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Although the term ‘tracheostomy’ simply means a hole entering the trachea, it can be usefully divided into tracheostomy (in which a hole is made between the anterior neck and the trachea, which remains otherwise intact) and laryngectomy (in which the larynx is removed and the trachea is joined to the neck as a blind-ending stoma). Both groups of patients have an increased risk of complications outside and within hospitals. Many of these are entirely avoidable by better knowledge and reliability of care. There is confusion about different types of tracheostomy and between management of complications of tracheostomy and laryngectomy stoma. There is a need for clear understanding of the differences and what represents good care of such patients and their airways. Complications include airway blockage and displacement. Harm may occur if airway emergencies are not managed promptly and in a structured manner. Standard operating procedures, algorithms and checklists have a role in improving reliability of care and approaches to emergencies. Recent evidence shows multidisciplinary teams using quality improvement principles can reduce complications, hasten decannulation and improve patient experience. The National Tracheostomy Safety Project and the Global Tracheostomy Collaborative have been established to improve education and safety of tracheostomy care.
Despite the training and skills of airway managers, airway management complications still occur and may cause patient harm or death. The causes are multifactorial and may include patient, environment and clinician factors. Airway complications likely contribute to a significant proportion of deaths due to anaesthesia and are certainly more common outside the operating theatre and especially in the critical care unit. Reported incidences of failure and harm during airway management vary depending on the population studied and definitions used. Numbers may be of less value than understanding themes that help us improve care and reduce harm. The chapter emphasises that conventional research (e.g. device evaluation studies and randomised controlled trials) may be of little use in identifying low frequency events and complications because of their restricted inclusion and exclusion criteria, the use of devices only by experts and in conventional settings and because of their focus on efficacy rather than safety. The chapter highlights the important and growing role of registries and databases. Several are described in detail including the 4th National Audit Project and the Dutch ‘mini-NAP’. The value and limitations of litigation databases are explored. Specific complications of note are described at the end of the chapter.
The perioperative complications rate in paediatric cardiac surgery, as well as the failure-to-rescue impact, is less known in low- and middle-income countries.
To evaluate perioperative complications rate, mortality related to complications, different patients’ demographics, and procedural risk factors for perioperative complication and post-operative death.
Risk factors for perioperative complications and operative mortality were assessed in a retrospective single-centre study which included 296 consecutive children undergoing cardiac surgery.
Overall mortality was 5.7%. Seventy-three patients (24.7%) developed 145 perioperative complications and had 17 operative mortalities (23.3%). There was a strong association between the number of perioperative complications and mortality – 8.1% among patients with only 1 perioperative complication, 35.3% – with 2 perioperative complications, and 42.1% – with 3 or more perioperative complications (p = 0.007). Risk factors of perioperative complications were younger age (odds ratio 0.76; (95% confidence interval 0.61, 0.93), previous cardiac surgery (odds ratio 3.5; confidence interval 1.33, 9.20), extracardiac structural anomalies (odds ratio 3.03; confidence interval 1.27, 7.26), concomitant diseases (odds ratio 3.23; confidence interval 1.34, 7.72), and cardiopulmonary bypass (odds ratio 6.33; confidence interval 2.45, 16.4), whereas the total number of perioperative complications per patient was the only predictor of operative death (odds ratio 1.89; confidence interval 1.06, 3.37).
In a program with limited systemic resources, failure-to-rescue is a major contributor to operative mortality in paediatric cardiac surgery. Despite the comparable crude mortality, the operative mortality among patients with perioperative complications in our series was significantly higher than in the developed world. A number of initiatives are needed in order to improve failure-to-rescue rates in low- and middle-income countries.
The major complication of end jejunostomy is excessive fluid and electrolyte loss through the stoma, leading to hypovolaemia and dyselectrolytaemia within days and malnutrition within weeks. The aim was to compare the results of two nutritional approaches: unrestricted and restricted oral intake in patients with end jejunostomy commencing home parenteral nutrition (HPN) in terms of liver and renal biochemical markers and time to reconstructive bowel surgery with correlation to stoma output. Twenty patients with stabilised high output end-jejunostomy were divided into two groups. Group A consisted of ten patients with oral intake restricted to keep stomal output under 1000 ml. Group B consisted of ten patients with unrestricted oral intake. The following parameters were evaluated over 6 months: stomal output, self-estimation of general condition, body weight gain, plasma bilirubin and creatinine, number of hospitalisations prior to reconstructive surgery, the frequency of ostomy bag emptying, feelings of hunger and thirst in the daytime, and the time to reconstructive surgery. Stoma losses were compensated by parenteral supply. In group B, lower quality of life was observed, reflected by weakness, permanent feelings of hunger and thirst and the need for night-time emptying of the stoma bag. Patients in group B developed more complications and required more time to prepare for surgery. One death occurred in group B due to renal insufficiency followed by septic complications. Restricted oral intake seems to be more effective for prevention of HPN-related complications and shortening of time to surgery. Unrestricted oral intake appears to provoke uncontrolled losses of energy and protein, inhibiting weight gain.
Inflammatory bowel disease (IBD) typically involves the large bowel, small bowel (ileum / jejunum), or both. Involvement of the upper GI tract is less common, although its frequency is uncertain because common causes of inflammation such as gastro-oesophageal reflux and Helicobacter pylori infection also require exclusion. In the setting of known IBD, upper GI inflammation generally favours Crohn’s disease over ulcerative colitis (UC), while granulomas strongly suggest involvement by IBD and indicate Crohn’s disease rather than UC. New upper GI inflammation may raise the possibility of IBD, while unexplained new upper GI granulomas require exclusion of Crohn’s disease. Unfortunately, few histological patterns apart from granulomas are specific or discriminant. Lymphocytic oesophagitis is a poorly defined entity associated with IBD and/or Crohn’s disease in some studies. Focally enhanced gastritis (FEG), though initially regarded as typical of Crohn’s disease, probably has limited value apart from perhaps predicting IBD in children. Rarely, UC patients develop a duodenitis resembling the colorectal changes histologically. UC may also be associated, infrequently, with characteristic patterns of gastritis. Compared with adults, children with IBD are more likely to have upper GI involvement, to develop GI granulomas, and to undergo investigation for upper GI disease. Overall, upper GI granulomas assist with the diagnosis and classification of IBD but few other upper GI features are discriminatory between IBD and other causes or between UC and Crohn’s disease.
Hypocalcaemia is the most common complication after total or completion thyroidectomy. This study assesses recent evidence on predictive factors for post-thyroidectomy hypocalcaemia in order to identify the patients affected and aid prevention.
Two authors independently assessed articles and extracted data to provide a narrative synthesis. This study was an updated systematic search and narrative review regarding predictors of post-thyroidectomy hypocalcaemia using the Ovid Medline, Embase, Cochrane and Cinahl databases. Results were limited to papers published from January 2012 to August 2019.
Sixty-three observational studies with a total of 210 401 patients met the inclusion criteria. The median incidence was 27.5 per cent for transient biochemical hypocalcaemia, 12.5 per cent for symptomatic hypocalcaemia and 2.2 per cent for permanent hypocalcaemia. The most frequent statistically significant predictor of hypocalcaemia was peri-operative parathyroid hormone level. Symptomatic hypocalcaemia and permanent hypocalcaemia were seen more frequently in patients undergoing concomitant neck dissection.
Many factors have been studied for their link to post-thyroidectomy hypocalcaemia, and this study assesses the recent evidence presented in each case.
Introduction: The majority of first trimester pregnancy care in Canada is provided by family physicians and emergency departments (EDs). Early pregnancy loss occurs in approximately 30% of pregnancies, and the majority take place in first trimester when many patients do not yet have an obstetrical care provider. In Ontario, nearly 70% of patients are rostered to a family physician, many of whom practice in Family Health Teams (FHTs). The objective of this study was to determine how Ontario family physicians manage early pregnancy complications and explore the services available for patients experiencing early pregnancy loss or threatened early pregnancy loss. Methods: Family physician leads from 104 Ontario FHTs were contacted by email and invited to complete a 19-item, online questionnaire using modified Dillman methodology. The survey was developed by investigators based on a review of relevant literature and consultation with clinical experts. Prior to distribution, the questionnaire was peer reviewed and tested for face and construct validity, as well as ease of comprehension. Results: Respondents from 50 FHTs across Ontario completed the survey (response rate 48.1%). Of the respondents, 45 (90.0%) reported access to an ED in their community, 45 (90.0%) had access to an obstetrician/gynecologist, 33 (66.0%) had access to an early pregnancy clinic, and 18 (36.0%) reported comprehensive obstetrical care from first trimester to delivery within their FHT. The following services were only accessible through the ED: administration of RhoGAM (n = 28; 56.0%); surgical management of spontaneous or missed abortion (n = 22; 44.0%); same day serum quantitative beta human chorionic gonadotropin (n = 21; 42.0%); same day radiologist-interpreted ultrasound assessment (n = 15; 30.0%); and medical management of spontaneous or missed abortion (n = 12; 24.0%). Forty (80.0%) respondents stated physicians in their practice would provide urgent follow-up care for patients with spontaneous abortion, 35 (70.0%) would provide care for threatened abortion, and 26 (52.0%) would provide urgent care for missed abortion. For patients with a stable ectopic pregnancy, 37 (74.0%) respondents would refer to the ED. Conclusion: This study suggests FHTs in Ontario provide comprehensive care to patients with uncomplicated early pregnancy loss such as spontaneous abortion, yet rely on the ED for management of complicated early pregnancy loss, when medical or surgical management is indicated or for ectopic pregnancy.
Introduction: Emergency Department (ED) utilization during pregnancy may be common, but data specific to universal healthcare systems like Canada are lacking, where pregnancy care is supposed to be standardized. The objective of this study was to quantify and characterize ED utilization among all Ontarian women who had a recognized pregnancy, including by trimester and within 42 days after pregnancy, and further stratified by pregnancy outcome. Methods: Utilizing provincial administrative health databases, this retrospective population-based cohort study included all recognized pregnancies in Ontario conceived between April 1, 2002 and March 31, 2017. Peri-pregnancy ED utilization was defined as any ED visit from 0-42 weeks’ gestation, or within 42 days after the end of pregnancy. Modified Poisson regression was used to generate relative risks (RR) and 95% confidence intervals (CI) for the outcome of any peri-pregnancy ED utilization in association with maternal characteristics. Results: Peri-pregnancy ED utilization occurred among 1,075,991 of 2,728,236 recognized pregnancies (39.4%), including among 35.8% of livebirths, 47.3% of stillbirths, 73.7% of miscarriages, and 84.8% of threatened abortions. There were 22,802 (0.84%) ectopic pregnancies among all pregnancies in the cohort. ED utilization peaked in the first trimester and in the first week postpartum. A dose-response effect was seen in the number of peri-pregnancy ED visits in relation to certain maternal characteristics. Women residing in rural areas had an odds ratio (OR) of 3.44 (95% CI 3.39 to 3.49) for ≥ 3 ED visits, compared to those in urban areas. Women with 3-5 (OR 1.99 95% CI 1.97-2.01), 5-6 (OR 3.55, 95% CI 3.49 to 3.61), or ≥ 7 (OR 7.59, 95% CI 7.39 to 7.78) pre-pregnancy comorbidities were more likely to have ≥ 3 peri-pregnancy ED visits than those with 0-2 comorbidities. Of all recognized pregnancies in the cohort, only 106,989 (3.9%) had an injury-related ED visit. Conclusion: Peri-pregnancy ED utilization occurs in nearly 40% of pregnancies, notably in the first trimester and immediately postpartum. Efforts are needed to streamline rapid access to ambulatory obstetrical care during these peak periods, when women are vulnerable to either a miscarriage, or a complication after a livebirth.
Management strategies for pulmonary atresia with intact ventricular septum are variable and are based on right ventricular morphology and associated abnormalities. Catheter perforation of the pulmonary valve provides an alternative strategy to surgery in the neonatal period. We sought to assess the long-term outcome in terms of survival, re-intervention, and functional ventricular outcome in the setting of a 26-year single-centre experience of low threshold inclusion criteria for percutaneous valvotomy.
Methods and results:
Retrospective analysis of patients diagnosed with pulmonary atresia with intact ventricular septum from 1990 to 2016 at a tertiary referral centre, was performed. Of 71 patients, 48 were brought to the catheterisation laboratory for intervention. Catheter valvotomy was successful in 45 patients (94%). Twenty-three patients (51%) also underwent ductus arteriosus stenting. The length of intensive care and hospital stay was significantly shorter, and early re-interventions were significantly reduced in the catheterisation group. There were eight deaths (17%); all within 35 days of the procedure. Of the survivors, only one has required a Fontan circulation. Twenty-eight patients (74%) have undergone biventricular repair and nine patients (24%) have one-and-a-half ventricle circulation. Following successful valvotomy, 80% of patients required further catheter-based or surgical interventions.
A low threshold for initial interventional management yielded a high rate of successful biventricular circulations. Although mortality was low in patients who survived the peri-procedural period, the rate of re-intervention remained high in all groups.
The case reports of two DSM III-R schizophrenic patients with a family history of bipolar disorder are presented. The two patients had a history of severe obstetric complications (OCs). These cases are discussed in the light of neurodevelopmental theories of schizophrenia and in the continuum view of psychosis.
The frequency of anxiety and depressive disorders was examined in 69 insulin-dependent diabetic mellitus (IDDM) outpatients and in two control group. Based on self-report measures, these disorders were similar in IDDM sample and in the control groups. In diabetic outpatients, according to DSM-III-R criteria, there was a high lifetime prevalence of not otherwise specified anxiety and depressive disorders (44% and 41.5%), of simple phobia (26.8%), social phobia (24.6%), and agoraphobia — with and without panic disorder (14.6%). Current social phobia, dysthymia and not otherwise specified depressive disorders were associated with impaired glycaemic control. Glycosylated haemoglobin was associated with compliance but psychiatric disorders were not, except for social phobia which was significantly associated with more frequent consultations and a bad compliance for dietary regimen (more snacking). Somatic complications were not associated with anxious and depressive disorders (current or lifetime) or compliance and were best explained by the duration of the illness and impaired glycaemic control.
Selective Serotonin Reuptake Inhibitors (SSRIs) have been accused of causing bleeding problems as a side effect. Theories about the mechanism are still being discussed. We report a case, presenting bleeding problems, during sertraline treatment. The SSRIs are widely used to treat depression and many other psychiatric disorders. Their lower severity of side effects and being markedly safer in overdose are some of the reasons of their preference as primary choice in most of the cases. Besides their common side effects like, agitation, headache, insomnia, weight gain or loss, and sexual dysfunction, SSRIs also have been suspected of increasing the risk of bleeding. A population-based cohort study supported the hypothesis of an increased risk of upper gastrointestinal bleeding during the use of SSRIs, and they also indicated that this effect is potentiated with concurrent use of NSAIDs or low-dose aspirin. We would like to report our recent experience with one patient who was on sertraline, 50mg/day.
Le deuil est défini comme la perte par décès d’une personne « significative » (objet d’un lien affectif fort). Évènement de vie mettant à l’épreuve les ressources adaptatives biopsychosociales, sa fréquence augmente avec l’allongement de la vie. Il s’agit le plus souvent d’une perte d’un conjoint, spécialement chez les personnes âgées. En France, environ 500 000 décès/an ; 5 millions de veuves et 500 000 veufs. D’autres situations, heureusement plus rares, mais sans doute plus traumatisantes correspondent à ce que l’on appelle les deuils traumatiques, lorsque le deuil est dû à une mort violente : suicide, homicide, accident. La personne décédée peut aussi être un enfant (deuil très difficile) ou les parents pour un jeune enfant (doublant le risque d’un état dépressif) ou bien encore la mort d’un adolescent (suicide ou accident)… Outre un état dépressif avéré immédiat, les deuils proprement psychiatriques correspondent à des épisodes cliniques caractérisés : anxiété pathologique, abus d’alcool et de médicaments, état confuso-délirant, PTSD, etc. Le problème majeur est représenté par l’état dépressif qui doit être traité d’emblée (sans attendre le 3e mois). Enfin, on connaît les situations paradoxales de deuil maniaque plus ou moins intense, le décès étant à l’origine d’une poussée libidinale et d’une excitation psychomotrice allant jusqu’à l’état maniaque complet (probablement révélateur d’un trouble bipolaire). Environ 20 % des deuils sont « compliqués » et devraient faire l’objet d’une prise en charge systématique.
We analysed the impact of the TaqI A1 allele of the D2 dopamine receptor gene on the risk for alcoholism, trying to depict three explanations frequently proposed to explain discrepancies in association and linkage studies: that the A1 allele may act as a marker rather than as a vulnerability factor, that stratification biases and unevaluated controls may explain positive results, and that the A1 allele is modifying the phenotype rather than increasing the risk for alcoholism. We thus tested another (dinucleotide STRP) marker within the DRD2 gene, selected a new homogenous sample of 113 alcoholic patients and 49 unaffected controls strictly matched for ethnic origins, and systematically assessed both samples with a semi-structured interview to detect (in both samples) alcohol dependence, but also such related traits as specificities of complications.
The frequency of the A1 allele was not significantly different between alcoholics and controls but when comparing different subgroups of alcoholics, the A1 allele was significantly more frequent in alcoholic patients with somatic complications (OR = 3.00, CI[1.37-6.62]), social and professional complications (OR = 2.72, CI[1.25-5.90]), or with co-morbid dependence (OR = 2.88, 95% IC [1.16-7.15]). The association for co-morbid dependence and somatic complications was also positive when taking into consideration both STRP and TaqIA polymorphisms.
The A1 allele does not increase the risk for alcoholism per se in our sample, but may be involved in a related trait which is partially dependent on the diagnosis of alcoholism, through a disequilibrium with another close mutation.
We sought to explore whether obstetric complications (OCs) are more likely to occur in the presence of familial/genetic susceptibility for schizophrenia or whether they themselves represent an independent environmental risk factor for schizophrenia.
The presence of OCs was assessed through maternal interview on 216 subjects, comprising 36 patients with schizophrenia from multiply affected families, 38 of their unaffected siblings, 31 schizophrenic patients with no family history of psychosis, 51 of their unaffected siblings and 60 normal comparison subjects. We examined the familiality of OCs and whether OCs were commoner in the patient and sibling groups than in the control group.
OCs tended to cluster within families, especially in multiply affected families. Patients with schizophrenia, especially those from multiply affected families, had a significantly higher rate of OCs compared to normal comparison subjects, but there was no evidence for an elevated rate of OCs in unaffected siblings.
Our data provides little evidence for a link between OCs and genetic susceptibility to schizophrenia. If high rates of OCs are related to schizophrenia genes, this relationship is weak and will only be detected by very large sample sizes.
In 55 chronic DSM III-R schizophrenics the occurrence of obstetric complications (OCs) was investigated using the familial/sporadic strategy and Leonhard's unsystematic/systematic distinction. The overall frequency and severity of OCs did not differ between patients and controls. A sub-sample of patients, whose genetic risk was supposed to be high in both classification systems (diagnosis of unsystematic and familial schizophrenia), had significantly fewer OCs than controls on the Lewis and Murray scale (P < 0.05). With reference to previous reports of increased mortality rates in the offspring of schizophrenics, high genetic risk and additional perinatal stressors may increase perinatal mortality. In contrast, patients whose genetic risk was supposed to be low in both systems (diagnosis of systematic and sporadic schizophrenia) showed a trend to an increased frequency of OCs in the Fuchs scale. In the context of the recently reported highly significantly increased rate of maternal infections during midgestation in these patients, it was supposed that perinatal complications may be of some aetiological importance in schizophrenics with low genetic risk.
On the basis of 24 maternity hospital records, the current study investigated the validity of maternal recall and the relationship of maternal infections during pregnancy and obstetric complications (OCs) to different diagnostic subgroups of endogenous psychoses on which we reported previously in this journal. Maternal recall showed good agreement to maternity hospital records in the Lewis and Murray scale (ϑ = 0.74). With regard to infectious diseases during pregnancy maternal recall and records showed a weaker, but also good correlation (ϑ = 0.18). Psychoses with low genetic loading had more OCs than psychoses with high genetic loading. Maternal infectious diseases, especially during the fourth or fifth month of gestation, were significantly allocated to Leonhard's systematic schizophrenias. Data from maternity hospital records support our report that infectious diseases during midgestation and further perinatal complications seem to be important etiologic factors in systematic forms of schizophrenia without marked familial loading.
The aim of this study was to test that deficit (D) schizophrenic patients as defined by Carpenter et al had a higher prevalence of family history of schizophrenia but less obstetric complications than non-deficit (ND) patients. A lower rate of obstetric complications but an excess of schizophrenic and a higher rate of alcoholism family antecedents in 18 D patients compared to 23 ND patients were found. These results could suggest that there is a different weight of genetic and early environmental factors in D and ND patients.
This prospective, epidemiological British Ophthalmological Surveillance Unit study into ophthalmic complications of functional endoscopic sinus surgery aimed to determine the minimum incidence, presenting features and management throughout the UK.
Cases of ophthalmic complications of functional endoscopic sinus surgery, between February 2016 and February 2018, were identified through the British Ophthalmological Surveillance Unit reporting card system. Reporting ophthalmic consultants were sent an initial questionnaire, followed by a second questionnaire at six months.
Twenty-six cases of ophthalmic complications of functional endoscopic sinus surgery were reported. The majority (16 cases (62 per cent)) had limitations of ocular motility at presentation. The most common final diagnosis was rectus muscle (33 per cent) and nasolacrimal duct trauma (27 per cent). Using national data, this study reports a minimum incidence of ophthalmic complications of functional endoscopic sinus surgery in the UK of 0.2 per cent over two years.
In terms of ophthalmic complications, functional endoscopic sinus surgery is shown to be safe. Ophthalmic complications are rare, but when they do occur, they commonly result in rectus muscle trauma, often requiring surgical intervention.