Traumatic brain injury (TBI) is often exacerbated by events that lead to secondary brain injury, and represent potentially modifiable causes of mortality and morbidity. Diffusion tensor imaging was used to characterize tissue at-risk in a group of 35 patients scanned at a median of 50 hours after injury. Injury progression was assessed in a subset of 16 patients with two scans. All contusions within the first few days of injury showed a core of restricted diffusion, surrounded by an area of raised apparent diffusion coefficient (ADC). In addition to these two well-defined regions, a thinner rim of reduced ADC was observed surrounding the region of increased ADC in 91% of patients scanned within the first 3 days after injury. In patients who underwent serial imaging, the rim of ADC hypointensity was subsumed into the high ADC region as the contusion enlarged. Overall contusion enlargement tended to be more frequent with early lesions, but its extent was unrelated to the time of initial imaging, initial contusion size, or the presence of hemostatic abnormalities. This rim of hypointensity may characterize a region of microvascular failure resulting in cytotoxic edema, and may represent a 'traumatic penumbra' which may be rescued by effective therapy.
Introduction Ultrasound has long been the radiological investigation of choice for right upper quadrant pain in the detection of gallstones and cholecystitis. However, previously reported sensitivity, specificity and other diagnostic metrics have varied widely and the underlying patient numbers have been small. We present robust and exhaustive diagnostic metrics based on a large series of 795 patients. Methods All laparoscopic cholecystectomies at our university hospital were prospectively logged between 2017 and 2020. Ultrasound findings, Nassar operative difficulty and histopathological findings were all collected in addition to patient biometrics. Results In our large patient series, the sensitivity of ultrasound for cholecystitis was lower than previously reported at 75.7% for acute cholecystitis, 34.6% for chronic cholecystitis and 42.7% overall. Moreover, we show that sensitivity degrades with the time between ultrasound and cholecystectomy, falling below 50% at 140 days. Finally, we show that ultrasound strongly predicts the Nassar difficulty grade of cholecystectomy and that its ability to do so is greatest when the interval between ultrasound and cholecystectomy is less than 27 days. Conclusions We present robust diagnostic metrics for ultrasound in the diagnosis of cholecystitis. These should caution the clinician that ultrasound may miss a quarter of cases of acute cholecystitis and over half of all cases of cholecystitis. Conversely, the finding of a thickened gallbladder wall on ultrasound can predict a ‘difficult cholecystectomy’ and highlight the need for appropriate expertise and resources. Both this prediction and the diagnostic sensitivity are best if the ultrasound is done less than 27 days before cholecystectomy.
Aims NICE NG89 Guidance introduced in 2018 recommends 28 days extended VTE pharmacological prophylaxis in patients who have major abdominal surgery for cancer. In 2018, our oesophagogastric unit protocols prescribed only inpatient VTE prophylaxis. Through the interventions of clinician education and modified unit protocols we improved our unit's compliance with NICE NG89. Methods We conducted a three cycle hybrid audit. 50 patients who underwent either oesophagectomy or gastrectomy were randomly chosen from 2017–19 (Cycle 1), 2019–21 (Cycle 2) and 2021–22 (Cycle 3). The first cycle intervention was the requirement for 14 days postoperative VTE pharmacological prophylaxis. The second cycle intervention increased this requirement to 28 days. All cycles additionally had interventions of clinician education. Results Against the NICE NG89 recommendation for 28 days postoperative pharmacological prophylaxis, our audit showed 14% compliance in Cycle 1, 26% in Cycle 2 and 91% in Cycle 3. The median duration of VTE prophylaxis prescription (combined inpatient and outpatient) was 7 days in Cycle 1, 23 days in Cycle 2 and 28 days in Cycle 3. The correct dose by weight for VTE prophylaxis was prescribed in 89% of cases in Cycle 1 and 100% of cases in Cycle 2 and 3. Whilst small numbers preclude statistical analysis, there were 2 bleeding events and 1 VTE event in both Cycles 1 and 2 but none in Cycle 3. Conclusions Our unit made a stepwise improvement against the NICE NG89 recommendation for extended VTE prophylaxis in cancer resections. Furthermore, clinician education improved correct weight based dosage.
Aims Ultrasound has long been the radiological investigation of choice for right upper quadrant pain for the detection of gallstones and cholecystitis. However, previously reported sensitivity, specificity and other diagnostic metrics have varied widely and the underlying patient numbers have been small. We present robust and exhaustive diagnostic metrics based on a large series of 793 patients. Methods All laparoscopic cholecystectomies at our university hospital were prospectively logged between 2017 and 2020. The ultrasound findings, Nassar operative difficulty and histopathological findings were all collected in addition to patient biometrics. Results In our large patient series, sensitivity of ultrasound for cholecystitis was lower than previously reported at 75.7% for acute cholecystitis, 34.6% for chronic cholecystitis and 42.7% overall. Moreover, we show that sensitivity degrades with the time between ultrasound and cholecystectomy, falling below 50% at 140 days. Finally, we show that ultrasound strongly predicts Nassar difficulty grade of cholecystectomy and that its ability to do so is greatest where the interval between ultrasound and cholecystectomy is less than 27 days. Conclusions We present robust diagnostic metrics for ultrasound in the diagnosis of cholecystitis. These should caution the clinician that ultrasound may miss a quarter of cases of acute cholecystitis and over half of all cases of cholecystitis. Conversely, the finding of a thickened gallbladder on ultrasound can predict a “difficult cholecystectomy” and highlight the need for appropriate expertise and resources. Both this prediction and the diagnostic sensitivity are best if the ultrasound is done less than 27 days before cholecystectomy.
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