Left Hospital Research Articles

Uterine balloon tamponade in combination with topical administration of tranexamic Acid for management of postpartum hemorrhage.

While uterine balloon tamponade is an effective modality for control of postpartum hemorrhage, the reported success rates have ranged from the level of 60% to the level of 80%. In unsuccessful cases, more invasive interventions are needed, including hysterectomy as a last resort. We developed a modified tamponade method and applied it to two cases of refractory postpartum hemorrhage after vaginal delivery. The first case was accompanied by uterine myoma and low-lying placenta. After an induced delivery, the patient had excessive hemorrhage due to uterine atony. Despite oxytocin infusion and bimanual uterine compression, the total blood loss was estimated at 2,800 mL or more. The second case was diagnosed as placental abruption complicated by fetal death and severe disseminated intravascular coagulation, subsequently. A profuse hemorrhage continued despite administration of uterotonics, fluid, and blood transfusion. The total blood loss was more than 5,000 mL. In each case, an intrauterine balloon catheter was wrapped in gauze impregnated with tranexamic acid, inserted into the uterus, and inflated sufficiently with sterile water. In this way, mechanical compression by a balloon and a topical antifibrinolytic agent were combined together. This method brought complete hemostasis and no further treatments were needed. Both the women left hospital in stable condition.

Postnatal care, not vouchers, will increase breastfeeding rates

British Journal of Midwifery • December 2014 • Vol 22, No 12 It is well known that in the UK, despite initial breastfeeding rates being relatively high, maintining these rates are a problem; the amount of women continuing to exclusively breastfeed past 6 weeks is dramatically low. In 2010, the Infant Feeding Survey found that the initial breastfeeding rate was highest in England at 83% (compared with 74% in Scotland, 71% in Wales, and 64% in Northern Ireland). However, exclusive breastfeeding at 6 weeks dropped to 24% in England and 22% in Scotland, compared to 17% in Wales and 13% in Northern Ireland (Health and Social Care Information Centre (HSCIC), 2012). There is a strong correlation between age, socioeconomic status and breastfeeding, with younger women in deprived areas being less likely to breastfeed than women in areas of low deprivation (HSCIC, 2012; Relton et al, 2014). The benefits of breastfeeding to the health and wellbeing of the mother and baby and to the NHS are well established; therefore, it is important that midwives and health professionals alike find ways to help increase these figures. A study published in the Lancet this week, detailed a controversial scheme in which financial support was offered to new mothers to incentivise them to breastfeed (Relton et al, 2014). The support, in the form of vouchers for supermarkets and high street shops, was offered to new mothers in a few areas in South Yorkshire and Derbyshire, which have low 6–8 week breastfeeding rates. It was hoped that offering vouchers to mothers will increase the prevalence and duration of breastfeeding (Relton et al, 2014). Preliminary results were encouraging and found that of the 108 women eligible for the scheme, 58 (53·7%) joined. Of which, 48 (44·4%) claimed 2-day vouchers, 45 (41·7%) claimed 10-day vouchers, and 37 (34·3%) claimed 6–8 week vouchers. Data for 3and 6-month rates are still accruing. Both the health professionals and the mothers participating in the scheme were very satisfied (Relton et al, 2014). While the preliminary results were positive, it is unclear whether this is due to the financial incentives or the additional support the women received. One of the statements that came out of an interview with a mother who participated in the scheme was: ‘It’s that support network, not the money, that spurs you on to continue’ (Dreaper, 2014). With midwifery services so underfunded and under-resourced, surely the money would be better spent on postnatal care so midwives can dedicate more of their time providing these essential ‘support networks’. There is evidence to suggest that support from a skilled health professional can have a positive effect on women’s initiation, duration and experiences of breastfeeding (Spilby et al, 2009). From personal experience, I know how invaluable one-on-one breastfeeding support is—I was one of the lucky ones, I left hospital (armed with some scribbled notes from my midwife that I could refer to when I got home—I still have them) having had fantastic care and support with breastfeeding and I went on to feed my little girl exclusively for 5 months. However, not everyone is so fortunate. The Royal College of Midwives is concerned that due to staff shortages women may not be getting the postnatal support they need from midwives while they establish breastfeeding in the early days after birth. So maybe we need to be more innovative in our approach to breastfeeding support and remember it’s the little things that make the difference to mothers. BJM

First reported case of systemic envenoming by the Sri Lankan keelback (Balanophis ceylonensis)

Envenoming by colubrid snakes is rarely reported. However, some colubrid snakes (e.g. Rhabdophis tigrinus and Rhabdophis subminiatus) have caused severe systemic envenoming. We report here the first case of a bite with systemic envenoming by Balanophis ceylonensis, an opisthoglyphous natricine colubrid, in Sri Lanka. A 33-year-old healthy male field biologist was bitten while handling the snake for photography. Within 5 min of the bite on the dorsum of the right hand, he reported severe occipital headache, photophobia, chills and transient loss of consciousness. He vomited blood-stained gastric contents and bled from venepuncture sites. He had a markedly elevated INR and positive D-dimer test suggestive of significant coagulopathy that was treated with infusions of fresh frozen plasma. He recovered and left hospital after 96 h and subsequent investigations, including electroencephalogram, were normal. We conclude that B. ceylonensis should be regarded as a medically significant venomous snake. This case highlights the need for further studies of the oral secretions (venoms) of colubrid snakes.

Contemporary therapy of intracoronary thrombus: laser and bioresorbable scaffold

A 25-year-old diabetic, smoker presented with an acute anterior ST-segment elevation myocardial infarction. Immediate coronary angiography demonstrated an occluded left anterior descending artery (LAD) with large proximal thrombus burden. Simple aspiration catheter thrombectomy restored some antegrade flow but was unsuccessful in removing the thrombus (Fig. 1a). Photoablation using excimer laser coronary atherectomy (ELCA) was more effective in debulking the thrombus and restored TIMI 3 blood flow (Fig. 1c). Optical coherence tomography (OCT) clarified that the atherothrombotic material was localised without distal or proximal thin-cap fibroatheroma in the LAD (Fig. 1b). A bioresorbable vascular scaffold (BVS) was deployed and post dilated (Fig. 1d, e) with full expansion demonstrated with OCT (Fig. 1f, g) resulting in complete resolution of ST-segment elevation and symptoms. He made an excellent recovery and left hospital on day 3 post MI. He has subsequently returned to a full, active life. This case highlights both the effectiveness of ELCA in treating massive intracoronary thrombus and use of BVS to avoid long-term residual metallic stent in a young patient with coronary heart disease embarking on their revascularisation journey.

Hymenoptera stings: a study of clinical profile, complication and outcome from a teaching hospital of central Nepal

Background Hymenoptera sting is a common health hazard in the tropics. Wasp and Bee stings can produce symptoms ranging from local allergic reactions to serious complications including anaphylaxis and multiple organ dysfunction syndromes.Objective To evaluate the clinical profile, management and early outcome of patients with gallbladder cancer.Methods We prospectively analyzed all the consecutive patients with Hymenopterid sting (Wasp and Bee stings), who were admitted in Nephrology Unit in college of Medical Sciences Teaching hospital over a period of two year; from June 2010 to May 2012. Data including demographic profile, clinical profile, complications and outcomes associated with the Hymenopterid stings were entered in a designated profroma and were analyzed.Results A total of 15 cases with Hymenopterid stings (Wasp and Bee stings) were analyzed. Majority of the cases were females (n=8). The male to female ratio was 0.88. The mean age of the case was 37.1± 17.38years. Most of the cases (n=11) were younger subjects d"45 years and majority of them felt in the age group of 21-30 years; (n=4). Mean number of stings (Wasp or Bee stings), were 46 ± 18.4 (12-74) and the mean time to reach the hospital from the bite time was 78.23±82.24 hours (30 minutes-13 days). Black Wasps were the commonest species to inflict the stings in (n=10) cases and Bees in (n=5) cases. The Hymenoptera stings were observed more frequently in the month of July to September in (n=8). The commonest site of bite was head and face seen in (n=11) cases. Among the clinical presentations the commonest clinical presentation was local burning pain and pruritus which was present in all the cases (n=15) followed by nausea (n=10). The commonest clinical sign was bipedal edema which was seen in (n=7) cases. Low Hb (defined as Hb <10gm/dl) was seen in (n=5) cases of Hymenopterid stings. Low platelet (defined as Platelet < 100X109/L) was documented in (n=10) cases. Serum creatinine >1.5mg /dl was seen in (n=7) cases. Low serum albumin (defined as Serum Albumin (<3.5gm/dl) was seen in (n=6) cases. Among the complications, the most common complication was Hepatitis which was seen in (n=9) cases, followed by Acute Kidney Injury. There was no mortality associated with Hymenopterid stings in our study. However 1 patient left against medical advice.Conclusion Black Wasps were the commonest species to inflict the stings in (n=10) cases. The most common complication of Hymenoptera sting was Hepatitis, which was seen in (n=9) of cases, followed by Acute Kidney Injury. Majority of complications were seen in Wasp stings which caused significant morbidity. No mortality was observed in our study except one case; that left hospital against medical advice. Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-3, 17-24

For love or money: registered nurses who return to hospital practice

This commentary explores the value that returning nurses bring to the hospital setting. Nurses who have left hospital practice, usually due to family obligations, often return once the children are older. They return because they love nursing or they need to make money. They are at a point in their lives where they want to make a difference and miss the nurse-patient relationship. During recessions, nurses return to hospital practice because recessions tend to affect male dominated occupations. Research and policy literature on the returning and/or older nurse was reviewed with a focus on the benefits and challenges of having returning nurses in hospital practice. Returning nurses serve as role models to younger nurses. They also bring experiential knowledge to patient situations. There is limited research on this group of nurses. Yet they are ready for reentry in short order during nursing shortages. When they return, they add value to the hospital unit. Returning nurses want shorter workdays, alternative roles, and less physically taxing work. This can be achieved by offering flexible scheduling and work hours, creating niche roles and providing a more worker friendly physical environment.

Mycobacterium fortuitumによる顎下部膿瘍例

Three months beforehand, a 13-year-old boy had a strange feeling in his left submandibular area.However, since there was neither a fever nor pain, he adopted a wait-and-see attitude.He noticed a swelling of the left submandibular area about one month prior to presenting at our department, and he came for a checkup.In the initial examination, although neither fever nor pain was present, we found a palpable hard lesion in his left submandibular area.A blood examination showed a WBC count of 7400 and a CRP level of 0.62. Under the diagnosis of a suspected submandibular inflammatory lesion of some kind, we started oral antibiotic (CFPN), and scheduled a further examinaiton after CT imaging.On the following day, the swelling of his lesion increased, and we examined him again 3 days after that.The enhanced CT imaging showed an extensive inflammatory lesion with abscess formation in the lesion.We hospitalized him that day and we started antibiotics (FMOX+CLDM) via intravenous drip infusion.We conducted the enhanced CT imaging again on the 7th day of hospitalization, but despite the antibiotics the abscess had not improved. We performed abscess drainage under local anesthesia, and inserted a penrose drain.We conducted laboratory culture of the pus and continued intravenous drip infusion (CFPN+CLDM).On the 15th day, the culture result showed non-tubercular anti-acid fungal infection, and we changed the antibiotic (LVFX) to oral administration based on the drug sensitivity test result.The patient had the drain tube extracted on the 26th day, and he left hospital on the 30nd post-admission day.After that, we continued oral antibiotics (STFX) on an outpatient basis.The swelling of his lesion improved and the operative incision had healed four months after leaving the hospital.About seven months after leaving the hospital, full recovery from the pathology was seen on CT and MRI imaging, and we stopped the medication.

Cardiac troponin-T in acute pericarditis

The long-term outcome of acute pericarditis with high cardiac troponin-T (cTnT) is unknown. Our purpose was to investigate the prognostic and clinical value of cTnT in myopericardial inflammatory syndromes. Between January 2001 and September 2011, 107 patients hospitalized for acute pericarditis or myopericarditis were enrolled. Postinfarction pericarditis and neoplastic pericarditis were excluded. Physical examination, ECG, echocardiography and blood tests were performed. Among the 105 patients (89% men, mean age 36 ± 15 years-old), a cTnT rise was detectable in 64 patients (60.9%). Only younger age was found as an independent factor for higher values of cTnT in multivariate analysis (P = 0.03). After a mean follow-up of 51 months, a similar rate of complications was found in patients with a positive or a negative cTnT test: recurrent pericarditis (11 vs. 19%, P = 0.23) and cardiac tamponade (2 vs. 5%, P = 0.56). No cases of constrictive pericarditis, residual left ventricular dysfunction or hospital death were detected. The left ventricular ejection fraction remained unchanged during the follow-up (62.6 ± 6.5 vs. 61.9 ± 5.8, P = 0.89). In acute pericarditis, a cTnT rise is a frequent finding and commonly found in younger patients. However, unlike acute coronary syndrome, cTnT rise is not a negative prognostic marker.

Schlangen als Haustiere – ein exotisches Hobby und seine Folgen

We report on a young man who presented at our emergency unit with pain and swelling of his left hand, after he had been bitten into his left middle finger by a sidewinder rattlesnake one hour ago. Local findings were a swollen left middle finger, a red-livid discoloration along his nail rim with paleness of the surrounding skin. Vital signs were stable, ECG showed sinus rhythm, laboratory parameters were normal, without signs of liver or kidney damage and without coagulopathy. Diagnosis was local tissue reaction due to a snake bite of a sidewinder rattlesnake without evidence of systemic toxic effect. Due to the absence of systemic toxic effects the patient received monitoring of his vital signs and we controlled local tissue reaction constantly and laboratory parameters every 6 hours, as recommended by the "Giftnotrufzentrale" (poison emergency advisory service). The patient left hospital on his own will against medical advice in the night after first laboratory control, which showed no signs of organ damage and we recommended reasessment the following morning. At that time the swelling had extended to the whole arm, furthermore large hematoma reaching up to the axilla had developed over night. Again we contacted the "Giftnotrufzentrale" and decided to begin the administration of an antivenom, after allergic testing. The administration was without complications, the swelling decreased constantly and since laboratory controll still showed no signs of systemic toxin effect, we could discharge the patient on day 3. Follow-up visit 6 months later showed complete and natural healing. Snake bites are altogether rare among our patients, nevertheless since possible toxin effects and its dynamics are unpredictable and can vary highly, they demand monitoring at close intervals of vitals signs, local swelling and laboratory parameters. As early as possible an advisory service, such as "Giftnotrufzentrale" should be contacted to acquire information on possible toxin effects and availability of antivenoms. Contact to other medical disciplines (e.g. dermatology, intensive care unit, surgery, neurology, dialysis…) should be sought, depending on the further course of toxin effects. Possible comorbidities as well as allergisation due to previous bites strongly influence the course of the disease and should be evaluated. We recommend to keep precise records on the ocurrence of systemic toxin effects, as well as on local findings (e.g. fotodocumentation, marking of erythema, measurement of swelling). Manipulation of the wound is usually ineffective and therefore not recommended, also in respect of self-endangerment. After stabilization of the patient a vaccination against tetanus, if necessary, should not be forgotten.

Fetal presentation of Klippel-Trénaunay-Weber syndrome with massive pleural effusion and ascites

Abstract Background: Although fetuses with Klippel-Trénaunay-Weber syndrome (KTS) show various morphological abnormalities on imaging studies, fetal presentation with hydrops fetalis is relatively uncommon in KTS. Case: A 28-year-old Japanese woman who had previously given birth to a healthy infant was referred to us at gestational week (GW) 22 due to huge pleural effusion and ascites. The possibility of fetal pulmonary hypoplasia prompted us to place bilateral thoracoamniotic shunts at GW 23 after extensive discussion with both parents. The bilateral shunts were effective in preventing recurrence of pleural effusion. However, ascites gradually increased and clinical signs of fetal cardiac failure necessitated cesarean section at GW 34. A male infant, weighing 4252 g at birth and 2860 g after removal of ascites, survived to the neonatal period and did not require oxygen after postnatal day 63. The infant left hospital on day 103 with a diagnosis of KTS. Conclusion: Fetuses with KTS may present with massive pleural effusion and ascites. Thoracoamniotic shunting may be effective in such hydropic fetuses with KTS.

‘Crystal’ in the heart

A 35-year-old man presented to the emergency unit with progressive dyspnoea of two weeks’ duration. He had no previous medical history, and denied chest discomfort. During echocardiography, a severely impaired biventricular systolic function with severe atrioventricular valve insufficiency was found. The left ventricular end diastolic diameter (LVEDD) was 74 mm (Fig. 1A). There was no evidence of coronary artery disease (CAD), as shown in Figure 1B. On inquiry, he confessed to a weekly consumption of ‘crystal’ (methyl amphetamine) of about 0.5–1 g. Haemodynamic findings showed a decreased cardiac index of 1.7 L/min/m2. The patient had an intra-aortic balloon pump implanted as a bridge to recovery. However, haemodynamic and echocardiographic parameters did not improve, so he received a levosimendan infusion. Left ventricular endomyocardial biopsies were taken, and histological and immunohistological examinations revealed severe methamphetamine-induced chronic myocardial injury with degeneration of hypertrophied myocytes neighbouring small arterioles with medial hyperplasie in the presence of a mild inflammatory reaction (Fig. 1D). There was no evidence of acute or chronic myocarditis, amyloidosis or preexisting dilated or other primary cardiomyopathies. No viral genomes were detected by nested PCR analysis. The results were confirmed by cardiac magnetic resonance imaging (MRI) (Fig. 1C). Late gadolinium enhancement indicating myocardial fibrosis or necrosis was not obvious. The patient slowly recovered over the course of two weeks. Long-term ECG showed a non-sustained ventricular tachycardia of 18 beats. He left hospital with a wearable cardioverter-defibrillator (LifeVest®). Chronic use of methyl amphetamine may result in severe heart failure, malnutrition, infections and permanent psychiatric illness. The patient was discharged for outpatient drug rehabilitation.

Rates of readmission and death associated with leaving hospital against medical advice: a population-based study

Leaving hospital against medical advice may have adverse consequences. Previous studies have been limited by evaluating specific types of patients, small sample sizes and incomplete determination of outcomes. We hypothesized that leaving hospital against medical advice would be associated with increases in subsequent readmission and death. In a population-based analysis involving all adults admitted to hospital and discharged alive in Manitoba from Apr. 1, 1990, to Feb. 28, 2009, we evaluated all-cause 90-day mortality and 30-day hospital readmission. We used multivariable regression, adjusted for age, sex, socioeconomic status, year of hospital admission, patient comorbidities, hospital diagnosis, past frequency of admission to hospital, having previously left hospital against medical advice and data clustering (patients with multiple admissions). For readmission, we assessed both between-person and within-person effects of leaving hospital against medical advice. Leaving against medical advice occurred in 21 417 of 1 916 104 index hospital admissions (1.1%), and was associated with higher adjusted rates of 90-day mortality (odds ratio [OR] 2.51, 95% confidence interval [CI] 2.18-2.89), and 30-day hospital readmission (within-person OR 2.10, CI 1.99-2.21; between-person OR 3.04, CI 2.79-3.30). In our additional analyses, elevated rates of readmission and death associated with leaving against medical advice were manifest within 1 week and persisted for at least 180 days after discharge. Adults who left the hospital against medical advice had higher rates of hospital readmission and death. The persistence of these effects suggests that they are not solely a result of incomplete treatment of acute illness. Interventions aimed at reducing these effects may need to include longitudinal interventions extending beyond admission to hospital.

APACHE II score is superior to SOFA, CTP and MELD in predicting the short‐term mortality in patients with acute‐on‐chronic liver failure (ACLF)

The aim of the study was to assess the performance of various prognostic scores including the acute physiology and chronic health evaluation (APACHE II), sequential organ failure assessment (SOFA), Child-Turcotte-Pugh (CTP) and model for end-stage liver disease (MELD) scores in predicting short-term mortality in patients with acute-on-chronic liver failure (ACLF). Altogether 100 consecutive patients with ACLF were evaluated prospectively. The diagnosis of ACLF was based on the Asian-Pacific Association for the Study of the Liver criteria except for the inclusion of non-hepatic insults as acute events. Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy for predicting short-term mortality was calculated for APACHE II, SOFA, CTP and MELD in all patients and Maddrey's discriminant function (DF) and Glasgow alcoholic hepatitis scores (GAHS) for patients with alcoholic hepatitis only. Most patients had alcohol-related cirrhosis and alcoholic hepatitis as acute insults for ACLF. A total of 53 patients either died or left hospital in very sick status and were confirmed to have died the same day after leaving hospital. Overall, the area under the receiver operating characteristic curve of APACHE II was higher than those of MELD, SOFA and CTP scores for predicting short-term mortality. Even for patients with alcoholic hepatitis, APACHE II performed better than DF and GAHS. Short-term mortality is high in patients with ACLF. APACHE II scoring system is superior to other prognostic scores in predicting its short-term mortality.

Multiple Left Ventricular Assist Device-Associated Hospital Readmissions Are Associated with Poorer Survival: A Single Center Experience

Repeat hospital admissions strongly predict higher mortality in patients with heart failure (HF) but this relationship is not clearly established among patients implanted with continuous-flow left ventricular assist devices (LVAD) with prolonged support.

Stroke Mortality in Intensive Care Unit from Tertiary Care Neurological Center

Stroke is the second most common cause of death and major cause of disability worldwide. About a quarter of stroke patients are dead within a month, about a third by six months, and a half by one year. Although the most substantial advance in stroke has been the routine management of patients in stroke care units, Intensive Care Unit has remained the choice for stroke patients' care in developing countries. This study explores the mortality of stroke patients in ICU setting in tertiary care neurological centre in a developing country. We collected data of stroke patients admitted in our ICU from August 2009 to August 2010 and analyzed. Total 44 (10.25%) patients were admitted for acute stroke. Age ranged from 17-93 years. Low Glasgow Coma Scale (GCS), uncontrolled hypertension and aspiration pneumonia were common indications for admission in ICU. Total 23 (52.3%) patients had hemorrhagic stroke and 21 (47.7%) patients had ischemic stroke. Total 13 (29.54%) patients of stroke died within seven days, nine (69.23%) patients of hemorrhagic stroke died within six days, and four patients (30.76%) of ischemic stroke died within seven days and six (13.63%) patients left hospital against medical advice. All of these patients had ischemic stroke. Stroke mortality in ICU remains high despite of care in tertiary neurological center in resource poor settings. Stroke Care Unit, which would also help dissemination of knowledge of stroke management, is an option for improved outcome in developing countries.

The association between self-reported history of physical diseases and psychological distress in a community-dwelling Japanese population: the Ohsaki Cohort 2006 Study

Patients with physical disease are known to suffer considerable psychological distress. Social support may confound the association between physical disease and psychological distress. Population-based epidemiological studies have not been conducted on the association between history of physical disease, psychological distress and social support. Using cross-sectional data from 2006, we studied 43 487 community-dwelling people aged ≥40 years living in Japan. We examined the association between 13 self-reported histories of physical disease and psychological distress evaluated using the Kessler 6-item psychological distress scale (K6), defined as ≥13 points out of 24. To investigate the association, we performed multiple logistic regression analyses adjusted for age, gender, social support and possible confounders. Social support, as the interaction between physical disease and psychological depression, was tested through the addition of cross-product terms to the multivariate-adjusted model. The following histories of physical disease were found significantly and positively associated with psychological distress: cancer, diabetes mellitus, hyperlipidemia, hypertension, myocardial infarction, stroke, gastric or duodenal ulcer, liver disease, arthritis, osteoporosis, kidney disease and fall or fracture (odds ratio, 1.2-2.3). Social support did not modify the association between most histories of physical disease and psychological distress. Subjects with a history of physical disease were significantly and positively associated with psychological distress, and social support did not modify this association for most physical diseases. Even after patients have left hospital following treatment for physical disease, they require continuous monitoring for psychological distress by doctors and paramedics.

Endovascular Treatment of Wide-Neck, Ruptured and Unruptured Aneurysms without Supporting Devices

Despite of development of various supporting devices in the endovascular treatment (EVT) of wide-neck aneurysms, the procedure remains very challenging. We describe a small series of patients with relatively wide-neck aneurysms treated only by use of 3D coils without supporting devices. In the period July 2011 - August 2012, we treated 23 patients with aneurysm necks > 4 mm or dome/neck ratios < 2. Aneurysms were located in the anterior circulation in 16 patients and in the posterior circulation in seven. The size of aneurysms ranged from three to 21 mm. EVT was achieved by introducing 3D coils of different dimensions in a "Russian doll" fashion. Immediate angiographic results showed complete aneurysm obliteration in 15 patients, small neck remnant in two, and coil protrusion/herniation in four. In one of these cases we had an occlusion of the parent artery and in another case occlusion of the ascending branch (superior cerebellar artery), fortunately both patients remained symptom-free. Clinical results were excellent in 19 patients. One patient developed mild neurologic deficit in the treated territory immediately after the procedure; the patient recovered with mild hemiparesis. One patient developed a delayed stroke in another territory: after treatment the patient left hospital with dysphasia and hemiparesis. The use of 3D coils without neck supporting devices may be a useful alternative in selected cases of wide-neck aneurysms. Larger series with longer follow-up are needed to evaluate the value of this approach.

Early re‐presentation to hospital after discharge from an acute medical unit: perspectives of older patients, their family caregivers and health professionals

To explore the perceptions of older patients who re-presented to hospital within 28days of discharge from an acute medical unit (AMU), their family caregivers and appropriately experienced health professionals. Hospitals are increasingly using AMUs to provide rapid assessment and treatment for medical patients. Evidence of efficacy is building, however in-depth exploration of the experiences of older patients who re-present to hospital soon after discharge from an AMU, and those who care for them, appears to be lacking. A qualitative, descriptive design was used. In 2007, our team purposively sampled older patients who re-presented to hospital within 28days of discharge from an AMU (n=12), family caregivers (n=15), and health professionals (n=35). Data were collected using semi-structured interviews and subjected to thematic content analysis. Four themes emerged: the health trajectory, communication challenges, discharge readiness and the decision to return. Re-presentation to hospital was seen as part of a declining health trajectory. The AMU was viewed as treating acute illness well, however patients and family caregivers left hospital with limited understanding of underlying health problems and, therefore, ill-prepared for future health crises. There are clear benefits for older patients from AMUs, which expedite treatment for acute health crises. However, AMU discharge planning needs to consider patients' overall health status and likely future needs to optimise outcomes. Such a requirement is problematic in the context of acute time pressures. To ensure prompt and expert attention to key aspects of discharge planning for older people leaving AMUs, there is a role for in-depth clinical expertise in the care of older people facing deteriorating life-limiting conditions. Therefore, a leadership role for nurses with geriatric and palliative care expertise, alongside medical and allied health professionals, merits attention in this context.

Operative treatment of acute acromioclavicular joint injuries graded Rockwood III and IV: risks and benefits in tight rope technique vs. k-wire fixation

BackgroundOperative treatment of acromioclavicular joint injuries is recommended for higher degree dislocations. Recently a new option has become available with the minimally-invasive tight rope technique. Whereas clinical studies justify the medical use, risks and benefits remain unclear. Therefore, this study analyzed these facts associated with this procedure and compared them to K-wire fixation.Material and MethodsA retrospective analysis was performed of patients surgically treated either with the TightRope™-technique (TR) or K-wires (KW) for a first event isolated Rockwood type III or higher acromioclavicular joint dislocation between 2004 and 2011. Timing for surgery, surgical duration, length of hospital stay, costs, complications and outpatient visits were recorded.Results41 patients were included (TR: n = 18; KW: n = 23) with comparable demographics and injury severity. A trend towards shorter operation time was seen in the TR group (TR: 64.3 ±19.8 min. vs. KW: 80.9 ±33.7 min., n.s.) A tendency for lower total operation theater costs was seen in the TR group (TR: 474 ±436.5€ vs. KW: 749.1 ±31.2€, n.s.). Patients from the TR group left hospital earlier (TR: 2 ±1d vs. KW: 3.6 ±1.8d, p = 0.002). Severe complications (i.e. a fracture of the clavicle or nerve damage) occurred in neither of the groups. Early loss of reduction (n = 1) and impaired wound healing (n = 2) was seen in the TR group. Migrating K-wires (n = 4), loss of reduction (n = 1) and impingement syndrome (n = 1) were recorded in the KW group.ConclusionUsage of the tight rope technique offered advantages, such as being a safe minimally-invasive technique and showed a tendency towards shorter operation time, and lower physician- and total operation and theater costs. Material costs were significantly higher for this device but patients were discharged earlier. The influence of different clinical long-term results on the financial outcome needs to be evaluated in further studies.

Kidney Autotransplantation in Complete Iatrogenic Injury of Ureter

Introduction: Ureteral injuries represent less than 1% of all genitourinary traumas. In 75% of cases such complications are iatrogenic in nature and are induced by a medical procedures or physical intervention on tissues. Only 18% of the total can be attributed to urologic treatment, mainly to endoscopic procedures. There are many corrective measures to counteract urethral injuries however the mode or type of an intervention is dependent on a damage location and the length of urethral loss. As for the total ureter damage, it is recommended to replace the ureter by ileal interposition or to perform kidney autotransplantation. Materials and methods: 32 year old man was hospitalized due to URS induced ureteral avulsion located at lower kidney pole. In his case URS had been conducted to treat stone of left ureter. In view of the mentioned complications he qualified for kidney autotransplantation. After performed nephrectomy prepared kidney was repositioned to a right iliac fossa and renal artery and vein were anastomosed with iliac external vessels end-to-side. Subsequently ureter was anastomosed with urinary bladder by Lich -Gregoira technique. The patient left hospital 10 days after the procedure had been carried out. Control tests conducted 3 weeks after the autotransplantation showed correct vessels anastomosis as well as right renal secretion function Summary: Kidney autotransplantation is definitely the optimal form of treatment applied to ureteral injuries as it allows to maintain physiological urine outflow and to preserve other organ functions. As opposed to ileal interposition in this scenario we can avoid abnormal mucous secretion, electrolyte absorption, bacteriuria and vesicoileal reflux. Despite of kidney autotransplantation being a complicated procedure taking into account the requirement of extensive expertise in vascular surgery, it provides unrivaled choice to young men who would find kidney loss extremely hard to accept. In addition, from medical point of view kidney autotransplantation constitutes a rare but fascinating example where urology and transplantology as two distinctive fields of medicine come together to preserve patients quality of life.