RESUMEN
OBJECTIVE: This study evaluated the nationwide trends in care and accompanied postoperative outcomes for patients with distal esophageal and gastro-esophageal junction cancer. SUMMARY OF BACKGROUND DATA: The introduction of transthoracic esophagectomy, minimally invasive surgery, and neo-adjuvant chemo(radio)therapy changed care for patients with esophageal cancer. METHODS: Patients after elective transthoracic and transhiatal esophagectomy for distal esophageal or gastroesophageal junction carcinoma in the Netherlands between 2007-2016 were included. The primary aim was to evaluate trends in both care and postoperative outcomes for the included patients. Additionally, postoperative outcomes after transthoracic and tran-shiatal esophagectomy were compared, stratified by time periods. RESULTS: Among 4712 patients included, 74% had distal esophageal tumors and 87% had adenocarcinomas. Between 2007 and 2016, the proportion of transthoracic esophagectomy increased from 41% to 81%, and neo-adjuvant treatment and minimally invasive esophagectomy increased from 31% to 96%, and from 7% to 80%, respectively. Over this 10-year period, postoperative outcomes improved: postoperative morbidity decreased from 66.6% to 61.8% ( P = 0.001), R0 resection rate increased from 90.0% to 96.5% (P <0.001), median lymph node harvest increased from 15 to 19 ( P <0.001), and median survival increased from 35 to 41 months ( P = 0.027). CONCLUSION: In this nationwide cohort, a transition towards more neo-adju-vant treatment, transthoracic esophagectomy and minimally invasive surgery was observed over a 10-year period, accompanied by decreased postoperative morbidity, improved surgical radicality and lymph node harvest, and improved survival.
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Adenocarcinoma , Neoplasias Esofágicas , Neoplasias Gástricas , Humanos , Adenocarcinoma/cirugía , Ganglios Linfáticos/patología , Unión Esofagogástrica/cirugía , Unión Esofagogástrica/patología , Escisión del Ganglio Linfático , Neoplasias Esofágicas/cirugía , Esofagectomía/efectos adversos , Neoplasias Gástricas/cirugía , Complicaciones Posoperatorias/etiología , Resultado del TratamientoRESUMEN
OBJECTIVE: This study investigated the patterns, predictors, and survival of recurrent disease following esophageal cancer surgery. BACKGROUND: Survival of recurrent esophageal cancer is usually poor, with limited prospects of remission. METHODS: This nationwide cohort study included patients with distal esophageal and gastroesophageal junction adenocarcinoma and squamous cell carcinoma after curatively intended esophagectomy in 2007 to 2016 (follow-up until January 2020). Patients with distant metastases detected during surgery were excluded. Univariable and multivariable logistic regression were used to identify predictors of recurrent disease. Multivariable Cox regression was used to determine the association of recurrence site and treatment intent with postrecurrence survival. RESULTS: Among 4626 patients, 45.1% developed recurrent disease a median of 11 months postoperative, of whom most had solely distant metastases (59.8%). Disease recurrences were most frequently hepatic (26.2%) or pulmonary (25.1%). Factors significantly associated with disease recurrence included young age (≤65 y), male sex, adenocarcinoma, open surgery, transthoracic esophagectomy, nonradical resection, higher T-stage, and tumor positive lymph nodes. Overall, median postrecurrence survival was 4 months [95% confidence interval (95% CI): 3.6-4.4]. After curatively intended recurrence treatment, median survival was 20 months (95% CI: 16.4-23.7). Survival was more favorable after locoregional compared with distant recurrence (hazard ratio: 0.74, 95% CI: 0.65-0.84). CONCLUSIONS: This study provides important prognostic information assisting in the surveillance and counseling of patients after curatively intended esophageal cancer surgery. Nearly half the patients developed recurrent disease, with limited prospects of survival. The risk of recurrence was higher in patients with a higher tumor stage, nonradical resection and positive lymph node harvest.
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Adenocarcinoma , Neoplasias Esofágicas , Adenocarcinoma/patología , Estudios de Cohortes , Esofagectomía , Humanos , Metástasis Linfática , Masculino , Recurrencia Local de Neoplasia/patología , Pronóstico , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
Preeclampsia is one of the leading causes of maternal and neonatal mortality and morbidity worldwide, affecting 2-8% of all pregnancies. Studies suggest a link between complement activation and preeclampsia. The complement system plays an essential role in the innate immunity, leading to opsonization, inflammation, and elimination of potential pathogens. The complement system also provides a link between innate and adaptive immunity and clearance of immune complexes and apoptotic cells. During pregnancy there is increased activity of the complement system systemically. However, locally at the placenta, complement inhibition is crucial for the maintenance of a normal pregnancy. Inappropriate or excessive activation of the complement system at the placenta is likely involved in placental dysfunction, and is in turn associated with pregnancy complications like preeclampsia. Therefore, modulation of the complement system could be a potential therapeutic target to prevent pregnancy complications such as preeclampsia. This review, based on a systematic literature search, gives an overview of the complement system and its activation locally in the placenta and systemically during healthy pregnancies and during complicated pregnancies, with a focus on preeclampsia. Furthermore, this review describes results of animal and human studies with a focus on the complement system in pregnancy, and the role of the complement system in placental dysfunction. Various clinical and animal studies provide evidence that dysregulation of the complement system is associated with placental dysfunction and therefore with preeclampsia. Several drugs are used for prevention and treatment of preeclampsia in humans and animal models, and some of these drugs work through complement modulation. Therefore, this review further discusses these studies examining pharmaceutical interventions as treatment for preeclampsia. These observations will help direct research to generate new target options for prevention and treatment of preeclampsia, which include direct and indirect modulation of the complement system.
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Activación de Complemento , Proteínas del Sistema Complemento/inmunología , Enfermedades Placentarias/inmunología , Placenta/inmunología , Preeclampsia/inmunología , Femenino , Humanos , Placenta/patología , Enfermedades Placentarias/patología , Enfermedades Placentarias/terapia , Preeclampsia/patología , Preeclampsia/terapia , EmbarazoRESUMEN
The well-being of residents, our future medical specialists, is not only beneficial to the individual physician but also conditional for delivering high-quality patient care. Therefore, the authors further explored how residents experience their own well-being in relation to their professional and personal life. The authors conducted a qualitative study based on a phenomenological approach. From June to October 2013, 13 in-depth interviews were conducted with residents in various training programs using a semi-structured interview guide to explore participants' experience of their well-being in relation to their professional life. The data were collected and analyzed through an iterative process using the thematic network approach. Effort-reward balance and perceived autonomy were dominant overarching experiences in influencing residents' well-being. Experiencing sufficient autonomy was important in residents' roles as caregivers, as learners and in their personal lives. The experienced effort-reward balance could both positively and negatively influence well-being. We found two categories of ways that influence residents' experience of well-being; (1) professional lives: delivering patient care, participating in teamwork, learning at the workplace and dealing with the organization and (2) personal lives: dealing with personal characteristics and balancing work-life. In residents' well-being experiences, the effort-reward balance and perceived autonomy are crucial. Additionally, ways that influence residents' well-being are identified in both their professional and personal lives. These dominant experiences and ways that influence well-being could be key factors for interventions and residency training adaptations for enhancing residents' well-being.
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Internado y Residencia , Médicos/psicología , Autonomía Profesional , Recompensa , Lugar de Trabajo/psicología , Actitud del Personal de Salud , Humanos , Entrevistas como Asunto , Grupo de Atención al Paciente/organización & administración , Rol del Médico , Equilibrio entre Vida Personal y LaboralRESUMEN
BACKGROUND: Residents' well-being is essential for both the individual physician and the quality of patient care they deliver. Therefore, it is important to maintain or possibly enhance residents' well-being. We investigated (i) the influence of mind fitness training (MFT) on quality of care-related well-being characteristics: work engagement, empathy, work satisfaction and stress perception and explored (ii) residents' perceptions of MFT. METHODS: A multicenter study was conducted in eight Dutch teaching hospitals, from September 2012 to February 2014, using mixed methodsthat is, quantitative and qualitative approaches to data collection and analysis. Eighty-nine surgical residents were invited to participate in pre- and post-intervention questionnaire surveys. Twenty-two residents participated in MFT and were additionally invited to evaluate the training by post-intervention interviews including open questions. RESULTS: At baseline 22 (100%) residents in intervention group and 47 (70.2%) residents in control group, and postintervention 20 (90.9 %) residents in intervention group and 41 (66.1%) residents in control group completed the questionnaires. In intervention-group, residents' specialty satisfaction increased by 0.23 point on 5-point Likert scale (95% CI 0.230.24, P < 0.001) while stress scores decreased by -0.94 point on 10-point scale (95% CI -1.77 to -0.12, P = 0.026). No substantial changes were observed in control group. Participation in MFT was positively associated with residents' empathy (b = 7.22; 95% CI 4.3310.11; P < 0.001) and specialty satisfaction scores (b = 0.42; 95% CI 0.180.65; P = 0.001). Residents positively evaluated MFT with median scores of 6.80 for training design and 7.21 for outcome (10-point scale). Residents perceived improvement in focusing skills and reported being more aware of their own state of mind and feeling calmer and more in control. CONCLUSION: Mind fitness training could improve residents' empathy, specialty satisfaction, stress perception, and focusing skills, and was positively received by surgical residents.
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Actitud Frente a la Salud , Competencia Clínica , Empatía/fisiología , Hospitales de Enseñanza , Internado y Residencia/métodos , Médicos/psicología , Adulto , Humanos , Proyectos Piloto , Encuestas y CuestionariosRESUMEN
Music and other forms of art are increasingly being integrated into hospitals. As well as the aesthetic value of art, more and more attention is being paid to its contribution to the healing of the patient. Scientific research indicates the possible benefits of specific art in healthcare facilities. Using this knowledge of the role and employability of surroundings and art in the healing of patients may be complementary to the high quality of care in the Netherlands. By means of proper, methodologically correct research, it is possible to investigate the use of different aspects of the patient's environment as simple, safe and low-cost measures in improving health and well-being of patients.
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Ambiente , Hospitales/normas , Terapias de Arte Sensorial/métodos , Humanos , Musicoterapia , Países Bajos , Evaluación del Resultado de la Atención al PacienteRESUMEN
BACKGROUND: Incisional hernia is one of the most frequent postoperative complications after abdominal surgery. Patients with an abdominal aortic aneurysm and patients with a body mass index of 27 or higher have an increased risk to develop incisional hernia. Primary mesh augmentation is a method in which the abdominal wall is strengthened to reduce incisional hernia incidence. This study focused on the short-term results of the PRImary Mesh Closure of Abdominal Midline Wounds trial, a multicenter double blind randomized controlled trial. METHODS: Between 2009 and 2012 patients were included if they were operated via midline laparotomy, and had an abdominal aortic aneurysm or a body mass index of 27 or higher. Patients were randomly assigned to either receive primary suture, onlay mesh augmentation (OMA), or sublay mesh augmentation. RESULTS: Outcomes represent results after 1-month follow-up. A total of 480 patients were randomized. During analysis, significantly (P = 0.002) more seromas were detected after OMA (n = 34, 18.1%) compared with primary suture (n = 5, 4.7%) and sublay mesh augmentation (n = 13, 7%). No differences were discovered in any of the other outcomes such as surgical site infection, hematoma, reintervention, or readmission. Multivariable analysis revealed an increase in seroma formation after OMA with an odds ratio of 4.3 (P = 0.004) compared with primary suture and an odds ratio of 2.9 (P = 0.003) compared with sublay mesh augmentation. CONCLUSIONS: On the basis of these short-term results, primary mesh augmentation can be considered a safe procedure with only an increase in seroma formation after OMA, but without an increased risk of surgical site infection.
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Hernia Ventral/prevención & control , Complicaciones Posoperatorias/prevención & control , Mallas Quirúrgicas , Técnicas de Sutura , Adhesivos Tisulares , Adulto , Anciano , Anciano de 80 o más Años , Método Doble Ciego , Femenino , Estudios de Seguimiento , Hernia Ventral/etiología , Humanos , Análisis de Intención de Tratar , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Complicaciones Posoperatorias/etiología , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Faculty members rely on residents' feedback about their teaching performance. The influence of residents' characteristics on evaluations of faculty is relatively unexplored. We aimed to evaluate the levels of work engagement and empathy among residents and the association of both characteristics with their evaluation of the faculty's teaching performance. METHODS: A multicenter questionnaire study among 271 surgery and gynecology residents was performed from September 2012 to February 2013. Residents' ratings of the faculty's teaching performance were collected using the system for evaluation of teaching quality (SETQ). Residents were also invited to fill out standardized measures of work engagement and empathy using the short Utrecht Work Engagement Scale and the Jefferson Scale of Physician Empathy, respectively. Linear regression analysis using generalized estimating equations to evaluate the association of residents' engagement and empathy with residents' evaluations of teaching performance. RESULTS: Overall, 204 (75.3 %) residents completed 1814 SETQ evaluations of 302 faculty, and 143 (52.8 %) and 140 (51.7 %) residents, respectively, completed the engagement and empathy measurements. The median scores of residents' engagement and empathy were 4.56 (scale 0-6) and 5.55 (scale 1-7), respectively. Higher levels of residents' engagement (regression coefficient b = 0.128; 95 % confidence interval (CI) 0.072-0.184; p < 0.001) and empathy (b = 0.113; 95 % CI 0.063-0.164; p < 0.001) were associated with higher faculty teaching performance scores. CONCLUSIONS: Residents' engagement and empathy appear to be positively associated with their evaluation of the faculty's performance. A possible explanation is that residents who are more engaged and can understand and share others' perspectives stimulate and experience faculty's teaching better than others.
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Empatía , Docentes Médicos , Internado y Residencia , Competencia Profesional , Enseñanza , Adulto , Estudios Transversales , Femenino , Cirugía General/educación , Ginecología/educación , Humanos , Masculino , Encuestas y CuestionariosRESUMEN
BACKGROUND: The aim was to study which dressing material was best for healing donor-site wounds (DSWs) after split-skin grafting as there is wide variation in existing methods, ranging from classical gauze dressings to modern silicone dressings. METHODS: This 14-centre, six-armed randomized clinical trial (stratified by centre) compared six wound dressing materials in adult patients with DSWs larger than 10 cm(2) . Primary outcomes were time to complete re-epithelialization and pain scores measured on a visual analogue scale (VAS) over 4 weeks. Secondary outcomes included itching (VAS, over 4 weeks), adverse events and scarring after 12 weeks rated using the Patient and Observer Scar Assessment Scale (POSAS). RESULTS: Between October 2009 and December 2011, 289 patients were randomized (of whom 288 were analysed) to either alginate (45), film (49), gauze (50), hydrocolloid (49), hydrofibre (47) or silicone (48) dressings. Time to complete re-epithelialization using hydrocolloid dressings was 7 days shorter than when any other dressing was used (median 16 versus 23 days; P < 0·001). Overall pain scores were low, and slightly lower with use of film dressings (P = 0·038). The infection rate among patients treated with gauze was twice as high as in those who had other dressings (18 versus 7·6 per cent; relative risk 2·38, 95 per cent confidence interval 1·14 to 4·99). Patients who had a film dressing were least satisfied with overall scar quality. CONCLUSION: This trial showed that use of hydrocolloid dressings led to the speediest healing of DSWs. Gauze dressing should be discontinued as they caused more infections. REGISTRATION NUMBER: NTR1849 (http://www.trialregister.nl).
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Vendajes , Trasplante de Piel/métodos , Sitio Donante de Trasplante , Cicatrización de Heridas/fisiología , Cicatriz/etiología , Estudios Cruzados , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/etiología , Prurito/etiología , Infección de la Herida Quirúrgica/etiología , Trasplante Autólogo/métodos , Resultado del TratamientoRESUMEN
In recent decades, numerous prospective randomized surgical trials have been performed in the Netherlands. Due to the unexpected high mortality rate in the PROPATRIA-trial, legislation pertaining to research involving human subjects has recently been changed. The resulting considerable legal and administrative burdens and financial consequences now necessitate a different way of organising clinical research in non-academic hospitals.
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Investigación Biomédica , Cirugía General , Selección de Paciente , Ensayos Clínicos Controlados Aleatorios como Asunto/legislación & jurisprudencia , Proyectos de Investigación/normas , Investigación Biomédica/métodos , Investigación Biomédica/normas , HumanosRESUMEN
BACKGROUND: Long-term results of laparoscopically assisted versus open ileocolic resection for Crohn's disease were evaluated in a randomized trial. METHODS: Sixty patients who underwent ileocolic resection between 1999 and 2003 were followed prospectively. Primary outcomes were reoperation, readmission and repeat resection rates for recurrent Crohn's disease. Secondary outcomes were quality of life (QOL), body image and cosmesis. RESULTS: Five patients were lost to follow-up. Median follow-up was 6.7 (interquartile range 5.7-7.9) years. Sixteen of 29 and 16 of 26 patients remained relapse free after ileocolic resection in the laparoscopic and open groups respectively (risk difference 6 (95 per cent confidence interval - 20 to 32) per cent). Resection of recurrent Crohn's disease was necessary in two of 29 versus three of 26 patients (risk difference 5 (-11 to 20) per cent). Overall reoperation rates for recurrent Crohn's disease, incisional hernia and adhesion-related problems were two of 29 versus six of 26 (risk difference 16 (-3 to 35) per cent). QOL was similar, whereas body image and cosmesis scores were significantly higher after laparoscopy (P = 0.029 and P < 0.001 respectively). CONCLUSION: Laparoscopically assisted ileocolic resection results in better body image and cosmesis, whereas open surgery is more likely to produce incisional hernia and obstruction.
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Colectomía/métodos , Enfermedad de Crohn/cirugía , Laparoscopía/métodos , Adulto , Imagen Corporal , Colectomía/mortalidad , Enfermedad de Crohn/mortalidad , Femenino , Humanos , Estimación de Kaplan-Meier , Laparoscopía/mortalidad , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Calidad de Vida , Recurrencia , Reoperación , Resultado del TratamientoRESUMEN
AN EXAMPLE FOR THE PRESENT DAY: The current requirement for explicit quality standards and examination of surgeons is an opportunity to contemplate surgical training from a historical perspective by looking at the regulations of the Amsterdam Surgeons' Guild (1461-1736). At that time Amsterdam surgeons usually trained for five years in a master-apprentice relationship under the guidance of a master surgeon in a surgeon's shop. An important part of the surgical training took place in the botanical gardens and anatomical theatre, where, during the weekly lessons, the praelector anatomiae would also demonstrate anatomy on the bodies of the deceased. Surgical training was complete after the trainee had passed the 'meesterproef' (master's exam), in which the manufacturing of lancets, blood-letting and performing a trepanation on a skull played a major part. However, over the course of time the final master's exam as the ultimate test of capability at the end of surgical training has disappeared. From the perspective of renewed interest in explicit quality standards and examination of surgeons, the reintroduction of a modern master's exam should perhaps be considered.
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Educación Médica/historia , Cirugía General/historia , Anatomía/educación , Anatomía/historia , Cirugía General/educación , Historia del Siglo XV , Historia del Siglo XVI , Historia del Siglo XVII , Historia del Siglo XVIII , Humanos , Países BajosRESUMEN
BACKGROUND: Laparoscopic cholecystectomy (LC) after an endoscopic retrograde cholangiography (ERC) has higher rates for complications and conversion caused by unpredictable adhesions. The risk factors for an adverse outcome of LC after an ERC were analyzed. METHODS: Variables from patients treated by LC after ERC for cholelithiasis in two clinics from 1996 to 2003 were retrospectively stored in a database. Complications and conversions were recorded. RESULTS: A total of 140 patients underwent LC after ERC (83 from clinic A and 57 from clinic B), 31% (44/140) of whom were men. Peri- or postoperative complications occurred for 28 patients (20%). For 19 patients (14%), a conversion was necessary. Significant variables associated with complications and conversions were an elevated level of C-reactive protein (CRP) at the time of LC (odds ratio [OR], 10.2; 95% confidence interval [CI], 1.1-91, P = 0.037 for both) and severe adhesions during laparoscopy (OR, 3.6; 95% CI, 1.5-8.6; P = 0.003 and OR, 5.2; 95% CI, 1.9-14.4; P = 0.002, respectively). Male gender (OR, 2.8; 95% CI, 1.1-7.6; P = 0.037) and serum bilirubin level at the time of ERC (OR, 3.7; 95% CI, 1.24-11; P = 0.014) were associated with conversion only. Time after ERC (LC within 1 week vs. >1 week or < or = 2 weeks vs. 2-6 weeks vs. >6 weeks or < or = 6 weeks vs. >6 weeks) was not associated with complications or conversion. Multivariate regression analysis showed a pre-LC CRP exceeding 6 to be predictive of complications (OR, 10.5; 95% CI, 1.1-95; P = 0.040) and conversion (OR, 10.6; 95% CI, 1.1-99; P = 0.034). CONCLUSION: Male gender, bilirubin levels during ERC, severe adhesions during LC, and pre-LC CRP levels were associated with an adverse outcome for an LC after endoscopic cholangiography. The time between LC and ERC failed to be a significant risk factor in this larger series.
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Colangiopancreatografia Retrógrada Endoscópica/métodos , Colecistectomía Laparoscópica/métodos , Coledocolitiasis/cirugía , Complicaciones Posoperatorias/epidemiología , Bilirrubina/sangre , Proteína C-Reactiva/metabolismo , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Estadísticas no Paramétricas , Adherencias Tisulares/epidemiología , Resultado del TratamientoRESUMEN
BACKGROUND: Publications in peer-reviewed journals are the main determinants of research rating and funding. The present study assesses worldwide scientific contributions in the field of surgical research. METHODS: Fifteen major surgical journals were selected for a bibliometric search in Medline/PubMed over a 6-year period (2000-2005). All articles with abstracts were totalled according to country of corresponding author. Publications (total and corrected for population size) and journal impact factor were assessed according to country. RESULTS: A total of 18,717 articles were identified. Fifteen countries generated 88.8 per cent of these: the USA produced 42.1 per cent, Japan 9.1 per cent and the UK 7.6 per cent. When corrected for population size, the Netherlands, Sweden and Switzerland topped the ranking; the USA was sixth. Ireland and Switzerland scored the highest mean impact factor. CONCLUSION: The USA is the most productive country in terms of absolute number of surgical publications in the selected journals. However, when population size is taken into consideration, certain smaller European countries were more prolific.
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Cirugía General/estadística & datos numéricos , Publicaciones Periódicas como Asunto/estadística & datos numéricos , HumanosRESUMEN
BACKGROUND: Preceding endoscopic retrograde cholangiography (ERC) in patients with choledochocystolithiasis impedes laparoscopic cholecystectomy (LC) and increases risk of conversion. We studied the influence of time interval between ERC and LC on the course of LC. METHODS: All patients treated for choledochocystolithiasis with ERC and LC during 1996-2001 were studied retrospectively, comparing the course of LC in three time interval groups; LC < 2, 2-6, and > 6 weeks after ERC. PRIMARY OUTCOMES: adhesions, bile duct injury, operating time, and conversion-rate. RESULTS: Eighty-three patients were studied (group 1, n = 23; group 2, n = 15; group 3, n = 45). Adhesions, operation time, and bile duct damage did not significantly differ between the groups. The conversion rate in group 2 is significantly higher compared to group 1 (p = 0.027, OR 11 (1.13-106.8)) CONCLUSIONS: A higher conversion rate of LC is found 2-6 weeks after ERC compared to LC within 2 weeks. However, further research is needed to gain more reliable data on whether this is caused by timing.
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Colecistectomía , Coledocolitiasis/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Colangiopancreatografia Retrógrada Endoscópica , Colecistectomía Laparoscópica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de TiempoRESUMEN
BACKGROUND: Several methods for skin closure are used, i.e. sutures, adhesive papertape and tissue adhesives. Little is known about the efficacy of these techniques in laparoscopic surgery. This study was performed to analyse the efficacy of octylcyanoacrylate, a new tissue adhesive, adhesive papertape and poliglecaprone for wound closure in laparoscopy. METHODS: From May 2000 to September 2001, 140 patients were included in a prospective randomized trial. Wounds were closed with octylcyanoacrylate (n = 48), adhesive papertape (n = 42) or poliglecaprone (n = 50). Closing time, wound infection, cosmetic results and costs were evaluated. A time-motion analysis was also performed. RESULTS: The patients in the three groups were well matched for age, gender and body mass index. Closing times per wound were 26, 33 and 65 s respectively for adhesive papertape, octylcyanoacrylate and poliglecaprone (P < 0.001). Cosmetic results, as scored by the patients, were no different. The number of actions required to close each wound was 5.7, 8.3 and 21.0 for octylcyanoacrylate, adhesive papertape (P = 0.05 versus octylcyanoacrylate) and poliglecaprone (P < 0.01 versus octylcyanoacrylate and adhesive papertape) respectively. Octylcyanoacrylate was significantly more expensive than poliglecaprone and adhesive papertape. CONCLUSION: Closure with adhesive papertape was the fastest method. The smallest number of actions required to close a wound was with octylcyanoacrylate. Adhesive papertape was the most cost-effective.
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Cianoacrilatos/uso terapéutico , Laparoscopía/métodos , Adhesivos Tisulares/uso terapéutico , Análisis de Varianza , Análisis Costo-Beneficio , Cianoacrilatos/economía , Femenino , Humanos , Laparoscopía/economía , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Infección de la Herida Quirúrgica/etiología , Adhesivos Tisulares/economía , Resultado del Tratamiento , Cicatrización de HeridasRESUMEN
Two patients, premenopausal women aged 48 years and 37 years, who were treated with tamoxifen following a mammary carcinoma operation, experienced abdominal complaints, hot flushes, vaginal discharge, an irregular menstrual cycle and/or concern about the increased risk of ovarian carcinoma. Transvaginal ultrasonography of the ovaries and laboratory tests indicated ovarian overstimulation. Both patients temporarily stopped using tamoxifen; in one of the patients both ovaries were ablated. The range of indications for treatment with tamoxifen has in recent years been extended to premenopausal patient groups and the length of treatment has been increased from two to five years. We recommend more extensive checks when prescribing tamoxifen to premenopausal patients in view of the possible adverse effects of ovarian stimulation associated with this treatment.
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Neoplasias de la Mama/tratamiento farmacológico , Neoplasias de la Mama/prevención & control , Síndrome de Hiperestimulación Ovárica/inducido químicamente , Premenopausia , Moduladores Selectivos de los Receptores de Estrógeno/efectos adversos , Tamoxifeno/efectos adversos , Adulto , Neoplasias de la Mama/cirugía , Femenino , Humanos , Mastectomía , Persona de Mediana Edad , Moduladores Selectivos de los Receptores de Estrógeno/uso terapéutico , Tamoxifeno/uso terapéuticoRESUMEN
PURPOSE: Subfascial division of incompetent perforating veins seems to be a successful treatment for patients with venous leg ulceration (CEAP 6). For postoperative wound complications, endoscopic techniques are more common than open subfascial division of incompetent perforating veins (Linton procedure). We investigated the long-term results of ulcer healing and recurrence rates and compared them with preoperative and postoperative duplex findings. METHODS: Patients with venous ulceration on the medial side of the lower leg were randomly allocated to endoscopic exploration or open exploration by means of the modified Linton approach. Ulcer healing and recurrence rates were documented. RESULTS: Thirty-nine patients were randomly allocated to exploration, 19 patients to open subfascial division of incompetent perforating veins (Linton group), and 20 patients to subfascial endoscopic division of incompetent perforating veins (SEPS group). During the follow-up period, four patients in the SEPS group died, all of causes other than the venous leg ulcer. Because of a squamous cell carcinoma that had developed in the venous ulcer, one patient in the SEPS group underwent a below-knee amputation. In a mean follow-up period of 50.6 months, the venous ulceration of all 18 patients in the Linton group who were available for follow-up initially healed. The recurrence rate in this group was 22% (4 patients). In the SEPS group, the mean follow-up period for 19 patients was 46.1 months, with the ulceration healing in 17 patients and a recurrence rate of 12% (2 patients). The presence of deep venous incompetence (DVI) did not influence the recurrence rates (P =.044, Fisher exact test), but it significantly influenced the development of new incompetent perforating veins (3 of 10 without DVI; 7 of 10 with DVI; P =.011, binomial test). CONCLUSION: The long-term follow-up results of the endoscopic division of perforating veins are comparable with those of the open division of perforating veins (modified Linton procedure).
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Endoscopía , Pierna/irrigación sanguínea , Úlcera Varicosa/cirugía , Venas/cirugía , Insuficiencia Venosa/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Ligadura , Masculino , Persona de Mediana Edad , Recurrencia , Ultrasonografía Doppler Dúplex , Venas/diagnóstico por imagen , Insuficiencia Venosa/diagnóstico por imagen , Cicatrización de HeridasRESUMEN
OBJECTIVE: To determine how the influx of patients in an emergency room (ER) is spread over the week and what factors play a part. DESIGN: Prospective. METHOD: The ER contacts in the De Weezenlanden Hospital of Zwolle, the Netherlands, were recorded on standardized forms during the period 1 May-14 June 1997 (6 weeks). RESULTS: 1995 ER contacts were recorded: 47% were referred by the GP and 8% by the municipal ambulance service, while 45% came at their own initiative. Injuries to the locomotor apparatus and wounds accounted for at least 50% of all contacts and were more frequent among patients attending at their own initiative (73%) or delivered by the ambulance service (49%) than among those referred by the GP (31%). Patients with various diseases, on the other hand, were mostly referred by the GPs (62%). 76% of all contacts occurred between 8 a.m. and 8 p.m. There was no Friday afternoon peak. The differences between the number of contacts during the week and in the weekend were not significant. Of the patients referred by the GP or delivered by the ambulance service more than half were admitted to the hospital, as against 18% of the patients attending at their own initiative. CONCLUSION: In the ER examined there were not more new patients on the Friday afternoon than during the rest of the week.