Significant Differences In Patient Outcomes Research Articles

Designing and implementing a COPD discharge care bundle

National surveys have revealed significant differences in patient outcomes following admission to hospital with acute exacerbation of COPD which are likely to be due to variations in care. We developed...

Pharmacy Students Provide Care Comparable to Pharmacists in an Outpatient Anticoagulation Setting

To evaluate whether student participation in ambulatory clinics influenced the percentage of therapeutic international normalized ratio (INR) results among patients on chronic warfarin therapy. Medical records in outpatient anticoagulation clinics managed by pharmacists under physician protocol were reviewed retrospectively in 2 university-affiliated clinics in Amarillo and Lubbock, TX. Pharmacy student activities included patient interviews, vital sign measurements, fingersticks, counseling, and documentation. Patient visits were conducted by a precepted pharmacy student or a pharmacist without a student, and the INR was measured at the subsequent patient visit. Records of 1,958 anticoagulation patient visits were reviewed; 865 patients were treated by pharmacists, and 1093 were treated by precepted students. The follow-up INR was therapeutic for 48.5% of third-year (P3) students' patients, 45.6% of fourth-year (P4) students' patients, 51.2% of residents' patients, and 44.7% of pharmacists's patients (p = 0.23). Eight variables were associated with the follow-up INR (baseline INR, warfarin noncompliance, held warfarin doses, a warfarin dosage adjustment, diet change, alcohol use, tobacco use, and any medication changes). Student participation in the patient-care process did not compromise patient care and no significant difference in patient outcomes was found between patients in an anticoagulation clinic cared for by precepted students and those cared for by pharmacists.

Abstract C19: High CCL2 protein expression is associated with poor outcome in ovarian cancer

Abstract Background: CCL2 is a potent chemoattractant for tumor-associated macrophages, which promotes tumor growth and metastasis. The CCL2/CCR2 interaction plays a key role in promoting tumor inflammation, angiogenesis, proliferation and metastasis. Ovarian tumors and tumor lines secrete CCL2, however, very little is known about the expression of CCR2 and macrophage markers in ovarian tumors. Using a Yale University ovarian cancer tissue microarray cohort with associated outcome data, we analyzed the expression of CCL2, CCR2, and macrophage markers CD68, iNOS (M1 marker) and Arginase-1 (M2 marker) using fluorescence immunohistochemistry methods. Methods: The Yale YTMA18-2 Ovarian Cancer tissue microarray cohort consists of 239 stage I–IV ovarian tumors of all major histological subtypes and also included 12 normal gynecologic tissue samples for comparison purposes. The expression levels were assessed using Automated QUantitative Analysis (AQUA® technology, HistoRx Inc.) and were correlated with clinical outcome. CCR2 and CCL2 were measured within pan-cytokeratin defined cytoplasmic regions, and CD68, iNOS and Arginase-1 were measured within the entire sample regions. These biomarkers were analyzed for relationships with each other by Spearman Rho analysis and unsupervised hierarchical clustering, and for association with outcome by Cox univariate analysis and Kaplan-Meier analysis. Punch cores from the tumor sample utilized in the ovarian cancer tissue microarray cohort were also analyzed for genotyping five SNPs in the CCL2 promoter region. Results: There was no significant difference in CCL2, CCR2, CD68, iNOS (M1 marker) and Arginase-1 (M2 marker) expression by age group, stage or major histology grouping (all p>0.05). When looking at all tumor tissues, there was a significant difference in patient outcome (10 year and full time period, p = 0.028 and p = 0.047, respectively) based on separation by CCL2 cluster-based expression groupings. High CCL2 expression patients have a worse outcome, with a 1.9 fold higher risk of death at 5 years than other patients in categorical Cox univariate analysis. Although there was no correlation between CCR2 and CCL2, Kaplan-Meier analysis of unsupervised cluster groupings based on both markers identified a subset of ovarian cancer patients with high expression of CCL2 and intermediate/high expression of CCR2 that have the poorest survival compared with other groupings. Additionally, ovarian tumor tissues expressed 3.5-fold higher level of CCL2 and 1.2 -fold higher levels of CCR2 (mean AQUA scores, respectively) compared to normal samples (p< .0001). There were no significant differences in patient outcome by CD68, iNOS (M1 marker) and Arginase-1 (M2 marker)cluster groupings. There was a statistically significant difference in patient outcome by Kaplan-Meier analysis between two SNPs but no correlation with CCL2 expression was observed. Conclusion: Taken together, these data suggest that there is a subset of ovarian cancer patients with elevated CCL2 protein expression levels associated with poor outcome. This is the first study to show a link between high CCL2 protein expression levels and poor survival in ovarian cancer. Thus, additional exploration of CCL2 expression levels as a predictive biomarker in ovarian cancer is warranted. Citation Information: Mol Cancer Ther 2009;8(12 Suppl):C19.

Plastic surgery and global health: How plastic surgery impacts the global burden of surgical disease

The global burden of surgical disease is estimated as being 11% of the total global burden of disease. In this article we discuss the portion of this burden which could be ameliorated with plastic surgical expertise. Although not necessarily seen as a major player in issues related to global health, plastic surgeons are uniquely qualified to decrease the burden of surgical disease afflicting people in the developing world. Burns, traumatic injuries, and congenital anomalies are some of the areas where the presence of plastic surgical expertise can make a significant difference in patient outcomes and thereby decrease the years of life lost due to disability due to these highly treatable conditions. In light of the severe shortage of plastic surgeons throughout the developing world, it falls to those concentrated in the developed world to harness their skills and address the vast unmet needs of the developing world so as to enhance global health.

Importance of treatment institution in head and neck cancer radiotherapy

Objective The treatment for head and neck cancer (HNC) often involves radiotherapy. Many HNC patients are treated at the academic center (AC) where the initial surgery or diagnosis was made. Because of the lengthy time course for radiotherapy, some patients are treated at community radiation facilities (non-AC) rather than the AC despite potential AC advantages in terms of experience and technology. Our goal is to determine if these potential AC advantages correspond to a difference in treatment outcome. Study Design Historical cohort study. Setting University of Kansas Medical Center, Kansas City, Kansas. Subjects and Methods Review of records of patients with HNC cancers evaluated at the otolaryngology (ENT) department of an AC. Each patient's information and treatment characteristics were recorded, including radiotherapy treatment venue and treatment outcome. Results Three hundred seventy-four patients were analyzed, 263 were treated at an AC and 101 at a non-AC. Patients treated at a non-AC were more likely to present with earlier stage tumors, be treated with radiation alone rather than chemoradiotherapy, and be treated with adjuvant rather than primary radiotherapy. There was no difference in overall survival or recurrence rates between AC and non-AC. Conclusion Patients treated at an AC are more likely to have advanced stage tumors and receive chemoradiotherapy as their primary treatment. In analyses of matching patient subsets, there was no significant difference in patient outcomes. Patients can be treated at a non-AC without affecting outcome compared with treatment at an AC.

Evidence vs experience in the surgical management of necrotizing enterocolitis and focal intestinal perforation

Necrotizing enterocolitis (NEC) and focal intestinal perforation (FIP) are neonatal intestinal emergencies that affect premature infants. Although most cases of early NEC can be successfully managed with medical therapy, prompt surgical intervention is often required for advanced or perforated NEC and FIP. The surgical management and treatment of FIP and NEC are discussed on the basis of literature review and our personal experience. Surgical options are diverse, and include peritoneal drainage, laparotomy with diverting ostomy alone, laparotomy with intestinal resection and primary anastomosis or stoma creation, with or without second-look procedures. The optimal surgical therapy for FIP and NEC begins with prompt diagnosis and adequate fluid resuscitation. It appears that there is no significant difference in patient outcome based on surgical management alone. However, the infant's weight, comorbidities, surgeon preference and timing of intervention should be taken into account before operative intervention.

The similarities of aromatase inhibitors outweigh the differences

Although the aromatase inhibitors (AIs) as a class exhibit clear differences in terms of their structure and mechanism of action, these differences do not always translate into clinically significant differences in patient outcomes. In fact, these differences may actually reflect differences in clinical trial design (i.e. upfront, sequential or switch therapy) or the patient population studied. The results of clinical trials demonstrate a clear superiority of third-generation AIs over tamoxifen. It will, however, be necessary to wait for the results of the ongoing head-to-head MA.27 and Novartis trials to determine whether there is any differentiation between the various third-generation AIs.

The Impact of an Emergency Department Toxicology Team in the Management of Acute Intoxication

Objective To evaluate the impact of the recently established Emergency Department (ED) Toxicology Team of Queen Mary Hospital (QMH) in the management of acute intoxication. Method A descriptive comparative study with retrospective data collection from all intoxicated and suspected intoxicated patients over two separate half-year periods in 2001 and 2006, before and after the establishment of the ED Toxicology Team in July 2005. Data on reasons of intoxication, drugs and substances involved, ED treatments, patient disposition, length of stay in ED, length of stay in hospital, patient outcome, and 30-day ED re-attendance and hospital re-admission were collected and examined. Results A total of 333 intoxicated patients were included in the study, 171 in 2001 and 162 in 2006. The basic epidemiological data were similar in both groups. There was a marked reduction in hospital admissions from 89.5% to 40.7% (P<0.01) and significant decline in average length of hospital stay from 46.8 hours to 29.2 hours (P<0.05). There was no statistically significant difference in patient outcome, 30-day ED re-attendance and hospital re-admission. Conclusion Our findings showed that the establishment of the ED Toxicology Team in QMH achieved significant reductions in hospital admissions and the length of stay in hospital in the management of patients with acute intoxication without jeopardising patient outcome. The results illustrate that the new model has a beneficial role in reducing cost and alleviating stress on hospital bed availability, therefore it can be recognised as a cost-effective means of management of acute intoxication.

Intervention following deliberate self-harm: enough evidence to act?

Readers of systematic reviews will be used to seeing authors conclude that research conducted to date provides insufficient evidence to guide the management of patients with a particular condition. Such...

Duration of Short-Term Indwelling Catheters—A Systematic Review of the Evidence

A systematic review on the effect of duration of catheterization on urinary retention. Published and unpublished randomized and nonrandomized control trials from January 1966 to July 2004 comparing the effects of duration of catheterization on patient outcomes were systematically reviewed. Relative risks (RR) for dichotomous data and a weighted mean difference for continuous data were calculated with 95% confidence intervals (CI). Where synthesis was inappropriate, a narrative overview was undertaken. Eight trials were included. Two trials on patients following urethrotomy demonstrated no statistically significant difference in the number of patients developing restenosis, epididymitis, or urethral pain at any follow-up periods. Two trials comparing removal of the indwelling urethral catheter within 24-48 hours to usual surgical criteria after transurethral surgery demonstrated no statistically significant difference in the number of patients requiring recatheterization. However, significant reduction in the length of hospitalization was reported after removal of the indwelling urethral catheter within 24-48 hours. An increased risk of urinary tract infection was found when the catheter was removed after 48 hours. Catheter removal on day 1 compared to day 3 after vaginal or retropubic surgery demonstrated no statistically significant difference in urinary retention or urinary tract infection. No significant differences in patient outcome were found, but the timing of catheter removal is a balance between avoiding infection by early removal and circumventing voiding dysfunction by later removal. Shorter catheterizations appear to reduce mean length of hospital stay.

Surgical repair of recurrent hiatal hernia

The surgical management results of recurrent hiatal hernia repair are unknown in the laparoscopic era. The experience of the senior authors (CJF) and (SKM) is reported herein. From 1993 to 2004, 52 patients underwent re-operative hiatal hernia surgery at our center. Preoperative symptoms were heartburn, chest pain, dysphagia, regurgitation and pulmonary manifestations of gastroesophageal reflux disease. Patients had preoperative evaluation by upper endoscopy, pH-monitoring, esophagogram and manometry to assess the mechanism of failure. Pre- and postoperative symptoms were assessed utilizing a standardized questionnaire. Patients underwent laparoscopic repair (n=18), open laparotomy (n=6) and transthoracic surgery (n=28). Ninety-five percent follow-up was achieved with a mean follow-up of 34 months. Thirty-seven percent of patients encountered para-operative complications one of them died due to respiratory insufficiency. Five patients experienced a re-recurrent hernia. The symptom resolution was 65% for dysphagia, 68% for heartburn, 95% for chest pain and 79% for regurgitation. The overall patient satisfaction was 6.94 on a scale of 1-10. There was no significant difference in patient outcome when comparing the operative approaches or disease process. Surgical repair of recurrent hiatal hernias is safe and effective. Laparoscopic surgery is an appropriate alternative approach for recurrent hiatal hernia repair in selected patients.

The Neurometric-Quantitative Electroencephalogram as a Predictor for Psychopharmacological Treatment: An Investigation of Clinical Utility

A retrospective validation study of the Neurometric method of the Quantitative Electroencephalogram (QEEG) in predicting response to psychotropic medication was conducted. The clinical outcomes of 2 groups of patients were compared: those patients prescribed medication regimens that were concordant with the QEEG predictors vs. those whose medication regimens were discordant with the QEEG predictors. Participants included 70 adolescent inpatients who were administered the QEEG upon admission. The results indicated no significant difference in clinical outcome between the 2 groups. The failure of this study to find significant differences in patient outcomes brings into question this particular use of the QEEG. The existing literature and future directions for research and clinical use of this method are discussed.

Cell-type-specific responses to chemotherapeutics in breast cancer.

Recent microarray studies have identified distinct subtypes of breast tumors that arise from different cell types and that show statistically significant differences in patient outcome. To gain insight into these differences, we identified in vitro and in vivo changes in gene expression induced by chemotherapeutics. We treated two cell lines derived from basal epithelium (immortalized human mammary epithelial cells) and two lines derived from luminal epithelium (MCF-7 and ZR-75-1) with chemotherapeutics used in the treatment of breast cancer and assayed for changes in gene expression using DNA microarrays. Treatment doses for doxorubicin and 5-fluorouracil were selected to cause comparable cytotoxicity across all four cell lines. The dominant expression response in each of the cell lines was a general stress response; however, distinct expression patterns were observed. Both cell types induced DNA damage-response genes such as p21(waf1), but the response in the luminal cells showed higher fold changes and included more p53-regulated genes. Luminal cell lines repressed a large number of cell cycle-regulated genes and other genes involved in cellular proliferation, whereas the basal cell lines did not. Instead, the basal cell lines repressed genes that were involved in differentiation. These in vitro responses were compared with expression responses in breast tumors sampled before and after treatment with doxorubicin or 5-fluorouracil/mitomycin C. The in vivo data corroborated the cell-type-specific responses to chemotherapeutics observed in vitro, including the induction of p21(waf1). Similarities between in vivo and in vitro responses help to identify important response mechanisms to chemotherapeutics.

Adherence to guidelines for community-acquired pneumonia: does it decrease cost of care?

Community-acquired pneumonia (CAP) is a common diagnosis and care of CAP is responsible for significant healthcare expenditures, the majority of which are for patients who require hospitalisation. Studies have shown that significant variation exists among institutions with respect to antibacterial costs and length of stay (LOS) for CAP. These variations do not appear to be associated with significant differences in patient outcomes. This information has stimulated the development of practice guidelines and critical pathways to optimise the care of patients with CAP. The central focus of guidelines is recommendations for antibacterial therapy; critical pathways include recommendations for therapy, but focus on the process of care for patients with CAP. Guidelines and critical pathways are time consuming to develop and their implementation requires significant institutional resources. Therefore, it is essential that they are shown to be effective, and there has been significant interest in determining if guidelines and pathways can improve the cost effectiveness of care. In the past several years, a number of studies have evaluated the impact of treatment consistent with guidelines on outcomes for patients with CAP. These studies have shown that antibacterial therapy that is consistent with guidelines can reduce LOS, decrease costs, and several have shown a favourable impact on mortality. The majority of these studies have been retrospective reviews. One multicenter prospective, randomised trial of a critical pathway for CAP revealed significant reductions in the hospital admission of patients, LOS and cost of care. Other studies of processes of care have been mainly 'before and after' interventions; many have shown reductions in LOS and costs. Based on the available data, it is reasonable to expect that adherence to guidelines and critical pathways can reduce the cost of care for CAP; however, randomised controlled trials that include a formal cost-effectiveness analysis are needed. Even if the data to support the use of guidelines and pathways are robust, those who develop and implement them need to anticipate and understand barriers to physician adherence.

Correlation of radiographic, clinical, and patient assessment of shoulder balance following fusion versus nonfusion of the proximal thoracic curve in adolescent idiopathic scoliosis.

Retrospective clinical, radiographic, and patient outcome review of surgically treated adolescent idiopathic scoliosis. To correlate radiographic and clinical features of shoulder balance and the proximal thoracic curve with patient satisfaction outcomes at a minimum 2-year follow-up. Traditionally, radiographic features of a structural proximal thoracic curve have been T1 tilt, proximal thoracic Cobb angle, and proximal thoracic side-bending Cobb; however, these do not always correlate with clinical shoulder balance. A total of 112 patients (single surgeon) with adolescent idiopathic scoliosis and a proximal thoracic curve >or=20 degrees (average 32 degrees, range 20-78 degrees) were evaluated in terms of shoulder balance and curve flexibility/correction. Four groups were analyzed: Group 1, posterior spinal fusion to T2 (proximal thoracic curve included, n = 24); Group 2, posterior spinal fusion to T3 (proximal thoracic curve partially included, n = 23); Group 3, posterior spinal fusion to T4 or T5 (proximal thoracic curve not included, n = 21); and Group 4, anterior spinal fusion to T4 or below (proximal thoracic not included, n = 44). Proximal thoracic, main thoracic, and thoracolumbar-lumbar upright coronal, side-bending, and sagittal Cobb measurements were assessed before surgery, 1 week after surgery, and at a minimum 2-year postoperative follow-up (average 3.8 years, range 2.0-7.6 years). In addition to T1 tilt, clavicle angle (intersection of a horizontal line and the tangential line connecting the highest two points of each clavicle), coracoid height difference, trapezius length (horizontal distance of the T2 pedicle to second rib-clavicle intersection), first rib-clavicle height difference (vertical distance of first rib apex to superior clavicle), and proximal thoracic, main thoracic, and thoracolumbar-lumbar apical vertical translation were determined. Shoulder asymmetry as measured by the radiographic soft tissue shadow was graded as balanced (<1 cm), slight (1-2 cm), moderate (2-3 cm), or significant (>3 cm). A postoperative patient questionnaire addressed shoulder balance and overall appearance at most recent follow-up. The four groups were found to be statistically equivalent in terms of preoperative proximal thoracic curve (P = 0.4146), proximal thoracic side-bending Cobb (P = 0.2199), main thoracic curve (P = 0.6999), and main thoracic side-bending curves (P = 0.7307). Radiographic: Preoperative proximal thoracic measurements correlating with postoperative shoulder balance (P < 0.05) included the clavicle angle (three of four groups with a trend toward statistical significance in the fourth group, P = 0.07) and coracoid height (two of four groups). No other measurement, including T1 tilt and proximal thoracic side-bending Cobb, correlated in more than one group. Proximal thoracic curve correction was greatest in Group 1 (posterior spinal fusion to T2; average 12 degrees) and Group 4 (anterior spinal fusion to T4 or below; average 12 degrees). Clinical: Shoulder balance improved in all four groups (range 0.38-1.00 grades). There was no difference in shoulder balance between groups (P = 0.2723). Patient assessment: All four groups also reported improvement in self-perceived shoulder balance (63% up to one grade, 37% over two-grade improvement), whereas no patient reported worsening of shoulder balance. There was no significant difference in patient outcomes between the four groups (P = 0.3654). The clavicle angle, not T1 tilt, upright proximal thoracic, or side-bending proximal thoracic Cobb, provided the best preoperative radiographic prediction of postoperative shoulder balance. In each of the four groups, postoperative shoulder balance and clinical appearance also improved and correlated with patient postoperative assessments.

Bridging the treatment gap

The leading cause of death and disability in the United States today is cardiovascular disease (CVD). The main risk factor, hypercholesterolemia, is grossly undertreated, although it is widely appreciated that lowering cholesterol levels is key to reducing the incidence of CVD. Cholesterol-lowering therapy decreases total mortality, cardiovascular events, the need for revascularization procedures, and hospitalization costs. A 25–35% reduction of low-density lipoprotein (LDL) indicates significant benefits with regard to morbidity and mortality. Unfortunately, most patients who are candidates for cholesterol-lowering treatment do not receive it. Wider use of lipid-lowering agents could, in fact, make a significant difference in patient outcomes. There is strong interest on the part of consumers in over-the-counter (OTC) cholesterol-lowering products that may help them reduce their risk of developing heart disease and live healthier lives. Surveys estimate that half of all patients with high cholesterol would like to have an OTC statin product made available. Increased availability of cholesterol-lowering therapies as well as changes in physician prescribing practices could benefit a broad spectrum of the population that is currently untreated or undertreated. Current prescribing practices and guidelines have not resulted in widespread use of these therapies; therefore, outcomes for CVD prevention remains suboptimal. The proposed advantages of making statins available over-the-counter include their known efficacy, dose consistency, and proven safety profile.

Effect of surgeon specialty interest on patient outcome after potentially curative colorectal cancer surgery.

There are significant differences in patient outcome after potentially curative surgery for colorectal cancer that relate to the surgeon performing the procedure. The reasons for these differences remain obscure. The aim of this study was to examine the effect of the surgeon's specialty on patient outcome after potentially curative colorectal cancer surgery and to identify factors that may help explain differences in outcome among specialty groups. Between 1990 and 1993, 378 patients underwent potentially curative surgery for colorectal cancer by surgeons with different specialty interests, vascular or transplant, general, and colorectal surgeons, in a large teaching hospital. Information on operative details, including the length of the resection specimen, resection margins, whether the tumor was removed with en bloc resection of adjacent clinically involved organs, number of lymph nodes removed, and stage was collected. Factors affecting both local and overall recurrence rates were analyzed using logistic regression analysis at both univariate and multivariate levels. At a median follow-up of 45 months the only factors associated with a significantly reduced local recurrence rate were the length of the resection specimen (odds ratio, 0.56; 95 percent confidence interval, 0.31-0.99) and colorectal specialty (P = 0.04). Patients operated on by a general surgeon were 3.42 times (95 percent confidence interval, 1.32-8.9) more likely to develop a local recurrence than those operated on by a colorectal surgeon. For overall recurrence, early stage disease (P < 0.0001), absence of vascular invasion (0.005), and colorectal specialty (0.025) were the only factors associated with significantly improved outcome at multivariate analysis. These data show that surgeons with an interest in colorectal cancer achieve lower local and overall recurrence rates compared with vascular or transplant or general surgeons. Differences in local recurrence rates seem to be predominantly related to the extent of resection performed and demonstrate the need to remove an adequate specimen when performing potentially curative colorectal cancer surgery.

Effects of a physiotherapist-led stroke training programme for nurses.

to assess the effects of a physiotherapist-led stroke training programme for nurses working in a rehabilitation ward on clinical practice and patient outcome. before and after group comparison with outcome assessment by observational and quantitative methods. Non-participant observation before and after the 5-month training programme recorded patient position, transfers and contact with nursing staff. Quantitative assessments of disability, satisfaction and mood were made at baseline, discharge and 4 months after stroke onset. We also noted selected stroke complications, rehabilitation ward length of stay and discharge destination. there was a significant improvement in the number of observed 'good' transfers of patients undertaken by nurses (chi2 = 9.13, df = 1, P = 0.003) but the training programme had no impact on the time the patients spent in 'poor' positions. There was no significant difference between the two groups for Barthel index scores at discharge and at 4 months. Neither was there any significant difference in the Hospital Anxiety and Depression scale, occurrence of secondary complications, length of stay or the Patient and Carer Satisfaction Questionnaires. within the limitations of the research design adopted, some improvements in clinical practice were reported but there were no significant differences in patient outcome. The training programme required no additional resources and should be replicable in most district general hospitals.

Can we justify ipratropium therapy as initial management of acute exacerbations of COPD?

Although inhaled ipratropium is commonly accepted as the drug of choice for long-term management of chronic bronchitis and emphysema, little evidence is available to promote its administration in conjunction with a beta2-agonist as part of initial management of exacerbations of chronic obstructive pulmonary disease (COPD) in the acute care setting. Reasons for its widespread acceptance for acutely ill patients may include its status as a first-line agent for long-term therapy, its relative safety, and attempts to provide optimal patient care. Since inhaled ipratropium is beneficial as immediate therapy for asthma in the emergency department, some practitioners attempted to extrapolate these findings to treatment of COPD. Review of available studies reveals wide variability in methodologies and results. Although some studies reported improvement in pulmonary function tests, no clinically significant differences in patient outcomes, including shorter hospitalization, were evident. In patients who fail traditional therapies, inhaled ipratropium is reasonable. Double-blind, randomized, placebo-controlled trials in patients receiving emergency department care and in hospitalized patients that reveal shorter length of stay or other improved outcomes, are necessary to establish routine addition of inhaled ipratropium to beta2-agonists in the initial management of acute COPD.

Primary vaginal melanoma: Thirteen-year disease-free survival after wide local excision and review of recent literature

Objectives: We present a case report of a woman who has survived 13 years after conservative treatment with wide excision for vaginal melanoma and review and evaluate the literature on this disease since the last metaanalysis in 1989. Study Design: A database literature search along with cross referencing from related articles uncovered 66 patients who were reported to have vaginal melanoma since 1989 with adequate information for our analysis. We add to this one original case reported by us. Where information was available, we analyzed outcomes on these cases on the basis of patient age, tumor thickness, tumor size, and treatment. Results: The patient we describe is only the eighteenth reported patient to survive vaginal melanoma 5 years and only the third to survive for 10 years. Of the 67 patients in our overall review, mean age at the time of diagnosis was 62 years. Patients with tumor size <3 cm had a mean survival of 41 months compared with 12 months for those with tumor size ≥3 cm ( p < 0.0024). Tumor thickness did not significantly affect patient survival at any of the depths analyzed, although there was a tendency toward significance at depths >8 mm ( p < 0.0778). There also was no significant difference in patient outcome among five treatment groups: (1) wide excision, (2) radical surgery, (3) radiation therapy, (4) wide excision plus radiation therapy, and (5) other. Conclusion: Tumor size appears to affect survival in patients with vaginal melanoma. Tumor thickness, at least at the levels at which vaginal melanomas are currently being diagnosed, does not seem to affect survival. Because no single treatment is clearly preferable, we suggest conservative resection where possible. We find it difficult to support radical surgery as primary treatment for vaginal melanoma unless necessary to achieve clear tumor margins. Radiation therapy appears to offer results comparable to those of surgery. (Am J Obstet Gynecol 1998;178:1177-84.)