Left Hospital Research Articles

Nursing of patients with superior mesenteric artery syndrome through duodenal circular drainage operation

Objective We discussed the nursing of patients with superior mesenteric artery syndrome (SMAS) through duodenal circular drainage operation. Methods We carried out a retrospective analysis for 42 SMAS patients undergoing duodenal circular drainage operation from. 1959 to 2007. They were given preoperative psychological nursing, correct lying style, postoperative nutritional support and health education instruction. The treatment effect was observed. Results All patients cured and left hospital. The treatment effect was good after one to fifteen years of follow-up visit. Five patients who changed to adopt duodenal circular drainage operation also got good result after nine to ten years of follow-up visit. The incidence of anastomotic ulcer and anastomotic stenosis as well as reflux gastritis was not seen. Conclusion SMAS could be cured earlier through duodenal circular drainage operation and effective nursing. Key words: Duodenum; Superior mesenteric artery syndrome; Circular drainage operation; Nursing

Behind the high-tech at NHS Direct

Elaine Collins left acute hospital nursing to help develop staff at NHS Direct. She explained her role and aspirations to Lucy Jolin

Clinical characteristics of 7 patients with gestational diabetes insipidus

To investigate the clinical feature, treatment and prognosis of both the mother and the fetus with gestational diabetes insipidus. A total of 7 cases of gestational diabetes insipidus collected in the First Affiliated Hospital of Wenzhou Medical College, Wenzhou Combination of Traditional Chinese Medicine with Western Medicine Hospital, and Zhejiang Taizhou Hospital from June 1993 to June 2006 were analyzed retrospectively. Seven cases symptoms all characterized by excessive thirst polydipsia and polyuria. The average 24 h urinary output was between 11 L to 13 L and manifested of hypobaricuria. After effective treatment (three cases were treated with 1-deamino-8-D-arginine vasopressin, another three patients were managed with hydrochlorothiazide, and the last one was cured with antisterone), seven patients with gestational diabetes insipidus did not have any severe consequences. Their symptoms of excessive thirst, polyuria, and polydypsia disappeared from 7 days to 3 months after parturition. Urinary volume returned to normal standard of 1000-2000 ml during 24 hours. Specific gravity of urine recovered normally between a range 1.015-1.025 and serum sodium recovered between 135-147 mmol/L. The average duration of illness was 52 days. Eight newborn infants survived. Two of them were sent to neonatal intensive care unit for treatment. One was because of premature delivery caused by antepartum eclampsia, and the other case was one of the twins who had hydronephrosis. The baby of the first case left hospital after 3 weeks' treatment. The latter one's symptom disappeared 2 weeks after delivery. No obvious symptom was discovered among all the babies through follow-up telephone calls 42 days after childbirth. Gestational diabetes insipidus is a rare endocrinopathy complicating pregnancy. This disorder is characterized by excessive thirst, polydypsia, polyuria, hypobaric urine and electrolyte disturbances usually manifesting in the third trimester of pregnancy or puerperium. This is a transient syndrome. The first treatment of choice in patients with gestational diabetes insipidus is 1-deamino-8-D-arginine vasopressin and the second-choice is hydrochlorothiazide. Early diagnosis and appropriate management of the disease may reduce the hazard for both the mother and the fetus during perinatal period.

Postoperative deep venous thrombosis in a woman with congenital afibrinogenaemia treated with fibrinogen concentrates

Postoperative deep venous thrombosis in a woman with congenital afibrinogenaemia treated with fibrinogen concentrates

Drotrecogin alfa (activated): real-life use and outcomes for the UK

IntroductionIn March 2001, the results of the Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study were published, which indicated a 6.1% absolute reduction in 28-day mortality. Drotrecogin alfa (activated; DrotAA) was subsequently approved for use in patients with severe sepsis.MethodsIn December 2002, critical care units in England, Wales and Northern Ireland were invited to participate in an audit of DrotAA. Data for each infusion of DrotAA were linked to case mix and outcome data from a national audit. Use of DrotAA was described and a nonrandomized comparison of effectiveness was conducted.Results1,292 infusions of DrotAA were recorded in 112 units; 61% commenced during the first 24 hours in the unit. The majority (77%) of patients had three or more organs failing; lung (42%) and abdomen (40%) were the most common primary sites of infection. Crude hospital mortality was high (45%); at 28 days, only 18% had left acute hospital and 19% were still in the unit. For 30%, the full 96-hour infusion was not completed; 24% of infusions were interrupted; 8.1% experienced one or more serious adverse events, of which 77% were serious bleeding events. Of eight relative risks estimated from individually-matched (0.75 to 0.85) and propensity-matched (0.82 to 0.90) controls, seven were consistent with the results of PROWESS. Restricting the analysis to patients receiving DrotAA during the first 24 hours resulted in larger treatment effects (relative risks 0.62 to 0.81). For all matches, similar patterns were seen across subgroups. No effect of DrotAA was seen for two organs failing or lower severity scores, compared with a significant mortality reduction for three or more organs failing or higher severity scores.ConclusionUse of DrotAA was approximately one in 16 for admissions meeting the definition for severe sepsis and with two or more organs failing. Patients receiving DrotAA were younger and more severely ill but were less likely to have serious conditions in their past medical history. Nonrandomized estimates for the effectiveness of DrotAA were consistent with the findings of PROWESS. DrotAA appeared not to be effective in patients with less severe disease.

Quality of life in patients with rectal cancer after laparoscopic colectomy

To assess the quality of life in patients with rectal cancer after laparoscopic colectomy. From Sep.2004 to Dec. 2005, 51 patients with rectal cancer were recruited in this prospective, non-randomized study.Twenty-three patients underwent laparoscopic colectomy (LC), 28 patients had open colectomy (OC). EORTC QLQ-C30 and QLQ-CR38 questionnaire were applied to evaluate quality of life baseline, discharging and 3 months after operation. Before operation,the median score of role functioning in LC group was lower. However, LC group patients complained less financial difficulties. The differences were of statistical significance (P<0.05), but not of clinical significance. The median scores of other function domains and symptom domains were similar between two groups (P>0.05). Postoperatively, the most median scores of function domains and symptom domains between two groups were similar (P>0.05). The only score with statistically significant difference was the pain when patients left hospital (U=218.5, P=0.042). However, the difference was not of clinical significance, too. Only minimal benefits in short-term postoperative quality of life are found with laparoscopic colectomy in patients with rectal cancer compared with open colectomy.

Twenty-year trends in diagnosis of life-threatening neonatal cardiovascular malformations

Background:Infants with cardiovascular malformations are usually asymptomatic at birth. Earlier diagnosis is likely to improve outcome.Objective:To examine trends in the diagnosis of potentially life-threatening cardiovascular malformations.Methods:Ascertainment of all cardiovascular malformations...

Fracture treatment by bonesetters in central Ghana: patients explain their choices and experiences

To understand factors influencing patients' decisions to choose either fracture treatment by a bonesetter or in the hospital and to explore patients' experiences with bonesetter treatment. In-depth interviews with 46 patients with a radiological proven fracture in a district hospital in central Ghana. Traditional healers, such as bonesetters, play a substantial role in the Ghanaian healthcare system. Over a period of 3 months, 14 patients with a proven fracture left hospital for treatment by a bonesetter. The hospital is considered the only institution where emergency care can be provided and reliable, extensive diagnostic and treatment facilities are available for fracture treatment. Patients opting for bonesetter treatment are guided by the severity of the fracture, availability of the service, their financial status and past experiences. The healing methods used by different bonesetters are based on mutual comparable principles. Fracture treatment can serve as a model for respectful and efficient co-existence of traditional and biomedical medicine.

The Airway Irrigated Nursing after Inhalation Injury by High Temperature Powder Dust

Objective To discuss the airway irrigated nursing after inhalation injury by high temperature powder dust. Methods To summary the nursing circumstances about 21 patients suffering inhalation injury by high temperature powder dust from 2000 to 2005, to take the best nursing of hospitalization emergency treatment, and to give the prompt and safe service about airway irrigation. Results 13 patients were healing well, 5 patients left hospital automatically because of the complication such as septicemia or MODS, and 3 patients died of ARDS after injury during 15 to36 days. Conclusion iterative irrigation, sputum suction, airway humidification and atomization inhalation after incision of trachea in the earlier period are effective therapeutic tools. Key words: Inhalation injury; Airway irrigation ; Nursing

208: Predicting mortality in damage control surgery

Introduction: The concept of damage control is an accepted form of life-saving surgery. Most cases can be exhaustive on scarce hospital resources such as blood products, intensive care beds and theatre slots. Despite survival rates having improved, the literature quotes mortality at about 45%. Aim: This study attempted to determine the incidence and mortality of damage control surgery in a Level 1 trauma unit. Factors that played a significant role in predicting mortality were analysed to attempt to devise a mathematical model that could predict mortality pre-operatively. Methods: A retrospective analysis of all cases undergoing damage control surgery at a Level 1 trauma unit between January 2002 and December 2004 was carried out. Thirty potentially predictive variables were analysed against mortality. Student t, chi-squared and straight log regression analyses were undertaken to assess predictive strengths and then utilised to devise a predictive model. The devised equation was validated retrospectively on all damage control patients between January 1998 and December 2001. Results: Between January 2002 and December 2004, seventy-two patients underwent damage control procedures: 56 (78%) were following gunshot wounds, 13 (18%) following blunt trauma and three (4%) following stabs. Overall mortality rate was 28%. Forty-eight (67%) underwent a planned re-look after a mean of 40.8 hours and 45 (94%) of these left hospital alive. An emergency re-look was necessitated in 11(15%) after a mean of 12.1 hours and 6(55%) of these left the hospital alive. The mean number of procedures per patient was 3 (Range 1-10) with 18 patients requiring 5 or more. The mean quantity of blood used in the first 24 hours per patient was 13(SD 8) units. Mean length of time in ICU and hospital was 10(SD 13) and 24(SD 24) days, respectively. The pre-operative factors that most significantly correlated with mortality were age (p=<0.0001), worst pH (p=<0.0001) and lowest temperature (p=0.001). The following predictive equation was devised: X= (0.012)Age - (0.707)pH - (0.032)Temperature + 6.002, with X>0.5 predicting inevitable mortality. Using this equation on the initial cohort (2002 to 2004), 5 of the 20 deaths (25% sensitivity) would have been predicted with a 100% positive predictive value. In the second cohort (1998 to 2001), 73 patients underwent damage control surgery of which 33 died. The damage control equation predicted the deaths of 8 of these with no incorrect predictions of death. The equation therefore retained a sensitivity of 25% and positive predictive value of 100% for both cohorts of patients. Conclusion: Preoperative factors with the highest predictive value of death are age, worst pH and lowest temperature. The devised equation is quick and easy to use. With a 100% positive predictive value over a period of 7 years (145 patients), it should not compromise patient care. It could prove invaluable in decision-making when a trauma unit is overwhelmed by multiple critically injured patients, particularly if ICU beds are in scarce supply.

Graft Versus Host Disease after Granulocyte Infusion.

INTRODUCTIONGraft versus host disease (GVHD) occurs when immunologycally competent cells are introduced into an immunoincompetent host. GVHD refers to both the immunologic insult and the consequences to the organism. The leading cause of GVHD is hematopoietic cell transplantation (HCT), other causes like solid organ transplants, blood transfusions, and maternal-fetal transfusions also reportedly cause GVHD.CASEWe present a 33 years old man, who was diagnosed in October 1997 of acute myeloid leukemia, treated with idarrubicin, etoposid and citarabine (IDICE), with complete remission; after that he received intensification treatment with mitoxanthrone and citarabine, and consolidation with an allogeneic HSCT from a sibling donor.The chimerism was 100% of the donor since first month.There wasn't any important complications after HSCT; except a GVHD skin, resolved with corticoids.Seven years after HCST, in November 2004, a routine control detected donor's chimerism 34% with a medullar relapse. Leukemia characteristics were the same than the initials, and a new treatment with IDICE was administrated, showing no response, therefore, a second cycle was administrated.One week after the first treatment fever appeared, which persisted besides large spectre antibiotics, so empiric antifungal treatment was added. Two months after the relapse the patient remained febrile, and skin lesions appeared in head, arms, legs, abdomen and oral mucosa. A biopsy was performed and diagnosed with Fusarium sp.The neutropenia persisted, and the overall status was worsening, so we decided donor granulocyte infusions from two HLA identical sisters; ten days later, neutropenia disappeared, the bone marrow hadn't blastic cells, and chimerism was 100% donor. A month later, new skin lesions appeared, the biopsy confirmed GVHD and severe liver affectation was also demonstrated by biopsy. It was treated with corticoids and cyclosporine, with rapid resolution.The patient left hospital, and until now chimerism remains 100% donor with complete remission, without treatment for GVHD.CONCLUSION: Graft versus Host disease is usually presented after hematopoietic stem cells infusion but other causes are been reported as lymphocytes infusion, where is not a rare event, and in other cases as granulocytes infusion as in our patient.GVHD after granulocyte infusion is not a common complication even though it has to be taken in mind in patients that show skin or liver affectation after infusion.

Service Use and Costs of Support 12 Years after Leaving Hospital

Background There have been major changes in the provision and organization of services for people with intellectual disabilities in England over the last 30 years, particularly deinstitutionalization and the development of the mixed economy of care. The experiences of the people who participated in the Care in the Community Demonstration Programme in the mid‐1980s provide evidence of the immediate and longer‐term effects of the reprovision policy.Methods Cross‐sectional and longitudinal evidence was gathered on service use and costs for over 250 people 12 years after they left long‐stay hospitals for community living arrangements. Comparisons were made with the situation in hospital, and 1 and 5 years after leaving. Relationships between costs after 12 years and individual characteristics assessed before people left hospital were explored.Results Community care at the 12‐year follow‐up remained more expensive than hospital‐based support, although the average cost was lower than at either of the 1‐ or 5‐year community follow‐up points. Service users were living in a wide variety of accommodation settings. Management responsibility fell on National Health Service (NHS) trusts, local authorities, voluntary agencies, or to private organizations or individuals. After standardizing for users’ skills and abilities, costs in minimum support accommodation were significantly lower than those in residential and nursing homes, costs in staffed group homes significantly higher, and costs in hostels slightly lower. When looking at differences between individuals, no relationship was found between costs and outcomes although, overall, people were better off in the community than they had been when in hospital.Conclusions Reprovision planning for hospital and other institutional modes of care requires major and long‐term commitment of resources. Quality of life improvements can be achieved at a cost little different in the long‐run from that for hospital care. The link between needs and costs (reflecting the services intended to meet those needs) would be made stronger through the individualization of care.

Can parathyroidectomy for primary hyperparathyroidism be carried out as a day-case procedure?

Surgery for primary hyperparathyroidism has traditionally involved a bilateral neck exploration performed as an in-patient procedure. We present a feasibility study to demonstrate whether, with a focused surgical exploration, the procedure can be carried out as a day case. Eighty-seven patients had pre-operative sestamibi and ultrasound scans of the neck. When the results of these scans agreed, a unilateral neck exploration was carried out. Sixty-seven patients received a focused approach parathyroidectomy. Ninety-seven per cent of these patients were normocalcaemic after the first operation. All patients who fitted the day-case criteria left hospital the following morning. When pre-operative imaging results agree, a parathyroidectomy can be carried out using a unilateral neck exploration, avoiding the increased risks associated with a bilateral exploration. Parathyroidectomy can be safely carried out as a day-case procedure in selected patients.

Nonoperative Treatment of 15 Benign Esophageal Perforations With Self-Expandable Covered Metal Stents

Spontaneous or iatrogenic esophageal perforations after endoscopic procedures are potentially life-threatening events with a considerable mortality rate. The aim of this study was to demonstrate that a nonoperative endoscopic treatment with self-expanding metal stents may have a lower morbidity and mortality rate compared with surgical treatment. A nonrandomized observational study was conducted with 15 consecutive patients between January 1997 and June 2004. Benign spontaneous and iatrogenic esophageal perforations after endoscopic procedures were treated with self-expandable metal stents. Seven patients (group 1) underwent stent insertion with an average time delay of 45 minutes. In 8 patients (group 2), the median delay was 123 hours. All patients in group 1 had an uneventful recovery and left hospital 5 days (range, 3 to 9) after stent insertion. One patient in group 2 (1 of 8) died of pneumonia after 6 days. In any other cases, perforations healed successfully after stent placement, but the clinical course was generally complicated with sepsis and multiple organ failure. The average hospital stay was 44 days (range, 15 to 70). Immediate insertion of a self-expandable metal stent enables an excellent outcome with minimal mortality and morbidity without the need for operation. Even in cases of old esophageal perforations, sealing with self-expandable metal stents is still a good option although the clinical course is much less impressive than in early treated perforations.

Levosimendan may improve survival in patients requiring mechanical assist devices for post-cardiotomy heart failure

IntroductionMost case series suggest that less than half of the patients receiving a mechanical cardiac assist device as a bridge to recovery due to severe post-cardiotomy heart failure survive to hospital discharge. Levosimendan is the only inotropic substance known to improve medium term survival in patients suffering from severe heart failure.MethodsThis retrospective analysis covers our single centre experience. Between July 2000 and December 2004, 41 consecutive patients were treated for this complication. Of these, 38 patients are included in this retrospective analysis as 3 patients died in the operating room. Levosimendan was added to the treatment protocol for the last nine patients.ResultsOf 29 patients treated without levosimendan, 20 could be weaned off the device, 9 survived to intensive care unit discharge, 7 left hospital alive and 3 survived 180 days. All 9 patients treated with levosimendan could be weaned, 8 were discharged alive from ICU and hospital, and 7 lived 180 days after surgery (p < 0.002 for 180 day survival). Plasma lactate after explantation of the device was significantly lower (p = 0.002), as were epinephrine doses. Time spent on renal replacement therapy was significantly shorter (p = 0.023).ConclusionLevosimendan seems to improve medium term survival in patients failing to wean off cardiopulmonary bypass and requiring cardiac assist devices as a bridge to recovery. This retrospective analysis justifies prospective randomised investigations of levosimendan in this group of patients.

Presentation of cancer to hospital as 'acute abdominal pain'.

In a survey of 5675 patients presenting to five hospitals in England, Scotland and Denmark with acute undiagnosed abdominal pain, 106 patients later proved to have intraabdominal cancer. The risk of cancer was age-dependent: amongst patients over 50 years with 'non-specific' pain the risk of cancer was 10 per cent. The commonest primary cancer site (in 57 cases, 53.8 per cent) was the large bowel. Most cancers neither perforated nor obstructed: 73 patients merely presented with a short history of unexplained abdominal pain. Of those patients with cancer presenting with 'unexplained' pain, half (37/73, 50.7 per cent) left hospital without a diagnosis of cancer having been made. Subsequently, a computer-aided system was constructed to discriminate (in patients over the age of 50) between those with unexplained acute abdominal pain who did and did not have cancer. Overall accuracy was 84.7 per cent in 138 cases. The most helpful clinical features in making this discrimination are listed. It is suggested (a) that cancer is now a relatively common cause of acute abdominal pain, (b) that the diagnosis is frequently difficult and (c) that urgent screening of all patients over 50 with non-specific acute abdominal pain may be warranted.

Self-expanding metal stents for the palliation of dysphagia due to inoperable oesophageal carcinoma.

Adequate palliation of dysphagia due to inoperable oesophageal carcinoma is difficult to achieve with low morbidity. Thirty-three patients (21 men and 12 women of mean(s.e.m.) age 69(2) years) with inoperable carcinoma of the oesophagus underwent insertion of self-expanding metal stents. In 22 patients the tumours were in the lower third of the oesophagus, in eight in the middle third and in three in the upper third. A stent was inserted as primary palliative therapy in 14 patients, after failed laser therapy in 13 and after oesophageal perforation following other treatments in six. Patients presented with dysphagia of grade 3 or 4. Three types of stent were used: Wallstent, Strecker and Gianturco; stents were inserted under fluoroscopic guidance after balloon dilatation of the stricture. All attempted insertions of metal stents were successful. Dysphagia reduced from grade 3 or 4 to 0 or 1. There were no perforations related to insertion. Patients who had stents inserted to seal previous perforations left hospital a median 7 days later. Dysphagia recurred in six patients, due to migration of the stent (three), blockage by food bolus (one) and tumour overgrowth (two). These problems were easily treated. Self-expanding metal stents seem to offer excellent palliation with minimal morbidity for patients with inoperable carcinoma of the oesophagus.

The injuries and management of riot casualties admitted to the Belfast hospital wards, August to October, 1969.

Abstract Belfast has experienced intermittent rioting for 18 months. An analysis of riot casualties admitted to the wards of Belfast hospitals from 1 Aug. to 31 Oct., 1969, is presented. Approximately 500 casualties came to hospital and of these only 164 were admitted. Eighty-three (50·6 per cent of admissions) required surgery. One-third of all admissions had left hospital within 48 hours and only 23 (14 per cent) remained for longer than 2 weeks. The demand for resuscitation was not high and the need for blood unexpectedly low. We describe in this article the types of injury and the treatment they were given. During rioting there are many reasons why surgical preparations may exceed the need for them. Pro-longed dislocation of normal hospital services does not seem justified by the pattern which emerged. The reception of the large number of casualties arriving over a 2–3-hour period on the first peak night is discussed. Some of the ethical difficulties of the riot situation are mentioned. Problems of internal security and communication are discussed.

Total excision or restorative resection for carcinoma of the middle third of the rectum.

Summary Restorative resection is being used increasingly for carcinoma of the mid rectum but it is not yet certain whether this operation is as curative as total excision. Between 1963 and 1972, 209 patients left St Mark's Hospital after a radical operation for a single rectal carcinoma situated between 8 and 12 cm from the anal verge. A total of 199 patients was followed up for 5 years. Of these, 112 had been treated by total excision of the rectum and 87 by restorative operation. Survival was correlated with the Dukes' stage, histological grade and extent of local spread in the two groups. There was no significant difference in 5-year survival after either total excision or restorative resection for Dukes' B (74 per cent, 71 per cent respectively) or average grade (61 per cent, 73 per cent respectively) tumours. Patients with Dukes' C tumours fared better when treated by restorative resection (36 per cent, 63 per cent), probably due to fewer high grade tumours in the restorative group (38 per cent, 18 per cent). Combining two variables, survival was not significantly different for patients with Dukes' B tumours of average grade (69 per cent, 62 per cent) or for Dukes' C tumours of average grade (48 per cent, 76 per cent). When the three pathological variables were combined, there was an improved survival after restorative resection for some pathological combinations. It is concluded that restorative resection for carcinoma of the mid rectum is as curative as total excision in terms of 5-year survival.

The Celestin tube in the palliation of carcinoma of the oesophagus and cardia.

A series of 105 patients with dysphagia due to inoperable carcinoma of the oesophagus or cardia of the stomach, and 11 patients with dysphagia secondary to malignant medistinal nodes, was treated by intubation with a Celestin tube. The hospital mortality was high but 81 patients left hospital and 29 were still alive at 6 months. The prognosis for those with dysphagia due to malignant posterior mediastinal nodes was very poor, with no survivors at 6 months. Oesophageal perforation was a serious operative complication, with a hospital mortality of 83 per cent. Chest and wound infections were the most common postoperative complications occurring in 28 and 20 per cent of the patients, respectively. The restoration of swallowing was satisfactory in the majority of survivors although readmission with a blocked or displaced tube was not uncommon.