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.     

Carotid endarterectomy in patients with chronic renal insufficiency: a recent series of 184 cases

BACKGROUND: The published results of carotid endarterectomy (CEA) in chronic renal insufficiency (CRI) patients are contradictory, mostly because of the relatively small number of patients in these studies. To better assess the neurologic complications and mortality, we reviewed a recent and substantially larger series of CRI patients who underwent CEAs. METHODS: From March 2000 to March 2003, 675 consecutive primary CEAs were performed in 609 patients (346 men, 57%) under general anesthesia. Asymptomatic carotid artery stenosis accounted for 71% of cases. CRI (serum creatinine level > or = 1.5 mg/dL) was detected in 166 patients (27%) who underwent 184 CEAs. The remaining 443 patients (73%) had 491 CEAs. RESULTS: Patients with CRI were different in age (76 +/- 8 years vs 72 +/- 9 years, P < .001), male gender (73% vs 51%, P < .001), coronary artery disease (50% vs 28%, P < .001), and diabetes mellitus incidence (38% vs 27%, P < .02). No significant difference in stroke rates was observed between the CRI patients and the control group (1.2% vs 0.5%). The mortality rate for CRI patients was 3%, whereas it was 0% for the control group ( P < .002). The 143 CRI patients with serum creatinine levels from 1.5 to 2.9 mg/dL had a 0.7% mortality rate, whereas it was 17% for 23 patients with serum creatinine levels of 3 mg/dL or more ( P < .001). The stroke rate for the former group was 0.7% and 4.3% for the latter group (NS). Asymptomatic (16) and symptomatic (7) patients with serum creatinine levels of 3 mg/dL or more had mortality rates of 13% and 28%, respectively, with P = .6. CONCLUSION: The high mortality rate observed in patients with serum creatinine levels of 3 mg/dL or more after CEA calls for a nonoperative approach in the management of asymptomatic patients.     

Quantitative motion analysis in patients with hallux rigidus before and after cheilectomy

The purpose of this study was to quantify changes in temporal‐spatial parameters and multisegmental foot/ankle kinematics in a group of patients with hallux rigidus following cheilectomy. Three‐dimensional motion analysis was conducted using a 15‐camera Vicon Motion Analysis System on a population of 19 patients who underwent cheilectomy for hallux rigidus. Data were analyzed using the four‐segment Milwaukee Foot Model. Preoperative and postoperative tests were compared using paired parametric methods. Results showed significant improvements in walking speed, cadence, stride length, and stance/swing ratio from preoperative to postoperative state. Altered hallux and forefoot positions preoperatively showed shifts towards normal after cheilectomy. Although clinical improvements in pain and passive range of motion were statistically significant, similar improvements in range of motion were not demonstrated during ambulatory testing. The results of this study provide insight into ambulatory improvements following cheilectomy, and suggest further study of the rehabilitation process to improve the recovery of functional range of motion. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27:128–134, 2009     

Revascularization of the Posterior Circulation

The primary objective of revascularization procedures in the posterior circulation is the prevention of vertebrobasilar ischemic stroke. Specific anatomical and neurophysiologic characteristics such as posterior communicating artery size affect the susceptibility to ischemia. Current indications for revascularization include symptomatic vertebrobasilar ischemia refractory to medical therapy and ischemia caused by parent vessel occlusion as treatment for complex aneurysms. Treatment options include endovascular angioplasty and stenting, surgical endarterectomy, arterial reimplantation, extracranial-to-intracranial anastomosis, and indirect bypasses. Pretreatment studies including cerebral blood flow measurements with assessment of hemodynamic reserve can affect treatment decisions. Careful blood pressure regulation, neurophysiologic monitoring, and neuroprotective measures such as mild brain hypothermia can help minimize the risks of intervention. Microscope, microinstruments and intraoperative Doppler are routinely used. The superficial temporal artery, occipital artery, and external carotid artery can be used to augment blood flow to the superior cerebellar artery, posterior cerebral artery, posterior inferior cerebellar artery, or anterior inferior cerebellar artery. Interposition venous or arterial grafts can be used to increase length. Several published series report improvement or relief of symptoms in 60 to 100% of patients with a reduction of risk of future stroke and low complication rates.     

A randomized trial of ultrasound-guided brachial plexus anaesthesia in upper limb surgery

Ultrasound guidance allows real-time identification of relevant anatomy and needle position when performing brachial plexus regional anaesthesia. The aim of this investigation was to determine whether the use of surface ultrasound could improve the quality of brachial plexus anaesthesia for upper limb surgery. Forty patients were randomized to either conventional "landmark-based" plexus anaesthesia, or to an ultrasound-guided approach using a 13 mHz linear array transducer Both interscalene and axillary techniques were used. The use of ultrasound significantly improved the onset and completeness of sensory (P=0.011) and motor (P=0.002) block. Ultrasound guidance also significantly reduced (P=0.012) the incidence of paraesthesia during the performance of the blocks. Ultrasound guidance increases the quality of sensory and motor blockade in brachial plexus regional anaesthesia, and by reducing the incidence of paraesthesia during performance of the blocks, may confer greater safety.     

Prospective randomized double-blind placebo-controlled trial of postoperative elastomeric pain pump devices used after laparoscopic ventral hernia repair

Background  

The laparoscopic repair of ventral hernias can result in significant postoperative pain necessitating a prolonged hospital stay, increased narcotic use, and patient dissatisfaction. Elastomeric pain pump devices with local analgesics may significantly reduce postoperative discomfort after laparoscopic ventral hernia repair. This prospective randomized, double-blind, placebo-controlled study evaluated the effect of local anesthetic continuously infused with an elastomeric pain pump device to reduce postoperative pain.     

Long-term follow-up for superior vena cava filter placement

The short-term effectiveness and safety placement of superior vena cava (SVC) filter in the treatment of upper extremity deep venous thrombosis in patients with contraindication to anticoagulation have been well documented. However, as opposed to the numerous reported experiences with inferior vena cava filter placement and its complications, there has been no documented long-term follow-up on SVC filter placement. We, therefore, reviewed our experience with SVC filter placement. A retrospective review was performed of the 154 cases of patients who underwent SVC filter placement between January 1994 and August 2005 at our institution. Seven additional patients had unsuccessful SVC filter placement due to widespread deep venous thrombosis. The data were evaluated for both insertion complications (pneumothorax, hemorrhage, filter misplacement) and long-term complications (pulmonary embolism, migration, caval occlusion). The follow-up included review of serial chest radiographs to evaluate for filter migration in patients who lived at least 60 days after filter insertion and had chest radiography performed (n = 40), patients' charts, clinic visits, and telephone contacts, hospital databases, city death records, and national databases. There were 69 males and 85 females with a mean age of 73.6 years (range, 16-96 years; +/-15.3 [SD] years). Follow-up ranged from 1 day to 3750 days (256.3 +/- 576 days [mean +/- SD]) and 5 patients were lost to follow-up. Of the 154 patients, 58 survived longer than 60 days with mean follow-up of 628.4 days. All SVC filters (TrapEase, n = 38; Greenfield, n = 116) were successfully deployed in the 154 patients. During the follow-up, 114 (74.0% mortality) of the patients died of chronic illness or from cancer complications. There were three cases of pericardial tamponade (1.9%), and one case of misplaced filter in innominate vein. There were no known cases of symptomatic pulmonary embolism, caval occlusion, pneumothorax, or filter migration. SVC filter placement is associated with a low incidence of complications with long-term follow-up. These data help to reaffirm the safety and effectiveness of SVC filter placement. However, SVC perforation in young males remains a significant issue.     

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.     

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.