These results confirm that preoperative evaluation by an enterostomal therapist, marking of the skin site, and providing patient education reduce adverse outcomes. All elective procedures that may result in stoma formation should, therefore, be assessed and marked preoperatively. Patients, likewise, should be informed and taught to care for their forthcoming stomas preoperatively and postoperatively.
In a five and one-half year period, 1023 patients with anorectal abscesses and fistulas were treated. Under regional anesthesia the abscesses were unroofed and debrided and a primary fistulotomy was performed whenever a low fistula was identified. In 355 (34.7 per cent) an internal fistulous opening was demonstrated at the time of abscess drainage. Thirty-two patients had suprasphincteric fistulas and underwent two-stage fistulotomy using a seton. Perianal abscesses were encountered in 42.7 per cent of the patients, followed by ischiorectal (22.7 per cent), intersphincteric (21.4 per cent), and supralevator (7.33 per cent). The patients with supralevator and intersphincteric abscesses had a high incidence of fistula identified during abscess drainage. The recurrence rates were 3.7 per cent in the group with abscess drainage only and 1.8 per cent in the group that had primary fistulotomy along with abscess drainage. The follow-up period averaged 36 months. To accomplish adequate drainage and identify the deeper components and associated fistulous opening (34.7 per cent of the entire group), careful examination under regional anesthesia is recommended. Early aggressive treatment of an anorectal abscess and fistula significantly reduces the possibility of recurrent abscesses and/or the need for further surgery.
Rationale:Patients hospitalized with chronic obstructive pulmonary disease (COPD) who require supplemental oxygen (O2) are at increased risk of hospital readmissions. There is a paucity of information regarding quality of evaluation and documentation regarding the need for supplemental O2 in this population. Objective: To determine the extent to which evaluation and documentation regarding the need for supplemental O2 occurs prior to hospital discharge in patients with COPD. Methods: We conducted a two-center retrospective cohort study of hospitalized adults with a physician diagnosis of COPD. We reviewed electronic health records to ascertain whether patients underwent evaluation beyond rest oximetry documenting hypoxemia and if there was adequate documentation of supplemental O2 requirements prior to discharge. Results: Of 526 patients hospitalized with a primary or secondary discharge diagnosis of COPD, 335 patients (mean age 69 years, 78% with diagnosis of COPD exacerbation) met eligibility criteria. Overall, 1 in 5 (22%, 73/335) hospitalized patients with COPD had an evaluation beyond rest oximetry for supplemental O2 requirements during admission. Adequate documentation of supplemental O2 requirements occurred in even fewer patients (16%, 54/335). Both evaluation (26% versus 5%, p=0.002) and documentation (19% versus 4%, p=0.001) of supplemental O2 requirements were more common in patients hospitalized for a COPD exacerbation compared to those hospitalized with COPD but without an exacerbation. Conclusions: Evaluation and documentation of supplemental O2 requirements beyond rest oximetry occur infrequently in patients hospitalized with COPD. AbstractAbbreviations: chronic obstructive pulmonary disease, COPD; oxygen, O 2 ; Centers for Medicare and Medicaid Services, CMS; Documentation and evaluation of Oxygen Requirements In COPD study, DORIC; electronic health records, EHR; forced expiratory volume in 1 second, FEV1; forced vital capacity, FVC; Global initiative for chronic Obstructive Lung Disease, GOLD; pulse oximetry, SpO2; LongTerm Oxygen Treatment Trial, LOTT; standard deviation, SD; against medical advice, AMA
The rodless, end-loop stoma was developed as an alternative to the more traditional loop stoma to minimize patient management problems. A retrospective review of our seven-year experience in 229 patients with end-loop colostomies (135), ileocolostomies (70), and ileostomies (24) is presented. A total of 30 stoma-related complications were observed in 27 stomas, for an overall complication rate of 13.1 percent. The most common complications were skin excoriation secondary to leakage (3.5 percent), retraction (3.5 percent), partial necrosis (2.6 percent), and peristomal sepsis (1.8 percent). Mucocutaneous separation, prolapse, and stenosis were each seen in less than one percent of patients. No cases of stomal herniation, obstruction, or hemorrhage were encountered. Twelve deaths occurred, but none was attributed to stoma-related complications. The rodless, end-loop stoma is a simple and safe procedure with many advantages and a low incidence of complications.
Learning Objectives: Reactive oxygen species (ROS) is known to contribute to the development of organ dysfunction during sepsis. Enteral feeding in the critically ill patients is crucial and immune-modulating diet (IMD) might have potential to prevent oxidative stress and inflammation. However we are not sure whether IMD containing whey protein as a complete peptide and EPA is suppressed excessive ROS production during sepsis. The present study was conducted to investigate the ROS production by the effect of IMD containing whey protein and EPA in a rodent sepsis model. Methods: Sprague-Dawley rats were fed with IMD containing whey protein and EPA or control diet (CD) for 7 days. Rats were injected with lipopolysaccharide (LPS) 10mg/kg or normal saline (NS) via intraperitoneally. Blood plasma samples were collected at 5 hours after injection for measurement of derivatives of reactive oxygen metabolites (d-ROMs) as an oxidative stress marker. Biological anti-oxidant potential (BAP) and oxy adsorbent test (OXY) as total anti-oxidant. BAP/dROMs and OXY/dROMs were used for compare between groups. Results: In normal S-D rat BAP/d-ROMs levels were (10.5 ± 0.3) and OXY/d-ROMs levels were (1.3 ± 0.03). In septic rat treated by LPS 10mg/kg BAP/d-ROMs and OXY/d-ROMs levels were (11.4 ± 0.9) and (1.1 ± 0.06) respectively. OXY/d-ROMs levels were significantly decreased between normal and septic rats. BAP/d-ROMs levels were lower in IMD-LPS (15.01 ± 1.0) group than CD-LPS (12.6 ± 0.4), IMD-NS (12.4 ± 0.8), CD-NS (12.5 ± 1.2) groups. OXY/d-ROMs levels were significantly higher in IMD-LPS (1.74 ± 0.1) than CD-LPS (1.32 ± 0.1), IMD-NS (1.5 ± 0.1), CD-NS (1.5 ± 0.1). Conclusions: These results indicate IMD suppressed excessive ROS production and enhanced total antioxidant in a rodent sepsis model. IMD with whey protein and EPA has potential to prevent oxidant injury.
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