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PubMed2006

In sickness and in health: transition of cancer-related care for older adolescents and young adults.

With nearly 80% of childhood cancer patients achieving cure, there are more adult survivors living now than at any other time in history. Because they are at risk for developing complications of treatment years later, it is recommended that survivors undergo systematic, regular monitoring into young adulthood and beyond. Occasionally, older adolescents and young adults are diagnosed with a relapsed, secondary or primary malignancy that requires urgent care. How best to manage each of these situations is a major challenge. A review of literature and clinical experience was performed. The medical, developmental, and psychosocial characteristics of older adolescents and young adults argue for a planned transition of care from a pediatric to more appropriate adult setting at that age. The 'health-oriented transition' involves the relatively healthy survivor, where an adult-oriented provider must be identified and supplied with a comprehensive treatment history, problem list, and monitoring plan. Continuity of medical insurance coverage must be preserved. The 2 basic models for this type of transition are either institution- or community-based. Each has relative advantages and disadvantages. In both, education and empowerment of the survivor are fundamental. The 'crisis-oriented transition' involves the older adolescent or young adult who is diagnosed in the pediatric setting with relapsed, secondary or primary cancer and is rapidly moved into the adult setting to begin treatment. With minimal time for preparation, this transition requires collaborative efforts by the pediatric and adult oncology teams. Having the capability to address both types of transition should be a central goal of any pediatric and adolescent oncology program.

Adolescent↗

PubMed2001

The high morbidity of blunt cerebrovascular injury in an unscreened population: more evidence of the need for mandatory screening protocols.

BACKGROUND: Blunt cerebrovascular injuries are rare injuries causing substantial morbidity and mortality. The appropriate screening methods and treatment options for these injuries are controversial. We examined our experience with these injuries at a community Level I Trauma center over a 51 month period. STUDY DESIGN: A retrospective review and analysis was done of all patients with the diagnosis of a blunt cerebrovascular injury during this period. RESULTS: Fourteen patients had blunt carotid injury (0.40%) and three had blunt vertebral injury (0.09%) out of 3,480 total blunt admissions. The overall incidence of blunt cerebrovascular injury was 0.49%. The most common associated injuries were to the head (59%) and chest (47%) regions. The overall mortality rate was 59% (10 of 17), with death occurring in 8 of 14 (57%) blunt carotid injury patients and 2 of 3 (67%) blunt vertebral injury patients. Eight of ten (80%) deaths were directly attributable to the blunt cerebrovascular injury. Median time until diagnosis was 12.5 h (range 1-336 h) for the entire group and 19.5 h for nonsurvivors. Diagnosis was delayed > 24h in 7 patients and > 48h in 5 patients. All five patients whose diagnoses were delayed > 48 h developed complications, and four (80%) of these patients died. CONCLUSIONS: Blunt cerebrovascular injury is uncommon, but lethal; particularly when the diagnosis is delayed. Aggressive screening protocols based on mechanism of injury, associated injuries, and physical findings are justified to minimize morbidity and mortality. Head and chest injuries may serve as markers for blunt cerebrovascular injury. Most deaths are directly attributable to the blunt cerebrovascular injury and not to associated injuries.

Biomechanical Phenomena↗

PubMedDate not supplied

Cystatin C and incident peripheral arterial disease events in the elderly: results from the Cardiovascular Health Study.

BACKGROUND: The association of cystatin C, a novel marker of renal function, with risk for developing complications related to peripheral arterial disease (PAD) has not been examined. METHODS: We evaluated the hypothesis that a high cystatin C concentration is independently associated with future PAD events among 4025 participants in the Cardiovascular Health Study who underwent serum cystatin C measurement at the 1992-1993 visit and who did not have PAD at baseline. The association of cystatin C quintiles with time to first lower-extremity PAD procedure (bypass surgery, angioplasty, or amputation) was evaluated using multivariable proportional hazards models. Secondary analyses were conducted using quintiles of serum creatinine level and estimated glomerular filtration rate (eGFR). RESULTS: The annualized risk of undergoing a procedure for PAD was 0.43% per year among participants in the highest cystatin C quintile (>1.27 mg/L) compared with 0.21% per year or less in all other quintiles. After multivariable adjustment for known risk factors for PAD, elevated cystatin C levels remained associated with the outcome (hazard ratio, 2.5 for highest vs lowest quintile of cystatin C, 95% confidence interval, 1.2-5.1). The highest quintiles of serum creatinine level and eGFR were not associated with future PAD events in either unadjusted or adjusted analyses. CONCLUSION: Elevated concentrations of cystatin C were independently predictive of incident PAD events among community-dwelling elderly patients.

Aged↗

PubMed1981

Hematogenous staphylococcal pneumonia secondary to soft tissue infection.

Staphylococcal pneumonia is rare, has a high mortality and morbidity rate, and occurs commonly during influenza epidemics (airborne) or during the course of right sided bacterial endocarditis in drug addicts (blood borne). In recent years, much emphasis has been given to the staphylococcal infections in intravenous drug abusers. This report describes ten patients with staphylococcal pneumonia resulting from soft tissue infection who were previously healthy and had no history of drug abuse. They were 12 to 45 years old. Eight were male patients. Soft tissue infection was community-acquired in nine and was most commonly located in the lower extremities. Three patients had diabetes. All presented with a clinical picture of acute pneumonia. Hemoptysis occurred in three. Chest roentgenogram showed multiple large or small round discrete densities in most of the patients. Lobar involvement was notably absent. Eight developed cavitary lesions in their lungs. The average length of hospital stay was 40 days. One patient died and six developed complications. Staphylococcal etiology should be suspected in patients with acute pneumonia who have soft tissue infection or have characteristic chest roentgenogram findings; antistaphylococcal agents should be included in the therapeutic regimens of such patients until the results of the cultures are known.

Adolescent↗

PubMed1999

Handoscopic surgery: a prospective multicenter trial of a minimally invasive technique for complex abdominal surgery. Southern Surgeons' Club Study Group.

HYPOTHESIS: We hypothesized that hand-assisted laparoscopic surgery (a new technique that involves a surgeon's hand passing through a pneumoperitoneum-protecting sleeve device and assisting in laparoscopic surgery) is feasable and outcomes are comparable to purely laparoscopic procedures in selected cases. DESIGN: A prospective, multicenter, nonrandomized, noncontrolled study was conducted with the participation of expert laparoscopic surgeons. SETTING: Academic and community medical centers in 16 states. PATIENTS: Any patient 18 years or older requiring abdominal surgery and determined to be suitable for laparoscopic surgery. MAIN OUTCOME MEASURES: Incision size, duration of the procedure, conversion rate to an open technique, detection of subtle disease, return of bowel function, length of hospital stay, complication rate, and subjective evaluation. RESULTS: The device was used in 58 patients for 24 different procedures, most commonly during colectomy (n = 21) and splenectomy (n = 7). Twenty-two percent of cases required conversion to open technique because of failure to maintain pneumoperitoneum or failure to complete the anticipated operation by this method. Average incision size was 7.6 cm. Mean duration of all procedures was 223 minutes (range, 110-415 minutes) and for nonconverted procedures was 178 minutes (range, 65-540 minutes). Preoperatively undetectable, subtle disease was palpated in 14 patients (24%). Mean length of hospital stay for all patients was 7.9 days and for the nonconverted group was 6.7 days. Twenty-four percent of patients developed complications, most commonly either wound complications (n = 4) or prolonged ileus (n = 3). In 58% of cases, surgeons thought that the technique shortened surgery, and 88% of surgeons found the technique "helpful" in all the completed procedures. CONCLUSIONS: This technique seems to be a useful tool in the management of cases that either are too complex or take too long to be managed with purely minimally invasive techniques. To further define the potential benefits of this technique in selected procedures, prospective randomized trials are needed.

Abdomen↗

PubMed1999

[Radiologic intervention in the biliary tract performed at a central hospital].

During the ten-year period 1987-96, 131 diagnostic percutaneous transhepatic cholangiographies (PTC) were performed in 103 patients due to obstructive jaundice. 54 cases of percutaneous transhepatic bile drainage (endoprosthesis) (PTBD) and 53 of percutaneous transhepatic external drainage (PTED) were also performed. In 89 patients (86%) the obstructive jaundice was caused by malignant disease. Puncture was done under fluoroscopic or ultrasonographic control. An 8 Fr. plastic endoprosthesis of 15 cm length was used for internal bile drainage, and a 7.6 Fr. 60 cm long catheter was used for external drainage. For combined external/internal drainage an 8.4 Fr. catheter of 60 cm length was used. 24 patients (23%) developed complications. Eight of these complications were serious, and three patients (2.5%) died as a result of the procedure. Three patients developed duodenal perforations. 11 out of 51 patients (20%) treated with endoprosthesis died within 30 days. Mean functioning time for endoprostheses was 128 days. Progress in radiologic intervention technique has changed the treatment of obstructive jaundice. In our view, endoscopic bile drainage should be the treatment of choice. Percutaneous transhepatic bile drainage is an alternative in cases where endoscopic therapy fails.

Adult↗

PubMed2004

[Staphylococcal pneumonia].

In January to December 2000, a total of 15 (8.8%) patients with staphylococcal community-acquired pneumonia (CAP), 13 (27.7%) patients with staphyloccocal nosocomial pneumonia (NP) that occurred at general units (GU), and 9 (50%) patients with GU that occurred under artificial ventilation (AV) at intensive care units (ICU) were followed up. Meticillin-resistant S. aureus strains were isolated in 6.7, 38.5, and 55.6% of cases, respectively. As compared with pneumococcal CAP, staphyloccocal CAP were more frequently characterized by the severe course of the disease (46.7% versus 15.4%), bilateral lesion (33.3% versus 5.1%), and the presence of complications (66.7% versus 30.8%). Staphyloccocal NP that had occurred at GU, as compared to that at ICU also showed the severe course of the disease (46.2% versus 2.9%), bilateral lesion (30.7% versus 0%), and developed complications (75% versus 25%). Staphylococcal NP developed under AV at ICU had no specific features as compared with NP of another etiology. Oxacillin and first-second-generation cephalosporins remain to be the drugs of choice when meticillin-sensitive S. aureus strains are isolated; lincomycin and erythromycin being alternative agents against these strains. Glycopeptides are the drugs of choice when meticillin-resistant S. aureus strains are isolated, its alernatives are linesolide or rifampicin. High mortality rates due to staphylococcal pneumonia are preserved. These are 7.1% in CAP, 7.7 and 66.7 in staphylococcal NP occurring at GU and under AV at ICU, respectively.

Acute Kidney Injury↗

PubMedDate not supplied

Poisoning : pattern and profile of admitted cases in a hospital in central Nepal.

An analysis of all poisoning cases admitted in medical and pediatric wards of Patan Hospital for one year (1st Jan to 31st Dec 2004) was carried out. A total of 154 cases were admitted which was 0.8% of total hospital admissions. Females outnumbered males and almost two-thirds patients were young adults (15-34 years). Seasonal variation in poisoning was observed with more cases in the summer months. Organophosphorus compounds (42%), drugs (25%), and zinc phosphide (6.5%) were common poisonings in total and in adult populations, whereas kerosene was the most frequent poisoning in pediatric age group. Paracetamol, benzodiazepines, and tricyclic antidepressants were the most frequently used drugs. The circumstances of poisoning were intentional (75%) and accidental (20%); most of the childhood poisonings were accidental in nature. The mean hospital stay for all type of poisoning was 7.5 days; whereas it was 10.2 days for organophosphorus, 2.5 days for paracetamol, and 1.5 days each for zinc phosphide and kerosene ingestion. Intensive care unit (ICU) service was required in 17% of patients; and almost 25% developed complications. Aspiration pneumonia and respiratory failure were the most frequently observed complications. Ninety four percent of admitted patients recovered completely; leaving a mortality rate of 5%.

Accidents, Home↗

PubMed1989

[Endocarditis of a natural valve caused by coagulase-negative staphylococci].

Eleven patients with endocarditis of a natural valve due to coagulase-negative staphylococci are reported. Nine had some underlying heart disease. The course was subacute in seven and acute (two weeks or less) in the remaining four. All patients developed complications: heart failure in nine, arterial emboli in eight, atrioventricular conduction disorders in four, development of paravalvular and/or myocardial abscesses in four, and perforation or rupture of valve leaflets in four. Eight patients were cured, seven of them requiring surgical treatment. Three of the isolated coagulase-negative staphylococci strains were methicillin-resistant; two of them caused community-acquired endocarditis. Natural valve endocarditis due to coagulase-negative staphylococci usually has a subacute course with a tendency to develop severe complications. This makes surgical therapy necessary in a sizeable number of patients.

Adult↗