Fractal and complexity measures of heart rate dynamics after acute myocardial infarction.
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Electrocardiography, Ambulatory↗
Biomedical subjects
S Dubner
Publications and source records attributed to S Dubner.
Re-operation for bleeding after thyroidectomy and parathyroidectomy.
BACKGROUND: This study was undertaken to determine the frequency and timing of re-operation for bleeding following thyroidectomy (THY) and parathyroidectomy (PARA) as well as the implications of this concerning the safety of ambulatory surgery. METHODS: Patients requiring re-operation after THY and PARA were identified from a computerized database of patients undergoing surgery between 3/l/95 and 12/31/99. The medical records of these patients were reviewed in detail. RESULTS: Six of 918 THY (0.7%) and 4 of 350 PARA (1.1%) required re-operation for bleeding. In two cases the wounds were opened emergently at the bedside due to worsening airway obstruction. One patient required an emergency tracheostomy. There were no deaths. Excluding one patient who bled five days post-operatively, the time interval from the completion of surgery to the identification of postoperative hematoma ranged from 2 to 48 hours, the median being 16 hours. CONCLUSIONS: Postoperative bleeding is an uncommon but unavoidable complication of THY and PARA. If treated promptly, serious consequences can be avoided. The relatively long interval between the initial operation and the development of the hematoma needs to be considered when recommending the performance of these procedures on an ambulatory basis.
Hemorrhage↗
The incidence of carcinoma in cytologically benign thyroid cysts.
BACKGROUND: The management of cytologically benign thyroid cysts is controversial. Treatment options include observation, chemical sclerosis, and surgery. This study was undertaken to determine the incidence of carcinoma in cytologically benign thyroid cysts that recur after complete aspiration and to determine the indications for surgery in these patients. METHODS: The medical records of 1189 consecutive patients undergoing thyroid surgery between July 1995 and November 2000 were reviewed. In 34 patients the indication for surgery was a thyroid cyst with benign cytologic findings that refilled at least once after complete aspiration. These patients were selected for further study. RESULTS: The 26 women and 8 men had a median age of 42 years. Fine-needle aspiration cytology was consistent with a benign cyst in all these cases. Final pathologic findings revealed the nodule to be a papillary carcinoma in 4 patients (12%). In another 4 patients (12%) an incidental microscopic papillary carcinoma, separate from the cyst, was identified on final pathologic findings. In all 4 patients with papillary carcinoma the cyst size was greater than 3 cm (range, 3.4 to 5.0 cm). CONCLUSIONS: The incidence of malignancy in cytologically benign thyroid cysts that recur after aspiration is high enough to warrant surgical excision, especially if the cyst is greater than 3 cm in size.
Adult↗
Nonsustained ventricular tachycardia in severe heart failure. Independent marker of increased mortality due to sudden death. GESICA-GEMA Investigators.
BACKGROUND: The goal of the study was to determine the prognostic value of nonsustained ventricular tachycardia (NSVT) in total mortality in severe congestive heart failure (CHF) and in death modes. NSVT is associated with an increased mortality in CHF. However, the predictive value of NSVT as a marker for sudden death or death due to progressive heart failure has not been determined. METHODS AND RESULTS: Five hundred sixteen patients from the GESICA trial (33.4% with NSVT) were initially studied with the results of 24-hour Holter and 2 years of follow-up. Within 2 years, 87 of 173 patients (50.3%) with NSVT and 106 of 343 patients (30.9%) without NSVT died. Relative risk (RR) was 1.69 (95% confidence interval [CI], 1.27 to 2.24; P < .0002), and Cox proportional hazard analysis was 1.62 (95% CI, 1.22 to 2.16; P < .001). Sudden death increased from 8.7% (30 of 343) to 23.7% (41 of 173) in patients with NSVT (RR, 2.77; 95% CI, 1.78 to 4.44; P < .001). Progressive heart failure death was also increased from 17.5% (60 of 343) to 20.8% (36 of 173) (P = .22). Quantitative analysis of 24-hour Holter (first 295 patients) demonstrated that couplets had a similar RR to that of NSVT for both total mortality (RR, 1.81; 95% CI, 1.22 to 2.66; P < .002) and sudden death (RR, 3.37; 95% CI, 1.57 to 7.25; P < .0005). Couplets and/or NSVT (ventricular repetitive beats) were even more predictive for sudden death (RR, 10.1; 95% CI, 1.91 to 52.7; P < .01). CONCLUSIONS: In patients with CHF, NSVT is an independent marker for increased overall mortality rate and sudden death. The absence of NSVT and ventricular repetitive beats in a 24-hour Holter indicates a low probability of sudden death.
Amiodarone↗
Long-term evaluation of patients undergoing immediate mandibular reconstruction.
BACKGROUND: Immediate reconstruction following segmental mandibulectomy is an accepted surgical technique. The benefits and patient selection criteria need to be established. PATIENTS AND METHODS: Forty-seven patients who underwent immediate reconstruction of the mandible were followed for up to 14 years. Survival, complication rates, and functional results were analyzed. RESULTS: Median survival was 39 months and actuarial 5-year survival was 40%. Two patients died in the postoperative period, and 9 suffered major reconstruction-related complications. The majority of these complications were related to the use of reconstruction plates, and occurred when the mandibular defect included the arch or when the plates were covered by pectoralis flaps. Half of the patients interviewed were able to eat a regular diet. CONCLUSIONS: Mandibular reconstruction can be performed safely and expeditiously in nearly all patients undergoing segmental mandibulectomy. Functional results and long-term survival will be acceptable in many cases.
Actuarial Analysis↗
Prognostic factors for recurrence and survival in head and neck soft tissue sarcomas.
BACKGROUND: Soft tissue sarcomas of the head and neck represent uncommon malignant neoplasms. With the exception of orbital and parameningeal sites, the treatment of sarcomas in the head and neck has not been standardized. The authors used a prospectively collected database of adult soft tissue sarcomas to identify prognostic factors for local control and survival. METHODS: A prospectively collected database of adult soft tissue sarcoma from 1982 to 1989 was analyzed for the impact of prognostic factors on local control and survival. Factors examined included histologic type, tumor grade, size, and resection margins. RESULTS: The overall and disease free survival at 5 years was 71 and 60%, respectively. Local control was 70% at 5 years. On univariate analysis, grade and margin status were predictors for local control. Analysis based on the Cox proportional hazard model revealed that margin status was the only significant factor in predicting local control. Grade and margin status were significant prognostic indicators for survival both on univariate analysis and in the Cox proportional hazard model. CONCLUSION: Patients with head and neck sarcomas should undergo wide excision with the removal of all gross disease and the acquisition of negative, microscopic surgical margins. Patients with positive margins should receive adjuvant radiotherapy for local control. High grade lesions place patients at risk for local recurrence and distant dissemination. Investigational regimens designed to prevent metastatic disease should be performed.
Adolescent↗
Parathyroid localization: inability to predict multiple gland involvement.
Preoperative localization using various imaging techniques can accurately predict the location of solitary parathyroid adenomas in about 75% of patients. Its value has been questioned because of the high success rate of parathyroid exploration without localization. The ability of localization studies to differentiate preoperatively between patients with solitary adenomas and those with multiple gland disease would be valuable because bilateral exploration might be avoided in many cases. Ultrasonography, thallium-201/technetium-99m subtraction scintigraphy, and magnetic resonance imaging were used to evaluate 16 patients with primary hyperparathyroidism who were ultimately found at surgery to have multiple enlarged parathyroid glands. No single imaging technique was able to identify more than 53% of enlarged glands, and only four patients were accurately predicted preoperatively to have enlargement of multiple parathyroid glands. Existing imaging techniques cannot be relied on to predict multiple gland involvement preoperatively. Bilateral surgical exploration is mandatory in all patients with primary hyperparathyroidism.
Humans↗
Accuracy of frozen section in the evaluation of salivary tumors.
The records of 333 patients who underwent surgery were reviewed to document the accuracy of frozen section in the evaluation of salivary gland tumors. Frozen sections were obtained in 310 patients. The final pathologic diagnoses included 210 benign tumors and 45 malignancies. The sensitivity for the detection of malignancy was 69%, and the specificity was 96%. The specific accuracy to correctly identify the type of malignancy present was only 51%. In four patients, a false-positive diagnosis of malignancy was made. Frozen section was much more accurate in the evaluation of benign salivary tumors. Forty-three of 45 Warthin's tumors were correctly identified by frozen section. Two tumors thought to be Warthin's tumors on frozen section proved to be low-grade mucoepidermoid carcinomas. One tumor reported to be a benign mixed tumor was actually a malignant mixed tumor. In this series of patients, frozen section proved to be no more accurate in the evaluation of salivary tumors than what has been reported in the literature for fine-needle aspiration biopsy.
Adenolymphoma↗
Value of fine needle aspiration biopsy of salivary gland masses in clinical decision-making.
The accuracy of fine needle aspiration biopsy (FNAB) in the diagnosis of salivary tumors has been well established. This study was undertaken to determine the impact of FNAB on patient management. One hundred one patients underwent FNAB of major salivary gland masses. The physician's initial clinical impression was compared with the FNAB diagnosis and the final diagnosis in each case. Forty patients had solitary masses thought to be benign tumors other than Warthin's tumors. FNAB in 13 of these patients (33%) yielded a diagnosis permitting modification of the planned procedure. The diagnosis of Warthin's tumor was suspected clinically in 23 patients. In nine of these patients (39%), FNAB resulted in a different diagnosis. Of the 10 patients believed to have malignant tumors, using FNAB, 1 was found to have sialadenitis and 1 a lymphoma. Overall, FNAB resulted in a change in the clinical approach to 35% of the patients. We recommend the performance of FNAB in almost all patients with salivary masses.
Adenolymphoma↗
Reinnervated radial forearm free flaps in head and neck reconstruction.
The radial forearm flap has proved to be a reliable free flap for intraoral reconstruction after major head and neck ablative surgery for cancer. In contrast to the myocutaneous flap, it is thin and flexible, and as a result, it is better suited to conforming to the irregular surface which remains over an intact or restored mandible. A criticism of both techniques however, is that while the flap effectively fills the defect, it serves as an insensate reservoir in which food and saliva can collect. A modification of the reinnervated radial forearm free flap is presented, with discussion of its use in three patients, following extensive resection of the floor of the mouth and tongue.
Combined Modality Therapy↗
Patterns of regional lymph node metastases from cutaneous melanomas of the head and neck.
A consecutive series of 111 patients treated between 1964 and 1989 with primary cutaneous malignant melanoma of the head and neck and histologically proven regional metastases was reviewed to determine the patterns of nodal metastases. The primary sites were grouped in the following categories: face (34), anterior scalp (25), anterior neck (16), posterior scalp (15), ear (11), and posterior neck (10). All patients underwent radical neck dissection: 80 of the procedures were therapeutic and 31 elective. A total of 106 specimens were positive for metastases. Thirty-three of the 57 patients undergoing parotidectomy had positive results for metastases (14 of 20 in therapeutic parotidectomies and 19 of 37 in elective parotidectomies). Based on the incidence of involvement of the parotid gland and the patterns of lymph node metastases from levels I through V, three observations are made. Patients undergoing regional lymphadenectomy for primary melanomas on the ear, face, and anterior scalp should be considered for parotidectomy. The use of selective limited neck dissection for elective regional lymphadenectomy appears justified based on the location of the primary site. In patients undergoing therapeutic neck dissection, a complete neck dissection should be performed due to the unpredictable distribution of lymph node metastases to the cervical lymph nodes.
Female↗
Salvage of upper arm access grafts by extension to the infraclavicular axillary vein.
A technique has been described to salvage upper arm graft fistulas using expanded polytetrafluoroethylene grafts by subcutaneous extension to the infraclavicular axillary vein. The axillary vein is exposed through an infraclavicular incision near the lateral end of the clavicle by splitting the pectoralis major muscle and by dividing or retracting the pectoralis minor muscle medially. A new segment of polytetrafluoroethylene graft is anastomosed to the axillary vein, and then to the old graft segment. This technique was employed in six patients over a 12 month period, with a 24 month graft patency rate of 84 percent. The advantage over a new access graft is immediate hemodialysis through a puncture of the preserved arterial limb of the polytetrafluoroethylene graft.
Arteriovenous Shunt, Surgical↗
The accuracy of computed tomography in the diagnosis of retroperitoneal blood in the presence of abdominal aortic aneurysm.
The use of computed tomography (CT) in the management of patients who are hemodynamically stable with symptoms suggestive of ruptured abdominal aortic aneurysm and in hemodynamically unstable patients without palpable or known aortic aneurysms was analyzed in a retrospective study. One hundred forty-two CT scans were performed; 48 patients had abdominal aortic aneurysms and 35 had no evidence of rupture or retroperitoneal blood. Ten patients had CT scans that showed evidence of rupture, and three patients had CT scans that were thought to be indeterminate for rupture, probably inflammatory. Forty patients underwent laparotomy. Excluding the three patients with inflammatory aneurysms, the results of CT scanning were compared with the findings at laparotomy. The sensitivity of CT scanning for the diagnosis of retroperitoneal blood in the presence of abdominal aortic aneurysm was 77% and the specificity was 100%, with an overall accuracy of 92%. An algorithm for the management of the patient with symptoms suggestive of a ruptured aneurysm is presented.
Aged↗
An unusual presentation of lymphoma in a homosexual man.
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Acquired Immunodeficiency Syndrome↗
Antiarrhythmic effect of tiapamil in patients with acute myocardial infarction.
The efficacy of intravenously administered tiapamil in treating premature ventricular contractions (PVCs) in the acute phase of acute myocardial infarction was evaluated in 20 patients using 24-hour continuous ECG monitoring (Holter). All patients presented frequent and/or complex ventricular arrhythmias (Lown classification II-V). Tiapamil reduced the number of PVCs to a statistically highly significant degree (p less than 0.01), i.e. 82-85% in the 4th hour of treatment. The number of PVCs increased again after therapy was discontinued. Where supraventricular ectopic beats were present in addition to PVCs, tiapamil reduced them by 93% in the 3rd and 4th hours of treatment. These results suggest that tiapamil could be an effective antiarrhythmic agent in acute myocardial infarction.
Adult↗
Median mandibulotomy: a critical assessment.
Median mandibulotomy (mandibular "swing") has supplanted mandibular resection for access to oral and oropharyngeal tumors when there is intervening grossly normal tissue between the tumor and bone. It has also proved useful for exposure in selected patients with deep lobe parotid or parapharyngeal space tumors. We have reviewed our experience with 313 mandibulotomies performed between 1959 and 1988 with emphasis on indications, complications, and modifications in technique. Most of our mandibulotomy patients had an uncomplicated recovery, but osteotomy-related complications occurred in 20%. These complications were usually minor and no instances of nonunion were recorded. There was no apparent relationship to antecedent or postoperative radiotherapy. Dental splints were used only in selected patients (40%). The technique of osteotomy has been evolving in recent years. Paramedian, rather than median mandibulotomy, minimizes trauma to the genioglossus, geniohyoid, and digastric muscles. Miniplates offer a useful alternative to conventional wire fixation. Preoperative dental assessment has facilitated better occlusion postoperatively in dentulous patients.
Adult↗
Postoperative radioactive iodine evaluation of total thyroidectomy for thyroid carcinoma: reappraisal and therapeutic implications.
The records of 430 patients who underwent total thyroidectomy with radioactive iodine (RAI) uptake studies performed postoperatively were reviewed. Indications for the administration of an ablative dose of iodine 131 are given. The majority (85.4%) had no or low (less than 2%) evidence of focal uptake and therefore were not treated with ablative doses of iodine 131. RAI scanning is necessary postoperatively to determine the completeness of the surgical procedure and to detect residual or metastatic disease. Small foci of residual disease or occult distant metastases can be adequately treated with therapeutic doses of RAI. Nodal or distant metastases that become clinically evident following thyroidectomy are usually not successfully treated with RAI.
Adolescent↗