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[Epidemiological analysis of hepatitis A morbidity].

A retrospective epidemiological analysis of hepatitis A morbidity for many years among the population of two neighboring towns in the temperate climatic zone of the USSR has revealed the cyclic character of the epidemic process without a perceptible decrease in its extensiveness and has determined the high-risk groups, as well as the beginning of the seasonal rise of morbidity in these groups. The results of the study indicate that different levels of hepatitis A morbidity and risk groups can be observed in these two neighboring towns. At periods of a lower morbidity level the high-risk group embraces schoolchildren, and when morbidity is at a higher level the risk group includes schoolchildren and preschool children in organized groups. Among the latter the morbidity level is influenced by factors acting all the year round and among school children, by seasonal factors. The beginning of the seasonal rise of morbidity falls on August, while in organized groups of children of preschool age the seasonal rise of hepatitis A morbidity begins 1-1.5 months later. All prophylactic measures for controlling hepatitis A should be carried out with due regard to these features of the epidemic process.

Age Factors↗

Risk factors for operative morbidity in patients with systemic lupus erythematosus: an analysis of 63 surgical procedures.

The surgical morbidity rate of patients with Systemic Lupus Erythematosus is considered very high; however, the experience in the literature is small. This study will determine the rate of surgical morbidity and the existence of predictive factors in patients with such a disease. The medical records of 53 patients with Systemic Lupus Erythematosus who underwent 63 major operations were analyzed retrospectively. The rate and causes of operative morbidity were registered. Univariate and multivariate statistical analysis was performed to ascertain the existence of predictive factors for morbidity. The overall morbidity and mortality were 16% and 6% respectively. Lymphopenia, hypoalbuminemia, increased SGOT and SGPT, urgent indication of operation, the physical status of the American Society of Anesthesiology, as well as a shorter duration of Systemic Lupus Erythematosus showed a significant correlation with operative morbidity in the univariate analysis; high blood urea nitrogen showed marginal significance. Physical status, urgent indication, and blood urea nitrogen remained as significant variables with the multivariate logistic regression analysis. The surgical morbidity rate of these patients may be lower than previously estimated. The physical status, urgency of operation, and level of blood urea nitrogen seemed to be the most useful independent predictors for surgical morbidity risk in patients with Systemic Lupus Erythematosus.

Adult↗

Long-term morbidity after regional isolated perfusion with melphalan for melanoma of the limbs. The influence of acute regional toxic reactions.

OBJECTIVE: To determine the influence of acute regional toxic reactions on the incidence and characteristics of long-term morbidity after regional isolated perfusion with melphalan. DESIGN: Retrospective study. SETTING: The Amsterdam and Rotterdam perfusion centers, the Netherlands. PATIENTS: All patients with melanoma who were treated between 1978 and 1990 and had a minimum follow-up of 1 year after perfusion (n = 367). INTERVENTION: Fifty-four patients (15%) had perfusion of the upper limb, 313 (85%) had perfusion of the lower limb, and 164 patients (45%) underwent regional lymph node dissection at the time of perfusion. MAIN OUTCOME MEASURE: Incidence and characteristics of morbidity 1 year after perfusion and the influence of acute regional toxic reactions on long-term morbidity. RESULTS: One hundred sixty patients (44%) showed some degree of objective or subjective morbidity; most (104 [28%]) had lymphedema. Other long-term morbidity consisted of muscle atrophy or fibrosis (42 [11%]), limb malfunction (55 [15%]), neuropathy (13 [4%]), pain (28 [8%]), and recurrent infection (11 [3%]). Miscellaneous complications were seen in 14 patients (4%). Seventy-one patients (19%) had more than one complication. Acute regional toxic reactions had a statistically significant effect on the incidence of long-term morbidity (P < .01). Moderate to severe acute regional toxic reactions were strongly linked to the occurrence of muscle atrophy or fibrosis (P < .001) and limb malfunction (P < .001). Regional lymph node dissection was statistically significantly related to lymphedema (P = .05). CONCLUSION: Improvement of the perfusion technique should be pursued in an effort to reduce acute regional toxic reactions, and thereby long-term morbidity, without compromising the therapeutic effect.

Adult↗

Predicting postoperative morbidity by clinical assessment.

BACKGROUND: The aim of this study was to determine the accuracy of prediction of the surgeon's 'gut-feeling' in estimating postoperative outcome. METHODS: A prospective series of 1077 consecutive patients undergoing major hepatobiliary or gastrointestinal surgery were studied. Patients having elective (n = 827) and emergency (n = 250) procedures were included. The surgeon predicted the development of postoperative complications immediately after completion of surgery on a scale from 0 to 100 percent. These predictions were compared with the actual outcome and with predictions made using the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM). The Portsmouth predictor equation (P-POSSUM) was applied for the estimation of mortality. RESULTS: The observed morbidity and mortality rates were 29.5 and 3.4 percent respectively. POSSUM predicted a morbidity rate of 46.4 percent and P-POSSUM a mortality rate of 6.9 percent. The surgeon's gut-feeling was more accurate in the prediction of morbidity at 32.1 percent. On the basis of gut-feeling, surgeons overpredicted morbidity in elective surgery, but underestimated the risk of complications in the emergency setting. The (P)-POSSUM scoring system overpredicted morbidity and mortality for elective and emergency operations. CONCLUSION: The surgeon's gut-feeling is a good predictor of postoperative outcome, especially after elective surgery. (P)-POSSUM overpredicted morbidity and mortality in this series of major gastrointestinal and hepatobiliary operations.

Attitude of Health Personnel↗

Gastroschisis: can the morbidity be avoided?

Although the mortality associated with gastroschisis (GS) has fallen markedly over recent years, postoperative morbidity and the incidence of complications remain high. Many different factors may contribute to this morbidity; the aim of this study was to determine which factors contributed most. Measures of morbidity used were time to full oral feeding (FOF), time on parenteral nutrition (PN), age at discharge, and incidence of complications. Between 1969 and 1995, 44 neonates with GS were treated; there were 6 deaths. The average initial temperature of the patients who died was 34.6 degrees C compared with 36.0 degrees C for the rest of the group (P = 0.02). Staged repair and prematurity were associated with increased time to FOF, time on PN, and age at discharge (P < 0.001). When the corrected post-term age was used, the difference between preterm and term babies was no longer significant. Mode of delivery did not influence any measure of morbidity. Seventeen patients (46%) had complications related to PN administration and 18 (43%) developed complications related to their surgery. There were no significant differences in these measures of morbidity when comparing patients born in the first half of the study period with those born in the last half. Multivariate analysis revealed that time to FOF, time on PN, and age at discharge were all strongly independently associated with staged repair and with the presence of complications of PN (all F > 7.2 and P < 0.01). Mode of delivery, gestational age, admission temperature, the need for postoperative ventilation, and complications of surgery were not independently associated with any of the measures of morbidity examined. Our data suggest that term delivery and primary closure of the defect are likely to minimise the morbidity experienced by infants with GS.

Abdominal Muscles↗

Vancomycin dosing in morbidly obese patients.

OBJECTIVES AND METHODS: Vancomycin hydrochloride dosing requirements in morbidly obese patients with normal renal function were computed to determine the dose of vancomycin necessary to achieve target steady-state peak and trough concentrations and compared with a normal weight population. RESULTS: Morbidly obese patients [total body weight (TBW) 165 kg, ideal body weight (IBW) 63 kg] required 31.2 mg x kg(-1) x d(-1) TBW or 81.9 mg x kg(-1) x d(-1) IBW to achieve the target concentrations. Normal weight patients (TBW 68.6 kg) required 27.8 mg x kg(-1) x d(-1) to achieve the same concentrations. Because of altered kinetic parameters in the morbidly obese patients (obese: t1/2 = 3.3 h, V = 52 L, CL = 197 ml x min(-1); normal: t1/2=7.2 h, V=46 L, CL=77 ml x min(-1), 20 of 24 patients required q8h dosing (1938 mg q8h) compared with q12h dosing (954 mg q12h) in all normal weight patients in order to avoid trough concentrations that were too low for prolonged periods. There was a good correlation between TBW and CL, but only fair correlation between TBW and V. CONCLUSION: Doses required to achieve desired vancomycin concentrations are similar in morbidly obese and normal weight patients when TBW is used as a dosing weight for the obese (approximately 30 mg x kg(-1) x d(-1)). Shorter dosage intervals may be needed when dosing morbidly obese patients so that steady-state trough concentrations remain above 5 microg x ml(-1) in this population. Because of the large amount of variation in required doses, vancomycin serum concentrations should be obtained in morbidly obese patients to ensure that adequate doses are being administered. Dosage requirements for morbidly obese patients with renal dysfunction require further study.

Adult↗

Perinatal mortality and morbidity. Comparison between maternal transport, neonatal transport and inpatient antenatal treatment.

The purpose was to assess differences in neonatal morbidity and mortality between maternally transferred, neonatally transferred and inborn neonates. We evaluated a continuous series of all antenatal transported infants (ATI, n=247) and postnatal transported infants (PTI, n=34) to the NICU and all preterm inborns (NTI, n=120) delivered at the University Hospital of Vienna. Data collected included sociodemographic, obstetrical and neonatal data. Mild neonatal morbidity was defined as RDS, BPD, ROP, PDA, NEC or IVH I-II, whereas severe neonatal morbidity was defined as the presence of PVL or IVH III-IV. Data were analyzed statistically using the Spearman correlation Coefficient, the Kruskal-Wallis test, and a multivariate model. There was a substantial gain in gestational age from transfer to delivery in the ATI group and from admission to delivery in the NTI group (2.1 and 5.6 weeks, respectively). The neonatal survival rate was 88.7% in the ATI and 97.5% in the NTI group. No neonate died in the PTI group; there was a significantly higher percentage of severe neonatal morbidity than in the ATI group (11.8% vs. 4.9%). We could not observe a significant difference with respect to the risk of death among the three study groups. There was a strong trend towards higher probability of severe neonatal morbidity in the NTI group. The risk of severe neonatal morbidity is much higher in the PTI-group (rel. risk 0.19, 0.06). Antenatal transfer guaranteed a significantly better neonatal outcome concerning severe neonatal morbidity than postnatal transport, and compared favorably with inborn admissions, even given the higher gestational age and birth weight in the NTI-group.

Adult↗

Comparison of objective outcomes following laparoscopic Nissen fundoplication versus laparoscopic gastric bypass in the morbidly obese with heartburn.

BACKGROUND: Heartburn and gastroesophageal reflux disease (GERD) affects approximately 25-50% of morbidly obese patients. Although objective physiologic testing has been reported extensively in patients following Nissen fundoplication, there are no previous reports of such testing in morbidly obese patients. A life-saving surgical alternative for the morbidly obese patient is gastric bypass surgery, which usually improves heartburn symptoms in addition to many serious health conditions such as diabetes, hypertension, and sleep apnea. We hypothesized that, in morbidly obese patients, gastric bypass surgery would be as effective as Nissen fundoplication in reducing both heartburn symptoms and esophageal acid exposure, as reflected by the DeMeester score. METHODS: Between 1995 and 2000, all patients undergoing laparoscopic Nissen fundoplication (LN) and laparoscopic gastric bypass (LGB) in our practice underwent preoperative and postoperative esophageal physiologic testing. Patients were included in this study that were morbidly obese and had significant heartburn symptoms or objective evidence of acid reflux, and had repeat esophageal physiologic testing after either LN or LGB. Data were obtained through retrospective review of prospectively collected data. RESULTS: Twelve patients met the inclusion criteria: six patients who had LN and six who had LGB. The mean body mass index (BMI) was 55 kg/m2 in the LGB group and 39.8 in the LN group. After surgery, the mean DeMeester score decreased from 64.3 to 2.8 in the LN group ( p = 0.01) and from 34.7 to 5.7 in the LGB group ( p = 0.1). Both groups' mean postoperative DeMeester scores were normal after surgery, and there was no significant difference between the two groups ( p = 0.3). Both groups experienced a significant improvement in heartburn symptoms postoperatively. The mean preoperative symptom score improved from 3.5 to 0.5 in the LN group ( p = 0.01) and from 2.2 to 0.2 in the LGB group ( p = 0.003). There was no difference in the mean postoperative symptom scores between the groups ( p = 0.35). After surgery, mean LES resting pressures increased from 12.9 to 35.5 ( p = 0.003) in the LN group and from 23.6 to 29.7 ( p = 0.45) in the LGB group. There were no complications in either group. CONCLUSION: Results of this study show that laparoscopic gastric bypass and laparoscopic Nissen fundoplication are both effective in treating heartburn symptoms and objective acid reflux in morbidly obese patients. The health benefits of weight loss after laparoscopic gastric bypass should make this operation the procedure of choice in the morbidly obese patient with heartburn.

Adult↗

Laparoscopic cholecystectomy in morbidly obese patients.

BACKGROUND: Morbid obesity is generally regarded as a risk factor for laparoscopic cholecystectomy due to increases in operative time, morbidity, and conversion rate to open cholecystectomy. The aim of this study was to evaluate the feasibility and outcome of laparoscopic cholecystectomy (LC) in morbidly obese patients. METHODS: A total of 864 consecutive patients underwent LC at our institution between 1990 and 1997. This series represents a continuing policy of LC for all comers. Data were collected prospectively. There were 659 nonobese (NO: BMI 40 kg/m2). Laparoscopic bile duct exploration was performed in 28 (4.2%), nine (4.8%), and one (5.9%) patients, respectively. RESULTS: Obesity and morbid obesity were associated with trends toward an increased conversion rate (2.3% NO; 4.3% OB; 5.9% MO), a longer operative time (median, 80, 85, and 107 mins, respectively), greater postoperative morbidity (4.7%, 5.9%, and 11.8%, respectively), and a reduced ability to obtain cholangiography (86.1%, 80.1%, and 71.4%, respectively). None of these differences, however, were statistically significant (c2 test, p > 0.05). Postoperative hospital stay for LC was similar for all three groups (median, 1 day). CONCLUSION: LC in morbidly obese patients is a safe procedure, but it may be associated with increased operative difficulty and morbidity, as compared with nonobese and obese patients.

Adult↗

Preoperative multivariate prediction of morbidity after gastrectomy for adenocarcinoma.

BACKGROUND: Gastrectomy remains the only curative treatment for gastric cancer. However, surgical morbidity and mortality remains high. Our aim was to identify the risk factors that determine operative morbidity and mortality and to describe a simple method for preoperative stratification of morbidity outcome. METHODS: Retrospective review of patients who underwent gastrectomy for gastric cancer. Multivariate analysis was used to define risk factors for surgical morbidity and mortality. RESULTS: A total of 208 cases were included. Fifty-one episodes of operative morbidity and 19 surgery-related deaths were found. Operative blood loss (risk ratio [RR], 1.0012), serum albumin (RR, 0.42), extent of gastrectomy (RR, 2.8), lymphocyte count (RR, 0.999), and splenectomy (RR, 1.51) were the most important risk factors for morbidity. However, location of the tumor, serum albumin level, and lymphocyte count were the most important preoperative risk factors that determine the appearance of surgical complications. Receiver operating characteristic analysis of this model allowed definition of three risk groups in terms of surgical morbidity (11.8%, 28.5%, and 52.4%, respectively). CONCLUSIONS: A new method for preoperative calculation of the probability of surgical complications was developed. It must be validated prospectively and in different settings to be used in preoperative interventions designed to reduce that risk.

Adenocarcinoma↗

Postpartum perineal morbidity after fourth-degree perineal repair.

OBJECTIVE: We attempted to determine the frequency of postpartum perineal morbidity (dehiscence, infection, and rectovaginal fistula) in women after fourth-degree perineal repair. STUDY DESIGN: The medical records of 390 women at Parkland Memorial Hospital with fourth-degree perineal repair during 1989 and 1990 were retrospectively reviewed in a case-cohort study. Statistical analysis included chi 2 contingency tables, Fisher exact test, Mann-Whitney test, and analysis of variance. RESULTS: Twenty-one of 390 women (5.4%) had postpartum perineal morbidity. Seven (1.8%) had dehiscence alone, 11 (2.8%) had infection and dehiscence, and 3 (0.8%) had infection alone. Overall there were 18 dehiscences (4.6%) and 14 infections (3.6%) in the total group with perineal morbidity. Two high rectovaginal fistulas were concomitantly detected in women with perineal dehiscence. Only shoulder dystocia, metritis, and postpartum fever occurred significantly more frequently in patients with postpartum perineal morbidity than in women without perineal morbidity. Smoking and human papillomavirus infection were not associated with perineal repair morbidity. CONCLUSIONS: Postpartum perineal morbidity after fourth-degree perineal repair is an uncommon event. It is not predicted by readily preventable antepartum or intrapartum factors.

Adult↗

Alcohol consumption and morbidity in the Canada Health Survey: inter-beverage differences.

This study examined inter-beverage differences in the relationship between alcohol consumption and health status as reported by 17 249 respondents to the Canada Health Survey. Self-reported morbidity rates (bed-days, activity loss, doctor visits) were computed for consumers of beer, wine, liquor and for those with no specific beverage preference. These rates were compared with the level of expected morbidity based on each group's demographic attributes. Subsequently, dose-response relationships were described relating frequency and quantity of consumption to a standardized morbidity rate for each beverage-preference group. In general, the results supported the importance of inter-beverage differences as an intervening variable in the relationship of consumption to morbidity. Overall morbidity rates and both frequency and quantity dimensions of the dose-response relationship varied markedly as a function of type of beverage consumed. Beer drinkers, in particular, varied from other consumers they had significantly lower rates of morbidity than expected. Increases in frequency of beer drinking were associated with reductions in morbidity, but mildly deleterious effects were associated with excessive consumption.

Accident Proneness↗

Mode of delivery and postpartum morbidity in Latin American and Caribbean countries among women who are infected with human immunodeficiency virus-1: the NICHD International Site Development Initiative (NISDI) Perinatal Study.

OBJECTIVE: The purpose of this study was to test whether cesarean delivery before labor and before ruptured membranes is associated with a higher risk of postpartum morbidity than vaginal delivery among women who are infected with human immunodeficiency virus-1 in Latin America and the Caribbean. STUDY DESIGN: Data from a prospective cohort study (National Institute of Child Health and Human Development International Site Development Initiative Perinatal Study) were analyzed. The study population consisted of women who were followed for > or = 6 to 12 weeks after delivery, who had singleton infants, and with a known mode of delivery. RESULTS: Of 819 enrollees, 697 women met inclusion criteria (299 vaginal deliveries, 260 cesarean deliveries before labor and before ruptured membranes, 138 cesarean deliveries after labor and/or after ruptured membranes); 36 women (5%) had postpartum morbidity (18 major, 18 minor). Mode of delivery was associated with postpartum morbidity (P = .02). Unadjusted odds ratios (95% CIs) for postpartum morbidity according to mode of delivery were cesarean delivery before labor and before ruptured membranes (odds ratio, 1.16 [95% CI, 0.5, 2.7]), cesarean delivery after labor and/or after ruptured membranes (odds ratio, 2.96 [95% CI, 1.3, 6.7]), and vaginal delivery (reference). These results did not differ appreciably with covariate adjustment. CONCLUSION: The rate of postpartum morbidity was low. Mode of delivery was associated with postpartum morbidity, possibly reflecting the larger proportion of minor postpartum morbidity events among those with cesarean delivery after labor and/or after ruptured membranes.

Adult↗

Audit of morbidity and mortality rates of 1792 hysterectomies.

STUDY OBJECTIVE: To audit morbidity and mortality rates of laparoscopic, abdominal, and vaginal hysterectomy. DESIGN: Retrospective review of monthly morbidity and mortality rates (Canadian Task Force classification II-2). SETTING: University teaching hospital. PATIENTS: One thousand seven hundred ninety-two women who underwent hysterectomy for benign, nonobstetric indications at the Sir Mortimer B. Davis-Jewish General Hospital. INTERVENTIONS: Laparoscopic supracervical (LASH), vaginal (VH), and abdominal (AH) hysterectomies. MAIN OUTCOME MEASURES: Morbidity outcomes of different types of hysterectomy. Reoperation, admission to the intensive care unit, discordant diagnosis, and prolonged hospitalization also were evaluated. RESULTS: We studied 223 cases of LASH, 1349 AH, and 220 VH. The overall hysterectomy-related morbidity rate was 6.1%. The rate of morbidity was higher in the LASH group (9.4%) than in the AH group (5.2%, p <.01), but no significant difference was noted between AH and VH (8.6%). The incidence of intraoperative bowel injury was 0.4% in the LASH group (a trocar injury in a patient) and 0.3% in the AH group. Bladder injury was encountered in two patients in the LASH group (0.9%) and in another two in the AH group (0.1%). Ureteral injury occurred in a patient in the AH group (0.07%). There were no cases of intraoperative vascular injury. Vaginal hysterectomy was associated with more urinary retention and hematoma formation than the other two groups. Discordant diagnosis was noted in four cases (two missed endometrial cancer, atonic and distended bladder mistaken for an ovarian cyst, and pelvic tuberculosis). The conversion rate to laparotomy was 1.7% in the LASH group and 0.4% in the VH group, and the incidence of reoperation was 0.4% in the AH group. CONCLUSIONS: The overall hysterectomy-related morbidity rate in our series is 6.1%. Compared with other types of hysterectomy, more urinary retention and hematoma formation occur after VH. Laparoscopic supracervical hysterectomy is associated with a higher morbidity rate than AH; mainly because of conversion to laparotomy and blood transfusion.

Adult↗

Risk factors for postoperative morbidity.

OBJECTIVE: Analysis of outcomes after coronary artery bypass grafting has focused on risk factors for operative mortality. Nonfatal perioperative morbidity is far more costly and more common after operation. To identify the risk factors that lead to postoperative morbidity, we evaluated 938 patients undergoing coronary artery bypass grafting at Albany Medical Center Hospital during 1993. METHODS: Multivariate statistical analysis was performed on preoperative patient variables to identify risk factors for either serious postoperative morbidity or increased hospital length of stay. Variables were considered both individually and in combination. For example, age was considered individually or in combination with other variables, including parameters of blood volume (i.e., age divided by red blood cell volume or Age/RBCVOL). Similar multivariate analysis was performed to identify independent risk factors for hospital mortality. RESULTS: In order of decreasing importance, the following patient variables were significantly associated with increased length of stay by stepwise Cox regression analysis: Age/RBCVOL, history of congestive heart failure, hypertension, femoral-popliteal peripheral vascular disease, chronic obstructive lung disease, and renal dysfunction. The combination variable, Age/RBCVOL, was an important risk factor for both increased length of stay and serious postoperative morbidity. Variables that were significant independent predictors of increased mortality, such as preoperative shock, and redo operation, were not risk factors for either serious morbidity or increased length of stay. CONCLUSIONS: We conclude that risk factors for postoperative morbidity are different from those for postoperative mortality. These results suggest that older patients with preoperative anemia and low blood volume who also have other comorbidities (congestive heart failure, stroke, chronic obstructive pulmonary disease, or hypertension) are at increased risk for postoperative complications. This allows identification of a high-risk cohort of patients who are likely candidates for interventions to lessen postoperative morbidity.

Age Factors↗

Maternal morbidity associated with cesarean delivery without labor compared with spontaneous onset of labor at term.

OBJECTIVE: To estimate the maternal morbidity associated with cesarean deliveries performed at term without labor compared with morbidity associated with spontaneous labor. METHODS: A 14-year, population-based, cohort study (1988-2001) using the Nova Scotia Atlee Perinatal Database compared maternal outcomes in nulliparous women at term undergoing spontaneous labor for planned vaginal delivery with singleton, cephalic presentation and nulliparous women delivering by cesarean without labor. RESULTS: From a total of 18,435 pregnancies, which satisfied inclusion and exclusion criteria, 721 were cesarean deliveries without labor. There were no maternal deaths or transfers for intensive care. There was no difference in wound infection, blood transfusion, or intraoperative trauma. Women undergoing cesarean deliveries without labor were more likely to have puerperal febrile morbidity (relative risk [RR] 2.2; 95% confidence interval [CI] 1.1, 4.5; P=.03), but were less likely to have early postpartum hemorrhage (RR 0.6; 95% CI 0.4, 0.9; P=.01) compared with women entering spontaneous labor. Subgroup analyses of maternal outcomes in women delivering by spontaneous and assisted vaginal delivery and cesarean delivery in labor were also performed. The highest morbidity was found in the assisted vaginal delivery and cesarean delivery in labor groups. CONCLUSION: The increased maternal morbidity in elective cesarean delivery compared with spontaneous onset of labor is limited to puerperal febrile morbidity. Maternal morbidity is increased after assisted vaginal delivery and cesarean delivery in labor compared with cesarean delivery without labor.

Adult↗

Posterior cervical fusion failure in three morbidly obese patients following circumferential surgery.

BACKGROUND: The stability of multilevel anterior corpectomy with fusion (ACF) is often enhanced by simultaneous posterior fusion (PF) which provides a "posterior tension band." Three morbidly obese patients undergoing circumferential surgery had posterior fusions performed without autogenous iliac crest graft to avoid donor site morbidity. METHODS: Three morbidly obese patients (300-350 lbs.), averaging 48 years of age, presented with rapidly progressive moderate/severe myelopathies. Magnetic resonance imaging (MRI) and computed tomography (CT) studies demonstrated severe ventral ossification of the posterior longitudinal ligament. Two to four level plated ACFs were performed utilizing fibula strut allograft and plates. Posterior spinous process wiring/fusion from C2-T1 were completed with braided titanium cables, fibula strut allografts, Inductive Conductive Matrix (a form of demineralized bone matrix), and allograft bone to avoid iliac crest donor site morbidity in such morbidly obese patients. Halo devices were utilized until fusion was documented on postoperative X-ray and 2D-CT studies subsequently obtained 3, 6, and up to 12 months postoperatively. Patients were followed an average of 3 years. RESULTS: Postoperatively, all 3 patients demonstrated mild residual myelopathy (Nurick Grade 0-I). Nevertheless, all 3 exhibited posterior pseudarthroses accompanied by anterior strut/plate extrusion (1 patient), partial anterior graft pseudarthrosis (1 patient), and a delayed strut fracture (1 patient). The first 2 patients required secondary posterior fusions performed with autogenous iliac crest graft, while the third fused with 6 months of additional bracing. CONCLUSIONS: Following circumferential cervical procedures, posterior fusions failed in 3 morbidly obese patients where iliac crest autograft was omitted in an attempt to avoid donor site morbidity.

Bone Plates↗

Correlates of psychiatric morbidity in typhoid fever in a Nigerian general hospital setting.

This study explored factors associated with psychiatric morbidity in typhoid fever in a Nigerian general hospital. Information such as sociodemographic characteristics, symptom manifestations, results of investigations, neuropsychiatric symptoms, outcome and disposal were obtained from the case files of patients admitted for typhoid fever over a period of six years. The patients with psychiatric morbidity conspicuous enough to be documented by the attending physicians-mostly internists-were compared with those with no documented psychiatric morbidity on sociodemographic and clinical indices. Of the 136 cases, 26 (19.1%) had psychiatric morbidity. This included delirium (73.1%), generalized anxiety disorder (3.8%), depressive episode (3.8%), schizophrenia like disorder (3.8%) and monosymptomatic neuropychiatric manifestations such as apathy, hallucinations and irrelevant talking (15.5%). The clinical and sociodemographic indices that were significantly associated with psychiatric morbidity were diarrhea, blood biochemical imbalance and age (P<.05). Adolescents and young adults were more predisposed to developing psychiatric complications. Some factors potentially associated with psychiatric morbidity in typhoid fever have been identified. There is the need to prospectively assess the burden from psychiatric morbidity and identify interventions that may reduce it.

Adolescent↗