Large Consecutive Case Series Research Articles

The GRACE (Global Registration of Acute Coronary Events) score predicts heart failure readmission

Purpose: The GRACE score is an established predictor of recurrent myocardial infarction/death following admission to hospital with acute coronary syndrome. Whether GRACE also predicts readmission with heart failure is unknown. Methods: In a large consecutive case-series of patients with acute coronary syndrome admitted to a single centre over a 5 year period, we evaluated the utility of the GRACE score for predicting readmission to hospital with a diagnosis of heart failure. Readmissions were identified via linkage to a national healthcare utilisation database. Heart failure readmission was defined as the presence of ICD10 code I50. Hazard ratios (HR) were estimated by quintile of GRACE score in unadjusted Cox regression models, and adjusting for age, gender and the presence of heart failure on the index admission. The area under the receiver operating characteristic curve (AUC) was estimated. The net reclassification index was calculated using cut-offs of 1,5,10 and 20% 1-year risk of heart failure readmission. Results: 2036 patients, mean age 66, 66% male, had a total of 243 events over 3.8 median years of follow-up. 44 patients had heart failure on the index admission. Compared to the lowest quintile, patients in the highest GRACE score quintile had more heart failure readmissions (82 vs 17) and a lower time to first heart failure readmission (1.5 vs 5.9 years, HR 8.48, 95% CI 5.03-14.3). Associations were also evident after adjusting for age (HR 4.89, 95% CI 2.69-8.79) and heart failure on index admission (3.84, 95% CI 2.10-7.02). The AUC for GRACE score, age and heart failure on index admission combined was 0.71. The net reclassification index (NRI) for the addition of GRACE score to age was 17.4% (13.7 for cases, NRI 3.7 for controls). Similar results were obtained after excluding patients with heart failure on the index admission. View this table: Rate of heart failure readmission by quintile of GRACE score Conclusions: When added to age, gender and heart failure on initial admission, the GRACE score improves prediction of heart failure readmission among people admitted to hospital with acute coronary syndrome.

Outpatient Vaginal Hysterectomy

To present tactics for optimizing outpatient vaginal hysterectomy and describe perioperative outcomes in a large consecutive case series. This is a descriptive study and review of clinical outcomes in 1,071 patients selected to undergo vaginal hysterectomy for benign indications from 2000 to 2010. The setting is a single-surgeon private practice in a community hospital. Outcome measures include length of hospital stay, estimated blood loss, operative time, uterine weight, and perioperative complications, including hospital readmissions and emergency room visits. One thousand seventy-one of 1,162 cases (92%, 95% confidence interval [CI] 90.5-93.7) were total vaginal hysterectomies, of which 1,029 (96%, 95% CI 94.9-97.3) were discharged the same day after surgery. The median operative time was 34 minutes (range 17-210 minutes), and estimated blood loss was 45 mL (range 5-800 mL). The median patient age was 46 years (range 27-86 years), and median uterine weight was 160 g (range 25-1,380 g). One hundred ninety-three patients (18%, 95% CI 15.8-20.5) were nulliparous and 218 (20%, 95% CI 18-22.9) had prior pelvic surgery. Five patients (0.5%, 95% CI 0.2-1.1) required readmission or emergency room evaluation within the first 30 days. Vaginal hysterectomy can be successfully adopted as a same-day discharge procedure. In this population, regardless of previous pelvic surgery or nulliparity, good perioperative outcomes have been achieved.

Long-Term Experience of Patch Graft Failure After Ahmed Glaucoma Valve ® Surgery Using Donor Dura and Sclera Allografts

To report the long-term incidence, timing, and experience of patch graft failure (PGF) after Ahmed Glaucoma Valve (AGV) (New World Medical, Inc., Rancho Cucamonga, CA) surgery in a large consecutive case series using donor dura mater and sclera sequentially as the allograft materials. The medical records of all AGV surgeries performed from June 1994 through December 2010 were retrospectively reviewed for cases of PGF. Patch graft failure occurred in 44 (6.3%) of the initial 695 procedures using dura and in 65 (5.8%) of the subsequent 1,121 procedures using sclera (P = .64). The time interval after AGV surgery until the occurrence of PGF was significantly longer for dura (5.8 ± 3.8 years) than for sclera (2.7 ± 1.9 years) (P < .001). After an average of 4 years, PGF occurred in 109 (6%) of 1,816 consecutive AGV surgeries using donor dura and sclera allografts. PGF may be the most frequent long-term complication after AGV surgery.

305: The influence of parity on maternal and neonatal outcomes in shoulder dystocia

305: The influence of parity on maternal and neonatal outcomes in shoulder dystocia

Delayed- Versus Acute-Onset Endophthalmitis After Cataract Surgery

To report a large consecutive case series of patients who developed delayed-onset and acute-onset endophthalmitis after cataract surgery. Retrospective consecutive case series. The current study is a retrospective consecutive case series of patients treated between January 2000 and December 2009 for culture-proven endophthalmitis after cataract surgery. The study defined 2 groups after cataract surgery: acute-onset endophthalmitis (≤6 weeks after surgery) and delayed-onset endophthalmitis (>6 weeks after surgery). A total of 118 patients met study criteria; cases included 26 delayed-onset cases and 92 acute-onset cases. The following clinical features and outcomes occurred in delayed- vs acute-onset cases: 1) the presenting visual acuity was ≤5/200 in 31% vs 89%; 2) hypopyon was found in 46% vs 80%; 3) the most frequent isolate was Propionibacterium acnes (11/26) vs coagulase-negative Staphylococcus (57/92); and 4) patients with the most frequent isolate achieved a visual outcome of ≥20/100 in 91% vs 56%. In delayed-onset cases, the intraocular lens was removed or exchanged in 19 of 26 cases (73%). Of these 19 cases, 13 achieved a visual outcome of ≥20/100. Patients with delayed-onset endophthalmitis generally presented with better initial visual acuities, had a lower frequency of hypopyon, and had better visual outcomes compared to acute-onset patients. Propionibacterium acnes and coagulase-negative Staphylococcus species were the most common organisms cultured in delayed- and acute-onset categories, respectively, and were associated with the best visual acuity outcomes in each group.

Prognostic significance of failure to cross esophageal tumors by endoluminal ultrasound

Failure to intubate and cross esophageal tumors by endosonography is reported in as many as 30% of cases and is thought to be associated with an especially poor prognosis. The aim of this study was to audit the above in a large consecutive case series of Endoscopic Ultrasound (EUS) examinations for esophageal cancer performed in a regional specialist cancer network with particular reference to outcome. A consecutive series of 411 patients underwent EUS examination by a specialist radiologist over a period of 9 years. Forty (10%) of patients required dilation, and there was total failure to cross the tumor in 12 patients (2.9%). Failure to traverse the primary tumor was associated with a diagnosis of squamous cell cancer (8 of 12 patients, 66%, rho = -0.182, P = 0.011). Limited staging information was obtained in 7 of these patients, which altered the computed tomography stage in 5 patients (71%, 3 upstaged, 2 downstaged). Six patients received definitive chemoradiotherapy, two patients surgery and four patients palliative chemotherapy. The median and 5-year survival in patients whose tumors were not crossed was 10 months and 28%, respectively, compared with 24 months and 24%, respectively in patients whose tumors were fully assessed. Failure to cross esophageal tumors in practice was far less common than the literature suggests, and esophageal tumor luminal stenosis should no longer be considered a limitation of endosonography.

Rapid Prenatal Diagnosis by QF‐PCR: Evaluation of 30,000 Consecutive Clinical Samples and Future Applications

Rapid prenatal diagnoses of major chromosome abnormalities can be performed on a large scale using highly polymorphic short tandem repeats (STRs) amplified by the quantitative fluorescent polymerase chain reaction (QF-PCR). The assay was introduced as a preliminary investigation to remove the anxiety of the parents waiting for the results by conventional cytogenetic analysis using amniotic fluid or chorionic cells. However, recent studies, on the basis of the analyses of several thousand samples, have shown that this rapid approach has a very high rate of success and could reduce the need for cytogenetic investigations. Its high efficiency, for example, allows early interruption of affected fetuses without the need of waiting for completion of fetal karyotype. The main advantages of the QF-PCR are its accuracy, speed, automation, and low cost that allows very large number of samples to be analyzed by few operators. Here, we report the results of using QF-PCR in a large series of consecutive clinical cases and discuss the possibility that, in a near future, it may even replace conventional cytogenetic analyses on selected samples.

Does family history influence survival in breast cancer cases?

A few studies have suggested a relatively better prognosis for breast cancer (BC) cases reporting a positive family history (FH). We aimed at comparing the survival of patients according to FH in a large hospital-based series of 1,278 BC cases. Information on FH for BC was obtained at diagnosis by interview. All cases reporting a first- or second-degree FH for breast carcinoma were compared with cases without FH. Overall survival was estimated using a product-limit method. Hazard ratios (HRs) and the corresponding 95% confidence intervals (95% CIs), adjusted for confounding factors, were computed using proportional hazard models. Overall, 240 (18.8%) cases reporting, at diagnosis, a positive FH (156 with at least 1 first-degree relative and 84 with at least 1 second-degree relative) were compared with 1,038 patients without FH for BC. No significant differences were found in terms of distribution of age at diagnosis, tumor stage, nodal involvement, receptor status and histology. Cumulative survival rates at 5 years for cases without FH and with first-degree and second-degree FH for BC were 79.8 (95% CI 77.0-83.0), 78.6 (95% CI 70.0-88.0) and 80.2 (95% CI 68.0-92.0), respectively (log-rank test, chi(2) (2) = 0.02, p = 1.0). After adjustment for age, pathologic size and nodal involvement, the HR among cases of invasive cancer with a first-degree FH of BC was 0.91 (95% CI 0.55-1.48); however, the HR for cases with second-degree FH was 1.18 (95% CI 0.62-2.25) compared to cases without FH. Our study, based on a large series of consecutive invasive BC cases, did not find any significant survival differences associated with a positive FH for breast carcinoma, suggesting the existence of a large heterogeneity among BC cases with FH.

Molluscum contagiosum: histologic patterns and associated lesions. A study of 578 cases.

Molluscum contagiosum (MC) is rarely associated with other skin diseases, especially cutaneous neoplasms. Such associations are exceptional and of unknown frequency. The aim of this study was to record the histologic variants and frequency of associated lesions in a large series of consecutive MC cases. We reviewed 578 MC cases from the Laboratory of Dermatopathology of the University Hospitals of Strasbourg, France (1959-1999). The locations of MC were as follows: head and neck (34.7%), trunk (27.1%), lower limbs (20.7%), upper limbs (8.7%), and genitalia (3.8%). Molluscum contagiosum occurred more often in female patients (56.7%). The age range of patients included in this study was 0 to 19 years (34.9%), 20 to 39 years (31.1%), 40 to 59 years (22.8%), and over 60 years (6.5%). Histologic variants of MC were noted in 46 cases (31 pseudocystic, 8 giant, and 7 pedunculated). An underlying abscess was present in 65 cases. Of the 578 cases, 22 were associated with other lesions (3.8%). There were 9 cases of epidermal cysts, 4 of nevocellular nevi, 3 of metaplastic ossifications, 2 of true epidermal nevi, 2 of sebaceous hyperplasias, 2 of soft fibromas, and 1 of Kaposi sarcoma. Except in immunocompromised patients, such associations are likely to be coincidental. The clinical diagnosis was correct in 42.3% of the cases. Clinical accuracy varied according to the age, localization, and histologic pattern of MC. Pseudocystic MC, giant MC, and MC associated with other lesions were responsible for frequent clinical misdiagnosis.

Pseudophakic retinal detachment: anatomic and visual results

Our purpose was to report the anatomic and visual results of pseudophakic retinal detachment surgery in a large series of consecutive cases and to analyze the risk factors for anatomic and functional failure. This retrospective study covered 290 primary cases of idiopathic rhegmatogenous retinal detachment operated on by the same surgeon during an 8-year period. Data relating to 26 pre-, per-, and postoperative variables were studied. For the statistical analyses we used both Chi-square and stepwise logistic regression tests. Vitreous loss occurred in 56 cases (19.3%), and the retina detached more than 2 years after lens extraction in 108 cases (37.2%). Breaks could be identified in 249 cases (85.8%), and the macula was involved in 235 (81%). The overall reattachment rate was 85.2% (247/290), and a postoperative visual acuity of 0.5 D or more was attained in 49.6% of cases (144/290). We found no difference between phakoemulsification, extracapsular, intracapsular techniques or between anterior chamber, posterior chamber, iris-fixated lenses as regards anatomic and functional outcomes. Proliferative vitreoretinopathy (PVR) and photoreceptor dysfunction were the main causes of anatomic and functional failure respectively. We identified extensive detachment, preoperative choroidal detachment, intraoperative hemorrhage and surgery for PVR as predictors of anatomic failure, while preoperative inflammation, preoperative PVR of grade B or worse, and surgery for PVR were predictors of functional failure. In this series, anatomic and visual results of reattachment surgery were much more affected by detachment features and by PVR than by the techniques and complications of cataract surgery.

PULMONARY PATHOLOGIC CONDITIONS IN INFANCY AND IN CHILDHOOD

Much has been written on the recognition and the management of foreign bodies in the respiratory tract in children and the attendant infections. Time and space do not permit individual references to the many publications of Jackson, Clerf and Tucker on this subject. The experiences of my co-workers and me over a ten year period have been described in a paper in which we analyzed a large series of consecutive cases of foreign bodies in the food and the air passages. 1 A second communication dealt with oxygen therapy in the postbronchoscopic care of children following the extraction of foreign bodies. 2 Hence, in the present paper I shall not deal with foreign bodies per se. Pulmonary suppuration has also had a voluminous literature since the advent of bronchoscopy. It is believed, nevertheless, that a presentation solely from the pediatric aspect will lack neither in clinical nor in therapeutic interest.