Early Postoperative Endoscopy for Evaluation of the Anastomosis after Esophageal Reconstruction.

BACKGROUND: Anastomotic leaks significantly affect hospital stay after esophageal surgery. Here, we investigated the efficacy of early endoscopy for predicting anastomotic healing and leaks after esophageal reconstruction. METHODS: A total of 65 consecutive esophageal cancer patients treated by cervical esophagogastrostomy underwent routine endoscopy between postoperative days 5 and 7. The anastomosis was scored for the degree of ischemia, stenosis, and torsion of the anastomotic axis. Independent associations between ischemia, stenosis, and torsion of the proximal esophagus and the risk of the anastomotic leak were examined using Spearman's rank correlation method. RESULTS: Assessment of the degree of mucosal ischemia in 65 patients shows well healing in 35, patch ischemia in 20, diffuse ischemia in 10, no necrosis in any patient. Stenosis was classified as 0 to 10% in 40 patients, 11 to 20% in 12, 21 to 80% in 11, and 81 to 100% in 2. The degree of torsion of the anastomotic axis was classified as 0 to 10 degrees in 52 patients, 11 to 90 degrees in 8, and 91 to 180 degrees in 5. With rising endoscopy scores, there was an increase in risk for leaks (score > 4.5, sensitivity 100%, and specificity 83.8%). CONCLUSIONS: Early postoperative endoscopy facilitates the management of esophagogastrostomy anastomosis to predict leaks.

Assessment of the endothelial function with changed volume of brachial artery by menstrual cycle.

BACKGROUND: The endothelial function has been proven to be an important factor in the pathogenesis of atherosclerosis, hypertension and heart failure. The flow-mediated vasodilation (FMD) of the peripheral artery is an endothelium-dependent function. Brachial-artery ultrasound scanning is the popular method for evaluating FMD. However, good technical training on ultrasonography is required for the user to obtain high-quality data. Therefore, the goal of this study was to propose a new method which only used a sphygmomanometer cuff to occlude the blood flow and record the vascular volume waveform (Vwave). RESULTS: We used this method to assess the FMD in the menstrual cycle for 26 volunteer females. All female subjects were evaluated two times (M: menstrual phase; F: luteal phase) in one menstrual cycle and for two cycles. In the first cycle, the FMD volume ratio in M was 101.9 ± 45.5 % and was higher in L, at 137.5 ± 62.1 % (p = 0.0032 versus M). In the second cycle, the FMD volume ratios in M and L were 91.4 ± 37.0 % and 124.0 ± 56.4 %, respectively (p < 0.001 vs. M). CONCLUSIONS: Our results have confirmed those results in the study of Hametner et al. Blood pressure measurement and FMD assessment all used the same mechanic of digital blood pressure monitor, which makes our method suitable using at home.

Intrapleural Epinephrine Irrigation for Massive Malignant Hemothorax.

Massive malignant hemothorax (MMH) is a rare and serious complication encountered in the field of oncology and can be life threatening. It is often difficult and complex to manage. Herein, we present cases of four patients who had MMH and in whom a hemothorax was successfully stopped via continuous intrapleural irrigation with epinephrine (5-mg epinephrine/1,000-mL normal saline, infused at 100 mL/h) instead of a conventional surgical approach. Although no patient deaths were attributed to intractable bleeding, two deaths were related to multiple organ failure. Despite the limited number of cases, this method was a convenient, effective, and inexpensive alternative to open surgical or thoracoscopic drainage for MMH.

Original Article: The impacts of DRG payment system on financial balance of multiple trauma: Experiences of three trauma centers in Taiwan.

INTRODUCTION: There are concerns regarding the adequacy of applying the diagnosis-related groups (DRG) payment system for multiple traumas (i.e., major diagnostic category 24, MDC-24) patients in Taiwan. Therefore, this study used a multi-center dataset to assess the influence of the DRG payment system on the cost and outcome of multiple trauma care. MATERIALS AND METHODS: We collected data of all multiple trauma patients from the Trauma Registry of three hospitals from 2014 - 2017. Next, we selected patients who met the criteria of MDC-24 and calculated the corresponding DRG payment. Subsequently, we combined the clinical care information with health insurance information to analyze the problems of applying the DRG payment system to multiple trauma care. RESULTS: Overall, of 465 cases, 367 met the criteria of MDC-24, and the mean injury severity score (ISS) was high (average 20.1). The total deficit of the polytrauma DRG cases amounted to 131,445 USD, and the average deficit in each case was 397 USD. In the multivariable analysis, higher revised trauma score and specific lower abbreviated Injury Scale (AIS) scores in certain body regions resulted in profits, while increased length of stay in intensive care units, longer operative time, and higher AIS score in the thorax were significantly correlated with deficits in medical costs. CONCLUSION: Our study revealed that the current DRG payment system results in financial losses for hospitals. Further, the payment grouping of MDC-24 should consider adding more disease severity factors to reduce the financial constraints faced by trauma centers.

Comparison between non-surgical and surgical management of rib fractures in major trauma patients without brain injuries.

BACKGROUND: This study aimed to evaluate the different outcomes between the non-surgical and surgical groups in patients with major trauma without brain injuries. METHODS: This study prospectively collected data from patients with traumatic rib fractures without brain injuries from June 2017 to November 2019. The primary outcomes were the pain score at admission and discharge and the length of hospital stay. We performed multiple regression analysis to compare the outcomes and surgical risk as the severity of chest trauma between both groups. RESULTS: Fifty-three patients were enrolled. There was no statistically significant difference in baseline characteristics between both groups. However, the surgical group had more severe chest trauma than the non-surgical group. After the analysis, the pain score improved significantly in the surgical group. The hospital stay of the surgical group was four days shorter than that of the non-surgical group, and there was severe chest trauma in the surgical group. CONCLUSIONS: Surgical management of rib fractures can reduce pain and hospital stay in major trauma patients.

Quality of life outcomes after surgical intervention in patients with multiple rib fractures: A prospective cohort study.

BACKGROUND: Optimized conservative treatment of rib fractures has long been practiced, but surgical fixation has not been promising until recently. We aimed to examine and analyze immediate postoperative outcomes and 6-month quality of life after injury in patients with moderately severe traumatic rib fractures. METHODS: We conducted a prospective cohort study between July 2017 and June 2019 at the National Taiwan University Hospital. Seventy-two patients with moderately severe thoracic trauma were enrolled; 38 received conservative treatment and 34 underwent surgical fixation. Quality of life was measured using the 36-item Short Form Survey at; the first 3 days of hospitalization; before discharge; and at 1-, 2-, and 6-month follow-ups (visits 1-5). Baseline characteristics and clinical outcomes were recorded, and linear regression analysis was conducted using the generalized estimating equation. RESULTS: Among patients with moderately severe thoracic injury (chest Abbreviated Injury Scale score≥ 2), the operative group had more severe injuries and longer intensive care unit and in-hospital stays. However, they had a comparable quality of life 6 months after injury and higher physical component scores in the early postoperative period. Linear regression analysis obtained an equation with several factors positively affecting prediction of the mean physical component score, such as body mass index ≤25, age ≤36 years, fewer ribs requiring fixation, and diabetes mellitus. Mental component score did not show an upward trend, but the Work Quality Index largely determined the predicted mean value of the mental component score. CONCLUSION: Surgical rib fixations hasten recovery in patients with severe thoracic injury (chest Abbreviated Injury Scale ≥3) to achieve 6-month quality of life comparable to patients injured less severely (chest Abbreviated Injury Scale ≥2). The ability to resume previous work positively influenced the mental component score; thus, surgical intervention should also aim to help patients regain their social function.

Recombinant factor VIIa use in refractory ulcer bleeding in uremic patient.

Peptic ulcer bleeding is thought to be a major cause of bleeding in patients with end-stage renal disease and is more complicated in uremic patients. We described a 41-year-old man with end-stage renal disease who underwent hemodialysis with refractory ulcer bleeding, failure to all traditional peptic ulcer treatments, and correction of uremic component, who has been successfully treated by using recombinant factor VIIa. There have been few case reports in dealing refractory upper gastrointestinal bleeding in uremic patients in the literature; and in this case report, we demonstrates that recombinant factor VIIa could be used as a rescue therapy in these high­surgical risk patients when medical therapy fails.

High APACHE II score and long length of bowel resection impair the outcomes in patients with necrotic bowel induced hepatic portal venous gas.

BACKGROUND: Hepatic portal venous gas (HPVG) is a rare but potentially lethal condition, especially when it results from intestinal ischemia. Since the literatures regarding the prognostic factors of HPVG are still scarce, we aimed to investigate the risk factor of perioperative mortality in this study. METHODS: We analyzed data for patients with intestinal ischemia induced HPVG by chart review in our hospital between 2000 and 2007. Factors associated with perioperative mortality were specifically analyzed. RESULTS: There were 22 consecutive patients receiving definite bowel resection. 13 cases (59.1%) died after surgical intervention. When analyzing the mortality in patients after bowel resections, high Acute Physiology And Chronic health Evaluation (APACHE) II score (p<0.01) and longer length of bowel resection (p=0.047) were significantly associated with mortality in univariate analyses. The complication rate was 66.7% in alive patients after definite bowel resection. CONCLUSIONS: Bowel resection was the only potential life-saving therapy for patients with mesenteric ischemia induced HPVG. High APACHE II score and severity of underlying necrotic bowel determined the results in patients after bowel resection.

Impact of timing of renal replacement therapy initiation on outcome of septic acute kidney injury.

INTRODUCTION: Sepsis is the leading cause of acute kidney injury (AKI) in critical patients. The optimal timing of initiating renal replacement therapy (RRT) in septic AKI patients remains controversial. The objective of this study is to determine the impact of early or late initiation of RRT, as defined using the simplified RIFLE (risk, injury, failure, loss of kidney function, and end-stage renal failure) classification (sRIFLE), on hospital mortality among septic AKI patients. METHODS: Patient with sepsis and AKI requiring RRT in surgical intensive care units were enrolled between January 2002 and October 2009. The patients were divided into early (sRIFLE-0 or -Risk) or late (sRIFLE-Injury or -Failure) initiation of RRT by sRIFLE criteria. Cox proportional hazard ratios for in hospital mortality were determined to assess the impact of timing of RRT. RESULTS: Among the 370 patients, 192 (51.9%) underwent early RRT and 259 (70.0%) died during hospitalization. The mortality rate in early and late RRT groups were 70.8% and 69.7% respectively (P > 0.05). Early dialysis did not relate to hospital mortality by Cox proportional hazard model (P > 0.05). Patients with heart failure, male gender, higher admission creatinine, and operation were more likely to be in the late RRT group. Cox proportional hazard model, after adjustment with propensity score including all patients based on the probability of late RRT, showed early dialysis was not related to hospital mortality. Further model matched patients by 1:1 fashion according to each patient's propensity to late RRT showed no differences in hospital mortality according to head-to-head comparison of demographic data (P > 0.05). CONCLUSIONS: Use of sRIFLE classification as a marker poorly predicted the benefits of early or late RRT in the context of septic AKI. In the future, more physiologically meaningful markers with which to determine the optimal timing of RRT initiation should be identified.

Predicting factors for major trauma patient mortality analyzed from trauma registry system.

OBJECTIVE: We investigated the predictors of mortality in major trauma patients using a trauma registry system database. METHODS: Data were obtained from the trauma registry of a level I trauma center for all patients aged ≥18 years admitted to an intensive care unit (ICU) between January 1, 2006 and December 31, 2013. Models were adjusted for patient demographics, injury mechanism, preexisting comorbidity, Glasgow coma scale (GCS), injury severity score (ISS), emergency department (ED) and ICU procedures, surgical procedures, and complications. Multivariate logistic regression analysis was used to determine predictors of mortality and odds ratios of its associated factors. RESULTS: In total, 1561 patients met the inclusion criteria. The overall mortality rate was 13.4%. After controlling for all variables in a logistic regression model, the factors associated with increased mortality risk (P < 0.05) were age ≥ 45 years; ISS > 24; GCS score < 8 and 8-12; fall accident; preexisting comorbidity of renal insufficiency; ED cardiopulmonary resuscitation (CPR) procedures; ICU blood transfusion; and cardiovascular, respiratory, digestive system and infection complications. CONCLUSION: Our data showed some predictors of patient mortality after major trauma, most of which were determined during the trauma event. Only those treatment complications may be improved when performing the treatment procedures.

Hemostatic Enhancement via Chitosan Is Independent of Classical Clotting Pathways-A Quantitative Study.

Hemostasis is a process causing bleeding to stop, and it is known from the literature that hemostasis can be enhanced using chitosan on wound gauzes. We proposed here a continuous flow-through device, with the test blood flowing through the gauze sample at a constant flow rate and the pressure drop across the gauze measured, for assessing the hemostatic performance of the gauze. Experiments were performed using the device with both whole blood and washed blood (with clotting factors and platelets removed from the whole blood), and their results agree with each other within 10% discrepancy, indicating quantitatively that hemostatic enhancement via chitosan is essentially independent of classical clotting pathways, which was demonstrated qualitatively through animal tests in the literature. The proposed device and method can be applied for evaluating quantitatively the hemostatic performance of various gauzes in a flowing blood environment (in comparison with static tests) with less test blood (20-60% less, in comparison with that of a flow-through device driven by a constant pressure gradient), and are thus, helpful for designing better wound gauzes. In particular, it is effective to enhance the hemostatic performance further (additional 30%) through acidification (changing the amino group to the ammonium group) of the gauze for chitosan-based wound gauzes.

Late initiation of renal replacement therapy is associated with worse outcomes in acute kidney injury after major abdominal surgery.

INTRODUCTION: Abdominal surgery is probably associated with more likelihood to cause acute kidney injury (AKI). The aim of this study was to evaluate whether early or late start of renal replacement therapy (RRT) defined by simplified RIFLE (sRIFLE) classification in AKI patients after major abdominal surgery will affect outcome. METHODS: A multicenter prospective observational study based on the NSARF (National Taiwan University Surgical ICU Associated Renal Failure) Study Group database. 98 patients (41 female, mean age 66.4 +/- 13.9 years) who underwent acute RRT according to local indications for post-major abdominal surgery AKI between 1 January, 2002 and 31 December, 2005 were enrolled The demographic data, comorbid diseases, types of surgery and RRT, as well as the indications for RRT were documented. The patients were divided into early dialysis (sRIFLE-0 or Risk) and late dialysis (LD, sRIFLE -Injury or Failure) groups. Then we measured and recorded patients' outcome including in-hospital mortality and RRT wean-off until 30 June, 2006. RESULTS: The in-hospital mortality was compared as endpoint. Fifty-seven patients (58.2%) died during hospitalization. LD (hazard ratio (HR) 1.846; P = 0.027), old age (HR 2.090; P = 0.010), cardiac failure (HR 4.620; P < 0.001), pre-RRT SOFA score (HR 1.152; P < 0.001) were independent indicators for in-hospital mortality. CONCLUSIONS: The findings of this study support earlier initiation of acute RRT, and also underscore the importance of predicting prognoses of major abdominal surgical patients with AKI by using RIFLE classification.

A novel surgical technique: gasless laparoscopy-assisted gastrojejunostomy.

Gastrojejunostomy is often performed to relieve the symptoms of gastric outlet obstruction. The recent trend is toward minimally-invasive procedures to reduce recovery time and increase quality of life. However, several problems and complications have been reported using gas-filled laparoscopy, especially in the elderly and patients with poor cardiopulmonary function. Consequently, we developed a new gasless laparoscopy-assisted gastrojejunostomy procedure to eliminate the cardiopulmonary risks of gas-filled laparoscopic surgery. The working cavity is created by lifting the mini-laparotomy incision using a self-supporting retractor that we designed, and two to three additional working ports are created. Antecolic side-to-side gastrojejunostomy is performed using an endostapler. Eleven patients (3 males and 8 females) underwent this new procedure between April 2005 and May 2006. Their median age was 75 years (range 34 to 85), and eight of the eleven had more than three comorbid conditions. The median duration of postoperative flatus was 2 days (1-10 days), and the median hospital stay 10 days (5-28 days). No postoperative leakage occurred. However, one patient with postoperative gastrostasis and another with ileus due to cancer-related peritonitis were noted; fortunately, both responded to conservative medical management. In conclusion, our gasless, laparoscopy-assisted gastrojejunostomy procedure appears to be both safe and effective in patients with gastric outlet obstruction.

Effects of moderate exercise on relieving mental load of elementary school teachers.

Long-term endurance exercise could increase activity of parasympathetic nervous and decrease activity of sympathetic nervous at rest. However, previous studies all focused on the effect of endurance training on heart rate variability (HRV) for athletes or sedentary subjects. In Taiwan, elementary school teachers teaching and processing the children's and administrative problems always stand and walk. They will sit down only when they review and correct the students' home work. Thus, the goal of this study was to elucidate the beneficial effect of moderate intensity exercise on relieving mental load of elementary school teachers. There were 20 participants in the exercise group and another 20 participants in the nonexercise group. The exercising teachers performed 12 weeks of moderate intensity exercise training for an average of 30 minutes per day, 3 times per week. HRV was measured before and after the 4th, 6th, and 12th weeks. The time and frequency domain parameters of HRV all had significant increases between the beginning and after 12 weeks of training. However, the time and frequency domain parameters of HRV in the nonexercise group had significant decreases between the beginning and after 12 weeks of training. The long-term moderate exercises can relieve mental load of elementary school teachers. Moreover, age was the considerable factor affecting HRV in this study.

Assessment of Stroke Volume From Brachial Blood Pressure Using Arterial Characteristics.

GOAL: The goal of this study is to present a modified pulse contour method to estimate the stroke volume (SV) based on an oscillometric sphygmomanometer. METHODS: The pulse contour was extracted from the pulse signal of the cuff pressure. The characteristics of the brachial artery, as well as the compliance ( C(artery)) and time constant τ of the Windkessel model, could be determined and used to estimate the SV once the apparatus finished the blood pressure measurement. RESULTS: Assessments of the SV by echocardiography and our method were carried out in 55 subjects. The change in the brachial arterial volume obtained by our method was significantly correlated with that of the two-dimensional ultrasound method (r(v) = 0.871). The estimated SV values by our method for male and female groups, SV(estimate), were also significantly correlated with the echocardiography results, SV(ref) (r(male) = 0.680, r(female) = 0.706 ). The Bland-Altman plot showed agreement between SV(ref) and SV(estimate), with all data points contained within the limits of agreement (± 2 SD). The mean difference and standard deviation (mean ± SD) were 0.101 ± 14.880 ml and 0.650 ± 11.990 ml for the male and female groups, respectively. CONCLUSION: The blood pressure, SV, and cardiac output were measured simultaneously, making our method well suited for home use. SIGNIFICANCE: Our method was embedded in an oscillometric sphygmomanometer.

The physical effects of aromatherapy in alleviating work-related stress on elementary school teachers in taiwan.

People use aromatherapy to relieve the symptoms of physical and psychological stress. However, previous studies have not precisely clarified a scientific basis for the beneficial effects of aromatherapy. Therefore, the overall purpose of this study was to elucidate the beneficial effect of aromatherapy in relieving work-related stress. Twenty-nine elementary school teachers from Taiwan participated in this study. The experimental procedures comprised 2 phases. First, we verified the effect of aromatherapy by conducting 2 blind tests. We used natural bergamot essential oil extracted from plants and synthesized a chemical essential oil as the placebo to do the aromatherapy. Second, we analyzed the performance of the aromatherapy treatment on the teachers who had various workloads. We measured the teachers' heart rate variability to evaluate their autonomic nervous system activity. The results show that only the natural bergamot essential oil had an effect and that the aromatherapy treatment relieved work-related stress of teachers with various workloads. However, the aromatherapy treatment had a weak effect on young teachers who had a heavy workload. Moreover, the aromatherapy treatment exhibited no effect on teachers who belong to the abnormal body mass index subgroup having a heavy workload.

Intrapleural steroid instillation for multiple organ failure with acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS) increases mortality in patients with multiorgan dysfunction syndrome (MODS). This study evaluates the feasibility of intrapleural steroid instillation (IPSI) in patients with ARDS and MODS unresponsive to conventional extracorporeal membrane oxygenation (ECMO). Ninety-two of 467 patients who underwent ECMO between 2005 and 2009 had ARDS, and 30 consecutive adult patients of these 92 patients with severe ARDS and MODS were retrospectively analyzed in this study. Nine of these 30 patients, who did not respond to therapy and whose condition deteriorated, were managed with IPSI. All patients met the inclusion criteria of hemodynamic instability with high catecholamine infusion requirement and 100% oxygen demand in ventilation and ECMO flow. On initial diagnosis of ARDS, no differences in prognostic scorings were observed in patients who underwent conventional treatment (n = 21) and those who underwent IPSI (n = 9). Blood oxygenation, tidal volume, changing in chest radiographic findings, and survival rates were analyzed. The primary outcome was survival until discharge from the hospital. Pulmonary radiographic appearance improved after 3 days of IPSI treatment (P = 0.008); the ratio of arterial partial pressure of oxygen to fraction of inspired oxygen also increased significantly after 5 days of IPSI treatment (P = 0.028). Moreover, the 28-day mortality rate (P = 0.017), 60-day mortality rate (P = 0.003), and survival rate (78% vs. 19%; P = 0.003) significantly improved in patients undergoing IPSI, which therefore appears to be an easily implemented and highly effective treatment for patients with severe ARDS in combination with MODS, particularly in patients who fail to respond to conventional treatment.