Biomedical subjects
Publications and source records attributed to Robin S McLeod.
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INTRODUCTION: To describe the epidemiology of acute appendicitis in the Province of Ontario, we carried out a retrospective population-based cohort study of all patients with acute appendicitis. METHODS: Using hospital discharge abstracts of patients with acute appendicitis from all acute care hospitals in Ontario for the fiscal years 1991-1998 coded for the Canadian Institute for Health Information, we studied the demographic features, particularly age and sex, length of hospital stay (LOS), incidence, and seasonal variation of acute appendicitis. RESULTS: During the observation period, 65,675 cases of acute appendicitis occurred in Ontario. Of these, 58% of the patients were male and 35.5% had perforation. The mean (and standard deviation [SD]) LOS for patients with perforation was 6.2 (5.3) days versus 3 (1.8) days for patients with no perforation (p < 0.001). The age-specific incidence of acute appendicitis followed a similar pattern for males and females, but males had higher rates in all age groups. The incidence was highest in those aged 10-19 years. The annual age and sex-adjusted incidence of acute appendicitis was 75 per 100,000 population. The female:male age-adjusted rate ratio was 1:1.4. During the study period, the rate of acute appendicitis decreased by 5.1%, but the rate of appendicitis with perforation increased by 13%. A significant seasonal effect was also observed, with the rate of acute appendicitis being higher in the summer months. CONCLUSIONS: Appendicitis is more common in males, in those aged 10-19 years, and during the summer months. The frequency of acute appendicitis appears to be decreasing whereas the proportion of cases with perforation appears to be increasing. This may reflect a change in the population structure in Ontario and restrictions placed on the patient access to the health care system.
PURPOSE: Salvage procedures for failed ileal pouch-anal anastomoses frequently require total reconstruction with a combined abdominal and perineal approach. The aim of this study was to determine the indications for surgery and the outcomes in this group of patients. METHODS: All patients who underwent combined abdominal and perineal ileal pouch-anal anastomosis reconstruction at the Mount Sinai Hospital between 1982 and 2000 were reviewed. Data were collected prospectively in the inflammatory bowel disease database. RESULTS: Sixty-three reconstructive procedures were performed in 57 patients, with a mean age of 33.9 (+/-10.4) years at the time of reconstruction. There were 14 males. The mean follow-up was 69.1 months. The initial indication for ileal pouch-anal anastomosis was ulcerative colitis in 98 percent. The primary indication for reconstruction was pouch-vaginal fistula in 21 patients, long outlet in 14, pelvic sepsis in 14, ileoanal anastomotic stricture in 5, pouch-perineal fistula in 2, and chronic pouchitis in 1. The mean operative time was four hours (+/-1.1), the average blood loss was 500 mL (+/-400), and the average length of stay was 10.3 days (+/-4.6). All patients had a diverting ileostomy. Forty-two (73.6 percent) of the patients have a functioning pouch. Seven (12.3 percent) patients have had their pouch excised. The ileostomy has not yet been closed in 8 (14 percent) patients; 3 of these patients are awaiting closure, whereas the remaining 5 have a permanently defunctioning ileostomy. Eighty-nine percent have ten or fewer bowel movements per day. No patients are incontinent of stool during the day, whereas two patients are incontinent at night. Seventeen percent complain of frequent urgency. Despite this, more than 80 percent rate their physical and psychological health as good to excellent. CONCLUSION: Reconstructive pouch surgery has a high success rate in experienced hands. The functional results in those whose pouch is in use are good.
OBJECTIVE: To determine the incidence of small bowel obstruction (SBO), to identify risk factors for its development, and to determine the most common sites of adhesions causing SBO in patients undergoing ileal pouch-anal anastomosis (IPAA). METHODS: All patients undergoing IPAA at Mount Sinai Hospital were included. Data were obtained from the institution's database, patient charts, and a mailed questionnaire. SBO was based on clinical, radiologic, and surgical findings. Early SBO was defined as a hospital stay greater than 10 or 14 days because of delayed bowel function, or need for reoperation or readmission for SBO within 30 days. All patients readmitted after 30 days with a discharge diagnosis of SBO were considered to have late SBO. RESULTS: Between 1981 and 1999, 1,178 patients underwent IPAA (664 men, 514 women; mean age 40.7 years). A total of 351 episodes of SBO were documented in 272 (23%) patients during a mean follow-up of 8.7 years (mean 1.29 episodes/patient). Fifty-four patients had more than one SBO. One hundred fifty-four (44%) of the SBOs occurred in the first 30 days; 197 (56%) were late SBOs. The cumulative risk of SBO was 8.7% at 30 days, 18.1% at 1 year, 26.7% at 5 years, and 31.4% at 10 years. The need for surgery for SBO was 0.8% at 30 days, 2.7% at 1 year, 6.7% at 5 years, and 7.5% at 10 years. In patients requiring laparotomy, the obstruction was most commonly due to pelvic adhesions (32%), followed by adhesions at the ileostomy closure site (21%). A multivariate analysis showed that when only late SBOs were considered, performance of a diverting ileostomy and pouch reconstruction both led to a significantly higher risk of SBO. CONCLUSIONS: The risk of SBO after IPAA is high, although most do not require surgical intervention. Thus, strategies that reduce the risk of adhesions are warranted in this group of patients to improve patient outcome and decrease healthcare costs.
OBJECTIVES: To determine the overall direct cost of liver transplantation in Canadian adults and to identify the factors that are associated with high cost. METHODS: The direct cost of liver transplantation from the perspective of third-party payers was determined in a retrospective analysis of data from hospital charts and databases. A consecutive series of 119 adults who underwent liver transplantation between 1991 and 1992 was followed from the date of listing for transplantation to the second anniversary of the transplant. Patient-specific services during the pre-transplantation, transplantation and post-transplantation phases were compiled and costed. The primary consideration was the impact of complications on the cost of transplantation. Secondary considerations were the impact of age, sex of the patient, diagnosis and severity of liver disease on the total cost. RESULTS: The overall mean measured cost of liver transplantation was Can$89,066 (range from Can$30,505-Can$690,431). The multivariate logistic regression model for overall costs revealed that severe liver disease (OR = 11.97), cytomegalovirus infection (OR = 6.12), additional operative procedure (OR = 4.22) and biliary complications (OR = 5.00) were associated with an increased likelihood of high cost. The addition of services that were not measured in the present analysis increased the total overall cost to a mean of $121,732 (1998 Canadian dollars, follow-up costs discounted and inflation adjusted). INTERPRETATION: The factors that were associated with high cost of liver transplantation in Canadian adults were advanced liver disease, postoperative cytomegalovirus infection, the requirement for additional operative procedures and biliary complications.
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This paper examines the safety and feasibility of providing short-term, in-home total parenteral nutrition (TPN) for patients with inflammatory bowel disease (IBD) for whom the alternative is prolonged hospitalization or early surgery. The records of all patients with IBD who were receiving temporary home TPN between June 1996 and July 2000 were reviewed. A quality-of-life phone interview was conducted at the time of review. Fifteen patients (11 men and 4 women) were identified whose average age was 35 years. The underlying diagnosis was Crohn's disease in 10 and ulcerative colitis in five. The indications for home TPN were complex internal fistulas and resolving sepsis in two, postoperative septic complications (anastomotic leak/enterocutaneous fistula) in five, high-output proximal stomas in four, prolonged ileus/partial obstruction in three, and spontaneous enterocutaneous fistula in one. The average duration of home TPN was 75 days (range 7 to 240 days). Two patients (13%) failed home TPN (1 with uncontrolled sepsis; 1 with dehydration) and were readmitted to the hospital. Home TPN was discontinued in one patient whose enterocutaneous fistula failed to heal with nonoperative treatment. Home TPN was successful in 12 patients (80%): eight (53%) who underwent planned definitive surgery and four (27%) whose conditions resolved without surgery. Complications of home TPN were line sepsis and pulmonary aspergillosis in one patient. All patients preferred home TPN to further hospitalization and reported good or excellent quality of life at home. Home TPN is a safe alternative to prolonged hospitalization or early surgery in patients with complicated IBD.
The purpose of this study was to determine the reliability and validity of the Body Image After Breast Cancer Questionnaire (BIBCQ) in a series of outpatients with breast cancer. One hundred sixty-four breast cancer patients attending outpatient clinics completed questionnaires at baseline. The patients' BIBCQ scores were compared with their scores on related psychological measures including depression, self-esteem, quality of life, and sexual functioning. Scores on the BIBCQ for women after mastectomy and breast conservation were compared. Select items of the BIBCQ were compared between women with and without breast cancer. Patients received a second questionnaire after a 2 week interval to assess test-retest reliability. Good reliability was found for the six scales (ranging from 0.77 to 0.87). The BIBCQ correlated with similar measures as predicted, but not with a measure of social desirability. The BIBCQ distinguished between women treated with lumpectomy and mastectomy, and between women with breast cancer and a control group, supporting the validity of the BIBCQ. The BIBCQ provides a reliable and valid assessment of the long-term impact of breast cancer on body image. It is suitable for use in research focusing on this issue.