Outcomes after implementing a tailored endoscopic step-up approach to walled-off necrosis in acute pancreatitis.

BACKGROUND: The aim of the study was to compare the outcomes of patients with pancreatic or peripancreatic walled-off necrosis by endoscopy using the conventional approach versus an algorithmic approach based on the collection size, location and stepwise response to intervention. METHODS: This was an observational before-after study of consecutive patients managed over two time intervals. In the initial period (2004-2009) symptomatic patients with walled-off necrosis underwent conventional single transmural drainage with placement of two stents and a nasocystic catheter, followed by direct endoscopic necrosectomy, if required. In the later period (2010-2013) an algorithmic approach was adopted based on size and extent of the walled-off necrosis and stepwise response to intervention. The main outcome was treatment success, defined as a reduction in walled-off necrosis size to 2 cm or less on CT after 8 weeks. RESULTS: Forty-seven patients were treated in the first interval and 53 in the second. There was no difference in patient demographics, clinical or walled-off necrosis characteristics and laboratory parameters between the groups, apart from a higher proportion of women and Caucasians in the later period. The treatment success rate was higher for the algorithmic approach compared with conventional treatment (91 versus 60 per cent respectively; P < 0·001). On multivariable logistic regression, management based on the algorithm was the only predictor of treatment success (odds ratio 6·51, 95 per cent c.i. 2·19 to 19·37; P = 0·001). CONCLUSION: An algorithmic approach to pancreatic and peripancreatic walled-off necrosis, based on the collection size, location and stepwise response to intervention, resulted in an improved rate of treatment success compared with conventional endoscopic management.

Minimally invasive vasectomy.

OBJECTIVE: To evaluate the associated morbidity and patient comfort of the 'minimally invasive, no scalpel' (MINS) vasectomy. PATIENTS AND METHODS: Eighty-nine consecutive patients presenting for vasectomy underwent a MINS procedure. Post-operatively, the pain experienced, recovery time and complication rate were assessed using a postal questionnaire. The questionnaire was also used to assess a group of historical controls who had undergone a vasectomy using a standard technique. RESULTS: The length of time to recovery was significantly reduced in patients who underwent the MINS vasectomy (P < 0.05) and the pain, bruising, swelling and complication rate were also less than in patients who underwent a standard vasectomy. CONCLUSIONS: The MINS vasectomy is preferable to a standard technique, reducing both patient morbidity and the complication rate. This is attributable to the minimal dissection and reduced tissue handling required to expose and isolate the vas.

PIP: A minimally invasive, no-scalpel, no-suture (MINS) technique of performing vasectomy was first introduced in 1974 in China. The technique is said to reduce operative time and patient morbidity compared to the standard procedure used to bring about vasectomy. The MINS technique has been adopted in some parts of the Far East and the US. The authors report their findings from a controlled study conducted to evaluate the complication rate and patient comfort of the technique. 89 consecutive patients received vasectomy through the MINS procedure. A postal questionnaire was then used to assess, postoperatively, the pain experienced, recovery time, and complication rate. Questionnaires were also sent to 75 men who had undergone vasectomy in the previous 6 months using a standard technique. 87% and 76%, respectively, responded to the questionnaire. The length of time to recovery was significantly reduced in patients who underwent the MINS vasectomy. Levels of pain, bruising, swelling, and complication were also less among patients who underwent MINS vasectomy.

Enhancing baccalaureate student nursing education. Collaboration with occupational health nurses for hands-on experience.

Historically, occupational health nursing has been underemphasized in most baccalaureate nursing education programs. Advances in medical technology resulting in higher costs for hospital care, increasing need and support for nursing students, and curriculum emphases on holistic health care are factors pointing to the potential for broader clinical experiences for students outside the traditional hospital setting. One school in Louisiana has found that providing opportunities for occupational health nursing affiliations with students in baccalaureate programs has benefitted practitioners, students, and faculty.