Predictors of morbidity following free flap reconstruction for cancer of the head and neck

BACKGROUND: Free flap reconstruction of head and neck cancer defects is complex with many factors that influence perioperative complications. The aim was to determine if there was an association between perioperative variables and postoperative outcome. METHODS: We evaluated 185 patients undergoing free flap reconstruction following ablation of head and neck cancer between 1999 and 2001. Demographic, laboratory, surgical and anesthetic variables were analyzed using univariate and multivariable techniques. RESULTS: Ninety-eight patients (53%) developed complications, of which 74 were considered major, giving a major morbidity rate of 40%. Predictors of major complications were increasing patient age, ASA class, and smoking. Predictors of medical complications were ASA class, smoking, age and crystalloid replacement. Predictors of surgical complications were tracheostomy, preoperative hemoglobin, and preoperative radiotherapy. CONCLUSION: Patient age, comorbidity, smoking, preoperative hemoglobin, and perioperative fluid management are potential predictors of postoperative complications following free flap reconstruction for cancer of the head and neck.     

A new clinical taxonomy for rating change in functional activities of patients with angina pectoris.

The treatment of patients with angina pectoris is commonly evaluated according to such indexes as the frequency of anginal attacks, quantity of supplemental nitroglycerin, and exercise performance in an ergometric laboratory test. None of these indexes demonstrates the clinical change in ordinary functional limitations that may have been the major reason why a patient sought medical help. The New York Heart Association ratings of functional capacity do not refer to different types of activity and the four categories of the scale are too coarse to show distinct changes that can occur while a patient retains the same rating. A new taxonomy has been devised for rating transitions in functional capacity as noted in three different kinds of functional performance: occupation, customary activities, and sporadic activities. The ratings of change in these three activities can be combined into single global rating. When applied to conventional questionaire data for 309 patients in a randomized double-blind therapeutic trial, the new classifications showed a statistically significant superiority, in each type of functional transition and in the global ratings, for patients receiving timolol maleate rather than placebo. By augmenting the conventional information used for therapeutic evaluation, the new taxonomic indexes can expand the scientific scope of antianginal treatment. Data derived from history-taking can be just as statistically significant as "harder" forms of information, while simultaneously being more pertinent for the clinical challenge of choosing and evaluating the agents used in patient care.     

Depressive symptomatology in a child psychiatric outpatient population: correlations with diagnosis

Assessment methodology in childhood depression is still complicated by uncertainty regarding which of a wide range of symptoms associated with the disorder are critical for diagnosis. In the research described, the Bellevue Index of Depression (BID) was used to collect data about a wide range of depression-related symptoms from 224 consecutive outpatients at a child psychiatry clinic. The BID data were subject to factor analysis and then correlated with the DSM-III diagnoses for these children. Dysphoric symptoms were prevalent in all diagnostic categories and did not discriminate among them. Self-deprecatory ideation in combination with dysphoria was highly discriminative. Antisocial behavior and self-deprecatory ideation were not found in the same factors. The data suggest that self-deprecatory ideation is a core feature of childhood depression and that antisocial behavior is not a strong indicator of depression.     

Feinstein and study design

Dr. Alvan Feinstein saw himself as the father of “clinical epidemiology” in the modern meaning of this term, of this “new intellectual domain of modern medical science.” In this role, he saw himself as drawing from his “clinical sophistication” and from “the rigorous scientific demands” to which “clinicians are accustomed,” while “public health” epidemiologists “often use a more arbitrary set of standards.” His conception of the scope of clinical epidemiology was remarkably Catholic and the same was the case in respect to cause-effect research in it. In the latter, he was firmly committed to the randomized-trial paradigm, including in his teachings on study design in etiologic research. Characteristically original, many of Dr. Feinstein's study-design ideas remain controversial.     

The controversial controversy of a passionate controversialist

Alvan Feinstein was among the pioneers who perceived the need to apply epidemiologic principles and methods to clinical medicine. In his attempt to convert his peers to his own views, he was very liberal in criticizing the work of others. Epidemiologists still recall his 1988 article in Science entitled “Scientific Standards in Epidemiologic Studies of the Menace of Daily Life,” in which he criticized observational epidemiology for its lack of scientific rigor. In this context, Feinstein's work has also been the center of controversies. One in particular, related to the fact that he carried out research and consulted for industries, in particular the tobacco industry, has tainted the last years of Feinstein's career. My purpose in this article is to discuss Feinstein's relationship with the tobacco industry. It is not to judge the validity of his work. Against this background, a question of historic relevance, one that can be discussed on the basis of some evidence, is whether Feinstein, world-reknowned epidemiologist and editor of this journal from 1982 until his recent death, helped the tobacco industry to publish articles minimizing the deleterious effects of smoking in the Journal of Chronic Diseases and (since 1988) the Journal of Clinical Epidemiology. To address this question I have searched the articles related to the effects of tobacco that were published in the Journal since 1978. The tobacco industry has had the opportunity, via its consultants, to defend its own ideas in the “Variance and Dissent” section. Perhaps in hindsight Feinstein could be criticized for not having clearly indicated the sponsorship of the tobacco industry behind these publications, of which he was fully aware. However, this does not suffice to infer that he was the tobacco industry's “man.” Feinstein's attitude in matters of publication appears balanced.