Severe Medical Complications Research Articles

The modified frailty index and 30-day adverse events in oncologic neurosurgery.

The modified frailty index (mFI) is emerging as a leading measure for preoperative risk assessment using routinely available medical record data. Our objective was to determine if mFI predicts morbidity and mortality in the diverse national cohort of patients undergoing neurosurgery for intracranial neoplasms. We identified patients in the National Surgical Quality Improvement Program who underwent oncologic neurosurgery procedures between 2008 and 2012. The mFI, ranging from 0 to 1, was calculated as the proportion of 11 possible risk factors present. We assessed the associations between mFI and 30-day mortality, neurologic and medical complications, prolonged length of stay, and unfavorable discharge in univariate and multivariable analyses and compare the index to established risk stratification techniques. A total of 9149 patients were identified. Mortality, severe medical complications, prolonged length of stay, and unfavorable discharge increased incrementally with increasing levels of frailty. Severe neurologic complications were highest in those with low frailty. In multivariable logistic regression analysis, increased frailty increased the odds of all adverse outcomes, including neurologic complications. The mFI increased the ability to predict all outcomes beyond available indices and was the most reliable predictor of neurologic complications. The mFI can be calculated from routinely collected medical record data and is predictive of 30-day adverse outcomes in a wide variety of neurosurgical oncology patients. The index may be a useful component of preoperative risk assessment with implications for shared decision-making, perioperative planning, and risk adjusted outcomes measurement in national quality registries.

Delayed manifestations of abdominal trauma: follow-up abdominopelvic CT in posttraumatic patients.

Our study aims to investigate the frequency and patterns of delayed manifestations of abdominal and pelvic injuries which may not be identified or which fail to manifest on the initial abdominopelvic CT in posttraumatic patients. For our institutional review board (IRB)-approved retrospective study, our hospital trauma registry was queried for patients with blunt multitrauma and Injury Severity Score (ISS)≥16 between January 2010 and August 2016, yielding 3735 patients. A total of 203 patients received a follow-up abdominopelvic CT within six months from the initial scan and those with new findings on follow-up CT were identified. A retrospective blinded review of the initial CT examinations was performed by two experienced radiologists. The retrospective readings and original reports were compared to categorize the new abnormalities detected on follow-up CT scans. The categories included missed injuries, late presentations and sequelae of trauma, and complications of surgery, hospital admission, and invasive procedures. The patients' notes were reviewed for the clinical indications, time interval for repeat CT examination, and subsequent clinical management. The software used for statistical analysis of the extracted data was Microsoft Excel for Mac (version 15.33). Out of 3735 patients, 203 patients received 232 follow-up abdominopelvic CTs. The average elapsed time between the initial CT and the follow-up CT was 15±27days. Evaluation for an abdominal fluid collection was the most common clinical indication, accounting for 40% of the total number (n=243) of indications. Delayed manifestations and complications of trauma were present in 41 patients due to 47 abnormalities, most commonly related to solid organ injury, followed by abdominal collections and hematoma. Twenty-nine CT findings (62%) were only detectable on follow-up CT, while nine injuries (19%) were missed on initial CT. The findings on repeated CT warranted eight surgical and 15 interventional procedures. A small percentage of traumatic injuries may be unidentified or fail to manifest on the initial CT, resulting in delayed manifestations of abdominopelvic trauma, which may lead to subsequent readmission, delayed management, and more severe medical complications.

The Impact of Gender on Tumour Stage in In-House Complications and Choice of Urinary Diversion: Results of the Austrian Cystectomy Registry

Introduction and Objectives: Bladder cancer is characterized by gender-dependent disparities. To further address this issue, we analysed a prospective, multicentre cystectomy registry. Methods: An online database was developed that included patient demographics, intra/perioperative data, surgical data and in-house complications. Results: Four hundred fifty-eight patients (112 [24.5%] women and 346 [75.5%] men) were analysed. Men and women were comparable regarding age (mean 68 years), body mass index (mean 26.5) and the mean Charlson score (4.8). Women had more advanced tumour-stages (pT3/pT4; women: 57.1%; men: 48.1%). The rate of incontinent urinary diversion was higher in women (83.1%) than in men (60.2%) and in a multivariate analysis, the strongest predictors were M+ status (OR 11.2), female gender (OR 6.9) and age (OR 6.5). Women had a higher intraoperative blood transfusion rate. The overall rate of in-house complications was similar in both genders (men: 32.0%, women: 32.6%). Severe (Clavien-Dindo grade >2) medical (women: 6.3%; men: 5.2%) and surgical (women: 21.5%; men: 14.4%) in-house complications, however, were more frequent in women. Conclusions: This multicentre registry demonstrates several gender-related differences in patients undergoing radical cystectomy. The higher transfusion rate, the rare use of orthotopic bladder substitutes and the higher in-house complication rate underline the higher complexity of this procedure in women.

Rehabilitation for bariatric patients

Morbidly obese patients can achieve functional improvement1 but they often experience increased post-acute rehabilitation length of stay due to the limitations of the healthcare system.2 This study aims to develop targeted interventions to optimise rehabilitation care delivery for bariatric patients. We reviewed the medical records of two inpatients at the rehabilitation ward in Sunshine Hospital, Victoria. The patients were morbidly obese (weight of 180 and 196 kg respectively) and had a few months of complicated acute hospital stay (10 and 12 weeks respectively). On admission to the rehabilitation ward, both patients required full nursing care and were non-ambulant. Factors related to the patients, staff and environment which posed challenges to the rehabilitation and discharge planning were recorded. Multiple factors account for the difficulties in rehabilitating bariatric patients. Morbidly obese patients tend to develop more frequent and severe medical complications during their subacute stay.3 It also takes longer for them to recover from the illnesses. Increased number of nursing staff is required to provide the appropriate care needs. Occupational health and safety issues are frequent, with multiple nursing staff having to take sick leave due to musculoskeletal injuries. A room with larger space and bariatric-specific equipment are essential for patient comfort, effective nursing care and physical therapies. Discharge planning process can be complex as extensive home modification and support are often required. Temporary discharge destination options need to be explored early on as bariatric patients take longer time to achieve functional improvement. Multiple factors contribute to challenges in bariatric rehabilitation. Prior to admitting morbidly obese patients into the rehabilitation ward, it is prudent to educate staff,4 involve the occupational health and safety department, and ensure the availability of the required equipment3 and room. To reduce the length of stay at the rehabilitation ward, the treating team needs to explore the available support options and assess home environment early on during admission. While increasing the number of nursing staff imposes a financial strain to the hospital, it will not only reduce the physical and psychological burden of the nursing team, but also allow the patient to have extra therapies. Close monitoring of the medical condition and provision of weight loss programme may potentially prevent hospital-related and obesity-related complications, and subsequently improve the patient’s functional gains during therapy sessions. Surmounting obstacles relating to rehabilitation of bariatric patients should commence at the earliest possible time and continue throughout the admission to optimise the outcome of the patients.

Safe and uncomplicated inguinal hernia surgery in the elderly - message from anesthesiologists to general surgeons.

Introduction Elderly patients are often discouraged from surgery due to the risk of complications that increases with age. Aim We wanted to assess mortality, morbidity, and complications in patients older than 75 years who underwent elective or emergency inguinal hernia repair in a single center. Methods All patients older than 75 years who were operated on because of inguinal hernia in the Department of General and Colorectal Surgery, Medical University of Lodz between 2003 and 2015 were analyzed. Detailed information was collected with regard to patient demographics, mode of admission, comorbidities, type of intervention, applied anesthesia, and 30-day outcomes. Postoperative outcomes included medical and surgical complications, readmissions, and survival status. Results One hundred thirty-two patients older than 75 years were operated on for inguinal hernia, 16 (12.1%) in an emergency setting and 116 (87.9%) in an elective setting. Eighteen patients (13.6%) developed complications, 8 (50%) in the emergency group, and 10 (8.6%) in the elective group. In the emergency group, severe medical complications (Clavien-Dindo 4) were frequent, whereas in the elective group, severity of surgical and medical complications was not significantly different (Clavien-Dindo median score 2, p=0.6084), and these complications were classified as mild (Clavien-Dindo 1-2). One death occurred in the emergency group. Conclusion Inguinal hernia surgery in the elderly may be safe and effective in an elective setting and if regional anesthesia is used. Careful examination of patients before surgery and identification of potential risk factors associated with co-existing diseases are vital for reducing the risk of complications. Key point: Hernia surgery in patients older than 65 years is a low-risk intervention, if carried out in an elective setting.

Seeking compulsory treatment as life-saving in the presence of eating disorders: a complex choice

Eating disorders (and especially anorexia nervosa) are associated with severe disability, poor quality of life and high mortality rate. Anorexia nervosa ranks among the main causes of death among young women. Despite physical and psycho-social impairment, patients suffering from anorexia nervosa do not recognize low body weight and extreme calorie restriction as a clinical problem and are ambivalent towards treatment. Some patients with anorexia nervosa refuse treatments though presenting severe medical complications and having a high mortality risk. Hence the need to evaluate when it could be appropriate to prescribe a compulsory treatment in the more complex cases who refuse interventions, deemed necessary for them. To date, the compulsory treatment in anorexia nervosa is still under debate: some authors take into account the negative impact on the therapeutic relationship, other authors consider it as a compassionate treatment or as life-saving therapy. Indeed, compulsory treatment for eating disorders must always be weighed very carefully because it is considered by law as the highest form of restriction of personal freedom. Political Institutions must provide a clear framework for the society and for professionals, while the health care services must face the problem of the adequacy of available resources (not only in terms of hospital beds but also of skilled professionals) compared to patients' needs, considering the organization and the integration of clinical services dedicated to the treatment of eating disorders.

Hot iron rods branding, its complications: Still continue in central India

Introduction: The middle of the 20th century has often been described as a golden age of scientific advancement and miraculous medical breakthroughs. In spite of a lot of awareness and many health education programs, still some traditional treatment exists in many places in our country including Central India. In some villages of Madhya Pradesh, many horrifying therapies such as iron rods branding are well known for a few common diseases such as ascites, headache, pneumonia, common cold, or hernia. Bruise marks can be seen on the bodies of a majority of villagers. Main reasons behind such therapy are lack of money for medical treatment, lack of medical facilities, and the unwillingness of medical officers to stay in small villages. Besides this, illiteracy compels them to follow old customs and practices. All these strengthen the faith of villagers in such treatments. It is all due to lack of education and proper awareness. Many female patients come to hospital with complications of iron rods branding suggest that despite being educated, strong cultural beliefs forces people to undergo branding as a treatment of many common diseases in India even in the 21st century. Aims and Objectives: To study the reasons and complications of hot iron branding. Materials and Methods: Sample size was 30. Thirty patients with old, healed (within 1 year), or recent scars of iron branding were included in the study. Patients were evaluated for the sociodemographic details and the information of underlying disease, pattern of lesions, and complications of branding. Results: Hot iron branding is still carrying on as traditional treatment in Central India. It is commonly seen in females of age 20–50 years. It is mostly found in illiterate patients of low socioeconomic status who have chronic disease and chronic pain. Conclusion: Skin branding which still has therapeutic uses in some cultural societies have severe medical complications in Central India.

Diagnostic Approaches to Diabetes Mellitus and the Role of Vitamins

Diabetes mellitus is a group of heterogeneous disorders commonly characterized by chronic hyperglycemia and glucose intolerance, as a result of defects in insulin secretion, defective insulin action, or both. Based on the aetiology and clinical presentation, diabetes mellitus is classified as either immune-mediated (Type 1 diabetes), insulin resistance (Type 2), gestational or others (environment, genetic defects, infections, and certain drugs). The major types of diabetes are type 1 and type 2. Type 1 diabetes is immune mediated and is caused by destruction to the islets cells of the pancreas while type 2 diabetes is caused by a combination of genetic factors related to impaired insulin secretion, insulin resistance and environmental factors such as obesity, overeating, lack of exercise and stress, as well as ageing. The progression of the disease there occurs tissue and vascular damages. This damage ultimately causes severe complications such as retinopathy, neuropathy, nephropathy, cardiovascular complications and ulceration. As diabetes mellitus is associated with severe medical complications it ultimately leads to premature death. The complications of diabetes are due to multiple factors, cellular pathways etc. Oxidative stress is one of the factors that cause this complication by generation of free radicals. The damage caused by these reactive free radicals can be minimized by the antioxidant capacity of vitamins especially vitamin C, E, A and others. Besides these the role played by some minerals is also critical. There are several parameters which can serve as a diagnostic to diabetes. Utilizing the methods for the measurement of these biomarkers is thus very critical and of utmost importance. Some of the diagnostic markers which can be utilized for the type of diabetes a patient is suffering from are blood sugar, HbA1c, c-peptide, GADA, glycated albumin and glycated proteins. The main idea and concern of writing this review is to explores diabetes mellitus in terms of its past historical perspective, biochemical basis, economic burden, management steps along with the future perspectives which needs to be taken to minimize the great loss of damage caused by this metabolic disorder.

Severe medical complications relating dental implant surgery

Severe medical complications relating dental implant surgery

A comprehensive analysis of continuous epidural analgesia's effect on labor and neonates in maternal hypertensive disorder patients.

Maternal hypertensive disorder is one of the most common and severe medical complications during pregnancy. Epidural analgesia administration is widely used during labor process. To evaluate the potential advantage or disadvantage of continuous epidural analgesia's on labor and neonates for maternal hypertensive disorder patients comprehensively. We have retrospectively analyzed 232 patients who diagnosed as maternal hypertensive disorder in our hospital since 2015. Among which, 126 patients including 28 cases of severe preeclampsia were administrated with continuous epidural analgesia (Analgesia group), the other 106 patients were untreated (Control group). We have compared the maternal age, body weight, gestational weeks, period for the first and second labor stage; the incidence of eclampsia, natural labor, cesarean section, forceps delivery and postpartum hemorrhage between these two groups respectively; furthermore, we recorded patients who received oxytocin and antihypertensive treatment during the delivery progress as well as evaluated the neonate body weight, Apgar score and performed umbilical cord blood gas analysis. Continuous epidural analgesia does not affect the first and second labor stage period (p=0.36), However, there is a significantly higher demand for oxytocin treatment (36.5% Vs 19.8%, p<0.01) and a significantly lower requirement for antihypertensive treatment (22.2% Vs 81.1%, p<0.001) in analgesia group compared to control group. We also notice that the natural delivery ratio in analgesia group is higher than control group and most importantly, continuous epidural analgesia can increase 1min Apgar score and has no other effect on neonates' body weight, umbilical cord blood gas parameters, 5min and 10min Apgar score. Our result based on a large cohort comprehensive analysis indicates that continuous epidural analgesia can benefit both maternal hypertensive disorder patients and neonates without any side effect.

Fertility, pregnancy and gynecological outcomes after fetoscopic surgery for congenital diaphragmatic hernia.

What is the impact of fetoscopic surgery for isolated Congenital Diaphragmatic Hernia (CDH) on future reproductive and gynecological outcomes? We did not observe an increase of obstetric or gynecological problems after fetoscopic surgery nor was there an increased risk for subsequent infertility. The reproductive and gynecological outcomes of patients undergoing open maternal-fetal surgery are known. The most relevant counseling items are the elevated risk for uterine dehiscence and rupture (up to 14%). Bi-centric study over a 10-year period including 371 women carrying a fetus with isolated CDH either managed expectantly (n = 167) or operated in utero (n = 204). Consenting patients filled out a survey with 23 questions (2 open and 21 multiple choice). Questionnaires were custom designed to obtain information on subsequent reproductive or gynecological problems as well as psychological impact. The response rate was 40% (147/371). More women in the FETO group attempted a subsequent pregnancy: 70% (62/89) when compared with 47% (27/58) in controls (P = 0.009). This coincided with a longer follow-up in the FETO group (76 versus 59 months; P < 0.001) and a lower survival rate in the index pregnancy (53 versus 72%; P = 0.028). There was no difference in the number of nulliparous or parous women, neither in the conception rate. In total, there were 129 subsequent pregnancies. Nobody reported secondary fertility problems. Four women in the FETO group and one in the control reported a congenital anomaly in a subsequent pregnancy. Twenty-one pregnancies were reported with at least one complication (FETO: 23% (14/60), controls 27% (7/26)). During delivery or in the post-partum period 11 patients reported at least 1 complication (FETO 17% (10/59), controls 4% (1/24)). New onset gynecological problems occurred in 14 participants (10%). None of these events were more likely in one or the other group. Psychological and emotional impacts were frequent in both the FETO (41%) and the control groups (46%) (P = 0.691). The response rate was 40% (147/371), less than desired. The use of unvalidated self-reported outcomes may skew exact determination of the nature and severity of medical complications. The number of observations for uncommon events was low. The mean follow-up period to detect gynecological complications may be too short. This is the first evidence that fetoscopic surgery for CDH does not compromise future reproductive potential or obstetrical outcome when compared with expectant management. A pregnancy complicated by a serious congenital birth defect, such as CDH, frequently has a measurable psychological impact. The authors have no conflicts to declare. J.D. receives a fundamental clinical research grant of the Fonds Wetenschappelijk Onderzoek - Vlaanderen (FWO; 18.01207). A.C.E. is supported by the Erasmus+Program of the European Union (Framework agreement number 2013-0040; contract 1011990). This was presented at the 61st meeting of the Society of Gynaecologic Investigation, in Florence, March 2014 (F-111).

Elective Total Knee Arthroplasty in Patients With End-Stage Renal Disease: Is It a Safe Procedure?

BackgroundThe purpose of this study was to compare outcomes and complications after total knee arthroplasty (TKA) between end-stage renal disease (ESRD) patients and patients without renal insufficiency. MethodsA retrospective case–control study with prospectively collected data was carried out to compare 15 ESRD patients with a matched cohort of 30 nonrenal patients. Clinical evaluation was performed by the Knee Society Scores (KSS) and reduced Western Ontario MacMasters University (WOMAC) questionnaire. Radiologic evaluation was also performed. ResultsThe mean postoperative follow-up was 3.4 years (range, 2-6). In the ESRD, the mean hospital stay and transfusion rate were significantly higher than control group. Preoperatively and postoperatively, there were no significant differences in KSS-knee or WOMAC-pain scores, but KSS-function and WOMAC-function were significantly lower in the ESRD group. There was no significant difference between groups in mean gain of KSS-function (45.1 vs 43.2, P = .071), but there was a significant lower mean gain for WOMAC-function in the ESRD group (37.0 vs 44.0, P = .003). In the ESRD group, 3 patients presented medical complications which were treated successfully. There were 2 superficial infections and no deep infection. One patient died at 30 postoperative months. In the control group, there were no medical complications, infections, or deaths during the follow-up period. In ESRD group, there were 2 knees with radiolucent lines. In either group, there was no loosening or revision. ConclusionTKA was a successful procedure for knee osteoarthritis in most ESRD patients. Dialysis patients may expect improvement in function after TKA, but the patients need to be informed of the possible risk of postoperative severe medical complications due to nature of their renal disease.

The medical complications associated with purging.

Purging behaviors, including self-induced vomiting, laxative abuse, and diuretic abuse, are present across many of the eating disorders. Here we review the major medical complications of these behaviors. Although we identified over 100 scholarly articles describing medical complications associated with purging, most papers involved case studies or small, uncontrolled samples. Given the limited evidence base, we conducted a qualitative (rather than systematic) review to identify medical complications that have been attributed to purging behaviors. Medical conditions affecting the teeth, esophagus, gastrointestinal system, kidneys, skin, cardiovascular system, and musculoskeletal system were identified, with self-induced vomiting causing the most medical complications. Purging behavior can be associated with severe medical complications across all body systems. Mental health professionals should refer patients with purging behaviors to medical providers for screening and treatment as needed. The medical work-up for individuals with eating disorders should include a comprehensive metabolic panel, complete blood count, and a full body exam including the teeth to prevent severe complications. Medical providers should screen patients for purging behaviors and associated medical complications, even in the absence of an eating disorder diagnosis, to increase the detection of eating disorders. Recognizing the link between purging and medical complications can aid in identifying potential eating disorders, particularly those that often elude detection such as purging disorder.

Secular Trends in Preeclampsia Incidence and Outcomes in a Large Canada Database: A Longitudinal Study Over 24 Years

BackgroundThe incidence of preeclampsia is increasing, but effects on women and infants are unclear. We measured the incidence of preeclampsia over time in a large Canadian population, and assessed trends in maternal and infant morbidity and mortality. MethodsWe carried out a population-based study of 1,901,376 linked hospital discharge abstracts for all deliveries in the province of Quebec, Canada from 1989 through 2012. We computed the annual incidence of preeclampsia, and used log binomial models to determine associations with severe morbidity and mortality for preeclamptic vs nonpreeclamptic pregnancies. Main outcomes included maternal, fetal, and infant mortality, admission to intensive care, intubation, preterm delivery, growth restriction, cesarean delivery, transfusion, and severe medical complications. ResultsThe incidence of preeclampsia increased from 26.4 per 1000 deliveries in 1989 to 50.6 in 2012. Maternal, fetal, and infant mortality decreased with time for preeclamptic but not for nonpreeclamptic pregnancies. By 2007-2012, risk for women with preeclampsia had declined for most maternal morbidities, except acute renal failure, which increased relative to no preeclampsia (risk ratio, 21.5; 95% confidence interval, 16.9-27.3). Risk of infant morbidity also decreased, but this coincided with an increase in the excess number of intubations and admissions for intensive care for preeclampsia relative to no preeclampsia. ConclusionsThe incidence of preeclampsia increased during the study, but with little effect on the risk of maternal and infant morbidity and mortality. For most outcomes, the risk decreased relative to no preeclampsia, with more aggressive medical management over time.

Historical outcomes of pediatric hematopoietic stem cell transplantation patients requiring critical care.

Hematopoietic stem cell transplantation (HSCT) is being used to treat numerous malignant and non-malignant medical conditions in pediatric patients, but frequently is associated with severe medical complications. We review the outcomes of HSCT patients who developed complications requiring pediatric intensive care unit (PICU) care. The earliest reported patient cohorts, who were transplanted prior to 1990, had high PICU mortality rates, exceeding 80%. Patients transplanted from the 1980s-1990s varied more widely in mortality rates, with mortalities of 56-88% reported for mechanically ventilated patients and rates of 44-50% reported for studies including both mechanically ventilated and non-mechanically ventilated patients in PICU. The patient group transplanted from the 1990s to the early 2000s had reported mortalities of 46-60%. For patients transplanted after 2000, mortality rates were reported ranging from 37-69%. Two centers reported a significant improvement in mortality over time at their centers, although other institutions did not find similar changes. Factors associated with increased mortality included the need for mechanical ventilation, pulmonary pathology as a cause for intubation, severity of lung disease, multiorgan failure, and severe graft versus host disease. The Pediatric Risk of Mortality scoring system has not been consistently predictive of mortality; the modified Oncological Pediatric Risk of Mortality system was more predictive of mortality in several studies. Overall, the mortality of pediatric HSCT patients requiring PICU care has decreased, but remains substantial. Further study is needed to define clinical factors that affect outcome, so that treatments might be modified to improve survival.

Consecutive Lacunar Strokes Mimicking Brainstem Symptoms in a Patient With Pseudobulbar Palsy

The pseudobulbar palsy affects both corticobulbar tracts leading to symptoms of the caudal brain nerves. These bulbar symptoms often may be misinterpreted and lead to a false localization of the ischemic lesion. Here we report on a patient with an acute small lacunar ischemic lesion who presented clinically with severe affection because of an identical old contralateral lesion. The patient presented with sudden onset of dysphagia, anarthria, and glossplegia. The clinical examination was suspicious of a brainstem lesion, however, stroke magnetic resonance imaging revealed a small ischemic lacuna within the right internal capsule. However, because of an old ischemic lesion within the left internal capsule, both corticobulbar tracts were involved and this pseudobulbar palsy was mimicking bulbar brainstem symptoms. Patients who suffer from a pseudobulbar palsy usually have—compared with the rather small lesions within the central nervous system—clinically dramatic presentations and due to bulbar symptoms severe medical secondary complications and social-economic consequences to deal with.

Temperament Dispositions, Problematic Eating Behaviours and Overweight in Adolescents.

Obesity, a common health condition in adolescence leading to severe medical complications, is assumed to be influenced by temperament factors. This paper investigates associations between reactive and regulative temperament, problematic eating behaviours and excess weight. Several self-report instruments were completed by 130 adolescents (mean age 14.13 ± 0.61 years), including 27 overweight and obese individuals (20.8%). Bootstrap analysis revealed a mediating effect of restrained eating on the relation between reactive temperament and body mass index percentile, which differed according to gender: Restrained eating, which predicted weight gain, was more present in girls having a higher sensitivity to reward and in boys showing a higher sensitivity to punishment. No effect of regulative temperament was found. These results have important implications for weight management programmes, as they suggest that reducing restrained eating by working on temperament may help to control weight.

Adjustment following chronic spinal cord injury: Determining factors that contribute to social participation

Spinal cord injury (SCI) is a catastrophic event that may result in diminished physical, social, and mental health. The main objective of this research was to establish inpatient factors that contribute to social participation following discharge into the community. Prospective longitudinal design with measures taken three times, soon after admission to rehabilitation (N = 88), at discharge from the inpatient phase (N = 81) and 6 months following discharge (N = 71). Participants included adults with SCI admitted into three SCI units over a 33-month period. Assessment included demographic, injury, and psychosocial health measures. Adjustment was defined by the extent of social re-integration or participation post-discharge after 6 months in the community. Social participation was measured by the Impact on Participation and Autonomy Questionnaire (IPAQ). Logistic regression models were used to establish inpatient factors that significantly predicted social participation 6 months post-discharge. Six months after discharge, around 55% of the sample had difficulties with social participation. The odds against being employed for an adult with poor social participation was found to be 8.4 to 1. Factors that predicted social participation included a younger age, having less severe secondary medical complications like bladder and bowel dysfunction, having a higher cognitive capacity, perceiving one has control (self-efficacy) over one's life and environment, and having greater perceived social support. These results provide direction for enhancing existing psychosocial health strategies within SCI rehabilitation, affording an opportunity for every person who sustains a permanent SCI to have optimal capacity for social participation. Statement of contribution What is already known on this subject? Spinal cord injury (SCI) is associated with significant challenges to wellbeing, including a high risk of secondary chronic illnesses, risk of co-morbid mental health problems, financial insecurity and social isolation. Research has shown poor social participation can lead to problems in re-integration into society following discharge from inpatient rehabilitation. Research to date has examined various factors related to poor social participation, but the majority of this research has been survey based with convenience samples. What does this study add? This study adds results of prospective longitudinal research on adjustment following SCI, where adjustment was defined by the rate of social participation when living in the community. About one-third of SCI participants were found to have very poor social participation, and only one-third had found some form of employment 6 months after discharge. Multiple factors were found to predict and contribute to poor social participation, including older age when injured, more severe medical complications, cognitive deficits, poor perceptions of control or self-efficacy, and poor social support.

Ethical considerations in the treatment of childhood obesity

Rates of obesity in children and adolescents appear to be stabilizing, though the prevalence of extreme obesity in this population remains fairly consistent at 4%. Childhood obesity contributes to serious health complications, such as hypertension, orthopedic problems, hormonal imbalances, and adult obesity. Psychological, as well as social issues are also com- mon comorbid conditions to childhood obesity. Families and health care providers have limited options in regard to treating childhood obesity, some of which come with complications and potentially severe consequences. Currently, though there are no standardized recommendations or guidelines for the treatment of childhood obesity, it is routinely suggested that families and medical practitioners attempt to decrease weight through family-based treatment prior to the prescription of medications or bariatric surgery. Family-based treatment options include therapy, psychoeducation, and lifestyle modification for the entire family, rather than solely focused on the overweight child. Using pharmacotherapy to treat childhood obesity has shown to be effec- tive in decreasing body mass index, along with changes in nutrition and activity. Use of these medications for managing obesity comes with undesirable side effects involving gastrointestinal and cardiovascular systems and raises concerns about malnutrition. Although bariatric surgery has increased over the last several years and has shown some success in the treatment of obesity, minor to severe medical complications have surfaced. Low calcium levels, unexpected pregnan- cies, risk of death postoperation, and the development or resurfacing of psychological disorders, such as binge eating disorder and depression, have occurred after bariatric surgery. The health of the child, efficacy of weight loss alternatives, risks and benefits associated with those choices, and the decision-making ability of minors must all be considered when determining the best treatment option for obese children.

Prise en charge de la maladie de Crohn

Crohn's disease is an inflammatory bowel disease that affects the entire digestive tract, from the mouth to the anus. The inflammatory disease is transmural and may be complicated by abscesses, fistulas, strictures. Budesonide is used as first-line treatment for a first episode of ileitis. Thiopurines and methotrexate are used as immunosuppressive maintenance therapy. Anti-tumour necrosis factors (TNF) alpha therapy is used as induction and maintenance therapy in case of severe flares or corticodependence. Combination of immunosuppressive therapy and anti-TNF-alpha (combotherapy) prevents the appearance of specific anti drug antibodies. Combotherapy is used in case of severe disease. The goal of the treatment is to achieve clinical remission, endoscopic mucosal healing, and to prevent the occurrence of complications such as strictures, fistulas or abscesses. Anoperineal lesions are found in 10% of the patients at diagnosis. Surgical treatment is indicated for severe medical treatment-resistant patients or complications such as symptomatic stenosis, fistula or abscess unresponsive to medical treatment or immediately complicated.