Assessment of grouping variable should have been blind in trial of dementia.
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Dementia↗
Biomedical subjects
P E Voutilainen
Publications and source records attributed to P E Voutilainen.
Prognosis after lymph node recurrence in papillary thyroid carcinoma depends on age.
Papillary thyroid carcinoma (PTC) is a malignancy that has good prognosis especially among patients up to 45 years of age; about half of the patients are female and of childbearing age. Lymph node recurrence (LNR) occurs in 10%-14% of patients but is considered to be associated with relatively good prognosis. The purpose of this study was to estimate the association between patient age at primary operation, and the behavior of the disease after LNR. Between 1967 and 1994, 495 patients underwent surgery for primary PTC at the Department of Surgery, Helsinki University Central Hospital. There were 391 (79.0%) women and 104 (21.0%) men with a mean age of 44.5 years (range, 10.8-85.4 years). Fifty-eight patients in whom LNR was the first clinical sign of persistent disease after complete clinical response to primary treatment were included in this series. At the time of primary operation, 37 (64.3%) of the 58 patients who developed LNR were younger than 45 years of age and 21 patients were older. The mean times to LNR in these groups were 42.0 months (range, 3.0-194.5 months) and 49.0 months (range, 3.6-209.0 months) respectively. Carcinoma-specific 5-year survival after LNR was 100% (95% confidence interval [CI] 88.8%-100.0%) in patients ages up to 45 years and 61.1% (40.5%-82.8%) in older patients; 10-year survival rates were 100%, and 41.3% (p < 0.0001), respectively. Relative survival at 10 years was 98.6% for patients ages up to 45 years and 42.6% for older patients (p = 0.0014). Using the Cox model it was shown that development of LNR after primary treatment has an independent highly significant negative effect on survival (p < 0.001) in patients over 45 years of age. Prognosis of PTC even after LNR on patients ages up to 45 years at the time of the primary operation is almost parallel to the normal reference population, but in patients over 45 years of age the prognosis is relatively poor.
Adolescent↗
Ultrasonically activated shears in thyroidectomies: a randomized trial.
OBJECTIVE: To test whether the advantages of the ultrasonically activated shears (UAS) observed in thyroidectomies in a previous matched-pair study could be repeated in a randomized trial. SUMMARY BACKGROUND DATA: The UAS has been documented, mainly in nonrandomized studies, to be a safe and fast device in video-assisted and conventional surgery. METHODS: Thyroidectomies and lobectomies performed for benign or malignant thyroid disease between August 1997 and January 1999 were included in this series. Separate randomization, resulting in four sets of envelopes, was done for one consultant endocrine surgeon and for senior residents for both lobectomies and for total thyroidectomies. The operations performed with the UAS were compared with operations performed with the conventional method, using ligatures as the main hemostatic method. Main outcome measures were operating time, postoperative serum calcium level, palsy of the recurrent laryngeal nerve, and amount of intraoperative and postoperative bleeding. Possible bias that could have been caused by imbalance between treatment groups for surgeon experience was tested by two-way analysis of covariance. RESULTS: Thirty-six patients were randomized, 19 to the UAS and 17 to the conventional group. Mean operating time was 99.1 minutes in the UAS group and 134.9 minutes in the conventional group. The average savings in operating time with the UAS was thus 35.8 minutes. There was no difference in complications between the groups. The estimated savings in operating time would have been 1.66 times that observed in this study if the groups had been unbalanced with reference to surgeon experience. CONCLUSION: The UAS is a usable device in total thyroidectomies and lobectomies.
Adenoma↗
Long term prognosis of medullary thyroid carcinoma in 39 patients.
BACKGROUND AND AIMS: Thyroidectomy and radical cervical lymph node dissection have been suggested as primary and secondary operations aimed at achieving biochemical cure in cases of medullary thyroid carcinoma (MTC). The purpose of this study was to find out behaviour of MTC in long-term follow-up, and to estimate possible difference in biological virulence between sporadic MTC and MTC in MEN2A. MATERIAL AND METHODS: From 1967 through 1994, 39 patients with MTC, including 9 patients with hereditary disease, were operated on at the Second Department of Surgery, Helsinki University Central Hospital. Enlarged lymph nodes were dissected selectively. The main outcome measure was carcinoma-specific survival. RESULTS: In sporadic MTC, ten-year carcinoma-specific survival was 57.9% (95% CI 39.1%-76.7%) and ten-year survival after reoperation due to lymphatic node recurrence was 51.4% (CI 18.7%-84.2%). The presence of distant metastases at diagnosis (p = 0.0001) and extrathyroidal growth of the primary tumor (p = 0.0008) were independent predictors of carcinoma-specific survival in the Cox model. The risk ratio of sporadic MTC to MTC in MEN2A was 5.40 (CI 0.67-43.2) after adjusting the survival time for the size of the primary tumor. CONCLUSION: Distant metastases and the local extrathyroidal extent of the primary tumor have a significant effect on the prognosis of MTC, lymphatic node metastases and other clinical factors being less important. The biological virulence of sporadic MTC may be clinically significantly higher than that of MTC in MEN2A.
Adult↗
Anaplastic thyroid carcinoma survival.
Anaplastic thyroid carcinoma is a rare, highly malignant tumor of elderly people. The purpose of this retrospective study was to characterize the patient population and to detect a potential subgroup with better prognosis or any intervention that would be useful. From 1967 through 1994 a total of 33 anaplastic thyroid carcinomas were operated on at the Second Department of Surgery, Helsinki University Central Hospital. There were 26 females and 7 males with mean age of 66.0 years (range 36-89 years). At the time of diagnosis 16 of 33 patients had distant metastases, and 32 of 33 of the tumors had invaded the thyroid capsule. Disease-specific survival was 9.7% (95% confidence interval from 2.0% to 25.9%) at 1 year using the product limit survival analysis. In the stepwise Cox proportional hazards regression model, local resectability (p = 0.0002), presence of distant metastases at diagnosis (p = 0.0014), radiotherapy (p = 0.014), and radioiodine ablation (p = 0.039) were independent prognostic factors. We concluded that even though statistically significant, independent, prognostic factors can be found the survival of the patients with the best prognostic characteristics is still poor. Only one patient, who had an anaplastic carcinoma focus within an encapsulated follicular thyroid carcinoma, survived in this series. At present there seems to be no surgical treatment that would be efficient for treating symptomatic anaplastic thyroid carcinoma.
Adult↗
Indications for early mandatory laparotomy in abdominal stab wounds.
BACKGROUND: Patients with an abdominal stab wound presenting with shock, peritonitis or evisceration are usually subjected to early laparotomy, although very few studies have been done to validate the criteria. METHODS: In a retrospective study of 209 consecutive patients with stab wounds of the anterior abdomen, flank or lower chest, 23 clinical and radiological criteria were evaluated for their accuracy in predicting the presence of significant abdominal organ injury. RESULTS: Overall, 89 patients (43 per cent) had a significant abdominal injury. The criteria with the highest positive predictive values for significant injury were: signs of continuing haemorrhage in initially normotensive patients (86 per cent), shock on admission (83 per cent) and generalized peritonitis (81 per cent). No positive direct or indirect signs of peritoneal penetration including omental evisceration, extraluminal air on plain radiography, or free peritoneal fluid on abdominal ultrasonography were independent predictors of significant injury. CONCLUSION: Signs of major internal haemorrhage or generalized peritonitis are reliable criteria by themselves for early laparotomy. Peritoneal penetration is a poor indicator of significant organ injury and warrants direct organ-specific evaluation, such as computed tomography or laparoscopy, to identify patients who can safely be treated without operation.
Abdominal Injuries↗
Angiographic 20-year follow-up of 61 consecutive patients with internal thoracic artery grafts.
OBJECTIVE: To assess the behavior of internal thoracic artery (ITA) grafts versus venous grafts in repeated angiograms up to 20 years. SUMMARY BACKGROUND DATA: Use of ITA grafts to bypass left anterior descending artery stenosis has been shown to be associated with improved survival in patients undergoing coronary artery bypass grafting. METHODS: Sixty-one consecutive patients who received one or two ITA grafts and who underwent surgery from Oct. 5, 1971, to Dec. 18, 1973, in Helsinki University Central Hospital, Finland, were included in this prospective follow-up series. Fifty-six of the patients (92%) also received at least one venous graft. The number of distal anastomoses was 157, of which 47.7% (75) were performed with ITA grafts. The median age of the patients was 47.7 years (range 30.0 to 63.1), and 85% (52) were men. RESULTS: After 20 years of follow-up, 18/20 (90%) of the survivors underwent angiography; the patency rate was 88.9% for ITA grafts and 47.8% for venous grafts. Cumulative graft patency at 20 years, using all the information obtained from repeated angiographic examinations and autopsies, was also calculated to eliminate selection bias. The cumulative 20-year patency rate was 81% for ITA-left anterior descending artery anastomoses, 53.8% for venous graft-right coronary artery anastomoses, and 48.5% for venous graft-left circumflex artery anastomoses. In paired comparisons between anastomoses, the patency time of the ITA-left anterior descending artery anastomoses was on average 2.8 years longer than the venous graft-left circumflex artery patency time and 2.6 years longer than the venous graft-right coronary artery. CONCLUSIONS: Internal thoracic artery grafts, especially in left anterior descending artery anastomoses, should be considered as a primary solution in coronary artery bypass grafting surgery in patients with >10 years of life expectancy; if venous grafting is preferred, further evidence is needed.
Adult↗
Ultrasonically activated shears in thyroid surgery.
BACKGROUND: Ultrasonically activated shears (UAS) have been documented to be both safe and fast devices in laparoscopic surgery. We studied whether the use of UAS would have some advantage in thyroid surgery. METHODS: Thyroidectomies, performed by one senior endocrine surgeon between December 1996 and February 1997, were retrospectively matched, with patients operated on by the same surgeon using the conventional method. RESULTS: Six pairs of total thyroidectomies and one pair of lobectomies could be matched. Mean operating time was 100 minutes for the patients operated on with the UAS and 154 minutes for the patients operated on with the conventional method. The mean operating time with the UAS was thus on average 64.6% of the operation time with the conventional method, with a 95% confidence interval from 50.1% to 83.5% (t = 4.00, 6 df, P = 0.007). CONCLUSIONS: In this material the use of UAS reduced significantly operating time in thyroidectomies.
Blood Loss, Surgical↗
"Myocardial O2 balance during fluid resuscitation in uncontrolled hemorrhage: computer model".
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Brain↗
Acute surgical treatment of bleeding peptic ulcer. A retrospective analysis of 193 patients.
A retrospective analysis of 193 consecutive patients over an 11 year period operated on for continued bleeding from gastric or duodenal ulcer is presented. All patients were operated on within the first 48 hours after hospitalization. Preoperative endoscopic examination was performed in 108 patients and it was diagnostic in 79% of the cases. A sole duodenal ulcer was responsible for bleeding in 59 patients (31%) and in 50 patients (26%) the bleeding ulcer was located in the lesser curvature of the stomach. Other gastric ulcerations were scattered irregularly in different parts of the stomach. Gastric resection and Billroth II reconstruction were the most common procedures performed. Vagotomy, either truncal or gastric, was added to the resection in 31 (16%) cases. Primary mortality rate within 45 days from the operation was 15%. The survivors were on the average ten years younger (mean 58 years) than those who died. Forty one (21%) of the patients were operated on as emergency cases. These patients survived significantly better than those operated on after an observation period. It is concluded, that aggressive surgical treatment immediately after fluid resuscitation was associated with a reduction in mortality and morbidity rates in patients with bleeding peptic ulcer.
Adult↗
Recovery of anal sphincter function following transabdominal repair of rectal prolapse: cause of improved continence?
Twenty-eight patients with complete rectal prolapse underwent anorectal manometry before and 6 months and 1-2 years after abdominal rectopexy and sigmoid resection in a study of the mechanisms responsible for postoperatively improved anal continence. Preoperatively, 22 patients reported defective and control. Seven patients (all with minor incontinence) regained normal control and eight other patients achieved improved continence after surgery. Anal resting, squeeze, and voluntary contraction pressures were significantly lower for defective than for normal control, with a significant rise in these pressures at 6 months after the operation, except for those incontinent patients in whom continence was not improved. No further pressure rise was seen later. Improvement of continence was not accompanied by changes in rectal sensation or reflexive functions of the internal anal sphincter. These results suggest that recovery of the resting and voluntary contraction functions of the sphincter muscles was the cause of continence improvement observed after surgery. Anal manometry was unable to predict outcome of function. Therefore, supplementary procedures for restoration of continence are not advisable, although patients with only minor incontinence are likely to regain full continence after rectopexy alone.
Adult↗
Prostate tumour markers and differentiation grade in prostatic cancer.
Serum acid phosphatase activity, prostate specific phosphatase and prostate specific antigen were measured in 100 patients with prostatic cancer. The patients were divided according to the differentiation grade into 3 groups: G1 (well), G2 (moderately) and G3 (poorly differentiated) carcinoma. Bone metastases were identified by scintigraphy. Among the 76 M0 patients the mean levels of all 3 markers were slightly higher in patients with moderately differentiated prostatic carcinoma. Among the 24 M1 patients the primary tumour was either G2 (18 patients) or G3 (6 patients); none had G1 lesions. Significantly higher serum ACP and PAP levels were found in patients with G2 tumours than in those with G3 lesions. It was concluded that the histological differentiation grade of prostatic carcinoma did affect serum levels of prostatic tumour markers; the tendency towards higher levels in the G2 group was noticeable in both non-metastatic and metastatic cases despite the limited number of patients in the latter category. In clinical practice this information may be an important additional tool in staging prostatic cancer.
Acid Phosphatase↗
Prostate tumour markers as an aid in the staging of prostatic cancer.
Serum acid phosphatase activity (ACP), prostate specific phosphatase (PAP) and prostate specific antigen (PSA) were measured in 100 patients with prostatic cancer. The patients were divided into 4 groups: T1-2 MO, T3-4 MO and M1 patients with less than or equal to 10 or greater than 10 metastatic foci in bone scintigraphy. The mean serum ACP levels were almost identical in the T1-2 MO and T3-4 MO groups and there was no significant difference between the mean PAP values. Significantly higher PSA levels were observed in the MO patients in the extracapsular category compared with those in the intracapsular category. The mean serum levels of all 3 tumour markers were significantly higher in the M1 than in the MO category. PSA seems to be the marker of choice as a diagnostic aid for differentiating between patients with intracapsular and those with extracapsular tumour growth. In prostatic cancer patients with bone metastases these markers were of similar value for staging the disease.
Acid Phosphatase↗
Amniotic fluid erythropoietin predicts fetal distress in Rh-immunized pregnancies.
Repeated amniotic fluid erythropoietin measurements in 23 Rh-immunized pregnancies were done to evaluate erythropoietin levels of amniotic fluid as an indicator of fetal distress (umbilical artery, pH 7.14 or less, or 1-minute Apgar score of 4 or less). Amniotic fluid erythropoietin levels did not vary significantly between 168 and 273 gestational days in the pregnancies without fetal distress. Increasing levels of amniotic fluid erythropoietin predicted highly reliably severe fetal distress at birth. Whether erythropoietin levels of amniotic fluid can also predict fetal distress in other pathologic pregnancies needs further study.
Amniotic Fluid↗
Tissue expander injection dome leakage.
Injection dome leakage was found to be the cause for partial disappearance of the saline solution injected into some tissue expanders. When the injection domes of 22 consecutively removed tissue expanders were checked, we found that the average leakage pressure of these was 32 mmHg, with a range of 8 to 110 mmHg. When the patients were lying on their expanders, the weight of the corresponding body part caused intraluminal pressures of up to 90 mmHg in their expanders. Following removal of the expanders, the total leakage was calculated quantitatively and found to be maximally over 50 percent of the injected volume in some instances. The leakage flow through the injection dome in seven consecutively removed expanders was checked at pressures of 25, 50, and 75 mmHg over 30 minutes and was found to be slow. The possibility of injection dome leakage should be kept in mind, however, as a potential complication under unfavorable conditions. At the same time, we want to emphasize that in most instances tissue expanders function quite well and in predictable ways.
Humans↗
Accelerated tissue expansion with the "overfilling" technique.
Temporary overexpansion of the tissues at each filling session increased the actual inflation volume by about 59 percent. This shortened the process of tissue expansion considerably. "Overexpansion" means that the pressure in the expander is increased to a point where the dermal capillary flow is zero or the patient experiences so much discomfort that inflation cannot be carried out any further. The pressure in the expander is thereafter gradually decreased by taking out saline until both the capillary refill and all other clinical criteria are sufficient for safe dermal circulation. Comparison of the expander volume at the final pressure to the initial filling volume at the same pressure before the "overfilling" confirmed an average gain of about 59 percent in 14 patients.
Blood Volume↗
Validity of laser Doppler flowmetry for measuring the effect of the tissue expander pressure on skin circulation. Simultaneous measurement of tissue pressure and laser Doppler flowmetry.
Intermittent Laser Doppler Flowmetry (LDF) was used in five patients to measure changes in the dermal blood flow when changing intraluminal pressures in tissue expanders (TE). In another patient, continuous monitoring of the intraluminal pressure in the TE and simultaneous LDF was used. Our finding is that LDF is a suitable method for the registration of reactions in dermal circulation, caused by TE pressure changes. A statistically significant association between the changes of the LDF values and the intraluminal pressure in the TE was observed.
Adolescent↗