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PubMed2004

Cannulation of the axillary artery with a side graft reduces morbidity.

BACKGROUND: The axillary artery is our preferred arterial cannulation site when the ascending aorta cannot be cannulated. Previously, we cannulated the artery directly; now we use a side graft. The purposes of this study were to (1) investigate cannulation-related morbidity and (2) determine whether use of a side graft reduces it. METHODS: From January 1993 to January 2001, 392 patients underwent 399 axillary artery cannulations. Indications included calcified ascending aorta (129, 32%), ascending aortic aneurysm (115, 29%), type I aortic dissection (85, 21%), cardiac reoperation (70, 18%), and calcified femoral artery (26, 6%). The axillary artery was cannulated directly in 212 (53%) and with a side graft in 187 (47%). Comparisons of cannulation-related morbidity between the direct cannulation and side graft groups were made overall and after both adjusting and matching for propensity score. RESULTS: Cannulation-related morbidity was infrequent, with brachial plexus injury in 7 (1.8%), axillary artery damage in 7 (1.8%), aortic dissection in 3 (0.8%), and arm ischemia in 3 (0.8%). Only 4 of 187 (2.1%) occurred in the side graft group, versus 16 of 212 (7.0%) with direct cannulation (p = 0.03). After propensity adjustment, the odds ratio for reduction of risk of cannulation-related morbidity with use of a side graft was 0.15 (p = 0.002). CONCLUSIONS: Use of the axillary artery as inflow for cardiopulmonary bypass is associated with low morbidity. However, cannulation with a side graft was associated with less cannulation-related morbidity than direct cannulation. Routine use of a side graft is recommended whenever axillary artery cannulation is indicated.

Adolescent↗
PubMed2005

Effects of a leukocyte depleting arterial line filter on perioperative morbidity in patients undergoing cardiac surgery: a controlled randomized trial.

BACKGROUND: Activated leukocytes may increase morbidity in cardiac surgery. The objective of this study is to investigate the influence on morbidity of leukocyte-depleting blood filters placed into the arterial line of cardiopulmonary bypass circuits. METHODS: Simple, blind, prospective, randomized and controlled clinical trial carried out in a cardiac surgery ICU at a university center. We included 159 consecutive low-risk patients (ie, Parsonnet score < 10) undergoing cardiac surgery who were initially stratified in three risk levels according to the Parsonnet score at admission into the hospital (ie, low, < 4; middle, 4 to 7; and high, 8 to 10). Once stratified, all patients were randomized to undergo cardiopulmonary bypass either with a conventional blood filter or with a leukocyte filter (randomization ratio, 2:1). The outcome variable was morbidity. Patients were considered to have a high morbidity if any of the following clinical situations were present (ie, pulmonary dysfunction, cardiac dysfunction, perioperative infections, postoperative hyperthermia, and hyperdynamic states). RESULTS: The leukocyte filter was used in 52 patients and the conventional filter in 107 patients. The morbidity rate was similar in both groups, but patients with leukocyte filter had a lower incidence of perioperative infections, fever, and hyperdynamic states as compared with patients with the conventional filter. CONCLUSIONS: Leukocyte filtration in patients undergoing cardiac surgery with extracorporeal perfusion showed no measurable effects on postoperative morbidity. However, although not statistically significant, a decrease was observed in the rates of perioperative infection, fever, and hyperdynamic states.

Blood Transfusion↗
PubMed2005

Co-morbid post-traumatic stress disorder in a substance misusing clinical population.

BACKGROUND: USA studies have reported high rates of co-morbid post-traumatic stress disorder (PTSD) and substance (drugs and alcohol) dependence/misuse. Avoidance of trauma reminders and associated distress may be achieved by the use of drugs and alcohol, alternatively a substance abusing lifestyle might predispose such individuals to experience traumatic events. This may have implications for treatment and management of patients with co-morbid substance misuse and PTSD. There have been no British studies looking at the extent of traumatic life events and post-traumatic stress disorder amongst substance misusers, although high rates of reported sexual and physical abuse have been reported in two recent UK studies with drug- and alcohol-dependent patients in clinical settings. AIMS: (i) To investigate the prevalence of co-morbid PTSD in a UK substance use disorder (SUD) inpatient clinical population; (ii) to identify the characteristics, severity and types of trauma experienced; (iii) to compare SUD patients with and without co-morbid PTSD on substance use and history, psychological/psychiatric and social variables METHOD: This is a cross-sectional study involving interviews with patients and case note review. SUD inpatients were interviewed about traumatic experiences, PTSD, and addiction. RESULTS: Ninety-four percentage reported experiencing one or more PTSD criterion A traumatic experiences. 38.5% met criteria for current PTSD and 51.9% for lifetime PTSD. Significant differences between the PTSD and non-PTSD groups were found in PTSD and trauma-related variables, notably social variables and distress associated with traumatic experiences, but few differences were found in addiction severity (medical and psychiatric composite scores of the ASI) and psychiatric symptomatology. CONCLUSIONS: This study highlights not only the importance of assessment of trauma and PTSD amongst substance misusers but, conversely the need for the assessment of substance abuse among victims of PTSD. Co-morbid psychopathology is common, so trauma histories and PTSD symptoms may become embedded in other co-morbid psychopathology.

Adaptation, Psychological↗
PubMed2005

Independent prognostic effect of co-morbidity in lymphoma patients: results of the population-based Eindhoven Cancer Registry.

The prevalence of co-morbidity among elderly lymphoma patients is associated with a decrease in the use of chemotherapy. This study assessed the independent prognostic effect of co-morbidity in 1551 unselected lymphoma patients, diagnosed between 1995 and 2001 in the area of the population-based Eindhoven Cancer Registry. The prevalence of serious co-morbidity was 58% for patients with Hodgkin's disease (HD) who were over 60 years of age and 66% for patients with non-Hodgkin's lymphoma (NHL) who were over 60 years of age. The administration of chemotherapy declined in the presence of co-morbidity for elderly patients with early-stage HD and elderly patients with aggressive NHL. Co-morbidity was associated with a 10-20% decline in 5-year survival. Whether less frequent application of chemotherapy in the presence of co-morbidity is justified as far as complications, prognosis and quality of life are concerned requires further investigation.

Adult↗
PubMed2005

The impact of morbid events on survival following hospitalization for complicated myocardial infarction.

BACKGROUND: Little is known about the importance of morbid events with respect to longer term survival following MI hospital discharge. AIMS: Establish the risk of death associated with morbid events following initial discharge from MI hospitalization. METHODS: We examined the rates of morbid events (reinfarction, stroke/TIA, revascularization, heart failure (HF) hospitalization, cardiovascular hospitalization and all-cause hospitalization) and the relationships of these events to subsequent death in patients who survived the initial hospitalization for MI (n = 5301) in the OPTIMAAL trial. Events were classified as Early (< or = 30 days post discharge) and Late (> 30 days post discharge) for an average of 2.7 years follow-up. RESULTS: Death rates were higher in the Early period (0.20 deaths/patient year) than in the Late period (0.05 deaths/patient year). Once a morbid event, excluding revascularization, occurred, the acute hazard ratios (HR, determined by Cox regression) for death on the day of event were higher than at time periods following the event and were highest for reinfarction and stroke/TIA. The acute HRs for death for all 6 morbid events were especially high for events occurring during the Late period. The highest chronic HR for death was associated with HF and all-cause hospitalizations. By contrast, the chronic HR for death from revascularization in both the Early (HR = 0.3) and Late (HR = 0.4) period indicated reduced risk. CONCLUSIONS: The results document event rates following hospitalization for MI, provide quantification of the associated risk for death, and may be useful in designing clinical trials. The serious morbid events examined may serve as potential surrogate endpoints in long-term studies and identify patients that should be targeted for aggressive management.

Aged↗
PubMedDate not supplied

Distress, psychiatric morbidity, and prescriptions for psychotropic medication in a breast cancer waiting room sample.

We examined relationships among psychiatric screening, the prevalence of psychiatric morbidity, and prescription rates for psychotropic medication in a waiting room sample of breast cancer patients (N=113). Rates of distress (29%), major depressive disorder (MDD; 9%), and generalized anxiety disorder (GAD; 6%) were low and similar to those found in primary care settings. A substantial proportion of patients (52%) had received psychotropic medication during treatment, including almost half (48%) of those without a current psychiatric diagnosis. Most individuals with MDD received pharmacotherapy during cancer treatment (80%), although only half of those with GAD were treated. Overall high rates psychotropic medication negatively impacted the efficiency of screening, and individuals with elevated distress were about 6 times less likely to represent a case of untreated psychiatric morbidity than to be a new case. We conclude that the risk of psychiatric morbidity attributable to breast cancer may be lower and treatment rates for psychiatric morbidity higher than previously believed and that screening is unlikely to provide efficient identification of untreated psychiatric morbidity. Adequacy of follow-up care is unclear and medication may be prescribed nonspecifically. The low rate of untreated psychiatric morbidity may signal a need for multisite collaborations to generate adequate numbers of participants in clinical trials.

Adult↗
PubMedDate not supplied

Morbidity and mortality in pregnancy: laying the groundwork for safe motherhood.

The Safe Motherhood Initiative is a global effort to reduce deaths and illnesses among women and infants. Despite the relatively low maternal mortality rate in the United States, ensuring safe motherhood is still critical. For several reasons, it is important to study maternal mortality and morbidity. First, the pregnancy-related mortality ratio has not declined; second, evidence suggests that at least half of pregnancy-related deaths may be preventable through changes in patient, provider, or system factors; and third, mortality rates are disproportionately high among certain racial and ethnic groups. In addition, deaths are only the tip of the iceberg: maternal morbidity also represents a huge burden of disease for women and their families. Broadening the research focus and prevention efforts to include the study of maternal morbidity, especially near-miss morbidity-life-threatening morbidity-can strengthen the study of maternal death. This paper presents an overview of maternal mortality and morbidity including incidence and etiology, issues and challenges for measurement, and issues of preventability. We also address specific strategies for change for health care providers, federal and state health agencies, and the public health community.

Ethnicity↗
PubMed2005

The influence of age and co-morbidity on treatment and prognosis of ovarian cancer: a population-based study.

OBJECTIVES: With the rising mean age, more patients will have one or more other serious diseases at the time of diagnosis of ovarian cancer (co-morbidity). In this study, the independent effects of age and co-morbidity on the application of treatment guidelines and prognosis were evaluated. METHODS: All patients with epithelial ovarian cancer diagnosed between 1995 and 2001 in the southern part of The Netherlands (N = 1116) were included. RESULTS: The prevalence of co-morbidity increased from 34% of the age group <70 to 63% of the older age group. Eighty-three percent of the patients with FIGO stage II or stage III younger than 70 years underwent the advised treatment (combination of surgery and chemotherapy) compared to only 45% of the patients aged 70 or older. In a multivariable analysis age, FIGO stage, presence of co-morbidity, and year of diagnosis seemed to be independent predictors of receiving the advised treatment. In multivariable analyses age 70 + (HR = 1.3, 95% CI = 1.03-1.7) and the use of both surgery and chemotherapy (HR = 0.4, 95% CI = 0.3-0.6, reference is only surgery) were independent prognostic factors for overall survival. CONCLUSIONS: Even in the absence of co-morbidity, standard combination therapy was prescribed significantly less often for elderly patients with FIGO II or III ovarian cancer. Age and combined treatment of surgery and platinum-based chemotherapy were independent prognostic factors. Co-morbidity did not seem to have a prognostic effect.

Age Factors↗
PubMed2002

Morbidity, mortality, and technical factors of distal pancreatectomy.

BACKGROUND: Pancreatic leak is a major source of morbidity associated with pancreatic surgery. We sought to identify disease and technique-dependent factors associated with morbidity and mortality after distal pancreatectomy. METHODS: Retrospective review of patients who underwent distal pancreatectomy during a 5-year period. Clinical, technical, and pathologic data were correlated with operative morbidity or mortality. RESULTS: Fifty-one patients underwent distal pancreatectomy for primary pancreatic disease, extrapancreatic malignancy, or trauma. Overall perioperative mortality and morbidity rates were 4% and 47%, respectively. Pancreatic leak was the most common complication, occurring in 26% of patients. Overall complications and pancreatic leaks occurred more often after distal pancreatectomy for trauma and in patients with a sutured pancreatic stump closure. CONCLUSIONS: Distal pancreatectomy can be performed with a low rate of mortality, though pancreatic leak is a common cause of morbidity. The urgency of the procedure and the method of pancreatic stump closure may influence postoperative morbidity.

Adolescent↗
PubMed2002

Orthotopic neobladder following radical cystectomy in patients with high perioperative risk and co-morbid medical conditions.

PURPOSE: A significant number of patients requiring radical cystectomy for bladder cancer have substantial co-morbidity. Nonetheless, these patients often prefer orthotopic neobladder reconstruction to avoid an abdominal stoma. We performed a retrospective study to determine perioperative morbidity in this group of patients. MATERIALS AND METHODS: We used the American Society of Anesthesiologists physical status classification to assign perioperative risk. Of 250 patients undergoing orthotopic neobladder reconstruction after radical cystectomy during a 5-year period we identified 84 with an American Society of Anesthesiologists score of 3 or greater. Charts were available for review for all patients and none was lost to followup. RESULTS: Median operative time (calculated from anesthesia ready time to completion of surgery and application of a dressing) was 256 minutes. In 14 patients (16.6%) transfusion of a median of 2 units of allogeneic blood was required. A total of 79 patients (94%) were transferred directly from the recovery room to the general urology floor without a need for postoperative cardiac monitoring. Median hospital stay was 7 days. One patient (1.1%) died on postopera-tive day 9 of a presumed pulmonary embolus after having been discharged home on postoperative day 6. Minor complications occurred in 16 patients (19%). Only 1 patient required a return to the operating room for endoscopic removal of a retained stent fragment. CONCLUSIONS: In experienced hands radical cystectomy and orthotopic neobladder can be offered to patients with co-morbid conditions. Expeditious performance of the surgical procedure, minimization of blood loss, restricting the surgical incision to an infraumbilical location, and avoidance of intraoperative complications all contribute to decreasing morbidity and mortality. Although orthotopic reconstruction is more complex than performance of an ileal conduit, there is no apparent increase in perioperative morbidity or mortality. Therefore, orthotopic reconstruction can be offered to patients who want to avoid an abdominal stoma even in the face of significant co-morbid conditions.

Adult↗
PubMed1990

Adolescent wellness. Facilitating compliance in social morbidities.

The establishment of a well adolescent schedule needs to be developed similar to the scheduled clinical visits in pediatric care. However, providing adolescent wellness visits without appropriate financial reimbursement for time expended and without increased provider training may make "well" adolescent visits an unrealistic expectation. However, two major trends will significantly impact on the future of adolescent health care. These include a sharp increase in numbers of adolescents beginning in 1990 and the poverty within the adolescent population. These data suggest that obstacles, whether personal, financial, or educational, need to be addressed quickly in order to resolve these problems because of increasing numbers of adolescents and related morbidities through the year 2000. The increasing trend of juvenile poverty in this population has been significantly associated with a number of the new morbidities such as substance abuse, STD, pregnancy, and the latest morbidity, AIDS. Without a wellness schedule, it is likely that adolescents will continue to represent an underserved population; as a consequence, mortalities and morbidities will increase through the year 2000. The issue of adherence to prescribed medical regimens in the adolescent population is an interesting, complex, and especially challenging one when faced with the social morbidities. Although preliminary work in this area has progressed in the last 15 years, greater attention must be paid to the needs of adolescents in order to determine effective strategies that can minimize the effects of the current morbidities. It is important for the primary care physician not to become overwhelmed with the scope of problems that adolescents have or become discouraged because anticipatory guidance seems ineffective. Repeated dosages of anticipatory guidance should not be viewed as limitations or failures but rather as necessary and standard care. One should consider such interventions as similar to immunizations, in which certain vaccines result in life-long immunity. One would not eliminate the tetanus vaccine because the patient must receive periodic boosters. Similarly, as health care professionals, we should not consider interventions designed to preclude behavior or mental health problems as failures if periodic and developmentally appropriate relevant "boosters" are necessary. Anticipatory guidance is an extremely effective tool that every primary care physician has at his or her disposal to assist in the diagnosis of problematic behavior in adolescents and to preclude problems. Future research needs to focus on documenting strategies that can be utilized by physicians on a daily basis without excessive time or financial constraints.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed1999

Predictive value for infection of febrile morbidity after vaginal surgery.

OBJECTIVE: To determine the screening value of febrile morbidity for detecting infections after vaginal surgery. METHODS: A cohort of 431 consecutive women had vaginal surgery at the M. S. Hershey Medical Center from September 1988 through June 1995. Outcomes of febrile morbidity and infection were analyzed. RESULTS: Fifty-four of 431 patients (12.5%) had febrile morbidity. Thirty-five infections (8.1%) were identified, of which only 13 were accompanied by febrile morbidity. Forty-one patients (9.5%) had unexplained fevers. The sensitivity of febrile morbidity for postoperative infection was 40%, specificity was 98%, positive predictive value was 26%, and negative predictive value was 94%. Stepwise logistic regression found blood loss (odds ratio 1.001/mL; confidence interval 1.0001-1.0035), uterine weight (0.987/g; 0.976-0.999), and parity (1.570; 1.146-2.050) as significant independent variables for developing fever. Patient weight (0.984/lb; 0.971-0.998) and type of procedure (2.16; 2.12-6.38) were confirmed as significant independent variables for postsurgical infections. CONCLUSION: Febrile morbidity had limited value as a screening test for postoperative infection, with poor sensitivity and positive predictive value after vaginal surgery.

Female↗
PubMed1998

Social inequalities in morbidity from diabetes mellitus in public primary care clinics in Trinidad and Tobago.

Associations between socio-economic status and non-communicable diseases in middle income countries have received little study. We conducted an interview survey to evaluate the associations of morbidity with social conditions among people attending government primary care health centres with diabetes mellitus in Trinidad. Data collected included morbidity from hyperglycaemia, foot problems, visual problems and cardiovascular disease, as well as social and demographic variables. Of 622 subjects, 35% were aged > or = 65 years, 54% were Indo-Trinidadian, 13% had no schooling, only 11% were in full-time employment, and 33% had no piped drinking water supply in the home. Prevalent symptoms included itching, reported by 215 (35%), nocturia in 315 (51%), burning or numbness in the feet in 350 (56%), and difficulty with eyesight in 363 (58%). A morbidity summary score was used as dependent variable in regression analyses. Comparing those with no schooling with those with secondary education, the mean difference in morbidity score was 1.77 (95% CI 1.15-2.39), attenuated to 0.71 (0.06-1.37) after adjusting for age, gender, ethnic group and diabetes duration. The equivalent differences for those with no piped water supply in the house, compared with those with, were 0.53 (0.17-0.88) and 0.57 (0.24-0.89). For the unemployed, compared with those in full-time jobs, at ages 15-59 years the differences were 0.85 (0.14-1.56) and 0.58 (-0.11-1.27). We conclude that morbidity in persons with diabetes is associated with indicators of lower socio-economic status and that this association is partly explained by confounding with older age, female gender, longer duration of diabetes and Indo-Trinidadian ethnic group. A negative association between socio-economic status and morbidity from diabetes contributes to a justification for investment of public health resources in the control of diabetes and other non-communicable diseases.

Adult↗
PubMed1996

Polyhydramnios is an independent risk factor for perinatal mortality and intrapartum morbidity in preterm delivery.

OBJECTIVE: To investigate the clinical significance of polyhydramnios as a predictor of perinatal death and intrapartum morbidity in patients with preterm delivery. STUDY DESIGN: The study population consisted of 4211 patients with singleton gestation, intact membranes and preterm delivery (< 37 weeks). Two groups were identified and compared according to the sonographic assessment of the amniotic fluid volume: increased and normal amniotic fluid. Analyses were conducted for the entire cohort as well as for the cohort excluding from each group all cases with congenital malformations. Logistic regression was used to assess the unique contribution of polyhydramnios to mortality and morbidity in the presence of other known risk factors. RESULTS: The prevalence of polyhydramnios among women who delivered preterm was 5% (210/4211) including and 3.7% (142/3818) excluding the cases of congenital malformations, respectively. Polyhydramnios was associated with a higher rate of diabetes, large for gestational age neonates, fetal malpresentation at delivery, previous perinatal death and with a lower Apgar score at 1 and 5 min. Polyhydramnios was an independent predictor of perinatal mortality and intrapartum morbidity. When adjusted for well recognized risk factors for perinatal mortality and intrapartum morbidity (e.g. diabetes, severe pregnancy induced hypertension, multiparity, congenital malformation, previous perinatal death, low gestational age at delivery), the presence of polyhydramnios significantly increased the rate of perinatal mortality (odds ratio (OR) 5.8; 95% confidence interval (CI) 3.68-9.11) and of intrapartum morbidity (OR 2.8; 95% CI 1.94-4.03). CONCLUSION: In the setting of preterm delivery, polyhydramnios is an independent risk factor for perinatal mortality and intrapartum complications even in the absence of congenital malformation and other conditions traditionally associated with increased perinatal mortality and morbidity.

Adult↗
PubMed2001

Lymphocyte radiosensitivity is a significant prognostic factor for morbidity in carcinoma of the cervix.

PURPOSE: To study the relationship between pretreatment peripheral blood lymphocyte radiosensitivity and morbidity following radiation therapy. METHODS AND MATERIALS: A prospective study was carried out in which patients with carcinoma of the cervix underwent radiation therapy. Intrinsic radiosensitivity was measured on pretreatment peripheral blood lymphocytes, using a limiting dilution clonogenic assay. Late morbidity was assessed using the Franco-Italian glossary. Results were correlated in an actuarial analysis. RESULTS: There were no correlations between the measured lymphocyte radiosensitivity (SF2) and colony-forming efficiency, patient age, tumor grade, or disease stage. For 83 patients, lymphocyte SF2 was a significant prognostic factor for the probability of developing both any (p = 0.002) and Grade 3 (p = 0.026) morbidity. In 174 patients, stage showed borderline significance as a prognostic factor for morbidity (p = 0.056). However, the type of treatment (intracavitary alone, intracavitary plus parametrial irradiation, single insertion plus whole-pelvis irradiation) was significantly associated with the probability of developing late complications (p = 0.013). There was a weak significant inverse correlation between lymphocyte SF2 and grade of morbidity (r = -0.34, p = 0.002). CONCLUSION: These data highlight the importance of normal cell radiosensitivity as a factor determining radiation therapy response. They also show that peripheral blood lymphocyte SF2 is a highly significant prognostic factor for the probability of developing late radiation morbidity, and that carcinoma of the cervix is a good model for testing radiobiologic principles in the clinic.

Age Factors↗
PubMed1998

Perioperative cardiovascular morbidity in patients with coronary artery disease undergoing vascular surgery after percutaneous transluminal coronary angioplasty.

OBJECTIVE: Patients with coronary artery disease (CAD) who undergo noncardiac surgery are at increased risk for perioperative myocardial infarction (PMI). Undergoing successful coronary artery bypass grafting (CABG) before such surgery has been shown to decrease perioperative cardiac morbidity and mortality. Percutaneous transluminal coronary angioplasty (PTCA) is an alternative treatment for these patients. Perioperative cardiac morbidity in patients with CAD who underwent PTCA before their vascular surgery was reviewed. SETTING: A tertiary care referral center for patients with cardiovascular heart disease. PARTICIPANTS: Review of vascular surgery database for patients who underwent vascular surgery preceded by PTCA between 1984 and 1995. Patients were excluded if they had a history of CABG within 2 years of surgery, had PTCA more than 18 months before surgery, or had incomplete data. MEASUREMENTS: Data were collected concerning cardiac history, left ventricular (LV) function, perioperative cardiac morbidity (angina, MI, congestive heart failure [CHF], and arrhythmias). MAIN RESULTS: Of 194 patients who underwent aortic abdominal surgery, carotid endarterectomy (CEA), or peripheral vascular surgery preceded by PTCA, 104 (54%) had a previous MI. Twenty-six patients (13.4%) had perioperative cardiac morbidity. Only one patient had an MI (0.5%; 95% confidence interval [CI], 0.0 to 2.8), whereas one patient died of CHF followed by multisystem organ failure (0.5%). The median interval between PTCA and surgery was 11 days (interquartile range, [IQR] 3 to 49 days). Patients who developed perioperative cardiac morbidity were older than those who did not (p = 0.02). Patients who had a history of CABG (before PTCA) had a higher incidence of postoperative angina (p = 0.04). The degree of preoperative LV dysfunction was linearly related to the incidence of new postoperative CHF (p = 0.01). Arrhythmias were more common in patients undergoing abdominal vascular surgery (17.9%) than in those undergoing CEA (2.5%; p = 0.03) or peripheral vascular surgery (5.2%; p = 0.02). CONCLUSION: High-risk cardiac patients undergoing vascular surgery who have had PTCA performed up to 18 months preoperatively have a low incidence of perioperative cardiac morbidity. Prophylactic PTCA may be beneficial in patients with CAD who are at high risk for perioperative cardiac complications.

Aged↗
PubMedDate not supplied

Does extended pancreaticoduodenectomy increase operative morbidity and mortality vs. standard pancreaticoduodenectomy?

The poor prognosis of pancreatic carcinoma after resection is related to distant metastases and local recurrence that is characterized by a strong tendency to infiltrate the retroperitoneal tissue and spread along the neural plexuses and lymph nodes. Thorough clearance of these tissues around the celiac and mesenteric axes, aorta, and inferior vena cava from the diaphragm to the inferior mesenteric artery (extended pancreaticoduodenectomy may lower the rate of local recurrence, but the procedure has been criticized for its higher morbidity and mortality. Our aim was to compare extended pancreaticoduodenectomy (EPD) with standard pancreaticoduodenectomy (SPD) in terms of postoperative morbidity and mortality. Data from 47 patients who underwent either EPD (n=24) or SPD (n=23) between November 1992 and October 1995 were retrospectively analyzed. Preoperative laboratory findings, operative risk (according to the American Society of Anesthesiologists classification), type of operation (classic Whipple vs. pylorus-preserving Whipple), operative time, intraoperative blood and plasma transfusion, postoperative morbidity and mortality, and postoperative hospital stay were scrutinized. The results showed that all of the parameters considered were similar in the EPD and SPD groups (intraoperative blood transfusion 800+/-490 ml vs. 700+/-586 ml, postoperative mortality 0% vs. 4.3%, overall morbidity 45.8% vs. 47.8%, surgical morbidity 37.5% vs. 34.7%, and postoperative hospital stay 16+/-8.1 days vs. 17+/-13.1 days. These two groups differed only in the operative time, which was significantly longer for EPD than for SPD (360+/-68.9 minutes vs. 330=66.9 minutes, P=0.02). Although the operative time is increased with EPD, there does not appear to be an increase in intraoperative complications, postoperative morbidity and mortality, or postoperative hospital stay with this procedure. However, definitive confirmation of these results can only be provided by a prospective randomized study.

Female↗
PubMed2003

Morbidity effect of the time gap between supplemental beam radiation and Pd-103 prostate brachytherapy.

PURPOSE: To determine if gap time variations between prostate brachytherapy and supplemental beam radiation (EBRT) affect postimplant morbidity. MATERIALS AND METHODS: Ninety-one patients with 1997 AJC clinical stage T1c-T2a prostatic carcinoma, Gleason grade 7-9, or PSA 10-20 ng/ml, were randomized to implantation with 90 Gy Pd-103 versus 115 Gy (NIST-1999) with 44 Gy versus 20 Gy preimplant supplemental beam radiation, respectively. Pd-103 implantation was performed by standard techniques, using a modified peripheral loading pattern. Beam radiation was delivered with a four-field arrangement, designed to cover the prostate and seminal vesicles with a 2-cm margin, reduced to 1.0 cm posteriorly. A post-implant computed tomography (CT) scan was obtained on the same day. Dosimetric parameters analyzed included the V100 - the percent of the postimplant prostate or rectal volume covered by the prescription dose, and the D90 - the dose that covers 90% of the post-implant prostate or rectal volume. For EBRT rectal D90s, the rectal volume included slices 0.9 cm above and below the seminal vesicles and apex, respectively. Treatment-related morbidity was monitored by mailed questionnaires, using standard American Urologic Association (AUA) and Radiation Therapy Oncology Group (RTOG) criteria at 1, 3, 6, 12, 18, and 24 months. Use of alpha-blockers to relieve obstructive symptoms was not controlled for, but was noted at each follow-up point. Median follow-up at the time of this analysis was 21 months, with a range of 18-26 months. RESULTS: Variability in the total radiation delivery time within each treatment arm was due almost exclusively to gap time variability. Patients receiving 20 Gy EBRT completed their beam radiation over an average of 12 days (+/-1 day). Patients receiving 44 Gy did so over an average of 31 days (+/- 2 days). The median gap interval for patients receiving 20 Gy EBRT was 5 days (range: 1-40 days) versus 9 days (range: 0-15 days) for patients receiving 44 Gy EBRT. Urinary morbidity, measured by a change in the AUA score from baseline (DeltaAUA) was greater at 1-month postimplant in patients who had shorter gap intervals. The effect of gap time on AUA score changes was lost by 6 months. When looking at the treatment arms separately, the dependence on gap interval was limited to those patients receiving 44 Gy beam radiation. No patient has developed RTOG grade 3 rectal morbidity, and no patient has required invasive therapy for rectal bleeding. There was no relationship between gap interval and rectal morbidity at any time point. There was no relationship between beam doses and RTOG rectal morbidity scores. CONCLUSIONS: The findings reported here are suggestive that short gap times are safe.

Brachytherapy↗