Evaluating the advantages of treating acute cholecystitis by following the Tokyo Guidelines 2018 (TG18): a study emphasizing clinical outcomes and medical expenditures.

BACKGROUND: Acute cholecystitis (AC) is a common surgical emergency. The Tokyo Guidelines 2018 (TG18) provides a reliable algorithm for the treatment of AC patients to achieve optimal outcomes. However, the economic benefits have not been validated. We hypothesize that good outcomes and cost savings can both be achieved if patients are treated according to the TG18. METHOD: This retrospective study included 275 patients who underwent cholecystectomy in a 15-month span. Patients were divided into three groups (group 1: mild AC; group 2: moderate AC with American Society of Anesthesiologists (ASA) physical status class ≤ 2 and Charlson Comorbidity Index (CCI) score ≤ 5; and group 3: moderate AC with ASA class ≥ 3, CCI score ≥ 6, or severe AC). Each group was further divided into two subgroups according to management (followed or deviated from the TG18). Patient demographics, clinical outcomes, and hospital costs were compared. RESULTS: For group 1 patients, 77 (81%) were treated according to the TG18 and had a significantly higher successful laparoscopic cholecystectomy (LC) rate (100%), lower hospital cost ($1896 vs $2388), and shorter hospital stay (2.9 vs 8 days) than those whose treatment deviated from the TG18. For group 2 patients, 50 (67%) were treated according to the TG18 and had a significantly lower hospital cost ($1926 vs $2856), shorter hospital stay (3.9 vs 9.9 days), and lower complication rate (0% vs 12.5%). For group 3 patients, 62 (58%) were treated according to the TG18 and had a significantly lower intensive care unit (ICU) admission rate (9.7% vs 25%), but a longer hospital stay (12.6 vs 7.8 days). However, their hospital costs were similar. Early LC in group 3 patients did not have economic benefits over gallbladder drainage and delayed LC. CONCLUSION: The TG18 are the state-of-the-art guidelines for the treatment of AC, achieving both satisfactory outcomes and cost-effectiveness.

A novel and effective acupuncture modality as a complementary therapy to acute pain relief in inpatients with rib fractures.

BACKGROUND: Pain control has been emphasized as a priority for both practitioners and inpatients with rib fractures, since analgesia could only offer limited relief from severe pain. A prospective and randomized controlled trial was conducted to analyze the efficacy and efficiency of acupuncture in acute pain relief for inpatients with rib fractures. METHODS: A total of 58 inpatients were recruited and allocated to two groups, receiving identical doses of conventional oral analgesics as well as filiform needles as treatment and thumbtack intradermal (TI) needles placed upon the skin surface as a control, respectively, via novel acupuncture modality once daily for three consecutive days. The effect of pain relief was evaluated during activities that induce pain, and sustained maximal inspiration (SMI) lung volumes and sleep quality were assessed. RESULTS: The patients treated with filiform needles had more effective pain relief than those in the TI needle group during deep breathing, coughing, and turning over the body (p < 0.05), and the effect persisted for at least 6 h in most patients. Sustained maximal inspiration lung volumes and sleep quality did not show improvement through every acupuncture intervention, and they could not respond accurately to pain relief via acupuncture. CONCLUSION: The active evaluation could provide a more adaptive model for assessing pain intensity due to rib fractures. This novel acupuncture modality in which the needle insertion sites are corresponding to the pain spots can be a safe and viable therapy for relieving pain in inpatients with rib fractures.

Long-term relapse-free rurvival rate and predictive factors of idiopathic thrombocytopenic purpura in adults undergoing splenectomy.

BACKGROUND: Our aim is to identify the long-term relapse-free rate and predictive factors of response to splenectomy in adults with idiopathic thrombocytopenic purpura (ITP). METHODS: Between 1999 and 2005, 54 patients of ITP, who underwent splenectomy in Chang Gung Memorial Hospital, Linkou, Taiwan were retrospectively reviewed. Various pre, intra and postoperative factors were analyzed to determine the predictive factors of response and long-term disease-free rate after splenectomy in adult patients. RESULTS: The relapse free survival rates in complete response patients of splenectomy at 1-, 3- and 5-yr are 91.9%, 88.4%, and 88.4%, respectively. Younger age, response to steroids, pre- and postsplenectomy high platelet counts were found to be have significant p value of < 0.05 as predictive factors in univariate analysis. In multivariate analysis, only pre-op and post-op platelet counts were significant. CONCLUSIONS: Significant long-term relapse-free survival rate is achieved by splenectomy in adults with ITP. In univariate analysis, age, response to steroids, pre- and postsplenectomy platelet counts were the significant predictive factors of response. But in multivariate analysis, only pre-op and post-op platelet counts were significant.

Negative catheter angiography after vascular contrast extravasations on computed tomography in blunt torso trauma: an experience review of a clinical dilemma.

BACKGROUND: Catheter angiography is often arranged when vascular contrast extravasations on computed tomography (VCEC) presents after blunt torso trauma. However, catheter angiograph can be negative for bleeding and further management about this condition is not well discussed. The purpose of this study was a review of our experience of this discrepancy and to propose management principle. METHODS: We conducted a retrospective analysis of patients who received catheter angiography due to VCEC after blunt torso trauma at a level one trauma center in Taiwan from January 1, 2006 to December 31, 2009. Patient data abstracted included demographic data, injury mechanism, Injury Severity Score, vital signs and laboratory data obtained in the emergency department, CT and angiography results, embolization status, rebleeding and outcome. Analysis was performed according to angiographic results, VCEC sites, and embolization status. RESULTS: During the study period, 182 patients received catheter angiography due to VCEC, and 48 (26.4%) patients had negative angiography. The kidney had the highest incidence (31.7%) for a discrepant result. Non-selective proximal embolization under negative angiography was performed mostly in pelvic fracture and spleen injury. Successful treatment without embolization after negative angiography was seen in the liver, kidney and pelvic fractures. However, some rebleeding happened in pelvic fractures with VCEC even after embolization on negative angiography. CONCLUSIONS: A negative catheter angiography after VCEC is possible in blunt torso trauma, and this occurs most in kidney. Embolization or not under this discrepancy requires an integrated consideration of injury site, clinical presentations, and the risk of rebleeding. Liver and kidney in blunt torso trauma can be managed successfully without embolization when catheter angiography is negative for bleeding after VCEC.

Traumatic pericardial effusion: impact of diagnostic and surgical approaches.

INTRODUCTION: In trauma patients with chest injuries, traumatic pericardial effusion is an important scenario to consider because of its close linkage to cardiac injury. Even with advances in imaging, diagnosis remains a challenge and use of which surgical approach is controversial. This study reviews the treatment algorithm, surgical outcomes, and predictors of mortality for traumatic pericardial effusion. PATIENTS AND METHODS: Information on demographics, mechanisms of trauma, injury scores, diagnostic tools, surgical procedures, associated injuries, and hospital events were collected retrospectively from a tertiary trauma center. RESULTS: Between June 2003 and December 2009, 31 patients (23 males and 8 females) with a median age of 31 (range 16-77), who had undergone surgical drainage of pericardial effusion were enrolled in the study. Blunt trauma accounted for 27 (87.1%) insults, and penetrating injury accounted for 4 (12.9%). Patients were diagnosed by Focused Assessment with Sonography for Trauma (FAST) (8 patients), computerized tomography (7 patients), echocardiography (9 patients), and incidentally during surgery (7 patients). Notably, sixteen (51.7%) patients required surgical repair for traumatic cardiac ruptures, including 6 (19.6%) with pericardial defects who presented initially with hemothorax. The surgical approaches were subxiphoid in 8 patients (25.8%), thoracotomy in 7 (22.6%), and sternotomy in 19 (61.2%), including 3 conversions from thoracotomy. The survival to discharge rate was 77.4% (24/31). Concomitant cardiac repair, associated pericardial defects, and initial surgical approach did not affect survival, but the need for massive transfusion, cardiopulmonary cerebral resuscitation (CPCR), trauma score, and incidental discovery at surgery all had a significant impact on the outcome. CONCLUSIONS: Precise diagnoses of traumatic pericardial effusions are still challenging and easily omitted even with FAST, repeat cardiac echo and CT. The number of patients with traumatic pericardial effusion requiring surgical repair is high. Standardized therapeutic protocol, different surgical approaches have not impact on survival. Correct identification, prompt drainage, and preparedness for concomitant cardiac repair seem to be the key to better outcomes.

A useful model to audit liver resolution from cirrhosis in rats using functional proteomics.

BACKGROUND: We conducted a rat cirrhosis and recovery model, on the basis of which proteomics was used to audit liver resolution from cirrhosis. MATERIALS AND METHODS: Micronodular cirrhosis was established using Sprague-Dawley rats fed thioacetamide, and spontaneous recovery from cirrhosis was acquired after thioacetamide withdrawal. RESULTS: Over the course of a 2-, 3-, and 6-week recovery, macronodular cirrhosis, uneven liver surface, and nearly normal liver surface were acquired, respectively. Specific liver enzymes, hepatitis activity index, hepatocytes apoptosis index, number of activated Kupffer cells and hepatic stellate cells, and area of fibrosis bands consistently peaked at the end of thioacetamide administration and decreased progressively during the recovery period. mRNA expression of proinflammatory cytokines and proapoptotic molecules peaked around the end of thioacetamide administration and decreased thereafter. Using two-dimensional gel electrophoresis, the seven most upregulated and six most downregulated protein spots were analyzed by matrix-assisted laser desorption/ionization time-of-flight. Of these, GST-P2 and its isoforms, GST-alpha and GST-M, were chosen for further validation using immunohistochemistry. Expression of GST-P peaked at the 2-week recovery, whereas GST-alpha and GST-M remained at strong levels at the 6-week recovery. CONCLUSIONS: The mechanism of resolution from cirrhosis can be extensively investigated using the presented model which, for example, showed GST isoforms performing their roles at different time phases.