Early rehabilitation programs after laparoscopic colorectal surgery:Evidence and criticism

During the past several decades,early rehabilitation programs for the care of patients with colorectal surgery have gained popularity.Several randomized controlled trials and meta-analyses have confirmed that the implementation of these evidence-based detailed perioperative care protocols is useful for early recovery of patients after colorectal resection.Patients cared for based on these protocols had a rapid recovery of bowel movement,shortened length of hospital stay,and fewer complications compared with traditional care programs.However,most of the previous evidence was obtained from studies of early rehabilitation programs adapted to open colonic resection.Currently,limited evidence exists on the effects of early rehabilitation after laparoscopic rectal resection,although this procedure seems to be associated with a higher morbidity than that reported with traditional care.In this article,we review previous studies and guidelines on early rehabilitation programs in patients undergoing rectal surgery.We investigated the status of early rehabilitation programs in rectal surgery and analyzed the limitations of these studies.We also summarized indications and detailed protocol components of current early rehabilitation programs after rectal surgery,focusing on laparoscopic resection.

Macrophage activation syndrome in children with Kawasaki disease: diagnostic and therapeutic approaches

Background Macrophage activation syndrome(MAS)is a rare,life-threatening complication of Kawasaki disease(KD).Early recognition and treatment of MAS are very important,but sometimes it is difficult to distinguish MAS from a severe form of KD.Data sources A PubMed search was performed in Clinical Queries using the key terms“macrophage activation syndrome or secondary hemophagocytic lymphohistiocytosis(HLH)”and“Kawasaki disease”.Results KD patients with MAS show high intravenous immunoglobulin(IVIG)resistance and coronary complications.Mortality is also as high as MAS in other diseases.Persistent fever greater than 10 days is highly associated with development of MAS in KD.Splenomegaly is observed in more than two-thirds of KD patients with MAS.Thrombocytopenia is often the earliest laboratory finding of MAS.Hyperferritinemia is highly specific and sensitive for detecting MAS in KD;so,ferritin levels should be checked if there are unexplained clinical exacerbations in KD patients.Given the under-recognition of MAS in KD,it is prudent to consider resistant KD as occult/subclinical MAS.Many KD patients with MAS have good outcomes on immune modulators.However,if KD patients fulfill the HLH-2004 diagnostic criteria,they may undergo longer and more intensive treatment than needed.Conclusions The possible existence of MAS should be taken into account when a KD patient shows persistent fever,splenomegaly,thrombocytopenia,hyperferritinemia,or IVIG resistance.The under-diagnosis of MAS in patients with KD is an important issue to be addressed.Therapeutically,however,there is a possibility of over-treatment of MAS in patients with KD.

Febrile infants:written guidelines to reduce non-essential hospitalizations

Management of febrile infants,especially those younger than 3 months of age,is of clinical importance due to the relatively high risk of serious bacterial infection(SBI),such as bacterial meningitis,bacteremia,or urinary tract infection(UTI)[1].Fortunately,reliable guidelines for assessing the risk of SB I in febrile infants have been developed to help determine whether an infant should be hospitalized,undergo lumbar puncture,or be treated with antibiotics[2].However,many hospitals do not have written institutional guidelines,so clinicians often make decisions based on their own experience and knowledge[3-5].For a consistent approach to febrile infants,our hospital plans to introduce written guidelines.In this study,we estimated the expected effects of these guidelines and compared our data with the results of previous domestic studies.

Antibiotic use in children with Kawasaki disease

As the diagnostic criteria for Kawasaki disease (KD) consist of the clinical features that are shared by other childhood febrile illnesses [1, 2], KD is sometimes confused with a bacterial infection, leading to clinical situations in which children with the disease receive antibiotics (3–5)Here, we report the extent of antibiotic use in children with KD and the clinical parameters confusing KD with a bacterial infection.