Detecting short-term change and variation in health-related quality of life: within- and between-person factor structure of the SF-36 health survey.

BACKGROUND: A major goal of much aging-related research and geriatric medicine is to identify early changes in health and functioning before serious limitations develop. To this end, regular collection of patient-reported outcome measure (PROMs) in a clinical setting may be useful to identify and monitor these changes. However, existing PROMs were not designed for repeated administration and are more commonly used as one-time screening tools; as such, their ability to detect variation and measurement properties when administered repeatedly remain unknown. In this study we evaluated the potential of the RAND SF-36 Health Survey as a repeated-use PROM by examining its measurement properties when modified for administration over multiple occasions. METHODS: To distinguish between-person (i.e., average) from within-person (i.e., occasion) levels, the SF-36 Health Survey was completed by a sample of older adults (N = 122, M age = 66.28 years) daily for seven consecutive days. Multilevel confirmatory factor analysis (CFA) was employed to investigate the factor structure at both levels for two- and eight-factor solutions. RESULTS: Multilevel CFA models revealed that the correlated eight-factor solution provided better model fit than the two-factor solution at both the between-person and within-person levels. Overall model fit for the SF-36 Health Survey administered daily was not substantially different from standard survey administration, though both were below optimal levels as reported in the literature. However, individual subscales did demonstrate good reliability. CONCLUSIONS: Many of the subscales of the modified SF-36 for repeated daily assessment were found to be sufficiently reliable for use in repeated measurement designs incorporating PROMs, though the overall scale may not be optimal. We encourage future work to investigate the utility of the subscales in specific contexts, as well as the measurement properties of other existing PROMs when administered in a repeated measures design. The development and integration of new measures for this purpose may ultimately be necessary.

Management of complex acute biliary disease for the general surgeon: A narrative review.

Acute gallbladder diseases are a common surgical emergency faced by General Surgeons that can sometimes be quite challenging. These complex biliary diseases require multifaceted and expeditious care, optimized based on hospital facility and operating room (OR) resources and the expertise of the surgical team. Effective management of biliary emergencies requires two foundational principles: achieving source control while mitigating the risk of injury to the biliary tree and its blood supply. This review article highlights salient literature on seven complex biliary diseases: acute cholecystitis, cholangitis, Mirizzi syndrome, gallstone ileus with cholecystoenteric fistula, gallstone pancreatitis, gall bladder cancer, and post-cholecystectomy bile leak.

A distinct case of an 8-year-old female with cyclic neutropenia presenting with C. septicum abdominal sepsis and myonecrosis requiring a bowel resection and leg fasciotomy.

Clostridium septicum is a very rare cause of severe spontaneous pediatric enterocolitis and is often associated with underlying malignancy or immunocompromise. Likewise, cyclic neutropenia is a rare congenital immunodeficiency that is characterized by cyclical periods of neutropenia, often with more severe symptoms in the pediatric population. Here, we present a unique case of spontaneous C. septicum enterocolitis, sepsis, and myonecrosis in a child with undiagnosed cyclic neutropenia. Early recognition of pediatric sepsis, frequent reevaluation and identification of rapidly progressive infection, and early surgical intervention are critical for the effective management of a rare and severe infection.

Which prediction models best identify additional axillary disease after a positive sentinel node biopsy for breast cancer?

To determine which web-based model best identifies women at low risk of further axillary disease after a positive sentinel lymph node (SLN+) biopsy. 673 women with T1-2cN0M0 SNB+ breast cancer who underwent completion axillary dissection (AxD) were identified. A subgroup not eligible to avoid AxD as part of the Z0011 study was defined (Z0011 exclusion group). Predicted risk of further axillary disease was generated using seven web-based models. "Low risk" was defined as a ≤10% risk of further axillary disease. False negative ("low risk" prediction but AxD+) rates (FNRs), area under the receiver operating characteristic curve (AUC), and Brier score were determined for each model. 6 of 7 models identified "low risk" patients but FNRs ranged from 14 to 30%. The Stanford and Memorial Sloan-Kettering (MSKCC) models had the best FNRs. FNRs were lower with SLN micrometastasis (7-15%) and higher in the Z0011 exclusion group (21-41%). All models under-predicted further nodal disease in low risk patients and over-predicted in higher-risk patients. The Stanford and MSKCC models were able to identify women with SLN micrometastasis with a ≤10% FNR. Models were not able to accurately identify low risk women from a cohort that would have been excluded from Z0011.

A rare case of a congenital pancreatic duplication cyst in an infant complicated by an upper GI bleed, pancreatitis, cyst infection and gastric outlet obstruction.

Enteric duplication cysts are rare congenital entities most commonly found in the esophagus, ileum or colon but can be in remote locations such as the biliary tree, liver or pancreas. Pancreatic duplication cysts are very uncommon and usually present in adulthood with pancreatitis or abdominal pain. Here, we present a unique and complex case of an infant with a pancreatic duplication cyst initially presenting with an upper gastrointestinal bleed followed by pancreatitis, cyst infection and gastric outlet obstruction.

Trauma association of Canada Pediatric Subcommittee National Pediatric Cervical Spine Evaluation Pathway: consensus guidelines.

BACKGROUND: The Institute of Medicine calls for the use of clinical guidelines and practice parameters to promote "best practices" and improve patient outcomes. In 2006, The Trauma Association of Canada Pediatric Committee set out to create an evidence-based, national pediatric cervical spine (c-spine) clearance guideline based on the literature, existing algorithms from each pediatric trauma center and from expert opinion from across Canada. METHODS: A review of the literature took place in September 2006 using the PubMed database. Search criteria were "cervical spine," "c-spine," "clearance," and "trauma." Limits that were applied were "Languages: English," "Humans," "Type of Article: Meta-Analysis, Practice Guidelines, Randomized Control Trial, Review," and "Ages: all child 0-18 years." These search criteria were repeated in December 2007, April 2009, and October 2009. A total of 248 articles were identified. Existing guidelines were identified and their practices examined as models of care. Two draft guidelines were created for discussion: one for the pediatric patient with a reliable clinical examination and the other for the pediatric patient with an unreliable clinical examination. Via email, telephone, and two national videoconferences, the content of the guidelines was reviewed, discussed, and amended. The final article was prepared and circulated for author input until consensus was reached. RESULTS: A consensus was reached on two pathways to evaluate the pediatric cervical spine: a patient with a reliable clinical examination and a patient with an unreliable examination. CONCLUSION: Presented herein are the consensus Trauma Association of Canada, National Pediatric Cervical Spine Evaluation Pathways for the patient with a reliable clinical examination, and the patient with and unreliable clinical examination.

Rituximab for management of refractory pregnancy-associated immune thrombocytopenic purpura.

BACKGROUND: Rituximab is a novel therapy for immune thrombocytopenic purpura (ITP); however, information about its safety in pregnancy is limited. This case illustrates the successful use of rituximab to treat pregnancy-associated ITP. CASE: A 34-year-old woman presented with severe ITP at 23 weeks' gestation. Standard treatment with corticosteroids, intravenous immune globulin, and splenectomy failed to raise the platelet count. Due to ongoing bleeding, rituximab was given in the 26th week of pregnancy. The platelet count rose to over 100 × 10(9)/L after four weeks. The neonatal B-lymphocyte count normalized at four months after delivery. There were no neonatal complications of rituximab therapy. CONCLUSION: Rituximab may be safe for use in treating pregnancy-associated ITP. This case highlights the need to investigate further the safety and efficacy of rituximab in pregnancy.

Laparoscopic removal of massive pediatric gastric trichobezoars: A brief report.

BACKGROUND: Trichobezoars are foreign bodies in the gastrointestinal tract composed of ingested hair. These can develop into large, hard, obstructing objects that are often impossible to remove endoscopically. The size often leads surgeons to remove these via laparotomy or laparoscopic-assisted procedure (midline laparotomy for specimen removal), with few removed completely laparoscopically. BRIEF REPORT: We present a case of a 5-year-old female with pica who had symptoms of foul-smelling diarrhea and weight loss and was found to have a massive gastric trichobezoar. The bezoar was removed laparoscopically with pfannensteil incision facilitating specimen extraction. Further, technical aspects of the procedure are discussed. CONCLUSION: We conclude that there are benefits to using a laparoscopic approach to remove a massive gastric trichobezoar. This includes the use of a Pfannensteil incision rather than a midline laparotomy for specimen removal.

CHIVA - A prospective study of a vein sparing technique for the management of varicose vein disease.

BACKGROUND: Varicose vein disease (VVD) affects approximately one third of adults. Cure Conservatrice et Hémodynamique de l'Insuffisance Veineuse en Ambulatoire (CHIVA) is a minimally invasive, vein sparing technique that is emerging as an alternative to ablative techniques for treating VVD. METHODS: This prospective study assessed the rate of recurrence of venous reflux with CHIVA. We evaluated 150 primary procedures with clinical and duplex ultrasound examinations pre and post operatively. Patients were followed at <3 months and >1-year post-op. Recurrence was defined as reflux in the diseased vessel at the saphenofemoral junction on duplex examination. RESULTS: There was no documented recurrence at the early follow up. To date, 58 legs have completed the late follow up and reflux was found in 5 legs resulting in a recurrence rate of 8.6%; 95% CI (2.4%, 19%). CONCLUSION: Our results indicate that CHIVA appears to offer a promising alternative for the treatment of VVD.

The quality of life of elderly women who underwent radiofrequency ablation to treat breast cancer.

The purpose of this article is to explore the effects of radiofrequency ablation (RFA), an investigational treatment for breast cancer, on the quality of life of elderly women. For this descriptive phenomenological study, the authors interviewed 12 White women (aged 60-81 years) 4 months to 1 year after treatment and analyzed these interviews for common themes. They asked questions regarding the lived experience of RFA treatment and its effects on quality of life. Analyses focused on the effects of deciding to have the RFA treatment and the treatment itself. They found quality of life improved because the women felt empowered by (a) their decision to have the procedure, (b) knowing that the procedure might kill the tumor, (c) and feeling that they were contributing to cancer research. The level of support received from the medical team, family and friends, and other cancer survivors also improved participant quality of life.

Call to care: the impact of 24-hour postdischarge telephone follow-up in the treatment of surgical day care patients.

BACKGROUND: Patient satisfaction and effective management of postoperative complaints are important factors in determining the success of outpatient surgery programs. METHODS: In September 2013, a 24-hour postdischarge telephone follow-up (TFU) call was initiated by surgical day care nurses at the Royal Jubilee Hospital in Victoria, BC. The study group was contacted to evaluate the effectiveness of the TFU in identifying and addressing postoperative complaints and determining the level of satisfaction with discharge instructions and care. RESULTS: A total of 854 patients were contacted. Overall, 313 (36.7%) received TFU and 541 (63.3%) did not; these served as our control group. Independent sample t-tests revealed that patients who received TFU had significantly fewer postoperative complaints compared with the controls (.19 vs .28, respectively). CONCLUSIONS: Day surgery patients receiving TFU reported fewer postoperative concerns. Results of this study suggest that a TFU call results in increased patient satisfaction with discharge care and is an appropriate tool to address patients' postoperative complaints and improve patient-reported outcomes.

Lymphovascular invasion is associated with reduced locoregional control and survival in women with node-negative breast cancer treated with mastectomy and systemic therapy.

BACKGROUND: The impact of lymphovascular invasion (LVI) on postmastectomy locoregional relapse (LRR) and its use in guiding locoregional therapy in node-negative breast cancer are unclear. This study evaluates the association of LVI with relapse and survival in a cohort of women with early-stage breast cancer. STUDY DESIGN: The study cohort comprised 763 women with pT1-2, pN0 breast cancer referred from 1989 to 1999 and treated with mastectomy and adjuvant systemic therapy without radiotherapy. Kaplan-Meier LRR, distant relapse, and overall survival rates at 7 years were compared between patients with and without LVI. Cox regression analyses were performed to evaluate the prognostic significance of LVI for relapse and survival. RESULTS: Median followup was 7.0 years (range 0.34 to 14.9 years). LVI was present in 210 (27.5%) patients. In log-rank comparisons of Kaplan-Meier curves stratified by LVI status, LVI-positive disease was associated with significantly higher risks of LRR (p = 0.006), distant relapse (p = 0.04), and lower overall survival (p = 0.02). In the multivariable Cox regression analysis, LVI was significantly associated with LRR (relative risk [RR] = 2.32; 95% CI, 1.26-4.27; p = 0.007), distance relapse (RR = 1.53; 95% CI, 1.00-2.35; p = 0.05), and overall survival (RR = 1.46; 95% CI, 1.04-2.07; p = 0.03). In patients with one of the following characteristics: age younger than 50 years, premenopausal status, grade III histology, or estrogen receptor-negative disease, 7-year LRR risks increased threefold from 3% to 5% when LVI was absent, to 15% to 20% in the presence of LVI. CONCLUSIONS: LVI is an adverse prognostic factor for relapse and survival in node-negative patients treated with mastectomy and systemic therapy. LVI, in combination with age older than 50 years, premenopausal status, grade III histology, or estrogen receptor-negative disease, identified patient subsets with 7-year LRR risks of approximately 15% to 20%. Prospective research is required to define the role of adjuvant radiotherapy in these patients.

Can general surgeons evaluate visceral slide with transabdominal ultrasound to predict safe sites for primary laparoscopic port placement? A prospective study of sonographically naïve operators at a tertiary center.

BACKGROUND: Port placement injuries are a potentially devastating complication of laparoscopic surgery. Ultrasound assessment for visceral slide has the ability to preoperatively determine adhesion-free areas. The utility of this technique has not been studied when performed by surgeons. METHODS: Surgeons without expertise in ultrasound were taught the visceral slide technique. Patients with a history of abdominal surgery were then assessed for adhesion-free areas on the abdominal wall. Ultrasound assessments were validated against intraoperative visualization. RESULTS: Nine surgeons using the visceral slide technique assessed 145 patients for the presence of adhesions immediately before surgery. Surgeon who performed ultrasound demonstrated a sensitivity of 69.6%, specificity of 98.7%, and positive predictive value of 99.5% for detection of areas free from critical adhesions. The median time to perform the examination was 2 minutes. CONCLUSION: The visceral slide technique was easily learned, was rapid to perform, and reliably identified adhesion-free areas of the abdominal wall.

Optimizing bowel preparation for colonoscopy: what are the predictors of an inadequate preparation?

BACKGROUND: This retrospective study evaluates factors that are associated with an inadequate bowel preparation. METHODS: A chart review was performed on 2,101 patients who underwent colonoscopy. The quality of preparation was classified as adequate or inadequate. Univariate and multivariate regression analyses identified factors associated with inadequate preparations. RESULTS: A total of 91.5% of preparations were adequate. Standard preparations using polyethylene glycol-electrolyte solution and sodium picosulfate alone were 91.1% adequate. Regimens with adjuncts were 91.9% adequate. Factors that predicted an inadequate preparation include the following: stroke/dementia (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.6 to 7.7, P = .002), opioids (OR 2.3, 95% CI 1.1 to 4.6, P = .02), male sex (OR 2.0, 95% CI 1.4 to 2.9, P = .000), calcium channel blockers (OR 1.9, 95% CI 1.1 to 3.3, P = .03), and antidepressants (OR 1.7, 95% CI 1.1 to 2.7, P = .02). CONCLUSIONS: Several factors are associated with inadequate preparations. Adjuncts do not improve preparation quality. The effect of patient education on preparation quality is an area for further research.

Initial experience with stapled anoplasty in the operative management of prolapsing hemorrhoids and mucosal rectal prolapse.

BACKGROUND: Excisional hemorrhoidectomy has remained the standard procedure in the operative management of hemorrhoids. Innovations in surgical technique have recently been introduced to try to decrease the pain associated with it. Stapled anoplasty has had promising early results in this regard. The aim of this study was to determine the ease or difficulty in introducing this new procedure, its efficacy, safety, and pain profile. DATA SOURCES: Nineteen patients underwent stapled anoplasty and were followed up from 8 weeks to 6 months postoperatively. Data were accrued through clinical evaluation and patient questionnaires. CONCLUSIONS: Seventy-two percent of patients had good to excellent results. There were no significant complications. Eighteen patients underwent surgery in an ambulatory setting and were discharged from hospital in a mean of 189 minutes. The procedure is safe and easily mastered. The staple line should be placed precisely at 3.5 to 4 cm from the dentate line to ensure greater efficacy.

Treatment of invasive breast carcinoma with ultrasound-guided radiofrequency ablation.

BACKGROUND: Radiofrequency ablation (RFA) is a minimally invasive thermal ablation technique. This study reports the safety and efficacy of RFA as a minimally invasive strategy for breast cancers <3 cm diameter in postmenopausal women. METHODS: Twenty-two postmenopausal women (aged 60 years or older) with clinical T-1N0 core biopsy proven breast cancers were studied. Thermocoagulation was undertaken using a sonographically guided RF probe under local anesthesia and sedation. The ablated tumor was resected between 1 and 2 weeks later. Endpoints were technical success, completeness of tumor kill, marginal clearance, skin damage, and patient reports of pain and procedural acceptability. RESULTS: The procedure was well tolerated and cosmesis was excellent. Pathology revealed a central ablation zone surrounded by hyperemia. Coagulative necrosis was complete in 19 of 22 patients. Disease at the ablation zone margin was found in 3 patients and 5 patients had disease distant to the ablation zone consisting of multifocal tumors (2), in-transit metastasis (1), and extensive ductal carcinoma in situ with microinvasive carcinoma (2). Ninety-five percent of patients would be willing to have RFA again. CONCLUSIONS: Radiofrequency ablation can be safely applied in an outpatient setting with acceptable patient tolerance. By itself, RFA cannot be considered effective local therapy. Trials to evaluate RFA complemented with breast irradiation are justified.