Severe Medical Complications Research Articles

Impact of the Use of Bowel for Urinary Diversion on Perioperative Complications and 90-Day Mortality in Patients Aged 75 Years or Older

Objective: A potential strategy to decrease the high complication rate of radical cystectomy (RC) in the elderly is to avoid the use of bowel for urinary diversion. The aim of this study was to address this issue in a multicentre study of patients aged ≥75 years. Patients and Methods: We performed a retrospective, multicentre study of a consecutive series of patients aged ≥75 years who underwent RC for muscle-invasive bladder cancer between 2006 and 2010. Medical, surgical and wound complications were graded according to the modified Clavien-Dindo classification. Results: A total of 256 patients (68% men, mean age 79.6 years) were analysed. 204 (80%) patients received a urinary diversion with use of bowel and 52 (20%) a ureterocutaneostomy (UC). Patients with UC were older (82.0 vs. 78.9 years, p < 0.001) and had a higher ASA score (2.6 vs. 2.3, p = 0.007), while the mean Charlson score was lower (4.2 vs. 5.6, p < 0.001). Patients with UC had a shorter operating time (279 vs. 311 min, p = 0.002) and a shorter period in the intensive care unit (0.9 vs. 2.2 days). The overall rate of severe complications graded as Clavien III-V was significantly lower in the UC group (11.5%) as compared to patients receiving bowel for urinary diversion (25.0%) (p = 0.003). Severe (Clavien grade III-V) medical (3.9 vs. 10.3%) and surgical (2.1 vs. 14.1%) complications were all less frequent in the UC group. Inpatient, 30- and 90-day mortality was 5.8, 7.7 and 17.3% in the UC group as compared to 3.9, 5.9 and 6.9% in the bowel cohort, respectively. Conclusion: UC following RC is associated with a lower complication rate in geriatric patients. The constantly increasing cohort of geriatric, multimorbid patients requiring cystectomy might justify reconsideration of this form of diversion.

Initial Movements and Interactions of a Child With Profound and Multiple Disabilities and Severe Medical Complications: A Case Study

Initial Movements and Interactions of a Child With Profound and Multiple Disabilities and Severe Medical Complications: A Case Study

Rural-metropolitan health differential for young persons with eating disorders referred for specialist treatment

Consistent with the hypotheses, living in a rural area was associated with a lower body mass index z-score, and a higher likelihood of medical complications at intake assessment. Contrary to our hypothesis, eating pathology and living in a rural area were negatively associated. No relationship was observed between living in a rural area and duration of illness or greater percentage of bodyweight lost. Conclusions The results suggest that living in a rural area and being a greater distance from specialist services is associated with more severe malnutrition and medical complications by the time the young person and their family obtain specialist care. These findings have implications for service planning and provision for rural communities. The modifications to service delivery in the study setting will be described. This abstract was presented in the Service Initiatives: Child and Adolescent stream of the 2014 ANZAED Conference.

A decade of data from a specialist statewide child and adolescent eating disorder service: does local service access correspond with the severity of medical and eating disorder symptoms at presentation?

BackgroundEating disorders affect up to 3% of children and adolescents, with recovery often requiring specialist treatment. A substantial literature has accrued suggesting that lower access to health care services, experienced by rural populations, has a staggering effect on health-related morbidity and mortality. The aim of this study was to evaluate whether lower service access foreshadowed a more severe medical and symptom presentation among children and adolescents presenting to a specialist eating disorders program.MethodThe data source was the Helping to Outline Paediatric Eating Disorders (HOPE) Project registry (N ~1000), a prospective ongoing registry study comprising consecutive paediatric tertiary eating disorder referrals. The sample consisted of 399 children and adolescents aged 8 to 16 years (M =14.49, 92% female) meeting criteria for a DSM-5 eating disorder.ResultsConsistent with the hypotheses, lower service access was associated with a lower body mass index z-score and a higher likelihood of medical complications at intake assessment. Contrary to our hypothesis, eating pathology assessed at intake was associated with higher service access. No relationship was observed between service access and duration of illness or percentage of body weight lost.ConclusionsLower service access is associated with more severe malnutrition and medical complications at referral to a specialist eating disorder program. These findings have implications for service planning and provision for rural communities to equalize health outcomes.

Management of Breast Cancer Patients with Chemotherapy-Induced Neutropenia or Febrile Neutropenia

Chemotherapy-induced neutropenia (CIN) is a common toxicity caused by the administration of anticancer drugs. This side effect is associated with life-threatening infections and may alter the chemotherapy schedule, thus impacting on early and long-term outcomes. Elderly breast cancer patients with impaired health status or advanced disease as well as patients undergoing dose-dense anthracycline/taxane- or docetaxel-based regimens have the highest risk of CIN. A careful assessment of the baseline risk for CIN allows the selection of patients who need primary prophylaxis with granulocyte colony-stimulating factor (G-CSF) and/or antimicrobial agents. Neutropenic cancer patients may develop febrile neutropenia and CIN-related severe medical complications. Specific risk assessment scores, along with comprehensive clinical evaluation, are able to define a group of febrile patients with low risk for complications who can be safely treated as outpatients. Conversely, patients with higher risk of severe complications should be hospitalized and should receive intravenous antibiotic therapy with or without G-CSF.

Medical and obstetric complications among pregnant women with cystic fibrosis

The objective of this study was to estimate the nationwide prevalence of cystic fibrosis (CF) in pregnancy and determine what medical complications exist at delivery among pregnant women with CF. The Nationwide Inpatient Sample (NIS) was queried for all delivery-related discharges. Women with CF were identified by International Classification of Diseases, 9th revision, Clinical Modifications codes and compared with women without CF. The prevalence of selected severe medical complications was compared between the 2 groups (NIS years 2008-2010) using multivariable logistic regression and the linear change in prevalence of CF at delivery determined (NIS years 2000-2010). From 2000 to 2010, there was a significant linear increase in the prevalence of CF at delivery from 3.0 to 9.8 per 100,000 deliveries, in 2000 and 2010, respectively (R(2)= 0.92, P < .0001). From 2008-2010, there were 1119 deliveries to women with CF and 12,627,627 to women without CF. Women with CF were more likely to be white (P < .0001) and have diabetes (odds ratio [OR], 14.0; 95% confidence interval [CI], 11.8-16.7) or asthma (OR, 5.1; 95% CI, 4.3-6.1). Multivariable logistic regression demonstrated that women with CF were more likely to die (adjusted OR [aOR], 76.0; 95% CI, 31.6-183), require mechanical ventilation (aOR, 18.3; 95% CI, 10.8-31.2), or have pneumonia (aOR, 56.5; 95% CI, 43.2-74.1), acute renal failure (aOR, 17.3; 95% CI, 9.1-32.6), preterm labor (aOR, 2.2; 95% CI, 1.9-2.6), or an adverse composite CF outcome (aOR, 28.1; 95% CI, 21.8-36.3). Pregnant women with CF are more likely to die, require mechanical ventilation, and have infectious complications compared with women without CF, although the absolute risks are low and these events are relatively rare.

Cardiac Arrhythmias in the Intensive Care Units

Background: Cardiac arrhythmias in critically ill patients often cause severe hemodynamic impairment or medical complications, precipitating rapid deterioration of patients’ conditions. This manuscript describes common or fatal cardiac arrhythmias occurring in patients hospitalized at intensive care units. Results: Differential diagnosis of wide QRS tachycardias includes ventricular tachycardias (VTs), supraventricular tachycardias with aberrant conduction and noise artifacts. Idiopathic VTs in patients with structurally normal hearts are responsive to antiarrhythmic agents and are cured by catheter ablation. Ventricular tachycardias in structural heart diseases require amiodarone for acute suppression and implantable defibrillator for longterm management. Polymorphic VTs or Torsades de Pointes are effectively suppressed by intravenous infusion of magnesium. Discontinuation of offending agents and, in some refractory cases, installation of temporary pacing is necessary. Atrial fibrillation (AF) is the most commonly observed tachyarrhythmias in intensive care settings. When combined with sepsis or congestive heart failure, AF with rapid ventricular response induces hypotension and sympathetic stimulation, which again aggravates rapid ventricular responses. This viscious cycle continues until adequate rate control measures are initiated. Intravenous amiodarone and anticoagulation are important initial management. In rare cases, electrical noises mimic ventricular tachycardias. Noises are distinguished from true VTs by identification of sharp QRS notches and stable hemodynamics during the events. Conclusion: Proper interpretation of monitoring or standard ECG is crucial for differential diagnosis of cardiac arrhythmias occurring in intensive care units. Management should be tailored based upon arrhythmia characteristics and individual medical conditions. Key Words: Tachycardia; Bradycardia; Intensive care

Perioperative Complications and 90-Day Mortality of Radical Cystectomy in the Elderly (75+): A Retrospective, Multicentre Study

Objective: To assess perioperative complications and 90-day mortality of radical cystectomy (RC) in elderly patients with muscle-invasive bladder cancer (MIBC). Materials and Methods: This is a retrospective, multicentre (n = 11) study of a consecutive series of patients ≥75 years who underwent RC for MIBC between 2006 and 2010. Medical, surgical and wound complications were graded according to the modified Clavien-Dindo classification. Results: A total of 256 patients with a mean age of 79.6 years (range 75.0-86.6) were analysed. Urinary diversion with the use of bowel was performed in 79.5% and ureterocutaneostomy in 20.5%, with a higher proportion in the ≥80 cohort (32.2 vs. 14%; p = 0.001). 41.4% of patients had an uneventful postoperative course (Clavien grade 0) and 26.6% developed severe complications (Clavien grade III-V). In a multivariable regression analysis, the Charlson comorbidity index (odds ratio 1.5 per unit increase; p < 0.001) and the body mass index (odds ratio 1.13 per kg/m² increase; p = 0.015) were predictors for the development of complications. The 90-day mortality rate was 9% and the independent correlates thereof were the development of severe medical complications (p = 0.004), the American Society of Anesthesiologists (ASA) score (p = 0.03) and age (p = 0.005). Conclusions: Morbidity and 90-day mortality of RC in the elderly remain substantial. The interrelation between comorbidity, complication rate and 90-day mortality underlines the need for a comprehensive geriatric assessment of elderly patients with MIBC in whom RC is indicated.

Management and treatment of eating disorders with severe medical complications on a psychiatric ward: a study of 9 inpatients in Japan

ObjectiveTo describe eating disorders inpatients with severe medical complications and elucidate the problems in managing them on a psychiatric ward. MethodOf the 111 eating disorders patients hospitalized on our psychiatric ward from January 2005 to December 2012, 9 had eating disorders with severe medical complications. Through chart review and computerized data collection, we retrospectively evaluated patient clinical data. ResultAll 9 patients were women, with a mean age of 22.4±5.7 years, mean body weight of 26.2±3.0 kg, and mean body mass index of 10.5±1.5 on admission. Severe medical complications commonly seen were severe hypoglycemia, refeeding syndrome, coagulation abnormality, and severe liver dysfunction. Three patients died during hospitalization. All patients were managed mainly on the psychiatric ward despite their abnormally low body weight and severe medical complications. ConclusionsPatients with eating disorders, although physically serious, often need to be managed on a psychiatric ward, even at the risk of providing less than ideal care for their physical complications. It is important to assess patient status both physically and psychologically and to select an appropriate therapeutic environment for safe and effective treatment.

EPA-0734 - Severe liver dysfunction in a male with life-threatening anorexia nervosa: a case report

Anorexia nervosa (AN), rare in young men, is potentially associated with severe medical complications. Mild liver involvement is common. However, rare cases of severe liver dysfunction associated with AN have been described. To present a rare, severe case of an adult male with AN. Describe uncommon, potentially lethal, medical complications associated with liver dysfunction. Describe medical/psychiatric presentation, course of disease and interventions during hospitalization and follow-up. Male 35 y.o. with AN for 20 years (purging type with use of diuretics/ laxatives and intensive exercise) was transferred involuntarily to the Psychiatric Department from Gastroenterology because of continuing weight loss, excessive exercise, non-compliance of food/fluid intake recommendations and use of diuretics. The patient on admission had BMI 13.5 kg/m 2 (recent weight loss of 20 kg), ascites, ankle edema, severe transaminases elevation (x20), and electrolytes dysregulation. In addition, the patient presented depressive symptoms, hoarding, and obsessive compulsive/avoidant personality traits. Feeding was started with parenteral administration, and then through nasogastric tube. Also, the patient was restricted to his room and energy expenditure was controlled. In addition, behavioral/family/cognitive psychotherapeutic interventions were employed. Patient was treated with S-Citalopram, Olanzapine, and Lorazepam. Weight gradually increased. After 4.5months of hospitalization, liver function was normal, BMI was 21 kg/m 2 , mood was elevated, and hoarding was diminished. In a 6 months outpatient follow-up the patient's BMI was 23 kg/m 2 and he was both socially and personally functional. Long hospitalization using an integrated approach that combines medical and psychotherapeutic interventions, may reverse severe liver dysfunction in life-threatening NA.

Management of acute hyperglycemic emergencies: focus on diabetic ketoacidosis.

Management of acute hyperglycemic emergencies: focus on diabetic ketoacidosis.

A decade of data from a specialist statewide child and adolescent eating disorder service: does local service access correspond with the severity of medical and eating disorder symptoms at presentation?

BackgroundEating disorders affect up to 3% of children and adolescents, with recovery often requiring specialist treatment. A substantial literature has accrued suggesting that lower access to health care services, experienced by rural populations, has a staggering effect on health-related morbidity and mortality. The aim of this study was to evaluate whether lower service access foreshadowed a more severe medical and symptom presentation among children and adolescents presenting to a specialist eating disorders program.MethodThe data source was the Helping to Outline Paediatric Eating Disorders (HOPE) Project registry (N ~1000), a prospective ongoing registry study comprising consecutive paediatric tertiary eating disorder referrals. The sample consisted of 399 children and adolescents aged 8 to 16 years (M =14.49, 92% female) meeting criteria for a DSM-5 eating disorder.ResultsConsistent with the hypotheses, lower service access was associated with a lower body mass index z-score and a higher likelihood of medical complications at intake assessment. Contrary to our hypothesis, eating pathology assessed at intake was associated with higher service access. No relationship was observed between service access and duration of illness or percentage of body weight lost.ConclusionsLower service access is associated with more severe malnutrition and medical complications at referral to a specialist eating disorder program. These findings have implications for service planning and provision for rural communities to equalize health outcomes.

Molecular clocks ticking in the court room

Molecular clocks ticking in the court room

Hämatologische Veränderungen bei Anorexia nervosa im Kindes- und Jugendalter

Hematological changes often occur in patients with acute anorexia nervosa (AN). However, the relationship between these disturbances and other clinical parameters remains unclear. Leucocyte, erythrocyte, and thrombocyte counts as well as hematocrit, hemoglobin, and differential blood counts were collected at admission and after weight restoration in 88 female adolescent patients with the diagnosis of AN according to DSM-IV. These were then compared to clinical parameters. At admission, there were mild changes in the blood count, most of which, however, were reversible after weight gain. Patients with a greater weight loss, a lower age-adjusted BMI, and a history of taking psychotropic drugs were more likely to develop hematological abnormalities. Although most of the hematological changes in adolescent patients with AN were mild, patients with high weight loss and/or low age-adjusted BMI as well as those on psychotropic medication should be monitored carefully in order to avoid severe medical complications. An altered immune function in adult patients with chronic AN might contribute to a higher rate of infections and thus to an increased mortality.

Drug-eluting cements for hard tissue repair: A comparative study using vancomycin and RNPA1000 to inhibit growth of Staphylococcus aureus

Bone cement used in orthopaedic applications can become colonized with bacterial biofilms, resulting in severe medical complications. Consequently, bone cements are often loaded with antibiotics in an effort to prevent bacterial colonization. However, current formulations may not release antibiotics into the environment at sufficient and sustained concentrations required to impede bacterial growth or may be incompatible with antibiotics that are effective against the colonizing organism. Thus, new cement formulation options are needed. This report describes the performance of a novel SiO2-TiO2-ZnO-CaO-SrO-based glass polyalkenoate cement as a carrier of antimicrobials active against Staphylococcus aureus, the predominant cause of orthopaedic biofilm-associated infections. The antibiotic vancomycin and a novel Staphylococcus aureus RnpA inhibitor under pre-clinical development, RNPA1000, were included in these studies. Rheological testing characterized the workability of the glass polyalkenoate cement over a range of powder-to-liquid ratios and polyacrylic acid concentrations and revealed that the most suitable powder-to-liquid ratio was 2/1.25 with 40 wt% polyacrylic acid. Loading glass polyalkenoate cement with either 20-30% RNPA1000 or vancomycin prevented bacterial growth. However, longer incubations allowed for Staphylococcus aureus colonies to form near the vancomycin-infused cement, indicating that vancomycin may not be suitable for long-term biofilm inhibition in comparison to RNPA1000. Scanning electron microscopy and energy-dispersive X-ray analyses confirmed successful incorporation RNPA1000 into the cement matrix and were indicative of its slow release. These studies establish a drug-eluting formulation of glass polyalkenoate cement with great potential in orthopaedic implants that incorporates known antibiotics as well as RNPA1000 to prevent growth of the dangerous pathogen Staphylococcus aureus.

RKIP Contributes to IFN-γ Synthesis by CD8+ T Cells after Serial TCR Triggering in Systemic Inflammatory Response Syndrome

Systemic inflammatory response syndrome (SIRS) is associated with the development of severe medical complications, including progression to multiple organ dysfunction syndrome and even death. To date, only marginal improvements in terms of therapeutic options have been established for patients affected by SIRS. Raf kinase inhibitor protein (RKIP) is a regulator of MAPK and NF-κB signaling cascades, which are both critical for production of the proinflammatory cytokines responsible for SIRS initiation. By testing a T cell-dependent mouse model of SIRS that utilizes staphylococcal enterotoxin A specific for Vβ3(+) T cells, we show that RKIP is necessary for the exaggerated production of IFN-γ from SIRS splenocytes. This effect was not due to differences in T cell expansion, IL-10 production, or APC priming, but rather a cell-intrinsic defect lying downstream of the TCR in staphylococcal enterotoxin A-specific CD8(+) T cells. Importantly, mice lacking RKIP were still able to proliferate, survive, and contribute to cytokine production in response to pathogen associated molecular pattern-TLR-mediated stimuli, despite the TCR-dependent defects seen in our SIRS model. Finally, by blocking RKIP in wild-type SIRS splenocytes, the IFN-γ response by CD8(+) Vβ3(+) T cells was significantly diminished. These data suggest that RKIP may be a potential therapeutic target in SIRS by curbing effector cytokine production from CD8(+) T cells during serial TCR triggering.

S07.2 The Extrusion Paradigm of Chlamydia Pathogenesis

Chlamydia is the most commonly reported bacterial disease in the United States, and remains the leading bacterial cause of sexually transmitted infection, responsible for approximately 90 million new STI cases...

Disease-specific knowledge and information preferences of young patients with congenital heart disease

Persons suffering from congenital heart defects require lifelong specialist medical care. Failure to attend cardiological follow-up examinations and risky health behaviour in the transition phase may cause severe medical complications. A good level of disease-specific knowledge enhances compliance. Therefore, the study's aim was to investigate: (a) the level of disease-specific knowledge, (b) information preferences, and (c) sources of information for children, adolescents, and young adults regarding their illness. In all, 596 patients, aged 10-30 years, participated in this cross-sectional survey study (response rate: 53%). All patients were already enrolled in the German National Register for Congenital Heart Defects. The main outcome measures included disease-specific knowledge, information preferences, and information sources regarding patients' individual cardiac condition. The patients demonstrated a major knowledge gap concerning their illness and how to live with it. For all three age groups, patients' information needs were unmet on nearly half of the topics of interest. Children's information needs were comparable to those of adolescents and adults concerning several important topics, for example, work/career, sports. Information preferences varied according to age and gender, rather than disease severity. The most important sources of information were physicians (71.0%), family and friends (58.2%), and the Internet (37.5%). The study revealed substantial knowledge gaps, indicating a need for structured multidisciplinary patient education interventions. These interventions should start as early as in childhood and help patients manage their condition and assume responsibility for their own health, so that the transition phase runs smoothly.

Is mid-upper arm circumference alone sufficient for deciding admission to a nutritional programme for childhood severe acute malnutrition in Bangladesh?

Mid-upper arm circumference (MUAC) and weight-for-height Z-score (WHZ) identify different populations of children with severe acute malnutrition (SAM) with only some degree of overlap. In an urban slum in Bangladesh, we conducted a prospective cohort study on children assessed as being severely malnourished by WHZ (<-3) but not by MUAC (>115 mm), to: 1. Assess their nutritional outcomes, and 2. Report on morbidity and mortality. Children underwent 2-weekly prospective follow-up home visits for 3 months and their anthropometric evolution, morbidity and mortality were monitored. Of 158 children, 21 did not complete follow-up (six were lost to follow-up and 15 changed residence). Of the remaining 137 children, nine (7%) required admission to the nutrition programme because of: MUAC dropping to <115 mm (5/9 children), weight loss ≥ 10% (1/9 children) and severe medical complications (3/9 children, of whom one died). Of the remaining 128 children who completed follow-up, 91 (66%) improved in nutritional status while 37 (27%) maintained a WHZ of <-3. Cough was less frequent among those whose nutritional status improved. It seems acceptable to rely on MUAC as a single assessment tool for case finding and for admission of children with SAM to nutritional programmes.

The prevalence of positive serum anticardiolipin antibodies and asymptomatic bacteriuria in women with recurrent abortions.

The asymptomatic colonization of the urinary tract in pregnant women may result in severe medical and obstetric complications. The aim of this study was to study the prevalence of asymptomatic bacteriuria in cases of elevated levels of the anticardiolipin antibody in women who experience spontaneous abortions. A total of 12 women were enrolled in this case control study, including 60 patients with a history of three or more abortions and 60 healthy pregnant women. All participants were screened for ACL (IgG) and with a urine culture. Overall, 19 (31.7%) patients and seven (11.7%) healthy pregnant women were positive for ACL. The mean concentrations were 67.1±27.2 IU/mL in the patients and 17.41±6.12 IU/mL in the healthy controls (p≤0.05). In the 60 patients, only 17 (28.3%) had significant bacteriuria, whereas 5 (8.3%) women in the control group had significant bacteriuria. The statistical analysis revealed a highly significant difference. Of the 19 patients with a positive elevation of ACL, 11 (57.9%) had significant bacteriuria, and eight (42.1%) had non-significant bacteriuria. Six patients had ACL-negative results associated with significant bacteriuria. The statistical analysis revealed a highly significant difference. A high serum anticardiolipin level was prevalent in women who experienced recurrent abortions associated with asymptomatic bacteriuria.