Addition Complications Research Articles

The effect of transcutaneous electrical nerve stimulation on postmastectomy skin flap necrosis

Transcutaneous electrical nerve stimulation (TENS) is primarily used for pain reduction and is thought to activate neural fibers modifying vascular resistance and local blood flow influencing flap necrosis. This study aimed to delineate the effects of TENS on the viability of skin flaps created during mastectomy in breast cancer patients. Patients treated with modified radical mastectomy were prospectively randomized to receive either TENS or no further local treatment postoperatively. High frequency (70 Hz) and low intensity (2 mA) TENS was applied and areas of flap ecchymosis and necrosis were measured after the completion of TENS application and compared between the two groups. Patients were also compared according to age, comorbid diseases, duration of anesthesia, flap area, amount of wound drainage and seroma, presence of wound infection and abscess. In addition, local and systemic complications related to TENS were recorded. About 173 patients with a median age of 49 (range 25-87) were included in the study. About 87 patients received TENS whereas 86 patients formed the control group. Patients' characteristics were comparable between the two groups. Number of patients with skin flap necrosis was higher in the control group compared to TENS group (P < 0.0001). Mean area of flap necrosis was significantly lower in TENS group (85.2 +/- 35.9) compared to control group (252.5 +/- 64.1; P = 0.024). Similarly, number of patients with skin flap ecchymosis was higher in the control group compared to TENS group (P = 0.002). However, although mean area of flap ecchymosis was lower in TENS group (105.5 +/- 49.8) compared to control group (172.9 +/- 49.9), this difference did not reach statistical significance (P = 0.34). In addition, there were no local or systemic complications related to TENS application in patients. TENS can be safely used to decrease the amount of skin flap necrosis after mastectomy in breast cancer patients without any additional complication.

A comprehensive model of health-related quality of life in Parkinson’s disease

Insight in how impairments and disabilities related to Parkinson's disease (PD) influence health-related quality of life (HRQoL) is required to review adequacy of current management strategies. The Scales for Outcomes in Parkinson's disease (SCOPA) evaluation was used to assess impairments and disabilities. HRQoL was assessed with the EuroQol-5D Visual Analogue Scale. 378 patients with PD who participated in the SCOPA/PROPARK cohort were assessed while on their usual treatment. Multiple linear regression analysis and structural equation modelling were used to construct a model of factors that influence HRQoL. A model with good fit was constructed that identified various impairments and disabilities as important contributors to HRQoL in PD. Of the disabilities, psychosocial well-being had a larger impact on HRQoL than physical functioning. Of the impairments, depression had the largest contribution to HRQoL, followed by axial motor symptoms, gastrointestinal symptoms, and urinary symptoms. In addition, pain, psychiatric and motor complications, and daytime sleepiness had small but significant influences on HRQoL. Multiple factors, including disabilities, nonmotor symptoms and axial motor symptoms, affect HRQoL in patients with PD. In patients who are on symptomatic treatment aiming to alleviate mainly motor symptoms, there is a large impact on HRQoL of nonmotor and nondopaminergic symptoms. Research is warranted to develop and evaluate management strategies for the aspects that currently impact on HRQoL as psychosocial well-being, depressive symptoms, axial motor symptoms, gastrointestinal symptoms, and urinary symptoms. These findings call for a multidisciplinary approach in the care of these features.

Risk factors for interstage death after stage 1 reconstruction of hypoplastic left heart syndrome and variants

The risk of death during the interstage period remains high after stage 1 reconstruction for single ventricle lesions, despite improved surgical results. The purpose of this study is to identify risk factors for interstage death and to describe the events leading to interstage death. A nested case-control study was conducted of 368 patients who underwent stage 1 reconstruction at a single center between January 1998 and April 2005. Among the 313 (85%) hospital survivors, there were 33 (10.5%) interstage deaths. Cases more frequently presented with intact or restrictive atrial septum (9 [27%] vs 4 [4%]; P < .001), were older at the time of surgery (5 [2-40] vs 3 [1-42] days; P = .005), had more postoperative arrhythmias (12 [36%] vs 15 [15%]; P = .01), and a higher incidence of airway or respiratory complications (12 [36%] vs 19 [19%]; P = .04). By multivariate analysis, only intact atrial septum (odds ratio 7.6; 95% confidence intervals 1.9-29.6; P = .003) and age at operation greater than 7 days (odds ratio 3.8; 95% confidence intervals 1.3-11.2; P = .017) were predictors of interstage death. The presence of intact atrial septum and older age at the time of surgery are associated with a higher risk of interstage death. In addition, postoperative arrhythmia and airway complications are associated with a higher risk of interstage death in univariate analysis. The results of this study provide a focus for interstage monitoring and risk stratification of these high-risk infants, which may improve overall survival.

Intrastromal Corneal Ring Segment Implantation by Femtosecond Laser for Keratoconus Correction

To report the outcomes after the implantation of intrastromal corneal ring segments (KERARING) aided by femtosecond laser for the correction of keratoconus. Prospective consecutive interventional study. Twenty-one eyes of 16 consecutive keratoconic patients with mean age 32+/-10.2 years. Forty-five percent were keratoconus grade I, 20% grade II, 15% grade III, and 20% grade IV. Intrastromal corneal ring segments KERARING were implanted for keratoconus correction after corneal tunnel creation with the aid of femtosecond laser (IntraLase Corp, Irvine CA). Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), refractive outcome, complete ophthalmologic examination, videokeratography, and corneal higher order aberrations (HOA) were determined or performed before and after surgery at 1 day, 1 week, and 3 and 6 months. In addition, operative and postoperative complications were recorded. KERARING implantation significantly increased UCVA from 0.06 to 0.3 (P< or =0.0001), BSCVA from 0.54 to 0.71 (P< or =0.0003), and decreased the spherical equivalent by 2.28 diopters (D) and the average keratometric values (K value) by 2.24 D (P<0.001). There was no significant difference between the 3 and 6 months follow-up. Forty percent (8 eyes with a relatively low RMS of total HOA) showed a nonsignificant increase in the RMS of total HOA and 60% (12 eyes with a relatively higher RMS of total HOA> or =3.0 microm) showed significant (P< or =0.01) decrease in the RMS of total HOA due to a significant (P< or =0.003) reduction in coma and comalike aberrations. The amount of change in corneal curvature (biomechanical response) ranged from a decrease of 18% from its initial value to an increase of 2.75% and was not correlated to any preoperative parameter. Localized infectious keratitis occurred in only 1 eye (4.8%), and incision opacification occurred in 8 eyes (38%). Intrastromal corneal ring segment implantation with femtosecond laser is an effective method for correcting keratoconus with reduction in corneal HOA in eyes with coma aberration > 3.0 microm.

FREQUENCY OF CATIONIC TRYPSINOGEN (PRSS1) GENE AND THE SERINE PROTEASE INHIBITOR, KAZAL TYPE 1 (SPINK1) GENE MUTATIONS IN PATIENTS WITH CHRONIC ALCOHOLIC PANCREATITIS (CAP)

Background: We have only limited information regarding the pathogenic mechanism by which alcohol leads to CAP. Aims & Methods: The aim of the study was to determine the frequency of PRSS1 and SPINK1 mutations in patients with chronic alcoholic pancreatitis (CAP) as well as to investigate their relation to the clinical course of the disease. The study included 37 patients with CAP and 46 healthy subjects. After isolated DNA from peripheral blood two trypsinogen mutations N29I and R122H have been detected and N34S mutation of SPINK1 (by ASA-PCR and PCR-RFLP). Results: Overall 9 (24.5%) N34S SPINK1 mutations in CAP group have been detected. The same mutations have also been found in 3 (6.5%) control subjects. N29I mutations of PRSS1 have been detected in 5 (13.5%) patients with CAP and only in those with accompanying SPINK1 mutations. R122H mutations of PRSS1 have been detected in 8 (21.6%) patients with CAP. Both mutations of PRSS1 concerned in 2 (4.3%) controls. In patients with CAP and the presence of SPINK1 mutations, pancreatic calcifications have been detected significantly less frequently (p < 0.05) that in patients with no mutations. In addition complications requiring endoscopic or surgical treatment (p < 0.01) have been also less frequently noted in CAP with detected mutations compared with the remaining CAP group. Compared to the remaining patients with CAP, diabetes was seen significantly more frequent in patients with R122H mutation. Conclusion: Those data suggest the high incidence of SPINK1 and PRSS1 mutations in Polish population generally, as well as in CAP patients. It may be speculated that those mutations contribute to the development of chronic pancreatitis in patients with alcohol overindulgence. On the other hand the clinical course of CAP seems to be more severe in patients with no SPINK1 mutations detected.

Laparoscopic Nephroureterectomy for Tuberculous Nonfunctioning Kidneys Compared with Laparoscopic Nephroureterectomy for Other Diseases

To summarize the results of 8 consecutive laparoscopic nephroureterectomies (LNUs) for tuberculous nonfunctioning kidneys and compare them with 10 LNUs performed for other benign etiologies (control group). From November 1999 to February 2004, 8 patients underwent LNU for tuberculous ureteric stricture with a nonfunctioning kidney at our center. During the same time period, 10 LNUs were performed for other benign conditions. Hospital records were reviewed to obtain demographic data. In addition, operative time, intraoperative and postoperative complications, duration of postoperative ileus, and hospital stay was recorded. The outcomes of surgery for tuberculosis were compared with that for the control group. Patients were followed up for long-term complications of laparoscopic surgery. The two groups had a comparable demographic data. Nephroureterectomy was successfully performed laparoscopically in all 8 patients with tuberculosis. One patient in the control group, with a large staghorn renal and ureteral calculus, required conversion to open surgery due to dense perinephric adhesions. The outcome of surgery for tuberculosis was compared with outcomes in the control group using SPSS software. The mean operative time, blood loss, analgesic requirement, duration of postoperative ileus, and hospital stay of both groups was comparable, and the differences between them were statistically insignificant. The results of this study indicate that LNU for a tuberculous nonfunctioning kidney is a safe, effective, and less invasive treatment modality. Comparing our results with those of nephroureterectomy for other, benign diseases shows that the procedure has similar safety and efficacy even for tuberculous kidneys. Tuberculosis should not be considered a contraindication for a laparoscopic approach. Laparoscopic nephroureterectomy should be offered as the treatment modality of choice to all patients with tuberculous nonfunctioning kidney whose disease involves the kidney and ureters.

Laparoscopic repair of incisional hernia: a retrospective study of 159 patients.

In this long-term retrospective study, a laparoscopic technique was used for incisional hernia repair. Over a 6-year period, we performed laparoscopic repairs with prosthetic mesh in 159 patients suffering from incisional hernia. Morbidity factors were noted and operative data were collected. In addition, early and long-term complications and recurrences were analyzed. There were no deaths as a result of the procedure. In 21 patients (13.8%), the operation was converted to an open procedure. Small bowel perforation occurred in three patients (1.9%). Mean hospital stay was 3.5 days. Early complications occurred in 61 patients (44%). The mean follow-up time was 49 months. There were no infections of the prosthetic mesh. Residual abdominal pain was reported in 31 patients (26%). Bowel obstructions requiring resection were found in two patients (1%), and hernia recurrence was observed in 19 patients (15.7%). Laparoscopic herniorraphy is a promising technique with all the advantages of minimal-invasive surgery. Nevertheless, close attention needs to be paid to the choice of the hernia and mesh size and to the fixing of the mesh.

ATHEROEMBOLIC RENAL DISEASE: EFFECT ON MORBIDITY AND SURVIVAL AFTER REVASCULARIZATION FOR ATHEROSCLEROTIC RENAL ARTERY STENOSIS

Purpose Atheroembolic renal disease is increasingly found in older patients with general atherosclerosis. We evaluated the impact of atheroembolic renal disease on morbidity and survival after surgical revascularization for atherosclerotic renal artery stenosis. Materials and Methods The study group comprised 44 patients who underwent surgical revascularization for atherosclerotic renal artery stenosis and concomitant intraoperative renal biopsy. Renal biopsy specimens were reviewed by a pathologist and evaluated for the presence or absence of atheroemboli, and the presence and severity of arteriolar nephrosclerosis. Postoperative patient data were reviewed to evaluate survival, and the incidence of renal and systemic morbid events. Patients were followed for 1 to 14.5 years (median 6.2) after surgical revascularization. Results Atheroembolic renal disease was identified in the intraoperative biopsy specimen in 16 patients (36%, group 1) and was absent in 28 (64%, group 2), termed groups 1 and 2. Atheroembolic renal disease correlated significantly with decreased patient survival. The 5-year survival in groups 1 and 2 was 54 and 85%, respectively (p = 0.011). Similarly the incidence of systemic atherosclerotic complications was significantly higher in group 1 than group 2 (86 versus 58%, p <0.05). In addition, renal or renovascular complications developed in more group 1 than group 2 patients (p = 0.07). There was no significant association between the presence or severity of arteriolar nephrosclerosis and postoperative survival or morbid events. Conclusions Our results indicate that atheroembolic renal disease is associated with decreased survival and an increased incidence of atherosclerotic morbid events after surgical revascularization for atherosclerotic renal artery stenosis. This information may be useful for therapeutic decision making in patients with atherosclerotic renal artery stenosis.

Lung transplantation.

Solid-organ transplantation has flourished during the last decade, with transplantation of heart and lungs becoming available to patients with end-stage cardiac or pulmonary diseases. The first lung transplant was performed in 1963 on a 58-year-old man with bronchogenic carcinoma. He survived for 18 days. During the next two decades, approximately 40 lung transplant procedures were attempted without success. These early attempts at lung transplantation were unsuccessful because of the development of lung rejection, anastomotic complications, or infection in the transplant recipients. In the early 1980s, human heart-lung transplantation was successfully performed for the treatment of pulmonary vascular disease. After this procedure, single-lung transplantation for the treatment of end-stage interstitial lung disease and obstructive lung disease was developed. More recently, the technique of double-lung transplantation has come into existence. This article reviews various aspects of lung transplantation, including immunosuppression, lung graft preservation, the various surgical techniques and types of lung transplant procedures available, recipient and donor selection criteria, and postoperative care of the transplant recipient. In addition, infectious and noninfectious complications seen in this particular patient population, including acute and chronic rejection, will be discussed.

Smallpox Vaccination: The End of an Era

Summary. In 1971 it wasrecommended that routine immunization against smallpox be discontinued in the United States. While smallpox vaccine has had a venerable record of disease control, deliberations which led to the reversal of the longstanding public health plicy reflect a reconsideration of smallpox status in the world. Smallpox was introduced into the western hemishere almost 450 yeas ago. Immunoprophylaxis was initiated in the United States more than 250 years ago. The record of smalpox vaccine is impressive. It may bbe credited with the reduction of cases in the United States from more than 110,000 in 1920 to an absence of cases since 1949. However, we cannot credit the continued maintenance of a smallpox‐free country to the routine use of vaccine and cannot credit the level of immunity of our population for the prevention of importations. The fact is that our “herd immunity” has not been challenged for 25 years.As the incidence of smallpox in the world has fallen, and with the disappearance of the disease altogether in the developed countries, the substantial toxicity of the vaccine began to stand out in bold relief. In the United States, 7–8 deaths attributable to complicatins of the smallpox vaccine occurred each year. In addition, significant nerrologic and dermal complications of the smallpox vaccine occurred each year. In addition, significant neurologic and dermal complications have occurred at the rate of 8,000 per year. These complications occurred among 5–6 million primary and 7–8 million revaccinees each year.The risk of importation of cases of smallpox in a given country is proportionate to the incidence of endemic smallpox in the world and the number of tramellers from endemic areas. World incidence of smallpox has fallen dramatically. As late as 1962, 61 countries reported smallpox. The current list includes only 4 countries where smallpox is endemic‐India, Pakistan, Bangladesh and Ethiopia. Exportations in the first portion of 1974 have been confined almost exclusively to adjacent land areas. Recently, the Americas, having gone without endemic cases for 2 years were declared disease free; Indonesia has recently received similar status.The success of recent control and eradication programs on a world‐wide basis is based upon a new understanding of smallpox epidemiology and a new and vigorous approach to its containment. Emphasis upon epidemiologic investigation of all suspected cases and systematic vaccination of contacts ha proved very effective. However, importations into non‐epidemic areas can theoretically occur as long as small‐pox exists anywhere in the world. Expericnce has shown that selective “ring vaccination” of contacts of such imported cases can effectively control spread. This policy plus continued vaccination of high risk individuals, i.e., health personnel and travellers to and from endemic areas, provides the least toll in morbidity and mortality. Continued active support is required for smallpox surveillance and eradication programs around the world.

A new formulation of the plastic design problem for plane frames

AbstractUsing a parametrie representation, it was proved in 19591 that the static and kinematic approaches to the plastic collapse problem are dual linear programming problems. In this paper, the generalized parameters used previously are given physical meaning and shown to be readily programmed for computer application. One important advantage of the method is that the equations can be written in general terms such that no assumptions regarding the structural from need to be built into the program. The application is extended to the more general problem of automatic plastic design and it is shown that the inclusion of a serviceability constraint (e.g. no plastic hinges at a given load factor) is trivial in this formulation. The difficult problem of several loading cases is shown to be readily, treated by designing for a given load factor for shakedown rather than plastic collapse. Thought this latter facility, by its dependence on elastic behavior, requires iteration of the stiffness of the structure, repaid convergence appears to be generally obtained. Finally a method is suggested whereby an adequate allowance for frame instability may be made without destroying the linearity of the equations. Thought the equations, as developed, have application to steel framed structures in mind, the extension to the limit design of reinforced concrete structures appears to present no addition complications.

EPIDEMIOLOGY OF ACUTE HEPATITIS IN THE ROYAL AIR FORCE.

Acute hepatitis has been recognized as an outstanding military disease for many years. Compulsory notification of acute hepatitis and jaundice in the Royal Air Force in recent years revealed many cases amongst Servicemen stationed at home and abroad. The number of cases together with the long duration of illness and the occurrence of three deaths attributed directly to acute hepatitis became matters of some concern. An investigation was, therefore, undertaken to study the epidemiology of acute hepatitis in the Royal Air Force and to determine the role, if any, of syringe transmission in a population which is constantly receiving many prophylactic inoculations for which a variety of methods and widely differing sterilization techniques are used. In addition, the clinical and laboratory features and complications of acute hepatitis were studied in some detail.