Clinical incidence of lymphoedema in breast cancer patients in Jönköping County, Sweden

The clinical incidence of lymphoedema of the arm in breast cancer patients was studied before and after general mammography screening in the country of jönköping, Sweden. There was a significant decrease of incidence of lymphoedema from 15% in 1983 to 8% in 1988. Clinical and pathological therapy data have been analysed in relation to lymphoedema. Significant factors contributing to lymphoedema were the number of lymph nodes examined and the number of pathologically positive lymph nodes. A higher proportion of patients receiving post-operative radiotherapy to the axilla developed lymphoedema, compared with those with surgery alone.
A comparison between the two groups is impossible due to the fact that post-operative radiotherapy was prescribed only to patients with pathologically positive lymph nodes.     

Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy in Acute Cholecystitis: Artificial Neural Networks Improve the Prediction of Conversion

Laparoscopic cholecystectomy is now also performed for acute cholecystitis. In the presence of inflammatory conditions, technical difficulties leading to conversion to open cholecystectomy may occur and overshadow the advantages of the laparoscopic approach. Factors associated with these undue events combined with techniques capable of learning from them may help in determining when to completely avoid the laparoscopic procedure. In this study we determined predictors of conversion in acute cholecystitis and tested their predictive ability by means of statistical multivariate analysis and artificial neural networks. Between January 1994 and February 1997, 225 patients underwent laparoscopic cholecystectomy for acute cholecystitis. Preoperative and operative data were prospectively collected on standardized forms. The first 180 laparoscopically approached cases entered the training set, which was learned by both the statistical and the artificial neural networks methods. Conversion was first studied in relation to a set of preoperative data. Prediction models were then fitted by both of these methods. The last 45 operated cases, which remained unknown to the learning systems, served for testing the fitted models. The forward stepwise logistic regression technique, the forward stepwise linear discriminant analysis, and the artificial neural networks method enabled positive prediction of conversion in 0%, 27%, and 100% of the cases, and a negative prediction in 80%, 85.5%, and 97% respectively, in the training set. A positive prediction of conversion in 0%, 25%, and 67% of the cases, and a negative prediction in 82%, 88%, and 94%, respectively, in the untrained, validation set of patients. An artificial neural networks based model provides a practical tool for the prediction of successful laparoscopic cholecystectomies and their conversion. The high degree of certainty of prediction in untrained cases reveals its potential, and justifies, under appropriate conditions, the complete avoidance of laparoscopy and turning directly to open cholecystectomy.     

Spontaneous hematoma of the iliac psoas muscle in chronic myeloid leukemia. A case report

Spontaneous hematoma in the ilio-psoas muscle is an uncommon condition, usually observed as a complication of anticoagulation or hemophilia. Clinically, the onset is marked by violent pain in the territory of femoral nerve and/or psoitis. The diagnosis is confirmed by echography or CT-scan. The most serious complications are loss of self-sufficiency and neuro-muscular after-effect. Surgery is recommended in patients with neurological suffering, followed by early physiotherapy. We report the case of a 42-year-old man, with an ilio-psoas muscle hematoma, revealing chronic myeloid leukemia, without any hemostasis disorder.     

Destructive osteoblastoma of the cervical spine with complete neurologic recovery

STUDY DESIGN: Case report. OBJECTIVE: To describe a patient with a large tumor lesion of the 6th vertebrae affecting surrounding soft tissue, and symptoms of cord compression. Histologic diagnosis indicated a destructive osteoblastoma following dorsal and anterior resection and internal fixation. SETTING: University Hospital, Germany. METHODS: A 23-year old male patient was admitted with a 2-month history of increasing upper extremity weakness and pain. X-ray and MRI indicated massive involvement of the anterior and posterior elements of the 6th vertebrae with a large soft tissue mass. Following emergency decompression and dorsal stabilization, the pathologic investigation revealed a destructive osteoblastoma. Subsequent dorsal and anterior resection with internal fixation were performed. RESULTS: The patient initially presented with symptoms of beginning paraplegia of C6/7. According to the neurologic classification of spinal cord injury, motor function score was 56 and sensory function score 83. After emergency dorsal decompression and internal fixation with Luque-Instrumentation he showed increasing neurological recovery. Complete neurological recovery was achieved at 2 and 12-months postoperatively, following secondary dorsal and anterior resection of the tumor and internal fixation with bone cement (PalacosR) and Harms-cage. Radiologic signs of local recurrence were identified 1 year postoperatively. CONCLUSION: Osteoblastoma of the cervical spine is rare. Patients often present with severe neurological symptoms due to significant tumor mass. Complete resection is necessary to regain full recovery, to prevent recurrence and, in some cases, malignant transformation.     

Spline functions in convolutional modeling of verapamil bioavailability and bioequivalence. II: study in healthy volunteers.

The pharmacokinetics of a new verapamil retard tablet formulation have been investigated in a randomized cross-over bioequivalence study on 12 healthy subjects. The drug was given orally at a single new or standard retard tablet dose of 240mg and at a single intravenous dose of 5mg. Plasma verapamil concentrations were determined by HPLC. New retard tablets produced peak plasma verapamil concentrations of 81.34+/-5.69microg/l, time to peak plasma concentrations of 4.91+/-0.89h and an AUC (0-24h) of 1291+/-103.4h x microg/l, with a terminal phase half-life of 55.1+/-14.9h. After intravenous administration verapamil exhibited biphasic elimination kinetics with a terminal plasma half-life of 2.36+/-0.42h and systemic clearance of 34.32+/-5.81 l/h. Bioavailability of the new peroral retard formulation ranged from 19.49+/-4.41% to 67.69+/-11.70%. Absorption rates and amounts were evaluated by means of the spline-convolutional method. Input rates for the new verapamil retard formulation ranged from 0.77+/-0.20mg/h to 5.57+/-1.58mg/h. The cumulative amount of verapamil input was 39.17+/-9.71% for the new retard tablets. All pharmacokinetic parameters for the new verapamil retard tablet formulation, were in reasonable agreement with the data obtained on already registered verapamil retard formulations, indicating their bioequivalence.     

Observing decision‐making in the general practice consultation: who makes which decisions?

OBJECTIVE: To investigate opportunities for, and types of decision making in the general practice (primary care) consultation, and examine differences in skills of those doctors who are successful at meeting their patients' preferences and those who are less successful. DESIGN: Observation study of doctor-patient consultations in general practice. PARTICIPANTS: Patients attending for routine appointments in 12 general practice surgeries across Oxfordshire. METHODS: A total of 212 doctor-patient consultations were video-recorded. The patients involved completed a questionnaire to elicit their perceptions of how decisions were made. The video-taped recordings were coded with a new instrument, the Evidence Based Patient Choice Instrument (EBPCI), to classify the number and type of decision-making opportunities arising during each consultation. A total of 149 recordings were coded using the Oxbridge Rating Scale to assess the doctors' consultation styles. RESULTS: There was a range of decision-making opportunities in addition to those involving medical treatment. With the exception of 'fitness for work', decisions were generally 'doctor led'. There was only moderate agreement between patient perceptions of their level of involvement in decision making and the objective ratings using the EBPCI. There was wide variation in the ability of doctors to meet their patients' preferences for involvement. CONCLUSIONS: There are many decisions made in primary care consultations, in addition to those about medical treatments, in which patients could be involved to a greater extent than they currently are. Some doctors are significantly better than others at meeting different patients' preferences for their decision-making role. Patients' perceptions of shared decision making appears to be influenced by the doctors' general consultation skills.     

Effects of back extensor strength training versus balance training on postural control

PURPOSE: Aim of this study was to investigate effects of 1) regular back extensor strength training as opposed to balance training, and 2) the influence of the sequence of both training types on postural control, force, and muscle efficiency. METHODS: Twenty-six young, healthy subjects were investigated at baseline, 1 month and 2 months later. At each examination, subjects completed a posturographic, balance skill, and isometric maximum voluntary (MVC) back extension testing, including surface electromyographic (SEMG) recordings. After baseline evaluation, subjects were assigned to either daily strength training or balance training. After 1 month, the type of training was exchanged between groups. RESULTS: After 1 month, back extensor strengthening led to decreased postural stability on hard surface, whereas there were no change after balance skill training. Analysis of the low- and high-frequency components of the sway signal revealed that strength training increased control efforts as indicated by an increased high-frequency component in order to maintain postural stability and unchanged low-frequency component. Balance skill training, however, increased postural stability as indicated by a decreased low-frequency component. The control effort remained unchanged. After completing either sequence of training, all postural parameters remained unchanged in both groups. Muscular efficiency as measured by SEMG root mean square during a standardized motor skill task revealed improved muscle economy regardless of the type of training. Back extension torque improved in both groups. CONCLUSION: To avoid reduction of postural stability in rehabilitation processes, we recommend to include antagonist muscles in a comprehensive strength training regime or balance skill training.     

Laparoscopic cholecystectomy for acute cholecystitis: Can the need for conversion and the probability of complications be predicted?

Background: Laparoscopic cholecystectomy (LC) in acute cholecystitis is associated with a relatively high rate of conversion to an open procedure as well as a high rate of complications. The aim of this study was to analyze prospectively whether the need to convert and the probability of complications is predictable. Methods: A total of 215 patients undergoing LC for acute cholecystitis were studied prospectively by analyzing the data accumulated in the process of investigation and treatment. Factors associated with conversion and complications were assessed to determine their predictive power. Results: Conversion was indicated in 44 patients (20.5%), and complications occurred in 36 patients (17%). Male gender and age >60 years were associated with conversion, but these factors had no sensitivity and no positive predictive value. The same factors, together with a disease duration of >96 h, a nonpalpable gallbladder, a white blood count (WBC) of >18,000/cc³, and advanced cholecystitis, predicted conversion with a sensitivity of 74%, a specificity of 86%, a positive predictive value of ∼40%, and a negative predictive value of 96%. However, these data became available only when LC was underway. Male gender and a temperature of >38°C were associated with complications, but these factors had no sensitivity and no positive predictive value. Progression along the stages of admission and therapy did not add predictive factors or improve the predictive characteristics. Male gender, abdominal scar, bilirubin >1 mg%, advanced cholecystitis, and conversion to open cholecystectomy were associated with infectious complications. Their sensitivity and positive predictive value remained 0 despite progression along the stages of admission and therapy. Conclusion: Although certain preoperative factors are associated with the need to convert a LC for acute cholecystitis, they have limited predictive power. Factors with higher predictive power are obtained only during LC. The need to convert can only be established during an attempt at LC. Preoperative and operative factors associated with total and infectious complications have no predictive power. Received: 14 July 1999/Accepted: 21 December 1999/Online publication: 10 July 2000     

The Combitube in elective surgery: a report of 200 cases

BACKGROUND: The Combitube has proved to be a valuable device for securing the airway in cases of difficult intubation. This study investigated the effectiveness of the Combitube in elective surgery during both mechanical and spontaneous ventilation. METHODS: Two hundred patients classified as American Society of Anesthesiologists physical status I and II, with normal airways, scheduled for elective surgery were randomly allocated into two groups: nonparalyzed, spontaneously breathing (n = 100); or paralyzed, mechanically ventilated (n = 100). After induction of general anesthesia and insertion of the Combitube, oxygen saturation, end-tidal carbon dioxide and isoflurane concentration, systolic and diastolic blood pressure and heart rate, as well as breath-by-breath spirometry data were obtained every 5 min. RESULTS: In 97% of patients, it was possible to maintain oxygenation, ventilation, and respiratory mechanics, as well as hemodynamic stability during either mechanical or spontaneous ventilation for the entire duration of surgery. The duration of surgery was between 15 and 155 min. CONCLUSIONS: The results of this study suggest that the Combitube is an effective and safe airway device for continued management of the airway in 97% of elective surgery cases.