The role of occipital artery resection in the surgical treatment of occipital migraine headaches
BACKGROUND:This study was designed to compare the success of occipital migraine headache surgery with and without occipital artery ligation. METHODS:The medical charts of 170 occipital migraine headache surgery recipients who fulfilled the study criteria were reviewed. Patients were divided into either the occipital artery resection group (one or both occipital arteries or its branches resected) or the control group (occipital arteries untouched). Preoperative and 12-month or more postoperative migraine frequency, duration, and intensity were analyzed. RESULTS:Fifty-five of the 170 patients met the inclusion criteria for the resection group; the remaining 115 were included in the control group. Of the 55 occipital artery resection patients, 44 (80.0 percent) had successful outcomes (â‰¥ 50 percent reduction in occipital migraine headaches), with 21 (38.2 percent) experiencing elimination of migraines. Of the 115 control patients, 105 (91.3 percent) experienced success, with 74 (64.3 percent) experiencing elimination of occipital migraine headache. The control group had significantly higher success (p = 0.047) and elimination rates (p = 0.002) compared with the resection group. The control group had significantly greater mean reduction in migraine duration compared with the resection group (p = 0.008). CONCLUSIONS:Occipital artery resection significantly lowered the success of occipital migraine headache surgery. Greater occipital nerve decompression alone, without ligation of the occipital artery, significantly improved or eliminated occipital migraine headache in most patients. This suggests that routine removal of the occipital artery or its branches may not be necessary.
Small bowel obstruction after hysterectomy to treat benign disease
STUDY OBJECTIVE/OBJECTIVE:To estimate the incidence of small bowel obstruction (SBO) after hysterectomy performed because of benign indications and to compare the incidence of SBO after laparoscopic, vaginal, and abdominal hysterectomy. DESIGN/METHODS:Single-center retrospective analysis of all hysterectomies performed to treat benign disease over 9 years (Canadian Task Force classification II-2). SETTING/METHODS:University-affiliated tertiary medical center. PATIENTS/METHODS:The study included 3229 women who underwent hysterectomy performed because of benign indications. INTERVENTIONS/METHODS:International Classification of Diseases, 9th revision, codes were applied to eligible patients' medical records to identify those who potentially had an SBO. Again, the electronic medical record was reviewed to confirm the occurrence of SBO. The Fisher exact test was used to evaluate the relationship between SBO and categorical variables, and the Wilcoxon rank sum test was performed to evaluate the relationship between SBO and continuous variables. MEASUREMENTS AND MAIN RESULTS/RESULTS:During the 9-year study, 3229 women with benign disease underwent hysterectomy: 38.3% abdominal, 39.3% vaginal, and 22.3% laparoscopic. Seventeen of 3229 women (0.53%; 95% confidence interval, 0.32-0.86) who underwent hysterectomy were identified as having an SBO. Among hysterectomy types, the incidence of SBO was not statistically significant for abdominal hysterectomy (9 of 17), vaginal hysterectomy (5 of 17), or laparoscopic hysterectomy (3 of 17) (p = .58). There were no differences in demographic data between patients with and without SBO. Incidence rates for SBO were calculated on the basis of hysterectomy route. CONCLUSION/CONCLUSIONS:The incidence of SBO after hysterectomy performed because of benign indications is low. The hysterectomy route does not seem to affect risk of SBO.
Utility of preoperative cardiac evaluation in pediatric patients undergoing surgery for obstructive sleep apnea
OBJECTIVES/OBJECTIVE:To identify the prevalence of clinically relevant findings during cardiac evaluations of pediatric patients with obstructive sleep apnea (OSA) undergoing adenotonsillectomy (TA), and to determine the association between cardiac findings and postoperative respiratory complications. DESIGN/METHODS:Retrospective medical chart review. PATIENTS/METHODS:Pediatric patients aged 10 months to 15 years who underwent both echocardiography and polysomnography (PSG) within 6 months prior to TA for OSA from April 2007 through April 2011. MAIN OUTCOME MEASURES/METHODS:Two pediatric cardiologists independently reviewed echocardiographic studies for evidence of cardiovascular disease. Patients were stratified based on apnea-hypopnea index (AHI) severity (1-5, >5-10, and >10). These groups were compared according to demographic, electrocardiographic (ECG), and echocardiographic values, and postoperative respiratory complications. RESULTS:The medical charts of 57 of 900 patients identified were reviewed following exclusion of those with congenital cardiac abnormalities. The AHI groupings did not differ demographically. No clinically relevant abnormalities were identified on the echocardiogram of any patient. There was a statistically significant association between increased AHI and the appearance of postoperative respiratory complications (PÂ <Â .05). Indicators of myocardial hypertrophy, such as left ventricular mass index, were not significantly related to AHI in contrast to previously published studies. No echocardiographic or ECG findings were identified that were associated with increased number of postoperative respiratory complications or OSA severity based on AHI. CONCLUSIONS:The lack of clinically relevant findings during preoperative cardiac evaluations suggests that aggressive cardiac workup in pediatric patients with OSA may not be indicated unless dictated by comorbidities. Consistent with results in prior studies, preoperative AHI can identify patients at risk for respiratory complications following TA.
Reanalysis of a randomized trial of 3 techniques of anterior colporrhaphy using clinically relevant definitions of success
OBJECTIVE:The purpose of this study was to reanalyze the results of a previously published trial that compared 3 methods of anterior colporrhaphy according to the clinically relevant definitions of success. STUDY DESIGN/METHODS:A secondary analysis of a trial of 114 subjects who underwent surgery for anterior pelvic organ prolapse who were assigned randomly to standard anterior colporrhaphy, ultralateral colporrhaphy, or anterior colporrhaphy plus polyglactin 910 mesh from 1996-1999. For the current analysis, success was defined as (1) no prolapse beyond the hymen, (2) the absence of prolapse symptoms (visual analog scale â‰¤ 2), and (3) the absence of retreatment. RESULTS:Eighty-eight percent of the women met our definition of success at 1 year. One subject (1%) underwent surgery for recurrence 29 months after surgery. No differences among the 3 groups were noted for any outcomes. CONCLUSION/CONCLUSIONS:Reanalysis of a trial of 3 methods of anterior colporrhaphy revealed considerably better success with the use of clinically relevant outcome criteria compared with strict anatomic criteria.
Drug-induced hematologic syndromes
Objective. Drugs can induce almost the entire spectrum of hematologic disorders, affecting white cells, red cells, platelets, and the coagulation system. This paper aims to emphasize the broad range of drug-induced hematological syndromes and to highlight some of the newer drugs and syndromes. Methods. Medline literature on drug-induced hematologic syndromes was reviewed. Most reports and reviews focus on individual drugs or cytopenias. Results. Drug-induced syndromes include hemolytic anemias, methemoglobinemia, red cell aplasia, sideroblastic anemia, megaloblastic anemia, polycythemia, aplastic anemia, leukocytosis, neutropenia, eosinophilia, immune thrombocytopenia, microangiopathic syndromes, hypercoagulability, hypoprothrombinemia, circulating anticoagulants, myelodysplasia, and acute leukemia. Some of the classic drugs known to cause hematologic abnormalities have been replaced by newer drugs, including biologics, accompanied by their own syndromes and unintended side effects. Conclusions. Drugs can induce toxicities spanning many hematologic syndromes, mediated by a variety of mechanisms. Physicians need to be alert to the potential for iatrogenic drug-induced hematologic complications.
Application of the TIMI risk score in ED patients with cocaine-associated chest pain
OBJECTIVE:The TIMI risk score has been validated as a risk stratification tool in emergency department (ED) patients with potential acute coronary syndrome. The goal of this study was to assess its ability to predict adverse cardiovascular outcomes in cocaine-associated chest pain. METHODS:This was a prospective cohort study of ED patients with chest pain with cocaine use. Data included demographics, medical history, and TIMI risk score. The main outcomes were acute myocardial infarction, revascularization, or death within 30 days of ED presentation. RESULTS:There were 261 patient visits. Patients were 43.2+8 years old, 73% male, 92% black, and 75% smokers. There were 33 patients with the composite outcome. The incidence of 30-day outcomes according to TIMI score is as follows: TIMI 0, 3.7% (95% CI, 0.1-8.3); TIMI 1, 13.2% (5.7-20.7); TIMI 2, 17.1% (4.3-29.8); TIMI 3, 21.4% (4.4-38.4); TIMI 4, 20.0% (0.1-43.6); TIMI 5/6, 50.0% (0.1-100). CONCLUSIONS:The TIMI risk score has no clinically useful predictive value in patients with cocaine-associated chest pain.
On the deluge of unsubscribed medical oncology information [Letter]