Post-pancreaticoduodenectomy hemorrhage:risk factors, managements and outcomes

BACKGROUND： Post-pancreaticoduodenectomy（PD） hemorrhage（PPH） is an uncommon but serious complication. This retrospective study analyzed the risk factors, managements and outcomes of the patients with PPH.METHODS： A total of 840 patients with PD between 2000 and2010 were retrospectively analyzed. Among them, 73 patients had PPH： 19 patients had early PPH and 54 had late PPH.The assessment included the preoperative history of disease,pancreatic status and surgical techniques. Other postoperative complications were also evaluated.RESULTS： The incidence of PPH was 8.7%（73/840）. There were no independent risk factors for early PPH. Male gender（OR=4.40, P0.02）, diameter of pancreatic duct（OR=0.64,P0.01）, end-to-side invagination pancreaticojejunostomy（OR=5.65, P0.01）, pancreatic fistula（OR=2.33, P0.04）and intra-abdominal abscess（OR=12.19, P0.01） were the independent risk factors for late PPH. Four patients with early PPH received conservative treatment and 12 were treated surgically. As for patients with late PPH, the success rate of medical therapy was 27.8%（15/54）. Initial endoscopy was operated in 12 patients（22.2%）, initial angiography in 19（35.2%）,and relaparotomy in 15（27.8%）. Eventually, PPH resulted in 19 deaths. The main causes of death were multiple organ failure,hemorrhagic shock, sepsis and uncontrolled rebleeding.CONCLUSIONS： Careful and ongoing observation of hemorrhagic signs, especially within the first 24 hours after PD or within the course of pancreatic fistula or intra-abdominal abscess, is recommended for patients with PD and a prompt management is necessary. Although endoscopy and angiography are the standard procedures for the management of PPH,surgical approach is still irreplaceable. Aggressive prevention of hemorrhagic shock and re-hemorrhage is the key to treat PPH.

Is low postoperative cholesterol level really an independent risk factor of adverse outcomes after living donor liver transplantation?

To the Editor:We read with great interest the article by Yang et al.[1]evaluating the effects of postoperative serum total cholesterol(s TC)changes on early allograft dysfunction and survival after living donor liver transplantation(LDLT).By the multivariate regression analysis,they showed that patients with s TC<1.42 mmol/L on postoperative day 3 had 4.08-fold and 2.72-fold greater risks of

Outcome and risk factors of early onset severe preeclampsia

Background Early onset severe preeclampsia is a specific type of severe preeclampsia, which causes high morbidity and mortality of both mothers and fetus. This study aimed to investigate the clinical definition, features, treatment, outcome and risk factors of early onset severe preeclampsia in Chinese women. Methods Four hundred and thirteen women with severe preeclampsia from June 2006 to June 2009 were divided into three groups according to the gestational age at the onset of preeclampsia as follows： group A （less than 32 weeks, 73 cases）, group B ,（between 32 and 34 weeks, 71 cases）, and group C （greater than 34 weeks, 269 cases）. The demographic characteristics of the subjects, complications, delivery modes and outcome of pregnancy were analyzed retrospectively. Results The systolic blood pressure at admission and the incidence of severe complications were significantly lower in group C than those in groups A and B, prolonged gestational weeks and days of hospitalization were significantly shorter in group C than those in groups A and B. Liver and kidney dysfunction, pleural and peritoneal effusion, placental abruption and postpartum hemorrhage were more likely to occur in group A compared with the other two groups. Twenty-four-hour urine protein levels at admission, intrauterine fetal death and days of hospitalization were risk factors that affected complications of severe preeclampsia. Gestational week at admission and delivery week were also risk factors that affected perinatal outcome. Conclusions Early onset severe preeclampsia should be defined as occurring before 34 weeks, and it is featured by more maternal complications and a worse perinatal prognosis compared with that defined as occurring after 34 weeks. Independent risk factors should be used to tailor the optimized individual treatment plan, to balance both maternal and neonatal safety.

Factors Associated with Thrombolysis Outcome in Ischemic Stroke Patients with Atrial Fibrillation

The outcome of early intravenous thrombolysis for ischemic stroke in patients with atrial fibrillation（AF）is worse than that without thrombosis. How to increase the efficacy of intravenous thrombolysis for AF-related ischemic stroke remains largely unknown. In this study, we investigated factors that influence the effect of intravenous thrombolysis in these patients. Our results showed that thrombolysis was independently associated with a favorable outcome（P ／ 0.001） and did not influence the mortality of AF-related ischemic stroke, although it increased the risk of hemorrhage within 24 h after treatment. Risk factors for a poor outcome at admission were：heart failure（P = 0.045）; high systolic pressure（P = 0.039）; high blood glucose（P = 0.030）; and a high National Institutes of Health Stroke Scale（NIHSS） score（P ／ 0.001）. Moreover, high systolic pressure at admission（P = 0.007）, high blood glucose（P = 0.027）, and a high NIHSS score（P ／ 0.001） were independent risk factors for mortality at 3 months. Besides thrombolysis, a high NIHSS score（P = 0.006） and warfarin taken within 48 h before stroke onset（P = 0.032） were also independent risk factors for symptomatic hemorrhage within 24 h after treatment. Ischemic stroke patients with AF benefited from intravenous thrombolysis with recombinant tissue plasminogen activator within 4.5 h after stroke.

Prognostic factors for community-acquired pneumonia in middle-aged and elderly patients treated with integrated medicine

OBJECTIVE:To identify prognostic factors in middle-aged and elderly patients with community-acquired pneumonia(CAP) who underwent integrated interventions involving traditional Chinese medicine(TCM) and modern medicine.METHODS:Patients aged ≥45 years and diagnosed with CAP were divided into a middle-aged cohort(45-59 years) and an elderly cohort(≥60 years),and clinical data comprising 75 predictor variables in seven classes were collected.After replacing missing data,calibrating multicenter differences and classifYing quantitative data,univariate and multivariate analysis were performed.RESULTS:On multivariate analysis,eight independent risk factors-respiration rate,C reactive protein(CRP),cost of hospitalization,anemia,gasping,confusion,moist rales and pneumonia severity index(PSI)-were correlated with the outcome "not cured" in the elderly cohort.Nine factors-neutrophil percentage(Neu%),blood urea nitrogen(BUN),time to clinical stability,appetite,anemia,confusion,being retired or unemployed,Gram-negative bacterial infection and educational level-were correlated with not cured in the middle-aged cohort.CONCLUSION:Independent predictive risk factors correlated with adverse outcomes in elderly patients were higher respiration rate,CRP≥four times the mean or median for the patient's center,cost of hospitalization>11,323 RMB and PSI>II,plus anemia,gasping,confusion and moist rales;those in middle-aged patients were higher Neu%,BUN≥mean or median,loss of appetite,anemia,confusion,being retired or unemployed and lower educational level.Gram-negative bacterial infection and time to clinical stability>9 days were protective factors.