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PubMed1994

Should years lost always be equated with life expectancy?

BACKGROUND: The 'years lost' by a person dying prematurely from some cause is usually equated with life expectancy at the age of death derived from a life table for either the general population or a population in which the cause does not operate. It is suggested that this procedure may not always be valid. METHODS: The calculation of years lost by individuals dying prematurely from smoking-related deaths is taken as an example using data from the American Cancer Society Cancer Prevention Study (ACS CPS II) and from Peto et al. An alternative hypothesis, whereby smoking advances the age of death by an amount considerably less than the life expectancy, is examined. RESULTS: It is shown that when smoking-related deaths are removed from the ACS CPS II data, the life expectancy of the smokers is still less than that of the non-smokers. Secondly, it is demonstrated that, if the alternative hypothesis is used to predict a survival curve in the absence of smoking, it would be incorrect to equate years lost with life expectancy calculated from that curve. CONCLUSIONS: Years lost cannot automatically be equated with life expectancy. In the case of smoking, estimates of years lost must still be subject to considerable uncertainty. Further research is needed to see if smokers dying at a given age have comparable physical and social characteristics to all smokers living at that age.

Adult↗
PubMed2000

Rebleeding, secondary ischemia, and timing of operation in patients with subarachnoid hemorrhage.

OBJECTIVE: To assess the time course of secondary ischemia and first rebleeding and the relation between the timing of operation and the time course of secondary ischemia in a consecutive series of patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS: Life table methods were used to assess the daily rates of ischemia and of rebleeding on day 0, day 1 to 3, day 4 to 10, day 11 to 14, and day 15 to 21. The authors compared the time course of secondary ischemia between patients operated within 4 days of SAH and those operated after 10 days. RESULTS: Of 346 patients included, 220 were operated, 131 within 4 days and 74 after 10 days. The rebleed rate was highest on the day of the initial hemorrhage, then diminished, and increased slightly again during the second week. The rate of secondary ischemia was highest on day 4, diminished after day 10, but peaked again from day 14 to 18 for patients who were operated later than 10 days after aneurysmal rupture. The peak rate of ischemia was much higher after early than after late operation. Although patients with early operation were in a better clinical condition on admission, with a relatively low risk of secondary ischemia, the overall rate of secondary ischemia was as high as in patients with delayed operation. From day 11 to 21 the rebleed rate was higher than the rate of secondary ischemia. CONCLUSIONS: These results indicate that operation is a risk factor for ischemia, especially when performed early. If operation is postponed, it should be planned soon after day 10, because of the relatively high rebleed rate from day 11 to 21.

Brain Ischemia↗
PubMed1989

Extra-anatomic bypass grafting: a rational approach.

To determine predictors of long-term patency in extra-anatomic bypass grafting, the authors studied retrospectively the charts of 134 patients who underwent bypass grafting (axillofemoral in 17, axillobifemoral in 32 and femorofemoral in 85). Of the study group, 64% were men; the mean age was 65 +/- 12 years (+/- SEM). The indications for grafting were limb salvage (102), claudication (27) and replacement of septic grafts (5), and for using the extra-anatomic route included high risk (83), sepsis (8) and unilateral disease (34). Operative mortality was 6% and the early graft occlusion rate 7.4%. The late death rate was 44%. At 3 years, the life-table patency rates for the various procedures were axillofemoral 52.5%, axillobifemoral 67.7% and crossfemoral 86.9%. Smoking significantly (p less than 0.05) decreased the patency rate, but diabetes did not. However, amputation was more frequent in diabetics. Indications for operation did not alter patency rates, but did affect operative mortality. The authors conclude that extra-anatomic bypass grafting is highly successful, but not as successful as anatomic bypass. When appropriate, the axillobifemoral graft is preferred to the axillounifemoral graft because of its increased patency. Crossfemoral grafts must be carefully monitored to ensure that no donor limb stenosis occurs and this procedure should not be attempted unless the disease is truly unilateral.

Adult↗
PubMedDate not supplied

Remission onset and relapse in depression. An 18-month prospective study of course for 100 first admission patients.

BACKGROUND: Few prospective studies of course for first admission depressives are reported. METHODS: One hundred consecutive depressed inpatients were followed prospectively over 18 months. Course was defined operationally using the Hamilton Depression scale and ICD-10 criteria. Results were analysed using life-tables. RESULTS: The cumulative probabilities of remission onset by 3 and 18 months were 0.67 (95% C.I.=0.57-0.77) and 0.82 (95% C.I.=0.74-0.90). The cumulative probability of relapse was 0.25 (95% C.I.=0.15-0.35); 53% of those relapsing did so in the first 2 months. Younger age at onset, longer illness length, higher depression and anxiety ratings, predicted delayed remission onset. ICD-10 episode severity predicted relapse. CONCLUSIONS: The chances of remission onset at 3 months and relapse were increased relative to other studies; risk of chronicity was similar. Predictors of outcome to emerge were similar to other studies. CLINICAL IMPLICATIONS: Adoption of these remission onset criteria may identify earlier (at 3 months), subjects at high risk of chronicity. After remission onset, subjects with severe illnesses warrant careful follow-up to detect relapse, particularly during the first 2 months. LIMITATIONS: The operational criteria used were different to other prospective studies. Relatively few psychosocial variables were included in the analysis.

Adolescent↗
PubMed2002

Analysis of mechanical sources of patient alignment errors in radiation therapy.

Certain radiation treatments, such as conformal and intensity modulated treatments, involve isocentric treatment fields delivered using multiple angles or continuous angulation of the gantry, collimator and table. At our institution, treatments involving three angles (gantry, collimator, and table) can, if uncorrected, exhibit misalignments of 2 mm or more on premarked field centers and borders on the patient surface during the initial setup on a linear accelerator (linac), even though the linac operates within allowable mechanical tolerances. This paper is an analysis of three principal mechanical sources of patient alignment errors observed on linacs: (i) errors in table and gantry angle, (ii) displacement of gantry rotational axis during gantry rotation, and (iii) displacement between collimator and table rotational axes. On patient surfaces, these small, systematic mechanical errors can each be expected to produce misalignments of up to 1.5 mm, increasing to over 2 mm with nearly horizontal fields delivered at nonzero table angles onto highly oblique patient surfaces. For the underlying target volumes, the mechanical errors can, in combination, be expected to produce target volume misalignments of up to 1 mm on newly installed linacs and 3 mm on older linacs. Thus, 1 mm appears to be a mechanical limit on the positional precision of radiation treatments.

Artifacts↗
PubMed1996

Results of peripheral endovascular procedures in the operating room.

PURPOSE: This study presents the results of closed (percutaneous) and open endovascular procedures performed exclusively by vascular surgeons in the operating room and compares them with results from combined series from the literature, including primarily closed procedures in radiology or cardiology facilities. METHODS: Retrospective review of 607 consecutive peripheral arterial and venous angioplasties, stents, thrombolytic cases, and inferior vena caval filters in 446 patients was analyzed for immediate success rate, complication rate, and 1-year life table patency rate. RESULTS: The incidence of initial technical success was: aorta, 89%; iliac artery, 91%; superficial femoral artery, 90%; popliteal artery, 91%; tibial arteries, 79%; arm arteries and veins, 86%; renal arteries, 100%; IVC filters, 98%; and iliofemoral veins, 100%. The 1-year primary patency rates, including technical failures, were 70.3% in 113 femoropopliteal procedures and 83.7% in 194 iliac arteries. Advantages to the use of the operating room included: (1) simultaneous angioplasty during a bypass operation for abnormalities proximal or distal to the graft, (2) correction of lesions first discovered during thrombectomy, and (3) optimum patient monitoring and sedation in the operating room. CONCLUSIONS: Endovascular procedures performed by vascular surgeons in the operating room lead to results comparable with procedures performed in nonsurgical interventional suites, and the use of the operating room has advantages.

Adult↗
PubMed1996

Treatment of the unstable (acute) slipped capital femoral epiphysis.

Slipped capital femoral epiphysis, the most common hip disorder in adolescence, traditionally has been classified according to symptom duration. An acute slip is 1 in which there are symptoms for < 3 weeks; for a chronic slip, there are symptoms for > 3 weeks. An acute-on-chronic slip is characterized by a combination of both with a recent exacerbation of symptoms. This classification system is misleading because it does not consider stability. A stable slipped capital femoral epiphysis has a good prognosis, but an unstable slip has a guarded prognosis. The priorities in treating an unstable (acute) slip are (1) to avoid avascular necrosis, (2) to avoid chondrolysis, (3) to prevent further slip, and (4) to correct deformity. The last priority, correcting the deformity, is associated with a high incidence of complications including avascular necrosis and chondrolysis, so manipulative reduction under anesthesia or an acute corrective osteotomy is not recommended. To address these priorities in treatment, the authors recommend preoperative bed rest to decrease the synovitis and intraarticular effusion. Operative stabilization is done in an elective fashion once the synovitis has subsided. The technique includes careful patient positioning on the fracture table, which may cause an incidental reduction, but no attempt is made to do a manipulative reduction. The technique is dependent on radiographic control. The femoral head and neck must be well visualized on the anteroposterior and lateral intensifier images before the operation is started. The slipped capital femoral epiphysis is stabilized with a single central screw, and nonweightbearing ambulation with crutches is recommended until a satisfactory painless range of motion has returned.

Acute Disease↗
PubMedDate not supplied

The PRIST-2 development environment: architecture and implementation.

The PRIST-2 system has been designed as an interactive and high-productivity tool for the rapid prototyping and development of medical applications. Three major issues were addressed in this research project which derived from the evolution of a previous 4th generation software package, called PRIST (patient record information system tool): a high transportability on different hardware and operating systems, a conversational and interactive user-interface and user-independence Relational Data Base Management System (RDBMS). Although we developed PRIST-2 on the top of the ORACLE RDBMS, it does not depend on SQL commercial products because the ORACLE features have been directly used only for SQL relational data base management. The application design methodology implemented in the system architecture allows an interactive and formal description of the application constraints in terms of the semantic data model rather than in terms of the data structure. The translation of the conceptual constraints into SQL tables is performed by several pre-defined routines. In the PC based release (MS/DOS, OS/2, Xenix operating systems), the Graphic-User Interface (GUI) has been developed using Microsoft Windows Software Development Kit. The UNIX release will use a GUI developed on top of the X-Windows environment.

Computer Graphics↗
PubMed1996

[Cranial bone graft in oral and maxillofacial surgery].

The sufficient donor bone volume is important to restore congenital, developmental and accidented defects of facial skeleton. In recent years, the outer table of cranial bone, as a better donor source, has been used in maxillofacial and craniofacial surgery extensively. But no clinical report was found in China. In this paper 16 cases were reported (5 cases of alveolar cleft, 5 cases of secondary deformity after cleft palate and ankylosis of TMJ, 6 cases of developmental deformity of jaws). All of these cases were treated by using cranial bone graft in strips or bone dust during orthognathic operations. The result showed no any complications in all cases. Compared with iliac and rib grafts, the outer table of cranial bone graft showed distinct advantages: greater graft volume survival, little postoperative pain at the donor site, and the skin incision within the hairline.

Adult↗
PubMed2002

The evolution of Z stent-based stent-grafts for endovascular aneurysm repair: a life-table analysis of 7.5-year followup.

BACKGROUND: The purpose of this study was to analyze the impact of stent-graft design and operator skills on outcomes after endovascular abdominal aortic aneurysm repair. STUDY DESIGN: One hundred sixty-four patients (mean age 71 years) underwent stent-graft repair. Patients were treated with four different types of stent-graft: first-generation (n = 58) and second-generation (n = 17) Ivancev-Malmö monoiliac stent-grafts (IM I and IM II, respectively) combined with femoral-femoral crossover, Chuter bifurcated stent-graft (n = 15), and the Zenith stent-graft (n = 74). Patients underwent digital subtraction angiography and contrast CT preoperatively and were then followed with CT scans postoperatively. Recently, followup was changed to CT scanning at 1 month and 1 year postoperatively and annually thereafter. Ultrasonographic duplex scanning substitutes in the remaining followup. Changes in aneurysm diameters and occurrence of endoleaks were recorded. Short- and midterm mortality and complications and postoperative secondary interventions were recorded, and life-table analysis for intervention-free stent-graft survival was calculated. RESULTS: Immediate and late conversions and 30-day mortality were reduced for second- (IM II and Zenith) compared with first-generation stent-grafts (IM I and Chuter). Stent-graft migrations occurred only with the IM I and Chuter stent-grafts. Type I endoleak was significantly more common in first-generation stent-grafts. First-generation stent-grafts required significantly more secondary interventions than second-generation stent-grafts up to 30 months postoperatively. CONCLUSION: Enhanced stent-graft design has improved the probability of stent-graft success after endovascular abdominal aortic aneurysm repair. Better technical skills and increased use of intraoperative adjunctive procedures may also have contributed to improved results.

Aged↗
PubMedDate not supplied

Antegrade biliary stenting versus T-tube drainage after laparoscopic choledochotomy--a comparative cohort study.

BACKGROUND/AIMS: Laparoscopic exploration of the common bile duct (LECBD) has been proven to be an effective and preferred treatment approach for uncomplicated common bile duct stones. However there is still controversy regarding the choice of biliary decompression after laparoscopic choledochotomy. METHODOLOGY: This is a retrospective comparison between the use of antegrade biliary stenting and T-tube drainage following successful laparoscopic choledochotomy. During the period between January 1995 and July 2003, biliary decompression was achieved by either antegrade biliary stenting or T-tube drainage based on the discretion of the operating surgeon. For antegrade biliary stenting, a 10-Fr Cotton-Leung biliary stent was inserted through the choledochotomy and passed down across the papilla. The stent position was confirmed by on-table choledochoscopy before interrupted single-layered closure of the common bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) was performed to remove the stent 4 weeks after operation and at the same time to check for any residual stones or other complications like stricture or leak. In the T-tube group, a 16-Fr latex T-tube was used and the long limb was brought out through the subcostal trocar port followed by the same method of bile duct closure. Cholangiogram through the T-tube was performed on day 7 and the tube would be taken off 1 week later (about 2 weeks after operation) if the cholangiogram did not reveal any abnormality. The two groups were compared according to the demographic data, operation time, length of hospital stay and complication rates. RESULTS: During the study period, 108 laparoscopic explorations of the common bile duct were performed in our centre of which 95 were attempted laparoscopic choledochotomies and 13 were transcystic duct explorations. Of the 95 patients with attempted laparoscopic choledochotomy, there were 9 open conversions, 17 laparoscopic bilioenteric bypasses and 6 primary closures of the common bile duct. All of these patients together with those receiving transcystic duct explorations were excluded and the remaining 63 patients having postoperative bile diversion by either antegrade biliary stenting or T-tube drainage were included in this study. Bile diversion was achieved by antegrade biliary stenting in 35 patients whereas 28 patients had T-tube drainage. There was no difference between the two groups in terms of age, clinical presentation, bilirubin level, length of hospital stay, follow-up duration, common bile duct size, size of common bile duct stones, incidence of residual/recurrent stone and complication rate. It was observed that more patients in the stenting group developed bile leak (14.2% vs. 3.5%) and required more intramuscular pethidine injections (182.86 +/- 139.30 vs. 92.81+/-81.15mg, P=0.000). On the other hand, the T-tube group had longer operation time (141.4+/-45.1 vs. 11 1.1+/-33.9 minutes, P=0.006) and had a longer postoperative hospital stay (10.0+/-7.4 vs. 8.8+/-9.3 days, P=0.020) reaching statistical significance. CONCLUSIONS: Postoperative bile diversion by antegrade biliary stenting after laparoscopic choledochotomy is shown to shorten operation duration and postoperative stay as compared to T-tube drainage, but the problem of bile leak needs further refinement of insertion technique.

Aged↗
PubMedDate not supplied

[Pseudoarthrosis of the scaphoid bone associated with carpal collapse: factors in choice of surgical approach].

INTRODUCTION: The most common fracture involving the wrist is a fracture of the scaphoid bone [1], and only 5% to 10% of these fractures proceed to nonunion. Although not symptomatic initially, most (if not all) nonunions later produce a painful wrist with impaired function, clinically significant loss of motion, increased weakness and degenerative arthritis. Nonunion of the scaphoid bone should be treated by open reduction and internal fixation. Many surgical procedures have been advocated to achieve union. Most widely used technique for the treatment of scaphoid nonunion was described by Russe [2], but this method may overcome the flexion deformity of the scaphoid and carpal deformities. The ununited scaphoid usually undergoes resorption of the fractures surfaces, principally over the anterolateral aspect of the fracture, so that the scaphoid becomes misshapen. The restoration of the exact length and form is enabled by insertion of a tight-fitting trapezoidal corticocancellous graft, a technique described by Fernandez [11]. AIM: We analysed the results of treatment of scaphoid nonunion utilized by two bone-grafting techniques and pointed out the need of choice of the best operative method. METHODS: From 1977 to 1993, at the Institute of Orthopaedic Surgery and Traumatology in Belgrade, 40 patients were surgically treated for symptomatic nonunion of the scaphoid bone. The mean duration of follow-up was 10.2 years (range, from 6 to 22 years). Eighteen (45%) patients were operated by Fernandez technique and 22 (55%) patients were operated using Russe's technique. Volar approach and Kirschner's wire fixation were performed in both operative methods. We used two rating scales proposed by Cooney [13] to evaluate the results. Objective scale (Table 1a) included the radiographic appearance of the wrist, the range of motion and grip strength. Subjective scale (Table 1b) comprised function, pain perception of a decrease in performance because of limited motion or strength, and satisfaction. These scales were used to compare the objective and subjective results in patients who had postoperatively carpal collapse with the results in patients who had not such deformity. RESULTS: The union rate was 92.5% in both methods. Russe's technique resulted in union in 20 (91%) of 22 cases with two ununited. Fernandez technique achieved union in 17 (94%) of 18 cases. Fracture union was determined by both clinical and roentgenographic examinations. Correction of the lateral interscaphoid angle was obtained in 14 (82%) patients operated by Fernandez technique and 9 (45%) patients operated by Russe's technique. Correction of dorsal tilt of the lunate were achieved in 6 (30%) patients operated by Russe's technique, and 13 (76.6%) patients operated by Fernandez technique. There was a highly significant correlation (p < 0.01) between increased deformity of the scaphoid and extent of carpal collapse (Graph 1). Also, there was significant difference between two operative techniques regarding correction of lateral interscaphoid angle (p < 0.05). Arthrosis of the wrist was present in all patients. We could not demonstrate a significant difference (p > 0.05) between intensity of degenerative changes and increase of lateral interscaphoid angle, but obviously, the large flexion deformity of the scaphoid the worse intensity of degenerative changes (Graph 2). The grip strength significantly increased after Fernandez technique (p > 0.05) (Graph 3), but wrist motion changed a little. The average objective score was 71 points for the patients in whom the lateral interscaphoid angle was 45 degrees or less, and 63 points for those in whom the angle was more than 45 degrees. This difference was significant (p < 0.05), but we could not demonstrate a significant difference between the two groups in terms of the average subjective score. DISCUSSION: In our series, both procedures provided a high union rate [2]. In cases with severe scaphoid shortening and flexion deformity, Russe's procedure has proved to be insufficient to restore anatomic length and correction of carpal alignment [6, 11, 17]. Previous authors have reported that the progression in degenerative changes was slower in patients who had a lateral interscaphoid angle less than 45 degrees [13]. Also, grip strength and range of motion increased in patients in whom flexion deformity of the scaphoid had been corrected [2, 4, 6, 16, 17]. Our study supports these findings, except results regarding the movement. We believe that this was due to postoperative scarring. Discrepancy between the subjective and objective results may have been due to postoperative relief of pain obtained by increased carpal stability or decreased range of motion of the carpal joints due to postoperative scarring. If pain is relieved, patients readily adapt to the functional deficit of decreased range of motion. We concluded that angulatory collapse of the scaphoid resulted in nonunion as well as malunion with secondary functional loss. Recognition and avoidance in acute fractures were important. When recognised late, volar wedge grafting appeared to be a satisfactory method of treatment.

Adolescent↗
PubMed2001

Ureteric stenting for repair of accidental ureteric injuries.

Intra-operative injury to the ureter is a well known but fortunately uncommon complication of any major pelvic surgical procedure. If recognised on table, it can be repaired by either a substitution ureteroplasty or end-to-end anatomical repair depending upon the extent of tissue loss. Either of these anastomoses could be secured by total internal stent placement. We describe an improvised technique of intra-operative open ureteric stenting particularly when radiological assistance is not available, i.e. during emergency situations.

Anastomosis, Surgical↗
PubMed2002

USAF treatment table 8: treatment for altitude decompression sickness.

INTRODUCTION: Altitude decompression sickness (DCS) has been treated with hyperbaric therapy since 1941. Treatment has essentially followed the diving DCS paradigm. Expanding space operations and higher flying, more remotely placed military aircraft have stimulated a re-examination of this paradigm. Can the oxygen and pressure-producing resources in these austere environs be reduced without sacrificing treatment efficacy? METHOD: A prospective series of 12 patients was treated with a new treatment table. USAF Treatment Table 8 (TT8) consists of 100% oxygen delivered at 2 ATA for four 30-min periods with intervening 10-min air breaks (a total oxygen dose of 2 h). Inclusion spanned 1985-1989. RESULTS: There were 10 patients who were treated 11 times for Type I altitude decompression sickness. Treatment was successful in 91%. There was one failure (a recurrence of elbow pain) requiring further therapy. Two patients were treated for Type II altitude decompression sickness. Treatment was successful in 50%. There was one failure (incomplete clearance of sensory deficits and weakness in the shoulder) requiring further therapy. CONCLUSION: Although TT8 had two failures, its successes suggest that a new protocol for the treatment of altitude decompression sickness is viable. In addition, its successes further suggest that a more extensive clinical trial is in order.

Adult↗
PubMed2002

Assessment of the ergonomically optimal operating surface height for laparoscopic surgery.

PURPOSE: The aim of this study was to find the ergonomically optimal operating surface height for laparoscopic surgery in order to reduce discomfort in the upper extremities of the operators and the assistants. The operating surface height was defined as the level of the abdominal wall of a patient with pneumoperitoneum. MATERIALS AND METHODS: Two pelvi-trainer tests were performed. One test was performed on six different operating surface heights. The (extreme) joint excursions of the shoulder, elbow, and wrist were measured by a video analysis method. Another test was performed by holding a laparoscope for 15 minutes while an electromyelograph of the biceps brachii was made. The results of both tests were evaluated subjectively by a questionnaire. RESULTS: The ergonomically optimal operating surface height lies between a factor 0.7 and 0.8 of the elbow height of the operator/assistant. At this height, the joint excursions stay in the neutral zone for more than 90% of the total manipulation time, and the activity of the biceps brachii when holding the laparoscope stays within 15% of the maximum muscle activity. CONCLUSIONS: The operating surface height influences the (extreme) upper joint excursions of the surgeon. The ergonomically optimal operating surface height reduces the discomfort in the shoulders, back, and wrists of the surgeon during laparoscopic surgery. This optimal table height range for laparoscopic surgery is lower than those currently available.

Electromyography↗