Beneficial impact of a clinical care pathway in patients with testicular cancer undergoing retroperitoneal lymph node dissection

PURPOSE: Since 1997, we have used a clinical collaborative care pathway for patients undergoing retroperitoneal lymph node dissection. We examined its impact on perioperative care and outcome. MATERIALS AND METHODS: We examined the records of all patients with germ cell carcinoma who underwent retroperitoneal lymph node dissection from July 1990 to July 2001. Variables examined included clinical/pathological stage, hospital stay, postoperative care and the complication rate. RESULTS: A total of 118 patients underwent retroperitoneal lymph node dissection for germ cell carcinoma during this period, including 46 (39%) before pathway implementation in 1997 and 72 patients (61%) after pathway implementation. Of the 118 patients 40 (34%) underwent the procedure after chemotherapy. This rate remained fairly constant in the period before and after pathway initiation (31% and 36%, respectively). After pathway implementation fewer patients received a nasogastric tube (94% versus 5%, p <0.001) and had complications (26% versus 16%, p = 0.036). Mean hospital stay decreased after pathway implementation in all primary and post-chemotherapy retroperitoneal lymph node dissection cases (4.2 versus 6.4 days, p <0.005). Although patients who underwent the procedure after chemotherapy were more likely to have complications than those who underwent a primary procedure, the difference was not statistically significant (p = 0.09). CONCLUSIONS: Our collaborative clinical care pathway safely and efficiently outlines routine postoperative care and significantly decreased hospital stay.     

Therapy of the pilonidal sinus--Primary wound closure or open wound after excision

The postoperative follow up of 177 operations in 162 patients with pilonidal sinus was investigated. After excision of the sinus a primary wound closure was performed in 80 cases; in 83 cases the wound was left open. After primary wound closure 40 % of the patients showed a primary healing of the wound. Although the remaining 60 % of the wounds healed secondarily the patients were not disabled longer and did not demonstrate more frequently recurrences than those with open wound management. As a consequence we recommend a primary wound closure after excision of a pilonidal sinus.     

Is Refractory Epilepsy Preventable?

About a third of the patients diagnosed with epilepsy will not be fully controlled with antiepileptic drugs (AEDs), and many of them will have frequent and disabling seizures. These patients will undergo multiple drug trials, most often without complete seizure remission. Moreover, refractory epilepsy is associated with increased morbidity (from seizures and medications), social isolation, unemployment, and overall reduced quality of life. There is evidence that refractory epilepsy can be a progressive disorder, which, if controlled early, might never develop into a full syndrome with all of its associated sequelae. The difficulty lies in identifying at an early stage patients who are likely to progress to intractability. No currently known markers enable clinicians to make this identification with confidence. Advances in pharmacogenomics and our understanding of pharmacologic responsiveness in epilepsy may change this situation. Even now, we are able to identify many patients with a poor prognosis earlier than before, particularly in the pediatric population, in which syndromic classification may provide an approach to predict intractability. The early initiation of aggressive therapy may improve outcome and overall quality of life.     

Encephalopathy and stroke after coronary artery bypass grafting: incidence,consequences, and prediction

BACKGROUND: In contrast to perioperative stroke, much less attention has been paid to those with evidence of diffuse brain encephalopathy, presenting as delirium, confusion, coma, and seizures in the immediate postoperative period. OBJECTIVE: To determine the incidence, consequences, and predictive factors for encephalopathy and stroke following coronary artery bypass grafting. METHODS: In a prospective evaluation of 2711 patients operated on between January 1, 1997, and December 31, 2000, preoperative risk factors were obtained before surgery and postoperative outcomes, encephalopathy and stroke, were determined on a daily basis. All strokes were confirmed by neurologic consultation and, in most instances, by imaging. Logistic regression analyses were performed to determine risk factors for these outcomes. RESULTS: The incidence of encephalopathy was 6.9% and of stroke, 2.7%. For patients without either of these outcomes, the average length of stay in the hospital was 6.6 days and the mortality was 1.4%. In contrast, patients with encephalopathy had a length of stay of 15.2 days and a mortality of 7.5%, and those with stroke, a length of stay of 17.5 days and a mortality of 22.0%. Predictive models were developed for encephalopathy involving 5 preoperative factors (age, past stroke, carotid bruit, hypertension, and diabetes) and 1 perioperative factor (time on cardiopulmonary bypass). The model for stroke involved only 3 preoperative risk factors (past stroke, hypertension, and diabetes). CONCLUSIONS: Encephalopathy or stroke is associated with significant increases in length of stay and mortality after coronary artery bypass grafting. Patients at higher risk for these outcomes can be identified before surgery.     

Ictal urinary urge indicates seizure onset in the nondominant temporal lobe

ARTICLE ABSTRACT: The authors describe six patients with medically refractory temporal lobe epilepsy whose seizures were characterized by an aura of ictal urinary urge. All seizures originated in the nondominant temporal lobe as evidenced from interictal spikes, ictal EEG, and MRI. Ictal SPECT, which was obtained in two patients, showed a hyperperfusion of the insular cortex, indicating a critical role of the insula for the generation of this symptom. Ictal urinary urge represents a new lateralizing sign indicating a seizure onset in the nondominant temporal lobe.     

Cluster analysis of clinical seizure semiology of psychogenic nonepileptic seizures

PURPOSE: To develop an objective classification of psychogenic nonepileptic seizures (NES) based on cluster analysis of clinical seizure semiology. METHODS: We studied the clinical seizure semiology in 27 patients with psychogenic NES documented by prolonged video-EEG monitoring. We analyzed the following clinical symptoms: clonic and hypermotor movements as well as trembling of the upper and/or lower extremities, pelvic thrusting, head movements, tonic posturing backward of the head, and falling. We used cluster analysis to identify symptoms occurring together in a systematic way and thus tried to achieve a clinical classification of psychogenic NES. RESULTS: We could identify three symptom clusters. Cluster 1 was characterized by clonic and hypermotor movements of the extremities, pelvic thrusting, head movements, and tonic posturing of the head, and therefore was named "psychogenic motor seizures." Cluster 2 comprised trembling of the upper and lower extremities and was termed "psychogenic minor motor or trembling seizures." Cluster 3 consisted of falling to the floor as the only symptom and was referred to as "psychogenic atonic seizures." CONCLUSIONS: Our study represents the first study to analyze the clinical semiology of psychogenic NES by cluster analysis, which should be useful for an objective classification of psychogenic NES. This classification should allow both a better characterization of psychogenic NES and an easier differential diagnosis against specific epileptic seizures.     

Erweiterte Diagnostische Laparoskopie (EDL)

Zusammenfassung   Grundlagen: Die sogenannte erweiterte diagnostische Laparoskopie (EDL) ist ein minimal-invasiver chirurgischer Eingriff, der die Exploration des gesamten Bauchraumes erm?glicht und somit das pr?therapeutische Staging bei malignen Erkrankungen erheblich verbessern kann. Methodik: Die EDL umfa?t die visuelle Inspektion mit gezielter Pr?paration aller relevanten Areale, die laparoskopische Ultraschalldiagnostik und die Gewinnung von Zytologie-Biopsiematerial. Ergebnisse: Beim Magenkarzinom konnten in einer eigenen Studie durch die EDL in 40,5 % der F?lle therapierelevante Zusatzinformationen gewonnen werden. Eine ?hnliche Bedeutung k?nnte die EDL auch für die Diagnostik des Adenokarzinoms der Speiser?hre gewinnen, m?glicherweise auch bei Malignomen von Leber und Pankreas. Schlu?folgerungen: Das Komplikationsrisiko der EDL ist gering; die Gefahr einer Tumorzellverschleppung durch den diagnostischen Eingriff ist jedoch nicht ganz auszuschlie?en, so da? die Indikation nur unter der Voraussetzung einer therapeutischen Konsequenz gestellt werden sollte.      

Stroke after cardiac surgery: short- and long-term outcomes

BACKGROUND: Stroke remains a devastating complication of cardiac surgery, but stroke prevention remains elusive. Evaluation of early and long-term clinical outcomes and brain-imaging findings may provide insight into stroke prognosis, etiology, and prevention. METHODS: Five thousand nine hundred seventy-one cardiac surgery patients were prospectively studied for clinical evidence of stroke. Stroke and nonstroke patients were compared by early outcomes. Data collected for stroke patients included brain imaging results, long-term functional status, and survival. Outcome predictors were then determined. RESULTS: Stroke was diagnosed in 214 (3.6%) patients. Brain imaging demonstrated acute infarction in 72%; embolic in 83%, and watershed in 24%. Survival for stroke patients was 67% at 1 year and 47% at 5 years. Independent predictors of survival were cerebral infarct type, creatinine elevation, cardiopulmonary bypass time, preoperative intensive care days, postoperative awakening time, and postoperative intensive care days. Long-term disability was moderate to severe in 69%. CONCLUSIONS: Stroke after cardiac surgery has profound repercussions that are independently related to infarct type and clinical factors. These data are essential for clinical decision making and prognosis determination.     

Odd-numbered long-chain fatty acids in propionic acidaemia

In patients with propionic acidaemia (PA), the increased intracellular concentration of propionyl-CoA leads to a relative abundance of odd-numbered long-chain fatty acids (OLCFAs) in body lipids. We investigated the relative amount of OLCFA in erythrocyte membrane lipids over a period of 1–8 years in five patients with early onset PA and present their clinical outcome. After extraction from erythrocyte membrane lipids and esterification, fatty acids were analysed by capillary column gas chromatography. The sum of the OLCFA 15- and 17- carbon saturated and 17-carbon monounsaturated fatty acids (C15:0, C17:0, C17:1) was calculated and expressed as a percentage of the total C14-C22 fatty acids in the sample. Three patients (pccBC-complementation group) presented with a stable clinical course and showed OLCFA values usually below 1.9% (median % ± SD: 1.4 ± 0.5, 1.6 ± 0.5, 1.8 ± 0.5). Two patients (pccA-complementation group) had a more severe course of the disease and showed higher medians and a broader range of OLCFA levels (2.2 ± 1.2 and 2.2 ± 0.8). Conclusion Our study shows that odd-numbered long-chain fatty acid concentrations are increased in patients with propionic acidaemia and are higher in those with a more severe clinical course. The value of odd-numbered long-chain fatty acids in the assessment of the phenotypic severity and in the management of propionic acidaemia remains to be proven in a prospective long-term study with more patients of differing phenotype. Received: 15 January 1999 and in revised forms: 18 February 1999, 4 May 1999, 21 June 1999 and 13 July 1999 / Accepted: 14 July 1999