Increase In Severe Complications Research Articles

1657 Resected Gastric Adenocarcinomas at a Single Institution: Outcomes and Trends over 17 Years.

Outside of clinical trials, real-world data of advanced gastric cancers (AGCs) managed with perioperative or adjuvant chemotherapy with a backbone of D2 lymphadenectomy is limited. Curative resections for gastric adenocarcinoma between January 2003 and January 2020 at the Tata Memorial Centre were analyzed, comparing three time periods marking major increments in annual gastric resections (GRs). 1657 radical gastric resections were performed with a morbidity and mortality rate of 34.9% and 1.4%, respectively. Over three consecutive periods, the number of annual GRs increased from 56/year to 97/year to 156/year (P < 0.001) with a significant escalation in surgical magnitude and complexity. Improvement in surgical quality indicators (median lymph node yield from 15 to 25, P < 0.001 and margin negativity from 8.2 to 5.5%, P = 0.002) was observed with no corresponding increase in severe complications (6.9%) or mortality (1.4%). The proportion of distal and signet ring cancers was found to decrease over time, with an increase in proximal cancers and younger age at presentation. Overall, 90% of GRs were for AGCs with a median overall survival (OS) of 4.4 years (± 6 months), and 5-year OS rate of 47.6% (± 1.9%). Change in pattern of tumor characteristics was observed. Aggressive treatment options for AGC were employed progressively with excellent survival. With increase in volumes, improvements in surgical quality indicators, and a relative improvement in postoperative mortality was observed. These results provide a roadmap for developing dedicated gastric cancer centers.

Has the COVID-19 Pandemic Affected the Prevalence of Diabetic Ketoacidosis in Polish Children with Newly Diagnosed Type 1 Diabetes? An Example of the Largest Polish Pediatric Diabetes Center (Upper Silesia-Katowice, Poland).

Purpose: The aim of this study was to analyze the prevalence of diabetic ketoacidosis (DKA) in children with newly disclosed type 1 diabetes (T1D) during the COVID-19 pandemic in 2020 compared to 2019. Methods: A retrospective analysis of the history database of all hospitalized children in our department. The International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines were used for the diagnosis of DKA. Results: The database of children with newly disclosed T1D included 196 patients (89 girls and 107 boys) from 2019, and 223 patients (113 girls and 110 boys) from 2020 (a total of 419 patients—202 girls and 217 boys) aged 0 to 18 years. A significantly higher percentage of DKA was observed in 2020 compared to the previous year (47.53% vs. 35.2% [p = 0.005]). The percentage of severe DKA increased in 2020 compared to 2019 (18.39% vs. 14.07% [p = 0.118]). Compared to 2019, the average HbA1c level was higher in 2020 (12.57 ± 2.75% vs. 11.95 ± 2.89% [p < 0.025]), and the average pH level (7.26 vs. 7.31 [p = 0.002], and average HCO3 level (16.40 vs. 18.66 [p = 0.001]) were lower, respectively. Conclusions: During the COVID-19 (2020) pandemic, the incidence of DKA increased in Polish children with newly diagnosed T1D. The conclusions from the analysis of the functioning of health systems during the pandemic should be used in the future to prevent, in similar periods, an increase in severe complications of delayed diagnosis of T1D.

Response to Combination Chemotherapy With Paclitaxel/Ifosfamide/Platinum Versus Paclitaxel/Platinum for Patients With Metastatic, Recurrent, or Persistent Carcinoma of the Uterine Cervix: A Retrospective Analysis.

Paclitaxel/ifosfamide/cisplatin triplet has shown a higher response rate than paclitaxel/cisplatin doublet, but the toxicity profile hindered the use of the triplet regimen. In this study, we adjusted the dosage of the triplet regimen and introduced carboplatin in cisplatin-intolerable patients. We tested the efficacy and toxicity of the modified triplet regimen in patients with recurrent or persistent cervical cancer. We retrospectively reviewed the medical records of patients with recurrent or persistent cervical cancer who were treated between 2003 and 2015 at Samsung Medical Center. Response rate, progression-free survival (PFS), overall survival (OS), and toxicity of paclitaxel/ifosfamide/platinum (TIP) and paclitaxel/platinum (TP) were compared. The overall response rate of TIP was significantly higher than that of TP (52.7% vs 36.4%, P = 0.031). In the TP group, response rate was higher in patients with progression-free interval longer than 12 months (P = 0.028) and those with squamous cell histology (P = 0.028). In TIP group, patients with older than 50 years (P = 0.017), progression-free interval longer than 12 months (P = 0.046), and squamous cell carcinoma histology (P < 0.001) showed higher response rates; but TIP showed higher response on all occasions. Median OS and median PFS were similar for TP and TIP (OS, 22.43 months vs 18.5 months, P = 0.44; PFS, 6.37 months vs 8.3 months, P = 0.48). Paclitaxel/ifosfamide/platinum showed a higher response rate than TP in patients with recurrent cervical cancer without an increase in severe complications. Considering the high response rate, TIP may be an option for persistent or recurrent cervical cancer.

The operative risk and natural history after the diagnosis of ileal penetrating Crohn's disease.

Crohn's disease (CD) is marked by transmural inflammation of the bowel wall leading to stricturing and/or penetrating complications in the majority of patients. The natural history and operative risk after the diagnosis of an ileal penetrating complication is understudied. The aim was to study the disease course and need for surgery in patients diagnosed with a penetrating ileal CD complication and to assess the risk factors associated with worse postoperative outcome. In this cohort study, all cross-sectional imaging exams (computed tomography and/or magnetic resonance imaging) performed between 2006 and 2014 in patients with CD in a tertiary referral centre were reviewed for the presence of ileal penetrating complications (defined as abscesses, phlegmones and/or fistula). Demographic, clinical, biochemical, radiological and endoscopic factors were assessed retrospectively in these patients as well as the need for surgery (intestinal resection and/or strictureplasties) and postoperative complications. In total, 1803 cross-sectional imaging exams in 957 CD patients were performed during the study period. In 113 patients, penetrating ileal CD complications were identified. The majority of these patients were referred for surgery (86%) (median time to surgery 1 month, interquartile range: 1-4.9 months). In multivariate analysis, only the presence of abscesses was associated with subsequent surgery (P=0.034; hazard ratio=1.65; 95% confidence interval: 1.04-2.61). Severe postoperative complications (Dindo-Clavien>II) were present in 13% of the patients. Albumin less than 32 g/l was associated with a five-fold increase in severe complications (P=0.039; hazard ratio=4.9; 95% confidence interval: 1-22). Up to 35% of the patients needed no further medical treatment during the first 5 years postoperatively. In this cohort, the majority of patients with penetrating ileal CD underwent surgery. The presence of an abscess showed a significant association with the need for surgery. There was an acceptable postoperative complication rate. Patients with low albumin had an unfavourable postoperative course. The long-term outcome after surgery was favourable.

Сравнительные аспекты бактериологической диагностики, течения и результатов лечения впервые выявленного туберкулеза, изолированного и при его сочетании с хронической обструктивной болезнью легких

Despite the use of modern methods of diagnostics and treatment of surgical infections, there is a steady tendency to the increase in severe complications after acute odontogenic infections (abscesses, sepsis, mediastinitis, and secondary intracranial complications). Sepsis associated with purulent-inflammatory processes of the maxillofacial area mainly develops in the presence of background pathology (68.4%). Patients without background disease (64.8% and 83.9%, respectively) predominate in the group of patients with systemic inflammatory response syndrome and local forms of purulent infections. The most common background pathology involves the respiratory and cardiovascular systems (60%), and rarely - diabetes mellitus, mainly of the second type (about 20%). The background diseases of the digestive system include chronic viral and toxic hepatitis, the disease of operated stomach, alcoholic disease. Isolated cases are those of chronic renal failure requiring hemodialysis (2.4 percent).

Outcome after pharyngeal reconstruction using pectoralis major and radial forearm flap after resection of pharyngeal and laryngeal squamous cell carcinomas.

The objective of this study is to assess the outcome after pharyngeal reconstruction using pectoralis major and radial forearm flaps in pharyngeal and laryngeal carcinomas. 90 patients who underwent flap surgery due to oro/-hypopharyngeal and laryngeal carcinomas were compared with 404 patients without pharyngeal reconstruction. Differences between the groups were analyzed using the Chi-square, Fisher exact, and the unpaired student's t test. Survival rates were calculated by Kaplan-Meier. Overall survival in oropharyngeal and hypopharyngeal/laryngeal cancer showed comparable results in patients with or without pharyngeal reconstruction (5-year: 53.4 vs. 64.2%, p=0.23; 5-year: 51.8 vs. 62.4%, p=0.94), while the survival time after flap surgery was significantly decreased (5-year: 44.8 vs. 62.4%, p<0.02; 5-year: 30.3 vs. 64.2%, p=0.07). Subgroup analysis attributed the worse survival after flap surgery to patients who underwent flap surgery due to functional deficits or recurrent disease (p=0.002). In these patients, the median survival after flap surgery was 26 (hypopharyngeal/laryngeal cancer) or 13months (oropharyngeal cancer) and associated with a significant increase in severe complications and hospitalization time (p<0.0001). The hospitalization time correlated with the history of prior radiotherapy and the extent of surgery (r=0.26; r=0.3; p<0.0001). Flap surgery in primary oropharyngeal and hypopharyngeal/laryngeal cancer showed an unaltered overall survival when compared with patients without reconstruction. Patients with recurrent disease or functional deficits demonstrated a significant decrease in survival combined with an increase of severe complications.

Does Antiplatelet Therapy Affect Outcomes of Patients Receiving Abdominal Laparoscopic Surgery? Lessons from more than 1,000 Laparoscopic Operations in a Single Tertiary Referral Hospital

The effect of antiplatelet therapy (APT) on surgical blood loss and perioperative complications in patients receiving abdominal laparoscopic surgery still remains unclear. A total of 1,075 consecutive patients undergoing abdominal laparoscopic surgery between 2005 and 2011 were reviewed. Our perioperative management protocol consisted of interruption of APT 1 week before surgery and early postoperative reinstitution in low thromboembolic risk patients (n = 160, iAPT group). Preoperative APT was maintained in patients with high thromboembolic risk or emergent situation (n = 52, cAPT group). Perioperative and outcomes variables of cAPT and iAPT groups, including bleeding and thromboembolic complications, were compared with those of patients without APT (non-APT group, n = 863). In this cohort, 715 basic and 360 advanced laparoscopic operations were included. No patient suffering excessive intraoperative bleeding due to continuation of APT was observed. There were 10 postoperative bleeding complications (0.9%) and 3 thromboembolic events (0.3%), but the surgery was free of both complications in the cAPT group. No significant differences were found between the groups in operative blood loss, blood transfusion rate, and the occurrence of bleeding and thromboembolic complications. Multivariable analyses showed that multiple antiplatelet agents (p = 0.015) and intraoperative blood transfusion (p = 0.046) were significant prognostic factors for postoperative bleeding complications. Increased thromboembolic complications were independently associated with high New York Heart Association class (p = 0.019) and history of cerebral infarction (p = 0.048), but not associated with APT use. Abdominal laparoscopic operations were successfully performed without any increase in severe complications in patients with APT compared with the non-APT group under our rigorous perioperative assessment and management. Maintenance of single APT should be considered in patients with high thromboembolic risk, even when an abdominal laparoscopic approach is considered.

Hospitalization for Acute Otitis Media as a Useful Marker for Disease Severity

An increase in severe complications to otitis media is a potential threat to antibiotic restrictions and is difficult to measure due to its low-prevalent nature. Easily accessible indicators sensitive to illness change are needed to benchmark the judicious use of antibiotics. To investigate whether there has been a constant increase of hospital admissions for acute otitis media after the year 2000. Registry-based study with complete data on hospitalization for acute otitis media and acute mastoiditis in Norway during 1999 to 2006. Mean incidence rate for acute otitis media hospitalization was 22.4 per 10,000 children and peak incidence in the second year of life 52.2 per 10,000 children. Corresponding mean incidence rate and peak incidence for acute mastoiditis were 1.5 and 3.5 per 10,000 children in the second year of life, respectively. There was a gradient increase of the incidence rates of acute otitis media hospitalization from the year 2000 to 2006 considering the Poisson regression model with a significant test of linear trend. Hospital admission for acute otitis media is prevalent enough to be a useful marker for otitis media severity and its distribution proportionate to that of acute mastoiditis.

Post Cardiac Arrest Syndrome

Out-of-hospital cardiac arrest (OHCA) is a common initial presentation of cardiovascular disease, affecting up to 325 000 people in the United States each year.1 In a recent meta-analysis of >140 000 patients with OHCA, survival to hospital admission was 23.8%, and survival to hospital discharge was only 7.6%.2 In patients who initially achieve return of spontaneous circulation (ROSC) after OHCA, the significant subsequent morbidity and mortality are due largely to the cerebral and cardiac dysfunction that accompanies prolonged whole-body ischemia. This syndrome, called the post cardiac arrest syndrome, comprises anoxic brain injury, post cardiac arrest myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating pathology3,4 (Table 1). The contribution of each of these components in an individual patient depends on various factors, including prearrest comorbidities, duration of the ischemic insult, and cause of the cardiac arrest. This review focuses on therapeutic strategies and recent developments in managing patients who are initially resuscitated from cardiac arrest. View this table: Table 1. Post Cardiac Arrest Syndrome: Pathophysiology and Potential Treatment Strategies There are 3 major aspects that require consideration in the management of the post cardiac arrest patient. After resuscitation, a decision must be made in relation to the appropriate triage of the OHCA patient. The next phase of management concerns the in-hospital treatment, which must address each component of the postarrest syndrome as appropriate for the individual patient. Finally, there are issues relating to prognostication and the deployment of various secondary prevention measures. Our recommended treatment algorithm is summarized in the Figure. This ideally follows from the implementation of basic and advanced life support measures, including effective cardiopulmonary resuscitation and defibrillation when appropriate, which are major determinants of outcome.2 Such an approach to care may be further modified according to the presence of other comorbidities and precipitating factors, which should be assessed …

Initial laboratory predictors of severe hepatitis and acute kidney injury in patients with acute hepatitis A

The number of adult patients with acute hepatitis A (AH-A) has markedly increased during the last 10 years in Korea. Of special note, an increase in severe complications of AH-A, such as severe liver dysfunction and acute kidney injury (AKI), has emerged as a significant problem. The objective of this study was to identify the initial predictors for development of severe AH-A and AKI in AH-A. We retrospectively reviewed the medical records of 194 patients with AH-A from January 2007 to March 2009. Severe AH-A and AKI developed in 16 (9.3%) and 11 (6.4%) patients, respectively. Independent predictors for severe AH-A were low albumin [odds ratio (OR), 10.91; 95% confidence interval (CI), 2.324−51.215; P = 0.002], low total cholesterol (OR, 5.54; 95% CI, 1.389−22.113; P = 0.015), and elevated alanine aminotransferase (OR, 20.87; 95% CI, 4.581–95.067; P < 0.001). Also, high level of C-reactive protein was independently associated with AKI occurrence in AH-A (OR, 10.91; 95% CI, 2.324−51.215; P = 0.002).

Early Management of Acute Gallstone Pancreatitis

Early Management of Acute Gallstone Pancreatitis

Experience with split-course external beam irradiation ± chemotherapy and integrated Ir-192 high-dose-rate brachytherapy in the treatment of primary carcinomas of the anal canal

Purpose: The effect of the treatment of anal cancer by performing a high-dose-rate (HDR) brachytherapy boost during a short split between the external beam radiotherapy series (EBR) ± chemotherapy was investigated. Methods and Materials: Thirty-nine patients with anal canal cancers, stages T1–T4 N0–2 M0, were treated with split-course EBR (50–50.4 Gy) and a Iridium 192 ( 192Ir-) HDR boost (6 Gy) performed during the 1–2-week split. Patients who failed to achieve a complete tumor response received additional brachytherapy. Chemotherapy with 5-fluorouracil and mitomycin C was offered to patients with tumors > 3 cm and employed concomitantly on days 1–5 and day 1, respectively, of each EBR series. Results: Follow-up ranged from 3 to 140 months (median 31). Median treatment duration was 56 days. The 3-year (5-year) actuarial rates of locoregional control (LRC) and disease-specific survival (DSS) were 81% (76%) and 80% (76%), respectively. The crude rate of anal preservation was 77% overall, and 97% in patients in whom LRC was achieved. Uncompromised anal function was recorded in 93% of these patients. The actuarial 3-year (5-year) rate of colostomy-free survival (CFS) was 78% (73%). There was a statistically significant difference in LRC and DSS according to stage, tumor size, and nodal status. Complications requiring surgical intervention occurred in 7.6% of patients. Conclusion: The integration of the HDR boost in a split-course EBR regimen ± chemotherapy resulted in excellent sphincter function without an increase of severe complications and with rates of LRC, DSS, and CFS, which compare favorably with those reported in the literature.

Complications of intraoperative radiation therapy

The ability to demonstrate an improvement in therapeutic ratio is critical in assessing new treatment modalities; an evaluation of treatment complications is essential for this purpose. We have studied the severe complications occurring after treatment with intraoperative radiation therapy (IORT) in patients with locally advanced carcinoma of the rectum. Four groups of patients were compared: Group 1 (80 patients) had treatment with surgery alone for mobile and resectable tumors, Group 2 (23 patients) had treatment with high dose preoperative irradiation followed by surgical resection for tumors which were fixed to adjacent structures and initially unresectable for cure; Group 3 (24 patients, primary disease) and Group 4 (17 patients, locally recurrent disease) had locally advanced tumors as in Group 2 but were treated with IORT after preoperative irradiation and attempted surgical resection. All but 3 complications occurred within one year of therapy. Severe complications were seen In 16% of patients in Group 1, 35% in Group 2, 21% in Group 3 and 47% in Group 4 (32% in Groups 3 and 4 combined). There was a statistically insignificant increase (p = .10) in the complication rate in all irradiated patients (locally advanced tumors) compared to surgery alone (clinically mobile tumors). These data indicate no increase in severe complications with the use of IORT. If the ongoing studies continue to show improved local control with the use of IORT, expanded use of this modality may be warranted.