Extent of atherosclerosis and prognosis of patients with aneurysmal subarachnoid haemorrhage

Summary Background and purpose. Atherosclerosis impairs the endothelial dependent vasodilatation and may change the diameter and plasticity of cerebral vessels. The aim of this study was to investigate if an index of the occurrence of atherosclerosis is associated with the risk of delayed cerebral ischemia or poor outcome after subarachnoid haemorrhage. Methods. To assess the likelihood of atherosclerosis we used a modified version of the Framingham Heart Study Coronary Heart Disease Prediction Chart. The relation of this index to the occurrence of delayed cerebral ischemia was studied by means of survival analysis and to poor outcome by regression analysis. A multivariate analysis was used to investigate the independent contribution of the atherosclerosis index. Results. Three hundred and twenty three patients were retrieved from our database from the period 1997 to 2004. The index of atherosclerosis related to a good clinical condition on admission (p = 0.01). A high risk of atherosclerosis independently predicted poor outcome (OR 4.3; 95%CI 1.6–12). This was not caused by an increase in the occurrence of delayed cerebral ischemia (HR 1.1; 95%CI 0.6–2.1), but, in part, by a marked decrease in recurrent bleeding in patients with no or minor atherosclerosis. Conclusions. An index of the occurrence of atherosclerosis is related to prognosis after subarachnoid haemorrhage. The use of the score may focus attention on patients at risk for poor outcome after subarachnoid haemorrhage.     

Efficacy and Safety of Seprafilm for Preventing Postoperative Abdominal Adhesion: Systematic Review and Meta-analysis

Background There is no clear consensus on the efficacy and safety of hyaluronate-carboxymethylcellulose membrane (Seprafilm) for preventing postoperative abdominal adhesion. This study is a meta-analysis of the available evidence. Methods A search of the MEDLINE, EMBASE, and the Cochrane Library identified eight studies that met the inclusion criteria for data extraction. Estimates of effectiveness were performed using fixed- and random-effects models. The effect was calculated as an odds ratio (OR) with 95% confidence intervals (CI) using the statistical software Review Manager Version 4.2. Level of significance was set at p < 0.05. Results Outcomes of 4203 patients were studied. The incidence of grade 0 adhesions among Seprafilm-treated patients was statistically significantly more than that observed among control group patients (OR 95%CI, 3.74–20.34; p < 0.01). There was no significant difference in the incidence of grade 1 adhesions between Seprafilm and control groups (OR 95%CI, 0.58–2.71; p = 0.56). The severity of grade 2 and grade 3 adhesions among Seprafilm-treated patients was significantly less than that observed among control group patients (OR 95%CI, 0.22–0.93; p = 0.03; OR 95%CI, 0.09–0.63; p < 0.01, respectively). The incidence of intestinal obstruction after abdominal surgery was not different between Seprafilm and control groups (OR 95%CI, 0.78–1.23; p = 0.84). Using Seprafilm significantly increased the incidence of abdominal abscesses (OR 95%CI, 1.06–2.54; p = 0.03) and anastomotic leaks (OR 95%CI, 1.18–3.50; p = 0.01). Conclusions Our systematic review and meta-analysis showed that Seprafilm could decrease abdominal adhesions after general surgery, which may benefit patients, but could not reduce postoperative intestinal obstruction. At the same time, Seprafilm did increase abdominal abscesses and anastomotic leaks.     

Hypotension in anaesthetized patients during aneurysm clipping: not as bad as expected?

Background: Patients with aneurysmal subarachnoid haemorrhage (SAH) often have disturbed autoregulation of cerebral blood flow. A reduction in systemic blood pressure during surgery may therefore lead to delayed cerebral ischaemia (DCI). To assess the incidence and severity of intra-operative hypotension, we performed a retrospective cohort study in 164 patients with recent SAH and surgical clipping of the aneurysm.
Methods: Intra-operative hypotension was defined in three levels of severity, as a decrease in mean arterial pressure (ΔMAP) of more than 30%, 40% or 50% compared with the pre-operative pressure. For each patient the total amount of time with intra-operative hypotension was retrieved. Logistic regression analysis was performed to study the relation between intra-operative hypotension and the occurrence of DCI and poor outcome.
Results: A period with ΔMAP>30% occurred in 128 patients (78%) with a median duration of this period of 105 min (25–75‰ 50–171 min). ΔMAP>40% occurred in 88 patients (54%) and ΔMAP>50% occurred in 22 patients (13%). In univariate analysis, ΔMAP>50% was associated with poor outcome. After adjusting for age and World Federation of Neurological Surgeons grade, the association with poor outcome was no longer statistically significant [odds ratio (OR) 1.018; 95% CI 0.996–1.041].
Conclusion: Hypotension during surgical clipping of intracranial aneurysms occurred frequently. In our study population of patients mostly in good clinical condition, hypotension was not confirmed as an independent risk factor for DCI or poor outcome. Anaesthesia may have had a cerebral protective effect.     

Predictive value of initial clinical status,intracranial pressure and transcranial Doppler pulsatility after subarachnoid haemorrhage

Summary Background. We examined the predictive value of initial clinical status, mean arterial blood pressure (MABP), intracranial pressure (ICP) and transcranial Doppler (TCD)-derived pulsatility and resistance indices for outcome and quality of life one year following aneurysmal subarachnoid haemorrhage (SAH). Method. Neuromonitoring was performed in 29 patients following clipping or coiling of an aneurysm. Mean arterial blood pressure was measured in the radial artery and intracranial pressure was assessed via a closed external ventricular drainage. Based on transcranial Doppler-recordings of the middle cerebral artery, Gosling’s pulsatility (PI) and Pourcelot’s resistance (RI) index were calculated. Glasgow outcome score (GOS) and short form-36 (SF-36) scores were determined one year after SAH. Findings. An unfavourable outcome (GOS 1–3) was observed in 34% of patients and correlated significantly (p < 0.05) with a poor initial clinical status, as determined by Glasgow Coma Scale (r = 0.55), Hunt and Hess (r = −0.62), World Federation of Neurosurgical Societies (WFNS) (r = −0.48) and Fisher (r = −0.58) score. Poor outcome was significantly associated with high mean arterial blood pressure (r = −0.44) and intracranial pressure (r = −0.48) as well as increased pulsatility (r = −0.46) and resistance (r = −0.43) indices. Hunt and Hess grade ≥4 (OR 12.4, 5–95% CI: 1.9–82.3), mean arterial blood pressure > 95 mmHg (19.5, 2.9–132.3), Gosling’s pulsatility >0.8 (6.5, 1.6–27.1) and Pourcelot’s resistance >0.57 (15.4, 2.3–103.4) were predictive for unfavourable outcome in logistic regression, however TCD-diagnosed vasospasm was not. Except for mental health, significantly reduced scores were observed in all short form-36 domains. Initial clinical status correlated significantly with the physical functioning, role physical, bodily pain, social functioning and physical component summary of short form-36. Conclusions. Mortality and morbidity following SAH remains high, especially in poor-grade patients. Outcome is mainly correlated with initial clinical status, mean arterial blood pressure, intracranial pressure, pulsatility and resistance indices. Those factors seem to be stronger than the influence of vasospasm.     

Predictors of Re-excision among Women Undergoing Breast-Conserving Surgery for Cancer

Background Up to 60% of breast cancer patients who undergo breast-conserving surgery (BCS) require re-excision to obtain clear margins, causing delays in adjuvant treatment and poor aesthetic results. However, patient and treatment-related factors associated with re-excision are not well defined. Methods We surveyed all women undergoing breast conserving surgery between January 2002 and May 2006 regarding their breast disease (n = 714, response rate = 79.5%). The medical record was reviewed to determine the receipt of re-excision lumpectomy following BCS, and obtain tumor stage, histology, and biopsy method (surgical versus needle biopsy). Patient age, breast size, tumor location in the breast, and receipt of chemotherapy were self-reported. Logistic regression was used to determine significant predictors of re-excision lumpectomy. Results In this sample, 51.4% of women required only one breast excision, 41.9% required two breast excisions, and 6.6% required three breast excisions. Overall, 10.8% of women required a mastectomy following initial attempt at BCS. Factors significantly correlated with re-excision lumpectomy included smaller breast size (A cup: OR = 2.7; 95%CI: 1.32–5.52; B cup: 1.63; 95%CI: 1.02–2.62), lobular histology (OR = 1.93; 95%CI: 1.15–3.25), and receipt of surgical biopsy (OR = 3.35; 95%CI: 2.24–5.02). Women who received adjuvant chemotherapy (OR = 2.49; 95%CI: 1.19–5.22) were more likely to require re-excision compared with women who received neoadjuvant chemotherapy. Conclusions Re-excision lumpectomy is common, and is significantly correlated with smaller breast size, lobular histology, surgical biopsy, and chemotherapy timing. Attention to these risk factors can improve the quality of care delivered to BCS patients by decreasing the cost and morbidity associated with multiple re-excision procedures.     

Predictive factors of chronic kidney disease in severe vesicoureteral reflux

The aim of this retrospective cohort study was to evaluate independent predictive factors of chronic kidney disease (CKD) in children with severe bilateral primary vesicoureteral reflux (VUR). Between 1970 and 2004, 184 patients were diagnosed with VUR (grades III–V) and were systematically followed up at a single tertiary renal unit. CKD was defined as estimated glomerular filtration rate <75 ml/min per 1.73 m² body surface area in two consecutive examinations. Risk of CKD was analyzed by the Kaplan–Meier method and Cox’s regression model. The probability of CKD for patients with bilateral severe reflux was estimated at 15% by 10 years after VUR diagnosis. After adjustment, four variables remained independently associated with CKD during follow-up: age at diagnosis >24 months [relative risk (RR)=4.8, 95% confidence interval (95%CI), 1.8–12.7, P<0.001], VUR grade V (RR=3.5, 95%CI, 1.5–7.9, P=0.002), bilateral renal damage (RR=2.86, 95%CI, 1.3–6.1, P=0.007), and decade of admission after 1990 as a protective factor (RR=0.16, 95%CI 0.06–0.43, P<0.001). A delay in the diagnosis of VUR more than 12 months after urinary tract infection (UTI) was also a predictive factor in an alternative model (RR=2.2, 95%CI, 1.1–6.6, P=0.03). Prognosis regarding renal function was relatively poor after a long-term follow-up of patients with bilateral severe reflux.     

Hypomagnesemia after aneurysmal subarachnoid hemorrhage

OBJECTIVE: Hypomagnesemia frequently occurs in hospitalized patients, and it is associated with poor outcome. We assessed the frequency and time distribution of hypomagnesemia after aneurysmal subarachnoid hemorrhage (SAH) and its relationship to the severity of SAH, delayed cerebral ischemia (DCI), and outcome after 3 months. METHODS: Serum magnesium was measured in 107 consecutive patients admitted within 48 hours after SAH. Hypomagnesemia (serum magnesium <0.70 mmol/L) at admission was related to clinical and initial computed tomographic characteristics by means of the Mann-Whitney U test. Hypomagnesemia at admission and during the DCI onset period (Days 2-12) was related to the occurrence of DCI and hypomagnesemia at admission, and hypomagnesemia that occurred any time during the first 3 weeks after SAH was related to outcome. RESULTS: Hypomagnesemia at admission was found in 41 patients (38%) and was associated with more cisternal (P = 0.006) and ventricular (P = 0.005) blood, a longer duration of unconsciousness (P = 0.007), and a worse World Federation of Neurosurgical Societies scale score at admission (P = 0.001). The crude hazard ratio for DCI with hypomagnesemia at admission was 2.4 (95% confidence interval, 1.0-5.6), and after multivariate adjustment it was 1.9 (95% confidence interval, 0.7-4.7). The hazard ratio of hypomagnesemia from Days 2 to 12 for patients with DCI was 3.2 (range, 1.1-8.9) after multivariate adjustment. The crude odds ratio for poor outcome (Glasgow Outcome Scale score, 1-3) with hypomagnesemia at admission was 2.5 (range, 1.1-5.5). Hypomagnesemia at admission did not contribute to the prediction of outcome in the multivariate model. CONCLUSION: Hypomagnesemia is frequently present after SAH and is associated with severity of SAH. Hypomagnesemia occurring between Days 2 and 12 after SAH predicts DCI.     

Gender and vesico-ureteral reflux: a multivariate analysis

The aim of this retrospective cohort study was to describe the characteristics of patients with primary vesico-ureteral reflux (VUR) with special attention to gender-specific differences. Between 1970 and 2004, 735 patients were diagnosed with VUR and were systematically followed in a single tertiary renal unit. The following variables were analyzed: race, age at diagnosis, clinical presentation, weight and height Z-score, unilateral/bilateral reflux, VUR grade, renal damage, severity of renal damage, constipation, and dysfunctional voiding. Comparison of proportion between genders was assessed by the chi-square test with Yates’ correction. The logistic regression model was applied to identify independent variables associated with gender. A survival analysis was performed to evaluate VUR resolution. After adjustment, five variables remained independently associated with male gender at baseline: non-white race [Odds ratio (OR) = 1.98, 95% confidence interval (95% CI) 1.33–2.95, P=0.001], moderate/severe grade of reflux (OR=2.16, 95% CI 1.45–3.22, P<0.001), severe renal damage (OR=1.60, 95% CI 1.04–2.52, P=0.04), age at diagnosis <24 months (OR=1.79, 95% CI 1.23–2.60, P=0.002), and antenatal clinical presentation (OR=3.56, 95% CI 1.91–6.63, P<0.001). Follow-up data were available for 684 patients (93%). Median follow-up time was 69 months (range 6 months to 411 months). Girls had a greater risk of urinary tract infection (UTI) during follow-up than boys (OR=1.68, 95% CI 1.18–2.38, P=0.003). There was no difference in progression to chronic renal insufficiency (CRI) between boys (3.8%) and girls (2.4%) during this period of follow-up (OR=1.58, 95% CI 0.59–4.15, P=0.44). Gender as an isolated variable is a poor predictor of clinical outcome in an unselected series of primary reflux. Although boys had a more severe pattern at baseline, girls had a greater risk of dysfunctional voiding and recurrent UTI during follow-up.     

Tension-free vaginal tape: poor intraoperative cough test as a predictor of postoperative urinary retention

The purpose of this study was to determine if the quality of the intraoperative cough test could help to predict which patient would fail the post void residual test (PVR) immediately after a tension-free vaginal tape (TVT) procedure. Patients undergoing a TVT procedure only, under spinal or local anesthesia were enrolled. Patients were divided into two groups based on the outcome of the first postoperative PVR, failure group (FG) vs successful group (SG). Before adjusting the tape, patients underwent a standardized cough test. The quality of the cough test was determined to be either good or poor based on whether every cough produced a spurt of urine or not. Variables analyzed between the FG and SG were demographic and urodynamic data. Multivariate logistic regression analysis was used to calculate the adjusted odds ratios. Twenty-six (60.5%) women passed and 17 (39.5%) failed the initial postoperative PVR evaluation. There was a 4.89-fold greater odds of failing the postoperative PVR for women 65 and older compared to younger women (OR 4.89, 95% CI [1.07–26.45]). In addition, there was an 8.63-fold greater odds of failing postoperative PVR for patients with poor quality cough test (OR 8.63, 95% CI [1.54–54.66]). However, multivariate logistic regression analysis revealed that poor quality cough test was the only significant predictor for failing a postoperative PVR (OR 6.83, 95% CI [1.39–33.49], P = 0.018). A poor quality intraoperative cough test at the time of TVT procedure is a predictor of immediate postoperative urinary retention. Presented at the IUGA 31st Annual Meeting, Athens, Greece, 2006.     

Sonic tooth brushing reduces gingival overgrowth in renal transplant recipients

Cyclosporine (CSA) is a commonly used immunosuppressive medication in pediatric transplantation. Drug-induced gingival overgrowth (DIGO) is a frequent side effect associated with CSA use and can impair the patient’s ability to achieve good oral hygiene. This study tested the hypothesis that sonic tooth brushing and oral hygiene instruction can reduce the occurrence or severity of DIGO in CSA-treated pediatric renal transplant recipients. Twenty-three pediatric renal transplant patients with DIGO were randomly allocated to treatment or control groups. The treatment group received oral hygiene instruction and use of a sonic toothbrush, while the control group continued their usual home care with manual brushes. Dental impressions and photographs of all subjects were taken at baseline and every 3 months for a year. The casts and photographs were evaluated by a dental panel to compare the DIGO levels from baseline until the end of the study. After 12 months the control group had significantly more severe DIGO than did the sonic tooth brushing and oral hygiene instruction group (OR=4.5, 95%CI=1.2–16.0, P=0.03). Of the risk factors considered, only male gender was significantly associated with worse outcome (OR=6.1, 95%CI=2.3–16.1, P=0.03). The use of a powered toothbrush, together with oral hygiene instruction, may be an important component of health maintenance for pediatric transplant patients on CSA.     

Relationships between SF-36 health profile and bone mineral density: the Hertfordshire Cohort Study

We utilised the Hertfordshire Cohort Study (HCS) to relate bone mineral density (BMD) to SF-36 health-related quality of life scores. We studied 737 men and 675 women who had completed a home interview and clinic. Four hundred and ninety-eight men and 468 women subsequently attended for bone densitometry [dual-energy X-ray absorptiometry (DXA)]. SF-36 questionnaire responses were mapped to eight domains: physical function (PF), role physical (RP), role emotional (RE), social functioning (SF), mental health (MH), vitality (VT), bodily pain (BP) and general health perception (GH). Subjects with scores in the lowest gender-specific fifth of the distribution were classified as having “poor” status for each domain. Odds ratios (OR) for poor status for each domain were calculated per unit increase in lumbar spine or total femoral BMD t score. Among men after adjustment for age, BMI, social class, lifestyle (including physical activity) and known comorbidity, higher total femoral t score was associated with decreased prevalence of poor SF-36 scores for PF [OR 0.72 (95%CI 0.53, 0.97), p=0.03], SF [OR 0.70 (95%CI 0.53, 0.94), p=0.02] or GH domains [OR 0.74 (95%CI 0.56, 0.99), p=0.05], but no relationships were apparent between SF-36 scores and lumbar spine t score. Among women, the adjusted relationship between higher total femoral t score and decreased prevalence of poor PF was consistent [OR 0.71 (95%CI 0.50, 1.00), p=0.05], but no other relationships were significant. Poorer functioning (assessed by SF-36 questionnaire) is associated with lower total femoral BMD in older men (but less so in women) after adjustment for lifestyle factors and comorbidity.     

The benefits of adding epidural analgesia to general anesthesia: a metaanalysis

The purpose of this metaanalysis was to determine the benefits of postoperative epidural analgesia in patients operated on under general anesthesia. By searching the American National Library of Medicine's Pubmed database from 1966 to July 10, 2004, 70 studies were identified. These included 5402 patients, of which 2660 had had epidural analgesia. Epidural analgesia reduces the incidence of arrhythmia, odds ratio (OR) = 0.59 (95%CI = 0.42, 0.81, P = 0.001); time to tracheal extubation, OR = −3.90 h (95%CI = −6.37, −1.42, P = 0.002); intensive care unit stay, OR = −2.94 h (95%CI = −5.66, −0.22, P = 0.03); visual analogical pain (VAS) scores at rest, OR = −0.78 (95%CI = −0.99, −0.57, P < 0.00001) and during movement, OR = −1.28 (95%CI = −1.81, −0.75, P < 0.00001); maximal blood epinephrine, OR = −165.70 pg·ml⁻¹ (95%CI = −252.18, −79.23, P = 0.0002); norepinephrine, OR = −134.24 pg·ml⁻¹ (95%CI = −247.92, −20.57, P = 0.02); cortisol, OR = −55.81 nmol·l⁻¹ (95%CI = −79.28, −32.34, P < 0.00001); and glucose concentrations achieved, OR = −0.87 nmol·l⁻¹ (95%CI = −1.37, −0.37, P = 0.0006). It also reduces the first 24-h morphine consumption, OR = −13.62 mg (95%CI = −22.70, −4.54, P = 0.003), and improves the forced vital capacity (FVC), OR = 0.23 l (95%CI = 0.09, 0.37, P = 0.001) at 24 h. A thoracic epidural containing a local anesthetic reduces the incidence of renal failure: OR = 0.34 (95%CI = 0.14, 0.81, P = 0.01). Epidural analgesia may thus offer many advantages over other modes of postoperative analgesia. Presented at the 30th Spring Annual Meeting of the American Society of Regional Anesthesia, Toronto, April 2005     

Adult urolithiasis in a population-based study in Iran: prevalence,incidence, and associated risk factors

The aim of this study was to determine the prevalence, incidence, and risk factors of adult urolithiasis in Iran. A total of 8,413 persons aged over 14 years enrolled in this cross-sectional study. They were questioned on the occurrence of urinary stones during their lifetime (prevalence) and on acute urolithiasis in 2005 (incidence) by 62 general practitioners. The subjects were randomly identified from 30 counties of Iran. Data on risk factors for urolithiasis including age, race, education, body mass index, hypertension, and current use of medication were also obtained by self-administered questionnaire. Of the 7,649 participants who provided information, 5.7% (436) [95% confidence interval (CI) 4.2–5.4], reported urinary stones. The prevalence increased from 0.9% in adults aged 15–29 years to 8.2% in those aged 60–69 years (test for trend, P = 0.001). Urolithiasis was slightly more frequent and persisted in males (6.1%) than females (5.3%) giving a male-to-female ratio of 1.15:1 [odds ratio (OR) 1.03; 95% CI 0.64–1.36; P = 0.814]. The annual incidence of urolithiasis in 2005 was 145.1. The average cumulative recurrence rate was 16% after 1 year, 32% after 5 years, and 53% after 10 years. Urinary stones were more in number among men and women who lived in south central and southwest counties, with odds increasing from west to east and from north to south. A positive association was found between urolithiasis and obesity (OR 1.74; 95% CI 1.21–2.31; P = 0.04), diuretic use (OR 1.62; 95% CI 1.18–2.70; P = 0.03), hypertension (OR 1.88; 95% CI 1.26–2.18; P = 0.04), unemployment (OR 2.10; 95% CI 1.43–2.14; P = 0.04), consumption of tea (OR 1.64; 95% CI 1.32–2.62; P = 0.03), consumption of cola (OR 1.49; 95% CI 1.23–2.19; P = 0.02), and meat consumption (OR 1.38; 95% CI 1.29–2.21; P = 0.02). This study provides a quantitative estimate of the prevalence, incidence, and main risk factors for adult urolithiasis in the Iranian population. Further studies are warranted in order to determine the incidence and prevalence of urolithiasis in different ethnic groups.     

Factors affecting neurological deficits and intractable back pain in patients with insufficient bone union following osteoporotic vertebral fracture

The purpose of this study was to examine factors affecting the severity of neurological deficits and intractable back pain in patients with insufficient bone union following osteoporotic vertebral fracture (OVF). Reports of insufficient union following OVF have recently increased. Patients with this lesion have various degrees of neurological deficits and back pain. However, the factors contributing to the severity of these are still unknown. A total of 45 patients with insufficient union following OVF were included in this study. Insufficient union was diagnosed based on the findings of vertebral cleft on plain radiography or CT, as well as fluid collection indicating high-intensity change on T2-weighted MRI. Multivariate logistic regression analysis was performed to determine the factors contributing to the severity of neurological deficits and back pain in the patients. Age, sex, level of fracture, duration after onset of symptoms, degree of local kyphosis, degree of angular instability, ratio of occupation by bony fragments, presence or absence of protrusion of flavum, and presence or absence of ossification of the anterior longitudinal ligament (OALL) in the adjacent level were used as explanatory variables, while severity of neurological deficits and back pain were response variables. On multivariate analysis, factors significantly affecting the severity of neurological deficits were angular instability of more than 15° [adjusted odds ratio (OR), 9.24 (95% confidence interval, CI 1.49–57.2); P < 0.05] and ratio of occupation by bony fragments in the spinal canal of more than 42% [adjusted OR 9.23 (95%CI 1.15–74.1); P < 0.05]. The factor significantly affecting the severity of back pain was angular instability of more than 15° [adjusted OR 14.9 (95%CI 2.11–105); P < 0.01]. On the other hand, presence of OALL in the adjacent level reduced degree of back pain [adjusted OR 0.14 (95%CI 0.03–0.76); P < 0.05]. In this study, pronounced angular instability and marked posterior protrusion of bony fragments in the canal were factors affecting neurological deficits. In addition, marked angular instability was a factor affecting back pain. These findings are useful in determining treatment options for patients with insufficient union following OVF.     

The association between personal habits and bladder cancer in Turkey

Aims  In this study, we analyzed the effect of Turkish coffee and black tea consumption, alcohol intake and smoking on bladder cancer. Methods  A total of 164 patients with bladder tumors and 324 individuals without primary tumors were included in the study. The habits of coffee and tea consumption, alcohol intake and smoking were queried. Results  No association was found between bladder cancer and drinking coffee (p = 0.89) and tea (p = 0.37), but alcohol intake was found to be associated, with an odds ratio (OR) of 1.85 (95% CI 1.15–2.96; p = 0.009). While there was a relationship between bladder cancer and smoking and quitting smoking (OR: 4.84 [95% CI 2.93–8.00; p < 0.001] and OR: 4.10 [95% CI 2.41–6.97; p < 0.001] respectively), the associations between bladder cancer and smoking and quitting smoking were similar (OR: 1.18, 95% CI 0.74–1.86; p = 0.477). Smoking <10 cigarettes a day created an OR of 2.14 (95% CI 1.11–4.12; p < 0.001); 10–20 cigarettes an OR of 4.50 (95% CI 2.74–7.37; p < 0.001); >20 cigarettes an OR of 14.85 (95% CI 6.83–32.27; p < 0.001); smoking by inhaling the smoke an OR of 4.72 (95% CI 2.94–7.59; p < 0.001), and smoking by not inhaling the smoke an OR of 3.34 (95% CI 1.75–6.38; p < 0.001). The associations between bladder cancer and inhaling smoke and not inhaling smoke were similar (OR: 1.41, 95% CI 0.85–2.48; p = 0.228). Conclusion  We found that smoking and alcohol consumption are closely connected with bladder cancer. Our data showed that not inhaling the smoke was as much associated with bladder cancer as inhaling the smoke. The association between smoking and bladder cancer lasts after quitting smoking.     

Relationships Between Risk Factors and Fractures Differ by Type of Fracture: A Population-Based Study of 12192 Perimenopausal Women

Relationship between selected factors and fractures according to type of fracture were retrospectively examined in 12192 women aged 47–56 years responding to the baseline postal enquiry of the Kuopio Osteoporosis Study, Finland, in 1989. A total of 1358 women reported fractures sustained during the previous 9.4 years, i.e. at ages 38–57 years. The incidence of fractures per 1000 person-years was 17.2 after menopause and 9.5 before (p < 0.0001). The adjusted fracture risk was elevated in smokers versus non-smokers (OR: 1.5; (95%CI = 1.3–1.9) and in those with chronic health disorders versus the healthy (OR = 1.3; 95% CI 1.1–1.5). Long-term work disability was associated with fractures independently of health disorders (OR = 1.3; 95% CI 1.1–1.6). Anthropometric measures were not associated with the overall fracture risk. Menopause was strongly and linearly related to wrist fracture but not to ankle fracture. A 1 SD increase in body mass index decreased the risk of wrist fracture by 21% (p = 0.0001) but increased that of ankle fracture by 24% (p = 0.002). Smoking was related to ankle fracture (OR = 2.2; 95% CI 1.6–3.2) but not to wrist fracture (OR = 0.9; 95% CI 0.6–1.4). Health disorders were more markedly associated with fractures other than those of the wrist or ankle. Relationships between several risk factors and pre- and perimenopausal fractures vary by type of fracture. This may affect, for example, the comparability of studies with varying fracture profiles.     

Predictors of Completion Axillary Lymph Node Dissection in Patients with Positive Sentinel Lymph Nodes

Background  Completion axillary lymph node dissection (CALND) is routinely performed in breast cancer patients with positive sentinel lymph nodes (SLN). We sought to determine the sociodemographic, pathologic, and therapeutic variables that were associated with CALND. Methods  From 7/1997 to 7/2003, 1,470 patients with invasive breast cancer were SLN positive by intraoperative frozen section or final pathologic exam by hematoxylin–eosin and/or immunohistochemistry (IHC). A comorbidity score was assigned using Adult Comorbidity Evaluation-27 system. Fisher’s exact, Wilcoxon tests, and multivariate logistic regression analysis were used. Results  CALND was performed less often in patients with age ≥ 70 years compared with age < 70 years, moderate or severe comorbidities compared with no or mild, IHC-only positive SLN and breast conservation therapy (BCT compared with mastectomy. Patients who did not undergo CALND were less likely than CALND patients to have grade III disease, lymphovascular invasion multifocal disease, tumor size > 2 cm or to receive adjuvant chemotherapy. However, they were more likely to undergo axillary radiotherapy (RT). On multivariate analysis, age ≥ 70 years [odds ratio (OR) 0.4, 95% confidence interval (CI) 0.26–0.63], IHC-only positive SLN (OR 0.13, 95%CI 0.09–0.19), presence of moderate to severe comorbidities (OR 0.64, 95%CI 0.41–0.99), tumor size ≤ 2 cm (OR 0.44, 95%CI 0.29–0.66), axillary RT (OR 0.39, 95%CI 0.20–0.78), and BCT (OR 0.54, 95%CI 0.37–0.79) were all independently associated with lower odds of CALND. Conclusions  The decision to perform CALND following positive SLN biopsy was multifactorial. Patient factors were a primary determinant for the use of CALND in our study. The decreased use of CALND in the BCT patients probably reflects reliance on the radiotherapy tangents to maintain local control in the axilla.     

Clinicopathological profile and long-term outcome in young adults with gastric cancer: multicenter evaluation of 214 patients

Background and aims Gastric cancer (GC) is usually diagnosed in the sixth and seventh decade of life, although it may also be found in younger patients. The aim of this study was to analyse the potential differences in demographic and clinicopathological factors between the younger (40 years of age and less) and older (above 40 years) population of GC. Materials and methods An electronic database covering all gastric cancer patients treated between 1977 and 1998 at eight university surgical centres was reviewed. Results Of 3,431 patients treated, 214 (6.2%) were 40 years of age or younger. No differences in tumour staging or location could be identified, but the diffuse type lesions were more common in the younger patients (52.6 vs 29.8%). No differences were found in morbidity and mortality rates, except a higher incidence of cardiopulmonary complications in older patients undergoing stomach resection (6.6 vs 12.3%). Median survival of patients after gastrectomy was 24.7 months (95% confidence interval [CI] 22.7–26.6) and was insignificantly longer in younger (30.8 months, 95%CI 21.0–40.5) than older (24.1 months, 95%CI 22.1–26.1) patients (P = 0.056). Median survival for unresectable cases was 5.4 months (95%CI 5.1–5.7) and was comparable in the younger (median 5.5 months, 95%CI 5.2–5.8) and older (median 4.4 months, 95%CI 3.7–5.1) groups. Conclusion GC in young adults demonstrates only minor deviations from the general population with a similar long-term outcome. R. Bandurski, A. Czupryna, A. Dabrowski, M. Drews, M. Fraczek, H. Jaroszewicz-Heigelmann, A. Jeziorski, M. Krawczyk, A. Kubisz, W. Laszewicz, K. Marlicz, J. Swirkowicz, M. Tenderenda, G. Wallner are members of the Polish Gastric Cancer Study Group.     

Alteration in brain natriuretic peptide (BNP) plasma concentration following severe traumatic brain injury

Summary Background. Brain natriuretic peptide (BNP) is a potent natriuretic and vasodilator factor which, by its systemic effects, can decrease cerebral blood flow (CBF). In aneurysmal subarchnoid hemorrhage (aSAH), BNP plasma concentrations were found to be associated with hyponatremia and were progressively elevated in patients who eventually developed delayed ischemic deficit secondary to vasospasm. The purpose of the present study was to evaluate trends in BNP plasma concentrations during the acute phase following severe (traumatic brain injury) TBI. Methods. BNP plasma concentration was evaluated in 30 patients with severe isolated head injury (GCS < 8 on admission) in four time periods after the injury (period 1: days 1–2; period 2: days 4–5; period 3: days 7–8; period 4: days 10–11). All patients were monitored for ICP during the first week after the injury. Findings. The initial BNP plasma concentrations (42 ± 36.9 pg/ml) were 7.3 fold (p < 0.01) higher in TBI patients as compared to the control group (5.78 ± 1.90 pg/ml). BNP plasma concentrations were progressively elevated through days 7–8 after the injury in patients with diffused SAH as compared to patients with mild or no SAH (p < 0.001) and in patients with elevated ICP as compared to patients without elevated ICP (p < 0.001). Furthermore, trends in BNP plasma concentrations were significantly and positively associated with poor outcome. Interpretation. BNP plasma concentrations are elevated shortly after head injury and are continuously elevated during the acute phase in patients with more extensive SAH and in those with elevated ICP, and correlate with poor outcomes. Further studies should be undertaken to evaluate the role of BNP in TBI pathophysiology.     

In vitro analysis of platelet function in acute aneurysmal subarachnoid haemorrhage

Platelet function might play an essential role in the pathogenesis of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid haemorrhage (SAH). Thus, impaired platelet function and disturbed primary haemostasis induced by intake of acetylsalicylic acid (ASA) might influence the rate of DCI. Primary haemostasis and platelet function can be measured with in vitro diagnosis (platelet function analyser test, PFA 100). The aim of this study is to evaluate the rate of DCI, haemorrhagic complications and the neurological outcome. Two groups were compared (patients with regular platelet function versus patients with impaired platelet function). This is a retrospective observational study. An initial cohort of 787 patients with SAH has been treated from January 2005 to September 2012. Seventy-nine patients (10%) with aneurysmal SAH, a history of ASA medication and PFA testing within the first 24 h after aneurysm rupture have been included. The overall rate of DCI in the present study was 43%. In vitro platelet function testing showed pathological primary haemostasis in 69.6%. The DCI rate was higher in patients with regular tested primary haemostasis (p = 0.02, OR = 3.16, 95%CI = [1.19; 8.83]). However, outcome assessment by mGOS did not show a significant difference between the groups. Patients with impaired primary haemostasis did not display a higher rate of haemorrhagic complications. Impairment of primary haemostasis resulting from an impairment of platelet function at an early stage after SAH might lead to a lower rate of DCI. In vitro testing of platelet function might be useful to predict the occurrence of DCI in the course.