1
|
Abstract
OBJECTIVES This study examines whether low or high blood hemoglobin concentration (HGB) is associated with stroke severity, worse clinical outcomes, and poorer prognosis after acute ischemic stroke (AIS). METHODS This retrospective cohort study included data from the Ontario Stroke Registry on consecutive patients with AIS who were admitted between July 2003 and March 2008. We excluded patients taking anticonvulsants or iron supplement; patients with cancer, renal failure, history of gastro-intestinal or genitourinary bleeding, and pregnancy. Patients were divided into groups as follows: low HGB, normal HGB, and high HGB. Outcome measures included the frequency of greater degree of disability at discharge (modified Rankin score: 3-6), 7-day, 30-day and 90-day mortality, and length of stay in the acute stroke care hospital. RESULTS Hemoglobin levels higher than the upper limit of normal are associated with a greater disability at discharge (OR = 1.49, 95% CI: 1.03-2.15, P = 0.0331), and higher 30-day mortality (HR = 1.98, 95% CI: 1.44-2.74, P < 0.0001) after adjustment for major potential confounders. The Kaplan-Meier curves indicate that abnormal HGB levels are associated with higher mortality after AIS (P < 0.0001). HGB levels below the lower limit of normal are associated with longer lengths of stay in the acute care hospital (OR = 1.11, 95% CI: 1.02-1.22, P = 0.017). Elevated HGB was associated with greater neurological deficit on admission (OR = 1.45, 95% CI: 1.06-1.95, P = 0.0195). CONCLUSIONS Our results suggest that an elevated HGB on the initial admission is associated with more severe strokes, greater disability at discharge, and higher 30-day mortality after AIS. A low HGB on admission is associated with longer stay in the acute care hospital.
Collapse
Affiliation(s)
- J. C. Furlan
- Division of Neurology; Department of Medicine; University of Toronto; Toronto ON Canada
- Division of Physical Medicine and Rehabilitation; Department of Medicine; Lyndhurst Centre; Toronto Rehabilitation Institute; Toronto ON Canada
| | - J. Fang
- Institute for Clinical Evaluative Sciences; Toronto ON Canada
| | - F. L. Silver
- Division of Neurology; Department of Medicine; University of Toronto; Toronto ON Canada
- Institute for Clinical Evaluative Sciences; Toronto ON Canada
- Division of Neurology; University Health Network; Toronto ON Canada
| |
Collapse
|
2
|
Furlan JC, Vergouwen MDI, Fang J, Silver FL. White blood cell count is an independent predictor of outcomes after acute ischaemic stroke. Eur J Neurol 2013; 21:215-22. [DOI: 10.1111/ene.12233] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 06/05/2013] [Indexed: 02/02/2023]
Affiliation(s)
- J. C. Furlan
- Division of Neurology; Department of Medicine; University of Toronto; Toronto ON Canada
- Department of Genetics and Development; Toronto Western Research Institute; Toronto ON Canada
- Lyndhurst Centre; Toronto Rehabilitation Institute; Toronto ON Canada
| | - M. D. I. Vergouwen
- UMC Utrecht Stroke Center; Department of Neurology and Neurosurgery; Rudolf Magnus Institute of Neuroscience; University Medical Center Utrecht; Utrecht The Netherlands
| | - J. Fang
- Institute for Clinical Evaluative Sciences; Toronto ON Canada
| | - F. L. Silver
- Division of Neurology; Department of Medicine; University of Toronto; Toronto ON Canada
- Institute for Clinical Evaluative Sciences; Toronto ON Canada
- Division of Neurology; University Health Network; Toronto ON Canada
| |
Collapse
|
3
|
Furlan JC, Fehlings MG. Blood alcohol concentration as a determinant of outcomes after traumatic spinal cord injury. Eur J Neurol 2013; 20:1101-6. [DOI: 10.1111/ene.12145] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 02/14/2013] [Indexed: 11/27/2022]
Affiliation(s)
- J. C. Furlan
- Division of Neurology; Department of Medicine; University of Toronto; Toronto ON Canada
- Department of Genetics and Development; Toronto Western Research Institute; University Health Network; Toronto ON Canada
- Lyndhurst Centre; Toronto Rehabilitation Institute; University Health Network; Toronto ON Canada
| | - M. G. Fehlings
- Department of Genetics and Development; Toronto Western Research Institute; University Health Network; Toronto ON Canada
- Krembil Neuroscience Centre; Spinal Program; Toronto Western Hospital; University Health Network; Toronto ON Canada
- Division of Neurosurgery; Department of Surgery; University of Toronto; Toronto ON Canada
| |
Collapse
|
4
|
Hawryluk GWJ, Austin JW, Furlan JC, Lee JB, O'Kelly C, Fehlings MG. Management of anticoagulation following central nervous system hemorrhage in patients with high thromboembolic risk. J Thromb Haemost 2010; 8:1500-8. [PMID: 20403088 DOI: 10.1111/j.1538-7836.2010.03882.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
SUMMARY BACKGROUND Patients who present with central nervous system (CNS) hemorrhage while on anticoagulation (AC) for thromboembolic (TE) risk factors are a challenge to manage. OBJECTIVE We sought to inform decisions surrounding the timing and intensity of AC resumption by performing a systematic review. METHODS Three reviewers screened publications from Medline and EMBASE and extracted data. Hemorrhagic and TE adverse events that occurred subsequent to the index hemorrhage were recorded, as was their timing relative to presentation and covariates that might influence their occurrence. RESULTS Data were extracted from 63 publications detailing 492 patients; 7.7% of patients experienced hemorrhagic complications and 6.1% experienced TE complications. Hemorrhagic complications were more common within 72 h of presentation while TE complications were more common thereafter. Patients restarted on AC after 72 h were significantly more likely to have a TE complication (P = 0.006) and those restarted before 72 h were more likely to hemorrhage (P = 0.0727). Factors associated with re-hemorrhage included younger age, traumatic cause, subdural hematomas and failure to reverse AC. TE complications were more common in younger patients and those with spinal hemorrhage, multiple hemorrhages, and non-traumatic causes of the index hemorrhage. Re-initiation of AC at a lower intensity also significantly increased the risk of TE complications. INTERPRETATION Our results suggest that it may be prudent to re-initiate AC earlier than previously thought, with the timing and intensity modified based on predictors of TE and hemorrhagic complications. These findings must be explored in a prospective study because of limitations inherent to the analyzed studies.
Collapse
Affiliation(s)
- G W J Hawryluk
- Division of Genetics and Development, Toronto Western Research Institute, University Health Network, Toronto, ON, Canada
| | | | | | | | | | | |
Collapse
|
5
|
Furlan JC, Craven BC, Ritchie R, Coukos L, Fehlings MG. Attitudes towards the older patients with spinal cord injury among registered nurses: a cross-sectional observational study. Spinal Cord 2009; 47:674-80. [DOI: 10.1038/sc.2009.23] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
6
|
Furlan JC, Urbach DR, Fehlings MG. Optimal treatment for severe neurogenic bowel dysfunction after chronic spinal cord injury: a decision analysis. Br J Surg 2007; 94:1139-50. [PMID: 17535012 DOI: 10.1002/bjs.5781] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND When conservative management fails in patients with chronic spinal cord injury (SCI) and neurogenic bowel dysfunction, clinicians have to choose from a variety of treatment options which include colostomy, ileostomy, Malone anterograde continence enema (MACE) and sacral anterior root stimulator (SARS) implantation. This study employed a decision analysis to examine the optimal treatment for bowel management of young individuals with chronic refractory constipation in the setting of chronic SCI. METHODS A decision analysis was created to compare the four surgical strategies using baseline analysis, one-way and two-way sensitivity analyses, 'worst scenario' and 'best scenario' sensitivity analyses, and probabilistic sensitivity analyses. Quality-adjusted life expectancy (QALE) was the primary outcome. RESULTS The baseline analysis indicated that patients who underwent the MACE procedure had the highest QALE value compared with the other interventions. Sensitivity analyses showed that these results were robust. CONCLUSION The MACE procedure may provide the best long-term outcome in terms of the probability of improving bowel function, reducing complication rates and the incidence of autonomic dysreflexia, and being congruent with patients' preferences. The analysis was sensitive to changes in assumptions about quality of life/utility, and thus the results could change if more specific estimates of utility became available.
Collapse
Affiliation(s)
- J C Furlan
- Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, Ontario, Canada.
| | | | | |
Collapse
|
7
|
Asano TK, McLeod RS, Blitz M, Butts C, Kneteman N, Bigam D, Oosthuizen JFM, Phang PT, Gouthro D, Ravid A, Liu M, O'Connor BI, MacRae HM, Cohen Z, McLeod RS, Al-Obeed O, Penning J, Stern HS, Colquhoun P, Nogueras J, Dipasquale B, Petras J, Wexner S, Woodhouse S, Raval MJ, Heine JA, May GR, Bass S, Brown CJ, MacLean AR, Asano T, Cohen Z, MacRae HM, O'Connor BI, McLeod RS, Asano TK, Toma D, Stern HS, McLeod RS, Irshad K, Ghitulescu GA, Gordon PH, MacLean AR, Lilly L, Cohen Z, O'Connor B, McLeod RS, Ravid A, O'Connor BI, Liu M, MacRae HM, Cohen Z, McLeod RS, St Germaine RL, de Gara CJ, Fox R, Kenwell Z, Blitz S, Wong JT, Mc-Mulkin HM, Porter GA, Jayaraman S, Gray D, Burpee SE, Schlachta CM, Mamazza J, Pace K, Poulin EC, Freeman J, Tranqui P, Trottier D, Bodurtha A, Sarma A, Bheerappa N, Sastry RA, de Gara CJ, Hanson J, Hamilton S, Taylor MC, Haase E, Stevens J, Rigo V, Richards J, Bigam DL, Cheung PY, Burpee SE, Schlachta CM, Mamazza J, Pace K, Poulin EC, Grace DM, Gupta S, Sarma A, Bheerappa N, Radhakrishna P, Sastry RA, Malik S, Duffy P, Schulte P, Cameron R, Pace KT, Dyer S, Phan V, Poulin E, Schlachta C, Mamazza J, Stewart R, Honey RJ, Kanthan R, Kanthan SC, Jayaraman S, Aarts MA, Solomon MJ, McLeod RS, Ong S, Pitt D, Stephen W, Latulippe J, Girotti M, Bloom S, Pace K, Dyer S, Stewart R, Honey RJ, Poulin E, Schlachta C, Mamazza J, Furlan JC, Rosen IB, Asano TK, Haigh PI, McLeod RS, Al Saleh N, Taylor B, Karimuddin AA, Marschall J, McFadden A, Pollett WG, Dicks E, Tranqui P, Trottier D, Freeman J, Bodurtha A, Urbach DR, Bell CM, Austin PC, Cleary SP, Gyfe R, Greig P, Smith L, Mackenzie R, Strasberg S, Hanna S, Taylor B, Langer B, Gallinger S, Marschall J, Nechala P, Chibbar R, Colquhoun P, Zhou J, Lee TDG, Meneghetti AT, McKenna GJ, Owen D, Scudamore CH, McMaster RM, Chung SW, Aarts MA, Granton J, Cook DJ, Bohnen JMA, Marshall JC, Colquhoun P, Weiss E, Efron J, Nogueras J, Vernava A, Wexner S, Poulin EC, Schlachta CM, Burpee SE, Pace KT, Mamazza J, Rosen IB, Furlan JC, Charghi R, Schricker T, Backman S, Rouah F, Christou NV, Obayan A, Keith R, Juurlink BHJ, Skaro AI, Liwski RS, Zhou J, Lee TDG, Hirsch GM, Powers KA, Khadaroo RG, Papia G, Kapus A, Rotstein OD, Furlan JC, Rosen IB, Stratford AFC, George RL, VanManen L, Klassen DR, Feldman LS, Mayrand S, Mercier L, Stanbridge D, Fried GM, Nanji SA, Hancock WW, Anderson C, Shapiro AMJ, Butter A, Martins L, Taylor B, Ott MC, Rycroft K, Wall WJ, Burpee SE, Schlachta CM, Mamazza J, Pace K, Poulin EC, Taylor MC, Christou NV, Jarand J, Sylvestre JL, McLean APH, Behzadi A, Tan L, Unruh H, Brandt MG, Darling GE, Miller L, Seely AJE, Maziak DE, Gunning D, Do MT, Bukhari M, Shamji FM, Abdurahman A, Darling G, Ginsberg R, Johnston M, Waddell T, Keshavjee S, Cuccarolo G, Charyk-Stewart T, Inaba K, Malthaner R, Gray D, Girotti M, Grondin SC, Tutton SM, Sichlau MJ, Pozdol C, McDonough TJ, Masters GA, Ray DW, Liptay MJ. Abstracts of presentations to the Annual Meetings of the Canadian Society of Colon and Rectal Surgeons Canadian Association of General Surgeons Canadian Association of Thoracic Surgeons: Canadian Surgery Forum, London, Ont., Sept. 19 to 22, 2002. Can J Surg 2002; 45:3-26. [PMID: 37381180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - D Pitt
- Ottawa Hospital, University of Ottawa, Ottawa, Ont
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Furlan JC, de Magalhães RP, de Aguiar ET, Shiroma S. Localization of the superior laryngeal nerve during carotid endarterectomy. Surg Radiol Anat 2002; 24:190-3. [PMID: 12375071 DOI: 10.1007/s00276-002-0025-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2001] [Accepted: 01/27/2002] [Indexed: 10/27/2022]
Abstract
Knowledge of the topographic anatomy is essential to prevent iatrogenic damage of the superior laryngeal nerve (SLN) in carotid endarterectomy (CEA). The purpose of this study was to analyze the anatomic relationship between the SLN and carotid arteries in order to prevent iatrogenic nerve injury. Anatomic dissections similar to CEA were performed bilaterally in 50 fresh human adult cadavers. The topography of the SLN was analyzed regarding its relationship with the carotid arteries. Furthermore, the distance between the external branch of the SLN and the point of bifurcation of the common carotid artery (dCAB) was analyzed regarding effects of gender, ethnicity, individual stature and side of the neck. The SLN was always located adjacent and posterior to the carotid arteries.The dCAB ranged from 20.3 mm below the point of bifurcation of the common carotid artery to 50.9 mm above this level (average 10.3 mm above). Most dissections (75%) showed the external branch of the SLN emerging from behind the carotid artery above the arterial bifurcation; in only 10% of cases did this nerve emerge from the artery below that anatomic reference. Based on Student's t-test, there were no significant differences in the dCAB between genders ( P=0.237), ethnicities ( P=0.410) and sides of the neck ( P=0.872). Moreover, tall stature was not significantly correlated with a shorter dCAB (linear regression: R(2)=0.009, P=0.357). We conclude that most SLNs were located above the carotid artery bifurcation, but anatomic variations occurred in 25% of the dissections. The dCAB was unaffected by gender, ethnicity, individual stature and side of the neck.
Collapse
Affiliation(s)
- J C Furlan
- Department of Surgery, Clinical Hospital of the Faculty of Medicine, University of São Paulo, São Paulo, Brazil.
| | | | | | | |
Collapse
|
9
|
Abstract
BACKGROUND The topography of the internal branch of the superior laryngeal nerve (ibSLN) was prospectively studied to evaluate the greater horn of the hyoid bone (ghHB) and the incisura of the thyroid cartilage (iTC) as anatomical repairs in laryngeal anesthetic block. Factors such as gender, ethnicity and side of the neck were also analyzed concerning their influence in the ibSLN position. METHODS One hundred neck dissections were performed in 50 human cadavers bilaterally identifying the ibSLN, the ghHB and iTC. The distance between the ghHB and ibSLN in the cranio-caudal direction (dHB), and the distance between the iTC and the ipsilateral thyrohyoid membrane ostium (dTC) were measured. Furthermore, the results were statistically analyzed according to ethnicity, gender and side of the neck. RESULTS The ibSLN was juxtaposed to the apex ghBH in 31 out of 100 dissections. The mean dHB was 2.4 mm, and mean dTC was 33.4 mm. The statistical analysis did not identify any significant difference regarding those distances between the groups in terms of ethnicity, gender and side of the neck. CONCLUSION The ibSLN was often dissected very close to the ghHB, and this result was not influenced by any factor studied. Therefore, the ghHB can be considered a good anatomical repair to localize the ibSLN in the local block of the larynx. Furthermore, the dTC could frequently be reached by routinely used nerve block needle. However, a few anatomical variations may occur, resulting in a low failure rate of this anesthetic procedure.
Collapse
Affiliation(s)
- J C Furlan
- Division of Head and Neck Surgery, Department of Surgery, Clinical Hospital of the Faculty of Medicine, University of São Paulo, São Paulo, Brazil.
| |
Collapse
|
10
|
Abstract
BACKGROUND Management of thyroid microcancer or occult well-differentiated thyroid cancer (OWDTC) is controversial. Our present study compared some clinical features of OWDTC and gross well-differentiated 10-mm thyroid carcinoma (GWDTC), which may offer a basis for treatment policy. METHODS From 1964 to 2000, 1000 patients underwent thyroidectomy for thyroid cancer. We randomly selected 428 cases for study in which node sampling was carried out in 88% of GWDTC and 60% of OWDTC and who were demographically comparable. All data were obtained by chart review and analyzed by chi-square test. RESULTS With the maximum limit of 10 mm for defining OWDTC, we found 113 such cases with a mean size of 6.1 mm and 315 GWDTC cases with a mean size of 27.6 mm. The incidence of metastatic nodal disease was 16.8% in OWDTC cases and 25.7% in GWDTC cases (P = .057). Distant metastases occurred in 1 of 113 (0.9%) cases of OWDTC and 11 of 315 (3.5%) cases of GWDTC (P = .149). After a mean follow-up time of 55.8 months, neck metastatic recurrent disease occurred in 3 of 113 (2.7%) cases of OWDTC and 7 of 315 (2.2%) cases of GWDTC (P = .770). OWDTC was found in 11.1% of the GWDTC group undergoing an operation. Multicentricity occurred in 31.9% of OWDTC cases and 35.9% of GWDTC cases (P = .447). No cause-specific death occurred. CONCLUSIONS One cannot be dogmatic in treatment of microcancer, but one is justified in extending similar treatment principles for OWDTC as in GWDTC, which in our center usually indicates near-total thyroidectomy and consideration for radioactive iodine ablation.
Collapse
Affiliation(s)
- J C Furlan
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | |
Collapse
|
11
|
Aguiar ET, Albers MT, Langer B, Fratezi AC, Furlan JC. [Surgical treatment of infections involving arterial prosthesis in aorto-femoral position]. Rev Hosp Clin Fac Med Sao Paulo 1993; 48:76-81. [PMID: 8235277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
This article is to evaluate the results of surgical treatment of aorto-femoral graft infections. The records of 20 patients with aorto-femoral graft infections were reviewed. The patients were submitted mostly to a combination of surgical procedures. They were: a) conservative treatment; b) partial removal of the infected graft and c) total removal of the infected graft. The removal of the prosthesis, partial or total, was followed by a new arterial reconstruction in some patients. The final treatment was: total removal of the infected graft in 11 (55%) patients, total removal plus arterial reconstruction in six, partial removal in two and partial removal plus arterial reconstruction in one. The results of treatment were presented as the survival rate and the effective palliation (patient alive, lower limbs preserved and infection cured). The survival rates after one month, 12, 24, 36 and 48 months were respectively: 80%, 60%, 53%, 42% and 27%. The effective palliation rates after one month and after 48 months were respectively 50% and 27%. The highest effective palliation rate was obtained when the infected prosthesis was removed and a new arterial reconstruction performed. We conclude that the treatment of choice of aorto-femoral graft infections seems to be the total removal of the graft followed by new arterial reconstruction.
Collapse
Affiliation(s)
- E T Aguiar
- Departamento de Cirurgia, Faculdade de Medicina, Universidade São Paulo
| | | | | | | | | |
Collapse
|