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Objective: The purpose of this study was to determine the association between hyperglycemia and mortality and late-onset infections (>72?h) in extremely low birth weight (ELBW) infants. Study design: Retrospective analysis of a prospective cohort study of 201 ELBW infants who survived greater than 3 days after birth. Mean morning glucose levels were categorized as normoglycemia (<120?mg/dl), mild-moderate hyperglycemia (120 to 179?mg/dl) and severe hyperglycemia (⩾180?mg/dl). Hyperglycemia was further divided into early (first 3 days of age) and persistent (first week of age). Logistic regression was performed to assess whether hyperglycemia was associated with either mortality or late-onset culture-proven infection, measured after 3 and 7 days of age. Results: Adjusting for age, the odds ratio (OR) for either dying or developing a late infection was 5.07 (95% confidence interval (CI): 1.06 to 24.3) for infants with early severe hyperglycemia and 6.26 (95% CI: 0.73 to 54.0) for infants with persistent severe hyperglycemia. Adjusting for age, both severe early and persistent hyperglycemia were associated with increased mortality. Among survivors, there was no significant association between hyperglycemia and length of mechanical ventilation or length of hospital stay. Persistent severe hyperglycemia was associated with the development of Stage II/III necrotizing enterocolitis, after adjusting for age and male gender (OR: 9.49, 95% CI: 1.52 to 59.3). Conclusion: Severe hyperglycemia in the first few days after birth is associated with increased odds of death and sepsis in ELBW infants.

PurposeIncreasingly, radiologic imaging is obtained as part of the pathway in diagnosing ventral hernias. Often, radiologists receive incomplete or incorrect clinical information from clinicians. Objective: The aim of the study is to determine if clinical exam findings alter radiological interpretation of ventral hernias on CT.MethodsThis is a single-institution double-blind, randomized trial. All patients with a recent abdominal/pelvic CT scan seen in various surgical clinics were enrolled. A surgeon blinded to the CT scan findings performed a standardized physical examination and assessed for the presence of a ventral hernia. Seven independent radiologists blinded to the study design reviewed the scans. Each radiologist received one of three types of clinical exam data per CT: accurate (correct), inaccurate (purposely incorrect), or none. Allocation was random and stratified by the presence of clinical hernia. The primary outcome was the proportion of radiologic hernias detected, analyzed by chi square.Results115 patients were enrolled for a total of 805 CT scan reads. The proportion of hernias detected differed by up to 25% depending on if accurate, no, or inaccurate clinical information was provided. Inaccurate clinical data in patients with no hernia on physical exam led to a significant difference in the radiologic hernia detection rate (54.3% versus 35.7%, p = 0.007). No clinical data in patients with a hernia on physical exam led to a lower radiologic hernia detection rate (75.0% versus 93.8%, p = 0.001).ConclusionsThe presence and accuracy of clinical information provided to radiologists impacts the diagnosis of abdominal wall hernias in up to 25% of cases. Standardization of both clinical and radiologic examinations for hernias and their reporting are needed.Trial registrationClinicaltrials.gov, Number NCT03121131, https://clinicaltrials.gov/ct2/show/NCT03121131.

Percutaneous drainage has been shown to be an acceptable method for treating both pancreatic abscesses and infected pancreatic necrosis. However, percutaneous techniques have certain shortcomings, including the time and labor required and failure of the catheters to adequately drain the particulate debris. Growing experience around the world indicates that there is a role for retroperitoneal laparoscopy as a means of facilitating the percutaneous drainage of infected pancreatic fluid collections and avoiding a laparotomy. Our technique is discussed in this paper. Once infection is documented in a pancreatic fluid collection by fine-needle aspiration, one or more percutaneous drains are placed into the fluid collection(s). A computed tomography (CT) scan is repeated. If further drainage is indicated, retroperitoneoscopic debridement is performed. Using a combination of the percutaneous drain(s) and the post-drain CT scan, ports are placed and retroperitoneoscopic debridement of the necrosectum is performed under direct visualization. Prior to completion of the operation, a postoperative lavage system is created. Six patients with infected pancreatic necrosis have been treated with this technique. Prior to commencement of our laparoscopic protocol, all six patients would have required open necrosectomy. Four of the six patients were managed with retroperitoneoscopic debridement and catheter drainage alone. Complications included a colocutaneous fistula and a small flank hernia. There were no bleeding complications and no deaths. Although open necrosectomy remains the standard of care for the treatment of infected pancreatic necrosis and pancreatic abscess, there is growing evidence that laparoscopic retroperitoneal debridement is feasible.

Percutaneous drainage of infected pancreatic fluid collections is often unsuccessful. Alternatively, open necrosectomy techniques are very morbid. We hypothesized that in selected cases, laparoscopic techniques could be used to facilitate percutaneous drainage of the residual particulate necrosectum and avoid a laparotomy. We report our experience with laparoscopic assisted retroperitoneal debridement as an adjunct to percutaneous drainage for patients with infected pancreatic necrosis. Case studies were reviewed retrospectively. We analyzed the course of six patients undergoing laparoscopic assisted debridement of infected pancreatic necrosis after failure of percutaneous drainage. With the drains and computed tomography (CT) scan used as a guide, laparoscopic debridement of the necrosectum was performed. Between November 1995 and December 1999, six patients were treated with this method. In four patients, laparoscopic assisted percutaneous drainage was successful. Two patients required open laparotomy. Complications included a self-limited enterocutaneous fistula and a small flank hernia. No deaths occurred. This early, limited experience has demonstrated the feasibility of laparoscopic assisted percutaneous drainage for infected pancreatic necrosis. With this technique, two-thirds of our patients avoided the morbidity of a laparotomy.

Sodic amphiboles in high pressure and ultra-high pressure (UHP) metamorphic rocks are complex solid solutions in the system Na20-MgO-Al2O3-SiO2-H2O (NMASH) whose compositions vary with pressure and temperature. A close approach to equilibrium was achieved by performing compositional reversals, by evaluating compositional changes with time, and by suppressing the formation of Na-phyllosilicates.

Despite their effectiveness, these pathways do not extend beyond discharge and sometimes fail to incorporate patient-reported outcome measures.1 Recovery periods after intermediate-grade abdominal surgical procedures (eg, laparoscopic cholecystectomy) are excluded from these pathways; thus, patients are left to recover from these uncomplicated day-surgery procedures by themselves. [...]little evidence is available to guide patients' expectations regarding patient-reported outcome measures (eg, time to return to work).2,3 In The Lancet, Eva van der Meij and colleagues report the findings of a multicentre randomised controlled trial in the Netherlands, in which e-health was compared with usual practice in the perioperative care of healthy adult patients undergoing laparoscopic cholecystectomy, laparoscopic adnexal surgery, and laparoscopic or open inguinal hernia repair.4 The study provides information not only regarding baseline patient-reported outcome measures after intermediate-grade abdominal surgery but also on the effectiveness of an e-health intervention. Patients from other racial and ethnic groups might be less willing to engage in e-health.7 Third, although the intervention had little effect on provider workload, patients were relatively well educated (82% had a medium-to-high education level) and had uncomplicated recoveries (1·5% complications). [...]we do not know if more complex patient populations would increase provider workload. [...]the e-health intervention had a higher cost, although the intervention was cost-effective depending on the providers' willingness to pay.

AbstractObjectiveTo determine whether robotic ventral hernia repair is associated with fewer days in the hospital 90 days after surgery compared with laparoscopic repair.DesignPragmatic, blinded randomized controlled trial.SettingMultidisciplinary hernia clinics in Houston, USA.Participants124 patients, deemed appropriate candidates for elective minimally invasive ventral hernia repair, consecutively presenting from April 2018 to February 2019.InterventionsRobotic ventral hernia repair (n=65) versus laparoscopic ventral hernia repair (n=59).Main outcome measuresThe primary outcome was number of days in hospital within 90 days after surgery. Secondary outcomes included emergency department visits, operating room time, wound complications, hernia recurrence, reoperation, abdominal wall quality of life, and costs from the healthcare system perspective. Outcomes were pre-specified before data collection began and analyzed as intention to treat.ResultsPatients from both groups were similar at baseline. Ninety day follow-up was completed in 123 (99%) patients. No evidence was seen of a difference in days in hospital between the two groups (median 0 v 0 days; relative rate 0.90, 95% confidence interval 0.37 to 2.19; P=0.82). For secondary outcomes, no differences were noted in emergency department visits, wound complications, hernia recurrence, or reoperation. However, robotic repair had longer operative duration (141 v 77 min; mean difference 62.89, 45.75 to 80.01; P≤0.001) and increased healthcare costs ($15 865 (£12 746; €14 125) v $12 955; cost ratio 1.21, 1.07 to 1.38; adjusted absolute cost difference $2767, $910 to $4626; P=0.004). Among patients with robotic ventral hernia repair, two had an enterotomy compared none with laparoscopic repair. The median one month postoperative improvement in abdominal wall quality of life was 3 with robotic ventral hernia repair compared with 15 following laparoscopic repair.ConclusionThis study found no evidence of a difference in 90 day postoperative hospital days between robotic and laparoscopic ventral hernia repair. However, robotic repair increased operative duration and healthcare costs.Trial registrationClinicaltrials.gov NCT03490266.

Firearm violence is a leading cause of injury and mortality in the United States. Hospital-based violence intervention programs (HVIPs) are a promising public health strategy designed to reduce recurrent violence by engaging patients during hospitalization and connecting them to support services after discharge. This protocol describes the design and implementation of the Houston Hospital-Based Violence Intervention Program (Houston-HVIP), which will be evaluated by a randomized controlled trial conducted at a Level 1 trauma center in Houston, Texas. The study plans to enroll individuals aged 16–35 who present with gunshot wounds (GSW) at the Level 1 trauma center. Participants are randomized to either a treatment group receiving six months of intensive case management with direct referrals to social services or a control group receiving usual care, which involves indirect referral and limited case management. The primary outcome is a composite measure of an individual’s exposure to firearm violence via (a) self-report, (b) hospital admission records, and (c) mortality records. Secondary outcomes measured at the individual level assess violent reinjury, attitudes toward violence, post-traumatic stress, aggression, and self-rated health. Outcomes are assessed at baseline and 3-, 6-, 9-, and 12-months post-enrollment. The study will enroll 274 participants and include both quantitative and qualitative assessments to evaluate program impact and participant experience. This protocol aims to contribute to the design and implementation of HVIPs in large Level 1 trauma centers.