Biomedical subjects
Publications and source records attributed to A L Weaver.
Among 375 patients who underwent a modified radical hysterectomy at the Mayo Clinic, the complication rate was 24%, and the operative mortality was 0.5%. When compared with radical hysterectomy, this procedure is associated with a lower overall incidence of complications, particularly those related to the urinary tract.
PURPOSE: In a previous, prospective, randomized study of the use of nasogastric tubes in patients undergoing elective abdominal colorectal surgery, we found that patients who did not have nasogastric (NG) decompression postoperatively had a significantly higher rate of abdominal distention, nausea, and vomiting. Patients from that study have now been followed for a median duration of 5.3 years to evaluate whether this elevation in perioperative intra-abdominal pressure would subsequently lead to an increased incidence of incisional hernia. RESULTS: Of the 251 patients who received NG decompression, 8 (3.2 percent) developed incisional hernias compared with 15 (6.6 percent) of 229 patients who were not decompressed (P = 0.085). CONCLUSION: The increase in postoperative abdominal distention and vomiting that occurs in patients who do not receive NG decompression does not lead to a significantly increased incidence of incisional hernia. Furthermore, we continue to support avoidance of routine prophylactic postoperative nasogastric decompression in uncomplicated, elective abdominal colorectal surgery.
Little information on functional status and well-being is available in patients with functional gastrointestinal disease. We aimed to evaluate whether quality of life is poorer in patients with functional dyspepsia. A consecutive sample of 73 patients with functional dyspepsia completed a validated questionnaire prior to endoscopy. Organic disease controls comprised 658 outpatients attending endoscopy. Quality of life was measured using the validated Medical Outcomes Survey (which assessed physical, role, and social functioning; mental health; health perception; and any bodily pain) and the Brief Symptom Inventory (for current anxiety and depression); additional specific gastrointestinal items were also included. A stepwise logistic regression analysis was used to assess the association between diagnostic group and the quality of life measures, adjusting for potential confounders. Patients who reported more interruptions in their daily activities due to abdominal pain and who had fewer limitations of physical functioning were more likely to have functional dyspepsia (vs other disease, P < 0.01). Mental health, social functioning, and health perception also tended to be poorer in functional dyspepsia. We conclude that quality of life may be more impaired in patients with functional dyspepsia than in patients with other conditions who present for upper endoscopy.
To better understand risk factors associated with early postoperative death or failure, we reviewed our entire experience with 702 consecutive patients who had the modified Fontan operation at the Mayo Clinic between October 1973 and December 1989. The event rate for takedown of repair or death during the initial hospitalization or within 30 days of the operation was 14.8% (successful takedown of the repair, n = 6; death, n = 98). To identify variables associated with early death or Fontan takedown, we analyzed 33 clinical and hemodynamic variables in a univariate and multivariate manner. On the basis of a stepwise logistic discriminant analysis, patients who were younger and operated on before 1980 with a higher preoperative pulmonary artery mean pressure, asplenia, higher intraoperative (after Fontan operation) right atrial pressure, longer aortic crossclamp time, and pulmonary artery ligation were more likely to have the outcome event of interest (p values < 0.05). A new variable, corrected pulmonary artery pressure (that is, mean preoperative pulmonary artery pressure divided by the ratio of pulmonary to systemic flow if the ratio of pulmonary to systemic flow is greater than 1.0), was significantly associated with the outcome event univariately (p = 0.002), but was no more predictive than the preoperative pulmonary artery mean pressure. Variables less predictive of the outcome event in this analysis included multiple prior operations, polysplenia syndrome, complex anatomy other than asplenia syndrome, and systemic atrioventricular valve regurgitation. These results represent the largest single-institution review of the Fontan operation and suggest that some anatomic and hemodynamic variables previously predictive of poor early outcome have been nullified by current operative methods.
PURPOSE: To determine if the degree of enhancement of pulmonary nodules is directly related to the likelihood of malignancy and to the vascularity of the nodule. MATERIALS AND METHODS: Uncalcified 6-40-mm-diameter pulmonary nodules were studied in 163 patients with malignant neoplasm (n = 111), granuloma (n = 43), and benign neoplasm (n = 9). Serial thin-section computed tomography (CT) was performed before and after injection of 100 mL of nonionic contrast material at 2 mL/sec. The maximum level of enhancement was recorded. Eighteen histologic specimens were graded after vascular staining. RESULTS: Malignant neoplasms enhanced (median, 40.0 HU; range, 20-108 HU) significantly more than granulomas and benign neoplasms (median, 12.0 HU; range, -4 to 58 HU) (P < .001). With 20 HU as the threshold for a positive test, sensitivity was 100%; specificity, 76.9%; positive predictive value, 90.2%; negative predictive value, 100%; and accuracy, 92.6% (prevalence of malignancy, 68.1%). Degree of enhancement was significantly related to amount of central vascular staining (P = .003). CONCLUSION: Enhancement is an indicator of malignancy and vascularity.
OBJECTIVE: To clarify the "natural history" of unresected cholangiocarcinoma. DESIGN: We reviewed the outcome in 103 patients with biopsy-proven cholangiocarcinoma managed at our institution during a 5-year period (1980 through 1984) who did not undergo curative resection. MATERIAL AND METHODS: The study group of 56 men and 47 women had initial manifestations of jaundice (71%), abdominal pain (49%), and weight loss (44%). The histopathologic features were confirmed by operation in 73 patients, percutaneous biopsy in 16, endoscopy in 3, or autopsy in 11. The primary tumor site was the common hepatic duct in 27%, the hepatic bifurcation in 27%, the common bile duct in 26%, the liver in 13%, and the right or left hepatic duct in 6%. Biopsy-proven metastatic lesions were identified in 70 patients, including 18 with proven nodal involvement. Surgical intervention (N = 57) most commonly consisted of biliary decompression (26%), biliary bypass (16%), or cholecystectomy (11%). RESULTS: The operative mortality was 4% (N = 2). The hospital mortality of medically managed patients was 12%. The survival after the onset of symptoms was 53% at 1 year, 19% at 2 years, and 9% at 3 years. Only four patients (4%) lived more than 5 years. Univariate analysis of all hospitalized patients (N = 90) revealed a survival advantage for women, patients 62 years of age or younger, those with blood group A or O, surgical patients, patients who did not require biliary decompression, and those who received further palliative treatment after any type of biliary decompression. Multivariate analysis showed a survival advantage for patients who underwent surgical exploration and those who had further palliative treatment after either operative or percutaneous biliary decompression. CONCLUSION: Unresected cholangiocarcinoma is a rapidly fatal process, but early intervention affects the course of the disease and likely prolongs patient survival.
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The effect of bolus viscosity on oropharyngeal and esophageal emptying is not known. We investigated this question in 38 healthy volunteers by measuring the transit of five semisolid boluses of varying viscosities across the oropharynx and the esophagus with the aid of scintigraphy. The studies were performed twice on consecutive days. The results show that oropharyngeal and esophageal emptying are reliably reproduced from day to day. Esophageal emptying was inversely related to bolus viscosity; however, oropharyngeal emptying was not influenced by bolus viscosity. We conclude that bolus viscosity has significant, but selective, effect on oropharyngoesophageal emptying.
BACKGROUND: Solitary metastases from a primary renal cell carcinoma (RCC) occur in < 10% of patients with metastatic RCC. To date, the benefit of surgically resecting such apparently solitary lesions has not been well documented. MATERIALS AND METHODS: Forty-one patients (25 men, 16 women) with metastatic renal cell carcinoma treated by surgical excision of solitary metastases (1970-1990) were retrospectively reviewed. They comprised 9% of patients with metastatic hypernephroma seen during this period. All patients had undergone previous curative nephrectomy with a median disease-free interval of 27 months. Patients with skeletal, spinal cord, and lymph node metastases were excluded. RESULTS: Metastases were intrathoracic (n = 20), intracranial (n = 7), and intraabdominal or in the extrapleural chest wall soft tissue (n = 10). Three patients had metastases to the thyroid gland and one had a solitary metastasis to an index finger. Median follow-up was 3.2 years. Complete resection was possible in 36 patients (88%) with a single lesion excised in 23 of these 36 patients (64%). There was no operative mortality. Predicted survival from the date of complete resection of metastases was 77%, 59%, and 31% at 1, 3, and 5 years, respectively, with a median survival of 3.4 years. One patient is alive without evidence of recurrent tumor 93 months from the first of 12 complete surgical resections. Varying adjuvant therapy was used in 50% of the patients. An increased histological tumor grade of the metastatic lesion relative to the original RCC was the only significant prognostic indicator identified. Disease-free interval and number of resected lesions were not significantly associated with patient survival. CONCLUSION: A small fraction of renal cell carcinoma patients are candidates for potentially curative surgical resection of solitary metastatic lesions. Excision of such lesions may contribute to prolonged survival in selected instances.
OBJECTIVE: To assess the role of breast conservation therapy in the management of early-stage invasive breast cancer. DESIGN: We reviewed the results of previously published trials and summarized 165 cases of breast conservation surgical procedures and irradiation at the Mayo Clinic between January 1979 and September 1989. MATERIAL AND METHODS: From the prior clinical trials, the criteria for selection of patients, the surgical and radiation techniques used, the complications of treatment, the cosmetic results, and the follow-up assessment and survival were analyzed. The 165 Mayo patients were also characterized, and their results were described. RESULTS: Breast conservation therapy consists of excision of the primary tumor followed by irradiation. A coordinated multidisciplinary approach should be used for selection of patients. Several large-scale clinical trials have demonstrated that breast conservation therapy is an appropriate option for most women with early-stage breast cancer and provides tumor control and survival rates equivalent to mastectomy. With a collaborative treatment program and judicious application of contemporary standards of practice, a good-to-excellent cosmetic outcome can be achieved in most patients, and the risk of treatment-related sequelae is minimal. The Mayo Clinic experience with breast conservation therapy is consistent with these observations and compares favorably with other institutional and clinical trial results. CONCLUSION: Patients should be fully educated about the options for primary management of early-stage breast cancer because the selection of therapy may profoundly influence psychologic adjustment and acceptance of the treatment program.
OBJECTIVE: To develop a questionnaire to measure gastroesophageal reflux disease in the community and to test its reliability and validity. MATERIAL AND METHODS: The reliability of the questionnaire was measured by a test-retest procedure in 38 outpatients and 77 community residents 25 to 74 years of age, whereas concurrent validity was evaluated by comparing findings from a physician interview with self-report data from 51 patients. For statistical analysis of the reliability of each question, the kappa statistic and the 95% confidence interval were calculated. RESULTS: The questionnaire was easy to understand and well accepted. The reliability (median kappa for outpatients, 0.70 [interquartile range, 0.59 to 0.81]; median kappa for population sample, 0.70 [interquartile range, 0.60 to 0.81]) and validity (median kappa, 0.62 [interquartile range, 0.49 to 0.74]) were acceptable. CONCLUSION: Our initial results suggest that this questionnaire is valid and should be applicable in population-based studies to assess gastroesophageal reflux disease.
OBJECTIVE: To assess the risks and benefits of incidental cholecystectomy in patients having colorectal surgery. SUMMARY BACKGROUND DATA: Cholelithiasis is found commonly during abdominal surgery. Previous studies used disparate methods to assess the risks and benefits of incidental cholecystectomy and have reached contradictory conclusions. METHODS: All patients in whom asymptomatic cholelithiasis was noted during colorectal surgery between January 1982 and December 1986 were studied. Operative morbidity and long-term outcome were assessed by chart review and questionnaire. RESULTS: Three hundred five patients were identified, of whom 195 (63.9%) had an incidental cholecystectomy and 110 (36.1%) did not. The two groups were similar in terms of age, sex, primary disease, and associated medical conditions, although fewer emergency procedures, abdominoperineal resections, and Hartmann's procedures were needed in the cholecystectomy group. The overall operative morbidity rate was the same in both groups. The long-term risk for developing small bowel obstruction was also similar. After a median follow-up of 6 years after hospital discharge, biliary pain or cholecystitis developed in 16 patients (14.6%) in the "no cholecystectomy" group, 12 of whom have had cholecystectomy. Two additional patients had cholecystectomy for acute postoperative cholecystitis while still in the hospital. Six more patients have had incidental cholecystectomy at subsequent laparotomies. The cumulative probability of needing cholecystectomy at 2 and 5 years after the initial colorectal operation was 12.1% and 21.6%, respectively. CONCLUSIONS: Incidental cholecystectomy was not associated with increased postoperative morbidity, whereas the long-term risk that previously asymptomatic gallstones would become symptomatic was substantial. Unless there are clear contraindications, patients with asymptomatic gallstones who have colorectal surgery should have concomitant cholecystectomy.
PURPOSE: To determine the value of color Doppler flow imaging in identification of deep venous thrombosis (DVT) of the femoropopliteal system without use of venous compression. MATERIALS AND METHODS: Color Doppler flow imaging was compared with venography in 103 lower extremities in 101 patients. Results of each examination were recorded as positive or negative for acute DVT or consistent with chronic DVT. RESULTS: Color Doppler flow imaging in 97 of 103 cases had a sensitivity of 95%, specificity of 99%, positive and negative predictive values of 95% and 99%, respectively, and accuracy of 98% in detection of acute DVT and was also helpful in differentiation of chronic from acute DVT. Color Doppler flow imaging prospectively identified six of eight patients with chronic DVT and correctly identified acute DVT in two patients with underlying chronic DVT. No results were false-positive for acute DVT in a patient with chronic DVT. CONCLUSION: Color Doppler flow imaging is complementary to compression ultrasonography in evaluation of suspected acute DVT and may be helpful in evaluation of suspected DVT in patients with previous or chronic DVT.
PURPOSE: To determine the sensitivity of time-of-flight and phase-contrast MR angiography for the detection of intracranial aneurysms. METHODS: Sixteen patients with 27 intracranial aneurysms previously identified with conventional angiography and 19 control patients were examined with three-dimensional time-of-flight, three-dimensional phase-contrast MR angiography, and standard MR imaging. Subvolumes of the carotid and posterior circulations, source images, and standard MR images were blindly interpreted by three experienced neuroradiologists. RESULTS: Detection of an aneurysm by a given sequence was defined as at least two of the three blinded readers identifying the aneurysm. The sensitivities of the sequences based on all 27 aneurysms were: transaxial T1, 25.9%; T2, 48.1%; PC, 44.4%; and TF, 55.6%. Two of 3 aneurysms detected with T2 but not MR angiography had adjacent blood products. Five millimeters appeared to be a critical size; the sensitivities for aneurysms greater than or equal to 5 mm were: T1, 37.5%; T2, 62.5%; PC, 75%; and TF, 87.5%. CONCLUSIONS: Three-dimensional time-of-flight MR with 512 x 256 matrix is more sensitive than three-dimensional phase-contrast or standard MR imaging for detection of aneurysms. Retrospectively, aneurysms 3 mm or larger can be identified with MR angiography; however, prospectively, 5 mm is the critical size for detection.
BACKGROUND: Considerable emphasis has been placed on early diagnosis and surgery for multiple endocrine neoplasia (MEN)-related medullary thyroid carcinoma (MTC) during the past two decades. Genetic screening now promises earlier and more accurate diagnosis. We examine our experience with MTC in MEN 2A and MEN 2B and assess the benefits of biochemical screening during the past 20 years. PATIENTS AND METHODS: Seventy-seven patients undergoing 63 primary total thyroidectomies and 14 reoperative procedures for MEN-related invasive MTC and/or preinvasive C-cell hyperplasia are reported. Fifty-eight patients had MEN 2A and 19 had MEN 2B; 79% of patients had a family history of MTC; 27% had pheochromocytoma, and 25% had hyperparathyroidism. RESULTS: Patients with MEN 2B had more advanced disease than those with MEN 2A, in spite of presentation at a younger age (15 years versus 24 years). Every patient with MEN 2B had invasive carcinoma, whereas 14% of patients with MEN 2A had C-cell hyperplasia without invasive disease. Nodal metastases were found less frequently in MEN 2A (14%) than MEN 2B (38%), and biochemical cure was achieved in 56% of patients with MEN 2A compared with none in patients with MEN 2B. Among patients with MEN 2A the occurrence of invasive carcinoma increased with age (p = 0.0003); 40% of patients for less than 5 years had invasive MTC compared with 100% at more than 20 years. Cause-specific mortality among patients with MEN and invasive tumors at 6, 12, and 18 years was 2%, 4%, and 7%, respectively, lower than that of patients with sporadic MTC (12%, 17%, and 23%, respectively) treated during the same time period (p = 0.028). CONCLUSIONS: Intensive biochemical screening of MEN 2 kindreds for MTC can result in detection of early disease and a significant prospect of surgical cure. Genetic testing promises additional benefits through more reliable detection of preinvasive disease, allowing prophylactic thyroidectomy in infancy. In MEN 2B, MTC is considerably more aggressive than in MEN 2A. A policy of routine thyroidectomy in infants with MEN 2B, regardless of serum calcitonin levels, is justified.
OBJECTIVE: We aimed to determine perceptions of diarrhea in the general population. METHODS: We obtained an age- and gender-stratified random sample of Olmsted County, Minnesota, residents aged 20 to 64 yr. Subjects were mailed a valid self-report questionnaire; 77% responded (n = 1644). RESULTS: A total of 57 subjects reported their usual bowel pattern as diarrhea alone (3.5%), whereas an additional 148 reported alternating diarrhea and constipation (9.0%). Among subjects with self-reported diarrhea, loose or watery stools and urgency were the commonest diarrheal symptoms, whereas in those with an alternating bowel habit a feeling of incomplete evacuation was the most common diarrheal symptom. Diarrheal symptoms inadequately discriminated self-reported diarrhea from a self-reported normal bowel habit in a logistic regression model adjusted for age, gender, and irritable bowel syndrome. Furthermore, only 39% of the subjects in the sample who had at least one of the four major symptoms compatible with diarrhea also reported their usual bowel habit as diarrhea. CONCLUSIONS: Because of the observed lack of agreement, we conclude that the term "diarrhea" should be interpreted very cautiously in epidemiological studies or clinical trials, as it is unlikely to accurately reflect symptoms of diarrhea.
OBJECTIVE: Although there is a paucity of data, environmental factors such as smoking, alcohol, and non-steroidal anti-inflammatory drugs (NSAIDs) are believed to be important in the pathogenesis of functional dyspepsia. We aimed to evaluate, in outpatients presenting for endoscopy, the role of environmental factors in functional dyspepsia. METHODS: A consecutive sample of 73 patients with functional dyspepsia completed a validated questionnaire prior to endoscopy. The comparison group consisted of outpatients attending for endoscopy who did not have functional dyspepsia (n = 658). Logistic regression analysis was used to estimate the association between functional dyspepsia and potential risk factors adjusting for age, gender, socioeconomic status, general health, and irritable bowel syndrome. RESULTS: Smoking, alcohol, aspirin, non-aspirin NSAIDs, and acetaminophen were not associated with functional dyspepsia. Patients were significantly less likely to have functional dyspepsia if they were current or past smokers, and there was a trend for patients to be less likely to have functional dyspepsia if they took NSAIDs regularly. When patients with functional dyspepsia were classified into symptom subgroups, the environmental factors were not found to be associated with ulcer-like dyspepsia (vs. nonspecific dyspepsia or organic disease). CONCLUSIONS: Smoking, alcohol, and NSAIDs are not associated with an increased risk of functional dyspepsia in outpatients presenting for endoscopy.
The objective of this study was to determine the reproducibility of serial bone blood flow (BBF) quantitation using multiple microsphere injections. Three consecutive estimates of BBF were obtained, using 15-mu radionuclide-labeled microspheres from 21 anesthetized adult dogs. A dose of 3 million spheres/kg was used in seven dogs (Cohort 1); a dose of 0.5 million spheres/kg was used in the remaining 14 dogs (Cohorts 2 and 3). Estimates of BBF were made at an average of 129, 153, and 175 minutes after the animals had been anesthetized in the first two cohorts and 179, 203, and 225 minutes in Cohort 3. The dogs in Cohort 1 had no surgical intervention; the dogs in Cohorts 2 and 3 had increasingly complex surgical interventions. Despite stabilization of cardiovascular status, BBF was found to vary by 33.4% in Cohort 1, 25.7% in Cohort 2, and 42.5% in Cohort 3 over the three injections. Cortical BBF fell by 13.9%, 12.1%, and 12.4% between the first and second, and by 31.0%, 11.2%, and 29.9% between the second and third estimates for Cohorts 1, 2, and 3, respectively. Variation in right to left blood flow was used as an overall measure of error caused by technique and did not consistently increase between the first, second, or third BBF estimates in any cohort. Cortical BBF data were found to be significantly more reliable than cancellous data (p < 0.01); error caused by technique was least in the midshaft femoral or midshaft humeral cortical samples. Increasing the dose of spheres administered from 0.5 to 3 million/kg for three serial microsphere injections increased the number of reliable samples and did not lead to increased technical error or shunting. This study demonstrates that there is a significant decrease in BBF over time in the anesthetized dog; therefore, serial estimates of BBF can only be interpreted if the results are normalized or if a control group of animals is included.