Emergency department patients with small bowel obstruction： What is the anticipated clinical course？

BACKGROUND:Emergency physicians(EPs)often care for patients with acute small bowel obstruction.While some patients require exploratory laparotomy,others are managed successfully with supportive care.We aimed to determine features that predict the need for operative management in emergency department(ED)patients with small bowel obstruction(SBO).METHODS:We performed a retrospective chart review of 370 consecutive patients admitted to a large urban academic teaching hospital with a diagnosis of SBO over a two-year period.We evaluated demographic characters(prior SBO,prior abdominal surgery,active malignancy)and clinical findings(leukocytosis and lactic acid)to determine features associated with the need for urgent operative intervention.RESULTS:Patients with a prior SBO were less likely to undergo operative intervention[20.3%(42/207)]compared to those without a prior SBO[35.2%(57/162)].Abnormal bloodwork was not associated with need for operative intervention.68%of patients with CT scan findings of both an SBO and a hernia,however,were operatively managed.CONCLUSIONS:Patients with a history of SBO were less likely to require operative intervention at any point during their hospitalization.Abnormal bloodwork was not associated with operative intervention.The CT finding of a hernia,however,predicted the need for operative intervention,while other findings(ascites,duodenal thickening)did not.Further research would be helpful to construct a prediction rule,which could help community EPs determine which patients may benefit from expedited transfer for operative management,and which patients could be safely managed conservatively as an initial treatment strategy.

Human epidermal growth factor receptor-2 in oesophageal cancers:An observational study

AIM:To determine the incidence of human epidermal growth factor receptor 2(HER2) over expression in oesophageal cancers.METHODS:A retrospective study,of one hundred consecutive cases of endoscopic histological samples of oesophageal cancers from a single British cancer network were included.Cancer cases were diagnosed between April 2007 and June 2010.HER2 over expression was assessed using immunohistochemistry,those that scored "0" and "+1" were considered "negative" for HER2;those that scored "+3" were considered "Positive".Cases that were scored "+2" on immunohistochemistry further went on to have HER2 gene analysis using the Ventana HER brightfield dual-colourin situ hybridisations(HER B DISH) assay and either came back to be positive or negative for HER2 over expression.Overall survival was measured from date of histological diagnosis until date of death.93% of the cases were followed up till five years or death,and all were followed up till two years.Cases of gastro-oesophageal junctional tumours were excluded.RESULTS:The median age of our sample was 66 years(range:38-91 years).Eighty one were male and 19 female.Ninety-one of the cases were adenocarcinoma of the oesophagus and the rest were cases of squamous cell carcinoma.The anatomical distribution of the tumours was;upper oesophagus 2,middle oesophagus 11,and 87 were in the lower oesophagus.Operative resection was completed in 15 cases;seven cases had attempted surgical resections,i.e.,open and close,33 patients received definitive chemo-radiation and 52 had palliative treatment.Twenty-five of the cancers showed evidence of HER2 over expression,all were adenocarcinomas.Of the 25 cases that showed evidence of HER2 over expression,21(84%) were located in the lower third of the oesophagus.On staging,24 out of the 25 HER2 positive cases were at stage 3 or more(13 at stage 3 and 11 at stage 4),For HER2 negative cases 37 were at stage 3 and 32 were staged as stage 4.Seventeen out of twenty five cases(68%) with HER2 over expression received palliative therapy,in comparison to thirty five out of seventy five(46.7%) in tumours not expressing HER2.No significant difference in overall survival was demonstrated between patients whose cancers showed evidence of HER2 over expression and those who did not;median overall survival for HER2 positive tumours was 15 mo(95%CI,11-19 mo) compared to 13 mo(95%CI,9-17 mo) for HER2 negative ones.Two years cumulative survival for cases with HER2 over expression was 33.7% compared to 31.6% in cases without HER2 over expression(P = 0.576).Only cancer's stage significantly affected overall survival on both univariant and multivariable analysis(P = 0.034 and P = 0.009 respectively).None of the patients included in this study received Trastuzumab.CONCLUSION:Twenty-seven point five percent of oesophageal adenocarcinomas showed evidence of HER2 over expression.Routine testing for human HER2 in oesophageal adenocarcinomas can have significant implication on treatments offered to patients that may potentially affect their prognosis.

Ultrasound diagnosis of diverticulitis

INTRODUCTION Diverticular disease accounts for approximately312 000 hospital admissions in the United States annually,and costs nearly 2.6 billion dollars.[1,2]Approximately20%of Americans with diverticular disease will experience at least one episode of acute diverticulitis,necessitating a visit to their physician's office or the emergency department(ED)for treatment.[3]As the risk of developing diverticulitis rises with age(nearly 50%of people aged over 60 years have colonic diverticula),

等渗盐水比低渗盐水更适于胃肠炎患儿的静脉补液:一项前瞻性随机研究

Aims:To determine whether the risk of hyponatraemia in children with gastroenteritis receiving intravenous(IV)fluids is decreased by the use of 0.9%saline.Methods:A prospective randomised study was carried out in a tertiary paediatric hospital.A total of 102 children with gastroenteritis were randomised to receive either 0.9%saline +2.5%dextrose(NS)or 0.45%saline +2.5%dextrose(N/2)at a rate determined by their treating physician according to hospital guidelines and clinical judgement.Plasma electrolytes,osmolality,and plasma glucose were measured before(T0)and 4 hours after(T4)starting IV fluids,and subsequently if clinically indicated.Electrolytes and osmolality were measured in urine samples.Results were analysed according to whether children were hyponatraemic(plasma sodium < 135 mmol/l)or normonatraemic at T0.Results:At T0,mean(SD)plasma sodium was 135(3.3)mmol/l(range 124-142),with 37/102(36%)hyponatraemic.At T4,mean plasma sodium in children receiving N/2 remained unchanged in those initially hyponatraemic(n = 16),but fell 2.3(2.2)mmol/l in the normonatraemic group.In contrast,among children receiving NS,mean plasma sodium was 2.4(2.0)-mmol/l higher in those hyponatraemic at baseline(n = 21)and unchanged in the initially normonatraemic children.In 16 children who were still receiving IV fluids at 24 hours,3/8 receiving N/2 were hyponatraemic compared with 0/8 receiving NS.No child became hypernatraemic.Conclusions:In gastroenteritis treated with intravenous fluids,normal saline is preferable to hypotonic saline because it protects against hyponatraemia without causing hypernatraemia.