Abstract Background This study evaluates the incidence of delirium and risk factors associated with delirium in elderly patients admitted to a general surgical ward. Methods Patients aged over ...60 years who were admitted with an acute or elective general surgical diagnosis were eligible for this prospective cohort study. Risk factors associated with delirium were analyzed using univariate and multivariate analysis to identify those independently associated with delirium. Results A total of 209 patients were included in the study. The incidence of delirium was 16.9% (23.2% for acute admission, P < .001). Variables associated with delirium were dementia, presence of an urinary catheter, cognitive decline at admission measured with the mini-mental state examination, white blood cell count >10.0 × 109 /L, and urea >7.5 mmol/L. Median length of hospital stay was 13 days (range 3–85) for patients with delirium versus 7 (range 1–54) for patients without ( P = .002). Conclusions The incidence of delirium is high in elderly patients, especially after an acute admission, leading to an increase in length of hospital stay. To minimize delirium, associated risk factors must be identified and, if possible, treated.
Abstract Background Multiple surgical techniques are advised to safely perform cholecystectomy in difficult cases, such as conversion to open surgery or subtotal cholecystectomy (STC). A ...reconstituting and a fenestrating STC are techniques for STC. The aim of this study was to investigate short and long-term morbidity and quality of life associated with STC and to compare the outcomes after fenestrating and reconstituting STC. Study Design Patients who underwent STC were identified. Assessed short-term morbidity included bile leakage, bile duct injury, intra-abdominal infection, reinterventions and readmittance. Long-term morbidity included bile duct stenosis and recurrent biliary events. Differences in outcome of fenestrating and reconstituting STCs were assessed. Quality of life was assessed by EQ-5D, SF-36 and GIQLI questionnaires. Results Subtotal cholecystectomy was performed in 191 patients, of which 102 (53%) underwent a fenestrating STC and 73 (38%) a reconstituting STC. Bile leakage was significantly more common after fenestrating STC (18% vs. 7%, respectively; p < 0.022). After a median of 6 years (IQR 5 -10 years) followup, recurrence rate of biliary events was lower after fenestrating than reconstituting STC (9% versus 18%, respectively, p < 0.022). Overall reintervention rate did not differ between the two groups: 32% in fenestrating STC group and 26% in reconstituting STC group (p 0.211). Completion cholecystectomy was performed significantly more in patients after fenestrating STC (9% vs. 4%, p <0.022) Conclusion Subtotal cholecystectomy is a safe and feasible technique for difficult cases, where conversion only will not solve the difficulty of an inflamed hepatocystic triangle. The choice for reconstituting or fenestrating STC depends on intraoperative conditions, and both techniques are associated with specific complications.
Abstract Introduction While predictors for mortality after hip fracture surgery have been widely studied, research regarding risk prediction models is limited. Risk models can predict mortality for ...individual patients, provide insight in prognosis, and be valuable in surgical audits. Existing models have not been validated independently. The purpose of this study is to evaluate the performance of existing risk models for predicting 30-day mortality following hip fracture surgery. Patients and methods In this retrospective study, all consecutive hip fracture patients admitted between 2004 and 2010 were included. Predicted mortality was calculated for individual patients and compared to the observed outcome. The discriminative performance of the models was assessed using the area under the receiver operating characteristic curve (AUC). Calibration was analysed with the Hosmer–Lemeshow goodness-of-fit test. Results A literature search yielded six risk prediction models: the Charlson Comorbidity Index (CCI), Orthopaedic Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (O-POSSUM), Estimation of Physiologic Ability and Surgical Stress (E-PASS), a risk model by Jiang et al., the Nottingham Hip Fracture Score (NHFS), and a model by Holt et al. The latter three models were specifically designed for the hip fracture population. All models except the O-POSSUM achieved an AUC greater than 0.70, demonstrating acceptable discriminative power. The score by Jiang et al. performed best with an AUC of 0.78, this was however not significantly different from the NHFS (0.77) or the model by Holt et al. (0.76). When applying the Hosmer–Lemeshow goodness-of-fit test, the model by Holt et al., the NHFS and the model by Jiang et al. showed a significant lack of fit ( p < 0.05). The CCI, O-POSSUM and E-PASS did not demonstrate lack of calibration. Discussion None of the existing models yielded excellent discrimination (AUC > 0.80). The best discrimination was demonstrated by the models designed for the hip fracture population, however, they had a lack of fit. The NHFS shows most promising results, with reasonable discrimination and extensive validation in earlier studies. Additional research is needed to examine recalibration and to determine the best risk model for predicting early mortality following hip fracture surgery.
OBJECTIVES:Early mortality after hip fracture surgery is high and preoperative risk assessment for the individual patient is challenging. A risk model could identify patients in need of more ...intensive perioperative care, provide insight in the prognosis, and allow for risk adjustment in audits. This study aimed to develop and validate a risk prediction model for 30-day mortality after hip fracture surgerythe Hip fracture Estimator of Mortality Amsterdam (HEMA).
METHODS:Data on 1050 consecutive patients undergoing hip fracture surgery between 2004 and 2010 were retrospectively collected and randomly split into a development cohort (746 patients) and validation cohort (304 patients). Logistic regression analysis was performed in the development cohort to determine risk factors for the HEMA. Discrimination and calibration were assessed in both cohorts using the area under the receiver operating characteristic curve (AUC), the Hosmer–Lemeshow goodness-of-fit test, and by stratification into low-, medium- and high-risk groups.
RESULTS:Nine predictors for 30-day mortality were identified and used in the final modelage ≥85 years, in-hospital fracture, signs of malnutrition, myocardial infarction, congestive heart failure, current pneumonia, renal failure, malignancy, and serum urea >9 mmol/L. The HEMA showed good discrimination in the development cohort (AUC = 0.81) and the validation cohort (AUC = 0.79). The Hosmer–Lemeshow test indicated no lack of fit in either cohort (P > 0.05).
CONCLUSIONS:The HEMA is based on preoperative variables and can be used to predict the risk of 30-day mortality after hip fracture surgery for the individual patient.
LEVEL OF EVIDENCE:Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
We evaluated the effect of Internet-based cognitive behavioral therapy (iCBT), with or without therapist support, on the perceived impact of hot flushes and night sweats (HF/NS) and overall levels of ...menopausal symptoms (primary outcomes), sleep quality, HF/NS frequency, sexual functioning, psychological distress, and health-related quality of life in breast cancer survivors with treatment-induced menopausal symptoms.
We randomly assigned 254 breast cancer survivors to a therapist-guided or a self-managed iCBT group or to a waiting list control group. The 6-week iCBT program included psycho-education, behavior monitoring, and cognitive restructuring. Questionnaires were administered at baseline and at 10 weeks and 24 weeks postrandomization. We used mixed-effects models to compare the intervention groups with the control group over time. Significance was set at P < .01. An effect size (ES) of .20 was considered small, .50 moderate and clinically significant, and .80 large.
Compared with the control group, the guided and self-managed iCBT groups reported a significant decrease in the perceived impact of HF/NS (ES, .63 and .56, respectively; both P < .001) and improvement in sleep quality (ES, .57 and .41; both P < .001). The guided group also reported significant improvement in overall levels of menopausal symptoms (ES, .33; P = .003), and NS frequency (ES, .64; P < .001). At longer-term follow-up (24 weeks), the effects remained significant, with a smaller ES for the guided group on perceived impact of HF/NS and sleep quality and for the self-managed group on overall levels of menopausal symptoms. Additional longer-term effects for both intervention groups were found for hot flush frequency.
iCBT, with or without therapist support, has clinically significant, salutary effects on the perceived impact and frequency of HF/NS, overall levels of menopausal symptoms, and sleep quality.
Background
In the setting of difficult dissection of Calot’s triangle during laparoscopic cholecystectomy, conversion is commonly advocated. An alternative approach aimed at preventing bile duct ...injury is laparoscopic partial cholecystectomy (LPC). The safety and efficacy of this procedure are unclear.
Methods
A systematic review of the literature was performed independently by three researchers. The outcomes were conversion rate, hospital length of stay (LOS), bile duct injury, bile leak, symptomatic gallstones in the remnant gallbladder, need for reoperation, postoperative endoscopic retrograde cholangiopancreaticography (ERCP), percutaneous intervention, and mortality.
Results
The review included 15 publications, which reported on 625 patients. Four different operative techniques could be distinguished. Conversion to open (partial) cholecystectomy was performed in 10.4 % of the cases. The median LOS was 4.5 days (range, 0–48 days). The most common complication was postoperative bile leak, which occurred in 66 patients (10.6 %). One case of bile duct injury occurred. During the follow-up period, 2.2 % of the patients experienced recurrent symptoms of gallstones. Eight patients (2.7 %) underwent reoperation. Postoperative ERCP was performed for 26 (7.5 %) of 349 patients. A percutaneous intervention was performed for 5 (1.4 %) of 353 patients. Three deaths were described in the reviewed series (1 of pulmonary sepsis and 2 of myocardial infarctions). A rough comparison showed that fewer bile leaks, less need for ERCP, and less recurrent symptoms of gallstones seemed to occur when the cystic duct and gallbladder remnant were closed.
Conclusions
Literature concerning LPC is scarce. Four different LPC techniques can be distinguished. When a difficult gallbladder is encountered during LC, LPC seems to be a safe and feasible alternative to conversion. Closing of the cystic duct, gallbladder remnant, or both seems to be preferable.
Introduction
Current guidelines for the treatment of phyllodes tumors recommend wide local excision for all histopathological subtypes. However, it is unknown which subtypes have tendency to recur ...after marginal or incomplete excision. This may lead to over-treatment by re-excision surgery for tumors with little or no potential to recur.
Materials and methods
All patients with benign, borderline or malignant phyllode tumors presenting at our institution between 2000 and 2016 were retrospectively analyzed.
Results
A total of 57 patients could be included, of which 39 tumors were benign (60%), three were borderline (5%), and seven were malignant phyllodes tumors (12%). There were also eight phyllodes-like fibroadenomas (14%). Fifty-two patients (91%) underwent local excision as primary treatment, resulting in tumor-positive or close-resection margins in 32 patients (61.5%) of whom five patients (15.6%) had re-excision surgery. During a median follow-up of 5 years, local recurrence occurred in four patients (7.0%) with a median time-to-recurrence of 12 months. Borderline and malignant subtypes were associated with a significantly higher recurrence rate compared to other subtypes (
p
= 0.039).
Conclusion
Although an adequate tumor-negative resection margin should be obtained for borderline and malignant phyllodes tumors, this study confirms that wide local excision is the appropriate primary treatment for all histopathological subtypes. However, if tumor-negative margins were not obtained at first excision, a wait-and-see approach is justified for benign phyllodes tumors.
Background Acute appendicitis can be difficult to diagnose, especially in children. Appendicitis scoring systems have been developed as a diagnostic tool to improve the decision-making process in ...patients with suspected acute appendicitis. This study evaluates the Appendicitis Inflammatory Response score, Alvarado score, and Pediatric Appendicitis Score in children suspected of acute appendicitis. Methods Data were collected retrospectively. All children younger than 18 years suspected of acute appendicitis who presented to the emergency department between January 2006 and June 2014 were included in this study. Variables were registered to evaluate 3 different appendicitis scoring systems. The diagnostic performance of the 3 scores was analyzed using the area under the receiver-operating curve and by calculating the diagnostic performances at different cut-off points. Results The present study included 747 consecutive children. There were 399 boys (53%) and 348 girls (47%) with a mean age of 11 years (range, 1–17 years). In total, 269 children (36%) were diagnosed with acute appendicitis. The area under the receiver-operating curve of the Appendicitis Inflammatory Response score was 0.90, the Alvarado score was 0.87, and the Pediatric Appendicitis Score was 0.82 ( P < .05, respectively). The specificity and positive predictive value of the Appendicitis Inflammatory Response score were better at predicting an acute appendicitis than that of the Alvarado score and Pediatric Appendicitis Score. In children with a low-risk acute appendicitis, false negative rates of 14% for the Appendicitis Inflammatory Response, 7% for the Alvarado, and 18% for the Pediatric Appendicitis Score were measured. Conclusion In this study, the Appendicitis Inflammatory Response score had the highest discriminating power and outperformed the Alvarado score and Pediatric Appendicitis Score in predicting acute appendicitis in children. Excluding acute appendicitis safely in children with the scoring systems still remains uncertain.
Delirium is characterized by disturbances in circadian rhythm. Melatonin regulates our circadian rhythm. Our aim was to compare preoperative cerebrospinal fluid (CSF) melatonin levels in patients ...with and without postoperative delirium.
Prospective cohort study with hip fracture patients ≥ 65 years who were acutely admitted to the hospital for surgical treatment and received spinal anaesthesia. CSF was collected after cannulation, before administering anaesthetics. Melatonin was measured by radioimmunoassay (RIA). Data on delirium was obtained from medical and nursing records. Nurses screened every shift for delirium using the Delirium Observation Screening Scale (DOSS). If the DOSS was ≥3, a psychiatrist was consulted to diagnose possible delirium using the DSM-IV criteria. At admission, demographic data, medical history, and information on functional and cognitive status was obtained.
Seventy-six patients met the inclusion criteria. Sixty patients were included in the analysis. Main reasons for exclusion were technical difficulties, insufficient CSF or exogenous melatonin use. Thirteen patients (21.7%) experienced delirium during hospitalisation. Baseline characteristics did not differ between patients with and without postoperative delirium. In patients with and without postoperative delirium melatonin levels were 12.88 pg/ml (SD 6.3) and 11.72 pg/ml (SD 4.5) respectively, p-value 0.47. No differences between patients with and without delirium were found in mean melatonin levels in analyses stratified for cognitive impairment or age.
Preoperative CSF melatonin levels did not differ between patients with and without postoperative delirium. This suggests that, if disturbances in melatonin secretion occur, these might occur after surgery due to postoperative inflammation.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Purpose We evaluated the effect of Internet-based cognitive behavioral therapy (CBT) on sexual functioning and relationship intimacy (primary outcomes) and body image, menopausal symptoms, marital ...functioning, psychological distress, and health-related quality of life (secondary outcomes) in breast cancer survivors (BCSs) with a DSM-IV diagnosis of a sexual dysfunction. Patients and Methods We randomly assigned 169 BCSs to either Internet-based CBT or a waiting-list control group. The CBT consisted of weekly therapist-guided sessions, with a maximum duration of 24 weeks. Self-report questionnaires were completed by the intervention group at baseline (T0), midtherapy (T1), and post-therapy (T2) and at equivalent times by the control group. We used a mixed-effect modeling approach to compare the groups over time. Results Compared with the control group, the intervention group showed a significant improvement over time in overall sexual functioning (effect size for T2 ES
= .43; P = .031), which was reflected in an increase in sexual desire (ES
= .48 and ES
= .72; P < .001), sexual arousal (ES
= .50; P = .008), and vaginal lubrication (ES
= .46; P = .013). The intervention group reported more improvement over time in sexual pleasure (ES
= .32 and ES
= .62; P = .001), less discomfort during sex (ES
= .49 and ES
= .66; P = .001), and less sexual distress (ES
= .59; P = .002) compared with the control group. The intervention group reported greater improvement in body image (ES
= .45; P = .009) and fewer menopausal symptoms (ES
= .39; P = .007) than the control group. No significant effects were observed for orgasmic function, sexual satisfaction, intercourse frequency, relationship intimacy, marital functioning, psychological distress, or health-related quality of life. Conclusion Internet-based CBT has salutary effects on sexual functioning, body image, and menopausal symptoms in BCSs with a sexual dysfunction.
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