Background
During the last two decades, an increasing number of bariatric surgical procedures have been performed worldwide. There is no consensus regarding optimal perioperative care in bariatric ...surgery. This review aims to present such a consensus and to provide graded recommendations for elements in an evidence-based “enhanced” perioperative protocol.
Methods
The English-language literature between January 1966 and January 2015 was searched, with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded. After critical appraisal of these studies, the group of authors reached a consensus recommendation.
Results
Although for some elements, recommendations are extrapolated from non-bariatric settings (mainly colorectal), most recommendations are based on good-quality trials or meta-analyses of good-quality trials.
Conclusions
A comprehensive evidence-based consensus was reached and is presented in this review by the enhanced recovery after surgery (ERAS) Society. The guidelines were endorsed by the International Association for Surgical Metabolism and Nutrition (IASMEN) and based on the evidence available in the literature for each of the elements of the multimodal perioperative care pathway for patients undergoing bariatric surgery.
•“We showed a poor completion rate of only 30%. There was a high percentage of previously undetected injuries within the study population who received a TTS. This may suggest the possibility that ...many injuries are missed within the remaining 70% population that did not receive a TTS.”•“The inclusion criteria of this audit are wider than the comparative studies. Rather than limiting it to patients who had triggered a trauma call, we chose to expand the inclusion criteria to be more representative of patients who we thought could benefit from a TTS.”•“Arguably, the inclusion criteria of this audit are more representative of patients who need tertiary surveys.”
A tertiary trauma survey (TTS) is a structured, comprehensive top-to-toe examination following major trauma 1. Literature suggests that the ideal time frame for the initial TTS should be completed within 24-hours of a patient's admission and repeated at important moments 2–4. Evidence suggests that formal TTS reduces the rate of missed injuries by up to 38% 2.
To determine the rate of TTS being conducted in trauma patients in a tertiary hospital without an admitting trauma service.
We performed a retrospective analysis of adult trauma patients admitted to Middlemore Hospital (MMH) over six months. To be included, patients were either deemed to have a significant mechanism of injury or triggered a trauma call when arriving in the Emergency Department.
We identified 246 patients who met our criteria for requiring a TTS. 74 (30%) had a TTS completed. Of those completed, 22 (30%) were documented using a standardised form. 35 (47%) were done within the ideal timeframe (24 h); a further 21 (28%) were done within 48 h. House Officers (Junior Medical Officers) conducted the majority (80%), with the remainder being done by final-year medical students (12%), Registrars (Residents) (4%) and Consultants (Attendings) (4%). Of the 74 TTS that were completed, 21 (28%) detected a possible new injury, with 22% leading to further investigations being ordered. 14 (19%) were found to have a previously undetected, clinically significant injury on TTS (defined as ‘injuries requiring further clinical intervention’). Most patients (90%) were admitted to either General Surgery or Orthopaedics. Sixty-two (54%) of patients admitted to General Surgery received a TTS; compared to just 11 (10%) admitted under Orthopaedics and 1 of 24 (4%) admitted to other specialities (including Hands, Plastics, Maxillo-Facial, Gynaecology and Medicine).
30% of patients requiring a TTS received one. 19% of TTS conducted detected clinically significant injuries.
Pain patterns in chronic pancreatitis and chronic primary pain Tuck, N.L.; Teo, K.; Kuhlmann, L. ...
Pancreatology : official journal of the International Association of Pancreatology (IAP) ... et al.,
06/2022, Letnik:
22, Številka:
5
Journal Article
Recenzirano
Abdominal pain is the most distressing symptom of chronic pancreatitis (CP), and current treatments show limited benefit. Pain phenotypes may be more useful than diagnostic categories when planning ...treatments, and the presence or absence of constant pain in CP may be a useful prognostic indicator.
This cross-sectional study examined dimensions of pain in CP, compared pain in CP with chronic primary pain (CPP), and assessed whether constant pain in CP is associated with poorer outcomes.
Patients with CP (N = 91) and CPP (N = 127) completed the Comprehensive Pancreatitis Assessment Tool. Differences in clinical characteristics and pain dimensions were assessed between a) CP and CPP and b) CP patients with constant versus intermittent pain. Latent class regression analysis was performed (N = 192) to group participants based on pain dimensions and clinical characteristics.
Compared to CPP, CP patients had higher quality of life (p < 0.001), lower pain severity (p < 0.001), and were more likely to use strong opioids (p < 0.001). Within CP, constant pain was associated with a stronger response to pain triggers (p < 0.05), greater pain spread (p < 0.01), greater pain severity, more features of central sensitization, greater pain catastrophising, and lower quality of life compared to intermittent pain (all p values ≤ 0.001). Latent class regression analysis identified three groups, that mapped onto the following patient groups 1) combined CPP and CP-constant, 2) majority CPP, and 3) majority CP-intermittent.
Within CP, constant pain may represent a pain phenotype that corresponds with poorer outcomes. CP patients with constant pain show similarities to some patients with CPP, potentially indicating shared mechanisms.
Sleeve gastrectomy (SG) is a commonly performed bariatric procedure. Weight regain following SG is a significant issue. Yet the defining, reporting and understanding of this phenomenon remains ...largely neglected. Systematic review was performed to locate articles reporting the definition, rate and/or cause of weight regain in patients at least 2 years post-SG. A range of definitions employed to describe weight regain were identified in the literature. Rates of regain ranged from 5.7 % at 2 years to 75.6 % at 6 years. Proposed causes of weight regain included initial sleeve size, sleeve dilation, increased ghrelin levels, inadequate follow-up support and maladaptive lifestyle behaviours. Bariatric literature would benefit from standardising definitions used to report weight regain and its rate in clinical series. Larger prospective studies are required to further understand mechanisms of weight regain following SG.
Background
Bariatric surgery is a proven effective method of reducing obesity and reversing or preventing obesity‐related comorbidities. The aim of this study is to describe the development of a tool ...to assist with the prioritization of patients with obesity for bariatric surgery. The tool would meet the criteria for being evidence‐based, fair, implementable and transparent.
Methods
The development of the tool involved a validated step‐by‐step process based on the consensus of clinical judgement of the New Zealand Ministry of Health working party. The process involved elicitation of criteria, clinical ranking of vignettes and creation of weightings using the 1000Minds® tool. The concurrent validity was tested by comparing tool rankings of vignettes to clinical judgement rankings.
Results
Four major criteria (impact on life, likelihood of achieving maximum benefit with respect to control of diabetes, duration of benefit and surgical risk) are used to characterize the need and potential to benefit. The impact on life criterion has the largest weighting (up to 44.3%). There was good concurrent validity with a correlation coefficient r = 0.67.
Conclusion
The tool as presented is evidence‐based, transparent and internally valid. The next step is to assess the predictive validity of the tool using real patient data to evaluate the effectiveness of the tool and determine what modifications may be required.
This article describes the development of a tool for prioritising patients with obesity for surgery. The development involved a multistep process, with four major criteria elicited. It is evidence‐based, transparent and shows good concurrent validity, however further data is essential to evaluate its effectiveness.
Acute mountain sickness (AMS) is a common problem among visitors at high altitude, and may progress to life-threatening pulmonary and cerebral oedema in a minority of cases. International consensus ...defines AMS as a constellation of subjective, non-specific symptoms. Specifically, headache, sleep disturbance, fatigue and dizziness are given equal diagnostic weighting. Different pathophysiological mechanisms are now thought to underlie headache and sleep disturbance during acute exposure to high altitude. Hence, these symptoms may not belong together as a single syndrome. Using a novel visual analogue scale (VAS), we sought to undertake a systematic exploration of the symptomatology of AMS using an unbiased, data-driven approach originally designed for analysis of gene expression. Symptom scores were collected from 292 subjects during 1110 subject-days at altitudes between 3650 m and 5200 m on Apex expeditions to Bolivia and Kilimanjaro. Three distinct patterns of symptoms were consistently identified. Although fatigue is a ubiquitous finding, sleep disturbance and headache are each commonly reported without the other. The commonest pattern of symptoms was sleep disturbance and fatigue, with little or no headache. In subjects reporting severe headache, 40% did not report sleep disturbance. Sleep disturbance correlates poorly with other symptoms of AMS (Mean Spearman correlation 0.25). These results challenge the accepted paradigm that AMS is a single disease process and describe at least two distinct syndromes following acute ascent to high altitude. This approach to analysing symptom patterns has potential utility in other clinical syndromes.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Brain swelling is a major predictor of mortality in pediatric cerebral malaria (CM). However, the mechanisms leading to swelling remain poorly defined. Here, we combined neuroimaging, parasite ...transcript profiling, and laboratory blood profiles to develop machine-learning models of malarial retinopathy and brain swelling. We found that parasite var transcripts encoding endothelial protein C receptor (EPCR)-binding domains, in combination with high parasite biomass and low platelet levels, are strong indicators of CM cases with malarial retinopathy. Swelling cases presented low platelet levels and increased transcript abundance of parasite PfEMP1 DC8 and group A EPCR-binding domains. Remarkably, the dominant transcript in 50% of swelling cases encoded PfEMP1 group A CIDRα1.7 domains. Furthermore, a recombinant CIDRα1.7 domain from a pediatric CM brain autopsy inhibited the barrier-protective properties of EPCR in human brain endothelial cells in vitro. Together, these findings suggest a detrimental role for EPCR-binding CIDRα1 domains in brain swelling.
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•Stringently defined cerebral malaria cases profiled for PfEMP1/var expression•Low platelet count linked to malarial retinopathy and brain swelling•EPCR-binding PfEMP1 enriched in malarial retinopathy and brain swelling•Parasite PfEMP1 CIDRα1.7 domain from brain autopsies counteracts EPCR protection
Brain swelling is associated with cerebral malaria mortality, but the parasite and host factors responsible for development of brain swelling are unknown. Kessler et al. demonstrate an association of low platelet count and EPCR-binding PfEMP1 with brain swelling in children with cerebral malaria.
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