Major Respiratory Complications Research Articles

Breast Reconstruction in the Morbidly Obese Patient

The authors assess the risk and safety profiles of both implant and autologous breast reconstructions in the morbidly obese population using the National Surgical Quality Improvement Program data sets. The authors reviewed the 2005 to 2010 National Surgical Quality Improvement Program databases, identifying encounters for Current Procedural Terminology codes including either implant-based reconstruction or autologous reconstruction. Patients were classified and compared based on World Health Organization obesity criteria. Complications were divided into three categories: major surgical complications, wound complications, and medical complications. During the study period, 15,937 breast reconstructions were identified. The incidence of obesity was 27.1 percent, with 4.0 percent defined as class III (morbidly) obese. Morbidly obese patients had significantly higher rates of almost all complications compared with nonobese patients, including major surgical complications (p < 0.001), medical complications (p < 0.001), respiratory complications (p = 0.015), venous thromboembolism (p = 0.001), and wound complications (p < 0.001). These patients also were more likely to require a return to the operating room both for any reason (p < 0.001) and specifically for prosthesis/flap failure (p < 0.001). Morbid obesity was found to be an independent predictor of wound complications (OR, 2.1; p < 0.001), surgical complications (OR, 1.6; p < 0.001), medical complications (OR, 1.6; p = 0.01), and return to the operating room (OR, 1.5; p < 0.001). There was no significant difference in the 30-day surgical complication rates between implant and autologous reconstructions in the morbidly obese (p = 0.23). Morbid obesity is associated with a significantly increased risk of perioperative complications that translates into progressive, higher rates of overall morbidity, regardless of reconstructive modality. Risk, II.

African American ethnicity as a risk factor for respiratory complications following adenotonsillectomy.

To evaluate whether African American ethnicity is a risk factor for major respiratory complications following adenotonsillectomy (T&A). Retrospective cohort study. A Canadian tertiary care center. PATIENTS Children aged 0 to 18 years who underwent T&A at our institution from 2002 to 2006 with planned or unplanned postoperative admissions. We evaluated the association between ethnicity and our main outcome measure, major perioperative respiratory complications of T&A. Parental report of ethnicity was available for 23% of our cohort. At our institution, African American children undergo a routine preoperative sickle cell test (TestSC). Data on TestSC were included for all children. We established that having a TestSC was an accurate proxy for African American ethnicity (sensitivity, 96%; specificity, 93%; positive predictive value, 77%; negative predictive value, 99%). Seventy-four of 594 children experienced major respiratory complications (12.5%). Compared with children who did not have major respiratory complications, those who did had a TestSC (P = .01), were 2 years or younger (P < .001) and had lower weight-for-age z scores (P = .04), moderate to severe obstructive sleep apnea (P = .003), and comorbidities (P < .001). When controlling for these variables in a multivariate analysis, children of African American ethnicity (TestSC used as a proxy) were at higher risk of having major perioperative respiratory complications (adjusted odds ratio, 1.82 [95% CI 1.05-3.14]) (P = .003). Children of African American ethnicity (TestSC used as a proxy) are nearly twice as likely to experience major respiratory complications related to T&A. Ethnicity may be an additional independent risk factor for clinicians to consider when planning for T&A.

Quantifying respiratory complications post-adenotonsillectomy in patients with normal or inconclusive overnight oximetry

BackgroundChildren with sleep-disordered breathing (SDB) are at risk of developing post-operative respiratory complications following adenotonsillectomy (T&A). Our goal was to describe and quantify these complications following T&A in children with clinical SDB but with a pre-operative overnight home oximetry score of “normal/inconclusive” (McGill Oximetry Score (MOS) of 1), and to determine whether these children could safely undergo surgery in peripheral hospitals or outpatient surgical centers.MethodsWe performed a retrospective chart review of patients 3 years and older who had T&A between 2003 and 2010 at 2 of our institution’s hospitals. To be included in the study, in addition to not having severe comorbidities, children had to have undergone an overnight home oximetry within 12 months of surgery that was normal or inconclusive (MOS of 1). This was defined as fewer than 3 episodes of oxygen desaturation below 90% and stable baseline saturation over 95%. Medical charts were reviewed for major and minor postoperative respiratory complications. The main outcome measure was post-T&A respiratory complications.ResultsOut of 2708 T&A patients, 231 met the inclusion criteria. No patient had a major postoperative respiratory complication requiring re-intubation or admission to the intensive care unit. Five patients (2.16%) had minor respiratory complications but only one required admission to the ward.ConclusionsAn overnight home oximetry that is “normal/inconclusive” (MOS of 1) can be used as a screening tool to identify patients with sleep-disordered breathing who can be safely sent to peripheral hospitals or outpatient surgical centers for T&A.

Predicting Severe Postoperative Respiratory Complications following Abdominal Wall Reconstruction

Patients undergoing abdominal wall reconstruction are at risk of developing major postoperative respiratory complications. The authors attempted to identify factors predictive of respiratory complications following abdominal wall reconstruction. All patients who underwent complex abdominal wall reconstruction over a 2-year period were reviewed. The primary endpoint studied was severe respiratory complication, defined as respiratory insufficiency requiring intubation or transfer to a higher level of care. Sixty patients underwent complex abdominal wall reconstruction during the study period. The incidence of respiratory complications was 20 percent. Factors predictive of postoperative respiratory complication included age (p = 0.05), American Society of Anesthesiologists score (p = 0.04), and hernia defect size (p = 0.01). In addition, patients who developed respiratory complications were more likely to have had a greater change in plateau pressure (5.8 versus 2.3 cmH(2)O; p = 0.01). The greater the change in plateau pressure, the greater the risk of developing a respiratory complication: for a change in plateau pressure greater than or equal to 6 cmH(2)O, the odds ratio was 8.67; for a change in plateau pressure greater than or equal to 9 cmH(2)O, the odds ratio was 11.5. Respiratory complications following abdominal wall reconstruction can be serious and are associated with prolonged hospitalizations. Patients with an increase in their plateau pressure of greater than 6 cmH(2)O are at an increased risk of severe postoperative respiratory complications.

Major respiratory adverse events after laparascopic gastric banding surgery for morbid obesity

Laparoscopic adjustable gastric banding surgery has become one of the most common restrictive surgical procedures for treatment of morbid obesity worldwide. Although short-term respiratory complications are well known, long-term data is scarce. We investigated the manifestations of major pulmonary complications showed at least six months after the procedure. A retrospective cohort study was conducted at a tertiary university medical center in the five years period of 2006-2010. We included every patient who had had major respiratory complication who needed hospitalization, at least 6 months after laparoscopic adjustable gastric banding procedure. Demographic, pre-operative and post-operative clinical data were collected. We documented respiratory symptoms, results of physical examination, pulmonary function tests, and imaging as well as therapies given and outcome. Out of 2100 patients who underwent LAGB, thirty subjects, mean age of 45.7 (range 29-64) with an equal number of males and females were included. Mean interval between operation and onset of respiratory symptoms was 51.5 months (range 10-150 months). All had dyspeptic complaints which included: regurgitation, fullness after meals, dysphagia and food aspiration with esophageal dilatation. Major respiratory complications included aspiration pneumonia (19) including pulmonary abscess (4) and empyema (2), exacerbation of asthma (3) and hemoptysis (1). Additionally we documented the emergence of chronic diseases such as interstitial lung disease (5) and bronchiectasis (3). One patient developed acute respiratory distress syndrome due to aspiration pneumonia and eventually died in the intensive care unit. The main mode of therapy was deflation of the gastric band. Those who refused to deflate or remove the gastric banding continued to suffer from dyspeptic and respiratory symptoms including recurrent pulmonary abscess. Although laparoscopic adjustable gastric banding surgery has few short-term risks and is highly effective at achieving weight reduction, we found an increased risk for major respiratory complications in the long-term period. The obesity epidemic and the increased use of surgical techniques to treat obesity will most likely lead to an increase in the incidence of long-term post-operative respiratory complications. This entity is probably under-reported and needs further research into how to reduce its incidence and morbidity.

Emergent Repair of Acute Thoracic Aortic Catastrophes

To provide a contemporary institutional comparative analysis of expedient correction of acute catastrophes of the descending thoracic aorta (ACDTA) by traditional direct thoracic aortic repair (DTAR) or thoracic endovascular aortic repair (TEVAR). Single-center retrospective review (April 2001-January 2010). Academic medical center. One hundred patients with ACDTA treated with either TEVAR (n=76) or DTAR (n=24). Indications for repair included ruptured degenerative aneurysm (n=41), traumatic transection (n=27), complicated acute type B dissection (n=20), penetrating ulcer (n=4), intramural hematoma (n=3), penetrating injury (n=3), and embolizing lesion (n=2). Demographics and 30-day and late outcomes were analyzed using multivariate analysis over a mean follow-up of 33.8 months. Among the 100 patients, mean (SD) age was 58.5 (17.3) years (range, 18-87 years). Demographics and comorbid conditions were similar between the 2 groups, except more patients in the DTAR group had prior aortic surgery (P=.02) and were older (P=.01). Overall 30-day mortality was significantly better among the TEVAR group (8% vs 29%; P=.007). Incidence of postoperative myocardial infarction, acute renal failure, stroke, and paraplegia/paresis was similar between the 2 treatment groups (TEVAR, 5%, 12%, 8%, and 8% vs DTAR, 13%, 13%, 9%, and 13%, respectively). Major respiratory complications were lower in the TEVAR group (16% vs 48%; P<.05). Mean length of hospital stay was also shorter after TEVAR (13.5 vs 16.3 days; P=.30). Independent predictors of patient mortality included age (P=.004) and DTAR (P=.001). Patients presenting with ACDTA are best treated with TEVAR whenever feasible.

Spinal Fusion for Scoliosis in Rett Syndrome With an Emphasis on Early Postoperative Complications

Retrospective case-control study. To examine the postoperative complications of posterior spinal fusion in a population of patients with Rett syndrome (RS). Scoliosis is a common feature of RS, a progressive neurologic disorder affecting almost exclusively females. Despite this, there is little published information regarding the surgical treatment of scoliosis in this disorder. Sixteen consecutive female patients with RS treated by posterior spinal fusion and unit rod instrumentation for progressive scoliosis between 1995 and 2003 were evaluated. Only patients with a minimum of 2-year follow-up were included. Preoperative medical conditions and postoperative complications were recorded. As a control group, we randomly selected 32 spastic quadriplegic patients who underwent the identical procedure during the same time period, selected from our database and matched according to age, level of neurologic impairment, and medical complexity. There was a high rate of early medical complications in the RS patients, with 28 major and 37 minor complications. Only 1 patient did not have a major medical complication, and every patient had at least 1 minor gastrointestinal and/or respiratory complication. Major respiratory complications occurred in 10 patients (63%) and comprised 61% of all major complications. Major gastrointestinal complications occurred in 6 patients (37%) and comprised 21% of all major complications. Other major complications included disseminated intravascular coagulopathy (1 patient), subacute bacterial endocarditis (1 patient), sacral decubiti requiring surgical debridement (2 patients), and extensive bilateral heterotopic ossification of the hips (1 patient). There were no cases of instrumentation failure, pseudarthrosis, deep infection, or need for rod revision. Postoperative complication scores were similar to those in patients with spastic quadriplegic pattern cerebral palsy. Spinal fusion for scoliosis in RS can give a satisfactory technical result, but a high rate of early postoperative medical problems should be anticipated.

Invited Commentary

Invited Commentary

1410 Postoperative Treatment in Picu. A 5-Year Experience

Aim: The objective of this study is to evaluate incidence, indications, length of stay and outcome of pediatric patients admitted postoperatively in a Pediatric Intensive Care Unit (PICU). Methods: Chart of 140 patients admitted to our PICU after different surgical procedures from January 2005 to December 2009, were reviewed retrospectively. Results: Age of patients ranged from 35 days to 14 years (mean age : 11,38 years) Types of surgical procedures demanding postoperative treatment in PICU are showed in table. Indications for PICU admission were : postoperative intensive treatment (88 patients), respiratory complications (31 patients), sepsis (11 patients) and low conscious level (10 patients). The incidence was 23,41% of total admissions. Mortality rate was 7,85% (mainly after major intracranial surgery). Mean duration of treatment was 7,82 days. Conclusions: Progress in intensive care improved outcome after major and complicated surgical procedures in pediatric population. In this study the main causes of admission in PICU postoperatively were major intracranial surgery (42,14%) and respiratory complications (22,14%).

Perioperative fluid management and major respiratory complications in patients undergoing esophagectomy

Esophageal surgery is often related to a high morbidity and mortality rate despite an improvement in postoperative care. Fluid administration has been described to be a factor that contributes to the development of postoperative respiratory complications after esophageal surgery. The aim was to study the relation between intraoperative and postoperative fluid administration and the development of respiratory complications after esophageal surgery. Patients undergoing esophageal surgery for cancer were selected from a prospective nonrandomized computer database. All of the patients underwent esophagectomy according to the Lewis-Tanner approach. Single-lung ventilation was used in all of the patients during the thoracic approach. The patients were divided in two groups with respect to the development of respiratory complications. Variables studied were American Society of Anesthesiologist Score, sex, preoperative chemoradiotherapy, albumin, smoking history, time until extubation, epidural analgesia, and fluid administration intraoperatively and 5 days postoperatively. Forty-five patients were included in the study. Respiratory complications were observed in nine patients (20%). None of the variables studied except fluid administration (P= 0.005 - odds ratio = 1.001 -95% confidence interval) were shown as a risk factor for the development of respiratory complications on the multivariate analysis. Fluid administration intraoperatively and postoperatively has shown to be a contributing factor for the development of respiratory complications after esophageal surgery.

Preoperative Evaluation for Thoracic Surgery

The goal of the preoperative evaluation for thoracic surgery is to assess and implement measures to decrease perioperative complications and prepare high-risk patients for surgery. Major respiratory complications, such as atelectasis, pneumonia, and respiratory failure, occur in 15% to 20% of patients and account for most of the 3% to 4% mortality rate. Development of pulmonary complications has been associated with higher postoperative mortality rates. Strategies aimed at preventing postoperative difficulties have the potential to reduce morbidity and mortality, decrease hospital stay, and improve resource use. One lung ventilation leads to a significant derangement of gas exchange, and hypoxemia can develop due to increased intrapulmonary shunting. Recent advances in anesthetic management, monitoring devices, improved lung isolation techniques, and improved critical care management have increased the number of patients who were previously considered inoperable. In addition, there is a growing tendency to offer surgery to patients with significant lung function impairment; hence a higher incidence of intraoperative gas-exchange abnormalities can be expected. The anesthesiologist must also consider the risks of denying or postponing a potentially curative operation in patients with lung cancer. Detailed consideration of the information provided by preoperative testing is essential to successful outcomes following thoracic surgery.

Therapeutic Lung Lavage with Diluted Surfactant in Neonates with Severe Meconium Aspiration Syndrome

Meconium aspiration syndrome (MAS) may result in considerable morbidity and mortality in newborn infants. The current standard treatment is still in need of improvement for the most severe patients. We report 3 cases with devastating MAS that was successfully treated with therapeutic lung lavage. These cases were all delivered in local obstetrics clinics or hospitals with meconium-stained amniotic fluid and non-vigorous appearance at birth. However, no endotracheal suction was performed when they were born. All of them suffered from severe hypoxia and unstable vital signs despite there being high ventilatory settings when they were transferred to the tertiary medical center. Therapeutic lung lavage with diluted surfactant (Survanta, 5 mg/mL, 30 mL/kg in 2 aliquots) was performed within 24 hours of age. Bloody fluid (about 40-50% of total lavage amount) was recovered in all 3 cases. Although brief desaturation and bradycardia were observed during the procedures, 2 of them tolerated the procedures well and improved soon after lavage. The other patient received lung lavage in a relatively unstable condition and needed chest tapping to relieve bilateral pleural effusion. Their respiratory condition improved after the procedures, and they were all discharged within 1 month without major respiratory complications. These successful experiences are compatible with previous animal studies and other case reports with different lavage protocols. We conclude that therapeutic lung lavage may improve the outcome in newborn infants with severe MAS, and there were no significant adverse side effects observed. Before performing lung lavage, stabilization and optimal support may prevent unexpected results during and after lavage.

Pathophysiology and Prevention of Bronchopulmonary Dysplasia

BPD is the major respiratory complication of preterm delivery and is typified by chronic oxygen dependency and respiratory insufficiency beyond 36 weeks postconceptional age. It is caused by a combination of insults on the developing lung precipitated by preterm birth and its subsequent respiratory management. The common pathway linking the various causative factors is inflammation, which may be initiated prior to birth in the setting of maternal chorioamnionitis, or after birth by mechanical ventilation, infection or oxidative stress. Inflammation in the developing lung induces airways remodeling which adversely affects lung function. Multiple inflammatory mediators are implicated in this process and modifying the course of the disease has proven difficult. The emphasis of management should be directed towards prevention with strategies aimed at minimizing early lung injury and oxidative stress. These include delivery room stabilization and mechanical ventilation techniques that aim to avoid volutrauma and atelectotrauma. Drugs may also influence BPD progression and can broadly be divided into three categories; those administered prenatally to accelerate lung maturation, those administered postnatally to reduce initiation of inflammatory stimuli and those to modify any established inflammatory response. In this review we have examined recent evidence for each of these ventilatory and therapeutic strategies to prevent BPD. A better understanding of the pathophysiology of airways remodeling in BPD could have significant implications for future potential targeted interventions.

Impact of obesity on outcomes in the management of localized adenocarcinoma of the esophagus and esophagogastric junction

Obesity trends in the Western world parallel the increased incidence of adenocarcinoma of the esophagus and esophagogastric junction. The implications of obesity on standard outcomes in the management of localized adenocarcinoma, particularly operative risks, have not been systematically addressed. This retrospective analysis of prospectively collected data included 150 consecutive patients (36 [24%] obese [body mass index > 30] and 114 nonobese), of whom 43 were normal weight (body mass index 20-25) and 71 were overweight (body mass index 25-30). Eighty-one patients underwent multimodal therapy. The primary end points were in-hospital mortality and morbidity, and median and overall survivals. Thirty of 36 obese patients (84%) had a body mass index from 30 to 35. Compared with those of the nonobese cohort, obese patients had significantly increased respiratory complications (P = .037), perioperative blood transfusions (P = .021), anastomotic leaks (P = .009), and length of stay (P = .001), but no difference in mortality (P = .582) or major respiratory complications (P = .171). Median and overall survivals were equivalent (P = .348) in both groups. Obesity was associated with increased respiratory complications and anastomotic leak rates but not with major respiratory complications, mortality, or survival. These outcomes suggest that the added risks of obesity on standard outcomes in esophageal cancer surgery are modest and should not independently have a significant impact on risk assessment in esophageal cancer management.

Respiratory Complications: A Major Concern after Right Hepatectomy in Living Liver Donors

One of the main concerns after living donor liver transplantation is the risk of morbidity and/or mortality that it imposes on the donors. Respiratory postoperative complications in living liver donors have already been reported but their frequency seems to be underestimated. We designed a prospective study to evaluate the rate and the nature of postoperative pulmonary complications in 112 consecutive donors. The medical records of the 112 living liver donors operated on at our center from 1998 to 2003 were reviewed and all the cases of respiratory complications were retrieved. Moreover, since 2000, all patients had a computed tomography angiography of the thorax at day 7 on a prospective basis. In all, 112 hepatectomies (44 right and 68 left) for adult-to-adult or adult-to-child liver donation were performed in our center. No postoperative mortality was recorded. Fourteen major respiratory complications developed in of 11 of 112 donors (9.8%), in all cases after right hepatectomy, and included nonsevere pulmonary embolism (n=7), right pleural empyema (n=3), and bacterial pneumonia (n=3). Minor respiratory complications (7.1% of the donors) included iatrogenic pneumothorax (n=3) and pleural effusion requiring thoracocentesis (n=5). Abdominal complications (mainly biliary leak) developed in 10 donors (8.9%), who in the vast majority remained free of pulmonary complications. In our series, pulmonary complications are frequent in living liver donors. These complications are mainly observed after right hepatectomy. The particular prevalence of pulmonary embolism should lead to focus on its early diagnosis and prevention.

Altered Respiratory Physiology in Obesity

The major respiratory complications of obesity include a heightened demand for ventilation, elevated work of breathing, respiratory muscle inefficiency and diminished respiratory compliance. The decreased functional residual capacity and expiratory reserve volume, with a high closing volume to functional residual capacity ratio of obesity, are associated with the closure of peripheral lung units, ventilation to perfusion ratio abnormalities and hypoxemia, especially in the supine position. Conventional respiratory function tests are only mildly affected by obesity except in extreme cases. The major circulatory complications are increased total and pulmonary blood volume, high cardiac output and elevated left ventricular end-diastolic pressure. Patients with obesity commonly develop hypoventilation and sleep apnea syndromes with attenuated hypoxic and hypercapnic ventilatory responsiveness. The final result is hypoxemia, pulmonary hypertension and progressively worsening disability. Obese patients have increased dyspnea and decreased exercise capacity, which are vital to quality of life. Decreased muscle, increased joint pain and skin friction are important determinants of decreased exercise capacity, in addition to the cardiopulmonary effects of obesity. The effects of obesity on mortality in heart failure and chronic obstructive pulmonary disease have not been definitively resolved. Whether obesity contributes to asthma and airway hyper-responsiveness is uncertain. Weight reduction and physical activity are effective means of reversing the respiratory complications of obesity.

Endoscopic treatment of congenital H-Type and recurrent tracheoesophageal fistula with electrocautery and histoacryl glue

Congenital H-Type tracheoesophageal fistulae (H-Type TEF) and recurrent fistulae after primary repair of esophageal atresia represent a difficult problem in diagnosis and management. The treatment traditionally involved an open technique via a cervical or thoracic route, approaches with high morbidity and mortality rates of up to 50%. Endoscopic closure of fistulae has been reported with various techniques such as tissue adhesives, electrocautery, sclerosants and laser. However, the published case series contain a small number of patients with usually short-term follow-up. The aim of this paper is to present the experience of a decade at Toronto's Hospital for Sick Children, using diathermy and histoacryl tissue adhesive and discuss the indications and limitations of this technique. Since 1995, 192 patients have been managed in this institution with tracheoesophageal fistulae of which 10 patients have been treated endoscopically. The fistulae were both of H-Type and recurrent tracheoesophageal fistulae following surgery for esophageal atresia and fistula division. One fistula occurred following trauma. The procedure was undertaken under general anesthesia in the image guided therapy suite under fluoroscopic control. Flexible ball electrocautery and injection of histoacryl glue were used either on their own or in combination. Fistula closure was achieved in 9 out of 10 fistulae. Four patients had a second endoscopic procedure. No major respiratory or other complications were encountered in association with the procedure. Follow-up has been between 3 months and 9 years. We conclude, endoscopic treatment of tracheoesophageal fistulae with electrocautery and histoacryl glue has been a safe and successful technique of managing H-Type and recurrent tracheoesophageal fistulae. In this paper, we discuss the indications and the surgical steps of the procedure. We highlight that diathermy should be carefully controlled and applied preferably in the small non-patulous fistulae. A fistula that has not closed after two endoscopic attempts is not suitable for further endoscopic treatment and therefore an external approach should be recommended.

Low Morbidity but Prolonged Viral Shedding Characterize Parainfluenza Virus 3 Infections in Allogeneic Peripheral Stem Cell Transplant Recipients.

Respiratory viruses including human parainfluenza virus 3 (hPIV3) may be significant causes of morbidity and mortality in patients undergoing allogeneic stem cell transplantation. It has been suggested that the acquisition of hPIV3 infections is independent of immunosuppression or transplant type and is driven primarily by patient exposure to the virus during periods of heightened community-wide or nosocomial activity. The incubation period for hPIV3 is 1–3 days and the duration of infectivity/ viral shedding in non-transplant patients is 1–2 weeks. Data regarding the duration of infectivity/ viral shedding and possible predictors of prolong infectivity in peripheral blood stem cell transplant patients (PBSCT) is limited. Of 56 recipients of sibling PBSCT seen at our insitution, 11 (6 inpatients and 5 outpatients) were positive for hPIV3 during a six weeks period, compared with only two positive cases recorded throughout the previous year. At the time of infection patients were between 1 and 7 weeks post transplant. The in-patient attack rate was 11%. Patients in whom respiratory virus infection was suspected were placed on respiratory isolation and followed with weekly nasopharygeal swab/wash (NPW). Care was also taken to limit patient contact of relatives or staff with respiratory symptoms. Most patients developed a flu like illness without major respiratory complications. No mortality was recorded. No case of hPIV 3 was recorded among patients with aplastic anemia receiving ATG in the unit during the same time-period. The median time to conversion from positive to negative hPIV 3 NPW was 2.0 weeks (range 1–6 weeks). The longest duration of viral shedding (six weeks) was in the only haplo-identical SCT patient, who was also the index case. No differences in duration of viral shedding was noted for conditioning regimen type (ablative vs non-ablative), days after transplant of viral acquisition (<15 or >15 days), cyclosporin levels (100–200 ng/l vs 201–400 ng/l), absolute neutrophil counts, absolute lymphocyte counts, CMV reactivation and co-existing peri-hPIV3 infections evidenced by positive blood, urine or sputum cultures. immunosuppression during the outbreak. Our study demonstrates that while hPIV infection in allogenic PBSCT patients has limited morbidity, prolonged duration of viral shedding in this group may contribute to recurrent cycles of epidemics or prolong outbreaks and establish an environmental (community/ nosocomial) contamination or “ping-pong” transmission from patients to asymptomatic health-care workers or family members and back. Our study also emphasize the importance of a universal policy for strict attention to infection-control practices and weekly surveillance NPW until patients are a symptomatic and NPW negative.

A Comparison of Intrathecal Opioid and Intravenous Analgesia for the Incidence of Cardiovascular, Respiratory, and Renal Complications after Abdominal Aortic Surgery

A multifaceted stress response occurs as a result of surgery that can produce a variety of symptoms that increase morbidity and adverse cardiac events. The authors studied whether providing intense analgesia in order to eliminate or decrease a source of stress following the surgical procedure would decrease major nonsurgical complications. Patients were randomized to receive either general anesthesia combined with intrathecal opioid or general anesthesia alone (control). Both groups received patient-controlled anesthesia postoperatively and identical postoperative care. A visual analog scale rating postoperative pain was given to each patient. Although the group that received intrathecal opioids experienced more intense analgesia than the other group, the groups did not differ in the incidence of major cardiovascular, respiratory and renal complications, nor did they differ in myocardial damage or infarction. The authors concluded that providing intense analgesia via neuraxial opioids, does not alter the ...

Squamous cell carcinoma and adenocarcinoma of the lower third of the esophagus and gastric cardia: similarities and differences.

Squamous cell carcinoma (SCC) and adenocarcinoma (ADC) of the lower esophagus and gastric cardia were compared in their clinical features and long-term prognosis. Two hundred and ninety-five patients with SCC and 263 with ADC were reviewed. Resectability rates for SCC and ADC were 74.2% and 73.2% respectively (P=0.8). Among those who underwent resection, ADC was more advanced, with 22.3% at stage IV compared with 7.4% for SCC (P=0.001). Postoperative cardiac events occurred in 24.2% of SCC patients and 14.7% of ADC patients (P=0.015), and major respiratory complications in 20.1% and 8.6% respectively (P=0.001). Thirty-day mortality rates were 2.7% and 4% (P=0.46), and hospital mortality rates were 11.4% and 7.6% (P=0.19). Median survival rates were 12.5 months for SCC and 11.6 months for ADC (P=0.99) and 5-year survival rates were 19.9% and 17.6% (P=0.55) respectively. Squamous cell carcinoma of the lower esophagus and ADC of the cardia differed in patient demographics and clinical features but long-term prognoses were similar.