Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The ...diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.
The initial management of patients with acute pancreatitis impacts both morbidity and mortality. Point-of-care decisions have been reported to differ from clinical guideline recommendations.
An ...online anonymous questionnaire was distributed through scientific associations and social media using REDCap. Multivariable logistic regression was used to identify the characteristics of participants associated with compliance with the recommendations.
A total of 1054 participants from 94 countries completed the questionnaire; median age (IQR) was 39 (32-47) years; 30.7% were women. Among the participants, 37% opted for nonmoderate flow of i.v. fluid, 31% for fluid type other than Ringer's lactate; 73.4% were in favor of nil per os to patients who could eat, 75.5% for other than enteral feeding to patients with oral intolerance; 15.5% used prophylactic antibiotic in patients with severe acute pancreatitis, 34.1% in necrotizing acute pancreatitis, and 27.4% in patients with systemic inflammatory response syndrome; 27.8% delayed cholecystectomy after biliary acute pancreatitis. Participants with publications in PubMed on acute pancreatitis showed better compliance (OR, 1.62; 95% CI: 1.15-2.32; P = .007) with recommendations of the clinical guidelines.
Feeding and nutrition require the greatest improvement efforts, but also the use of prophylactic antibiotics and timing of cholecystectomy should be improved.
Amended Classification of the Open Abdomen Björck, M.; Kirkpatrick, A. W.; Cheatham, M. ...
Scandinavian journal of surgery,
03/2016, Letnik:
105, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Background:
In 2009, a classification system for the open abdomen was introduced. The aim of such a classification is to aid the (1) description of the patient’s clinical course; (2) standardization ...of clinical guidelines for guiding open abdomen management; and (3) facilitation of comparisons between studies and heterogeneous patient populations, thus serving as an aid in clinical research.
Methods:
As part of the revision of the definitions and clinical guidelines performed by the World Society of the Abdominal Compartment Syndrome, this 2009 classification system was amended following a review of experiences in teaching and research and published as part of updated consensus statements and clinical practice guidelines in 2013. Among 29 articles citing the 2009 classification system, nine were cohort studies. They were reviewed as part of the classification revision process. A total of 542 patients (mean: 60, range: 9–160) had been classified. Two problems with the previous classification system were identified: the definition of enteroatmospheric fistulae, and that an enteroatmospheric fistula was graded less severe than a frozen abdomen.
Results:
The following amended classification was proposed: Grade 1, without adherence between bowel and abdominal wall or fixity of the abdominal wall (lateralization), subdivided as follows: 1A, clean; 1B, contaminated; and 1C, with enteric leak. An enteric leak controlled by closure, exteriorization into a stoma, or a permanent enterocutaneous fistula is considered clean. Grade 2, developing fixation, subdivided as follows: 2A, clean; 2B, contaminated; and 2C, with enteric leak. Grade 3, frozen abdomen, subdivided as follows: 3A clean and 3B contaminated. Grade 4, an established enteroatmospheric fistula, is defined as a permanent enteric leak into the open abdomen, associated with granulation tissue.
Conclusions:
The authors believe that, with these changes, the requirements on a functional and dynamic classification system, useful in both research and training, will be fulfilled. We encourage future investigators to apply the system and report on its merits and constraints.
Anaplastic Thyroid Carcinoma Survival Voutilainen, Petri E.; Multanen, Markku; Haapiainen, Reijo K. ...
World journal of surgery,
September 1999, Letnik:
23, Številka:
9
Journal Article
Recenzirano
.
Anaplastic thyroid carcinoma is a rare, highly malignant tumor of elderly people. The purpose of this retrospective study was to characterize the patient population and to detect a potential ...subgroup with better prognosis or any intervention that would be useful. From 1967 through 1994 a total of 33 anaplastic thyroid carcinomas were operated on at the Second Department of Surgery, Helsinki University Central Hospital. There were 26 females and 7 males with mean age of 66.0 years (range 36–89 years). At the time of diagnosis 16 of 33 patients had distant metastases, and 32 of 33 of the tumors had invaded the thyroid capsule. Disease‐specific survival was 9.7% (95% confidence interval from 2.0% to 25.9%) at 1 year using the product limit survival analysis. In the stepwise Cox proportional hazards regression model, local resectability (p= 0.0002), presence of distant metastases at diagnosis (p= 0.0014), radiotherapy (p= 0.014), and radioiodine ablation (p= 0.039) were independent prognostic factors. We concluded that even though statistically significant, independent, prognostic factors can be found the survival of the patients with the best prognostic characteristics is still poor. Only one patient, who had an anaplastic carcinoma focus within an encapsulated follicular thyroid carcinoma, survived in this series. At present there seems to be no surgical treatment that would be efficient for treating symptomatic anaplastic thyroid carcinoma.
The significance of trauma as a mechanism and cause of mortality and morbidity on a global scale is increasing. The combination of both large-scale disasters, whether natural or man-made, and the ...every day accidents, and intentional violence pose a grave challenge to the ability of our medical systems' ability to cope with the increasing demands of trauma care at system level as well as on individual providers. Despite significant advances in clinical practice, the economical, educational, and organisational limitations prevent us from providing the best available care to many of our patients, at least on a global scale. Fresh solutions and new paradigms are needed, and in order to approach the key issues successfully a wider scope with a look at the global perspective forming the 'environment of trauma' is required. This review updates the recent trends in trauma with emphasis on the causes and manifestations of trauma on a global scale.
To investigate whether marker(s) of systemic inflammation detect, at an early stage of acute pancreatitis, patients who may ultimately develop severe disease.
Prospective study.
University hospital ...emergency unit.
Thirty patients with mild acute pancreatitis (SEV0 group) and 27 with severe acute pancreatitis. Of the latter, 11 did not develop organ failure (SEV1 group), whereas the other 16 patients developed acute respiratory failure and 9 of them also developed renal failure (SEV2 group).
Blood samples were collected at admission to the hospital (T0), and at 12 hrs (T12) and 24 hrs (T24 after admission.
The plasma concentrations of procalcitonin (PCT), soluble E-selectin (sE-selectin), soluble interleukin-2 receptor (sIL-2R), and the serum concentration of C-reactive protein (CRP) were monitored. PCT levels at T0 were significantly higher in the SEV1 group (median 0.4 ng/mL, range 0.2-2.3) and the SEV2 group (0.8 ng/mL, 0.2-73.5) than in the SEV0 group (0.3 ng/mL, 0.1-3, p < .05 and p < .001, respectively). At T12, PCT level in the SEV2 group was significantly higher than that in the SEV1 group (2.2 ng/mL, 0.2-86.6 vs. 0.4 ng/mL, 0.3-2.8, p = .05), as it also was at T24 (2.2 ng/mL, 0.4-73.3 vs. 0.5 ng/mL, 0.3-4, p < .01). Among SEV2 patients, PCT concentration correlated negatively with the time elapsed between admission and the diagnosis of organ failure. At T12, sIL-2R levels of the SEV1 group (1,011 U/mL, range 334-2,211) and the SEV2 group (1,495 U/ml, range 514-4,526) both differed significantly from the SEV0 group (636 U/ml, range 356-1,678, p < .05 and p < .001, respectively) as they also did at T24. Although CRP level in the SEV1 group at T12 did not differ from the SEV0 group, the difference between SEV2 (272 microg/mL, range 46-462) and SEV0 was significant (53 microg/mL, range 5-243, p < 0.01). sE-selectin levels did not differ between groups.
At admission to hospital, concentrations of PCT, but not those of CRP, sE-selectin, or sIL-2R, are higher in patients with severe acute pancreatitis than in patients with mild pancreatitis. PCT test had sensitivity of 94% and specificity of 73% for development of organ failure. PCT may be useful to identify the patients who benefit from novel therapies aimed at modifying the course of systemic inflammation.
Hydrogels prepared from water solutions containing 10–20 mass% gelatine are generally accepted muscle tissue simulants in terminal ballistic research. They, however, do not have a surface layer which ...simulates the effect of human skin. The purpose of this research was to find a suitable skin simulant for enhancing the testing fidelity and the credibility of the results with gelatine-based materials when assessing the injury potential of not only high energy bullets, but also especially that of non-penetrating “less lethal” kinetic impact ammunition and relatively low energy ricochet fragments. A skin simulant also permits the simulation and assessment of exit wounds.
The mechanical and ballistic properties of human skin and target simulant were established on the basis of results found in the literature. Some errors in these were found. The corrected values are included in this paper for comparison. The target values of the mechanical properties of the skin simulant were the following: threshold velocity
v
th = 94 ± 4
m/s, tensile strength 18 ± 2
N/mm
2 and elongation at break 65 ± 5%.
A selection of synthetic and natural materials was evaluated as skin simulants by analysing their mechanical and ballistic properties. The results were compared to literature values obtained with human cadavers.
The tests showed that the best skin simulant of the ones evaluated was semi-finished chrome tanned upholstery “crust” cowhide of 0.9–1.1
mm nominal thickness. Its threshold velocity was 90.7
m/s, tensile strength 20.89 ± 4.11
MPa and elongation at break 61 ± 9%. These values are the same as the average values of human skin. Of the synthetic materials evaluated, 1
mm thick natural rubber can be used on impact side as a threshold velocity filter with some reservations although its theoretical threshold velocity is only 82.9
m/s.
To determine the prevalence of nonfluoride enamel hypomineralization in the permanent first molars, we examined 488 7– to 13–year–old children. We further examined the impact of such defects on the ...treatment need by evaluating the number of caries lesions, restorations and extractions of the target teeth. Nonfluoride hypomineralization(s) were seen in 94 children (19.3%). The severity of defects varied from mild lesions with local color change to more severe ones where the hypomineralized tissue had been replaced by a restoration or the tooth had been extracted. Further examination of 65 children with nonfluoride hypomineralization showed that the defects had significantly increased the treatment need of the target teeth compared with the age– and sex–matched controls (p<0.001). Consequently, also the DMFT index of the whole dentition was higher in the children with hypomineralizations than in the controls (p<0.05). The results indicate that nonfluoride hypomineralizations have a significant impact on treatment need in the present child population with low caries activity.
Acute pancreatitis (AP) is a common abdominal disorder with severity varying from mild to fatal disease. Predicting a patient's outcome remains problematic. The aim of this study was to analyze a ...large consecutive series of patients with severe AP and to identify prognostic factors for hospital mortality. Between 1989 and 1997, a consecutive series of 270 patients with severe AP were included in the study. All patients fulfilled the criteria of Atlanta classification for severe AP. Retrospectively and prospectively collected data included age, gender, etiology, number of previous episodes of pancreatitis, medication history, type of admission, body-mass index (BMI), respiratory failure, renal failure, need for pressor support, and abdominal surgery performed during hospitalization. The overall mortality rate was 24.4%. In univariate survival analysis advanced age, history of continuous medication, patient transferred from other hospital, high BMI, respiratory or renal failure, need for pressor support, and need for abdominal surgery were significant prognostic factors for hospital mortality. In a multivariate stepwise logistic regression analysis, the need of pressor support, renal failure requiring dialysis, advanced age, history of continuous medication and need for abdominal surgery were identified as independent prognostic factors for mortality. A logistic regression analysis of variables available on admission (the first seven above mentioned variables) showed that transferral admission, advanced age, and history of continuous medication were independent prognostic factors for mortality. In patients with severe AP, advanced age, history of continuous medication, and need for dialysis, mechanical ventilator support, and pressor support predict fatal outcome and thus should be taken into account in clinical evaluation.
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