Nguyenlowery3654
Shared decision-making is critical to optimal patient-centered care. For elective operations, when there is sufficient time for deliberate discussion, little is known about how surgeons navigate decision-making and how surgeons align care with patient preferences. In this context, we sought to explore surgeons' approaches to decision-making for adults ≥65 years at high-risk of postoperative complications or death.
We conducted semistructured in-depth interviews with 46 practicing surgeons across Michigan. Transcripts were iteratively analyzed through steps informed by inductive thematic analysis.
Four major themes emerged characterizing how surgeons approach high-risk surgical decision-making for older adults (1) risk assessment was defined as the process used by surgeons to identify and analyze factors that may negatively impact outcome; (2) expectations and goals described the process of surgeons engaging with patients and families to discuss potential outcomes and desired objectives; (3) external anded, we found that surgeons who perform high-risk operations among older adults predominantly focused on assessing risk and setting expectations with patients and families rather than inviting them to actively participate in the decision-making process. Surgeons also reported influences on decision-making from quality metrics, referrals, and personal experiences. Patient involvement, however, was seldom discussed suggesting that surgeons may not be engaging in true shared decision-making when benefits should be weighed against a high likelihood of harm.
Since 1999, international guidelines recommend fasting from solid foods up to 6 hours and clear liquids up to 2 hours before surgery. Early recovery after surgery programs recommend restoration of oral intake as soon as possible. This study determines adherence to these guidelines up to 20 years after its introduction.
A 2-center observational study with a 10-year interval was performed in the Netherlands. In period 1 (2009), preoperative fasting time was observed as primary outcome. In period 2 (2019), preoperative fasting and postoperative restoration of oral intake were observed. Fasting times were collected using an interview-assisted questionnaire.
During both periods, 311 patients were included from vascular, trauma, orthopedic, urological, oncological, gastrointestinal, and ear-nose-throat and maxillary surgical units. Duration of preoperative fasting was prolonged in 290 (90.3%) patients for solid foods and in 208 (67.8%) patients for clear liquids. Median duration of preoperative fasting from solid foods and clear liquids was respectively 2.5 and 3 times the recommended 6 and 2 hours, with no improvements from one period to another. Postoperative food intake was resumed within 4 hours in 30.7% of the patients. Median duration of perioperative fasting was 2346 hours (interquartile range 2000-3030 hours) for solid foods and 1100 hours (interquartile range 753-1600 hours) for clear liquids.
Old habits die hard. Despite 20 years of fasting guidelines, surgical patients are still exposed erroneously to prolonged fasting in 2 hospitals. Patients should be encouraged to eat and drink until 6 and 2 hours, respectively, before surgery and to restart eating after surgery.
Old habits die hard. Despite 20 years of fasting guidelines, surgical patients are still exposed erroneously to prolonged fasting in 2 hospitals. Patients should be encouraged to eat and drink until 6 and 2 hours, respectively, before surgery and to restart eating after surgery.
Pneumatosis intestinalis (PI) is a rare but critical condition in which gas is found in the bowel wall. Although organ transplant recipients have an increased PI risk because of long-term immunosuppression, alpha-glucosidase inhibitors (α-GI), a standard diabetes therapy, often contribute to PI. However, little is known about the postorgan transplantation relationship between PI and α-GI. To the best of our knowledge, this is the first reported case of PI in a lung transplant recipient treated with α-GI.
A 59-year-old man underwent hybrid (living-donor and cadaveric) lung transplantation (LTx). The patient was treated with prednisolone and tacrolimus as immunosuppressive therapy and α-GI for diabetes for 4 years. He developed asymptomatic PI 1031 days after transplantation without any acute abdominal finding. After excluding other possible causes of PI, his PI was attributed to α-GI. The suspected α-GI was immediately withdrawn. RG7388 molecular weight The patient was managed conservatively with bowel rest and oxygen therapy. After 11 days of α-GI discontinuation, PI improved, and the patient completely recovered.
Physicians should keep this rare adverse drug reaction in mind when prescribing α-GI, particularly in patients with diabetes after organ transplantation and including LTx. The management strategy for asymptomatic PI caused by α-GI is the immediate discontinuation of α-GI therapy, followed by conservative management initiation.
Physicians should keep this rare adverse drug reaction in mind when prescribing α-GI, particularly in patients with diabetes after organ transplantation and including LTx. The management strategy for asymptomatic PI caused by α-GI is the immediate discontinuation of α-GI therapy, followed by conservative management initiation.This paper studies the robust stability of the fractional-order (FO) LTI systems with polytopic uncertainty. Generally, the characteristic polynomial of the system dynamic matrix is not an affine function of the uncertain parameters. Consequently, the robust stability of the uncertain system cannot be evaluated by well-known approaches including LMIs or exposed edges theorem. Here, an over-parameterization technique is developed to convert the main characteristic polynomial into a set of local over-parameterized characteristic polynomials (LOPCPs). It is proved that the robust stability of LOPCPs implies the robust stability of the uncertain system. Then, an algorithm is proposed to explore system's robust stability through investigating the robust stability of these LOPCPs based on the exposed edges idea. For the sake of feasibility comparison, extensive examples are elaborated that reveal the superiority of the proposed algorithm.
