The value of CT imaging and CRP quotient for detection of postbariatric complications.

BACKGROUND: The diagnosis of major complications seems to be more challenging in obese patients. We aimed to show the relevance of routinely assessed clinical and paraclinical parameters as well as the relevance of CT scans in the diagnosis of major complications after bariatric procedures. METHODS: All patients who underwent operations (primary or revisional) in a 3-year period were retrospectively studied after bariatric surgery with a specific focus on the routinely assessed clinical parameters (tachycardia, temperature), paraclinical parameters on postoperative day (POD) 1 and 3 (C-reactive protein (CRP), leukocytes), and additional computed tomography (CT) scan results for the diagnosis of leakage, bleeding, intraabdominal abscess, superficial abscess, and other complications. RESULTS: A total of 587 patients were examined. In this cohort, 73 CT scans were performed due to suspected intraabdominal or pulmonary complication according to our hospital standard operating procedure. In total, 14 patients (2.4%) had a major complication (Clavien-Dindo grade IV/V). Of those, 10 patients (1.7%) had postoperative leakage. While the correct leakage diagnosis was only found in 33% of the patients by CT scan, the overall specificity of CT as a diagnostic tool for all kinds of complications remained high. Especially for abscess detection, CT scan showed a sensitivity and specificity of 100%. Multivariate analysis showed a significantly higher risk of leakage development characterized by a doubling of postoperative CRP level (odds ratio 4.84 (95% confidence interval 2.01-11.66, p < 0.001)). To simplify the use of CRP as a predictive factor for the diagnosis of leakage, a cut-off value of 2.4 was determined for the CRP quotient (POD3/POD1) with a sensitivity of 0.88 and a specificity of 0.89. CONCLUSION: CT diagnostic after bariatric surgery has a high positive predictive value, especially for intraabdominal abscess formation. Nevertheless, CT scan for the diagnosis of leakage has a low sensitivity. Thus, a negative CT scan does not exclude the presence of a leakage. Using the described CRP quotient with a cut-off of 2.4, the risk of early leakage can be easily estimated. Furthermore, in any uncertain case of clinically suspected leakage, diagnostic laparoscopy should be performed.

Major stressors among elderly home care clients.

By understanding the stressors that elderly home care patients face when returning from the hospital, home healthcare nurses can help their clients toward a more satisfactory recovery and sustain better self care.

Loss of olfactory function after exposure to barbituric acid.

In this case report a patient with anosmia due to occupational exposure to barbituric acid will be presented. Occupational exposure to high concentrations of barbituric acid resulted in bloody nasal secretion and nasal itching with immediate onset following exposure. After several days of exposure, a progressive loss of smell resulted in anosmia. Psychophysical and electrophysiological assessment of olfactory function with the "Sniffin Sticks" test and event-related potentials based on air dilution olfactometry confirmed the patients' reports. After 2 years no recovery is remarked. Toxic anosmia has repeatedly been described due to exposure to chemicals, although barbituric acid has not been reported to be the cause of anosmia to date. Awareness of clinicians to toxic anosmia and the report of those cases appear to be mandatory to reduce occupational risks.

Teaching wound care in the home.

A survey of Medicare-certified agencies in Alaska, Idaho, Montana, Oregon, and Washington identified wound care and teaching wound care as being among the highest ranked clinical problems related to earlier hospital discharges that have resulted from Medicare Diagnostic Related Groupings (DRGs). Home care nurses are treating increasingly complex wounds and are required to teach complex wound care skills to clients and caregivers. This paper provides guidelines and resources to home care nurses for teaching wound care to their elderly clients and caregivers. The process of developing and implementing a teaching plan is described through the use of the community health nursing process. Following the presentation of the process content, a sample teaching wound care plan and sample teaching handouts are presented with a list of available teaching resources about wound care.

Home intravenous therapy: Part II--Resource guide.

Part II of the paper is a resource guide which lists resources that agencies may use to develop a home intravenous therapy program. In the first section, national organizations and journals and books concerned with intravenous therapy are listed as well as journal articles, guidelines and guidebooks and client and provider educational materials. National and regional product and service representatives of intravenous therapy related companies are also listed. In the second section, addresses for the State Boards of Nursing are given for Alaska, Idaho, Montana, Oregon and Washington. Each state section includes a list of those agencies who indicated in the 1988 survey that they would be willing to share materials. In addition, product and service vendors of intravenous therapy supplies and equipment are listed for the State of Washington.

Home intravenous therapy: Part I--Issues.

Concerns related to providing home intravenous therapy were among the top ten clinical problems identified by Northwest Medicare-certified home care agencies in a 1986 survey. This paper addresses issues related to home intravenous therapy and provides lists of resources for the development of home intravenous therapy programs. Part I of the paper covers concerns related to intravenous therapy as expressed by home care agencies in the Northwest and synthesized the literature about home intravenous therapies. Survey results are presented, followed by a discussion of client and caregiver concerns. These include: discharge planning, client admission criteria and client and caregiver education. Standards, staffing, and staff education issues are discussed followed by sections on economics, marketing regulations and legal and ethical concerns. Finally, there is a discussion of issues related to specific types of intravenous therapies: parenteral nutrition, antibiotic therapy; chemotherapy; blood and blood component therapy and other less frequently used types of intravenous therapies. Each therapy is discussed with regard to complications, client and caregiver instruction and financial considerations. Part II of the paper is a resource guide which lists resources that agencies may use to develop a home intravenous therapy program. In the first section, national organizations and journals and books concerned with intravenous therapy are listed as well as journal articles, guidelines and guidebooks and client and provider educational materials. National and regional product and service representatives of intravenous therapy related companies are also listed. In the second section, addresses for the State Boards of Nursing are given for Alaska, Idaho, Montana, Oregon and Washington. Each state section includes a list of those agencies who indicated in the 1988 survey that they would be willing to share materials. In addition, product and service vendors of intravenous therapy supplies and equipment are listed for the State of Washington.

Cancer symptom management in the elderly.

Clear and concise written guidelines must designate accountability for coordination of the persons involved. As might be assumed by the preceding discussion, the process takes considerable time and effort. The development of clear guidelines is a long term venture and usually does not occur quickly. In some cases a nearby agency may have developed a useful protocol that when shared with area providers, is quickly accepted. However, one to two years is not uncommon to developing a complex plan of care or protocol which can be used effectively and is specific to the conditions in a particular setting. Written guides, when developed correctly, should save all providers' time, and ensure better client care. Clear directions regarding the care to be provided and well-established lines of communication can save health care providers time and increase the likelihood of better health outcomes for the client. The coordination of planning within the home care agency, and across professional, agency and geographic boundaries is a prerequisite for successful cancer symptom management. The central aim in planning is to enhance the family's ability to manage independently and to facilitate continuity of care in the use of health care services. For the client to have the greatest potential for symptom amelioration, the home care agency must assume a major role in the coordination of care providers in the delivery of care.