Long-term results of anterior resection using the double-stapling technique

PURPOSE: This study was designed to determine the anastomotic leak rate, local recurrence rate, and survival of patients undergoing anterior resection with the double-stapling technique for rectal cancer. METHODS: Between 1981 and 1992, 189 patients underwent a curative (166) or palliative (23) anterior resection using the double-stapling technique. A chart review was performed, and follow-up information was obtained from the patient or family physician. Follow-up was complete in 186 patients (98 percent). RESULTS: There were five (2.6 percent) stapler-related complications, of which two patients required a defunctioning colostomy. Postoperative mortality was 1.6 percent, and clinical leak rate was 7.3 percent. Clinical leak rate was significantly higher in patients with lesions in the lower third (20 percent) compared with those in the middle and upper thirds (9 and 1 percent, respectively;P <0.05). After a mean follow-up of 32±29 months, local recurrence rate was 9.1 percent but was significantly higher in patients more than 65 years old (14 vs.1 percent;P <0.005) and in patients with resection margins less than 2.0 cm (17 vs.5.5 percent;P <0.05). Five-year survival was 78 percent. CONCLUSIONS: Anterior resection performed with the double-stapling technique has an acceptable clinical leak rate, local recurrence rate, and survival rate. However, the clinical leak rate appears to be increased in patients with low tumors and, therefore, a defunctioning colostomy should be considered. Resection margins of more than 2 cm are necessary.Read at the meeting of the Royal College of Physicians and Surgeons of Canada, Vancouver, British Columbia, Canada, September 10 to 13, 1993, and the Tripartite Colorectal Meeting, Sydney, Australia, October 17 to 20, 1993.     

Comparison of myocardial tissue velocities measured by two-dimensional speckle tracking and tissue Doppler imaging

Myocardial velocities have prognostic implications, and transmitral E wave to mitral annular early diastolic tissue velocity ratio (E/Em) is utilized to estimate left ventricular (LV) end-diastolic pressure (EDP). There are no reference values for 2-dimensional (2D) speckle tracking myocardial velocities (S(2D), E(2D), A(2D)), and it is unknown if they are comparable with color tissue Doppler imaging (TDI). Predictors of E/E(2D) ratios are unknown and E/E(2D) has not been validated with LVEDP. The myocardial velocities of 142 subjects were measured by TDI and 2D speckle tracking. Mean E/Em and E/E(2D) were calculated as transmitral E wave to mean 6 basal early diastolic myocardial velocities using TDI and 2D speckle tracking respectively, and compared with LVEDP during catheterizations (n = 20). Mean E(2D) was lower but mean S(2D) and A(2D) were higher than TDI (all p <0.001). When TDI sample volume was tracked throughout the cardiac cycle, this directional difference was no longer apparent with S(2D), E(2D), and A(2D) higher than TDI (all p <0.05). Age, systolic blood pressure, LV ejection fraction, and mean S(2D) were independent correlates of E/E(2D). Receiver-operator characteristic analysis showed E/E(2D) (p = 0.03), not E/Em, identified elevated LVEDP (>/=12 mm Hg). E/E(2D) of 11.6 had 83% sensitivity and 70% specificity to predict elevated LVEDP. In conclusion, TDI and 2D speckle tracking myocardial velocities are not comparable due to angle independency and ability for tissue tracking with the latter. LV systolic function, age, and afterload are independent correlates of E/E(2D). Only E/E(2D) identifies elevated LVEDP, and an E/E(2D) of 11.6 has the optimal sensitivity and specificity.     

Soluble ST2 and Risk of Arrhythmias,Heart Failure,or Death in Patients with Mildly Symptomatic Heart Failure: Results from MADIT-CRT

Soluble ST2 is an established biomarker of heart failure (HF) progression. Data about its prognostic implications in patients with mildly symptomatic HF eligible to receive cardiac resynchronization therapy defibrillators (CRT-D) are limited. In a cohort of 684 patients enrolled in Multicenter Automated Defibrillator Implantation Trial (MADIT)-CRT, levels of soluble ST2 (sST2) were serially assessed at baseline and 1 year (n?=?410). In multivariable-adjusted models, elevated baseline sST2 was associated with an increased risk of death, death or HF, and death or ventricular arrhythmia (VA) even when adjusting for baseline brain natriuretic protein (BNP) levels. In addition, patients with lower baseline sST2 levels had greater risk reduction with CRT-D (p?=?0.006). Serial assessment revealed increased risk of VA and death or VA (HR per 10 % increase in sST2 1.11 (1.04–1.20), p?=?0.004). Among patients with mildly symptomatic HF and eligibility for CRT-D, baseline and serial assessments sST2 may provide important information for risk stratification.     

Usefulness of four echocardiographic risk assessments in predicting 30-day outcome in acute myocardial infarction

One thousand fifty-one consecutive patients who had acute myocardial infarction were classified into 3 risk groups by 4 echocardiographic risk assessments: left ventricular ejection fraction, left ventricular filling pattern, estimated systolic pulmonary artery pressure, and mitral regurgitation, with 30-day mortality rates of 13.7%, 3.8%, and 1%, respectively (p <0.001). Independent echocardiographic and clinical predictors of 30-day mortality included age (10 years, hazard ratio [HR] 1.30, 95% confidence interval [CI] 0.91 to 1.89), female gender (HR 2.12, 95% CI 0.94 to 4.74), Killip's class > or =II on admission (HR 3.09, 95% CI 1.38 to 7.11), group 2 (moderate) risk (HR 2.89, 95% CI 1.07 to 8.56), and group 1 (high) risk (HR 8.16, 95% CI 2.95 to 25.23).     

RACK1 binds to inositol 1,4,5-trisphosphate receptors and mediates Ca2+ release

RACK1 is not a G protein but closely resembles the heterotrimeric Gbeta-subunit. RACK1 serves as a scaffold, linking protein kinase C to its substrates. We demonstrate that RACK1 physiologically binds inositol 1,4,5-trisphosphate receptors and regulates Ca2+ release by enhancing inositol 1,4,5-trisphosphate receptor binding affinity for inositol 1,4,5-trisphosphate. Overexpression of RACK1 or depletion of RACK1 by interference RNA markedly augments or diminishes Ca2+ release, respectively, without affecting Ca2+ entry. These findings establish RACK1 as a physiologic mediator of agonist-induced Ca2+ release.     

The quality of medical care provided to vulnerable older patients with chronic pain

OBJECTIVES: To assess the quality of chronic pain care provided to vulnerable older persons. DESIGN: Observational study evaluating 11 process-of-care quality indicators using medical records and interviews with patients or proxies covering care received from July 1998 through July 1999. SETTING: Two senior managed care plans. PARTICIPANTS: A total of 372 older patients at increased risk of functional decline or death identified by interview of a random sample of community dwellers aged 65 and older enrolled in these managed-care plans. MEASUREMENTS: Percentage of quality indicators satisfied for patients with chronic pain. RESULTS: Fewer than 40% of vulnerable patients reported having been screened for pain over a 2-year period. One hundred twenty-three patients (33%) had medical record documentation of a new episode of chronic pain during a 13-month period, including 18 presentations for headache, 66 for back pain, and 68 for joint pain. Two or more history elements relevant to the presenting pain complaint were documented for 39% of patients, and at least one relevant physical examination element was documented for 68% of patients. Treatment was offered to 86% of patients, but follow-up occurred in only 66%. Eleven of 18 patients prescribed opioids reported being offered a bowel regimen, and 10% of patients prescribed noncyclooxygenase-selective nonsteroidal antiinflammatory medications received appropriate attention to potential gastrointestinal toxicity. CONCLUSION: Chronic pain management in older vulnerable patients is inadequate. Improvement is needed in screening, clinical evaluation, follow-up, and attention to potential toxicities of therapy.     

Functional capacity impairment in patients with coronary artery disease: prevalence, risk factors and prognosis

BACKGROUND: Some patients developing heart failure and functional capacity impairment have no history of myocardial infarction (MI), and stable angina pectoris is their principal clinical manifestation of coronary artery disease (CAD). The present study was aimed to evaluate the outcome of CAD-related functional capacity impairment in patients with and without a history of MI over a 7.7-year follow-up. METHODS: The study sample comprised 14,283 coronary patients aged 45-74 years, screened for participation in the Bezafibrate Infarction Prevention study. The presence of NYHA functional class II was defined as mild functional capacity impairment and the presence of NYHA functional class III-IV was defined as advanced functional capacity impairment. RESULTS: The patients were divided in two groups: (1) those with a history of MI, 10,307 patients, who formed three subgroups: NYHA I 7,551 patients (73.3%); NYHA II 2,176 patients (21.1%); NYHA III + IV 580 patients (5.6%), and (2) those without a history of MI, 3,976 patients, who also formed three subgroups: NYHA I 2,744 patients (69.0%); NYHA 981 patients (24.7%); NYHA III + IV 251 patients (6.3%). Multivariate analysis identified a history of MI as a consistent predictor of increased all-cause and cardiac mortality for patients with NYHA I, II and III + IV subgroups with escalating significance for patients with advanced functional capacity impairment: hazard ratios of 1.55 (95% CI 1.36-1.75), 1.56 (95% CI 1.30-1.86) and 1.72 (95% CI 1.24-2.40) for all-cause and 1.93 (95% CI 1.60-2.33), 1.73 (95% 1.35-2.20) and 3.22 (95% CI 1.87-5.54) for cardiac mortality, respectively. CONCLUSIONS: The prevalence of low functional capacity is similar among coronary patients with and without a history of MI, but their long-term survival differs substantially in favor of the latter. Therefore, two different types of CAD-related advanced functional capacity impairments (post-MI and non-post-MI) can be distinguished.     

Efficacy of fluconazole and itraconazole in the treatment of oral candidiasis in HIV patients

A total of 46 strains of Candida were collected from HIV infected patients, of which 25 strains were isolated from patients with oral candidiasis, and 21 strains were from mouthwash samples of asymptomatic carriers. The most common species isolated was Candida albicans (73.9%), followed by Candida tropicalis (21.7%). In vitro susceptibility of the strains to fluconazole and itraconazole was tested using minimum inhibitory concentration (MIC) studies by agar dilution technique. Out of the 18 strains of C. albicans isolated from mouthwash samples, four were resistant to fluconazole whereas only two were resistant to itraconazole. Out of 16 strains of C. albicans isolated from oral lesions, one was resistant to fluconazole where as all were sensitive to itraconazole. Among the other species of Candida tested, C. tropicalis gave higher MIC values to both drugs than other species such as Candida guillermondii and Candida krusei. In vitro MIC values correlated well with in vivo responses in patients. Hence, itraconazole may be used as an alternative in the treatment of candidiasis, which does not respond to fluconazole therapy.