Disruptive behavior in the operating room: prevalence, consequences, prevention, and management

Purpose of review Disruptive workplace behavior can have serious consequences to clinicians, institutions, and patients. There is a range of disruptive behaviors, and the consequences are often underappreciated. The purpose of this manuscript is to review the definition, prevalence, consequences, prevention, and management of disruptive behavior in the operating room. Recent findings Although a small minority of operating room clinicians act disruptively, 98% of clinicians report having recently been exposed to disruptive behavior, with the average being 64 events per clinician per year. The causes include intrapersonal factors, workplace relationships, workplace logistics, and broader contextual factors. Disruptive behavior undermines patient care by decreasing individual and team clinical performance. It decreases clinician well being, sets a poor example for medical students who are susceptible to negative role models, and decreases hospital efficiency. The way that clinicians respond to disruptive behavior may either exacerbate or reduce the consequences of the behavior. In order to prevent disruptive behavior, the causes must be addressed. Institutions must have robust policies to deal with disruptive behavior and have preventive measures that include regular staff education. Whenever disruptive behavior does occur, it must be expeditiously addressed, which may include graded discipline. Summary Disruptive intraoperative behavior is prevalent and harms multiple parties in the operating room. Institutions require comprehensive measures to prevent the behavior and to mitigate consequences. Correspondence to Dr Eric Jacobsohn, MBChB, MHPE, FRCPC, AE215, Harry Medovy House – 671 William Avenue, Winnipeg, MB R3E 0Z2, Canada. Tel: +1 204 787 1518; e-mail: EJacobsohn@exchange.hsc.mb.ca Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Transjugular Intrahepatic Portosystemic Shunt Insertion for the Management of Portal Hypertension in Children

Objectives: To describe our 20-year experience with transjugular intrahepatic portosystemic shunt (TIPSS) procedures for children with resistant portal hypertension (PHTN). Methods: Retrospective review of all children that had a TIPSS performed at Birmingham Children's Hospital from 1st January 1995 - 1st January 2015. Results: 40 children underwent 42 attempted TIPSS for resistant PHTN with recurrent variceal bleeding (n = 35), refractory ascites (n = 4), and hypersplenism (n = 1). Median age at operation was 12 years (range, 7 months - 17 years). Thirty-four procedures were elective and 8 were emergency cases. TIPSS was established in 33 cases (79%). Median portal venous pressure reduction was 10mmHg. Variceal bleeding ceased in 27 (96%) and ascites improved in all. Clinical improvement following TIPSS enabled 7 children to be bridged to transplantation and 7 others to become suitable for transplantation. The 1-year and 5-year survival with TIPSS was 57% and 35%, respectively. Child-Pugh score C was an independent risk factor for adverse outcome (LR = 8.0; 95% CI 2.7 - 23.5; P = 0.001). There were 6 major complications: hepatic artery thrombosis and infarction (n = 1), hepatic artery pseudoaneurysm (n = 1), bile leak (n = 1), and hepatic encephalopathy (n = 3). Encephalopathy was resistant to medical treatment in 2 cases, necessitating staged closure in one. Ten patients (30%) required intervention to maintain TIPSS patency. The 1-year and 5-year freedom from reintervention was 71% and 55%, respectively. Conclusion: A TIPSS is highly successful in controlling symptoms in children with resistant PHTN and facilitating liver transplantation. However, it is technically demanding and not without risk. Patients must be appropriately selected and counselled. Address correspondence and reprint requests to Lauren Johansen, Liver Unit, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH (. e-mail: ljohansen@nhs.net). Received 15 December, 2017 Accepted 3 April, 2018 Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). Conflicts of Interest and Source of Funding: None declared © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Osteopontin Levels in Human Milk vary Across Countries and within Lactation Period: Data from a Multicenter Study

Objectives: Osteopontin (OPN) is a multifunctional protein expressed in many cell types, tissues and body fluids with the highest concentrations found in milk; significantly higher in human than in bovine milk. Intervention studies have indicated beneficial effects of supplementing infant formula with bovine OPN. In this multicenter study, we determined the OPN content in human milk samples from 629 Chinese, Danish, Japanese and Korean mothers. Methods: At each study site, milk samples were collected and analyzed for OPN and protein concentration using ELISA and infrared spectroscopy, respectively. Results: A total of 829 milk samples from 629 women were included. When delivering the first sample, mean maternal age was 31.4 years (SD 4.0), and median infant age was 13.4 weeks (IQR 4.6-17.9). The median OPN concentration varied across sites; from 99.7 mg/L in Danish, 182.5 mg/L in Japanese, 216.2 mg/L in Korean to 266.2 mg/L in Chinese mothers (p 

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Value of Serum Zinc in Diagnosing and Assessing Severity of Liver Disease in Children with Wilson Disease

Supplemental Digital Content is available in the text ABSTRACT Objectives: Wilson disease (WD) is a rare inborn error of copper metabolism with diverse manifestations. There has been no study of zinc (Zn), the copper's antagonist, in WD diagnosis and severity so far. Our aims were to evaluate serum Zn in WD and its correlation with the disease severity score (revised WD index). Although the ATP7B mutation analysis is highly accurate for WD diagnosis, it may not be readily available in a resource-limiting setting. We proposed a disease diagnostic score (Proposed WD diagnostic score) which incorporates serum Zn. Methods: Medical records of WD and non-WD children seen at King's College Hospital from 2005 to 2015 were reviewed for the selected parameters using the Proposed WD diagnostic score. Available serum Zn data in WD children before disease diagnosis and the calculated severity score were statistically analysed. Diagnostic values of the Proposed WD diagnostic score were evaluated. Results: Serum Zn level was significantly lower in 8 WD-acute liver failure (ALF) (5.8 [4.1–8.3] μmol/L) compared to 18 WD-non-ALF (13.5 [6.1–22.2] μmol/L) and 9 ALF from indeterminate cause (9.8 [7.0–12.1] μmol/L) (P 

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Anemia in Pediatric Inflammatory Bowel Disease

Objectives: Anemia is the most frequent extra-intestinal finding in Inflammatory Bowel Disease. The aim of this study is to determine the prevalence and types of anemia in pediatric patients with Inflammatory Bowel Disease at diagnosis and at approximately one year follow up. Methods: This is a retrospective chart review of patients diagnosed with Inflammatory Bowel Disease from 2005 to 2012, ages 1-18 years. Patients who had hemoglobin, hematocrit, mean corpuscular volume and iron indices obtained at the time of diagnosis and at approximately one year follow up were included in the study. The prevalence of anemia at the beginning and the end of the study was recorded. Using the soluble transferrin receptor index the type of anemia was determined. Results: At diagnosis, 67.31% of patients were anemic. Overall, 28.85% of patients had either Iron deficiency anemia or a combination of Iron deficiency anemia and anemia of chronic disease, while 38.46% had anemia of chronic disease alone. At follow up 20.51% were anemic. 15.38% had either iron deficiency anemia or a combination of iron deficiency anemia and anemia of chronic disease; 5.13% had anemia of chronic disease alone. The pattern of anemia and response to therapy differed among the inflammatory Bowel disease phenotypes Conclusion: Anemia is frequent in Inflammatory Bowel Disease. The prevalence was higher in Crohn's Disease. At one year, the prevalence of anemia decreased significantly, but persisted. Anemia of Chronic Disease predominated in CD. Iron Deficiency Anemia continued to be present in CD and UC. Address correspondence and reprint requests to Robert D. Baker, Digestive Diseases and Nutrition Center, Women and Children's Hospital of Buffalo, 219 Bryant Street, Buffalo, NY 14222, Tel: +716 878 7793; fax: +716 888 3842;(e-mail: rbaker@upa.chob.edu). Received 14 August, 2017 Accepted 11 January, 2018 There was no outside funding for this research. Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Anaesthesia in High-Risk Patients

No abstract available

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Breathlessness amplifies amygdala responses during affective processing

Psychophysiology, EarlyView.


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