Biomedical subjects

G E Darling

Publications and source records attributed to G E Darling.

8 recordsLinked to original sources

PubMed1999

Surgeons' assessment of symptoms suggesting extrathoracic metastases in patients with lung cancer. Canadian Lung Oncology Group.

BACKGROUND: In patients with apparently operable non-small cell lung cancer (NSCLC), clinicians often omit investigation for M disease in asymptomatic patients. Previous investigations have not specified in detail what is meant by "symptomatic," and this could differ between surgeons. We have investigated the extent to which surgeons' criteria differ for presence of symptoms. METHODS: Participating surgeons from seven centers, enrolled patients they judged "asymptomatic" in a randomized trial of investigational strategies for NSCLC. Patients completed a structured questionnaire describing symptoms of the central nervous system (CNS). In 685 patients, we documented CNS symptom recurrence after resectional surgery over 1 year of follow-up. RESULTS: Two centers enrolled only patients without even the mildest symptoms. Three centers took an intermediate approach, occasionally classifying patients with mild symptoms as "asymptomatic" and thus enrolling them in the trial. Two centers classified an appreciable number of patients with minimal symptoms, and occasionally with more than minimal symptoms, as "asymptomatic." Patients with even mild CNS symptoms were more likely to subsequently present with CNS metastases. CONCLUSIONS: Thoracic surgeons differ in their ideas of what may constitute the symptoms of M disease. Patients with structured questionnaire results that suggest symptoms of CNS disease are more likely to have CNS symptom recurrence after resectional surgery.

Bone Neoplasms↗

PubMed1997

Staging of the patient with small cell lung cancer.

Patients with SCLC should have a complete history and physical examination with particular attention paid to symptoms and signs of extensive disease and paraneoplastic syndromes. Hematology and biochemistry should be obtained at the initial assessment. A chest radiograph will usually have been performed prior to diagnosis. Further imaging should then be done to determine if the patient has limited or extensive disease. In the nonprotocol setting, extensive radiologic investigations are not required once a site of metastatic disease has been identified. If symptoms or signs are present to indicate a site of extensive disease, then this should direct the next test. In the absence of any specific findings then either bone scan or abdominal imaging with either US or CT scanning may be done based on the roughly equal likelihood of metastatic disease in liver or bone. Because a bone scan is less expensive, it is often the next test selected. If the bone scan is negative, abdominal imaging should then be performed, followed by brain CT scan. If these investigations are negative, the next study should be a thoracic CT scan. Bone marrow examination is probably unnecessary in the nonprotocol setting unless serum LDH levels are elevated. In the setting of a clinical trial, complete staging should be done and even more precise staging using the TNM system should be considered based on the improved survival of patients with proven stage I disease. Using more precise staging will allow accurate comparisons of clinical trials and eliminate or minimize the question of patient selection. Surgical staging with mediastinoscopy may come to have a role in accurately determining stage I or II disease.

Carcinoma, Small Cell↗

PubMed1996

Pulmonary complications in inhalation injuries with associated cutaneous burn.

This retrospective study of 100 consecutive patients with inhalation injury documents that adult respiratory distress syndrome (ARDS) and pneumonia are common complications. Pulmonary complications cause or directly contribute to death in 77% of patients with combined inhalation and cutaneous burn injury. Additionally, the high fluid requirements of these patients worsens their pulmonary injury and is associated with adverse outcome. Independent factors predictive of death include ARDS and expected fluid requirements as well as age and percentage of total body surface area burned. An abnormal chest roentgenogram in the first 48 hours after injury is also associated with death. The development of ARDS is predicted by the actual volume of fluid resuscitation, despite normal pulmonary wedge pressure or normal central venous pressure reflecting increased microvascular permeability. These findings indicate a need for reevaluation of fluid resuscitation of patients with inhalation injury.

Adolescent↗

PubMed1995

Modified anterior approach to the cervicothoracic junction.

STUDY DESIGN: This study reports the experience with four patients regarding a modified anterior approach to the cervicothoracic junction. OBJECTIVES: This technique was evaluated with respect to extent of exposure, ease of technique, and postoperative morbidity. SUMMARY OF BACKGROUND DATA: Previously reported anterior approaches to the cervicothoracic junction have described either full sternotomy resection of the left sternoclavicular junction or osteotomy of the clavicle. A simplified approach was chosen using a partial sternotomy, which has not been described previously for approaches to the spine. METHODS: Four patients with metastatic disease, in the region of the cervicothoracic junction, required decompression and stabilization for palliation of symptoms. An anterior approach was required for decompression. A standard cervical approach was combined with a partial median sternotomy and transverse osteotomy through the synostosis between the manubrium and body of the sternum. In three patients, the left innominate vein was divided. Decompression and anterior stabilization were followed by posterior stabilization at an interval of 4 to 7 days. RESULTS: This procedure was simple to perform, requiring little additional operative time for opening or closure. It provided excellent exposure from C3-T4. There was no associated morbidity related to the division of the manubrium or innominate vein. CONCLUSION: Partial sternotomy combined with a standard cervical incision provides excellent exposure to the cervicothoracic junction from C3-T4. It is technically simple to perform and avoids the risk of injury to subclavian vessels inherent in resection of the clavicle or sternoclavicular junction. There is no additional morbidity associated with this approach.

Cervical Vertebrae↗

PubMed1994

Gastrobronchial fistula: an unusual complication of esophagectomy.

Gastrobronchial fistula is an extremely rare condition. A case of gastrobronchial fistula secondary to a benign gastric ulcer 9 years after esophagectomy and gastric pull-up for treatment of esophageal carcinoma is described. A review of the literature is provided.

Aged↗

PubMed1990

Early and late results after isolated coronary artery bypass surgery in 159 patients aged 80 years and older.

We have studied 159 patients 80 years of age or older who have had isolated coronary artery bypass grafting (CABG) since 1977. Eighty-seven percent have had surgery since 1984. Two thirds of the patients were male, and the mean age was 82 years. Most patients (97%) were in New York Heart Association (NYHA) functional class III or IV, 89% had unstable/postinfarction angina pectoris, and 67% had rest pain. Almost half (47%) required preoperative admission to the coronary care unit, 6% required preoperative use of an intra-aortic balloon pump, and 20% were operated on emergently. Significant left main coronary artery disease (greater than or equal to 50% stenosis) was present in 41%. Ten patients (6.3%) died within 30 days of surgery, with seven more patients dying during the same hospital admission or soon after transfer to another institution. This resulted in an overall hospital mortality of 10.7%. The median hospital stay was 10 days. On univariate analysis, the significant predictors of hospital mortality were NYHA IV, angina at rest, preoperative admission to the coronary care unit, emergency operation, ejection fraction less than 0.50, and the presence of mitral regurgitation. On multivariate analysis, ejection fraction less than 0.50 was the only significant risk factor (p less than 0.01). Of hospital survivors, 98% have been followed for a mean of 29 months. The estimated 5-year survival (+/- SEM) of all patients was 71 +/- 4.5%, and for hospital survivors, 80 +/- 4.5%. The most important predictor of adverse survival was an ejection fraction less than 0.50. Seventy-nine percent are angina-free, and 89% are in NYHA classes I and II. The majority of patients felt that they were improved by surgery. We conclude that CABG in patients 80 years or older, although associated with increased operative risk, gives excellent relief of symptoms and good 5-year survival. Patients should not be denied CABG because of age alone.

Aged↗

PubMed1988

Prospective analysis of intraoperative and postoperative urinary cyclic adenosine 3',5'-monophosphate levels to predict outcome of patients undergoing reoperations for primary hyperparathyroidism.

Twenty-five consecutive patients with either persistent or recurrent symptomatic primary hyperparathyroidism after 36 prior operations were prospectively studied to compare the usefulness of intraoperative measurement of urinary cyclic adenosine monophosphate (UcAMP) levels with standard surgical procedures to predict outcome during tedious parathyroid reoperations. The criterion based on UcAMP to predict successful outcome was a 50% decline in intraoperative UcAMP levels from the median baseline level after removal of abnormal parathyroid tissue. Standard surgical criteria were resection of four abnormal glands for hyperplasia and resection of one abnormal gland and biopsy examination of one normal gland for adenoma. In 15 patients (60%) surgery was terminated on the basis of UcAMP criterion. In one patient elevated UcAMP levels never changed and correctly predicted unsuccessful surgery. In nine patients surgery was terminated on the basis of surgical criteria, and each of these patients had a successful outcome. Operative UcAMP levels dropped after the completion of the procedure in six of these latter nine patients. Three patients did not show a significant decrease in UcAMP levels despite successful surgery, and one patient displayed an early false-positive decrease in UcAMP level. The intraoperative UcAMP criterion accurately predicted outcome in 21 of 25 patients (84%). Sensitivity of the UcAMP criterion was 87% and specificity was 50%. The results indicate that by either method a reliable prediction of the outcome of reoperative parathyroid surgery may be made. Intraoperative determination of UcAMP levels will allow successful termination of the reoperation in some patients before operative identification of adequate parathyroid tissue necessary to confidently establish the pathologic diagnosis.

Cyclic AMP↗

PubMed1988

Multiorgan failure in critically ill patients.

Of 1136 patients admitted consecutively to two medical-surgical intensive care units, 100 were found to have multiorgan failure, defined as failure of more than two organ systems. The average duration of stay in the intensive care units was 13.4 days. The overall death rate was 78% compared with 12.8% for patients without multiorgan failure. The most common initiating illnesses or insults were sepsis, surgery, accidental trauma and cardiogenic shock. Of potential risk factors studied, shock, sepsis, surgery, pre-existing organ disease and age over 65 years were the most common. Although sepsis occurred before or during the course of multiorgan failure in 78 patients, in only 34 was sepsis judged to be the prime insult leading to multiorgan failure. Surgery during the course of multiorgan failure had neither an adverse nor beneficial effect on outcome. The mean number of organ systems failing was 4.36 for survivors and 5.03 for nonsurvivors. The most common systems to fail were central nervous, cardiovascular and respiratory.

Adolescent↗