing, and biopsy with immunohistochemistry and clonality studies. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Logistic regression model can reduce unnecessary artificial liver support in hepatitis B virus-associated acute-on-chronic liver failure: decision curve analysis.

PubMed

Qin, Gang; Bian, Zhao-Lian; Shen, Yi; Zhang, Lei; Zhu, Xiao-Hong; Liu, Yan-Mei; Shao, Jian-Guo

2016-06-04

Several models have been proposed to predict the short-term outcome of acute-on-chronic liver failure (ACLF) after treatment. We aimed to determine whether better decisions for artificial liver support system (ALSS) treatment could be made with a model than without, through decision curve analysis (DCA). The medical profiles of a cohort of 232 patients with hepatitis B virus (HBV)-associated ACLF were retrospectively analyzed to explore the role of plasma prothrombin activity (PTA), model for end-stage liver disease (MELD) and logistic regression model (LRM) in identifying patients who could benefit from ALSS. The accuracy and reliability of PTA, MELD and LRM were evaluated with previously reported cutoffs. DCA was performed to evaluate the clinical role of these models in predicting the treatment outcome. With the cut-off value of 0.2, LRM had sensitivity of 92.6 %, specificity of 42.3 % and an area under the receiving operating characteristic curve (AUC) of 0.68, which showed superior discrimination over PTA and MELD. DCA revealed that the LRM-guided ALSS treatment was superior over other strategies including "treating all" and MELD-guided therapy, for the midrange threshold probabilities of 16 to 64 %. The use of LRM-guided ALSS treatment could increase both the accuracy and efficiency of this procedure, allowing the avoidance of unnecessary ALSS.

The self-adjusting file (SAF) system: An evidence-based update

PubMed Central

Metzger, Zvi

2014-01-01

Current rotary file systems are effective tools. Nevertheless, they have two main shortcomings: They are unable to effectively clean and shape oval canals and depend too much on the irrigant to do the cleaning, which is an unrealistic illusionThey may jeopardize the long-term survival of the tooth via unnecessary, excessive removal of sound dentin and creation of micro-cracks in the remaining root dentin. The new Self-adjusting File (SAF) technology uses a hollow, compressible NiTi file, with no central metal core, through which a continuous flow of irrigant is provided throughout the procedure. The SAF technology allows for effective cleaning of all root canals including oval canals, thus allowing for the effective disinfection and obturation of all canal morphologies. This technology uses a new concept of cleaning and shaping in which a uniform layer of dentin is removed from around the entire perimeter of the root canal, thus avoiding unnecessary excessive removal of sound dentin. Furthermore, the mode of action used by this file system does not apply the machining of all root canals to a circular bore, as do all other rotary file systems, and does not cause micro-cracks in the remaining root dentin. The new SAF technology allows for a new concept in cleaning and shaping root canals: Minimally Invasive 3D Endodontics. PMID:25298639

The Value of Ultrasound Monitoring of Adnexal Masses for Early Detection of Ovarian Cancer

PubMed Central

Suh-Burgmann, Elizabeth; Kinney, Walter

2016-01-01

Although ultrasound has so far been found to be ineffective as a screening tool for ovarian cancer, it is commonly used as a means of evaluating or following ovarian or adnexal masses once they are detected. We review the use of serial ultrasound for the management of adnexal masses and propose an approach to monitoring based on an understanding of the overall risk of cancer among the population in question and an assessment of how the potential benefit of monitoring compares with potential risk. In our approach, masses that are symptomatic, large (>10 cm), associated with an elevated CA 125 level or overt signs of malignancy, or that are determined to have a worrisome appearance by stringent ultrasound criteria should be evaluated surgically. Women with masses that have none of these characteristics should be offered monitoring. Short-term initial ultrasound monitoring carries significant potential benefit in terms of aiding detection of early malignancy and avoidance of unnecessary surgery. However, if a mass remains stable but persistent, the potential benefit of ongoing monitoring wanes with time, whereas the potential harms, in terms of patient anxiety, cost, and the risk of incidental findings and unnecessary surgery increase. Therefore, monitoring of stable lesions should be limited in duration in order to limit potential harms from overtreatment and overdiagnosis. PMID:26904503

Complex regional pain syndrome type i. An analysis of 7 cases in children.

PubMed

Pedemonte Stalla, V; Medici Olaso, C; Kanopa Almada, V; Gonzalez Rabelino, G

2015-01-01

Complex regional pain syndrome (CRPS) is characterised by the presence of pain accompanied by sensory, autonomic and motor symptoms, usually preceded by a lesion or immobilisation. The clinical course is disproportionate to the initial injury in intensity and in duration. Its distribution is regional, predominantly in limbs. It is classified as type I and type II according to the absence or presence of nerve injury. We present the cases of seven children, 6 girls and 1 boy, aged 7 to 15 years. Three had a history of previous trauma. In 5 cases, the symptoms were located in the lower limbs. Time to diagnosis was between 4 and 90 days. Three patients had clinical features of anxiety and depression. Imaging and immunological studies were performed to rule out differential diagnoses in all the children. Interdisciplinary treatment was performed with physiotherapy, psychotherapy, and gabapentin or pregabalin. All patients had a good clinical outcome, with no relapses in the follow-up period (between 4 and 30 months). CRPS is frequently unrecognised in children, leading to family anxiety and unnecessary para-clinical costs. Paediatricians and paediatric neurologists should be aware of this syndrome in order to avoid delay in diagnosis, unnecessary studies, and multiple visits to specialists, with a view to providing effective treatment. Copyright © 2013 Sociedad Española de Neurología. Published by Elsevier España, S.L.U. All rights reserved.

[The Alvarado score validation in diagnosing acute appendicitis in children at Braga Hospital].

PubMed

Gonçalves, Jean Pierre; Cerqueira, Arnaldo; Martins, Sofia

2011-12-01

Acute appendicitis (AA) is the leading cause of emergency abdominal surgery in children. The diagnosis is essentially clinical, but some methodologies, such as Alvarado score (AS), have been developed in order to avoid non-therapeutic laparotomy (15-30%). AS ≥ 5 or 6 is compatible with AA and is an indication for the patient to remain on observations, if AS ≥ 7 a laparotomy procedure may be indicated. To validate the AS for the AA diagnosis of children admitted at Braga Hospital. A validation study of diagnostic method (AS) using the histological examination as a gold standard. The study population consisted of 192 children (4-17 years) with abdominal pain that underwent appendectomy in the last 20 months (December 2008 to July 2010). It was determined the values of sensitivity (S), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), likelihood ratio (LR) and the ROC curve for three different cut-off points (SA =5, 6 and 7). We found that as the cut-off point of AS decreases progressively the sensitivity and specificity increases and reduces the VPN and VPP. Assuming a cut-off value of 5, only 18 children would be false negatives, instead of the 67 children if the cut-off point was 7 points. The analysis of ROC curves demonstrated a greater area under the curve for a cut-off equal to or greater than 5 (AUC = 70%). We recommend using a cut-off value of 5 points, since only 18 children with AA were initially classified as appendicitis unlikely, this value would increase to 67 patients for the SA value of ≥ 7. The AS is a valuable tool in screening children with abdominal pain for the diagnosis of AA. Nonetheless the diagnosis and final decision must be based on clinical and systematic reassessment of patients.

Pancreaticoatmospheric fistula following severe acute necrotising pancreatitis

PubMed Central

Simoneau, Eve; Chughtai, Talat; Razek, Tarek; Deckelbaum, Dan L

2014-01-01

Severe acute necrotising pancreatitis is associated with numerous local and systemic complications. Abdominal compartment syndrome requiring urgent decompressive laparotomy is a potential complication of this disease process and is associated with increased morbidity and mortality. We describe the case of a pancreaticoatmospheric fistula following decompressive laparotomy in a patient with severe acute necrotising pancreatitis. While this fistula was managed successfully using the current standard of care for pancreatic fistulas, the wound care for in this patient with drainage of the fistula through an open abdomen, is a significant challenge. PMID:25519860

Comparison of Topical Hemostatic Agents in a Swine Model of Extremity Arterial Hemorrhage: BloodSTOP iX Battle Matrix vs. QuikClot Combat Gauze

DTIC Science & Technology

2016-04-12

sponge was immediately placed over the product, pressing against the wound with sufficient and equal pressure to try to stop blood loss. Resuscitation...intervals. Any shed blood and blood absorbed by the dressing or laparotomy sponge during this period was collected and measured as post-treatment blood...the hemostasis provided by Int. J. Mol. Sci. 2016, 17, 545 10 of 12 the test products. At the conclusion of these tests, the laparotomy sponge and

Robotic radical hysterectomy in the management of gynecologic malignancies.

PubMed

Pareja, Rene; Ramirez, Pedro T

2008-01-01

Robotic surgery is being used with increasing frequency in gynecologic oncology. To date, 44 cases were reported in the literature of radical hysterectomy performed with robotic surgery. When comparing robotic surgery with laparoscopy or laparotomy in performing a radical hysterectomy, the literature shows that robotic surgery offers an advantage over the other 2 surgical approaches with regard to operative time, blood loss, and length of hospitalization. Future studies are needed to further elucidate the equivalence or superiority of robotic surgery to laparoscopy or laparotomy in performing a radical hysterectomy.

Special diets are common among preschool children aged one to five years in south-east Sweden according to a population-based cross-sectional survey.

PubMed

Servin, Caroline; Hellerfelt, Sofia; Botvid, Christina; Ekström, Magnus

2017-04-01

Information about the prevalence of special diets in preschool children is limited. The aim of this study was to measure the prevalence of all special diets among preschool children in a Swedish municipality. This was a population-based cross-sectional survey of all 3276 preschool children aged one to five years in the municipality of Karlskrona, Sweden. The questionnaire assessed the number of children at each preschool, how many were on special diets, their dietary requirements, age, sex, whether they had a medical certificate and whether the special diet had a perceived medical cause. We obtained data for 3221 (98%) of the children, and 19% had special diets, including 12% on nonmedical diets and 6.3% on medical diets. The five most common diets were avoiding pork (7.8%), a vegetarian diet (4.8%), and avoiding cows' milk (3.5%), hens' eggs (1.2%) and lactose (1.1%). Gluten avoidance was more common in girls than boys (0.8% versus 0.2%, p = 0.032). Half (47%) of the children on special medical diets lacked a medical certificate. Special diets were common in preschool children in south-east Sweden, and the causes were mainly nonmedical. Mandatory medical certificates for medically based special diets might reduce unnecessary dietary restrictions. ©2017 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.

Effect of peritoneal cavity lavage with 0.9% and 3.0% saline solution in the lung and spleen of gerbils with induced peritonitis.

PubMed

Nunes, Vinícius Rodrigues Taranto; Barbuto, Rafael Calvão; Vidigal, Paula Vieira Teixeira; Pena, Guilherme Nogueira; Rocha, Silvia Lunardi; de Siqueira, Lucas Tourinho; Caliari, Marcelo Vidigal; de Araujo, Ivana Duval

2014-04-01

Peritoneal cavity lavage is used widely in the treatment of peritonitis. Nonetheless, some studies question its rationale and prove it to be deleterious to the mesothelium. The present study aims to determine whether 0.9% and 3.0% saline lavage of the peritoneal cavity have an effect on the early systemic inflammatory response, namely, in the lung injury and splenic cellularity of gerbils with induced peritonitis. Thirty-four male gerbils were divided into four groups: Control (n=9), submitted to laparotomy at time zero, re-laparotomy after 2 h, and sacrificed after a total of 6 h from start; untreated (n=8), submitted to peritonitis induction through cecal ligation and puncture (CLP) at time zero, re-laparotomy intended for drying of abdominal cavity and resection of the ischemic cecum after 2 h, and sacrifice after a total of 6 h from start; saline (n=8), submitted to peritonitis induction through CLP at time zero, re-laparotomy intended for warm 0.9% saline lavage of the abdominal cavity and resection of the ischemic cecum after 2 h, and sacrificed after a total of 6 h from start; and hypertonic (n=9), submitted to peritonitis induction through CLP at time zero, re-laparotomy intended for warm hypertonic saline (3.0%) lavage of the abdominal cavity and resection of the ischemic cecum after 2 h, and sacrificed after a total of 6 h from start. After sacrifice, we collected the left lung and the spleen for morphometric analysis. In the both the saline and hypertonic groups, there was significant decrease in the mean nuclei count in the lungs, compared with the untreated group (p<0.01). There was no difference in terms of nuclei count in the spleen among groups (p>0.05). The present study demonstrated that the peritoneal lavage with large volumes of warm 0.9% and 3.0% saline has a beneficial effect on the early systemic inflammatory response in infected animals, modulating and reducing the lung injury but having no effect on splenic cell count.

Surgical management and outcome of blunt major liver injuries: experience of damage control laparotomy with perihepatic packing in one trauma centre.

PubMed

Lin, Being-Chuan; Fang, Jen-Feng; Chen, Ray-Jade; Wong, Yon-Cheong; Hsu, Yu-Pao

2014-01-01

This retrospective study aimed to assess the clinical experience and outcome of damage control laparotomy with perihepatic packing in the management of blunt major liver injuries. From January 1998 to December 2006, 58 patients of blunt major liver injury, American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) equal or greater than III, were operated with perihepatic packing at our institute. Demographic data, intra-operative findings, operative procedures, adjunctive managements and outcome were reviewed. To determine whether there was statistical difference between the survivor and non-survivor groups, data were compared by using Mann-Whitney U test for continuous variables, either Pearson's chi-square test or with Yates continuity correction for contingency tables, and results were considered statistically significant if p<0.05. Of the 58 patients, 20 (35%) were classified as AAST-OIS grade III, 24 (41%) as grade IV, and 14 (24%) as grade V. At laparotomy, depending on the severity of injuries, all 58 patients underwent various liver-related procedures and perihepatic packing. The more frequent liver-related procedures included debridement hepatectomy (n=21), hepatorrhaphy (n=19), selective hepatic artery ligation (n=11) and 7 patients required post-laparotomy hepatic transarterial embolization. Of the 58 patients, 28 survived and 30 died with a 52% mortality rate. Of the 30 deaths, uncontrolled liver bleeding in 24-h caused 25 deaths and delayed sepsis caused residual 5 deaths. The mortality rate versus OIS was grade III: 30% (6/20), grade IV: 54% (13/24), and grade V: 79% (11/14), respectively. On univariate analysis, the significant predictors of mortality were OIS grade (p=0.019), prolonged initial prothrombin time (PT) (p=0.004), active partial thromboplastin time (APTT) (p<0.0001) and decreased platelet count (p=0.005). The mortality rate of surgical blunt major liver injuries remains high even with perihepatic packing. Since prolonged initial PT, APTT and decreased platelet count were associated with high risk of mortality, we advocate combination of damage control resuscitation with damage control laparotomy in these major liver injuries. Copyright © 2013 Elsevier Ltd. All rights reserved.

Management of children with solid organ injuries after blunt torso trauma.

PubMed

Wisner, David H; Kuppermann, Nathan; Cooper, Arthur; Menaker, Jay; Ehrlich, Peter; Kooistra, Josh; Mahajan, Prashant; Lee, Lois; Cook, Lawrence J; Yen, Kenneth; Lillis, Kathy; Holmes, James F

2015-08-01

Management of children with intra-abdominal solid organ injuries has evolved markedly. We describe the current management of children with intra-abdominal solid organ injuries after blunt trauma in a large multicenter network. We performed a planned secondary analysis of a prospective, multicenter observational study of children (<18 years) with blunt torso trauma. We included children with spleen, liver, or kidney injuries identified by computed tomography, laparotomy/laparoscopy, or autopsy. Outcomes included disposition and interventions (blood transfusion for intra-abdominal hemorrhage, angiography, laparotomy/laparoscopy). We performed subanalyses of children with isolated injuries. A total of 12,044 children were enrolled; 605 (5.0%) had intra-abdominal solid organ injuries. The mean (SD) age was 10.7 (5.1) years, and injured organs included spleen 299 (49.4%), liver 282 (46.6%), and kidney 147 (24.3%). Intraperitoneal fluid was identified on computed tomography in 461 (76%; 95% confidence interval [CI], 73-80%), and isolated solid organ injuries were present in 418 (69%; 95% CI, 65-73%). Treatment included therapeutic laparotomy in 17 (4.1%), angiographic embolization in 6 (1.4%), and blood transfusion in 46 (11%) patients. Laparotomy rates for isolated injury were 11 (5.4%) of 205 (95% CI, 2.7-9.4%) at non-freestanding children's hospitals and 6 (2.8%) of 213 (95% CI, 1.0-6.0%) at freestanding children's hospitals (difference, 2.6%; 95% CI, -7.1% to 12.2%). Dispositions of the 212 children with isolated Grade I or II organ injuries were home in 6 (3%), emergency department observation in 9 (4%), ward in 114 (54%), intensive care unit in 73 (34%), operating suite in 7 (3%), and transferred in 3 (1%) patients. Intensive care unit admission for isolated Grade I or II injuries varied by center from 9% to 73%. Most children with solid organ injuries are managed with observation. Blood transfusion, while uncommon, is the most frequent therapeutic intervention; angiographic embolization and laparotomy are uncommon. Emergency department disposition of children with isolated Grade I to II solid organ injuries is highly variable and often differs from published guidelines. Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Long-term results of the Heller-Dor operation with intraoperative manometry for the treatment of esophageal achalasia.

PubMed

Mattioli, Sandro; Ruffato, Alberto; Lugaresi, Marialuisa; Pilotti, Vladimiro; Aramini, Beatrice; D'Ovidio, Frank

2010-11-01

Quality of outcome of the Heller-Dor operation is sometimes different between studies, likely because of technical reasons. We analyze the details of myotomy and fundoplication in relation to the results achieved over a 30-year single center's experience. From 1979-2008, a long esophagogastric myotomy and a partial anterior fundoplication to protect the surface of the myotomy was routinely performed with intraoperative manometry in 202 patients (97 men; median age, 55.5 years; interquartile range, 43.7-71 years) through a laparotomy and in 60 patients (24 men; median age, 46 years; interquartile range, 36.2-63 years) through a laparoscopy. The follow-up consisted of periodical interview, endoscopy, and barium swallow, and a semiquantitative scale was used to grade results. Mortality was 1 of 202 in the laparotomy group and 0 of 60 in the laparoscopy group. Median follow-up was 96 months (interquartile range, 48-190.5 months) in the laparotomy group and 48 months (interquartile range, 27-69.5 months) in the laparoscopy group. At intraoperative manometry, complete abolition of the high-pressure zone was obtained in 100%. The Dor-related high-pressure zone length and mean pressure were 4.5 ± 0.4 cm and 13.3 ± 2.2 mm Hg in the laparotomy group and 4.5 ± 0.5 cm and 13.2 ± 2.2 mm Hg in the laparoscopy group (P = .75). In the laparotomy group poor results (19/201 [9.5%]) were secondary to esophagitis in 15 (7.5%) of 201 patients (in 2 patients after 184 and 252 months, respectively) and to recurrent dysphagia in 4 (2%) of 201 patients, all with end-stage sigmoid achalasia. In the laparoscopy group 2 (3.3%) of 60 had esophagitis. A long esophagogastric myotomy protected by means of Dor fundoplication cures or substantially reduces dysphagia in the great majority of patients affected by esophageal achalasia and effectively controls postoperative esophagitis. Intraoperative manometry is likely the key factor for achieving the reported results. Copyright © 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Abdominal Incision Injection of Liposomal Bupivacaine and Opioid Use After Laparotomy for Gynecologic Malignancies.

PubMed

Kalogera, Eleftheria; Bakkum-Gamez, Jamie N; Weaver, Amy L; Moriarty, James P; Borah, Bijan J; Langstraat, Carrie L; Jankowski, Christopher J; Lovely, Jenna K; Cliby, William A; Dowdy, Sean C

2016-11-01

To investigate opioid use and pain scores associated with incisional injection of liposomal bupivacaine compared with bupivacaine hydrochloride after laparotomy for gynecologic malignancies. A retrospective cohort study was conducted to compare abdominal incision infiltration with liposomal bupivacaine with bupivacaine hydrochloride after modification of a pre-existing enhanced recovery pathway. Patients undergoing staging laparotomy or complex cytoreductive surgery under the updated pathway were compared with patients treated under the original pathway (historic controls). Endpoints included cumulative opioid use (primary outcome) in oral morphine equivalents and cumulative pain score. In the complex cytoreductive cohort, median oral morphine equivalents were lower in the liposomal bupivacaine group through 24 hours (30 compared with 53.5 mg, P=.002), 48 hours (37.5 compared with 82.5 mg, P=.005), and the length of stay (62 compared with 100.5 mg, P=.006). Fewer liposomal bupivacaine patients required intravenous rescue opioids (28.9% compared with 55.6%, P<.001) or patient-controlled analgesia (4.1% compared with 33.3%, P<.001). Cumulative pain score was no different between groups through 48 hours (161 compared with 158, P=.69). Postoperative nausea and ileus were less frequent in patients receiving liposomal bupivacaine. Median hospital stay was 5 days in both groups. In the staging laparotomy cohort, cumulative opioids and cumulative pain score were no different between groups (through 48 hours: 162 compared with 161, P=.62; 38 compared with 38, P=.68, respectively). Intravenous rescue opioids (15.3% compared with 28.6%, P=.05) and patient-controlled analgesia (1.4% compared with 8.3%, P=.05) were used less frequently in the liposomal bupivacaine group. Median hospital stay was 4 days in both groups. Despite the higher cost of liposomal bupivacaine, total pharmacy costs did not differ between groups. Abdominal incision infiltration with liposomal bupivacaine was associated with less opioid and patient-controlled analgesia use with no change in pain scores compared with bupivacaine hydrochloride after complex cytoreductive surgery for gynecologic malignancies. Improvements were also seen in patients undergoing staging laparotomy.

The QUiPP App: a safe alternative to a treat-all strategy for threatened preterm labor.

PubMed

Watson, H A; Carter, J; Seed, P T; Tribe, R M; Shennan, A H

2017-09-01

To evaluate the impact of triaging women at risk of spontaneous preterm birth (sPTB) using the QUiPP App, which incorporates a predictive model combining history of sPTB, gestational age and quantitative measurements of fetal fibronectin, compared with a treat-all policy (advocated by the UK National Institute for Health and Care Excellence) among women with threatened preterm labor before 30 weeks' gestation. Prospectively collected data of pregnant women presenting with symptoms of preterm labor (abdominal pain or tightening) at 24-34 weeks' gestation were retrieved from the research databases of the EQUIPP and PETRA studies for subanalysis. Each episode of threatened preterm labor was retrospectively assigned a risk for sPTB within 7 days using the QUiPP App. A primary outcome of delivery within 7 days was used to model the performance accuracy of the QUiPP App compared with a treat-all policy. Using a 5% risk of delivery within 7 days according to the QUiPP App as the threshold for intervention, 9/9 women who presented with threatened preterm labor < 34 weeks would have been treated correctly, giving a sensitivity of 100% (one-sided 97.5% CI, 66.4%) and a negative predictive value of 100% (97.5% CI, 98.9-100%). The positive predictive value for delivery within 7 days was 30.0% (95% CI, 11.9-54.3%) for women presenting before 30 weeks and 20.0% (95% CI, 12.7-30.1%) for women presenting between 30 + 0 and 34 + 0 weeks. If this 5% threshold had been used to triage women presenting between 24 + 0 and 29 + 6 weeks, 89.4% (n = 168) of admissions could have been safely avoided, compared with 0% for a treat-all strategy. No true case of preterm labor would have been missed, as no woman who was assigned a risk of < 10% delivered within 7 days. For women with threatened preterm labor, the QUiPP App can accurately guide management at risk thresholds for sPTB of 1%, 5% and 10%, allowing outpatient management in the vast majority of cases. A treat-all approach would not have avoided admission for any woman, and would have exposed 188 mothers and their babies to unnecessary hospitalization and steroid administration and increased the burden on network and transport services owing to unnecessary in-utero transfers. Prediction of sPTB should be performed before 30 weeks to determine management until there is evidence that such a high level of unnecessary intervention, as suggested by the treat-all strategy, does less harm than the occurrence of rare false negatives. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Value of digital exploration for diagnosing injuries to the left side of the diaphragm caused by stab wounds.

PubMed

Morales, C H; Villegas, M I; Angel, W; Vásquez, J J

2001-10-01

The digital exploration of stab wounds in the left thoracoabdominal region allows the early diagnosis of diaphragmatic lesions. Diagnostic test study. The digital exploration of the diaphragm was compared with laparotomy (the gold standard) and thoracoscopy. The study setting was the Hospital Universitario San Vicente de Paúl (Medellín, Colombia). This is a referral trauma center for the general community. The study included 82 consecutive patients who were admitted to our institution during a 12-month period with injuries caused by stab wounds to the left thoracoabdominal region and who did not have indications for immediate surgery. Digital exploration of the wound was performed by the attending surgeon in the emergency department. If a lesion of the diaphragm was identified, a laparotomy was performed; if no diaphragmatic lesion was found, a diagnostic left thoracoscopy and/or laparotomy was performed. Results of the laparotomy (n = 63) or thoracoscopy (n = 19) were used as the standard of reference for the determination of sensitivity, specificity, and predictive values of digital exploration. The integrity of the diaphragm was determined by digital exploration through the stab wound. Sensitivity, specificity, predictive value, and likelihood ratio were calculated. For the detection of diaphragmatic lesions, digital exploration demonstrated a sensitivity of 96%, a specificity of 83.3%, a positive predictive value of 91%, and a negative predictive value of 93.7%. Digital exploration is a reliable method for the detection of injuries to the left side of the diaphragm caused by stab wounds.

Contraction of Abdominal Wall Muscles Influences Incisional Hernia Occurrence and Size

PubMed Central

Lien, Samuel C.; Hu, Yaxi; Wollstein, Adi; Franz, Michael G.; Patel, Shaun P.; Kuzon, William M.; Urbanchek, Melanie G.

2015-01-01

Background Incisional hernias are a complication in 10% of all open abdominal operations and can result in significant morbidity. The purpose of this study is to determine if inhibiting abdominal muscle contraction influences incisional hernia formation during laparotomy healing. We hypothesize that reducing abdominal musculature deformation reduces incisional hernia occurrence and size. Study Design Using an established rat model for incisional hernia, a laparotomy through the linea alba was closed with one mid-incision, fast-absorbing suture. Three groups were compared: a SHAM group (SHAM; n = 6) received no laparotomies while the Saline Hernia (SH; n = 6) and Botox Hernia (BH; n = 6) groups were treated once with equal volume saline or Botulinum Toxin (Botox®, Allergan) before the incomplete laparotomy closure. On post-operative day 14, the abdominal wall was examined for herniation and adhesions and contractile forces were measured for abdominal wall muscles. Results No hernias developed in SHAM rats. Rostral hernias developed in all SH and BH rats. Caudal hernias developed in all SH rats, but in only 50% of the BH rats. Rostral hernias in the BH group were 35% shorter and 43% narrower compared to those in the SH group (p < 0.05). The BH group had weaker abdominal muscles compared to the SHAM and SH groups (p < 0.05). Conclusions In our rat model, partial paralysis of abdominal muscles reduces the number and size of incisional hernias. These results confirm abdominal wall muscle contractions play a significant role in the pathophysiology of incisional hernia formation. PMID:25817097

Effect of bacterial sepsis on gluconeogenic capacity in the rat

DOE Office of Scientific and Technical Information (OSTI.GOV)

Holman, J.M. Jr.; Saba, T.M.

Since sepsis places increased demands on the host for energy and on other substrates for tissue repair and host defense, hepatic gluconeogenesis is critical for the host's adaptation to sepsis. Substrate-stimulated gluconeogenesis (i.e., gluconeogenic capacity) was assessed by the alanine load method in mannoheptulose-pretreated rats made septic by cecal ligation after laparotomy, as well as by cecal ligation and puncture after laparotomy. Fasted rats subjected to laparotomy only (sham-ligated) and fasted, nonoperated rats (controls) were investigated simultaneously. Following an overnight (-18 to 0 hr) fast, nonoperated animals converted 17.9 +/- 1.5% of (/sup 14/C)alanine to (/sup 14/C)glucose. Continued fasting inmore » nonoperated animals resulted in enhanced (P less than 0.05) gluconeogenic capacity (6 hr = 27.2 +/- 3.0%; 24 hr = 26.2 +/- 1.9%; and 48 hr = 28.5 +/- 2.6%) relative to Time 0. Laparotomy alone (sham ligation) delayed the fasting-induced increase (P less than 0.05) in gluconeogenesis capacity (6 hr = 21.1 +/- 1.2%; 24 hr = 18.5 +/- 1.3%; 48 hr = 27.8 +/- 1.0%) relative to Time 0. In contrast, postoperative sepsis produced a sustained depression (P less than 0.05) of gluconeogenic capacity relative to nonoperated sham-ligated controls at 48 hr (cecal ligation, 18.4 +/- 1.4%; and cecal ligation and puncture, 18.8 +/- 1.2%). Thus, (1) fasting enhances hepatic gluconeogenic capacity; (2) surgical trauma transiently blunts the gluconeogenic response to fasting; and (3) sepsis undermines the gluconeogenic response to fasting.« less

Novel Approach to Treat Uncomplicated Sigmoid Volvulus Combining Minimally Invasive Surgery with Enhanced Recovery, in a Rural Hospital in Zambia.

PubMed

van der Naald, Niels; Prins, Marloes I; Otten, Kars; Kumwenda, Dayson; Bleichrodt, Robert P

2018-06-01

In sub-Saharan Africa, sigmoid volvulus is a frequent cause of bowel obstruction. The aim of this study was to evaluate the results of acute sigmoid resection and anastomosis via a mini-laparotomy in patients with uncomplicated sigmoid volvulus, following the principles of "Enhanced Recovery After Surgery (ERAS)", in a low-resource setting. Patients with uncomplicated sigmoid volvulus were operated acutely, via a mini-laparotomy, according to the principles of ERAS. Intraoperative complications, duration of operation, morbidity, mortality and length of hospital stay were evaluated, retrospectively. From 1 March 2012 to 1 September 2017, 31 consecutive patients were treated with acute sigmoid resection and anastomosis, via a mini-laparotomy. There were 29 men and 2 women, median age 57 (range 17-92) years. Patients were operated after a median period of 4 (range 1.5-18) hours. The median duration of the operative procedure was 50 (range 30-105) minutes. Two patients died (6.3%). One patient died during an uncomplicated operation. The cause of death is unknown. One patient with a newly diagnosed HIV infection had an anastomotic dehiscence. After Hartmann's procedure, he died on the 17th post-operative day as a result of a HIV-related double-sided pneumonia, without signs of abdominal sepsis. One patient had an urinary retention and 1 patient haematuria after bladder catheter insertion. Acute sigmoid resection and primary anastomosis via a mini-laparotomy for uncomplicated sigmoid volvulus, without preoperative endoscopic decompression is a safe procedure with a low morbidity and mortality.

Outcomes following trauma laparotomy for hypotensive trauma patients: a UK military and civilian perspective.

PubMed

Marsden, Max; Carden, Rich; Navaratne, Lalin; Smith, Iain M; Penn-Barwell, Jowan G; Kraven, Luke M; Brohi, Karim; Tai, Nigel R M; Bowley, Douglas M

2018-05-25

The management of trauma patients has changed radically in the last decade and studies have shown overall improvements in survival. However, reduction in mortality for the many may obscure a lack of progress in some high-risk patients. We sought to examine the outcomes for hypotensive patients requiring laparotomy in UK military and civilian cohorts. We undertook a review of two prospectively maintained trauma databases; the UK Joint Theatre Trauma Registry (JTTR) for the military cohort (4th February 2003 to 21st September 2014), and the trauma registry of the Royal London Hospital MTC (1st January 2012 to 1st January 2017) for civilian patients. Adults undergoing trauma laparotomy within 90 minutes of arrival at the Emergency Department (ED) were included. Hypotension was present on arrival at the ED in 155/761 (20.4%) military patients. Mortality was higher in hypotensive casualties 25.8% vs 9.7% normotensive casualties (p<0.001). Hypotension was present on arrival at the ED in 63/176 (35.7%) civilian patients. Mortality was higher in hypotensive patients 47.6% vs 12.4% normotensive patients (p<0.001). In both cohorts of hypotensive patients neither the average injury severity, the prehospital time, the ED arrival SBP, nor mortality rate changed significantly during the study period. Despite improvements in survival after trauma for patients overall, the mortality for patients undergoing laparotomy who arrive at the Emergency Department with hypotension has not changed and appears stubbornly resistant to all efforts. Specific enquiry and research should continue to be directed at this high-risk group of patients. IV; Observational Cohort Study.

The Effect of Human-Immunodeficiency Virus Status on Outcomes in Penetrating Abdominal Trauma: An Interim Analysis.

PubMed

McPherson, Deidre; Neuhaus, Valentin; Dhar, Rohin; Edu, Sorin; Nicol, Andrew J; Navsaria, Pradeep H

2018-01-31

The purpose of this study was to determine whether the outcomes of hemodynamically stable patients undergoing exploratory laparotomy for penetrating abdominal trauma differed as a result of their HIV status. This was an observational, prospective study from February 2016 to May 2017. All hemodynamically stable patients with penetrating abdominal trauma requiring a laparotomy were included. The mechanism of injury, the HIV status, age, the penetrating abdominal trauma index (PATI), and the revised trauma score (RTS) were entered into a binary logistic regression model. Outcome parameters were in-hospital death, morbidity, admission to intensive care unit (ICU), relaparotomy within 30 days, and length of stay longer than 30 days. A total of 209 patients, 94% male, with a mean age of 29 ± 10 years were analysed. Twenty-eight patients (13%) were HIV positive. The two groups were comparable. Ten (4.8%) laparotomies were negative. There were two (0.96%) deaths, both in the HIV negative group. The complication rate was 34% (n = 72). Twenty-nine patients (14%) were admitted to the ICU. A higher PATI, older age, and a lower RTS were significant risk factors for ICU admission. After 30 days, 12 patients (5.7%) were still in hospital. Twenty-four patients (11%) underwent a second laparotomy. The PATI score was the single independent predictor for complications, relaparotomy, and hospital stay longer than 30 days. Preliminary results reveal that HIV status does not influence outcomes in patients with penetrating abdominal trauma.

Gastrointestinal surgery in cystic fibrosis: a 20-year review.

PubMed

Farrelly, Paul J; Charlesworth, Caroline; Lee, Sophie; Southern, Kevin W; Baillie, Colin T

2014-02-01

The purpose of this study was to evaluate outcomes of the surgical management for meconium ileus (MI) and Distal Intestinal Obstruction Syndrome (DIOS) in Cystic Fibrosis (CF). Children born between 1990 and 2010 were identified using a regional CF database. Retrospective case note analysis was performed. Outcome measures for MI were mortality, relaparotomy rate, length of stay (LOS), time on parental nutrition (TP), and time to full feeds (TFF). Outcome measures for DIOS were: age of onset, number of episodes, and need for laparotomy. Seventy-five of 376 neonates presented with MI. Fifty-four (92%) required laparotomy. Contrast enema decompression was attempted in nineteen. There were no post-operative deaths. Thirty-nine (72%) neonates with MI were managed with stomas. LOS was longer in those managed with stomas (p=0.001) and in complex MI (p=0.002). Thirty-five patients were treated for DIOS. Twenty-five patients were managed with gastrograffin. Ten patients underwent surgical management of DIOS. Overall, MI did not predispose to later development of DIOS. There was a significantly greater incidence of laparotomy for DIOS in children who had MI. The proportion of neonates with complex meconium ileus was high (49%) and may explain the infrequent utilisation of radiological decompression. Complex MI or management with stomas both significantly increase LOS. Re-laparotomy rate is high (22%) in MI irrespective of the type of management. DIOS is not a benign condition, particularly when the child has had previous abdominal surgery. Early referral to a surgical team is essential in these children. Copyright © 2014 Elsevier Inc. All rights reserved.

IMPLEMENTING LAPAROSCOPY IN BRAZIL'S NATIONAL PUBLIC HEALTH SYSTEM: THE BARIATRIC SURGEONS' POINT OF VIEW

PubMed Central

SUSSENBACH, Samanta; SILVA, Everton N; PUFAL, Milene Amarante; ROSSONI, Carina; CASAGRANDE, Daniela Schaan; PADOIN, Alexandre Vontobel; MOTTIN, Cláudio Corá

2014-01-01

Background Although Brazilian National Public Health System (BNPHS) has presented advances regarding the treatment for obesity in the last years, there is a repressed demand for bariatric surgeries in the country. Despite favorable evidences to laparoscopy, the BNPHS only performs this procedure via laparotomy. Aim 1) Estimate whether bariatric surgeons would support the idea of incorporating laparoscopic surgery in the BNPHS; 2) If there would be an increase in the total number of surgeries performed; 3) As well as how BNPHS would redistribute both procedures. Methods A panel of bariatric surgeons was built. Two rounds to answer the structured Delphi questionnaire were performed. Results From the 45 bariatric surgeons recruited, 30 (66.7%) participated in the first round. For the second (the last) round, from the 30 surgeons who answered the first round, 22 (48.9%) answered the questionnaire. Considering the possibility that BNPHS incorporated laparoscopic surgery, 95% of surgeons were interested in performing it. Therefore, in case laparoscopic surgery was incorporated by the BNPHS there would be an average increase of 25% in the number of surgeries and they would be distributed as follows: 62.5% via laparoscopy and 37.5% via laparotomy. Conclusion 1) There was a preference by laparoscopy; 2) would increase the number of operations compared to the current model in which only the laparotomy is available to users of the public system; and 3) the distribution in relation to the type of procedure would be 62.5% and 37.5% for laparoscopy laparotomy. PMID:25409964

Local Infiltration of Analgesics at Surgical Wound to Reduce Postoperative Pain After Laparotomy in Rats.

PubMed

Kroin, Jeffrey S; Li, Jinyuan; Moric, Mario; Birmingham, Brian W; Tuman, Kenneth J; Buvanendran, Asokumar

There is an increasing use of local infiltration analgesia (LIA) to reduce postoperative pain. Despite widespread use of LIA, wide variations in drug combinations and concomitant use of systemic analgesics have made it difficult to determine the optimal drug combinations for LIA. Using a previously validated rat laparotomy model, the optimal LIA combination of medications to reduce postoperative pain was determined. Laparotomy was performed in an adult rat model under isoflurane anesthesia. During surgery, combinations of bupivacaine, ketorolac, and dexamethasone were injected over the sutured muscle wound before skin closing, and compared to saline (placebo). The same medications were injected systemically as controls. Postoperative pain was assessed by measuring spontaneous rearing activity. A high-dose 3-drug LIA combination (50 μL of bupivacaine 0.75%, ketorolac 6.0 mg/mL, and dexamethasone 2.0 mg/mL) increased rearing (decreased pain) at 2 hours (P = 0.0032) postsurgery compared to saline. However, the same 3 drugs injected systemically had a similar analgesic effect (P = 0.0002). Bupivacaine 0.75% alone was not effective for LIA. When low-dose (9-fold reduction) 3-drug LIA combination was used, LIA increased rearing (P = 0.0034) whereas the same 3 drugs injected systemically had no effect. Low-dose LIA ketorolac/dexamethasone (2-drug combination) also increased rearing (P = 0.0393). Our animal study suggests that clinical trials with low-dose LIA combinations of local anesthetic, nonsteroidal anti-inflammatory drug, and corticosteroid may be useful for reducing postoperative pain after laparotomy.

Transdiaphragmatic resuscitative open cardiac massage: description of the technique and a first case-series of an alternative approach to the heart.

PubMed

Schnüriger, Beat; Studer, Peter; Candinas, Daniel; Seiler, Christian A

2014-07-01

The purpose of this paper is to describe the transdiaphragmatic approach to the heart for open CPR in patients that arrest at laparotomy and to present a first case series of patients that have undergone this procedure. All patients who had undergone intraperitoneal transdiaphragmatic open CPR between January 1, 2002 and December 31, 2012 were retrieved from the operation registry at Bern University Hospital, Switzerland. Transdiaphragmatic access to the heart is initiated with a 10-cm-long anterocaudal incision in the central tendon of the diaphragm--approximately at 2 o'clock. Internal cardiac compression through the diaphragmatic incision can be performed from both sides of the patient. From the right side of the patient, cardiac massage is performed with the right hand and vice versa. A total of six patients were identified that suffered cardiac arrest during laparotomy with open CPR performed through the transdiaphragmatic approach. Four patients suffered cardiac arrest during orthotopic liver transplantation and two trauma patients suffered cardiac arrest during damage control laparotomy. In three patients, cardiac activity was never reestablished. However, three patients regained a perfusion heart rhythm and two of these survived to the ICU. One patient ultimately survived to discharge. In patients suffering cardiac arrest during laparotomy, the transdiaphragmatic approach allows for a rapid, technically easy, and almost atraumatic access to the heart, with excellent CPR performance. After this potentially life-saving procedure, pulmonary or surgical site complications are expected to occur much less compared with the conventionally performed emergency department left-sided thoracotomy.

Surgical management and perioperative morbidity of patients with primary borderline ovarian tumor (BOT).

PubMed

Trillsch, Fabian; Ruetzel, Jan David; Herwig, Uwe; Doerste, Ulrike; Woelber, Linn; Grimm, Donata; Choschzick, Matthias; Jaenicke, Fritz; Mahner, Sven

2013-07-09

Surgery is the cornerstone for clinical management of patients with borderline ovarian tumors (BOT). As these patients have an excellent overall prognosis, perioperative morbidity is the critical point for decision making when the treatment strategy is developed and the primary surgical approach is defined. Clinical and surgical parameters of patients undergoing surgery for primary BOT at our institutions between 1993 and 2008 were analyzed with regard to perioperative morbidity depending on the surgical approach (laparotomy vs. laparoscopy). A total of 105 patients were analyzed (44 with primary laparoscopy [42%], 61 with primary laparotomy [58%]). Complete surgical staging was achieved in 33 patients at primary surgical approach (31.4%) frequently leading to formal indication of re-staging procedures. Tumor rupture was significantly more frequent during laparoscopy compared to laparotomy (29.5% vs. 13.1%, p = 0.038) but no other intraoperative complications were seen in laparoscopic surgery in contrast to 7 of 61 laparotomies (0% vs. 11.5%, p = 0.020). Postoperative complication rates were similar in both groups (19.7% vs. 18.2%, p = 0.848). Irrespective of the surgical approach, surgical management of BOT has acceptable rates of perioperative complications and morbidity. Choice of initial surgical approach can therefore be made independent of complication-concerns. As the recently published large retrospective AGO ROBOT study observed similar oncologic outcome for both approaches, laparoscopy can be considered for staging of patients with BOT if this appears feasible. An algorithm for the surgical management of BOT patients has been developed.

Aetiology, management and outcome of entero-cutaneous fistula in Maiduguri, Nigeria.

PubMed

Eni, U E; Na'aya, H U; Gali, B M

2007-03-01

Enterocutaneous fistula (ECF) remains an important surgical problem with significant morbidity and mortality. This study aims to review the aetiology and management outcome in a depressed economy like ours. A retrospective review of 54 patients with ECF admitted into the surgical wards of the University of Maiduguri Teaching Hospital (UMTH) between January 1994 and December 2004 (11 year period). Thirty two (59.3%) were males and 22 (40.7%) were females giving a male/female ratio of 1.5 to 1. The age ranged from 1 to 58 years with two peak incidents of 20-29 years and 40-49 years. Eighteen cases (33%) occurred following appendicectomy, 12 (22%) following laparotomy for intestinal obstruction, 10 (18.5%) following laparotomy for abdominal malignancies, 7 (13%) followed laparotomy for penetrating abdominal injuries, 3 (5.5%) followed laparotomy for perforated typhoid enteritis, 2 (3.7%) cases were due to spontaneous rupture of strangulated and neglected inguinal hernia, 1 (1.9%) case followed chest tube insertion for pleural effusion in a PTB patient and 1 (1.9%) case followed a native healer's incision on a lumber hernia. Altogether,45 (83.3%) were referred cases from peripheral hospitals. Fourty one (76%) were high output type, while 13 (24%) were low output type. Most patients 32 (59.3%) healed spontaneously on conservative management. Eighteen (33%) had surgical intervention. Eight patients demised giving a mortality rate of 15%. The average hospital stay was 56 days. The main cause of ECF in our environment is postoperative (94.4%) with post appendicectomy cases alone accounting for 33%. Majority of our patients (66.7%) were managed conservatively.

Significance of computed tomography finding of intra-abdominal free fluid without solid organ injury after blunt abdominal trauma: time for laparotomy on demand.

PubMed

Mahmood, Ismail; Tawfek, Zainab; Abdelrahman, Yassir; Siddiuqqi, Tariq; Abdelrahman, Husham; El-Menyar, Ayman; Al-Hassani, Ammar; Tuma, Mazin; Peralta, Ruben; Zarour, Ahmad; Yakhlef, Sawsan; Hamzawi, Hazim; Al-Thani, Hassan; Latifi, Rifat

2014-06-01

Optimal management of patients with intra-abdominal free fluid found on computed tomography (CT) scan without solid organ injury remains controversial. The purpose of this study was to determine the significance of CT scan findings of free fluid in the management of blunt abdominal trauma patients who otherwise have no indications for laparotomy. During the 3-year study period, all patients presenting with blunt abdominal trauma who underwent abdominal CT examination were retrospectively reviewed. All hemodynamically stable patients who presented with abdominal free fluid without solid organ injury on CT scan were analyzed for radiological interpretation, clinical management, operative findings, and outcome. A total of 122 patients were included in the study, 91 % of whom were males. The mean age of the patients was 33 ± 12 years. A total of 34 patients underwent exploratory laparotomy, 31 of whom had therapeutic interventions. Small bowel injuries were found in 12 patients, large bowel injuries in ten, and mesenteric injuries in seven patients. One patient had combined small and large bowel injury, and one had traumatic gangrenous appendix. In the remaining three patients, laparotomy was non-therapeutic. A total of 36 patients had associated pelvic fractures and 33 had multiple lumbar transverse process fractures. Detection of intra-peritoneal fluid by CT scan is inaccurate for prediction of bowel injury or need for surgery. However, the correlation between CT scan findings and clinical course is important for optimal diagnosis of bowel and mesenteric injuries.

Vasopressor use after initial damage control laparotomy increases risk for anastomotic disruption in the management of destructive colon injuries.

PubMed

Fischer, Peter E; Nunn, Andrew M; Wormer, Blair A; Christmas, A Britton; Gibeault, Lindsay A; Green, John M; Sing, Ronald F

2013-12-01

Management of destructive colon injuries during damage control (DC) laparotomy is debated. The authors reviewed a single institution's experience with destructive colon injuries to identify risk factors for anastomotic failure after colon reconstruction. The authors identified all trauma patients sustaining destructive colon injuries between 2002 and 2011 from their medical center's trauma registry. Anastomotic leak was defined as suture or staple line disruption or enteral fistula formation. Of 171 identified patients, 68 had DC procedures, 41 (60%) had subsequent anastomoses performed during the same hospitalization, and 27 (40%) were diverted. The colon anastomotic leak rate in patients who underwent DC laparotomy was higher than in patients who were reconstructed at the primary operation in a non-DC setting (17% vs 6%, P = .09). The use of vasopressors after the initial DC operation more than quadrupled the leak rate to 50% (P = .02). Colonic anastomotic disruptions yield deadly consequences, and diversion rather than anastomosis should be used in patients who require vasopressor support after the initial DC procedure. Copyright © 2013 Elsevier Inc. All rights reserved.

The use of laparoscopy in the diagnosis and treatment of blunt and penetrating abdominal injuries: 10-year experience at a level 1 trauma center.

PubMed

Johnson, Jeremy J; Garwe, Tabitha; Raines, Alexander R; Thurman, Joseph B; Carter, Sandra; Bender, Jeffrey S; Albrecht, Roxie M

2013-03-01

Diagnostic laparoscopy (DL) has decreased the rate of nontherapeutic laparotomy for patients suffering from penetrating injuries. We evaluated whether DL similarly lowers the rate of nontherapeutic laparotomy for patients with blunt injuries. All patients undergoing DL over a 10-year period (ie, 2001-2010) in a single level 1 trauma center were classified by the mechanism of injury. Demographic and perioperative data were compared using the Student t and Fisher exact tests. There were 131 patients included, 22 of whom sustained blunt injuries. Patients suffering from blunt injuries were more severely injured (Injury Severity Score 18.0 vs 7.3, P = .0001). The most common indication for DL after blunt injury was a computed tomographic scan concerning for bowel injury (59.1%). The rate of nontherapeutic laparotomy for patients sustaining penetrating vs blunt injury was 1.8% and nil, respectively. DL, when coupled with computed tomographic findings, is an effective tool for the initial management of patients with blunt injuries. Copyright © 2013 Elsevier Inc. All rights reserved.

Characteristics of patients with a retained wireless capsule endoscope (WCE) necessitating laparotomy for removal of the capsule.

PubMed

Purdy, Martin; Heikkinen, Markku; Juvonen, Petri; Voutilainen, Markku; Eskelinen, Matti

2011-01-01

A capsule endoscope is a wireless miniature camera used to take images of the small bowel mucosa. Retention of the wireless capsule endoscope (WCE), defined as at least two weeks' retention or an obstruction demanding removal by laparotomy, is the main and practically only complication of the procedure. The aim of this study was to evaluate the characteristics of patients with a retained WCE necessitating laparotomy for removal of the capsule or capsule fragments. The medical records of 555 patients who had undergone the WCE procedure over a 7-year period (2002-2008) were reviewed. The indications for the WCE procedure were, obscure gastrointestinal bleeding, Crohn's disease, abdominal pain and suspicion of malignancy. A retained WCE requiring operative treatment was found in 10 cases (in nine patients, twice in one patient). The WCE retention frequency of 1.8% (10/555) equalled that in the literature. The retention rate of WCE capsules is low and routine examination of the small bowel with MRI or CT is not necessary before WCE. These examinations were enable to predict WCE retention according to our results.

From clinical integration to accountable care.

PubMed

Shields, Mark

2011-01-01

Four key challenges to reforming health care organizations can be addressed by a clinical integration model patterned after Advocate Physician Partners (APP). These challenges are: predominance of small group practices, dominant fee-for-service reimbursement methods, weaknesses of the traditional hospital medical staff structure and a need to partner with commercial insurance companies. APP has demonstrated teamwork between 3800 physicians and hospitals to improve quality, patient safety and cost-effectiveness. Building on this model, an innovative contract with Blue Cross Blue Shield of Illinois serves as a prototype for a commercial Accountable Care Organization. For this contract to succeed, APP must outperform the market competition. To accomplish this, APP has implemented strategies to reduce readmissions, avoid unnecessary admissions and emergency room visits, expand primary care access, and enhance quality and patient safety.

Molecular Signature of Indeterminate Thyroid Lesions: Current Methods to Improve Fine Needle Aspiration Cytology (FNAC) Diagnosis

PubMed Central

Cantara, Silvia; Marzocchi, Carlotta; Pilli, Tania; Cardinale, Sandro; Forleo, Raffaella; Castagna, Maria Grazia; Pacini, Furio

2017-01-01

Fine needle aspiration cytology (FNAC) represents the gold standard for determining the nature of thyroid nodules. It is a reliable method with good sensitivity and specificity. However, indeterminate lesions remain a diagnostic challenge and researchers have contributed molecular markers to search for in cytological material to refine FNAC diagnosis and avoid unnecessary surgeries. Nowadays, several “home-made” methods as well as commercial tests are available to investigate the molecular signature of an aspirate. Moreover, other markers (i.e., microRNA, and circulating tumor cells) have been proposed to discriminate benign from malignant thyroid lesions. Here, we review the literature and provide data from our laboratory on mutational analysis of FNAC material and circulating microRNA expression obtained in the last 6 years. PMID:28383480

Clinical trials--a brave new partnership?

PubMed Central

Thornton, H

1994-01-01

The need for informed consent is considered from the patient's viewpoint by an examination of the shortcomings of the UK Ductal Carcinoma In Situ (DCIS) trial and its failure satisfactorily to accrue both profession and patient. The impersonal, negative aspects of the informed consent process in the research situation are contrasted with the positive benefits of confidence fostered by the traditional doctor/patient relationship. The need for new research with a partnership between patient and profession, the necessity for rigorous re-assessment of treatments and care both within and outside of trials to avoid waste by the perpetration of unnecessary treatments together with the need for evaluation of the efficacy of treatments employed outside of trials, especially in 'new' conditions, to foster progress and maintain public confidence in the profession, is advocated. PMID:8035434

Activating the critical lure during study is unnecessary for false recognition.

PubMed

Zeelenberg, René; Boot, Inge; Pecher, Diane

2005-06-01

Participants studied lists of nonwords (e.g., froost, floost, stoost, etc.) that were orthographic-phonologically similar to a nonpresented critical lure, which was also a nonword (e.g., ploost). Experiment 1 showed a high level of false recognition for the critical lure. Experiment 2 showed that the false recognition effect was also present for forewarned participants who were informed about the nature of the false recognition effect and told to avoid making false recognition judgments. The present results show that false recognition effects can be obtained even when the critical lure itself is not stored during study. This finding is problematic for accounts that attribute false memories to implicit associative responses or spreading activation but is easily explained by global familiarity models of recognition memory.

Issues of medical necessity: a medical director's guide to good faith adjudication.

PubMed

Quinn, C

1997-06-01

The term medical necessity is difficult to define, a problem for insurers who need to clearly describe what is and is not covered in their contracts with subscribers. An unclear, vague definition of medical necessity leaves insurers vulnerable to litigation by subscribers denied care deemed medically unnecessary. To avoid lawsuits, insurers must make every effort to educate their subscribers about their medical coverage, going beyond merely providing a lengthy subscriber handbook. In decisions on medical necessity, medical directors at insurance companies play a key role. They can bolster the insurer's position in denial-of-care cases in numerous ways, including keeping meticulous records, eliminating unreasonable financial incentives, maintaining a claims denial database, and consulting with other insurers to achieve a consensus on medical necessity.

Protecting worker and public health during responses to catastrophic disasters-learning from the World Trade Center experience.

PubMed

Newman, David M

2014-11-01

Despite incremental lessons learned since 9/11, responder and community health remain at unnecessary risk during responses to catastrophic disasters, as evidenced during the BP Deepwater Horizon spill and Hurricanes Katrina, Rita, and Sandy. Much of the health harm that occurs during disaster response, as distinct from during the disaster event itself, is avoidable. Protection of public health should be an integral component of disaster response, which should "do no additional harm." This commentary examines how challenges and gaps the World Trade Center response resulted in preventable occupational and environmental health harm. It proposes changes in disaster response policies to better protect the health of rescue and recovery workers, volunteers, and impacted worker and residential communities. © 2014 Wiley Periodicals, Inc.

Lateralized hyperkinetic motor behavior.

PubMed

Krishnaiah, Balaji; Acharya, Jayant; Ahmed, Aiesha

2018-01-01

Seizures are followed by a post-ictal period, which is characterized by usual slowing of brain activity. This case report describes a 68-year old woman who presented with right-sided rhythmic, non-voluntary, semi-purposeful motor behavior that started 2 days after an episode of generalized seizure. Her initial electroencephalogram (EEG) showed beta activity with no evidence of epileptiform discharges. Computed tomography scan showed hypodensity in the left parieto-occipital region. Magnetic resonance imaging (MRI) showed restricted diffusion/fluid-attenuated inversion recovery hyperintensities in the left precentral and post-central gyrus. Unilateral compulsive motor behavior during the post-ictal state should be considered, and not confused with partial status epilepticus to avoid unnecessary treatment. Abnormal magnetic resonance imaging (MRI) findings, which are reversible, can help with the diagnostic and therapeutic approach.

[Mild head injury in children and adults: Diagnostic challenges in the emergency department].

PubMed

Leidel, B A; Lindner, T; Wolf, S; Bogner, V; Steinbeck, A; Börner, N; Peiser, C; Audebert, H J; Biberthaler, P; Kanz, K-G

2015-06-01

Mild head injuries are one of the most frequent reasons for attending emergency departments and are particularly challenging in different ways. While clinically important injuries are infrequent, delayed or missed injuries may lead to fatal consequences. The initial mostly inconspicuous appearance may not reflect the degree of intracranial injury and computed tomography (CT) is necessary to rule out covert injuries. Furthermore, infants and young children with a lack of or rudimentary cognitive and language development are challenging, especially for those examiners not familiar with pediatric care. Established check lists of clinical risk factors for children and adults regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging. Clinically important intracranial injuries can be reliably detected and unnecessary radiation exposure avoided at the same time.

[Mild head injury in children and adults. Diagnostic challenges in the emergency department].

PubMed

Leidel, B A; Lindner, T; Wolf, S; Bogner, V; Steinbeck, A; Börner, N; Peiser, C; Audebert, H J; Biberthaler, P; Kanz, K-G

2015-01-01

Mild head injuries are one of the most frequent reasons for attending emergency departments and are particularly challenging in different ways. While clinically important injuries are infrequent, delayed or missed injuries may lead to fatal consequences. The initial mostly inconspicuous appearance may not reflect the degree of intracranial injury and computed tomography (CT) is necessary to rule out covert injuries. Furthermore, infants and young children with a lack of or rudimentary cognitive and language development are challenging, especially for those examiners not familiar with pediatric care. Established check lists of clinical risk factors for children and adults regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging. Clinically important intracranial injuries can be reliably detected and unnecessary radiation exposure avoided at the same time.

Fail-over file transfer process

NASA Technical Reports Server (NTRS)

Semancik, Susan K. (Inventor); Conger, Annette M. (Inventor)

2005-01-01

The present invention provides a fail-over file transfer process to handle data file transfer when the transfer is unsuccessful in order to avoid unnecessary network congestion and enhance reliability in an automated data file transfer system. If a file cannot be delivered after attempting to send the file to a receiver up to a preset number of times, and the receiver has indicated the availability of other backup receiving locations, then the file delivery is automatically attempted to one of the backup receiving locations up to the preset number of times. Failure of the file transfer to one of the backup receiving locations results in a failure notification being sent to the receiver, and the receiver may retrieve the file from the location indicated in the failure notification when ready.

Carotenemia associated with green bean ingestion.

PubMed

Sale, Tanya A; Stratman, Erik

2004-01-01

Carotenemia is a condition characterized by yellow discoloration of the skin and elevated blood carotene levels. Excessive and prolonged ingestion of carotene-rich, yellow- or orange-colored foods such as carrots and winter squash is the most common cause, but more rarely it may be associated with consumption of other foods as well as with hypothyroidism, diabetes mellitus, anorexia nervosa, liver disease, or kidney disease. Though not uncommon in children, there are few reports in the pediatric literature since its early descriptions in the late 1800s and early 1900s. Awareness of carotenemia can help the provider resolve confusion with jaundice and avoid unnecessary worry and costly tests. Herein we describe carotenemia in an 8-month-old Caucasian girl secondary to increased consumption of commercial infant food green beans.

Endoscopic Ultrasound Elastography: Current Clinical Use in Pancreas.

PubMed

Mondal, Utpal; Henkes, Nichole; Patel, Sandeep; Rosenkranz, Laura

2016-08-01

Elastography is a newer technique for the assessment of tissue elasticity using ultrasound. Cancerous tissue is known to be stiffer (hence, less elastic) than corresponding healthy tissue, and as a result, could be identified in an elasticity-based imaging. Ultrasound elastography has been used in the breast, thyroid, and cervix to differentiate malignant from benign neoplasms and to guide or avoid unnecessary biopsies. In the liver, elastography has enabled a noninvasive and reliable estimate of fibrosis. Endoscopic ultrasound has become a robust diagnostic and therapeutic tool for the management of pancreatic diseases. The addition of elastography to endoscopic ultrasound enabled further characterization of pancreas lesions, and several European and Asian studies have reported encouraging results. The current clinical role of endoscopic ultrasound elastography in the management of pancreas disorders and related literature are reviewed.

Pregnancy Luteoma in Ectopic Pregnancy: A Case Report

PubMed Central

Brar, Rupinder Kaur; Bharti, Jyotsna Naresh; Nigam, Jitendra Singh; Sehgal, Sahil; Singh, Hena Paul; Ojha, Pushpanjali

2017-01-01

Background: Pregnancy luteoma is a rare non neoplastic condition of the ovary. It is usually asymptomatic and found incidentally during imaging in pregnancy or during cesarean section. Pregnancy luteoma can also occur after ectopic pregnancy. Case Presentation: A 30 year old female presented to G.B. Pant Hospital, Andaman and Nicobar Islands institute of Medical Sciences, Port Blair in October 2015 with abdominal pain. After initial investigations, exploratory laporotomy was done for ruptured ectopic pregnancy. Enlarged ovary was removed along with the ruptured portion of fallopian tube. Histopathological examination revealed solid aggregates of large cells with abundant eosinophilic cytoplasm; diagnosis of pregnancy luteoma was given. Conclusion: It must be considered in the differential diagnosis of ovarian masses in pregnant females that early diagnosis of this entity may avoid unnecessary radical surgery. PMID:29062798

Acute colonic pseudoobstruction in a child with sickle cell disease treated with neostigmine.

PubMed

Khosla, Arjun; Ponsky, Todd A

2008-12-01

Sickle cell disease is a disorder that produces significant morbidity and mortality. Vaso-occlusive pain crises are the most common presenting symptom associated with sickle cell patients. A rare, yet important to recognize, complication of sickle cell disease is acute colonic pseudoobstruction, also known as Ogilvie's syndrome. These patients may present with symptoms that are difficult to distinguish from other etiologies of abdominal pain, but a thorough diagnostic workup can provide important clues. Furthermore, there is no agreement on optimal treatment of pseudoobstruction. We report the first pediatric case of acute pseudoobstruction secondary to sickle cell disease that was treated successfully with neostigmine. Early recognition of this phenomenon is important as it alters patient management, can be treated medically, and may avoid unnecessary surgical intervention.

Clinical utility of contrast-enhanced spectral mammography as an adjunct for tomosynthesis-detected architectural distortion.

PubMed

Patel, Bhavika K; Naylor, Michelle E; Kosiorek, Heidi E; Lopez-Alvarez, Yania M; Miller, Adrian M; Pizzitola, Victor J; Pockaj, Barbara A

Supplement tomosynthesis-detected architectural distortions (AD) with CESM to better characterize malignant vs benign lesions. Retrospective review CESM prior to biopsied AD. Pathology: benign, radial scar, or malignant. 49 lesions (45 patients). 29 invasive cancers, 1 DCIS (range, 0.4-4.7cm); 9 radial scars; 10 benign. 37 (75.5%) ADs had associated enhancement. PPV 78.4% (29/37), sensitivity 96.7% (29/30); specificity, 57.9% (11/19); NPV, 91.7% (11/12). False-positive rate 21.6% (8/37); false-negative rate, 8.3% (1/12). Accuracy 81.6% (40/49). High sensitivity and NPV of CESM in patients with AD is promising as an adjunct tool in diagnosing malignancy and avoiding unnecessary biopsy, respectively. Copyright © 2017 Elsevier Inc. All rights reserved.