RESUMO
OBJECTIVE: The aim of this study was to determine which initial surgical treatment results in the lowest rate of death or neurodevelopmental impairment (NDI) in premature infants with necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP). SUMMARY BACKGROUND DATA: The impact of initial laparotomy versus peritoneal drainage for NEC or IP on the rate of death or NDI in extremely low birth weight infants is unknown. METHODS: We conducted the largest feasible randomized trial in 20 US centers, comparing initial laparotomy versus peritoneal drainage. The primary outcome was a composite of death or NDI at 18 to 22âmonths corrected age, analyzed using prespecified frequentist and Bayesian approaches. RESULTS: Of 992 eligible infants, 310 were randomized and 96% had primary outcome assessed. Death or NDI occurred in 69% of infants in the laparotomy group versus 70% with drainage [adjusted relative risk (aRR) 1.0; 95% confidence interval (CI): 0.87-1.14]. A preplanned analysis identified an interaction between preoperative diagnosis and treatment group (P = 0.03). With a preoperative diagnosis of NEC, death or NDI occurred in 69% after laparotomy versus 85% with drainage (aRR 0.81; 95% CI: 0.64-1.04). The Bayesian posterior probability that laparotomy was beneficial (risk difference <0) for a preoperative diagnosis of NEC was 97%. For preoperative diagnosis of IP, death or NDI occurred in 69% after laparotomy versus 63% with drainage (aRR, 1.11; 95% CI: 0.95-1.31); Bayesian probability of benefit with laparotomy = 18%. CONCLUSIONS: There was no overall difference in death or NDI rates at 18 to 22âmonths corrected age between initial laparotomy versus drainage. However, the preoperative diagnosis of NEC or IP modified the impact of initial treatment.
Assuntos
Drenagem , Enterocolite Necrosante/cirurgia , Doenças do Prematuro/cirurgia , Perfuração Intestinal/cirurgia , Laparotomia , Transtornos do Neurodesenvolvimento/epidemiologia , Enterocolite Necrosante/mortalidade , Enterocolite Necrosante/psicologia , Estudos de Viabilidade , Feminino , Humanos , Recém-Nascido de Peso Extremamente Baixo ao Nascer , Recém-Nascido , Recém-Nascido Prematuro , Doenças do Prematuro/mortalidade , Doenças do Prematuro/psicologia , Perfuração Intestinal/mortalidade , Perfuração Intestinal/psicologia , Masculino , Transtornos do Neurodesenvolvimento/diagnóstico , Taxa de Sobrevida , Resultado do TratamentoAssuntos
Adaptação Psicológica , Colostomia/enfermagem , Doença Diverticular do Colo/enfermagem , Perfuração Intestinal/enfermagem , Traumatismos da Perna/enfermagem , Relações Enfermeiro-Paciente , Papel do Doente , Lesões dos Tecidos Moles/enfermagem , Idoso , Colostomia/psicologia , Doença Diverticular do Colo/psicologia , Feminino , Humanos , Perfuração Intestinal/psicologia , Traumatismos da Perna/psicologia , Papel do Profissional de Enfermagem/psicologia , Lesões dos Tecidos Moles/psicologiaAssuntos
Nível de Alerta/fisiologia , Aprendizagem da Esquiva/fisiologia , Cuidados Críticos , Inibição Psicológica , Memória de Curto Prazo/fisiologia , Qualidade de Vida/psicologia , Retenção Psicológica/fisiologia , Choque Séptico/fisiopatologia , Síndrome de Resposta Inflamatória Sistêmica/fisiopatologia , Animais , Doenças do Ceco/fisiopatologia , Doenças do Ceco/psicologia , Modelos Animais de Doenças , Perfuração Intestinal/fisiopatologia , Perfuração Intestinal/psicologia , Ratos , Choque Séptico/psicologia , Síndrome de Resposta Inflamatória Sistêmica/psicologiaRESUMO
We describe a schizophrenic man whose lack of pain and related objective signs of a perforated small bowel led to a delay in diagnosis and surgical intervention. A review of the literature suggests that both psychodynamic and specific biologic factors can produce atypical presentations in psychotic patients with illnesses in which pain is characteristically a prominent presenting symptom. While research into the cause of altered pain perception in psychotic patients is continuing, clinicians should maintain a high index of suspicion of serious medical illness when evaluating such patients.
Assuntos
Abdome Agudo/psicologia , Hipestesia/psicologia , Doenças do Íleo/psicologia , Perfuração Intestinal/psicologia , Esquizofrenia/diagnóstico , Psicologia do Esquizofrênico , Abdome Agudo/cirurgia , Adulto , Delusões/psicologia , Negação em Psicologia , Humanos , Doenças do Íleo/cirurgia , Perfuração Intestinal/cirurgia , Masculino , Dor Pós-Operatória/psicologiaRESUMO
The evolutionary changes of evoked potentials (EPs) were studied from the neonatal period up to 1 year of age in 41 infants with various perinatal disorders. Abnormal EPs in the first week of life recovered quickly. In infants with normal outcome, abnormal EPs became normal within a month. In infants with cerebral palsy (CP) or mental retardation (MR), EPs recovered within 2-3 months of age. Infants with more severe neurological damage showed abnormal EPs even beyond 6 months of age. Abnormal EPs beyond 2 weeks of age indicated poor prognosis. As for the wave form of EPs, absent responses or abnormal wave form reflected more severe brain dysfunction. AEPs tended to show more profound abnormalities than VEP. However, some infants with absent AEP in the first week of life had a favorable prognosis. AEPs seemed to be more easily affected by brain dysfunction.