Prolonged survival in patients with resected non-small cell lung cancer and single-level N2 disease

OBJECTIVES: To test the hypothesis that patients with non-small cell lung cancer and single-level N2 metastases constitute a favorable subgroup of patients with mediastinal metastases, we analyzed the results of the Eastern Cooperative Oncology Group 3590 (a randomized prospective trial of adjuvant therapy in patients with resected stages II and IIIa non-small cell lung cancer) by site of primary tumor and pattern of lymph node metastases. METHODS: Accurate staging was ensured by mandating either systematic sampling or complete dissection of the ipsilateral mediastinal lymph nodes. The overall survival of patients with left lung non-small cell lung cancer and metastases in only 1 of lymph node levels 5, 6, or 7 and right lung non-small cell lung cancer with metastases in only 1 of levels 4 or 7 was compared with that of patients with N1 disease originating in the same lobe. RESULTS: The median survival of the 172 patients with single-level N2 disease was 35 months (95% confidence interval: 27-40 months) versus 65 months (95% confidence interval: 45-84 months) for the 150 patients with N1 disease (median follow-up 84 months, P =.01). However, among patients with left upper lobe tumors, survival was not significantly different between patients with N1 disease and patients with single-level N2 disease (49 vs 51 months, P =.63). The median survival of the 71 patients with single-level N2 metastases without concomitant N1 disease (skip metastases) was 59 months (95% confidence interval: 36-107 months) versus 26 months (95% confidence interval: 16-36 months) for the 145 patients with both N1 and N2 metastases (P =.001). CONCLUSIONS: Survival of patients with left upper lobe non-small cell lung cancer and metastases to single-level N2 lymph nodes is not significantly different from that of patients with N1 disease. The presence of isolate N2 skip metastases is associated with improved survival when compared with patients with both N1 and N2 disease. Survival should be reported by the lobe of primary tumor and metastatic pattern to guide future clinical trial development, treatment strategies, and revisions of the TNM staging system.     

Divergent effect of glucagon antibodies on arginine and glucose-stimulated insulin secretion in the rat

Summary The effects of glucose and arginine on insulin secretion in the presence of glucagon antibodies were investigated in rats in vivo. In contrast to controls, animals given glucagon antibodies showed an inhibition of arginine-stimulated (p < 0.001), but not glucose-stimulated, insulin secretion. That these effects were not due to incomplete neutralisation of endogenous glucagon is evidenced by the presence of large antibody excess throughout the duration of the experiments. Both the glucagonotropic effect of arginine (319 ± 60ng/l, p < 0.01) and the insulinotropic effect of exogenous glucagon (8.3 ± 0.8 g/l, p < 0.001) were demonstrable under our experimental conditions in the absence of exogenous glucagon antibodies. These observations suggest that different mechanisms are involved in the stimulation of insulin release by arginine and by glucose, and that glucagon may play an important physiological role in the mediation and regulation of insulin secretion by secretogogues, such as arginine.     

Vitamin A therapy in patients with Crohn's disease

Vitamin A therapy has been claimed in isolated reports to be of benefit to patients with Crohn's disease. To investigate this further, 86 patients were entered into a long-term double-blind study of vitamin A, 50,000 U twice daily, as compared with placebo. After a mean of 14.1 mo of treatment there was no significant difference between the groups as measured by a variety of activity indices (including the National Cooperative Crohn's Disease Activity Index), the number of acute attacks, and the surgical rate. No toxic effects of vitamin A were observed during the study. In this study vitamin A has not been shown to be of benefit to patients with Crohn's disease who are in remission.     

Cost-based analysis of the treatment of mandibular fractures in a tertiary care center

BACKGROUND: The objective of this study was to assess the cost effectiveness of alternative treatment algorithms for the management of isolated mandibular fractures. METHODS: This is an institutional review board-approved retrospective study consisting of a chart review of 25 patients who underwent operative repair of an isolated mandible fracture between July 1, 1999, and June 30, 2000. Patients were stratified into two groups: patients who were immediately admitted to the hospital from the emergency department (ED) versus patients who were discharged from the ED and who returned for elective scheduled operative repair. Patients' total hospital charges were compared on the basis of operating room (OR) time, operative materials, and hospital charges. RESULTS: Seventeen of the study patients were directly admitted from the ED, and eight underwent elective scheduled operative repair. Of the patients directly admitted from the ED, the mean age was 34.9 years (range, 19-57 years), and the study population consisted of 16 men and 1 woman. This group had a mean OR time of 161 minutes, a mean OR time charge of $1,978.66, a mean OR supply charge of 1,049.43 US dollars, a mean hospital floor charge of 5,041.02 US dollars, and an average hospital stay of 2.82 days. The treatment group of patients undergoing scheduled operative repair (n = 8) had a mean age of 30.3 years (range, 19-49 years), and all were men. This second treatment group had a mean OR time of 167.1 minutes, a mean OR time charge of 2,162.03 US dollars, a mean OR supply charge of 871.00 US dollars, a mean hospital floor charge of 2,759.38 US dollars, and a mean hospital stay of 0.88 days. Comparison of the two study groups demonstrated operative charges were made on the basis of time and materials and were shown to have no statistically significant difference (p = 0.753 and p = 0.289, respectively). Comparison of hospital charges revealed that patients admitted directly from the ED had a mean charge 2,276.70 US dollars higher (p = 0.019) and stayed 1.95 days longer in the hospital than patients discharged from the emergency department who returned for elective scheduled repair. There were two complications in the study patients; both occurred in the group admitted directly from the emergency room. CONCLUSION: The results of this study indicate that the most cost-effective management of an isolated mandibular fracture is initial evaluation in the ED with elective interval operative repair. This management protocol is, of course, only applicable if the patient is clinically stable and has no other injuries or comorbidities necessitating in-hospital observation.     

Report of a National Conference on Donation after Cardiac Death

A national conference on organ donation after cardiac death (DCD) was convened to expand the practice of DCD in the continuum of quality end-of-life care. This national conference affirmed the ethical propriety of DCD as not violating the dead donor rule. Further, by new developments not previously reported, the conference resolved controversy regarding the period of circulatory cessation that determines death and allows administration of pre-recovery pharmacologic agents, it established conditions of DCD eligibility, it presented current data regarding the successful transplantation of organs from DCD, it proposed a new framework of data reporting regarding ischemic events, it made specific recommendations to agencies and organizations to remove barriers to DCD, it brought guidance regarding organ allocation and the process of informed consent and it set an action plan to address media issues. When a consensual decision is made to withdraw life support by the attending physician and patient or by the attending physician and a family member or surrogate (particularly in an intensive care unit), a routine opportunity for DCD should be available to honor the deceased donor's wishes in every donor service area (DSA) of the United States.     

A Prospective Randomized Clinical Trial in Total Hip Arthroplasty—Comparing Early Results Between the Direct Anterior Approach and the Posterior Approach

Background

We report a prospective randomized study comparing early clinical results between the direct anterior approach (DAA) and posterior approach (PA) in primary hip arthroplasty.

Inpatient Mortality Analysis of Paraesophageal Hernia Repair in Octogenarians

Introduction

Paraesophageal hernia repair is often performed in an elderly population. Few studies have evaluated perioperative mortality in this group. We identified predictors of inpatient mortality using a nationally representative sample.

Methods

Patients ≥80 years old undergoing transabdominal paraesophageal hernia repair were identified in the 2005 Nationwide Inpatient Sample. Congenital diaphragmatic defects and traumatic injuries were excluded.

Results

One thousand five discharges (73% female) with mean age 84.7 met inclusion criteria. Mean length of stay was 10.1 days (95% confidence interval 8.9–11.3) with a mortality of 8.2%. Non-elective repair was performed in 43%. For these patients, mortality and mean length of stay (16%; 14.3 days) were increased compared to elective repair (2.5%; 7.0 days, p?<?0.05). Non-elective repair was the sole predictor of inpatient mortality in adjusted analyses (odds ratio 7.1, 95% confidence interval 1.9–26.3, p?<?0.05).

Conclusion

Non-elective repair was associated with a six to sevenfold increase in mortality and longer length of stay. Earlier elective repair of paraesophageal hernia may reduce mortality.