Delay In Surgical Treatment Research Articles

Abstract P6-06-08: Impact of initial surgical treatment delay on survival according to hormone responsiveness in breast cancer

Abstract Previous studies on the issue of the prognostic importance of treatment delay in breast cancer have shown inconsistent results. Furthermore, the association between the impact of treatment delay and molecular characteristics of tumors has not been adequately addressed. The purpose of this study is to examine the prognostic impact of initial surgical treatment delay after biopsy-proven cancer diagnosis in breast cancer patients. A total of 1,393 consecutive invasive breast cancer patients, treated in Seoul National University Hospital, Seoul, Korea, between July 2006 and June 2008, were included in this study. Patients with in situ or metastatic carcinoma at the time of diagnosis and patients in whom the dates of the initial pathologic diagnosis were unknown were excluded. The median time from biopsy-confirmed cancer diagnosis to initial surgical treatment was 25 days (range 0-134). When the patients were classified according to their treatment delay days (0 to 29, 30 to 59, and ≥60days), there was no difference in survival between ‘0-29days’ group and ‘30-59days’ group. However, for patients who experienced more than 60 days of initial delay in surgical treatment, the survival was significantly worse when compared to other groups (p = 0.034). The association between the treatment delay and poor outcome was only seen in patients with ER and PR negative tumors (p = 0.018) while patients with hormone-responsive tumors showed no such association. Patients with ER and PR negative tumors developed more recurrence and had shorter disease-free survival if they had treatment delay of more than 60 days. The prognostic importance of treatment delay of more than 60 days remained significant in predicting disease-free survival after adjusting for other known prognostic factors such as age, tumor size, nodal status, cancer stage, nuclear grade and Ki-67 expression (HR 5.127; 95% CI, 1.350 to 19.472; p = 0.016). Our results suggest that having treatment delay of more than 60 days is associated with poor treatment outcome in patients with ER and PR negative breast cancer. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-08.

Utility of the Pectoralis Major Index in the Diagnosis of Structurally Significant Pectoralis Major Tears.

Background:Diagnosis of pectoralis major tears early in the acute phase is important for optimizing surgical repair and outcomes. However, physical examination of pectoralis major injuries can be misleading, often resulting in a potentially detrimental delay in surgical treatment.Purpose:To establish and validate a quantifiable clinical diagnostic test for structurally significant pectoralis major tears.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:A total of 50 healthy male participants (mean age, 43.3 ± 11.9 years) with normal uninjured pectoralis major anatomy were examined. Digital photographs of all participants were taken in the “military press” starting position (90° of shoulder abduction, 90° of shoulder external rotation). The length between the ipsilateral nipple and the apex of the pectoralis major muscle curvature along the anterior axillary fold, known as the pectoralis major distance, was measured bilaterally. Two orthopaedic surgeons measured all photographs on 2 separate occasions. The pectoralis major index (PMI) was calculated as a ratio of pectoralis major distance values to establish normal values. The PMI was also calculated in a cohort of 19 male patients (mean age, 33.8 ± 6.8 years) with a pectoralis major rupture to assess the diagnostic utility of this novel quantifiable physical examination technique.Results:Mean (± standard deviation) PMI for the uninjured group was 1.0 ± 0.07. A diagnostic threshold of a PMI <0.9 resulted in a sensitivity of 79%, specificity of 98%, and overall accuracy of 93% in identifying structurally significant pectoralis major ruptures. There was no correlation between PMI and age or activity level, including participation in sports and/or weight training. The PMI technique demonstrated good to excellent intrarater reliability (intraclass correlation coefficient [ICC] = 0.82, 0.74) and interrater reliability (ICC = 0.63, 0.76).Conclusion:The PMI technique is a simple, quantifiable, and accurate clinical diagnostic test for structurally significant pectoralis major tears. Routine application of the PMI technique by clinicians may improve accurate identification of structurally significant rupture and expedite referral to a surgical specialist for optimal treatment and outcome.

Benign Subcutaneous Emphysema of the Upper Extremity

Benign subcutaneous emphysema is a rare clinical entity, documented by only a small collection of case reports. The presence of crepitus on physical examination and subcutaneous gas on radiographs is concerning for necrotizing fasciitis. Necrotizing fasciitis is a dangerous and deadly infection accounting for 500 to 1000 cases annually in the United States, with mortality rates of up to 76%. Delay in surgical treatment is related to increased morbidity and mortality; therefore, a high clinical suspicion should be maintained in patients with subcutaneous emphysema and/or crepitus. It is critical to recognize that no laboratory result or radiologic finding should delay surgical intervention if a high clinical suspicion for necrotizing fasciitis exists. However, not all subcutaneous emphysema represents a life-threatening infection. This article presents a case of benign subcutaneous emphysema treated with close observation and prophylactic antibiotics. Patients with necrotizing fasciitis typically appear ill and have the triad of swelling, erythema, and disproportionate pain. Patients who are not systemically ill and have minimal pain, no significant inflammatory changes at the site of crepitus, and stable hemodynamic parameters can be treated conservatively, with the caveat that close clinical monitoring is essential to avoid the unnecessary morbidity and mortality that can result from delaying intervention in the case of necrotizing fasciitis.

Effects of early antibiotics and debridement on infection control in a rat open fracture model

Objective To observe effects of early antibiotics and debridement on infection control in a rat open fracture model.Methods We used a rat femur model with a defect which was contaminated with Staphylococcus aureus and treated with systemic cefazolin (5 mg/kg) and debridement and irrigation,both of which were initiated independently at 2,6 and 24 h time points.After 14 days the bone and hardware were harvested for separate microbiological analysis.Results No animal that received antibiotics and surgery 2 h after injury had detectable bacteria.When antibiotics were started at 2 h,a delay in surgical treatment from 2 to 6 h significantly increased the development of infection (mean bacterial quantities of bone specimen,4.25 × 10s colony-forming units,P ＜ 0.05).However,delaying surgery to 24 h increased the rate of infection,but showed no significant difference (mean bacterial quantities of bone specimen,4.12 × 105 colony-forming units,P ＞0.05).The timing of antibiotics had a more significant effect on the proportion of positive samples than earlier surgery.Delaying antibiotics to 6 or 24 h had a profoundly detrimental effect on the infection rate regardless of the timing of surgery.Conclusion The earlier treatment with systemic antibiotics or surgery is initiated,the greater the reduction in infection.Earlier administration of antibiotics reduces,but does not eliminate the negative impact of delayed surgery.Early antibiotics appear to have a greater impact on reducing infection than early surgery. Key words: Antibiotics ; Debridement ; Infection ; Open fracture

Asynchronous Bilateral Ovarian Torsion. A Case Report and Mini Review

BackgroundAdnexal torsion is a serious condition and delay in surgical intervention may result in loss of ovary. Children and adolescents who have suffered from uterine adnexal torsion may be at risk for asynchronous torsion of the contralateral adnexa. CaseWe report the case of asynchronous bilateral ovarian torsion in a 9-year-old girl, resulting in right and subsequently left salpingo-oophorectomy. ConclusionThe diagnosis of ovarian torsion often is delayed. When ovarian torsion is suspected, laparoscopy should be performed without delay, and conservative management should be strongly considered to prevent surgical castration. Oophoropexy of the ipsilateral and contralateral ovary should be considered to prevent a recurrent torsion.

Cystic Biliary Atresia: A Wolf in Sheep's Clothing

Neonatal obstructive jaundice is frequently explained by biliary atresia (BA) or the presence of a choledochal cyst (CC). Cystic biliary atresia (CBA) has been a proposed as a subtype of BA with projected improved outcomes. We aimed to characterize these lesions further. We conducted an Institutional Review Board-approved review of all patients treated for obstructive jaundice at our tertiary children's hospital over 10 years. Over the decade we evaluated 91 children with obstructive jaundice: 13 CBA, 52 BA, and 26 CC. Patients with isolated CBA and BA were diagnosed significantly earlier than those with CC (15.9, 54, and 281 days, respectively; P = 0.0001). There was a significant delay between diagnosis and surgical intervention for patients with CBA compared with BA: 17 days versus 5.7 days (P = 0.004). There was no difference in rate of transplant between CBA and BA (31 vs. 50%; P = 0.35). The time from surgery until transplant was 13.9 and 18.6 months for CBA and BA, respectively (P = 0.62). Although radiographically similar to CC, CBA behaves similarly to isolated BA. Delay in recognition and surgical treatment may affect outcomes and lead to an increased incidence of liver failure. The presence of a cystic biliary malformation in the setting of neonatal jaundice should be regarded as CBA until proven otherwise.

Chronic epilepsy due to low grade temporal lobe tumors and due to hippocampal sclerosis: Do they differ in post-surgical outcome?

Chronic seizures as a presenting feature of low grade temporal lobe gliomas and hippocampal sclerosis (HS) are reported to have similar outcomes although the prognostic indicators may not be the same. This study seeks to identify the variables that are associated with poor surgical outcome in both conditions. A retrospective analysis from our epilepsy data base was performed. All low-grade temporal lobe gliomas were selected and relevant variables were compared to the same variables in HS patients. There were 34 tumors (out of 233 cases of chronic temporal lobe epilepsy = 14.6 %) with a mean age of onset of 19 years, and the preoperative duration was 12.3 years. When compared to 120 HS patients both of these factors were significantly different (p < 0.001). Age at the time of surgery for tumors was 31.08 (p = 0.5). Tumors were left sided in 20 patients. In tumor cases amygdala resection was complete in 75 %, for hippocampus 24 % were complete and 39 % partial. Astrocytoma, ganglioglioma and oligodendroglioma constituted 80 % of tumor cases. Good outcome (Engel's Class I) was achieved in 88.2 % of tumor cases and 71 % of HS cases while poor outcome (Class III + IV) was seen in 5.9 and 16.7 % respectively. The follow up period for the two groups was not significantly different. In multivariate logistic regression analysis, the groups differed significantly in preoperative delay (between diagnosis and surgery) and in epilepsy outcome. Chronic temporal lobe epilepsy due to low-grade tumors had significantly better surgical outcome with considerably less preoperative delay. The age of onset of seizures was younger in HS patients but a delay in surgical treatment was significantly longer. Given that the diagnosis of treatment-resistant TLE secondary to HS can be established after two failed AED trials at optimal doses, shortening the interval between diagnosis and surgery may improve epilepsy outcome.

Help Wanted: Champions for Breastfeeding Success in Newborns With Ankyloglossia

<h2>Newborn Care Poster Presentation</h2><h3>Background</h3> Ankyloglossia refers to a tethered frenulum that restricts the movement of the tongue or lips. When too restrictive, the newborn may ineffectively suckle at the breast. Breastfeeding difficulties such as long periods nursing or damaged nipples may indicate treatment, and referrals can be made to pediatricians and surgeons. Historically, formula gained popularity in the United States due to cultural influences. Frenulectomy was not needed to enable sucking on a bottle. The procedure was viewed as unnecessary trauma for the newborn. However, for many infants, breastfeeding can be preserved only with timely treatment of ankyloglossia. Parents should be educated about their options and have their decisions supported. A team approach with lactation consultants can empower nurses to champion for the necessary medical evaluation and possible intervention. <h3>Case</h3> In one case, a second time mother concerned over her newborn's <i>tongue‐tie</i> status informed the maternity nurse that despite intending to fully breastfeed her first child, she did not reach her goal. The first child had difficulty latching, was not satisfied with a feed, and lost excessive weight. A painful latch resulted in bleeding nipples. The nurse suspected ankyloglossia, however, the pediatrician opted for delay in surgical intervention hoping the tongue "would come out on its own." The doctor recommended formula bottles to rest the nipples initially. During breastfeeding attempts several times over the next 2 months, the first infant lost weight. Finally, she was referred to an oral surgeon, but by this time, the disappointed mother had given up hopes of breastfeeding and ceased her efforts. In contrast, with her second child, the mother's concerns were acknowledged by the maternity nurse who had gained knowledge of ankyloglossia from the hospital‐based lactation consultant. The nurse instructed the mother on breast pumping and ordered an early lactation consult. Upon confirming ankyloglossia with a digital exam, the consultant collaborated with the nurse for early intervention. This time, the pediatrician ordered an immediate, in‐hospital evaluation by an oral surgeon. A frenulectomy was performed within 24 hours of the newborn's birth. The mother breastfed immediately after the bedside procedure and continued successfully breastfeeding her son. <h3>Conclusion</h3> Recognizing that a tight frenulum affects breastfeeding allows nurses to collaborate for timely breastfeeding interventions. Involving an interdisciplinary team can maximize breastfeeding success. Nurses can ensure that all mothers reach their breastfeeding goals by championing newborns whose ankyloglossia prevents them from effectively nursing.

Delay in Surgical Treatment and Survival After Breast Cancer Diagnosis in Young Women by Race/Ethnicity

Breast cancer in women between the ages of 15 and 39 years (adolescents and young adults [AYAs]) constitutes 5% to 6% of all breast cancer cases in the United States. Breast cancer in AYA women has a worse prognosis than in older women. Five-year survival rates are lowest for AYA women, and only a few studies have examined the impact of delay in treatment, race/ethnicity, and other socioeconomic factors on survival in AYA women. To examine the impact of treatment delay time (TDT), race/ethnicity, socioeconomic status, insurance status, cancer stage, and age on the survival from breast cancer among AYA women. This is a retrospective case-only study of 8860 AYA breast cancer cases diagnosed from 1997 to 2006 using the California Cancer Registry database. Treatment delay time was defined as the number of weeks between the date of diagnosis and date of definitive treatment. Kaplan-Meier estimation was used to generate survival curves, and a multivariate Cox proportional hazards regression model was performed to assess the association of TDT with survival while accounting for covariates (age, race/ethnicity, socioeconomic status, insurance status, cancer stage [American Joint Committee on Cancer], tumor markers, and treatment). Five-year survival rates for breast cancer as influenced by host factors, tumor factors, and TDT. Treatment delay time more than 6 weeks after diagnosis was significantly different (P < .001) between racial/ethnic groups (Hispanic, 15.3% and African American, 15.3% compared with non-Hispanic white, 8.1%). Women with public or no insurance (17.8%) compared with those with private insurance (9.5%) and women with low socioeconomic status (17.5%) compared with those with high socioeconomic status (7.7%) were shown to have TDT more than 6 weeks. The 5-year survival in women who were treated by surgery and had TDT more than 6 weeks was 80% compared with 90% (P = .005) in those with TDT less than 2 weeks. In multivariate analysis, longer TDT, estrogen receptor negative status, having public or no insurance, and late cancer stage were significant risk factors for shorter survival. AND RELEVANCE: Young women with breast cancer with a longer TDT have significantly decreased survival time compared with those with a shorter TDT. This adverse impact on survival was more pronounced in African American women, those with public or no insurance, and those with low SES.

Influence of guideline-concordant adjuvant therapy on all-cause and disease-specific survival among breast cancer patients in rural Georgia.

1130 Background: This study examines whether receipt of chemo-, radiation, and hormonal therapy regimens that are jointly guideline concordant improve survival outcomes among women diagnosed with breast cancer in a rural region of the United States. Methods: All women identified by the state cancer registry residing in rural southwest Georgia diagnosed with early stage breast cancer during 2001-2003 were included. Medical chart abstraction and registry data were used to determine treatment concordance with the 2000 NIH consensus development conference guidelines on breast cancer treatment. Patients were Concordant versus Non-Concordant according to whether their receipt (or non-receipt) of each adjuvant therapy type was according to guidelines. To examine the effects of concordance on all-cause and breast cancer-specific survival, Cox models were developed that used both propensity score weighting and 2-stage residual inclusion instrumental variable techniques to adjust for patient selection effects. Results: In all-cause analyses, Concordance versus Non-Concordance was associated with significantly better survival (hazard ratios (HRs) 0.41 (95% CI: 0.24-0.72) to 0.54 (95% CI: 0.33-0.87). Similar findings emerged in breast cancer-specific survival analyses, with HRs significantly less than 1.0 in most cases. Diagnosis at older age or later disease stage strongly predicted poorer survival outcome; being not married was significant in all-cause but not breast cancer-specific models. Survival was not generally associated with surgical treatment delay, insurance status, socioeconomic status, rural/urban status, comorbidities, tumor grade, or hormonal status. HR for black women versus white was greater than 1.0 across models but never significant (p=0.05). Conclusions: Breast cancer patients in rural Georgia who received guideline-concordant adjuvant therapy had significantly better all-cause and breast cancer-specific survival, based on Cox model analyses that attempted to control for multiple clinical and demographic factors, as well as selection effects. These findings extend the evidence that guideline bundles of care improve outcomes.

Heterotopic Ossification After Surgery for Fractures and Fracture-Dislocations Involving the Proximal Aspect of the Radius or Ulna

The objectives of this study were to (1) determine the prevalence of heterotopic ossification after surgery for fractures and fracture-dislocations involving the proximal aspect of the radius or ulna, (2) identify risk factors associated with the development of heterotopic ossification in these injuries, and (3) characterize the severity and location of the heterotopic ossification and the associated range of elbow motion. From 2004 to 2008, 142 elbow fractures and fracture-dislocations involving the proximal aspect of the radius or ulna were treated surgically at our institution. Records and radiographs of 130 elbows with adequate follow-up were retrospectively reviewed to identify cases of heterotopic ossification, characterize the ectopic bone, and analyze associated risk factors. The most frequent injuries included olecranon fractures, Monteggia fracture-dislocations, and various combinations of fractures of the radial head and coronoid with or without dislocation or subluxation. Heterotopic bone was identified on the radiographs of forty-eight elbows (37%). Heterotopic ossification interfered with motion in twenty-six elbows (20%), and thirteen elbows (10%) underwent additional surgery to remove heterotopic bone with the goal of improving motion. Risk factors associated with the development of heterotopic ossification included elbow subluxation or dislocation at the time of presentation, an open fracture, a severe chest injury, and a delay in definitive surgical treatment. Ectopic bone was preferentially located at the origin of torn soft-tissue structures or around fracture sites, and it was particularly common around the posterior aspect of the ulna and the neck of the radius. Heterotopic ossification was classified on radiographs as hazy immature in twenty-two elbows, limited mature in eighteen, extensive mature in five, and a complete bone bridge in three. Heterotopic ossification was more common in patients with an associated distal humeral fracture, radial head and coronoid fractures with an associated elbow dislocation (terrible triad injury), and a transolecranon fracture-dislocation. Thirty-seven percent of elbows treated surgically for fractures involving the proximal aspect of the radius and/or ulna developed heterotopic ossification. In twenty percent of elbows, heterotopic ossification was associated with clinically relevant motion deficits. More severe heterotopic ossification was encountered in patients presenting with an associated distal humeral fracture, terrible triad injury, transolecranon fracture-dislocation, or Monteggia fracture-dislocation. Patients with an open injury, instability, severe chest trauma, or delay in definitive surgical treatment had a higher prevalence of heterotopic ossification.

Platelet-Rich Plasma Added to the Patellar Tendon Harvest Site During Anterior Cruciate Ligament Reconstruction Enhanced Healing

Background: The objectives of this study were to (1) determine the prevalence of heterotopic ossification after surgery for fractures and fracture-dislocations involving the proximal aspect of the radius or ulna, (2) identify risk factors associated with the development of heterotopic ossification in these injuries, and (3) characterize the severity and location of the heterotopic ossification and the associated range of elbow motion. Methods: From 2004 to 2008, 142 elbow fractures and fracture-dislocations involving the proximal aspect of the radius or ulna were treated surgically at our institution. Records and radiographs of 130 elbows with adequate follow-up were retrospectively reviewed to identify cases of heterotopic ossification, characterize the ectopic bone, and analyze associated risk factors. The most frequent injuries included olecranon fractures, Monteggia fracture-dislocations, and various combinations of fractures of the radial head and coronoid with or without dislocation or subluxation. Results: Heterotopic bone was identified on the radiographs of forty-eight elbows (37%). Heterotopic ossification interfered with motion in twenty-six elbows (20%), and thirteen elbows (10%) underwent additional surgery to remove heterotopic bone with the goal of improving motion. Risk factors associated with the development of heterotopic ossification included elbow subluxation or dislocation at the time of presentation, an open fracture, a severe chest injury, and a delay in definitive surgical treatment. Ectopic bone was preferentially located at the origin of torn soft-tissue structures or around fracture sites, and it was particularly common around the posterior aspect of the ulna and the neck of the radius. Heterotopic ossification was classified on radiographs as hazy immature in twenty-two elbows, limited mature in eighteen, extensive mature in five, and a complete bone bridge in three. Heterotopic ossification was more common in patients with an associated distal humeral fracture, radial head and coronoid fractures with an associated elbow dislocation (terrible triad injury), and a transolecranon fracture-dislocation. Conclusions: Thirty-seven percent of elbows treated surgically for fractures involving the proximal aspect of the radius and/or ulna developed heterotopic ossification. In twenty percent of elbows, heterotopic ossification was associated with clinically relevant motion deficits. More severe heterotopic ossification was encountered in patients presenting with an associated distal humeral fracture, terrible triad injury, transolecranon fracture-dislocation, or Monteggia fracture-dislocation. Patients with an open injury, instability, severe chest trauma, or delay in definitive surgical treatment had a higher prevalence of heterotopic ossification. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Immunocompromised Status in Patients With Necrotizing Soft-Tissue Infection

There is a scarcity of research on immunocompromised patients with necrotizing soft-tissue infection (NSTI). To evaluate the effect of immunocompromised status in patients with NSTI. Single-institution retrospective cohort study at a tertiary academic teaching hospital affiliated with a major cancer center. Patients with NSTI. Treatment at Brigham and Women's Hospital and Dana-Farber Cancer Institute between November 25, 1995, and April 25, 2011. Necrotizing soft-tissue infection-associated in-hospital mortality. Two hundred one patients were diagnosed as having NSTI. Forty-six were immunocompromised (as defined by corticosteroid use, active malignancy, receipt of chemotherapy or radiation therapy, diagnosis of human immunodeficiency virus or AIDS, or prior solid organ or bone marrow transplantation with receipt of chronic immunosuppression). At presentation, immunocompromised patients had lower systolic blood pressure (105 vs 112 mm Hg, P = .02), glucose level (124 vs 134 mg/dL, P = .03), and white blood cell count (6600/μL vs 17 200/μL, P < .001) compared with immunocompetent patients. Immunocompromised patients were less likely to have been transferred from another institution (26.1% vs 52.9%, P = .001), admitted to a surgical service (45.7% vs 83.2%, P < .001), or undergone surgical debridement on admission (4.3% vs 61.3%, P = .001). Time to diagnosis and time to first surgical procedure were delayed in immunocompromised patients (P < .001 and P = .001, respectively). Immunocompromised patients had higher NSTI-associated in-hospital mortality (39.1% vs 19.4%, P = .01). AND RELEVANCE Immunocompromised status in patients with NSTI in this study is associated with delays in diagnosis and surgical treatment and with higher NSTI-associated in-hospital mortality. At presentation, immunocompromised patients may fail to exhibit typical clinical and laboratory signs of NSTI. Physicians caring for similar patient populations should maintain a heightened level of suspicion for NSTI and consider early surgical evaluation and treatment.

Location and timing of care for colon cancer patients in the VA Health System

BackgroundWe sought to identify colon cancer patients within the Veterans Affairs (VA) system who experienced lengthy wait times for surgery or chemotherapy. We looked specifically at the relationship between location of treatment and timing of care. MethodsWe performed a retrospective cohort study of 4635 patients diagnosed with colon cancer in the VA Health System during 2002–2010 and treated with surgery followed by chemotherapy. We used VA administrative databases, including the VA Outpatient Clinic, Patient Treatment, and Fee Basis inpatient and outpatient files. Time from diagnosis to surgery and time from surgery to initiation of chemotherapy were the primary outcome measures. ResultsPatients who required referral to a hospital different from their home VA facility for surgery experienced delays in surgical intervention compared with patients treated at their home VA medical center. For patients referred outside of the VA system, this delay was almost 2 wk (13.5 d, P < 0.001). When these patients then went to another hospital for chemotherapy, they experienced further delays in care. Patients treated surgically outside the VA system who returned to the VA system for chemotherapy were more likely to initiate chemo >8 wk following surgery (OR 1.69, P = 0.01). The average adjusted time from surgery to chemotherapy for these patients compared with those treated wholly within the VA system was 11.4 d (P = 0.003). ConclusionsVA patients who require treatment at multiple hospitals for colon cancer, especially those who require surgery outside of the VA system, are more likely to experience delays in care compared with patients treated at a single hospital.

175 A treatment delay in surgical intervention for elderly patients with small renal masses does not impact oncological outcomes

175 A treatment delay in surgical intervention for elderly patients with small renal masses does not impact oncological outcomes

Orthopaedic surgical treatment delays at a tertiary hospital in sub Saharan Africa: Communication gaps and implications for clinical outcomes

Background:Delay in surgical treatment is a source of distress to patients and an important reason for poor outcome. We studied the delay before carrying out scheduled operative orthopaedic procedures and the factors responsible for it.Materials and Methods:This prospective study was carried out between March 2011 and December 2012. Temporal details of the surgical procedures at our hospital were recorded in a proforma including the patients’ perception of the causes of the delay to surgery. Based on the urgency of the need for surgery, patients were classified into three groups using a modification of the method employed by Lankester et al. Data was analyzed using the Statistical Package for the Social Sciences, version 17.0. Predictors of surgical delay beyond 3 days were identified by logistic regression analysis.Results:Two hundred and forty-nine patients with a mean age 36.2 ± 19.2 years and M:F ratio 1.3 were recruited. 34.1% were modified Lankester group A, 45.4% group B and 20.5% group C. 47 patients (18.9%) had comorbidities, hypertension being the commonest (22 patients; 8.8%). Median delay to surgery was 4 days (mean = 17.6 days). Fifty percent of emergency room admissions were operated on within 3 days, the figure was 13% for other admissions. Lack of theatre slot was the commonest cause of delay. There was full concordance between doctors and patients in only 70.7% regarding the causes of the delay. In 15.7%, there was complete discordance. Logistic regression analysis confirmed modified Lankester groups B and C (P = 0.003) and weekend admission (P = 0.016) as significant predictors of delay to surgery of >3 days.Conclusion:Promptness to operative surgical care falls short of the ideal. Theatre inefficiency is a major cause of delay in treating surgical patients in our environment. Theatre facilities should be expanded and made more efficient. There is a need for better communication between surgeons and patients about delays in surgical treatment.

Emergent and Nonemergent Nonbowel Torsion: Spectrum of Imaging and Clinical Findings

Although bowel torsion is more commonly described in the medical literature, torsion can affect various organs within the chest, abdomen, and pelvis, including the testes, ovaries, gallbladder, spleen, heart, and pulmonary lobes. A structural abnormality such as a mass (a "lead point") that promotes twisting around a vascular pedicle often predisposes an organ or other anatomic structure to torsion. Radiologists play a central role in detecting torsion, identifying the anatomy involved, and triaging patients for either emergent surgical intervention, which may be critical for organ salvage, or conservative management. Imaging findings that are suggestive or indicative of emergent torsion include an ectopic location and enlargement or edema of part or all of an organ, decreased blood flow at color Doppler ultrasonography, and a twisted vascular pedicle. Blood flow to an organ is quickly compromised by the constriction of vessels within the twisted pedicle, and ischemia may result; a delay in diagnosis and surgical treatment can lead to complications such as infarction, hemorrhagic necrosis, and abscess. By contrast, torsion of mobile fatty structures such as testicular appendages, epiploic appendages, omental fat, and pericardial fat pads, although it may produce pain mimicking that in an emergent condition, requires only conservative management. Imaging features of this nonemergent condition include a fatty mass, which is usually located alongside the colon when torsion involves the omentum or an epiploic appendage, with associated inflammatory stranding and tenderness at palpation. The radiologist should be familiar with these manifestations of nonemergent torsion to prevent unnecessary surgical intervention.

Treatment of Recurrent Primary Spontaneous Pneumothorax – Own Experience

Primary spontaneous pneumothorax could be a serious therapeutic problem in case of recurrence. Lack of therapeutic standards sometimes leads to delay in definitive surgical treatment and could cause respiratory complications. The aim of the study was the evaluation of treatment results in patients with recurrence of primary spontaneous pneumothorax and looking for optimal therapeutic method after first recurrence (surgical treatment vs. pleural drainage). Between 01.01.2009 and 31.07.2010 fifty four patients with recurrent primary spontaneous pneumothorax was hospitalized in Wrocław Thoracic Surgery Centre (24.3% of all patients with pneumothorax). The recurrence was treated surgically in 24 cases, in 30 pleural drainage was performed: simple drainage (n=14) or drainage with chemical pleurodesis (n=16). Mean age of patients treated without surgery was higher than surgically treated (p=0,012). In surgery group no recurrence was found, in drainage group 11 recurrences occurred (p=0.0009). In group of 11 patients with second recurrence, pleurodesis was performed four times (36%) vs. 12 times (63%) in 19 patients without a recurrence of the disease. 70% of non-surgically treated patients vs. 50% of surgically treated were afraid of recurrence (p=0.01). Among 11 patients in drainage group, nine underwent surgery at the second episode of recurrence. The optimal treatment method in case of first recurrence of primary spontaneous pneumothorax is surgical treatment. When it is not possible chemical pleurodesis should be performed during pleural drainage. Most of the patients after second recurrence are treated surgically anyway. The surgical treatment significantly reduces patient's fears for future recurrence of the disease. Younger patients are most often surgically treated.

APPENDICITIS IN PREGNANCY

Acute appendicitis is the most common non-obstetric indication for surgical intervention in pregnancy, complicating 1/500 to 1/2000 deliveries. Due to the anatomical and physiological changes associated with pregnancy, appendicitis may present a diagnostic dilemma, leading to management delays and thus increasing the risk of appendiceal perforation. Many of the common presenting symptoms of appendicitis are common features of normal pregnancy including lower abdominal pain, nausea, vomiting and leukocytosis. Furthermore, the enlarging gravid uterus may displace the appendix to varying degrees thus altering the classic symptom pattern of appendicitis. The often nonspecific presentation in pregnancy may necessitate the utilization of diagnostic imaging to aid in accurate diagnosis. However, the perforated appendix is the most common surgical cause of fetal loss and the time required for any diagnostic aid must be weighed against the increasing risk of perforation caused by delay in surgical intervention.

The influence of hospital volume and surgical treatment delay on long-term survival after cancer surgery

We conducted a population-based retrospective cohort study to investigate the influence of hospital volume, delay of surgery, and both together on the long-term survival of postoperative cancer patients. Using information from the Korea Central Cancer Registry from 2001 through 2005 and the National Health Insurance claim database, we determined survival for 147 682 patients who underwent definitive surgery for any of six cancers. Regardless of cancer site, surgical patients in low- to medium-volume hospitals showed significantly worse survival [adjusted hazard ratio (aHR) = 1.36-1.86] than those in high-volume hospitals in multivariable analyses. Among the latter, treatment delays > 1 month were not associated with worse survival for stomach, colon, pancreatic, or lung cancer but were for rectal [aHR = 1.28; 95% confidence interval (CI), 1.17-1.40] and breast (aHR = 1.59; 95% CI, 1.37-1.84) cancer. For patients in low- to medium-volume hospitals, treatment delay was associated with worse survival for all types of cancer (aHR = 1.78-3.81). Our findings suggest that the effect of hospital volume and surgical treatment delay on overall survival of cancer patients should be considered in formulating or revising national health policy.