Biomedical subjects

R K Orr

Publications and source records attributed to R K Orr.

At least 19 recordsLinked to original sources

PubMed2001

Hormone replacement therapy after breast cancer: a systematic review and quantitative assessment of risk.

PURPOSE: Hormone replacement therapy (HRT) is typically withheld from women with breast cancer because of concern that it might increase the risk of recurrence. The purpose of this study was to quantify the risk of recurrent breast cancer associated with HRT among breast cancer survivors. METHODS: We performed a systematic literature review through May 1999, calculating the relative risk (RR) of breast cancer recurrence in each study by comparing the number of recurrences in the HRT group to those in the control group. In studies that did not contain a control group, we constructed one by estimating the expected number of recurrences based on data from the Early Breast Cancer Trialists' Collaborative Group, adjusting for nodal status and disease-free interval. RRs across all studies were combined using random-effects models. RESULTS: Of the 11 eligible studies, four had control groups and included 214 breast cancer survivors who began HRT after a mean disease-free interval of 52 months. Over a mean follow-up of 30 months, 17 of 214 HRT users experienced recurrence (4.2% per year), compared with 66 of 623 controls (5.4% per year). HRT did not seem to affect breast cancer recurrence risk (RR = 0.64, 95% confidence interval [CI], 0.36 to 1.15). Including all 11 studies in the analyses (669 HRT users), using estimated control groups for the seven uncontrolled trials, the combined RR was 0.82 (95% CI, 0.58 to 1.15). CONCLUSION: Although our analyses suggest that HRT has no significant effect on breast cancer recurrence, these findings were based on observational data subject to a variety of biases.

Adult↗

PubMed2001

Use of an artificial neural network to quantitate risk of malignancy for abnormal mammograms.

BACKGROUND: The purpose of this study was to develop a simplified method for standardized categorization of patients with abnormal mammograms by incorporating quantitative risk assessment. METHODS AND PATIENTS: A prospective collection of 1288 outpatient referrals to a surgeon for abnormal mammograms, 185 (14.4%) with malignancy, was studied. Artificial neural network (ANN) and logistic regression (LR) models were developed and compared with the surgeon's clinical impression. The first 490 patients were used as the training set for each model. The ANN and LR were tested on the remaining patients, who were divided into 2 consecutive groups. The main outcome measures were (1) the accuracy (receiver operating characteristic [ROC] curve analysis) of biopsy recommendations based on the surgeon's impression and created by the 2 models and (2) the percentage of cancers that were falsely categorized as benign by the surgeon or the 2 models. RESULTS: Despite the fact that the surgeon's clinical impression showed good discrimination (area under ROC = 0.86), 13 of 708 cases (1.8%) thought to be benign by the surgeon proved to be carcinomas. The neural network (but not the LR model) was statistically superior to the surgeon's impression (ANN: ROC = 0.89, P =.004; LR: ROC = 0.86). Additionally, the computerized models were able to quantitate risk. Those patients predicted to be "benign" by the network (n = 391) had only a 0.5% risk of intraductal carcinoma and no invasive carcinoma, whereas 47% of those patients in the highest risk quartile had cancer. Both computerized models predicted a need for biopsy in 11 of 13 of the lesions (85%) missed by the surgeon's impression. Each model missed only 2 cases of intraductal carcinoma in young women. CONCLUSIONS: Computerized risk stratification models, used in routine practice, may help surgeons with decision making. The use of either model helps quantitate risk, thereby facilitating discussions with patients, and may reduce the number of "missed" cancers.

Adolescent↗

PubMed2001

Institutional learning curve for sentinel node biopsy at a community teaching hospital.

Sentinel lymph node biopsy (SLB) is gaining popularity as an alternative to axillary lymph node dissection for breast cancer staging. Although publications have described the inherent learning curve few have analyzed actual performance in community hospitals. This study analyzes the institutional learning curve for SLB in a community teaching hospital without a formal sentinel node credentialing policy. We conducted an analysis of the initial 96 SLBs performed by 15 general surgeons over a 34-month period. The main outcomes were rate of identification of sentinel node and accuracy of SLB. Overall SLB was successful in identifying one or more sentinel nodes (mean = 2.2) in 73 per cent of attempted cases. There were marked differences in performance of individual surgeons; identification rates varied from 25 to 100 per cent. Only one surgeon performed more than 15 procedures during the study period. Nineteen of 21 cases with positive nodes were correctly characterized (sensitivity = 90.5%; 95% confidence interval = 76-100%; false negative rate = 9.5%). Our institutional learning curve was longer than high-volume individual experiences published in the literature, with a lower rate of sentinel node identification. SLB appears to be sensitive for detecting malignancy, but the small number of patients with positive nodes in our series limits our conclusions. The marked variability in individual surgeon performances and the slow rate of overall improvement in our institution suggest a need for a formalized policy for SLB training.

Breast Neoplasms↗

PubMed1999

Individualizing therapy to prevent long-term consequences of estrogen deficiency in postmenopausal women.

BACKGROUND: Alendronate sodium and raloxifene hydrochloride were recently approved for the prevention of postmenopausal osteoporosis, but data on their clinical efficacy are limited. We compared these drugs with hormone replacement therapy (HRT) to help women and physicians guide postmenopausal treatment decisions. OBJECTIVE: To help physicians understand how they can best help women choose the most beneficial therapy after menopause based on their individual risk profile. METHODS: We developed a decision analytic Markov model to compare the effects of alendronate therapy, raloxifene therapy, and HRT on risks of hip fracture, coronary heart disease (CHD), breast cancer, and life expectancy. Regression models linked individual risk factors to future disease risks and were modified by drug effects on bone density, lipid levels, and associated breast cancer effects. RESULTS: Hormone replacement therapy, alendronate therapy, and raloxifene therapy have similar predicted efficacies in preventing hip fractures (estimated relative risk, 0.57, 0.54, and 0.58, respectively). Hormone replacement therapy should be more than 10 times more effective than raloxifene therapy in preventing CHD, but raloxifene therapy may not induce breast cancer. Women at low risk for hip fracture, CHD, and breast cancer do not benefit significantly from any treatment. Among women at average risk, HRT was preferred unless raloxifene therapy could reduce the risk of breast cancer by at least 66%, compared with a 47% increase for HRT. Women at high risk for CHD benefit most from HRT; women at high risk for breast cancer but low risk for CHD benefit most from raloxifene therapy, but only if it lowers the risk of breast cancer. CONCLUSION: Because of significant differences in the impact of these drugs, treatment choice depends on an individual woman's risk for hip fracture, CHD, and breast cancer.

Alendronate↗

PubMed1999

The learning curve for sentinel node biopsy in breast cancer: practical considerations.

HYPOTHESIS: Performance of sentinel node biopsy (SNB) instead of full axillary lymph node dissection (ALND) by inexperienced surgeons will lead to understaging of some women with breast cancer and increased costs. DESIGN: A decision analysis model was used to investigate the implications of SNB vs. full ALND during the learning phase (60-80 procedures). This model simulates a randomized trial of 10000 women in each arm. Data regarding the learning curve were obtained from published series. MAIN OUTCOME MEASURES: Percentage of women with inaccurate staging of their breast cancer, overall survival, quality-adjusted survival, and potential costs of SNB vs ALND. RESULTS: Performance of SNB instead of ALND results in inability to locate a sentinel node in 38% of attempts during the learning phase (compared with 10% in later cases) and understaging in 12% of patients during the learning phase (compared with 0% in later cases). This understaging is associated with a small decrement in survival (1%-2%) and an increased risk of axillary recurrence. Sentinel node biopsy is cost-effective only when the ability to detect sentinel nodes exceeds 80%; and the cost of SNB is less than 50% of the cost of ALND. CONCLUSIONS: To ensure accurate staging of patients with breast cancer, all surgeons should perform full ALND while learning SNB techniques. Only after documentation of accuracy of SNB (sensitivity >90%) should full ALND be omitted for women with negative sentinel nodes.

Biopsy↗

PubMed1999

A cost-effectiveness analysis of axillary node dissection in postmenopausal women with estrogen receptor-positive breast cancer and clinically negative axillary nodes.

PURPOSE: The purpose of this study was to examine the cost-effectiveness of immediate axillary lymph node dissection (ALND) in estrogen receptor-positive women with clinically negative nodes. METHODS: We constructed a Markov model comparing hypothetical cohorts of postmenopausal women who were estrogen receptor positive with clinically negative axillae. The women underwent immediate ALND or watchful waiting, with ALND performed only for those patients developing palpable axillary nodes. Recurrence risks, chemotherapeutic benefits, and treatment costs were estimated from the published literature. The main outcome measures were quality-adjusted survival and incremental cost per quality-adjusted life-year (QALY). RESULTS: For 55-year-old women with palpable (3 cm) tumors, immediate ALND results in improved survival (10.3 versus 10.05 QALYs) and a cost-effectiveness ratio of $36,700 per QALY, if chemotherapy is given to those with histologically positive lymph nodes. The benefits of ALND are greatest for younger women with larger palpable tumors. Because of the lower risk of nodal metastases, patients with 1-cm nonpalpable tumors experience minimal benefit at markedly higher incremental costs ($308,000 per QALY). If chemotherapy will not be given to patients with histologically positive lymph nodes because of a patient's or a physician's wishes, then there is no benefit to immediate ALND in any patient subgroup. CONCLUSION: When the results of ALND are used to guide postoperative decisions, immediate ALND results in considerable benefit at a reasonable cost for most women with palpable tumors. Because the benefits are lower in patients with nonpalpable tumors, ALND should not be considered mandatory for that subgroup. Decisions for ALND should be based on patient age, tumor size and palpability, individual patient preferences, the likelihood of receiving postoperative chemotherapy, and other prognostic factors.

Age Factors↗

PubMed1998

Neoadjuvant chemoradiotherapy for esophageal cancer: is it worthwhile?

BACKGROUND: With promising results from several institutions, many centers began treating patients with esophageal cancer with neoadjuvant chemoradiotherapy (NC) followed by esophagectomy. This approach is demanding for the patient and has not been proved to be better than esophagectomy alone. OBJECTIVE: To assess survival time and measures of quality of life associated with NC. DESIGN: A retrospective review during 1990 to 1996. SETTING: The 3 tertiary academic hospitals affiliated with the University of Massachusetts Medical School, Worcester. PARTICIPANTS: All patients (N=51) with cancer of the middle or lower esophagus who were treated with NC followed by esophagectomy during this period. MAIN OUTCOME MEASURES: Median and 1-, 2-, and 3-year survival times; median preoperative treatment time (first office visit for surgical consultation before beginning NC to the date of surgery), median hospital stay, and postoperative swallowing function. RESULTS: The median survival time of all patients was 16.3 months; 1-, 2-, and 3-year overall survival rates were 67%, 46%, and 39%, respectively. The median hospital stay was 12 days. The median postoperative treatment time was 3.3 months, which was 20% of the median survival time. Of the 51 patients, 19 were alive with a median follow-up time of 2.5 years. Twenty-nine percent of the patients had a complete pathological response with median and 1-, 2-, and 3-year survival rates of 17.5 months, 73%, 57%, and 57%, respectively. Palliation of dysphagia was excellent, with 44 (93%) of 47 operative survivors taking either a soft diet (18 [38%]) or a regular (26 [55%]) diet by the first postoperative visit. CONCLUSIONS: Median survival time with NC followed by esophagectomy for resectable cancer of the esophagus does not appear to be significantly better than that reported for esophagectomy alone. Further, treatment time with NC consumed 20% of survival time. Examining only these outcome variables suggests that NC is not worth-while. However, examining a longer-term outcome survival variable, such as 3-year survival time, suggests that NC followed by esophagectomy may result in greater long-term survival than that reported for esophagectomy alone. We conclude that further randomized, controlled studies are necessary before NC followed by esophagectomy is considered superior to esophagectomy alone for the treatment of resectable esophageal cancer.

Adenocarcinoma↗

PubMed1998

Long-term economic evaluation of resectoscopic endometrial ablation versus hysterectomy for the treatment of menorrhagia.

STUDY OBJECTIVE: To assess long-term costs of resectoscopic endometrial ablation versus hysterectomy in women with menorrhagia. DESIGN: Controlled cohort study (Canadian Task Force classification II-2). SETTING: Multispeciality group practice. PATIENTS: Sixty-four women who underwent endometrial ablation during 1992-1994 and 46 women who underwent hysterectomy during 1990-1992. To attain comparable controls, patients with uterine size exceeding 14 weeks or uterine weight greater than 300 g, ovarian pathology, endometriosis, or neoplasia were excluded. INTERVENTIONS: Endometrial ablation and hysterectomy, followed by economic evaluation. MEASUREMENTS AND MAIN RESULTS: Direct costs were hospitalization charges, professional fees, preoperative depot leuprolide, and gynecologic care during 3 years after primary surgery. Indirect costs were calculated based on known demographic data, recovery time, and lost productivity. Surgical outcomes, complications, repeat surgeries, menstrual outcomes, and overall patient satisfaction were assessed. Operating time (38 vs 107 min), hospital stay (0.7 vs 2.7 days), frequency of postoperative complications (6.3% vs 21.7%), and recuperation time (5 vs 32 days) were less with endometrial ablation than with hysterectomy. Mean follow-up was 48.5 months (range 36-68 mo), with rates of amenorrhea, hypomenorrhea, and eumenorrhea of 49%, 29%, and 8%, respectively. One patient was lost to follow-up. There were eight failures (12%): repeat endometrial ablations (2 women), abdominal hysterectomy (1), and laparoscopic-assisted hysterectomy (5). Most women (85%) remained satisfied with the operation. Total direct costs/case for endometrial ablation were $5434 versus $8417 for hysterectomy; respective indirect costs/case were $525 and $3360. Conclusion. Long-term direct and indirect costs of endometrial ablation were significantly less than those of hysterectomy ($5959 vs $11,777) for the treatment of menorrhagia.

Adult↗

PubMed1997

Patient-specific decisions about hormone replacement therapy in postmenopausal women.

OBJECTIVE: To examine the effect of hormone replacement therapy on life expectancy in postmenopausal women with different risk profiles for heart disease, breast cancer, and hip fracture. DESIGN: Decision analysis using a Markov model. Published regression models were used to link risk factors to disease incidence and to estimate the lifetime risks of developing coronary heart disease (CHD), breast cancer, hip fracture, and endometrial cancer. The impact of hormone therapy on disease incidence was estimated from published epidemiologic studies. SETTING: Mathematical model applicable to primary care. INTERVENTIONS: Treatment with hormone replacement therapy or no hormone replacement therapy. MAIN OUTCOME MEASURE: Life expectancy. RESULTS: Hormone replacement therapy should increase life expectancy for nearly all postmenopausal women, with some gains exceeding 3 years, depending mainly on an individual's risk factors for CHD and breast cancer. For women with at least 1 risk factor for CHD, hormone therapy should extend life expectancy, even for women having first-degree relatives with breast cancer. Women without any risk factors for CHD or hip fracture, but who have 2 first-degree relatives with breast cancer, however, should not receive hormone therapy. CONCLUSIONS: The benefit of hormone replacement therapy in reducing the likelihood of developing CHD appears to outweigh the risk of breast cancer for nearly all women in whom this treatment might be considered. Our analysis supports the broader use of hormone replacement therapy.

Aged↗

PubMed1997

Gastrointestinal complications following cardiac surgery. An analysis of 1477 cardiac surgery patients.

OBJECTIVE: To determine preoperative and perioperative risk factors for gastrointestinal (GI) complications following cardiac surgery. DESIGN: A database including records of patients who underwent cardiac surgery was reviewed, with univariate analysis of several variables thought to be relevant to GI complications. Using a risk-adjusted model, preoperative stratification was used to fit a logistic regression model including operative features. SETTING AND PATIENTS: All patients undergoing cardiac surgery from January 1, 1991, to December 31, 1994, at a university-affiliated teaching hospital. MAIN OUTCOME MEASURES: Incidence of GI complications, postoperative mortality, length of hospital stay, and relative risk of GI complications based on multivariate analyses. RESULTS: Gastrointestinal complications occurred in 2.1% of patients and had an associated mortality of 19.4%; this was higher than the mortality in patients without GI complications (4.1%; P < .001). Length of hospital stay was significantly longer in patients with GI complications (43 vs 13.4 days; P < .001). In patients who underwent coronary artery bypass grafting only, cardiopulmonary bypass time was significantly longer in patients with GI complications (166 vs 138 minutes; P = .004). In patients who underwent valve replacement, bypass time was not associated with GI complications. Use of a left internal mammary artery graft was associated with a lower incidence of GI complications. CONCLUSIONS: Patients who have GI complications after cardiac surgery have a higher mortality and a longer hospital stay. The use of a left internal mammary artery seems to have a protective effect against GI complications. Based on these observations, patients may be stratified into low-, medium-, and high-risk groups.

Aged↗

PubMed1997

Staging endometrioid adenocarcinoma. Clinical and financial comparison of laparoscopic and traditional approaches.

OBJECTIVE: To compare laparoscopically assisted surgical staging (LASS) of endometrioid adenocarcinoma with traditional surgical staging by laparotomy. STUDY DESIGN: A retrospective review of all cases of uterine cancer (n = 108) insured by one health maintenance organization during 1990-1995. During this period, 29 patients underwent successful LASS and were compared to 64 who underwent laparotomy for treatment of surgical stage I endometrioid adenocarcinoma. RESULTS: LASS was performed successfully in 29 of 32 attempted cases. All patients on whom LASS was attempted were found to have surgical stage I. Laparoscopic pelvic lymphadenectomy was highly successful, with no failures and a mean number of 14 nodes obtained. The overall complication rate was significantly higher for laparotomy than for LASS (28% vs. 7%, P < .001). The average length of stay for laparotomy was significantly higher than for LASS (5.1 vs. 2.3 days, P < .001). CONCLUSION: LASS for stage I endometrioid adenocarcinoma is an attractive alternative to traditional surgical staging. It causes fewer complications and shortens the hospital stay.

Adenocarcinoma↗

PubMed1997

Treating adnexal masses. Operative laparoscopy vs. laparotomy.

OBJECTIVE: To compare operative laparoscopy vs. laparotomy for the treatment of adnexal masses. STUDY DESIGN: A retrospective review of all surgical cases who underwent operative laparoscopy or laparotomy for an adnexal mass during 1988-1995 at one multispecialty group practice. Preoperative screening for women over 45 included a CA-125 and ultrasound. If a malignant mass was encountered, it was immediately staged by laparotomy with the assistance of a surgical oncologist. During the study period 121 patients underwent ovarian cystectomy and 284 patients, oophorectomy. RESULTS: Laparoscopy was successfully completed in 118 of 127 (93%) oophorectomy and 71 of 72 (98%) of ovarian cystectomy patients. The incidence of malignant lesions at operative laparoscopy was 2%. The hospital stay for ovarian cystectomy was significantly shorter for laparoscopy (0.8 vs. 3.1 days). Hospital stay for oophorectomy was significantly shorter for laparoscopy (0.8 vs. 4.1 days). Ovarian cystectomy by laparotomy resulted in slightly more total complications than did laparoscopy (8% vs. 1%). Oophorectomy by laparotomy resulted in significantly more total complications than did oophorectomy by laparoscopy (29% vs. 3%). The mean total charge for laparoscopic oophorectomy was $5,873 versus $7,007 for laparotomy. The mean total charge for laparoscopic ovarian cystectomy was $4,507 vs. $5,541 for laparotomy. CONCLUSION: Treatment of adnexal masses by operative laparoscopy can be performed safely, with reduced morbidity and patient disability, and at a reduced cost. By having an oncologist backup in house, we have been able to convert most procedures to the laparoscopic approach.

Adnexal Diseases↗

PubMed1996

Outcomes and resource utilization in a managed care setting for lower extremity vein bypass grafts.

BACKGROUND: This 17-year review was undertaken to examine clinical outcomes and the changing trends in resource utilization for lower extremity bypass grafts performed in a managed care setting. PATIENTS AND METHODS: Between 1979 and 1995, 338 bypasses in 276 patients (199 men, 77 women; 62% diabetics) were carried out for limb salvage. Autogenous vein bypasses (AVB) were performed in 324 (96%) of the cases, which included 150 (43%) femoropopliteal (FP) and 174 (57%) femoro-tibial (FT) bypasses. There were 32 secondary AVB reconstructions included in the study group. RESULTS: The 30-day mortality rate was 2.2% and patient survival was 46% and 21% at 5 and 10 years. At 1 and 5 years, primary patency rates for the AVB were 87% and 79% for FP; 80% and 67% for FT AVB, whereas the limb salvage rates at those intervals were 96% and 94% for FP; 87% and 77% for FT, respectively. Despite an average annual inflation rate of 8%, significant reductions in hospital charges were noted during the study period. These were made possible by decreasing lengths of hospital stay, the development and application of guidelines and protocols for the management of leg ischemia, and the implementation of angioscopy for improving the surgical technique for in situ AVB. CONCLUSIONS: High-quality outcomes for lower extremity AVB are possible in a managed care setting with demonstrated improvements in the efficiency of resource utilization.

Aged↗

PubMed1995

A comparison of four severity-adjusted models to predict mortality after coronary artery bypass graft surgery.

OBJECTIVE: To assess the validity of four severity-adjusted models to predict mortality following coronary artery bypass graft surgery by using an independent surgical database. DESIGN: A prospective observational study wherein predicted mortality for each patient was obtained by using four different published severity-adjusted models. SETTING: A university-affiliated teaching community hospital. PATIENTS: Eight hundred sixty-eight consecutive patients who underwent coronary artery bypass graft surgery without accompanying valve or aneurysm repair during the period from 1991 to 1993. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Predicted mortality rates for each model were obtained by averaging individual patient predictions and were compared with actual morality rates. We assessed the accuracy of overall prediction for the total series, as well as compared individual patient predictions created by each model. The discrimination of models was assessed with receiver operating characteristic curves and the Hosmer-Lemeshow goodness-of-fit statistic. RESULTS: The observed crude mortality rate was 3.7%. The predicted mortality rate ranged from 2.8% to 9.2%, despite relatively good discrimination by the models (area under the receiver operating characteristic curve, 0.70 to 0.74). The individual patient mortality predicted by different models varied by as much as a ninefold difference. CONCLUSIONS: The currently used coronary artery bypass graft predictive models, although generally accurate, have significant shortcomings and should be used with caution. The predicted mortality rate following coronary artery bypass graft surgery varied by a factor of 3.3 from lowest to highest, making the choice of model a critical factor when assessing outcome. The use of these models for individual patient risk estimations is risky because of the marked discrepancies in individual predictions created by each model.

Aged↗

PubMed1995

Parity is associated with axillary nodal involvement in operable breast cancer.

INTRODUCTION: Although multiparous women have a decreased incidence of breast cancer, several series have observed that multiparous women have a higher risk of axillary nodal metastases and diminished survival. METHODS: To study this hypothesis in greater detail, this study analyzed data from 223 consecutive women with clinically operable (T1-3, N0-1, M0) breast cancer, all of whom had undergone axillary node dissection (AND) by one surgeon (83 mastectomy/AND, 140 lumpectomy/AND). The number of pregnancies and other hormonally related factors were recorded. Results were compared to pathologic data (node status, tumor size, estrogen and progesterone receptors). RESULTS: Seventy-eight patients (35.0%) had positive axillary nodes. Increasing parity was associated with an increased likelihood of positive nodes (Odds ratio 1.22 (95% CI: 1.04-1.42), p = 0.012) as was increasing tumor size (Odds ratio 1.31 (1.07-1.59), p = 0.007). The effect of parity was independent of tumor size, age, or hormone receptors. CONCLUSIONS: In this series, which includes only operatively staged patients, increasing parity is associated with nodal positivity. This effect is of a magnitude similar to that of increasing tumor size, and confirms observations from other studies. Information regarding parity may be useful for prognostic purposes, as well as providing insights into basic breast cancer biology.

Adult↗

PubMed1995

Ultrasonography to evaluate adults for appendicitis: decision making based on meta-analysis and probabilistic reasoning.

OBJECTIVES: To review ultrasonography (US) test performance and to develop recommendations for the use of US to aid in the evaluation of potential appendicitis. METHODS: A meta-analysis was conducted using all English-language articles published since 1986 (17 studies; 3,358 patients) to ascertain sensitivity and specificity of US for diagnosing appendicitis in adults and teenagers. Calculation of the predictive value of US was performed for three groups of patients: group I--usually operated on (prevalence of appendicitis = 80%); group II--usually observed in hospital (prevalence = 40%); and group III--usually released home (prevalence 2%). RESULTS: Overall sensitivity was 84.7% (95% CI: 81.0-87.8%), and specificity 92.1% (88.0-95.2). The accuracy and usefulness of US were related to the likelihood of appendicitis. In group I, a positive test was accurate [positive predictive value (PPV) = 97.6%], but a negative study could not rule out appendicitis [negative predictive value (NPV) = 59.5%]. The converse was true for group III patients (PPV = 19.5%, NPV = 99.7%). Test performance accuracy was balanced only for group II patients (PPV = 87.3%, NPV = 89.9%). CONCLUSIONS: 1) US should not be used to exclude appendicitis for patients who have "classic" signs/symptoms, due to the underlying high false-negative rate. 2) US is most useful for patients who have an indeterminate probability of disease after the initial evaluation--if US is positive, the patient should have an operation; otherwise, he or she should be observed. 3) US is not recommended for screening patients who have a low probability of appendicitis, due to the low prevalence of disease and high false-positive rate in this group.

Adult↗

PubMed1987

Early discharge after mastectomy. A safe way of diminishing hospital costs.

In order to assess the risks and benefits of early discharge after major breast surgery, the authors analyzed 73 consecutive private patients who underwent operations by four surgeons over a 1-year period. Patient's ages ranged from 34 to 84 years, with a mean of 56.2 years. One patient was excluded from analysis because thoracotomy with a pulmonary resection was performed during the same hospitalization. Thirty-seven patients underwent total mastectomy with complete axillary dissection, 30 underwent segmental mastectomy with complete axillary dissection, and five underwent total mastectomy alone. For each patient the chest wall and axilla were drained by means of one or two Jackson-Pratt (American Heyer Schulte Corp., Goleta, CA) closed suction drains. Prior to discharge, all patients were instructed in the proper technique of drain care and were directed to record the daily drainage. Patients were discharged when they were fully mobile, did not require injectable narcotics, and felt capable of taking care of the drains as outpatients. The length of postoperative stay ranged from 1 to 9 days (mean 2.9), with all but three patients being discharged by the fifth postoperative day. Patient acceptance of early discharge with drains was excellent. Drains were pulled on an outpatient basis, usually within 7 to 10 days after surgery. Complications were observed in twelve patients (18%), consisting of seromas (8 patients), cellulitis (2 patients), and minimal superficial skin necrosis (2 patients). All complications were managed easily on an outpatient basis. We conclude that early discharge with Jackson-Pratt drains remaining in place is safe, well tolerated by patients, and has tremendous potential for substantial cost savings.

Adult↗

PubMed1984

Gastric pseudolymphoma. A challenging clinical problem.

Gastric pseudolymphoma is a benign inflammatory condition that is usually associated with chronic gastric ulcer and often mimics gastric carcinoma or malignant lymphoma. Our experience with 12 histologically documented gastric pseudolymphomas at the Medical College of Virginia is presented with an emphasis on the approach to both diagnosis and surgical management. Preoperative diagnoses in this series ranged from benign gastric ulcer to gastric cancer. Treatment was by gastric resection in all cases and it included, as a minimum, antrectomy and excision of the lesion with an adequate gross margin. Of 11 cases with adequate follow-up, there are eight asymptomatic patients without recurrence and one patient who died of other causes without recurrence 5 years after gastrectomy. One patient developed recurrent pseudolymphoma in the proximal gastric remnant 39 months after a distal subtotal gastrectomy for pseudolymphoma. Another patient subsequently developed Hodgkin's disease of the gastric remnant, with regional lymph node and liver involvement, and died 35 months after the earlier subtotal gastrectomy for pseudolymphoma. Our clinical experience with this confusing and uncommon entity is compared with that previously reported in the medical literature.

Adolescent↗