The bothersomeness of patient self-rated "complications" reported 1 year after spine surgery.

PURPOSE: The last few decades have witnessed a paradigm shift in the assessment of outcome in spine surgery, with patient-centred questionnaires superseding traditional surgeon-based assessments. The assessment of complications after surgery and their impact on the patient has not enjoyed this same enlightened approach. This study sought to quantify the incidence and bothersomeness of patient-rated complications 1 year after surgery. METHODS: Patients with lumbar degenerative disorders, operated with the goal of pain relief between October 2006 and September 2010, completed a questionnaire 1 year postoperatively enquiring about complications arising as a consequence of their operation. They rated the bothersomeness of any such complications on a 5-point scale. Global outcome of surgery and satisfaction at the 12-month follow-up were also rated on 5-point Likert scales. The multidimensional Core Outcome Measures Index (COMI) was completed preoperatively and at the 12-month follow-up. RESULTS: Of 2,282 patients completing the questionnaire (92% completion rate), 687 (30.1%) reported complications, most commonly sensory disturbances (36% of those with complications) or ongoing/new pain (26%), followed by motor problems (8%), pain plus neurological disturbances (11%), and problems with wound healing (6%). The corresponding "bothersomeness" ratings for these were: 1% not at all, 23% slightly, 27% moderately, 31% very, and 18% extremely bothersome. The greater the bothersomeness, the worse the global outcome (Rho = 0.51, p < 0.0001), patient satisfaction (Rho = 0.44, p < 0.0001) and change in COMI score (Rho = 0.52, p < 0.0001). CONCLUSION: Most complications reported by the patient are perceived to be at least moderately bothersome and hence are not inconsequential. Complications and their severity should be assessed from both the patient's and the surgeon's perspectives--not least to better understand the reasons for poor outcome and dissatisfaction with treatment.

Relations between anthropometric parameters and sexual activity of Hungarian men.

In the last decades, there were visible achievements in the evaluation of sexuality-related problems and issues regarding sexual life. However, there are limited reliable and comparable data on the average values of sexual activity and its relation to anthropometric parameters in different populations and age cohorts. This study tries to examine the association between anthropometric parameters and male sexual activity. A clinical population of 1146 male patients between 25 and 45 years of age attending an outpatient clinic of andrology in Budapest (Hungary) was examined and questioned in a medical setting. Age, body height, weight, body mass index (BMI) and self-reported sexual activity were the main outcome measures. The patients were allotted into age groups (25-29, 30-39 and 40-45 years), the youngest group showing the highest coital activity. Although obesity and overweight were present in 61% of the study population, no connections between BMI and sexual activity were apparent. Comparing less active persons with those reporting at least two intercourses per week, significant difference was found between body height groups. Men below 170 cm reported higher activity than men over 180 cm. Despite the fact that the prevalence of obesity among younger generations is increasing, it has had no visible influence on the sexual activity of this age cohort as yet. Our data suggest that sexual activity was not clearly related to other anthropometric parameters, and depends mainly on the characteristics of the population examined. There is a great need for large-scale studies worldwide on larger representative samples, using similar methods, to acquire reliable data from other nations and different age groups.

Impact on survival of surgery after concomitant chemoradiotherapy for locally advanced cancers of the esophagus.

BACKGROUND: To evaluate the results of chemoradiotherapy with or without surgery in locally-advanced esophageal carcinomas (T3 and/or nodal involvement). METHODS: One hundred twelve patients with locally-advanced carcinoma of the esophagus without histologically proven invasion of the tracheobronchial tree or distant visceral metastases were treated with concomitant chemoradiotherapy followed by re-evaluation; surgery was performed or chemoradiotherapy continued, based on tumor regression and the patient's general status. Chemoradiotherapy consisted of concomitant 5-fluorouracil (5FU)(1 g/m(2) day 1-3), cisplatinum (50 mg/m(2) day 1 and 2), and external beam irradiation up to a dose of 40 or 43.2 Gy. After a 4-week rest period, radical esophagectomy or a new cycle of chemoradiotherapy (up to a total dose of 65 Gy) was performed. RESULTS: A complete clinical response was obtained in 25.7% of the patients and a partial response in 45.9%. Fifty patients underwent surgery, but only 38 patients had an esophagectomy. Post-esophagectomy mortality was 5.3%. A complete histologic response rate of 23.7% was obtained. Two- and 5-year survival rates were, respectively, 41.5% and 28.6% for the whole population. According to multivariate analysis, prognostic factors for survival were Karnofsky index, esophagectomy, and response to chemoradiotherapy. Five-year survival for patients who experienced a partial response to radiation and chemotherapy was 49.1% for those who had surgery and 23.5% for those treated without surgery (p = 0.003). There was no obvious benefit for the small number of patients treated surgically after complete response to radiation and chemotherapy. Toxicity, essentially hematologic, was moderate. CONCLUSION: For locally-advanced esophageal carcinomas, esophagectomy, after concomitant chemoradiotherapy, could improve the survival rate, especially for patients who responded partially to the latter.

[Effectiveness and adverse effects of sildenafil in erectile dysfunction]. / A hatékonyság és a mellékhatások vizsgálata erekciós zavarok sildenafil-kezelése során.

Sildenafil is a selective and by oral administration potent type-5 phosphodiesterase (PDE 5) inhibitor, which increases the erection by corpus cavernosum smooth muscle relaxation. In a non-placebo controlled study, 134 patients with erectile dysfunction were treated with oral sildenafil. The aim of the study was to estimate the efficacy and adverse effects of this treatment. 51 patients (38%) had psychogenic, and 83 (62%) organic origin of the erectile dysfunction. 73 of them have already had some treatment for this problem before. The effective dose was 50 mg for 84 patients (63%), 100 mg for 32 (24%) and 25 mg for 4 patients. The treatment was effective for 120 patients (90%). The most common adverse effect was flushing in 18 (13%) and headache in 9 (7%) cases, two patients had headache and flushing together. Nasal congestion and visual disturbances were complained by two patients. Two patients reported prolonged (max. 2h) erections. Cardiological investigation was performed for cardiovascular patients and for patients with risk factors. Exact criteria of the cardiological opinion of sildenafil treatment are reviewed. Cardial or other serious adverse effects were not observed. It was not necessary to stop the treatment because of the adverse effects. The authors found, that sildenafil is an effective and safe treatment for the erectile dysfunction.

[Local curative treatment of superficial adenocarcinoma in Barrett's esophagus. First results of photodynamic therapy with a new photosensitizer]. / Traitement curatif local des adénocarcinomes superficiels sur endobrachyoesophage. Premiers résultats de thérapie photodynamique avec un nouveau photosensibilisateur.

Pre-cancerous lesions and mucosally confined superficial cancers can benefit from local therapy given with curative intent due to the absence of near metastatic lymph nodes. Photodynamic therapy (PDT) which acts by laser irradiation with an appropriate wave-length after administration of a photosensitiser retained preferentially by the cancerous tissue can destroy tumour cells selectively, but its efficiency depends upon the photosensitiser. The results presented concern 10 sites on Barrett's mucosa (BO). They consisted of either an association of intramucosal cancer (IMC) with high-grade dysplasia (HGD) or of high-grade dysplasia alone. The method consisted of intravenous injection of Temoporfin 0,15 mg/kg 4 days before irradiation of the lesion with a green laser light emitting 514 nm through a windowed diffuser. The light fluence was 75 J per cm2 and irradiation 100 mW per cm2. Irradiation time was 12,5 mn. Omeprazole was routinely prescribed after treatment at a dose of 40 mg daily. The follow-up protocol was 2 years with endoscopic surveillance at 2, 3, 6, 12, 18 and 24 months. Biopsies obligatory at 2 and 3 months were in fact carried out at all the other delays. Efficacy was judged on the absence of high-grade dysplasia or intra mucosal carcinoma on biopsies at treated sites. Undesirable side effects noted have been moderate for the most part. No stenosis appeared. Treatment has been 100% successful for the 10 lesion after 15 treatments with PDT. The follow up varies from 6-36 months and was more than 18 months for 6 lesions on 5 patients. Our series has demonstrated a great heterogeneity in lesions which were sometimes visible and highly localised, but more often invisible, multi-focal and diagnosable only by biopsy at different levels. In keeping with the literature and our experience, PDT has several advantages over the other locally curative therapies, mucosectomy and thermocoagulation. These are the possible treatments without general anaesthesia, selectively for cancer cells, an action on more extensive areas with eradication of non visible lesions. Temoporfin has contributed notably to the field of photodynamic therapy compared to previously used sensitisers. It is a pure, synthetic product which guarantees more reproducible results. Compared with Photofrin, Temoporfin has many advantages with smaller doses of drugs and less energy, better selectivity and rapid elimination which reduce the risk period for photosensitisation. The frequency of important undesirable side effects is diminished. Finally, it produces a consistent effect on the surface and in depth producing a complete reepithelialisation of the treated zones. Subject to validation of the method on a greater number of patients, the first results obtained on superficial cancer in Barrett's aesophagus allow us to propose green light Temoporfin PDT as an alternative first line therapy with curative intent.

[Palliative treatment of adenocarcinoma of the cardia: is there a role for surgery?]. / Traitement palliatif de l'adénocarcinome du cardia: y a-t-il une place pour la chirurgie?

OBJECTIVES: The value of palliative surgery for adenocarcinoma of the cardia (AC) is controversial, and specific studies are lacking. The aim of this study was to report the results of a palliative resection for AC in 69 patients. METHODS: From 1980 to 1993, 69 patients (mean age 59 +/- 10 years) underwent a palliative resection for AC. Palliative resection was defined by macroscopically incomplete resection, tumoral involvement of resection margins, visceral or serosal metastasis, or N3 metastatic nodes. Patients were classified according to the diagnosis of palliation established preoperatively (group A, n = 26), peroperatively (group B, n = 35), or postoperatively (group C, n = 8) respectively. RESULTS: Six patients (8.7%) died postoperatively. Mortality rates were 3.8%, 8.6% and 25% in groups A, B and C, respectively. Twenty one patients (30%) had postoperative non-fatal complications. Median global survival was 9 months (mean 11 +/- 7 months) without significant difference between groups A, B and C. Forty-four out of 51 patients (86%) followed until death did not have dysphagia. The other patients were free of dysphagia during an average of 70% of the follow-up duration. Among the 14 patients surviving postoperatively with a tumoral esophageal margin, none experienced dysphagia from anastomotic recurrence during follow-up. CONCLUSIONS: In selected patients with AC, a palliative resection can be achieved with an acceptable mortality and a very good functional result. This result can justify a prospective comparison between palliative surgery and alternative treatments.

[Late perforation of pre-sternal coloplasty: echocardiography diagnosis]. / Perforation tardive d'une coloplastie présternale: un diagnostic échographique.

The authors report a previously non described case of late rupture of a presternal colon esophagoplasty in a patient with history of caustic ingestion. The role of sonography was the diagnosis of the rupture due to presternal position of the coloplasty.

[Polysomnography in the prevention of crib death]. / A polysomnographia helye a bölcsóhalál megelözésében.

The authors stress the importance of polysomnography--a new electrophysiologic method--in the prevention of SIDS (cot death). SIDS is the most important and frequent cause of infant mortality between 1 and 12 months of age in western countries (nowadays between 1-2/1000!). In Hungary the frequency is not so high. In the last few years the incidence declined after the "back to sleep" campaigns, but to reach further success, it is very important to seek the so called "risk" babies. The unique cause of cot death is not yet understood exactly, but some instability in respiration (mostly during the sleep) is one of the accepted principal basic factors. The mentioned new method helps in choosing the SIDS risk infants from the "normal" population, allows to examine their respiratory irregularity or even disorders during the sleep and gives possibility for the prevention of lethal apneas. The authors describe the details of the prevention in case of abnormal polysomnography in their other publications.

Somatic deletion of the 5' ends of both the COL4A5 and COL4A6 genes in a sporadic leiomyoma of the esophagus.

Leiomyomata of the esophagus are sporadic benign tumors of unknown etiology. We studied a collection of nine tumors for the expression of extracellular matrix components and found the same aberrant expression pattern as previously observed in inherited diffuse leiomyomatosis. We demonstrate here the occurrence of a somatic deletion at the COL4A5/COL4A6 locus at Xq22 in a frozen leiomyoma sample. These data confirm the hypothesis that the same underlying etiology is responsible for circumscribed smooth muscle proliferation in sporadic leiomyomata as for diffuse smooth muscle cell proliferation in inherited diffuse leiomyomatosis.

[Some aspects of the use of prostaglandin E1 in cases of erectile dysfunction]. / Néhány szempont a prosztaglandin E1 alkalmazásához merevedési zavarok esetén.

The author reports about his first experience of the use of prostaglandin E1 (PGE1) for the treatment of the erectile dysfunction. Results and observations of the self injection treatment with PGE1 of 46 patients are reported. Main indications and some practical aspects of the use of PGE1 are discussed after 5 short case reports. Upon the international experience and his own first results the authors opinion is, that the PGE1 is especially useful for the self injection treatment of the erectile dysfunction because of its rare complication rate.

Nosocomial Streptococcus pneumoniae infection causing children's acute otitis media.

Streptococcus pneumoniae is the most frequent pathogen in young children's acute otitis media. It also plays a significant role in nosocomial ear infection in children, while it causes pneumonia with or without bacteremia in hospitalized elderly people. Multiple antibiotic resistant strains are prevalent among S. pneumoniae isolates from the respiratory tract of hospitalized patients in Hungary. This fact makes therapeutic reconsiderations concerning the use of oral beta-lactams mandatory. In this retrospective study two nosocomial outbreaks caused by multiresistant S. pneumoniae in two pediatric hospitals are described. The patients admitted with a chronic underlying disease (milk intolerance and gastro-oesophageal reflux were predominant) or respiratory tract infection acquired acute otitis media. Therapy with oral beta-lactams (first and second generation cephalosporins and amoxicillin), macrolides and co-trimoxazole was ineffective in most of the cases or resulted in transient improvement. In some cases acute otitis media resolved with the improvement of the underlying condition, in two cases administration of cefotaxime resulted in recovery and in one case mastoidectomy became necessary.

[Total duodenal diversion in the treatment of complex peptic esophagitis]. / La diversion duodénale totale dans le traitement des oesophagites peptiques complexes.

AIMS OF THE STUDY: The aims of this study was to report the results of total duodenal diversion in patients with complex peptic esophagitis (peptic stenosis, acquired short esophagus, columnar lined esophagus, previous surgery). PATIENTS-METHODS: Total duodenal diversion has been performed in 107 patients with complex peptic esophagitis. The standard procedure--including a troncular vagotomy, an antrectomy and a 70 cm Roux-en-Y gastro-jejunostomy--was used in 68 cases (64%). Technical adjustments were necessary in the 39 others patients. RESULTS: Two patients (1.8%) died postoperatively. Permanent healing of esophagitis was observed within 3 months in 88% of patients. Esophagitis healed in all patients operated with the standard technique. Three hours postprandial pH-monitoring was normal postoperatively in 92% of patients. Four anastomotic ulcers occurred in patients who did not have vagotomy. Among patients with columnar lined esophagus, one complete and six partial regressions were observed; no malignant degeneration was observed with a 210-patient-year follow-up. Among the 39 peptic stenoses, all except one (2.6%) resolved. Functional disorders occurred in 27% of patients within the first postoperative months; these disorders persisted in 14% of patients (Visick III or IV) after 3 years. The main disorders (dumping syndrome, anastomotic ulcer, diarrhea) were observed when a two-thirds distal gastrectomy has been performed to avoid the dangerous completion of vagotomy after a previous Heller's myotomy. CONCLUSION: These results suggest that total duodenal diversion is a suitable treatment of complex peptic esophagitis.

[Results of the surgical treatment of cancer of the cardia]. / Résultats du traitement chirurgical du cancer du cardia.

OBJECTIVES: In the curative treatment of the adenocarcinoma of the cardia (AC), the extent of the esogastrectomy and the need for lymph node dissection are still debated. The palliative treatment of AC is now currently non-surgical. The aim of this study was (a): to assess early results of palliative surgery; and (b) to evaluate the results of curative resection with reference to the influence of the extent of gastrectomy and lymph node dissection on early results and long-term survival. Methods. From 1979 to 1989, 179 patients (mean age = 60 +/- 12 years) with AC had 45 palliative resections (mean age = 56 +/- 15) and 134 curative resections (mean age = 61 +/- 12). Thirty-eight proximal subtotal esogastrectomy (PSOG) and 7 total esogastrectomy (TOG) were palliative; 72 PSOG and 62 TOG extended to the spleen were curative and associated with lymphadenectomy. RESULTS: The operative mortality rate was 8.9% regardless of the palliative or curative intent of resection. After palliative resection, the mortality rate was 2.6% (1/38) after PSOG and 42.9% (3/7) after OGT = (p = 0.01); the median survival was 8 months. After curative resection, the mortality rate was 12.5% (9/72) after PSOG and 4.8% (3/62) after extended TOG (p = 0.2); actuarial 5-year survival rate was 42% after PSOG and 39% after extended TOG. CONCLUSIONS: These results suggests that: (a) palliative PSOG for AC can be performed with a low mortality; and (b) resection with extensive lymphadenectomy allows substantial survival regardless of the extent of gastrectomy.

Pseudotumor developing in heterotopic pancreas.

Cystic dystrophy in heterotopic pancreas (CDHP) is characterized by the presence of cystic formations surrounded by inflammation and scarring. It usually involves the duodenal wall and can be responsible for strictures and pain. The diagnosis of this disorder was previously based on pancreatoduodenectomy specimens removed for a suspected pancreatic tumor. Six cases were observed in young men (mean age 40 years) between 1989 and 1993. Computed tomography (CT) and endoscopic ultrasonography (EUS) features allowed definitive preoperative diagnosis of CDHP. After surgical resection of the tissue-bearing segments that included five pancreatoduodenectomies and one antrectomy, symptoms disappeared in all patients. Patients were followed 2 to 45 months; one patient experienced recurrence of pain and hyperamylasemia 17 months after surgery. The preoperative diagnosis of CDHP is presently possible because of modern imaging procedures and improved knowledge of specific signs. Resection is the most appropriate treatment.

[Total duodenal diversion in the treatment of complex peptic esophagitis]. / La diversion duodénale totale dans le traitement des oesophagites peptiques complexes.

Two duodenal diversion was performed in 107 patients with complex peptic oesophagitis (peptic stenosis, Barrett's mucosa, past history of gastro oesophageal surgery). A standard operation included truncular vagotomy, antrectomy and gastro-jejunal anastomosis on a 70 cm Y loop in 68 patients. Technical adaptations were required in 39 patients. Two patient died (pulmonary embolism and duodenal fistula). The operation was successful with stable cure of the oesophagitis at 3 months in 89% of the patients. Post-prandial pHmetry over 3 hours confirmed control of the reflux in 92% of the cases. Anastomotic ulcer occurred in 4 patients who did not have a vagotomy. One complete regression of Barret's oesophagitis was achieved and in 6 other cases the regression was partial. Stenosis improved in all patients except 1, sometimes after 1 or several dilatations. Digestive sequellae, were observed during the first few months after surgery in 27% of the cases. Persistant sequellae were found in 14% of the operation patients after a delay of 36 months. These results suggest that duodenal diversion is a useful treatment for complicated and complex peptic oesophagitis.

[Adenocarcinoma of the cardia: does the extent of gastric resection and lymph node excision influence survival?]. / Adénocarcinome du cardia: l'étendue de l'exérèse gastrique et du curage ganglionnaire influence-t-elle la survie?

OBJECTIVES: In the curative treatment of the adenocarcinoma of the cardia (AC), the extent of the esogastrectomy and the need for lymph node dissection are still debated. The palliative treatment of AC is now currently non-surgical. The aim of this study was: a) to assess early results of palliative surgery; b) to evaluate the results of curative resection with reference to the influence of the extent of gastrectomy and lymph node dissection on early results and long-term survival. METHODS: From 1979 to 1989, 179 patients (mean age = 60 +/- 12 years) with AC had 45 palliative resections (mean age = 56 +/- 15) and 134 curative resections (mean age = 61 +/- 12). Thirty-eight proximal subtotal esogastrectomies (PSOG) and 7 total esogastrectomies (TOG) were palliative; 72 PSOG and 62 TOG extended to the spleen were curative and associated with lymphadenectomy. RESULTS: The operative mortality rate was 8.9% regardless of the palliative or curative intent of resection. After palliative resection, the mortality rate was 2.6% (1 case out of 38) after PSOG and 42.9% (3 cases out of 7) after OGT (P = 0.01); the median survival was 8 months. After curative resection, the mortality rate was 12.5% (9 cases out of 72) after PSOG and 4.8% (3 cases out of 62) after extended TOG (P = 0.2); actuarial 5-year survival rate was 42% after PSOG and 39% after extended TOG. CONCLUSIONS: These results suggest that: a) palliative PSOG for AC can be performed with a low mortality; b) resection with extensive lymphadenectomy allows substantial survival regardless of the extent of gastrectomy.