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Management of potential T-tube inpatient complications; and 10. Management of T-tube complications in the outpatient setting.
Although their use has decreased substantially, the role of biliary T-tubes in some patients is essential. Given the reality of less frequent experience with T-tube insertion and management, this 10-step pathway will provide an adequate mental and technical framework for safe biliary T-tube use.
Level V, Expert opinion.
Level V, Expert opinion.
Loco-regional analgesia (LRA) remains underutilized in patients with chest wall injuries. Surgical stabilization of rib fractures (SSRF) offers an opportunity to deliver surgeon-directed LRA under direct visualization at the site of surgical intervention. We hypothesized that a single-dose liposomal bupivacaine (LB) intercostal nerve block provides comparable analgesia to an indwelling, peripheral nerve plane analgesic catheter with continuous bupivacaine infusion (IC), each placed during SSRF.
Non-inferiority, single center, randomized clinical trial (2017-2020). Patients were randomized to receive either IC or LB during SSRF. The IC was tunneled into the surgical field (subscapular space) and LB involved thoracoscopic intercostal blocks of ribs 3-8. The primary outcome was the Sequential Clinical Assessment of Respiratory Function (SCARF) score, measured daily for 5 days post-operatively. Secondary outcomes included daily narcotic equivalents and failure of primary LRA, defined as requiring a second LRA modality.
Thirty-four patients were enrolled; 16 IC and 18 LB. Age, injury severity score, RibScore, Blunt Pulmonary Contusion Score, and use of non-narcotic analgesics was similar between groups. Duration of IC was 4.5 days. There were three failures in the IC group versus one in the LB group (p=0.23). There was no significant difference in SCARF score between the IC and LB groups. selleck chemical On post-operative days 2-4, narcotic requirements were less than half in the LB, as compared to the IC group; however, this difference was not statistically significant. Average wholesale price was $605 for IC and $434 for LB.
In this non-inferiority trial, LB provided at least comparable, and potentially superior LRA as compared to IC among patients undergoing SSRF.
Level II, Therapeutic.
Level II, Therapeutic.
School refusers often display somatic symptoms which are temporally related to school attendance. The aim of this systematic review is to summarize characteristics and causes of somatic symptoms and their management in the context of school refusal. Findings of this review may help clinicians in their daily practice.
Pubmed and Psycinfo databases were systematically searched (according to PRISMA guidelines) for articles mentioning somatic symptoms in school refusal by May 2020. Among 1,025 identified studies, 148 were included.
Unspecific somatic symptoms were frequently the first complaints in school refusal. Abdominal pain, headache, nausea, vomiting, muscular or joint ache, diarrhea, dizziness, fatigue and palpitation were the most commonly encountered symptoms and were usually not accounted for by an identifiable physical disease. Anxiety was the most recurrent etiology found, but physicians' lack of awareness about psychological comorbidities often delayed psychological/psychiatric referral. Succesists is needed to improve wellbeing in children who experience somatic symptoms as related to school avoidance.
Aged population with comorbidities demonstrated high mortality rate and severe clinical outcome in the patients with coronavirus disease 2019 (COVID-19). However, whether age-adjusted Charlson comorbidity index score (CCIS) predict fatal outcomes remains uncertain.This retrospective, nationwide cohort study was performed to evaluate patient mortality and clinical outcome according to CCIS among the hospitalized patients with COVID-19 infection. We included 5621 patients who had been discharged from isolation or had died from COVID-19 by April 30, 2020. The primary outcome was composites of death, admission to intensive care unit, use of mechanical ventilator or extracorporeal membrane oxygenation. The secondary outcome was mortality. Multivariate Cox proportional hazard model was used to evaluate CCIS as the independent risk factor for death.Among 5621 patients, the high CCIS (≥ 3) group showed higher proportion of elderly population and lower plasma hemoglobin and lower lymphocyte and platelet counts. The  .001) and patient mortality (HR 22.96, 95% CI 7.20-73.24, P  less then  .001). The nomogram showed that CCIS was the most important factor contributing to the prognosis followed by the presence of dyspnea (hazard ratio [HR] 2.88, 95% confidence interval [CI] 2.16-3.83), low body mass index  less then  18.5 kg/m2 (HR 2.36, CI 1.49-3.75), lymphopenia ( less then 0.8 x109/L) (HR 2.15, CI 1.59-2.91), thrombocytopenia ( less then 150.0 x109/L) (HR 1.29, CI 0.94-1.78), anemia ( less then 12.0 g/dL) (HR 1.80, CI 1.33-2.43), and male sex (HR 1.76, CI 1.32-2.34). The nomogram demonstrated that the CCIS was the most potent predictive factor for patient mortality.The predictive nomogram using CCIS for the hospitalized patients with COVID-19 may help clinicians to triage the high-risk population and to concentrate limited resources to manage them.
Whether breast-conserving therapy (BCT) should be chosen as a local treatment for young women with early-stage breast cancer is controversial. This study compared the survival benefits of BCT or mastectomy in young women under 40 with early-stage breast cancer and further explored age-stratified outcomes. This study investigated whether there is a survival benefit when young women undergo BCT compared with mastectomy.The characteristics and prognosis of white women under 40 with stage I-II breast cancer from 1988 to 2016 were analyzed using the Surveillance, Epidemiology, and End Results (SEER) database. These women were either treated with BCT or mastectomy. The log-rank test of the Kaplan-Meier survival curve and Cox proportional risk regression model were used to analyze the data and survival. The analysis was stratified by age (18-35 and 36-40 years).A total of 23,810 breast cancer patients were included, of whom 44.9% received BCT and 55.1% underwent mastectomy, with a median follow-up of 116 months. Patients undergoing mastectomy had a higher tumor burden and younger age.