Residual Morbidity Research Articles

Five Year Outcomes Study of Dental Rehabilitation Conducted Under General Anesthesia for Special Needs Patients

We assessed the safety of general anesthesia for dental treatment of special needs patients as it related to American Society of Anesthesiology Physical Status (ASAPS) classification, procedure, and other factors. After Institutional Review Board review and approval, special needs patients who were admitted to the outpatient surgical operating room for comprehensive dental rehabilitation (CDR) under general anesthesia within a period of 5 years had their medical records evaluated retrospectively for intraoperative and postoperative complications both related to anesthesia and surgery. All records were evaluated by an independent evaluator who tabulated the patients' age, gender, ASAPS, and duration of procedure. N = 363, age mean = 46.93 +/- 16.835 years, age median = 48 years, male patients = 180, female patients = 183, ASAPS I =183, ASAPS II = 127, ASAPS III = 53, duration of surgery mean = 140.631 +/- 23.104 minutes, duration of surgery median time = 142.000 minutes, and number of complications = 2. One complication resulted in an ASAPS I 16-year-old boy, which was airway related, and a second was an ASAPS III 22-year-old woman, which was surgically related. Both led to unplanned inpatient admissions and were treated successfully with no residual morbidity. Dental rehabilitation of special needs patients under general anesthesia is safe. While morbidity is very low, larger studies are needed to establish risk versus benefit stratification among this patient population.

Mapping of Visuospatial Functions during Brain Surgery

Mapping of Visuospatial Functions during Brain Surgery

Postpartum haemorrhage: a preventable cause of maternal mortality.

To assess the preventable predictors of severe postpartum haemorrhage and the adverse outcome associated with it. Observational study. Department of Obstetrics and Gynaecology, Hayatabad Medical Complex, PGMI, Peshawar, form January to December 2001. All the admitted patients who developed severe postpartum haemorrhage (>1500 ml) were included in the study. Clinical and sociodemographic data was obtained along with results of investigations to categorize the complications encountered. Odds ratio (OR) and 95% confidence intervals were determined. During the study period, 75 out of 4683 obstetrical admissions, developed severe postpartum haemorrhage (1.6 %). About 65% of the patients were admitted with some other complications including obstructed labour, antepartum haemorrhage and eclampsia. The risk factors were grand multiparity (OR=3.4), pre-eclampsia (OR=2.75), antepartum haemorrhage (OR=13.35), active labour of more than 10 hours (OR=46.92), twin delivery (OR=3.25), instrumental delivery (OR=8.62) and caesarean section (OR=9.74). Maternal mortality in these cases was 2.66% and residual morbidity being 40%. Birth attendant other than doctor and delivery outside the study unit were significantly associated with the adverse outcome in these patients. Maternal outcome associated with postpartum haemorrhage is a function of care given during labour and postnatal period with early diagnosis and management of the complication and its risk factors, being the key of good maternal outcome.

Quel risque néonatal pour les grossesses à bas risque : implications pédiatriques pour l'organisation des maisons de naissance ?

Aim This study was designed to identify pregnant women at low risk for severe neonatal morbidity. This population should apply for delivery in birth centers. Population and methods This study was retrospective and included all livebirths in Burgundy over a 4-year period. Fifteen obstetric criteria recorded in the regional perinatal database were used to select pregnant women at low risk for severe neonatal morbidity. Incidence of severe neonatal morbidity in the low and high risk groups was assessed from the following markers: postnatal death; severe neurological conditions (ischemic encephalopathy, seizures, meningitis, intraventricular hemorrhage stage 3–4 and cystic periventricular leukomalacia in preterm infants) ; tracheal intubation ; hospitalization in neonatal intensive care unit. Results The incidence of severe neonatal morbidity was significantly different ( P < 0.0001) in the low risk group (0.34% [IC 95%: 0.29–0.40]; N = 46 345) as compared with the high risk group (5.6% [IC 95%: 5.3–5.9]; N = 24 961). The main neonatal diseases in the low risk group were: respiratory diseases (29.8%); congenital heart diseases (17.9%) and perinatal asphyxia (15.3%). Conclusion Even though the low risk criteria were associated with a low incidence of severe neonatal morbidity, residual morbidity should be considered in organization of birth centers in France.

Mechanical support availability in pediatric cardiac surgery: Program size should not matter

Intractable heart failure may require Extracorporeal Life Support (ECLS) techniques for rescue therapy. Nevertheless, in many small to middle-sized centers in Europe, this valuable resource is not available. In our University pediatric intensive care unit 0.9% of 1360 open-heart surgical patients required mechanical assistance over the latest 9 years with a survival rate of 69.2% and low residual morbidity. This favorable overall outcome suggests that regardless of the program size, it is possible to ensure the availability of efficient mechanical assistance that appears to be fundamental in a center performing surgery for complex congenital or acquired cardiac diseases.

The use of a pediatric emergency medicine–staffed sedation service during imaging: a retrospective analysis

Hypothesis A sedation service staffed by pediatric emergency medicine (PEM) physicians can sedate children during imaging, with a low adverse event risk and minimal sedation failures. Design/Methods We reviewed 1042 PEM-administered sedations during a 12-month period, collecting data regarding demographics, presedation evaluation, medications used, sedation length, adverse events, corrective measures, and postsedation disposition. Successful image completion without patient awakening defined effective sedation. Minor adverse events included hypoxia (<93%), malaligned airway, self-resolving transient bradycardia, and atypical reactions to sedation agents. Cardiorespiratory incidents requiring resuscitation were considered major events. Results Of 923 sedation episodes, 92 (10.0%) experienced adverse events; 7 (0.76%) were major. Sedation failed in 17 (1.8%). No sedation resulted in an increased level of care or permanent injury. Conclusions A PEM-staffed sedation service provided sedation to children undergoing imaging with a low adverse event risk, minimal failures, and no residual morbidity. However, all sedating clinicians should possess critical airway skills.

Liver morbidity due to Schistosoma mekongi in Cambodia after seven rounds of mass drug administration

Severe liver disease due to Schistosoma mekongi was frequent in northern Cambodia. Between 1995 and 2002, seven rounds of mass chemotherapy (praziquantel) reduced infection from 50% to below 3%. In 2002, we assessed hepatosplenic morbidity by historical, clinical and ultrasonographic investigations in adults (older than 14 years) from endemic (n=342) and non-endemic (n=103) areas (Kratie province). Clinical hepatomegaly (25 vs. 0%), splenomegaly (55 vs. 0%), reported blood in stool (41 vs. 20%) and abdominal pain (78 vs. 57%) were significantly higher in the endemic area. In this area, significantly more subjects reported a family history of death due to schistosomiasis (12 vs. 0%); 63% (vs. 0%) reported having at least three treatments of praziquantel in previous years; and only 11% (vs. 99%) had normal liver ultrasonographic examination. Periportal fibrosis with portal hypertension was diagnosed in 46% (vs. 0%) of people in this area; 18% (vs. 0%) and 5% (vs. 0%) of portal hypertension was classified as moderate and severe, respectively. People aged between 24 and 35 years were mostly affected. There was no gender difference. The pathology in the endemic district is most probably residual morbidity of S. mekongi infections. Contributions of co-infections (hepatitis) cannot be excluded. Careful monitoring of the affected communities is required.

Long-acting neuroleptics used in wildlife management do not impair thermoregulation or physical activity in goats (Capra hircus)

Long-acting neuroleptics commonly are used in wildlife management to decrease stress-related mortality in wild animals, but with possible effects on thermoregulation, which may contribute to residual morbidity and mortality. We investigated the effects of haloperidol (0.01, 0.1, 1 mg kg(-1), n=4), zuclopenthixol (0.1, 1, 10 mg kg(-1), n=4) and perphenazine (0.1, 1, 10 mg kg(-1), n=8), as well as control injections of sunflower oil, on body temperature and physical activity of laboratory goats under hot, cold and thermoneutral ambient temperatures. Implanted data loggers continuously recorded abdominal temperature, and data loggers attached externally on the foreleg recorded movement of unrestrained goats, in a climatic chamber at 35 degrees C, 10 degrees C and 22 degrees C. Cycling ambient temperature between 35 degrees C in daytime and 10 degrees C at night time caused a significant increase in amplitude of the circadian rhythm of body temperature in goats given sunflower oil (P=0.0012, unpaired t-test, n=8), but the administration of zuclopenthixol or perphenazine did not affect this change in amplitude (P>0.05, two-way ANOVA, n=4). Mean daily body temperature after administration of zuclopenthixol or perphenazine, and mean daily activity after zuclopenthixol administration, were not significantly different to those after control injections, at any ambient temperature, for the expected duration of drug activity (all P>0.05, two-way ANOVA, n=4). Thermal response indices, and mean activity, during heat, cold or thermoneutral exposure, of goats for 7 h after haloperidol injection, were not significantly different, at any dose or any ambient temperature, to those following control injections (all P>0.05, repeated measures ANOVA, n=4). Long-acting neuroleptics did not impair activity or thermoregulation of goats subjected to inescapable thermal challenges.

Arthroscopic Removal of an Osteoid Osteoma in the Radial Head: A Case Report

We describe an unusual case of osteoid osteoma of the radial head that was treated by means of elbow arthroscopy. A 42-year-old man presented with a history of elbow pain lasting for 2 years that progressed after an unsuccessful previous operative procedure. Computed tomography and bone scan evaluation revealed the possibility of an osteoid osteoma of the radial head. Elbow arthroscopy under image intensifier guidance was completed to locate and remove the lesion. The shavings were collected, and a histologic analysis was performed, the findings of which were consistent with the preoperative diagnosis. An immediate decline in pain with an excellent and lasting increase in function was observed postoperatively. Radical open surgery is curative for osteoid osteoma and also allows for an excellent histologic confirmation of the diagnosis in the setting of a juxta-articular osteoid osteoma, but the residual morbidity does not justify it around accessible joint locations in this self-limited, albeit painful, disease. Thought should be given to the possibility of arthroscopic retrieval or excision with minimal operative damage before proceeding with open surgery. The use of a motorized instrument for excision does not preclude pathologic evaluation of the specimens.

Study on residual morbidity from schistosomiasis by means of ultrasonography in the municipality of Bananal, São Paulo, Brazil

Study on residual morbidity from schistosomiasis by means of ultrasonography in the municipality of Bananal, São Paulo, Brazil

The Role of Psychosocial Stress in the Onset and Progression of Bipolar Disorder and its Comorbidities: The Need for Earlier and Alternative Modes of Therapeutic Intervention

Psychosocial stress plays an important role at multiple junctures in the onset and course of bipolar disorder. Childhood adversity may be a risk factor for vulnerability to early onset illness, and an array of stressors may be relevant not only to the onset, recurrence, and progression of affective episodes, but the highly prevalent substance abuse comorbidities as well. A substantial group of controlled studies indicate that various cognitive behavioral psychotherapies and psycho-educational approaches may yield better outcomes in bipolar disorder than treatment as usual. Yet these approaches do not appear to be frequently or systematically employed in clinical practice, and this may contribute to the considerable residual morbidity and mortality associated with conventional treatment. Possible practical approaches to reducing this deficit (in an illness that is already underdiagnosed and undertreated even with routine medications) are offered. Without the mobilization of new clinical and public health a...

Patterns of Psychotropic Drug Prescription for U.S. Patients With Diagnoses of Bipolar Disorders

Patterns of Psychotropic Drug Prescription for U.S. Patients With Diagnoses of Bipolar Disorders

Repair of large urethrocutaneous fistula with dartos-based flip flap: A study of 23 cases

ABSTRACTThe commonest complication of hypospadias repair is occurrence of urethrocutaneous fistulae. These fistulae may be caused by a variety of factors and occur in different sizes at various sites of the previous repair. Small fistulae are easier to close with local tissue and flaps but larger fistulae which are 4 mm or more in size are difficult to close because of the paucity of available tissues and chances of recurrence. A variety of methods have been described in the literature for the repair of urethrocutaneous fistulae with variable results. In this study of 23 cases, we have successfully repaired large urethrocutaneous fistulae using dartos-based flip flaps for their closure in the period from June 2001 to May 2006. These flaps can cover any fistulae from the penoscrotal region to the distal penile shaft. Dartos-based flip flaps are robust and vascularized and provide watertight closure and at the same time they are easy to elevate and leave no residual donor site morbidity.

Repair of large urethrocutaneous fistula with dartos-based flip flap: A study of 23 cases

The commonest complication of hypospadias repair is occurrence of urethrocutaneous fistulae. These fistulae may be caused by a variety of factors and occur in different sizes at various sites of the previous repair. Small fistulae are easier to close with local tissue and flaps but larger fistulae which are 4 mm or more in size are difficult to close because of the paucity of available tissues and chances of recurrence. A variety of methods have been described in the literature for the repair of urethrocutaneous fistulae with variable results. In this study of 23 cases, we have successfully repaired large urethrocutaneous fistulae using dartos-based flip flaps for their closure in the period from June 2001 to May 2006. These flaps can cover any fistulae from the penoscrotal region to the distal penile shaft. Dartos-based flip flaps are robust and vascularized and provide watertight closure and at the same time they are easy to elevate and leave no residual donor site morbidity.

Introduction-Neuroprotection: A Therapeutic Strategy to Prevent Deterioration Associated with Schizophrenia

Schizophrenia is a neurodevelopmental disorder associated with persistent symptomatology, severe functional disability, and residual morbidity characteristic of neurodegenerative brain diseases. The illness begins with genetic susceptibility and generally expresses itself after puberty through subtle changes that begin during the prodromal stage. Symptoms get progressively worse and tend to become more resistant to treatment with each relapse. Evidence for a neuroprotective effect of some forms of early treatment is beginning to emerge. While the underlying mechanisms remain uncertain, atypical antipsychotics may counteract some of the progressive deteriorative effects by enhancing synaptic plasticity and cellular resilience. However, identifying and treating patients in the earliest disease states presents methodological challenges as there is no consensus on the best methods of intervention and differences in at-risk children are not readily detectable or substantial enough to predict which ones will develop schizophrenia. In this expert roundtable supplement, Jeffrey A. Lieberman, MD, reviews the historical context of progressive deterioration in schizophrenia. Next, Diana O. Perkins, MD, MPH, reviews some of the challenges to early identification of illness as well as the impact of early versus delayed treatment. Finally, L. Fredrik Jarskog, MD, focuses on the neurobiology of functional progression in schizophrenia as well as pharmacology and the potential for neuroprotection.

Hepatectomy for hepatolithiasis

目的 研究肝切除和不同范围肝切除术对肝内胆管结石的治疗效果.方法 分析我院近14年择期手术治疗的肝内胆管结石病人498例,比较肝切除组和无肝切除组、不同范围肝切除组的术后残余结石率、治疗效果和手术并发症.结果 本组63.7%的病人行肝切除术.2001年后肝切除术的比例(74.6%)明显高于1991-1995年(49.5%)和1996-2000年(51.1%),而胆肠吻合术和单纯胆管切开取石T管引流术的比例逐渐减少.肝切除组术后结石残余率明显低于无肝切除组(19.2% vs 31.7%,χ2=9.996,P=0.002);肝切除组的优良率明显优于无肝切除组(85.2% vs74.7%,χ2=7.251,P=0.007),但肝切除组术后的并发症(伤口并发症除外)发生率和死亡率与无肝切除者无统计学差异.局限在肝左外叶的结石,肝左外叶切除效果好,术后无一例有残余结石.对结石分布超过左外叶时,左外叶切除、左半肝切除、右半肝切除和肝段切除的结石残余率分别为51.2%,14.3%,6.25%和11.5%,左外叶切除术后结石残余率明显高于左半肝切除、右半肝切除和肝段切除(P＜0.001).半肝切除和肝段切除的优良率明显高于左外叶切除(94.8% vs 76.1%,χ2=15.454,P＜0.001).结论肝切除是治疗肝内胆管结石最有效的方法,对于非局限在左外叶的肝内结石,半肝切除和肝段切除术优于左外叶切除。

Inflammation in Diabetes Mellitus: Role of Peroxisome Proliferator-Activated Receptor–α and Peroxisome Proliferator-Activated Receptor–γ Agonists

Patients with type 2 diabetes mellitus and/or the metabolic syndrome have considerable cardiovascular risk. Treatment with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) and with antihypertensive and some antihyperglycemic agents reduces this risk, but residual macrovascular morbidity and mortality persist, even in patients assigned to intensive multifactorial intervention programs. Therapeutic strategies that target inflammation and lipid abnormalities not well addressed by statins may offer additional opportunities for improving the prognosis of these patients. Inflammation, a key mechanism of atherogenesis, appears to have particular relevance to diabetic vascular complications, as well as in the development of diabetes itself. Oxidative stress and hyperglycemia also figure among the pathogenic factors that promote cardiovascular complications in patients with the metabolic syndrome and/or diabetes and may augment the ongoing inflammation. Peroxisome proliferator-activated receptor (PPAR)-alpha and PPAR-gamma, members of the nuclear receptor family, form ligand-activated transcription factors that regulate key important metabolic pathways. PPARs have become therapeutic targets through the use of the fibrate class of antidyslipidemic drugs (PPAR-alpha) and the insulin-sensitizing thiazolidinediones (PPAR-gamma). The activation of these PPARs may also suppress inflammation and atherosclerosis. Recent clinical trials (Fenofibrate Intervention and Event Lowering in Diabetes [FIELD], Prospective Pioglitazone Clinical Trial in Macrovascular Events [PROactive]) have considered the impact of these PPAR agonists on cardiovascular disease, with mixed effects that require careful analysis, especially given ongoing trials and additional PPAR agonists in development.

Effect of Insulin–Glucose Infusion on Mortality Following Acute Myocardial Infarction in Patients with Diabetes: The Diabetes and Insulin–Glucose Infusion in Acute Myocardial Infarction Studies

People with type 2 diabetes and other glucose abnormalities are very common among today's patients with acute coronary syndrome (ACS) and recent studies indicate that they still have an unfavorable prognosis compared to patients with normal glucose metabolism. In fact, they account for a substantial proportion of the residual morbidity and mortality in the ACS population. The common denominator seems to be an elevated blood glucose during the acute event and current evidence indicates that acute and long-term tight glucose control will improve the prognosis for this rapid growing patient population.

Urgent inhibitor issues: targets for expanded research

Although up to 80% of high-responding inhibitors in patients with severe factor VIII deficiency can be eliminated using heterogeneous regimens for immune tolerance induction, the residual morbidity in this population of haemophilic patients is far from trivial. There is an exigent need for focussed basic, translational and clinical research to extend our understanding of the pathogenesis of haemophilic inhibitor development. In this article, we identify four key research needs, including (i) whether presently available clotting factor concentrates (CFCs) have differential antigenicity, giving rise to clinically relevant immunogenicity; (ii) the interplay of quantitative and qualitative (e.g. age at first exposure) influences of CFCs as well as host-environmental factors (e.g. vaccination effects) on inhibitor development; (iii) the therapeutic role (if any) that concurrent immune tolerance with suppressive or immune-competitive therapeutic strategies play in inhibitor eradication and (iv) pending any major therapeutic advances, alternative or enhanced strategies for treating acute haemorrhage and for preventing chronic haemorrhagic events in these patients.

The role of psychosocial stress in the onset and progression of bipolar disorder and its comorbidities: The need for earlier and alternative modes of therapeutic intervention

Psychosocial stress plays an important role at multiple junctures in the onset and course of bipolar disorder. Childhood adversity may be a risk factor for vulnerability to early onset illness, and an array of stressors may be relevant not only to the onset, recurrence, and progression of affective episodes, but the highly prevalent substance abuse comorbidities as well. A substantial group of controlled studies indicate that various cognitive behavioral psychotherapies and psychoeducational approaches may yield better outcomes in bipolar disorder than treatment as usual. Yet these approaches do not appear to be frequently or systematically employed in clinical practice, and this may contribute to the considerable residual morbidity and mortality associated with conventional treatment. Possible practical approaches to reducing this deficit (in an illness that is already underdiagnosed and undertreated even with routine medications) are offered. Without the mobilization of new clinical and public health approaches to earlier and more effective treatment and supportive interventions, bipolar illness will continue to have grave implications for many patients' long-term well being.