Beyond prophylaxis: Extended risk of venous thromboembolism following primary debulking surgery for ovarian cancer.

OBJECTIVE: To determine the incidence and risk factors for venous thromboembolism (VTE) within six months after primary debulking surgery (PDS) for epithelial ovarian cancer (EOC). METHODS: In a historical cohort, we estimated the cumulative incidence of clinically diagnosed VTE within 6 months among consecutive women who underwent PDS for EOC at a single institution from 1/1/2003 to 12/31/2011. We evaluated perioperative variables as potential risk factors of VTE within 6 months during the postoperative period using univariate and multivariable Cox proportional hazards models. RESULTS: Among 860 women without an immediate history (past 30 days) of a VTE, the cumulative incidence of VTE was 7.5% (95% CI, 5.7-9.3) by 30 days and 13.8% (95% CI, 11.4-16.2) by 6 months following surgery. Macroscopic residual disease (adjusted HR 1.99 [95% CI 1.35-2.94] vs microscopic), increasing estimated blood loss (1.25 [1.05-1.49] per doubling), longer hospital length of stay (3.00 [1.57-5.75]), and experiencing a cardiac event within 30 postoperative days (2.72 [1.55-4.80]) were independently associated with subsequent VTE within 6 months. In-hospital VTE prophylaxis included heterogeneous approaches; dual prophylaxis did not impact 30-day or 6-month VTE rates. CONCLUSIONS: VTE occurred in 1 in 7 women with EOC within 6 months of PDS-a substantial risk of VTE that extends into the adjuvant chemotherapy period. Novel prophylactic measures should be explored in these women at high risk for VTE.

Incidence and predictors of venous thromboembolism after debulking surgery for epithelial ovarian cancer.

OBJECTIVE: The aim of this study was to determine the incidence and the risk factors of venous thromboembolism (VTE) within 30 days after primary surgery for epithelial ovarian cancer (EOC). METHODS: In a historical cohort study, we estimated the postoperative 30-day cumulative incidence of VTE among consecutive Mayo Clinic patients undergoing primary cytoreduction for EOC between January 2, 2003, and December 29, 2008. We tested perioperative patient characteristics and process-of-care variables (defined by the National Surgical Quality Improvement Program, >130 variables) as potential predictors of postoperative VTE using the Cox proportional hazards modeling. RESULTS: Among 569 cases of primary EOC cytoreduction and/or staging and no recent VTE, 35 developed symptomatic VTE within 30 days after surgery (cumulative incidence = 6.5%; 95% confidence interval, 4.4%-8.6%). Within the cohort, 95 (16.7%) received graduated compression stockings (GCSs), 367 (64.5%) had sequential compression devices + GCSs, and 69 (12.1%) had sequential compression devices + GCSs + postoperative heparin, with VTE rates of 1.1%, 7.4%, and 5.8%, respectively (P = 0.07, χ(2) test). The remaining 38 (6.7%) received various other chemical and mechanical prophylaxis regimens. In the multivariate analysis, current or past tobacco smoking, longer hospital stay, and a remote history of VTE significantly increased the risk for postoperative VTE. CONCLUSIONS: Venous thromboembolism is a substantial postoperative complication among women with EOC, and the high cumulative rate of VTE within 30 days after primary surgery suggests that a more aggressive strategy is needed for VTE prevention. In addition, because longer hospital stay is independently associated with a higher risk for VTE, methods to decrease length of stay and minimize factors that contribute to prolonged hospitalization are warranted.

Validity and specificity of the Persian version of the Saint George Respiratory Questionnaire.

INTRODUCTION: The Saint George Respiratory Questionnaire (SGRQ) is a well-known questionnaire for evaluating the quality of life in asthmatic patients. It has been translated to Persian and its validity and specificity should be evaluated for chronic obstructive pulmonary disease patients. In this study, we attempted to improve the questionnaire's adaptability to Persian culture and also evaluate its validity, specificity, and applicability among asthmatics at our tertiary referral center. MATERIALS AND METHODS: Previously translated and psychometrically evaluated SGRQ for chronic obstructive pulmonary disease patients was made more adaptive to Persian. Upon acceptability of the questionnaire by a small group of patients, 301 asthmatics referred for spirometry and completed the form. Consistency was evaluated using Cronbach's α coefficient and validity was assessed by comparison of scores with other measures of asthma exacerbation. These measures included FEV1, patient's clinical presentation, visual analog scale (used to assess difficulty breathing), Katz activity index and section scores of the General Health Questionnaire, anxiety, depression, and social impact. RESULTS: The study group included 165 female and 139 male asthmatics with a mean age of 44.4 ± 1.0 years. Measurement of consistency for the SGRQ revealed Cronbach's α to be 0.699 for symptoms, 0.805 for activity, 0.879 for impact, and 0.916 for the total questionnaire. By omitting question 8, time of wheezing during the day increased Cronbach's coefficient of the symptoms section to 0.719. Omitting "uselessness of respiratory drugs" from the impact section increased Cronbach's α to 0.881. However, scoring of the section then varied from the original questionnaire. A statistically significant correlation was found between the SGRQ sections and total score (using Katz index and General Health Questionnaire, p < .001). CONCLUSION: Our study showed good validity and reliability for the Persian version of SGRQ for a population of asthmatics referred to our tertiary pulmonary clinic.

Advanced paternal age is a risk factor for schizophrenia in Iranians.

BACKGROUND: Since 1958 many, but not all studies have demonstrated that paternal age is a risk factor for schizophrenia. There may be many different explanations for differences between studies, including study design, sample size, collection criteria, heterogeneity and the confounding effects of environmental factors that can for example perturb epigenetic programming and lead to an increase in disease risk. The small number of children in Western families makes risk comparisons between siblings born at different paternal ages difficult. In contrast, more Eastern families have children both at early and later periods of life. In the present study, a cross-sectional population study in an Iranian population was performed to compare frequency of schizophrenia in younger offspring (that is, older paternal age) versus older offspring. METHODS: A total of 220 patients with the diagnosis of schizophrenia (cases) from both psychiatric hospitals and private clinics and 220 individuals from other hospital wards (controls), matched for sex and age were recruited for this study. Patients with neurological problem, substance abuse, mental retardation and mood disorder were excluded from both groups. RESULTS: Birth rank comparisons revealed that 35% vs 24% of the cases vs the controls were in the third or upper birth rank (P = 0.01). Also, the mean age of fathers at birth in case group (30 ± 6.26 years) was significantly more than the control group (26.45 ± 5.64 years; P = 0.0001). The age of 76 fathers at birth in case group was over 32 versus 33 fathers in control group. Individuals whose fathers' age was more than 32 (at birth) were at higher risk (2.77 times) for schizophrenia versus others (P < 0.0001, 95% CI 1.80 to 4.27). The maternal age at parturition of the case versus controls groups was 26.1 ± 5.41 vs 25.07 ± 4.47 (P = 0.02). Logistic regression analysis suggests that maternal age is less likely to be involved in the higher risk of schizophrenia than advanced parental age. DISCUSSION: This study demonstrates a relationship between paternal age and schizophrenia in large families of an Iranian population. Arguments have been put forth that DNA bases changes or epigenetic changes in sperm account for the increased risk associated with older fathers. However, it would not be surprising that both de novo germline mutations and epigenetic changes contribute to disease occurrence because DNA replication and DNA methylation are closely linked at both the macromolecular level (that is, methylation closely follows replication), and at the metabolic level (both processes require folate), and susceptible to modulation by the environment. Further research on samples such as those collected here are needed to sort out the contributions of de novo mutations versus epigenetic changes to schizophrenia.

Application of intra-aortic balloon pump in resection and anastomosis of trachea.

The intra-aortic balloon pump (IABP) is a mechanical device used to assist cardiac circulatory function in patients suffering from cardiogenic shock, congestive heart failure, refractory angina and complications of myocardial infarction. While using IABP in cardiac surgery is well established, there are few studies on the utility of IABP support in high-risk cardiac patients undergoing non-cardiac surgery. Major non-cardiac surgeries are associated with high rates of cardiac complications in patients with advanced coronary disease. Recent case studies have reported favorable outcomes with the use of IABP support in non-cardiac surgery in patients with severe cardiac compromise. Using IABP may reduce cardiac complications by providing hemodynamic stability. Here, we present five cases of IABP use in high-risk cardiac patients undergoing resection and anastomosis of the trachea. IABP was inserted prior to induction of anesthesia in four of the cases, while IABP insertion was withheld in one case. In the four cases where IABP support was utilized, the IABP was removed between 6-48 hours postoperatively with no complications. The patient who did not undergo IABP insertion died on the 8th postoperative day due to uncontrollable pulmonary edema and progressive myocardial infarction. We also review the literature and discuss the role of IABP use in non-cardiac surgery.

Churg-Strauss syndrome following cessation of allergic desensitization vaccination: a case report.

INTRODUCTION: Churg-Strauss syndrome is a vasculitis of medium to small sized vessels. Diagnosis is mainly clinical with findings of asthma, eosinophilia, rhinosinusitis and signs of vasculitis in major organs. CASE PRESENTATION: We present a case of a 19-year-old Persian male who developed signs and symptoms of this syndrome related to hyposensitization treatments for allergy control. CONCLUSIONS: No unifying etiology for the disease can be presented as it is found associated with environmental factors, medications, infections and is even considered a variant of asthma with predisposition to vasculitic involvement. Therefore, it is important to recognize this disease and be aware of underdiagnosis because of emphasis on pathologic evidence. Here, we present a case of allergic desensitization causing Churg-Strauss syndrome in the absence of other known factors.

Churg Strauss Syndrome after polypectomy in asthmatic and allergic patients.

Churg Strauss Syndrome (CSS) is a form of primary vasculitis that is characterized by severe eosinophilia and often granulomatous inflammation as well as history of asthma or allergy. Previously, the association between cysteinyl leukotrien receptor antagonists (LTRAs), corticosteroid withdrawal or a sudden change in its used method and CSS had been established. We report three cases that have been referred because of dyspnea, wheezing and cough with a history of allergic rhinitis and nasal polypectomy. After polypectomy, disseminated skin purpuric rashes appeared on their forelegs, abdomen and all of them had experienced neuropathic signs in their extremities. Clinical findings, marked eosinophilia in blood and skin biopsies finally led to the diagnosis of CSS. The patients have been free of symptoms after receiving prednisolone; routine examinations and blood tests have rended regular results. Here, we report a probable occurrence of an association between nasal polypectomy and CSS on the basis of our findings. Further, extended researches are required to establish this correlation.

Measurement of the validity and reliability of the persian translation of the saint george respiratory questionnaire for patients with chronic obstructive pulmonary disease.

BACKGROUND: One of the important tools in measuring the quality of life in patients having a chronic disease is using questionnaires in which the impact of disease and its different types of treatments on daily tasks and social activities are evaluated. MATERIALS AND METHODS: At first, the questionnaire was translated into Persian and some of the concepts were changed by the researchers. Next, it was back translated by a person living in an English-speaking area who was unaware of the subject. At the fourth stage, the concepts were revised by a group of 15 patients and then 55 patients filled out the questionnaire. Finally, it's internal consistency was evaluated by calculating the Cronbach's alpha coefficient. RESULTS: After translation of the questionnaire, the researchers modified 17% of the sentences and phrases according to the Iranian culture. Questions which were controversial and those for which appropriate proposals were made by the COPD patients were ultimately modified and were responded to by an additional group of 55 patients. Statistical analysis and internal consistency of the questions in the different sections were obtained. For the first section ("complaints") and following the deletion of the last question (which was in regards to wheezing), the Cronbach's alpha was equal to 0.74. In the second section, where the patients' physical activities and the impact of disease on them were evaluated, the Cronbach's alpha coefficient was equal to 0.93. The last question of this section concerning the impact of activity on the rate of respiratory difficulty was deleted due to heterogeneous choices and unresponsiveness of 5 patients (15%). As a result, the Cronbach's alpha coefficient rose to 0.95 on this section and the Cronbach's alpha coefficient for the entire questionnaire was calculated at 0.93. CONCLUSION: In addition to conformity with the concepts of the English version, the translated Persian version of this questionnaire approximately matches the Iranian culture and can be used for the evaluation of the quality of life in chronic respiratory patients.

Comparison of clinicoradiologic manifestation of nonspecific interstitial pneumonia and usual interstitial pneumonia/idiopathic pulmonary fibrosis: a report from NRITLD.

BACKGROUND: Ever since Katzenstein and Fiorelli introduced the term nonspecific interstitial pneumonia (NSIP) to denote those cases of interstitial pneumonia that cannot be categorized as any of the other types of idiopathic interstitial pneumonias (IIP), there has been continuing debate on whether it is a real clinical entity or not. The American Thoracic Society/European Respiratory Symposium task group tried to identify idiopathic NSIP as a separate disease and exclude it from the category of IIP. However, it appears that the clinical presentation of NSIP and usual interstitial pneumonia (UIP) are the same. OBJECTIVE: To show that the radiologic features of NSIP and UIP should be relied upon, instead of clinical presentation and pathologic findings, to differentiate between the two. MATERIALS AND METHODS: Consecutive patients who had received a diagnosis of either NSIP or UIP on the basis of open lung biopsy between January 2001 and December 2007 were identified for inclusion in this retrospective review. The study included 61 subjects: 32 men and 29 women with a mean age of 59.39 +/- 14.5 years. Chest computed tomography images of all the cases were collected for a review. High resolution computed tomography (HRCT) and all pathologic specimens were also evaluated. A weighted kappa coefficient was used to evaluate whether radiology can be used instead of biopsy for the diagnosis of NSIP and UIP. Comparison of the mean ages and the time intervals (i.e., interval between symptom onset and the time of diagnosis) in the UIP and NSIP groups was done using the Mann-Whitney U test. Association between gender and biopsy result was evaluated by the Fisher exact test. Data were evaluated using SPSS, v.13. RESULTS: Sixty-one patients were included in this study, 32 were male and 29 were female. On the basis of biopsy findings, 50 (82%) patients had UIP and 11 (18%) had NSIP. Thirty (60%) of the 50 patients who had UIP were male and 20 (40%) were female; 2 (18.2%) of the 11 patients who suffered from NSIP were male and 9 (81.8%) were female. Based on HRCT findings, 36 (60%) patients were diagnosed to have UIP and 24 (40%) were diagnosed with NSIP. When diagnosis was based on biopsy findings, the time interval in the UIP group was 13.59 +/- 8.29 months and in the NSIP group it was 7.90 +/- 4.18 months. When diagnosed on the basis of HRCT findings, the time interval in the UIP group was 14.22 +/- 8.94 months and in the NSIP group it was 10.54 +/- 5.78 months. When diagnosis was on the basis of biopsy, the mean age in the UIP group was 61.30 +/- 14.18 years and in the NSIP group it was 50.73 +/- 13.14 years. CONCLUSION: HRCT can be used instead of invasive methods like lung biopsy to differentiate between UIP and NSIP.