Bleeding after Hysterectomy: Recommendations and What to Expect

Bleeding after gynecological surgery remains an infrequent life-threatening complication, demanding appropriate medical and surgical management. Classified as early/“reactionary” and delayed/secondary, unexpected postoperative hemorrhage may arise regardless of the route or subtype of hysterectomy. Timely recognition and prompt intervention to arrest bleeding are essential strategies for the suitable outcome of the patient. The present chapter presents an overview on different aspects of bleeding after hysterectomy such as incidence rate, risk factors, mechanisms, and management techniques aiming to expand knowledge and skills in recognizing and treating this unpredicted potentially serious problem. Furthermore, we intend to offer a guide toward standardizing treatment practice across bleeding issues following hysterectomy considering clear recommendations and algorithms.

Nachsorge unter erschwerten Vorzeichen – Erfahrungen forensischer Nachsorgeambulanzen mit Sexualstraftätern, die nach der Novelle der Verhältnismäßigkeitsregelung entlassen wurden

A major amendment of the German Criminal Code concerning treatment in forensic psychiatric hospitals (Secs. 63, 67 StGB) became effective in August 2016 and has led to an increasing number of discharges of sex offenders. In addition to inpatient treatment practice, this also poses great challenges for forensic aftercare. After a brief overview of the amendment, this article examines how it affects the release practice and legal probation. Based on the analysis of the post-inpatient development of ten sex offenders from North Rhine-Westphalia who were released for disproportionate reasons, the far-reaching consequences of the amendment forensic aftercare have to deal with are illustrated. Finally, attention is drawn to the great need for action and alternative solutions to reduce the length of stay and strengthens the patients fundamental right to freedom are proposed.

Theoretical and methodological principles of psychosynthesis application in dealing with eating disorders

The article analyzes the basic principles, stages and objectives of psychosynthesis in the provision of medical and psychological care to patients with eating disorders (ED). It is noted that a patients' compliance with dietary recommendations is often impossible due to the low level of their self-awareness, reflection, volitional self-regulation and trauma of the individual, which is experienced as an unconscious psychological problem that requires urgent solution. Nutritionists are invited to provide professional assistance based on psychosynthesis in cooperation with a psychologist in order to optimize a holistic approach to the treatment of ED through the psychological support of the patient (client) directly during medical counseling. The basic methodology of psychosynthesis is presented through a theoretical analysis of the principles of polypsychism and self-determination, which are explained through the R. Assagioli`s idea of the psyche, the concept of unifying centers and the theory of subpersonalities. It has been suggested that food and eating behavior replace the subject's self-consciousness (“I”) and become unifying centers around which the whole personality is neurotized. It leads to the displacement of not only traumatic experience that caused the disorder itself, but also the unmet personal need satisfaction of which is often ignored in modern treatment practice. The authors developed the stages and tasks of psychosynthesis as its special methodology for working with ED and began to test it in the form of an individual care program in medical and psychological practice. Particular attention in highlighting the preliminary results of the implementation of their developments is paid to the development of patients' ability to perform a voluntary act, which permeates all stages of treatment by psychosynthesis and is aimed not only at the change of eating behavior but also at self-actualization of a personality. The article briefly presents a partial methodology of psychosynthesis, which includes techniques of disidentification, image transformation and construction of an ideal model.

Uncertainty in Wastewater Treatment Design and Operation

Uncertainty in Wastewater Treatment Design and Operation aims to facilitate the transition of the wastewater profession to the probabilistic use of simulators with the associated benefits of being better able to take advantage of opportunities and manage risk. There is a paradigm shift taking place in the design and operation of treatment plants in the water industry. The market is currently in transition to use modelling and simulation while still using conventional heuristic guidelines (safety factors). Key reasons for transition include: wastewater treatment simulation software advancements; stricter effluent requirements that cannot be designed for using traditional approaches, and increased pressure for more efficient designs (including energy efficiency, greenhouse gas emission control). There is increasing consensus among wastewater professionals that the performance of plants and the predictive power of their models (degree of uncertainty) is a critical component of plant design and operation. However, models and simulators used by designers and operators do not incorporate methods for the evaluation of uncertainty associated with each design. Thus, engineers often combine safety factors with simulation results in an arbitrary way based on designer ‘experience’. Furthermore, there is not an accepted methodology (outside modelling) that translates uncertainty to assumed opportunity or risk and how it is distributed among consultants/contractors and owners. Uncertainty in Wastewater Treatment Design and Operation documents how uncertainty, opportunity and risk are currently handled in the wastewater treatment practice by consultants, utilities and regulators. The book provides a useful set of terms and definitions relating to uncertainty and promotes an understanding of the issues and terms involved. It identifies the sources of uncertainty in different project phases and presents a critical review of the available methods. Real-world examples are selected to illustrate where and when sources of uncertainty are introduced and how models are implemented and used in design projects and in operational optimisation. Uncertainty in Wastewater Treatment Design and Operation defines the developments required to provide improved procedures and tools to implement uncertainty and risk evaluations in projects. It is a vital reference for utilities, regulators, consultants, and trained management dealing with certainty, opportunity and risk in wastewater treatment. ISBN: 9781780401027 (Paperback) ISBN: 9781780401034 (eBook) ISBN: 9781789062601 (ePub)

Operating procedures, risk management and challenges during implementation of adaptive and non-adaptive MR-guided radiotherapy: 1-year single-center experience

Background Main purpose was to describe procedures and identify challenges in the implementation process of adaptive and non-adaptive MR-guided radiotherapy (MRgRT), especially new risks in workflow due to the new technique. We herein report the single center experience for the implementation of (MRgRT) and present an overview on our treatment practice. Methods Descriptive statistics were used to summarize clinical and technical characteristics of treatment and patient characteristics including sites treated between April 2019 and end of March 2020 after ethical approval. A risk analysis was performed to identify risks of the online adaptive workflow. Results A summary of the processes on the MR-Linac including workflows, quality assurance and possible pitfalls is presented. 111 patients with 124 courses were treated during the first year of MR-guided radiotherapy. The most commonly treated site was the abdomen (42% of all treatment courses). 73% of the courses were daily online adapted and a high number of treatment courses (75%) were treated with stereotactic body irradiation. Only 4/382 fractions could not be treated due to a failing online adaptive quality assurance. In the risk analysis for errors, the two risks with the highest risk priority number were both in the contouring category, making it the most critical step in the workflow. Conclusion Although challenging, establishment of MRgRT as a routinely used technique at our department was successful for all sites and daily o-ART was feasible from the first day on. However, ongoing research and reports will have to inform us on the optimal indications for MRgRT because careful patient selection is necessary as it continues to be a time-consuming treatment technique with restricted availability. After risk analysis, the most critical workflow category was the contouring process, which resembles the need of experienced staff and safety check paths.

The effectiveness of antihistamines in the treatment of atopic dermatitis in children

Histamine is one of the key endogenous mediators involved in the regulation of essential physiological and pathological processes in the human body. Its effects are implemented through several types of specific cell surface histamine (H)-receptors. H1-receptors are the most studied ones. The main clinical effects of their stimulation are vasodilation, bronchoconstriction, pituitary gland stimulation of hormone production, increased mucus production by the nasal glands, etc. Histamine H1 receptor antagonists of two generations are pathogeneticaUy justified agents for the treatment of most allergic diseases in accordance with the current clinical guidelines. The second-generation antihistamines that are devoid of sedative effects and are clinically more effective than the first-generation drugs have been currently introduced into the allergic disease treatment practice. They are the main drugs for the treatment of allergic diseases, especially in acute symptoms of the disease. Dimetindene maleate is the drug of choice for the symptomatic treatment of skin lesions, especially in infants. The article presents the result of the analysis of 26 out-patient medical records of infants (aged from 4 to 12 months) with a verified diagnosis of “atopic dermatitis, limited form, in the exacerbation phase”. A mild course of the disease was observed in 17 children, and a moderately severe course in 9 children. The duration of treatment was 7 to 16 days. Against the background of therapy (group 1), the following results were obtained: on day 3 of treatment the SCORAD-TIS index decreased to 16.4 ± 1.6 and on day 7 to 9.1 ± 1.3 points in children with a moderate course, and to 6.7 ± 0.8 and 4.1 ± 0.9 points in children with a mild course, respectively. In the children from group 2, the decrease in SCORAD-TIS was less significant: 19.5 ± 1.5 points on day 3, 12.2 ± 1.1 points on day 7 in children with a moderate course, respectively. Similar values decreased to 9.0 ± 0.9 on day 3, and to 6.9 ± 1.2 points on day 7 in children with a mild course of atopic dermatitis. The conducted analysis demonstrates the high clinical efficacy, good tolerance and the absence of tachyphylaxis of dimetindene maleate, drops. No side effects including those associated with anticholinergic properties (dry mouth, agitation) were identified.

Clinical Practice Patterns of Speech-Language Pathologists Delivering Dysphagia Services to Persons with COPD: Analysis of Survey Outcomes

Swallowing impairments co-occur with chronic obstructive pulmonary disease (COPD) leading to aspiration, disease exacerbations, and malnutrition. This pilot survey study aimed to identify current clinical practice patterns for swallowing evaluation and treatment in persons with COPD. A 35-question Qualtrics survey was deployed to medical speech-language pathology (SLP) social media sites and professional boards; flyers were distributed at a professional conference. Forty-eight SLPs completed the study. SLPs routinely include a clinical swallow examination (96%), videofluoroscopic swallowing study (79%), adjunctive respiratory measures (respiratory rate [83%], and pulse oximetry [67%], respiratory–swallow pattern [77%]) but less frequently include fiberoptic endoscopic evaluation of swallowing (23%). Self-reported advanced clinical experience and expert respiratory analysis skills were associated with adjunctive respiratory measure (respiratory rate, pulse oximetry) inclusion during assessment. Compensatory strategy training (77%) is a preferred treatment for dysphagia in COPD; however, respiratory–swallow pattern training and expiratory muscle strength training are increasing in use. SLPs self-report a comprehensive, individualized patient-centered care approach with inclusion of adjunctive respiratory-focused methods in dysphagia evaluation and treatment practice in persons with COPD. Advances in the identification of the integral role of respiratory function in swallowing integrity may be translating to clinical practice methods for dysphagia management in persons with COPD.

Bridge over Troubled Water: Patients’ Opportunities for Collective Participation in Substance Use Institutions through Research Circles

This study explores patients’ opportunities for collective participation in an institution for people with substance use disorder. Patients and staff from the treatment institution cooperated with researchers to make changes in the treatment practice, using a research circle as a model for the project. In the article, we discuss the following research questions: How and in what areas did patients have the opportunity to participate collectively in the treatment institution? How did the patients experience participation in the research circle? Data consist of minutes from meetings, seminars, and focus-group interviews. The participants analysed the material together, and the authors carried out a thematic analysis after the project. The participants chose to explore how milieu therapy could build a bridge from treatment in the institution to life after treatment, a “Bridge over troubled waters”, to quote Simon and Garfunkel. Findings show that activities in the research circle led to changes at the institution, e.g., regular Sunday afternoon meetings, a weekly quiz, and less controlling procedures of substance use, and that the institutional culture in general became based more on participation and equality. Patients, staff, and researchers participated in a partnership; mutual recognition promoted cooperation and fellowship in the research circle. We conclude that the project provided the participants with opportunities for collective participation in the institution. In addition, the patients experienced partnership and empowerment in the research circle. Our attempts to change institutional practices yielded some improvements but also met with structural and cultural barriers. Thus, the project experienced challenges and obstacles mostly related to limitations in the institutional system and culture.

Design Evaluations of Aerosol Suction Machine for Dental Treatment Practices in COVID-19 Era

The aim of this paper is to demonstrate the evaluation process to select the Aerosol Suction Machine (ASM) design to be implemented in a dental treatment practice to prevent the spread of COVID-19. There are two designs evaluated, the movable ASM and the fixed mounting ASM. The evaluation process involved four evaluation criteria: flexibility, safety level, manufacturability, and maintenance. The evaluation is conducted based on a specific requirement of a small dental clinic located in Surakarta, Indonesia. The evaluation results show that the fixed mounting is more suitable for implementing in a small dental clinic with many natural ventilation openings.

Real-world treatment of adult patients with Guillain-Barré syndrome over the last two decades

This study investigated treatment characteristics of Guillain-Barré syndrome (GBS) in a real-world setting between 2000 and 2019. We analyzed clinical improvement between nadir and last follow-up in patients with severe GBS (defined as having a GBS disability scale > 2 at nadir) and aimed to detect clinical factors associated with multiple treatments. We included 121 patients (74 male; median age 48 [IQR 35–60]) with sensorimotor (63%), pure motor (15%), pure sensory (10%) and localized GBS (6%) as well as Miller Fisher syndrome (6%). 44% of patients were severely affected. All but one patient received at least one immunomodulatory treatment with initially either intravenous immunoglobulins (88%), plasma exchange (10%) or corticosteroids (1%), and 25% of patients received more than one treatment. Severe GBS but not age, sex, GBS subtype or date of diagnosis was associated with higher odds to receive more than one treatment (OR 4.22; 95%CI 1.36–13.10; p = 0.01). Receiving multiple treatments had no adjusted effect (OR 1.30, 95%CI 0.31–5.40, p = 0.72) on clinical improvement between nadir and last follow-up in patients with severe GBS. This treatment practice did not change over the last 20 years.