Perianal Bowen's disease: associated tumors, human papillomavirus, surgery, and other controversies

BACKGROUND

Perianal Bowen's disease (BD) is an intraepithelial nonkeratinizing carcinoma, associated historically with internal tumors.

METHODS

A review of patients with perianal BD presenting consecutively during a 25-year span was undertaken, excluding Bowenoid papulosis and contiguous genital BD. Histologic slides were resubmitted for review by an experienced pathologist, in a "blind" fashion among other slides. Follow-up was updated in every patient. Survival and recurrence curves were generated by the Kaplan-Meier method and were compared with a normal age-matched population (log-rank test).

RESULTS

Nineteen patients were identified; 15 of them were females. Mean age +/- standard deviation was 49.6 +/- 10.6 years. Five patients had a coincidental diagnosis (hemorrhoidectomy or wart excision). No associated carcinomas were found; however, eight patients had isolated BD of the vulva. Eleven patients had a history of anal warts, cervical/vulvar dysplasia, or both. Wide resection, including V-Y flaps, was performed in 18 patients without dysfunction. One-year and five-year recurrence was 16 and 31 percent. Recurrence was treated in all but one case by wider resection. Mean follow-up was 8.4 years. Five-year survival was 75 percent, lower than the matched population (P = 0.001); however, only one death was related to BD.

CONCLUSIONS

Perianal BD has no association with internal tumors. Despite a high rate of recurrence, perianal BD can be treated by local excision. An increased rate of human papilloma virus-related entities was found, which could suggest a causative role.

Bone-graft augmentation for acetabular deficiencies in total hip arthroplasty. Results of long-term follow-up evaluation

The results of 102 consecutive primary and revision total hip arthroplasties performed with bone-grafting for acetabular bone deficiencies were reviewed at an average of 10.2 years (range, 4-18.6) after surgery. Ninety-one percent had structural bone defects and 57% had underlying developmental dysplasia of the hip. Overall acetabular revision rates for aseptic loosening were 8% at 5 years and 26% at 10 years. In addition, in the patients with developmental dysplasia who had primary hip arthroplasties, acetabular revision rates for aseptic loosening were 3 and 18% at 5 and 10 years, respectively. Ninety-six percent of all uninfected grafts incorporated. Bulk grafts fared better than particulate grafts. No difference in failure rate was noted between primary and revision hip arthroplasty, type of deficiency, or amount of graft coverage. Although early results are encouraging, acetabular failure increased significantly with longer follow-up evaluation; however, graft incorporation was successful and facilitated subsequent revision surgery.

Utility of preload alteration in assessment of left ventricular filling pressure by Doppler echocardiography: a simultaneous catheterization and Doppler echocardiographic study

OBJECTIVES

The aim of this study was to demonstrate the usefulness of preload alterations in assessing left ventricular filling pressures with transmitral Doppler velocity curves.

BACKGROUND

Doppler mitral inflow velocities, used to estimate left ventricular filling pressures noninvasively, are limited in predicting left ventricular filling pressures, especially in patients with normal systolic function and a "pseudonormal" mitral filling pattern.

METHODS

Forty-nine patients were studied in the cardiac catheterization laboratory with simultaneous Doppler echocardiography using high fidelity catheters to compare left ventricular diastolic filling pressures (pre-A wave left ventricular pressure) and Doppler mitral inflow at baseline and during reduction of preload during the strain phase of the Valsalva maneuver (n = 27) or sublingual nitroglycerin (n = 36), or both (n = 14). Doppler measurements consisted of E (initial peak velocity), A (velocity at atrial contraction), deceleration time (time from E velocity to deceleration of flow extrapolated to baseline) and absolute A wave velocity (A' [peak A wave velocity minus velocity at onset of atrial contraction]).

RESULTS

In patients with high pre-A wave pressure (> or 15 mm Hg), there was a greater change in the E/A' ratio during the Valsalva maneuver than in patients with a normal pre-A wave pressure (-1.22 +/- 1.1 vs. -0.35 +/- 0.17; p = 0.02). A similar change was seen when comparing the change in the E/A' ratio after administration of nitroglycerin in patients with a high versus a normal pre-A wave pressure (0.81 +/- 0.49 vs. 0.18 +/- 0.17; p < 0.001). These differences were present in patients with a normal E/A ratio at baseline.

CONCLUSIONS

Alterations in preload during assessment of Doppler echocardiographic indexes may be useful in noninvasively assessing left ventricular filling pressures.

Concordance of Medicare data and population-based clinical data on cataract surgery utilization in Olmsted County, Minnesota

The authors assessed concordance of local Medicare health care utilization data on cataract surgery and estimates generated using the databases of the Rochester Epidemiology Project, which capture virtually all medical care received by residents of Olmsted County, Minnesota. The Rochester Project databases identified 1,353 primary cataract extractions performed in Olmsted County between October 1989 and December 1993 among county residents aged > or = 65 years. Medicare data identified 1,148 claims-84.8% of the number of procedures identified by the Rochester Project. Ratios of numbers of encounters (Medicare/Rochester Project) were 189/350 (0.540) for 1992 versus 959/1,003 (0.956) for the other years combined. Changes in Medicare data file transfer procedures may have produced the 1992 data shortfall. Medicare data should periodically be compared with source data to assess concordance.

Clinical comparison of BACTEC 9240 plus aerobic/F resin bottles and the isolator aerobic culture system for detection of bloodstream infections

The Plus Aerobic/F resin bottle of the BACTEC 9240 automated blood culture system (Becton Dickinson Diagnostic Instrument Systems, Sparks, Md.) was compared with aerobic culture of the Isolator system (Wampole Laboratories, Cranbury, N.J.) for the detection of bloodstream microorganisms from 6,145 blood cultures collected from adult patients with suspected septicemia. The BACTEC resin bottles were incubated for 7 days, and the sediment from the Isolator tube was inoculated to sheep blood and chocolate agars which were incubated for 72 h and to inhibitory mold, brain heart infusion, and Sabouraud agars which were incubated for 21 days. A total of 622 microorganisms were recovered from 583 blood cultures. The BACTEC resin bottle recovered statistically significantly more pathogens overall than the Isolator system (P = 0.0006). When individual pathogens isolated from either system for a 7-day study period were assessed, it was determined that the BACTEC resin bottle detected statistically significantly more isolates of Staphylococcus aureus (P = 0.0113) and coagulase-negative Staphylococcus spp. (P = 0.0029) than the Isolator system. The BACTEC resin bottle also detected statistically significantly more bloodstream infections (septic episodes) caused by coagulase-negative Staphylococcus spp. (P = 0.0146). The Isolator system recovered statistically significantly more contaminants overall (P < 0.0001), and among this group of microorganisms, recovered statistically significantly more Bacillus spp. (P < 0.0001), coagulase-negative Staphylococcus spp. (P < 0.0001), and viridans group Streptococcus spp. (P = 0.0156). The Isolator system detected statistically significantly more isolates of Histoplasma capsulatum (P = 0.004), but all of these isolates were detected at > or = 7 days of incubation of fungal plates, i.e., after the system to system comparison study period (7 days). In blood culture sets which produced growth of the same pathogen in both systems, there was a statistically significant difference in median time to detection for all pathogens combined favoring the BACTEC resin bottle over the Isolator tube (P < 0.05). When assessing individual microorganisms, the median times for detection of S. aureus, Enterococcus spp., and Pseudomonas spp. were all statistically significantly less for the BACTEC system (P < 0.05). The BACTEC instrument had 79 (1.3%) false positive signals. The BACTEC system required less processing time than the Isolator system and eliminates the hands-on time for detection of positive cultures required with the Isolator system.

Anorectal melanoma--an incurable disease?

PURPOSE

This study was designed to describe recurrence and survival rates after operative treatment for anorectal melanoma and to identify predictive factors for recurrence.

METHODS

Records of 50 patients with anorectal melanoma from 1939 to 1993 were reviewed.

RESULTS

Overall five-year survival and disease-free survival were 22 and 16 percent, respectively. At the time of diagnosis, 26 percent of patients had metastatic disease, and all died within 12 (mean, 6.3) months. Five-year survival and recurrence rates were identical after either abdominoperineal resection (APR) or wide local excision, both with curative intent. Gender, size of tumor, presence of melanin, positive perirectal lymph nodes, or treatment were not predictive of recurrence. Anorectal melanoma was found incidentally after hemorrhoidectomy or polypectomy in five patients. Three other patients underwent an excisional biopsy of a lesion measuring less than 2 cm. Of these eight patients, five underwent APR and three underwent wide local excision with no microscopic residual tumor at pathology. All developed regional or systemic recurrence at a mean of 21 (range, 4-88) months, and all died of their disease at a mean of 29 (range, 5-98) months.

CONCLUSION

Prognosis for anorectal melanoma is poor, irrespective of surgical treatment performed. No predictive factors for recurrence were identified in this series. Wide local excision with a negative margin of a least 1 cm is suggested as the treatment of choice. APR should be reserved for tumor not amenable to local excision or for palliative treatment of large obstructive lesion until effective adjuvant therapies are available.

Follicular and Hürthle cell thyroid neoplasms. Is frozen-section evaluation worthwhile?

OBJECTIVES

To determine whether (1) frozen-section (FS) evaluation of follicular and Hürthle cell thyroid neoplasms (FHCNs) is accurate, (2) FS aids in intraoperative decision-making, and (3) FS is cost-effective.

DESIGN

Retrospective review of patient histories and FS and paraffin-embedded slides. Permanent histologic sections were considered the standard criterion. Follow-up was achieved in 92% of patients with a mean follow-up of 5.7 years.

SETTING

Tertiary care referral center.

PATIENTS

All patients undergoing thyroidectomy for a suspected FHCN between January 1, 1985, and December 31, 1994. Patients included were those whose condition was diagnosed as FHCN, either on FS, permanent histologic sections, or both.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of FS analysts were determined. Total adjusted hospital charges were compared for those undergoing 1 vs 2 cancer operations. Multivariate analyses were carried out to determine the optimal predictive model for follicular cancer.

RESULTS

The study group included 1023 patients (737 women and 286 men), of whom 83 (8.1%) were diagnosed as having a malignant FHCN on permanent section. The diagnosis of malignant neoplasm was correctly established in 65 (78%) of the 83 patients on FS, thereby permitting definitive surgical management at the first operation. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for FS diagnosis of malignant FHCN were 78%, 99%, 90%, 98%, and 98%, respectively. In a multivariate analysis, FS was the most significant variable predictive of malignant neoplasm. Approximately $400,000 was saved in hospital charges by the use of FS as a result of the elimination of many 2-stage operations.

CONCLUSION

Frozen-section evaluation of FHCN can be performed with a high degree of accuracy, permitting considerable cost savings.

Hepatic resection for metastatic colorectal cancer results in cure for some patients

OBJECTIVES

To determine the long-term disease-free and overall survivals for patients undergoing hepatic resection for colorectal cancer metastases and to define significant predictors of improved patients survival.

DESIGN

Retrospective review.

SETTING

Single tertiary care center.

PATIENTS

Two hundred eighty consecutive patients underwent hepatic resection for colorectal cancer metastases at the Mayo Clinic from 1960 to 1987. Fifty patients alive at the completion of the study had a mean follow-up of 11.3 years (median, 121 months).

MAIN OUTCOME MEASURES

Disease-free interval following initial hepatic resection and death.

RESULTS

The overall 5-year survival of the 280 patients was 27%. Twenty-eight patients were alive at 10 years from the time of hepatic resection, and the 10-year actuarial survival was 20%. Only 2 patients alive and free of disease at 5 years had recurrent disease. For all other patients who were free of disease more than 5 years after hepatic resection and died, the cause of death was not cancer related. No patients characteristics or features of the primary tumor affected survival. Clinical presentation of metastatic disease, configuration of hepatic lesions, the presence of extrahepatic lymph node involvement, and the existence of resectable extrahepatic disease significantly affected long-term patient survival. Need for perioperative blood product transfusion was associated with a lower probability of long-term survival.

CONCLUSIONS

Disease-free patient survival beyond 5 years from surgical resection of colorectal cancer metastases to the liver represents patient cure in nearly all instances.

Staphylococcus aureus prosthetic joint infection treated with debridement and prosthesis retention

Debridement and retention of the prosthesis was the initial treatment modality in 30 patients with 33 Staphylococcus aureus prosthetic joint infections (PJIs) who presented to the Mayo Clinic between 1980 and 1991. Treatment failure, defined as relapse of S. aureus PJI or occurrence of culture-negative PJI during continuous antistaphylococcal therapy, occurred in 21 of 33 prosthetic joints. The 1-year and 2-year cumulative probabilities of treatment failure were 54% (95% confidence interval [CI], 36%-71%) and 69% (95% CI, 52%-86%), respectively. A median of 4 additional surgical procedures (range, 1-9) were required to control the infection in the 21 prosthetic joints for which treatment failed. Prostheses that were debrided >2 days after onset of symptoms were associated with a higher probability of treatment failure than were those debrided within 2 days of onset (relative risk, 4.2; 95% CI, 1.6-10.3). These data suggest that debridement and retention of the prosthesis as the initial therapy for PJI due to S. aureus is associated with a high cumulative probability of treatment failure and that the probability of treatment failure may be related to the duration of symptoms.

The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules

BACKGROUND

A clinical prediction model to identify malignant nodules based on clinical data and radiological characteristics of lung nodules was derived using logistic regression from a random sample of patients (n = 419) and tested on data from a separate group of patients (n = 210).

OBJECTIVE

To use multivariate logistic regression to estimate the probability of malignancy in radiologically indeterminate solitary pulmonary nodules (SPNs) in a clinically relevant subset of patients with SPNs that measured between 4 and 30 mm in diameter.

PATIENTS AND METHODS

A retrospective cohort study at a multispecialty group practice included 629 patients (320 men, 309 women) with newly discovered (between January 1, 1984, and May 1, 1986) 4- to 30-mm radiologically indeterminate SPNs on chest radiography. Patients with a diagnosis of cancer within 5 years prior to the discovery of the nodule were excluded. Clinical data included age, sex, cigarette-smoking status, and history of extrathoracic malignant neoplasm, asbestos exposure, and chronic interstitial or obstructive lung disease; chest radiological data included the diameter, location, edge characteristics (eg, lobulation, spiculation, and shagginess), and other characteristics (eg, cavitation) of the SPNs. Predictors were identified in a random sample of two thirds of the patients and tested in the remaining one third.

RESULTS

Sixty-five percent of the nodules were benign, 23% were malignant, and 12% were indeterminate. Three clinical characteristics (age, cigarette-smoking status, and history of cancer [diagnosis, > or = 5 years ago]) and 3 radiological characteristics (diameter, spiculation, and upper lobe location of the SPNs) were independent predictors of malignancy. The area (+/-SE) under the evaluated receiver operating characteristic curve was 0.8328 +/- 0.0226.

CONCLUSION

Three clinical and 3 radiographic characteristics predicted the malignancy in radiologically indeterminate SPNs.

Long-term results of surgery for chronic constipation

BACKGROUND

Developments in anorectal physiologic testing have facilitated better understanding of the process of defecation and factors that might cause chronic constipation.

AIM

Patients with severe idiopathic chronic constipation were evaluated using colonic transit and pelvic floor function in an attempt to identify those patients suitable for aggressive surgical intervention.

MATERIALS AND RESULTS

Among 1,009 patients studied using either a marker or scintigraphic transit technique and tests of pelvic floor function, 52 with slow-transit constipation (STC) were identified and underwent abdominal colectomy and ileorectostomy (IRA). Twenty-two patients had pelvic floor dysfunction and STC; these patients underwent initial pelvic floor retraining followed by IRA. A total of 249 patients had pelvic floor dysfunction without evidence of slow-transit and were offered pelvic floor retraining alone. The remaining 597 patients had no quantifiable abnormality of colon or pelvic floor dysfunction; these patients had normal transit constipation/irritable bowel syndrome and were treated medically. There were, thus, 74 patients operated on, 68 women, with a mean age of 53 years and a mean follow-up of 56 months. There was no operative mortality, seven patients (9 percent) had small-bowel obstruction, and nine patients (12 percent) had prolonged ileus. All patients were able to pass a stool spontaneously, 97 percent of patients were satisfied with the results of surgery, and 90 percent have a good or improved quality of life. There was no difference in the outcome of surgery in patients with STC alone compared with STC and pelvic floor dysfunction.

CONCLUSION

Physiologic evaluation reliably identified patients with severe chronic constipation who might benefit from surgery. IRA is safe and effective, resulting in prompt and prolonged relief of constipation.

Analysis of 281,797 consecutive blood cultures performed over an eight-year period: trends in microorganisms isolated and the value of anaerobic culture of blood

The results for 281,797 blood culture sets of specimens collected from adult patients at the Mayo Clinic over an approximately 8-year period (1 November 1984 through 30 November 1992) were analyzed in order to determine whether there were differences in the types of microorganisms isolated over this time and to assess the usefulness of anaerobic culturing of blood. Each blood culture set consisted of two aerobic blood cultures (Septi-Chek [Becton Dickinson, Sparks, MD] and Isolator [Wampole Laboratories, Cranbury, NJ]) and one anaerobic culture (nonvented tryptic or trypticase soy broth [NVTSB; Difco Laboratories, Detroit, or Becton Dickinson]). The relative frequency of isolation of aerobic and facultatively anaerobic gram-positive bacteria and obligately anaerobic bacteria increased over the second half of the 1984-1992 surveillance period. The value of the NVTSB anaerobic blood culture was demonstrated for diagnosing bloodstream infections caused by certain facultatively anaerobic bacteria in addition to obligately anaerobic bacteria and supported the inclusion of the NVTSB anaerobic blood culture as a standard part of the three-component blood culture set used at this institution.

Event status of the Starr-Edwards aortic valve to 20 years: a benchmark for comparison

BACKGROUND

Considerable effort and expense has been invested in the evolutionary development of cardiac valvular prostheses with the goal of reducing or minimizing specific events related to these prostheses. It is important to measure any improvement achieved with such development by comparison against a historic standard. The Starr-Edwards caged-ball prosthesis model 1260 has been used for 30 years as the predominant or sole model of its kind for aortic valve replacement. This historic opportunity provides a benchmark for subsequent improvement and comparison of current prostheses.

METHODS

Between 1969 and 1991, 1,100 patients (median age, 57 years; 838 men and 194 women) underwent aortic valve replacement with or without coronary artery bypass grafting (aortic valve replacement, 964; aortic valve replacement plus coronary artery bypass grafting, 136) with the 1260 Starr-Edwards caged-ball prosthesis.

RESULTS

Operative mortality was 6.2% (68 patients). Univariate patient characteristics predictive of early mortality were female sex (p = 0.003), age (> 56 years; p = 0.002), recent operative interval (1985 to 1991 versus 1969 to 1976 or 1977 to 1984; p = 0.002), presence of atrial fibrillation (p = 0.001), and small valve size (7A to 8A = 19 to 21 mm; p < 0.001). Follow-up extended to 11,293 patient-years (mean, 24.8 years) and was 96.9% complete. Survival at 5, 10, 15, and 20 years for all patients including operative mortality was 76.6%, 59.6%, 44.9%, and 31.2%, respectively. Operative variables predictive of poor late survival were advanced New York Heart Association class (III or IV); (p = 0.0001), older age (> 56 years; p = 0.0001), and lower (< 0.56) ejection fraction (p = 0.0001). Freedom from thromboemboli and anticoagulant-related bleeding at 5 years was 90.8% and 98.7%, respectively. Univariate model for greater risk of late thromboemboli identified female sex (p = 0.04), older age (> 56 years; p = 0.0002), and New York Heart Association class III or IV (p = 0.0058), as risk factors. Multivariate analysis for thromboemboli demonstrated older age (p = 0.0007) and New York Heart Association class III or IV (p = 0.0041) as significant. Alternatively, univariate analysis for late bleeding found only the most recent operative interval (p = 0.009) as significant, and the rarity of events prevented a multivariate query. There were no valve failures.

CONCLUSIONS

The late results of survival and freedom from late anticoagulant-related bleeding or thromboemboli are excellent, especially in larger (9A and above) sizes, and with the long implant record comparable with more recent prostheses, the Starr-Edwards valve provides an excellent, safe, and durable alternative in the aortic position and provides a benchmark against which to compare other prostheses.

Dual-chamber pacing for hypertrophic cardiomyopathy: a randomized, double-blind, crossover trial

OBJECTIVES

In a double-blind, randomized, crossover trial we sought to evaluate the effect of dual-chamber pacing in patients with severe symptoms of hypertrophic obstructive cardiomyopathy.

BACKGROUND

Recently, several cohort trials showed that implantation of a dual-chamber pacemaker in patients with severely symptomatic hypertrophic obstructive cardiomyopathy can relieve symptoms and decrease the severity of the left ventricular outflow tract gradient. However, the outcome of dual-chamber pacing has not been compared with that of standard therapy in a randomized, double-blind trial.

METHODS

Twenty-one patients with severely symptomatic hypertrophic obstructive cardiomyopathy were entered into this trial after baseline studies consisting of Minnesota quality-of-life assessment, two-dimensional and Doppler echocardiography and cardiopulmonary exercise tests. Nineteen patients completed the protocol and underwent double-blind randomization to either DDD pacing for 3 months followed by backup AAI pacing for 3 months, or the same study arms in reverse order.

RESULTS

Left ventricular outflow tract gradient decreased significantly to 55 +/- 38 mm Hg after DDD pacing compared with the baseline gradient of 76 +/- 61 mm Hg (p < 0.05) and the gradient of 83 +/- 59 mm Hg after AAI pacing (p < 0.05). Quality-of-life score and exercise duration were significantly improved from the baseline state after the DDD arm but were not significantly different between the DDD arm and the backup AAI arm. Peak oxygen consumption did not significantly differ among the three periods. Overall, 63% of patients had symptomatic improvement during the DDD arm, but 42% also had symptomatic improvement during the AAI backup arm. In addition, 31% had no change and 5% had deterioration of symptoms during the DDD pacing arm.

CONCLUSIONS

Dual-chamber pacing may relieve symptoms and decrease gradient in patients with hypertrophic obstructive cardiomyopathy. In some patients, however, symptoms do not change or even become worse with dual-chamber pacing. Subjective symptomatic improvement can also occur from implantation of the pacemaker without its hemodynamic benefit, suggesting the role of a placebo effect. Long-term follow-up of a large number of patients in randomized trials is necessary before dual-chamber pacing can be recommended for all patients with severely symptomatic hypertrophic obstructive cardiomyopathy.

Waddell's nonorganic signs and Minnesota Multiphasic Personality Inventory profiles in patients with chronic low back pain

STUDY DESIGN

An analysis of clinical data gathered at an orthopedic outpatient clinic is presented.

OBJECTIVE

To examine the relationship between Waddell scores and the Minnesota Multiphasic Personality Inventory response patterns.

SUMMARY OF BACKGROUND DATA

Waddell's study of nonorganic signs of low back pain showed consistent correlations with Minnesota Multiphasic Personality Inventory scales 1 to 3.

METHODS

A Waddell score was obtained from 507 consecutive patients with chronic low back pain to whom an Minnesota Multiphasic Personality Inventory also was administered. The sample was divided into those patients with a high Waddell score (high waddell score = 3 to 5) and those with a low Waddell score (low waddell score = 0 to 2); men and women were scored separately.

RESULTS

Among male patients, statistically significant differences were found between the high Waddell score and low Waddell score groups on Minnesota Multiphasic Personality Inventory scales, 1, 3, and 8, but among females, differences were statistically significant only on scale 8.

CONCLUSIONS

Correlations between the Waddell score and the first three scales of the Minnesota Multiphasic Personality Inventory were not fully replicated. The difference between the high Waddell and low Waddell groups on scale 8, however, was significant for men and women.

Impact of arterial surgery and balloon angioplasty on amputation: a population-based study of 1155 procedures between 1973 and 1992

BACKGROUND

Limited population-based data are available on trends in the incidence of arterial surgery, balloon angioplasty, and amputation for arterial occlusive disease of the legs over the past two decades.

METHODS

We identified all elective and emergency arterial operations, balloon angioplasty procedures, and amputations performed for all residents of a defined community, Olmsted County, Minn., between 1973 and 1992. We focused on gender mix, type of procedure, and secular trends in utilization.

RESULTS

A total of 1155 procedures were performed, including 733 arterial surgical procedures, 59 balloon angioplasty procedures, and 363 amputations (288 major and 75 minor). Emergency procedures were performed in 12%. Suprainguinal inflow procedures were the most common arterial reconstruction (60%) compared with infrainguinal procedures (40%). The incidence of all revascularization procedures increased in the first decade but reached a plateau after 1985. Utilization rates of revascularization procedures from 1988 to 1992 were higher for men (141.9/100,000 person-years [p-yr]) than women (57.4/100,000 p-yr.). Angioplasty (17.0/100,000 p-yr) rates lagged behind surgery until 1985, but tripled in the past 10 years and have not yet reached a plateau. Although minor amputation rates remain unchanged in 20 years, major amputation rates have been reduced by 50% from 36.7/100,000 p-yr between 1973 and 1977 to 19.0/100,000 p-yr from 1988 to 1992.

CONCLUSIONS

From this long-term population-based analysis (1973 to 1992), we conclude that increased vascular surgery and balloon angioplasty rates have coincided with a significant reduction in major amputation rates in the past 10 years.

Safety, feasibility, and early efficacy of subfascial endoscopic perforator surgery: a preliminary report from the North American registry

PURPOSE

The North American Subfascial Endoscopic Perforator Surgery (NASEPS) Registry was established to evaluate the safety, feasibility, and efficacy of minimally invasive endoscopic Linton operations for treatment of chronic venous insufficiency.

METHODS

Retrospective analysis was performed on the clinical data of 151 patients who underwent attempt at 158 SEPS in 17 medical centers in the United States and Canada between June 1993 and February 1996.

RESULTS

SEPS was completed on 155 limbs of 148 patients, 81 male and 67 female (mean age, 56 years; range, 27 to 87 years). Three procedures were aborted. Seven patients had bilateral procedures (data from one limb were analyzed). One hundred four limbs (70%) had active ulcers, and 22 (15%) had healed ulcers. A single endoscopic port without insufflation was used in 66 procedures (45%) and laparoscopic instrumentation, with two or three ports, in 82 (55%), with CO2 insufflation in 78 (53%). A tourniquet was used on 112 patients (76%). Concomitant venous procedures were performed in 106 patients (72%; saphenous stripping in 71, high ligation in 17, varicosity avulsion in 85). No early deaths or thromboembolism occurred. Complications included wound infections (9), superficial thrombophlebitis (5), cellulitis (4), and saphenous neuralgia (10). Seven patients with wound infection had open ulcers; nine of 10 with neuralgia had concomitant procedures. A roll-on tourniquet caused skin necrosis in one patient. The clinical score improved from 9.4 to 2.9 after surgery (p < 0.0001). Mean follow-up was 5.4 months; 31 patients had > or = 6 months follow-up. Ulcers healed in 88% (75 of 85); recurrence or new ulcer was reported in 3% (4 of 120).

CONCLUSIONS

The SEPS modified Linton operation appears safe, with no postoperative deaths or early thromboembolism. Wound infection after SEPS remains important. Early results indicate rapid ulcer healing. Prospective evaluation of long-term results is warranted.

Characteristics of patients surgically treated for primary hyperparathyroidism with and without renal stones

BACKGROUND

Between 1980 and 1984, 312 (30%) of 1038 patients undergoing initial cervical exploration for primary hyperparathyroidism (pHPT) at our institution had proven renal stones.

METHODS

In this retrospective study we focused on clinical characteristics, biochemical tests, perioperative and pathologic findings, and immediate outcomes of operation, comparing findings in patients with and without renal stones.

RESULTS

Patients with renal stones were more often younger male patients, had serum phosphorus levels significantly lower (p < 0.02) and 24-hour urinary calcium excretion significantly higher (p < 0.0001) than patients without renal stones, and had a significantly higher (p < 0.05) proportion of abnormal glands weighing less than 250 mg. Relevant diagnostic preoperative variables were evaluated by means of multivariate analysis to determine whether they independently had predictive power with regard to renal stones. Male gender and younger age were significantly associated with the presence of renal stones, providing odds ratios of 2.5 and 1.4, respectively. In addition, the risk of having renal stones was significantly related to minimally elevated serum calcium levels (p < 0.05), serum phosphorus levels (p = 0.02), and 24-hour urine calcium excretion (p < 0.05).

CONCLUSIONS

In patients with renal stones the diagnosis of pHPT should be considered. If the diagnosis is confirmed, a liberal approach to cervical exploration should be taken.

Noninvasive doppler echocardiographic evaluation of left ventricular filling pressures in patients with cardiomyopathies: a simultaneous Doppler echocardiographic and cardiac catheterization study

OBJECTIVES

The purpose of this study was to examine the relation of the mitral flow velocity curves to left ventricular filling pressures in patients with two different types of myocardial problems: hypertrophic cardiomyopathy and severe left ventricular systolic dysfunction.

BACKGROUND

Previous studies have suggested that assessment of Doppler-derived mitral flow velocity curves can be used to predict left ventricular filling pressures in specific disease entities. However, it is unclear whether information derived from specific mitral flow velocity curves obtained from one disease entity can be valid in other disease states.

METHODS

The study group consisted of 42 patients with left ventricular systolic dysfunction (group A) and 55 patients with hypertrophic cardiomyopathy (group B); both groups underwent simultaneous cardiac catheterization and were studied by Doppler echocardiography. High fidelity measures of left atrial and left ventricular pressures were obtained simultaneously with mitral flow velocity curves.

RESULTS

There was a significant relation between the Doppler echocardiographic variables and mean left atrial pressure in group A patients. The left atrial pressure was directly related to the E/A ratio (r = 0.49, p = 0.004) and inversely related to the deceleration time (r = 0.73, p < 0.001). The sensitivity and specificity of the deceleration time, < 180 m/s, which indicated a mean left atrial pressure > or = 20 mm Hg, were both 100%. In group B patients, there was no significant relation between mean left atrial pressure and deceleration time.

CONCLUSIONS

Doppler echocardiographic mitral flow velocity curves are useful in predicting and estimating left ventricular filling pressures in patients with left ventricular dysfunction. However, because of the complexity of the multiple interrelated factors that determine diastolic filling of the left ventricle, these flow velocity curves cannot be used in patients with other disease entities, such as hypertrophic cardiomyopathy. Future studies of different disease states are necessary to fully understand the role of Doppler echocardiography in the assessment of diastolic filling.

Risk factors of invasive Candida and non-Candida fungal infections after liver transplantation

Fungal infections are associated with a high mortality rate after liver transplantation. To describe risk factors for fungal infections, 405 consecutive liver transplant recipients were analyzed. Forty-five patients (11%) developed invasive fungal infection. Median posttransplantation time to the first episode was 60 days. Pathogens were Candida species (spp) (n=24, 53%), Cryptococcus neoformans (n=10, 22%), Aspergillus spp (n=6, 13%), Rhizopus spp (n=l), and others (n=4). Presentations of infection included disseminated (n=9), intra-abdominal (n=9), esophageal (n=9), lung (n=8), blood (n=6), and central nervous system infections (n=3), and sinusitis with esophagitis (n=1). Eighteen patients (40%) with invasive fungal infection died, and 13 (72%) of these deaths were attributable to fungi. Mortality in the nonfungal infection group was 12%. Univariate analysis identified separate risk factors for Candida (intra-abdominal bleeding), Aspergillus (fulminant hepatitis), and cryptococcal (symptomatic cytomegalovirus infection) infections. In both univariate and multivariate analyses, a high intratransplant transfusion requirement and posttransplant bacterial infection were identified as significant risk factors for all types of fungal infection. The risk factor analysis reported here suggests that different pathogenic processes lead to Candida and non-Candida infection in liver transplant recipients. Their identification should prompt specific prophylactic measures to reduce morbidity and mortality in this population.

Assessment of routine use of an anaerobic bottle in a three-component, high-volume blood culture system

The relative value of routine anaerobic blood culture for recovery of organisms and identification of episodes of bloodstream infection was assessed in a three-component, high-volume blood culture system which employs aerobic and anaerobic bottles of BacT/Alert (Organon-Teknika, Durham, N.C.) and aerobic cultures of Isolator (Wampole Laboratories, Cranbury, N.J.). The results of 5,595 blood culture sets from patients with suspected bloodstream infection were analyzed. Compared with either the aerobic BacT/Alert bottle or aerobic culture of Isolator, the BacT/Alert anaerobic bottle recovered significantly fewer isolates (242 versus 294, P < 0.05; 242 versus 298, P < 0.05) but did not detect significantly fewer episodes of bloodstream infection (141 versus 157, P > 0.05; 141 versus 147, P > 0.05). The BacT/Alert anaerobic bottle recovered significantly more isolates of obligately anaerobic bacteria (16 versus 4, P < 0.05; 16 versus 0, P < 0.05) and detected significantly more episodes of bloodstream infection caused by obligately anaerobic bacteria (10 versus 3, P < 0.05; 10 versus 0, P < 0.05) than either the aerobic bottle of BacT/Alert or the aerobic culture of Isolator. The combination of the BacT/Alert anaerobic bottle and the aerobic culture of Isolator recovered as may isolates (374 versus 377) and detected as many episodes of bloodstream infection (194 versus 191) as the combination of the aerobic bottle of BacT/Alert and the aerobic culture of Isolator, and both of these combinations identified at least 8% more isolates and detected at least 3% more bloodstream infections than the combination of the BacT/Alert aerobic and anaerobic bottles. Further analysis of the data revealed that the utility of the BacT/Alert anaerobic bottle, especially when combined with the aerobic culture of Isolator, resulted from not only enhanced recovery of obligately anaerobic bacteria but also effective recovery of facultatively anaerobic bacteria. These results demonstrate the utility of the anaerobic BacT/Alert bottle for detecting bloodstream infection caused by either facultatively anaerobic bacteria or obligately anaerobic bacteria and support the routine inclusion of anaerobic blood culture in the three-component blood culture system used in our hospital.

Risk of recurrent biliary tract disease after cholecystectomy in patients with duodenal diverticula

OBJECTIVE

To determine if the presence of duodenal diverticula predisposes to the development of common bile duct stones.

DESIGN

Cohort study; median follow-up, 10.0 years (25th and 75th percentiles, 5.2 and 16.1 years, respectively).

SETTING

Tertiary care center.

PATIENTS

One hundred fifty-seven patients with radiologically diagnosed duodenal diverticula who had undergone cholecystectomy from 1950 through 1987 and were asymptomatic at the initiation of follow-up.

MAIN OUTCOME MEASURES

All patients were followed up for evidence of recurrent biliary tract disease to the following end points: (1) evidence of choledocholithiasis demonstrated by radiologic surgical, or biochemical means and (2) clinical or biochemical evidence of biliary pancreatitis.

RESULTS

Of the 157 patients in the study cohort, 13 patients were categorized as having had recurrent biliary tract disease. Using the Kaplan-Meier survivorship method, the cumulative probabilities of recurrent biliary tract disease in patients with radiologically diagnosed duodenal diverticula were 3.6% at 5 years (95% confidence interval, 0.5-6.9), 5.5% at 10 years (95% confidence interval, 1.5-9.4), and 10.2% at 15 years (95% confidence interval, 3.8-16.7). Age, common bile duct exploration and choledochotomy, and the presence of common bile duct dilatation were not found to be significantly associated with recurrence based on a univariate analysis of risk factors by means of the log-rank statistic.

CONCLUSIONS

For patients with radiologically diagnosed, second-portion duodenal diverticula, the risk of developing recurrent bile duct stones after cholecystectomy is lower than has been suggested in previous studies. In the absence of concurrent choledocholithiasis, sphincterotomy or biliary bypass at the time of cholecystectomy seems unwarranted.

Outcome after Colles fracture: the relative responsiveness of three questionnaires and physical examination measures

Clinical evaluation of outcome after Colles fracture has not been standardized. To assess the relative responsiveness of various clinical and questionnaire measures for the assessment of outcome after Colles fracture, 21 patients were surveyed on the day fracture immobilization was discontinued and again 3 months after that date with the following measures: a short form general health survey (SF-36), the Arthritis Impact Measurement Scale (AIMS2), the Brigham and Women's Hospital carpal tunnel questionnaire; pinch strength, grip strength, pressure sensibility, range of motion, and dexterity. Significant changes, all in the direction of improved health status, occurred in the following scales or measures: AIMS2 mobility, hand and finger function, arm function, household tasks, "arthritis" (fracture) pain, self-care, satisfaction, physical health, affect, and tension; Brigham function; SF-36 physical role and mental health; and grip, pinch, dexterity, and range of motion. The impairments that occur after Colles fracture are multidimensional and are only partially captured by traditional physical measures. Questionnaires such as the SF-36, AIMS2, and Brigham and Women's instruments provide a mechanism to capture the function and symptom dimensions objectively.

Surgical treatment of Graves' disease in patients younger than 18 years

Eighty-two children and adolescents (18 males, 64 females; median age 14 years) surgically treated for Graves' disease at a single institution between 1979 and 1993 were retrospectively reviewed. Most of the patients (74%) coming to thyroidectomy had been treated medically for a period ranging from 2 to 80 (median 15) months. Bilateral subtotal thyroid resection was the most frequently performed procedure (86%). Postoperatively, no permanent recurrent laryngeal nerve palsy or permanent hypocalcemia occurred. Operative mortality was zero. With a median follow-up of 8.3 years, recurrent hyperthyroidism occurred in five patients (6%), one of whom required reoperation. Most children and adolescents with Graves' disease can be rendered euthyroid by nonsurgical treatment options. However, prolonged and ineffective medical treatment should be avoided in these patients who are in the formative years of their lives. Surgical treatment, when indicated and employed, offers young patients with Graves' disease a safe, rapid, definitive, cost-effective treatment with a high success rate.

Development of monoclonal gammopathy precedes the development of Epstein-Barr virus-induced posttransplant lymphoproliferative disorder

Epstein-Barr virus (EBV)-induced posttransplant lymphoproliferative disorder (PTLD) develops in 3% to 10% of solid organ transplant recipients with a resultant mortality of up to 70%. Unfortunately, there is no current marker which identifies patients who will develop this disease. We therefore conducted a risk factor analysis of variables that might predict the development of PTLD. Specifically, since EBV may cause both PTLD and the development of monoclonal proteins (M protein), we sought to determine if the development of an M protein preceded and therefore might serve as a predictive marker of subsequent PTLD. Before and after liver transplantation, 201 patients were evaluated for the presence of urine and serum M proteins. Patients were followed to monitor the development of PTLD for a mean of 1,733 days. PTLD developed in seven patients (3.5%), three (43%) of whom died from disseminated PTLD. PTLD was classified as polymorphous in six patients and monomorphous in one patient. Fifty-seven patients (28%) developed an M protein after transplantation: five of seven patients (71%) with PTLD and 52/194 (27%) of patients without PTLD. Multivariate risk factor analysis for the development of an M protein after transplantation identified cytomegalovirus (CMV) donor seropositivity (P = 0.0002) and postoperative symptomatic CMV infection (P = 0.019) as risk factors. Whereas EBV serostatus of either the donor or recipient was not found to be a risk factor for the occurrence of either an M protein or PTLD, the development of a serum immunoglobulin M (IgM) M protein (P = 0.04) and of any urine M protein (P = 0.01) was identified by univariate analysis as being associated with the development of PTLD. Further studies are needed to determine the predictive value of M proteins as a marker for PTLD. Until such time, the development of serum or urine M protein should heighten the suspicion of developing PTLD.