Showing papers by "Dirk R. Larson published in 2004"

Clinical course of patients with relapsed multiple myeloma.

Abstract: OBJECTIVE To study the clinical course of patients with multiple myeloma (MM) that relapses after initial therapy. PATIENTS AND METHODS Patients with MM, seen at the Mayo Clinic in Rochester, Minn, between January 1, 1985, and December 31, 1998, were identified from a prospectively maintained database. Our study population consisted of 578 patients with newly diagnosed MM who were followed up and monitored throughout their clinical course at our institution. RESULTS The median age of the 578 patients with MM was 65 years (range, 26-92 years); 228 patients (39%) were women. The median follow-up of 71 surviving patients was 55 months (range, 0-202 months). The overall survival (OS) for the 578 patients at 1, 2, and 5 years was 72%, 55%, and 22%, respectively; the median OS from initial therapy was 28.4 months. The median OS of 355 patients who experienced relapse after initial treatment was 17.1 months from initiation of the second therapy, and 84% died within 5 years. The duration of response decreased consistently with each successive regimen. Patients with a high plasma cell labeling index (≥1.0%), low platelet count ( 9 /L), high creatinine level (≥2.0 mg/dL), and low albumin level ( CONCLUSIONS Our study revealed decreasing response duration with increasing number of salvage regimens, probably reflecting acquired drug resistance and an increasing proliferative rate of the myeloma cells. Patients who experienced relapse after initial treatment and received salvage therapy had a median survival of nearly 1.5 years. This must be remembered when making treatment decisions for these patients and must be factored in when assessing the efficacy of new therapies.

Medical and Surgical Comanagement after Elective Hip and Knee Arthroplasty: A Randomized, Controlled Trial

Abstract: Background Hospitalists are assuming an increasing role in the care of surgical patients, but the impact of this model of care on postoperative outcomes is unknown. Objective To determine the impact of providing a collaborative, hospitalist-led model of care on postoperative outcomes and costs among patients having hip or knee arthroplasty. Design Randomized, controlled trial. Setting Academic medical center. Participants 526 patients having elective orthopedic surgery who are at elevated risk for postoperative morbidity. Measurements Length of stay, inpatient postoperative medical complications, health care provider satisfaction, and inpatient costs. Interventions A comanagement medical Hospitalist-Orthopedic Team compared with standard postoperative care by orthopedic surgeons with medical consultation. Results More patients in the hospitalist group were discharged from the hospital with no complications (61.6% vs. 49.8%; difference, 11.8 percentage points [95% CI, 2.8 to 20.7 percentage points]). Fewer minor complications were observed among hospitalist patients (30.2% vs. 44.3%; difference, -14.1 percentage points [CI, -22.7 to -5.3 percentage points]). Observed length of stay was not statistically different between treatment groups. However, when adjusted for discharge delays, mean length of stay for patients in the hospitalist model of care was shorter (5.1 days vs. 5.6 days; difference, -0.5 day [CI, -0.8 to -0.1 day]). Total costs did not differ between groups. Orthopedic surgeons and nurses preferred the hospitalist model. Limitations Care providers and patients were aware of intervention assignments, and the study could not capture all costs associated with the hospitalist model. Conclusions The comanagement medical Hospitalist-Orthopedic Team model reduced minor postoperative complication rates with no statistically significant difference in length of stay or cost. The nurses and surgeons strongly preferred the comanagement hospitalist model. Additional research on the clinical and economic impact of the hospitalist model in other surgical populations is warranted.

Major Hepatic Resection for Hilar Cholangiocarcinoma: Analysis of 46 Patients

Abstract: Hypothesis Major hepatectomy, bile duct resection, and regional lymphadenectomy for hilar cholangiocarcinoma are associated with actual long-term (>5 years) survival. Design Retrospective outcome study. Setting Single tertiary referral institution. Patients Between 1979 and 1997, 46 consecutive patients had resection of hilar cholangiocarcinoma by major hepatectomy, bile duct resection, and regional lymphadenectomy. Main Outcome Measures Overall survival and tumor recurrence were correlated to clinicopathological factors, operative morbidity, and mortality. Results Twenty-five patients underwent left hepatectomy, 17 underwent right hepatectomy, and 4 had extended right hepatectomy. Eighteen patients underwent resection of segment 1. Negative (R0) resection margins were achieved in 37 patients (80%). The operative mortality rate was 9%, and the surgical morbidity rate was 52%. Actual 1-year, 3-year, and 5-year survival rates were 80%, 39%, and 26%, respectively. Factors adversely associated with patient survival rates included: male sex, lymph node metastases, tumor grade 3 or 4, elevated direct serum bilirubin level at diagnosis, elevated preoperative activated partial thromboplastin time, and more than 4 U of red blood cells transfused perioperatively. Tumor size and R0 resection approached significance for survival. Factors associated with tumor recurrence included: male sex, tumor grade 3 or 4, a low hemoglobin level both at diagnosis and preoperatively, and a low preoperative prothrombin time and low alkaline phosphatase level at diagnosis and preoperatively. Median time to recurrence was 3.6 years. Tumor recurrence was predominantly local and regional. Conclusions The actual 5-year survival rate of 26% justifies major partial hepatectomy, bile duct resection, and regional lymphadenectomy for hilar cholangiocarcinoma. The high frequency of local and regional recurrence warrants investigation of adjuvant therapy.

Long-term follow-up of 241 patients with monoclonal gammopathy of undetermined significance: the original Mayo Clinic series 25 years later.

Abstract: OBJECTIVE To determine the long-term outcome of patients with monoclonal gammopathy of undetermined significance (MGUS). PATIENTS AND METHODS We reviewed the medical records of 241 patients with MGUS who were examined at the Mayo Clinic in Rochester, Minn, between January 1, 1956, and December 31, 1970. RESULTS Follow-up was 3579 person-years (median, 13.7 years; range, 0-39 years). Only 14 patients (6%) were alive and had no substantial increase of M protein at last follow-up; 138 patients (57%) died without evidence of multiple myeloma or a related disorder; a malignant lymphoplasma cell proliferative disorder developed in 64 patients (27%). The interval from diagnosis of MGUS to diagnosis of multiple myeloma or related disorder ranged from 1 to 32 years (median, 10.4 years). CONCLUSIONS The median survival rate of study patients with MGUS was only slightly shorter than that of a comparable US population. Risk of progression of MGUS to lymphoplasma cell malignancy is indefinite and persists even after more than 30 years of follow-up, with no reliable predictors of malignant evolution.

Concurrent vs. Staged Colectomy and Hepatectomy for Primary Colorectal Cancer With Synchronous Hepatic Metastases

Abstract: Resection of hepatic metastases is the preferred treatment for selected patients after resection of primary colorectal carcinoma, but timing is controversial. This study was designed to compare outcomes of patients receiving concurrent resection of hepatic metastases and the primary colorectal tumor with those of patients receiving staged resection (within 6 months). We retrospectively analyzed medical records (1986–1999) of 96 consecutive patients with synchronously recognized primary carcinoma and hepatic metastases who underwent concurrent (64 patients) or staged (32 patients) colonic and hepatic resections performed at our institution. Concurrent and staged groups were similar in demographics, tumor grade, stage, preoperative comorbidity (cardiac and respiratory), characteristics of hepatic metastases, and single vs. multiple lesions. No significant differences were observed between groups (concurrent vs. staged) in type of colon resection (P = 0.45) or hepatic resection (P = 0.09), overall operative duration (mean, 430 vs. 427 minutes; P = 0.39), blood loss (mean, 890 vs. 889 ml; P = 0.87), volume of blood products transfused (mean, 326 vs. 185 ml; P = 0.08), perioperative morbidity (53 vs. 41 percent; P = 0.25), disease-free survival from date of hepatectomy (median, 13 vs. 13 months; P = 0.53), or overall survival from date of hepatectomy (median, 27 vs. 34 months; P = 0.52). There was no operative mortality. Overall duration of hospitalization was significantly shorter for concurrent than for staged resection (mean, 11 vs. 22 days; P ≤ 0.001). Concurrent colectomy and hepatectomy is safe and more efficient than staged resection and should be the procedure of choice for selected patients in medical centers with appropriate capacity and experience.

Pregnancy and delivery before and after ileal pouch-anal anastomosis for inflammatory bowel disease: immediate and long-term consequences and outcomes

Abstract: This study was designed to evaluate pregnancy, delivery, and functional outcome in females before and after ileal pouch-anal anastomosis for chronic ulcerative colitis From a prospective database of 1,454 patients who underwent ileal pouch-anal anastomosis for chronic ulcerative colitis between 1981 and 1995, a standardized questionnaire was sent to all female patients aged 40 years or younger at the time of ileal pouch-anal anastomosis (n = 544) The response rate was 83 percent (450/544) with a mean follow-up after ileal pouch-anal anastomosis of 13 years A total of 141 females were pregnant after the chronic ulcerative colitis diagnosis, but before ileal pouch-anal anastomosis (236 pregnancies; mean, 17) and 87 percent delivered vaginally A mean of five (range, 1–16) years after ileal pouch-anal anastomosis, 135 females were pregnant (232 pregnancies; mean, 17) Comparison of pregnancy and delivery before and after ileal pouch-anal anastomosis in the same females (n = 37) showed no difference in birth weight, duration of labor, pregnancy/delivery complications, vaginal delivery rates (59 percent before vs 54 percent after ileal pouch-anal anastomosis), and unplanned cesarean section (19 vs14 percent) Planned cesareans occurred only after ileal pouch-anal anastomosis and were prompted by obstetrical concerns in only one of eight Pouch function at first follow-up after delivery (mean, 7 months) was similar to pregravida function After ileal pouch-anal anastomosis, daytime stool frequency was the same after delivery as pregravida (54 vs 54, not significant) but was increased at the time of last follow-up (68 months after delivery; 54 vs 64; P < 0001) The rate of occasional fecal incontinence also was higher (20 percent after ileal pouch-anal anastomosis and 21 percent pregravida vs 36 percent at last follow-up; P = 001) No difference in functional outcome was noted compared with females who were never pregnant after ileal pouch-anal anastomosis (n = 307) Age and becoming pregnant did not affect the probability of pouch-related complications, such as stricture, pouchitis, and obstruction Successful pregnancy and vaginal delivery occur routinely in females with chronic ulcerative colitis before and after ileal pouch-anal anastomosis The method of delivery should be dictated by obstetrical considerations Pouch function and the incidence of complications in females with pregnancies seem largely unaffected long-term

The effect of ageing on function and quality of life in ileal pouch patients: a single cohort experience of 409 patients with chronic ulcerative colitis.

Abstract: Ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for patients requiring proctocolectomy for chronic ulcerative colitis (CUC), because the goals of eliminating disease and preserving fecal continence are achieved in the great majority of patients. Over the past 2 decades, several analyses from this1–4 and other institutions5–8 have shown that IPAA is a safe and effective operation for patients with CUC; bowel functional generally is acceptable, and quality of life (QoL) is good and comparable to that of the general population.9 However, these observations are based for the most part on the results of gathered within 5 to 8 years of operation among groups of patients followed for variable lengths of time. Whether these outcomes remain durable is unknown. Furthermore, follow-up in IPAA patients must still be considered short term, as most of the patients undergoing pouch surgery are young and have life expectancies of another 40 to 50 years. Our aim, therefore, was to evaluate functional outcome and QoL in a single cohort of patients with CUC followed annually for 15 years after IPAA. Such a longitudinal study of outcomes, in which the same patients are followed sequentially over time, provides a unique set of data which should provide a clear picture of the effect of time and ageing on the function of ileal pouches.

Long-term survival after traumatic brain injury: A population-based analysis

Abstract: This population-based retrospective cohort study identified all Olmsted County, MN residents with any diagnosis indicative of potential traumatic brain injury (TBI) during the years 1985 to 2000. The complete community-based medical records of a random sample (n =7 ,175) were reviewed to confirm and characterize the event, and to determine vital status through 2002. The review identified 1,448 confirmed incident cases; 164 (11%) were moderate to severe; 1,284 were mild. The estimated 30-day case fatality rate was 29% for moderate to severe cases and 0.2% for mild cases. Comparison of observed mortality over the full period of follow-up with that expected revealed a risk ratio (95% CI) of 5.29 (4.11-6.71) for moderate to severe cases and 1.33 (1.05-1.65) for mild cases. Proportional hazards modeling showed the adjusted hazard of all-cause mortality for moderate to severe cases relative to mild cases was 5.18 (3.65-7.3) within six months of the event and 1.04 (0.57-1.88) for the remaining follow-up period. This analysis indicates that persons who experience mild TBI exhibit a small but statistically significant reduction in long-term survival compared to the general population. The case fatality rate for persons with moderate to severe TBI is very high, but among six-month survivors, long-term survival is similar to that for persons with mild TBI.

Long-term survival after local excision for T1 carcinoma of the rectum

Abstract: Many authors have reported high rates of local recurrence after local excision for early carcinoma of the rectum, which raises the question of whether oncologic resection gives better results. This study was designed to compare the long-term recurrence rate, long-term survival, and risk factors for T1 adenocarcinoma of the rectum treated with local excision or oncologic resection. We identified 144 patients who had T1 sessile adenocarcinoma in the lower third or middle third of the rectum. Patients who received adjuvant therapy or who had pedunculated lesions were excluded. Data included age, gender, size of lesion, histologic type of carcinoma, grade, presence of lymphovascular invasion, and depth of invasion. Outcomes were defined as five-year and ten-year cumulative probabilities of local recurrence, distant metastasis, overall survival, and cancer-free survival. The mean follow-up was 9.2 years; median follow-up was 8.1 years. We compared 70 patients who underwent local excision with 74 patients who underwent oncologic resection. Among patients with lesions in the middle or lower third of the rectum, 1) the five-year and ten-year outcomes were significantly better for overall survival and cancer-free survival in the oncologic resection group, but there were no significant differences in local recurrence or distant metastasis; 2) the multivariate risk factors for long-term, cancer-free survival were invasion into the lower third of the submucosa, local excision, and older than aged 68 years; and 3) for lesions with invasion into the lower third of the submucosa, the oncologic resection group had lower rates of distant metastasis and better survival. Among patients with lesions in the lower third of the rectum, 1) the five-year and ten-year outcomes showed no significant differences in survival, local recurrence, or distant metastasis between the two groups; and 2) for lesions with invasion into the lower third of the submucosa, the oncologic resection group showed a trend of improved survival, which was not statistically significant, possibly because of low statistical power from the small sample size. Patients who undergo local excision or oncologic resection for T1 carcinoma in the lower two-thirds of the rectum have a high incidence of local recurrence and distant metastasis. To improve the cure rate, the rate of recurrence must decrease. A randomized, controlled study is needed to determine whether adjuvant therapy may be beneficial.

Double-blind, prospective, randomized study of warmed, humidified carbon dioxide insufflation vs standard carbon dioxide for patients undergoing laparoscopic cholecystectomy.

Abstract: Hypothesis Patients undergoing warmed, humidified carbon dioxide (CO 2 ) insufflation for laparoscopic cholecystectomy will (1) maintain a warmer intraoperative core temperature, (2) have their surgeon experience less fogging of the camera lens, and (3) have less postoperative pain than patients undergoing laparoscopic cholecystectomy with standard CO 2 insufflation Design A double-blind, prospective, randomized study comparing patients undergoing laparoscopic cholecystectomy with standard CO 2 insufflation vs those receiving warmed, humidified CO 2 (Insuflow Filter Heater Hydrator; Lexion Medical, St Paul, Minn) was performed Main variables included patient core temperature, postoperative pain, analgesic requirements, and camera lens fogging Results One hundred one blinded patients (69 women, 32 men) undergoing laparoscopic cholecystectomy were randomized into 2 groups—52 receiving standard CO 2 insufflation (group A) and 49 receiving warmed, humidified CO 2 (group B) Mean patient intraoperative core temperature change (group A decreased by 003°C, group B increased by 029°C, P = 01) and mean abdominal pain (Likert scale, 0-10) at 14 days postoperatively (group A, 10; group B, 03; P = 02) were different Other variables (camera lens fogging, early postoperative pain, narcotic requirements, recovery room stay, and return to normal activities) between groups were similar Conclusion While patients undergoing laparoscopic cholecystectomy with warmed, humidified CO 2 had several advantages that were statistically significant, no major clinically relevant differences between groups A and B were evident

Digital resistance and tendon strength during the first week after flexor digitorum profundus tendon repair in a canine model in vivo.

Abstract: Background: After flexor tendon repair, the strength of the repair and the resistance to digital motion are important considerations in deciding when to initiate postoperative rehabilitation. Our objective was to assess these factors in a short-term in vivo canine model of flexor tendon repair. Methods: Forty-eight dogs were randomly allocated to four groups based on the duration of postoperative follow-up (one, three, five, or seven days). In each group, two flexor digitorum profundus tendons of one forepaw were exposed. One tendon (the repair tendon) was sharply transected and repaired with a modified Kessler suture, and the other one (the sham tendon) was simply exposed without laceration. The involved paw was immobilized until the animal was killed on the designated day. Three tendons from each dog, including the repair tendon, the sham tendon, and a control tendon from a corresponding normal digit on the contralateral side, were tested. Results: The mean peak total digital resistance force in the repair group was lowest at five days (p 0.05 compared with one and three days). The mean peak force needed to overcome the internal gliding resistance between the repaired tendon and sheath was significantly higher than that in both the sham and control groups at all time-points (p 0.05). Conclusions: When we evaluated tendon-gliding and suture strength after flexor tendon repair, the least favorable ratio of repair strength to force needed to overcome the resistance to digital motion was noted on Day 7, whereas the best combination of tendon strength and low peak resistance force was noted on Day 5. Clinical Relevance: The results of the present study suggest that postoperative Day 5 may be the best time to begin rehabilitation, with either active or passive therapies, as the amount of tendon force necessary to initiate tendon motion is least at this time.

Presence of monoclonal free light chains in the serum predicts risk of progression in monoclonal gammopathy of undetermined significance.

Abstract: We hypothesized that the presence of monoclonal free light chains (FLC) in the serum of patients with monoclonal gammopathy of undetermined significance (MGUS) is a marker of clonal evolution and a risk factor for progression. Forty-seven patients with MGUS and documented progression to myeloma or related malignancy were compared with 50 age- and gender-matched patients with MGUS and no evidence of progression after 5 or more years of follow-up. The presence of an abnormal kappa/lambda FLC ratio in the serum was associated with a higher risk of MGUS progression (relative risk 2.5; 95% confidence interval: 1.6-4.0; P < 0.001).

Impact of Primary Resection on the Outcome of Patients With Perforated Diverticulitis

Abstract: Background Primary resection has replaced the conventional drainage procedure in the management of patients with generalized peritonitis complicating diverticular disease of the colon. This study investigates the impact of primary resection on operative mortality, identifies predictors of mortality, and compares the results with those of our earlier experience. Hypothesis Primary resection of the perforated diseased segment of the colon is associated with lower mortality rates than the drainage procedure in patients with Hinchey stages 3 and 4 diverticulitis. Design Retrospective analysis. Setting Tertiary care referral center. Patients We included 138 consecutive patients who underwent emergent operation for generalized peritonitis complicating diverticular disease of the colon (Hinchey stages 3 and 4) during a period of 16 years (January 1983 to May 1999). Main Outcome Measures The 30-day mortality rate was analyzed and predictors of mortality identified. Results Patients were classified as having spreading purulent peritonitis (n = 44, 31.9%), diffuse peritonitis (n = 64, 46.4%), or fecal peritonitis (n = 30, 21.7%). One hundred thirty-one patients (94.9%) underwent primary resection, 6 patients (4.3%) underwent resection and primary anastomosis, and 1 patient required total colectomy and end ileostomy. Thirteen of the 138 patients in the present group died (1983-1998), representing a perioperative mortality rate of 9%. There was no significant difference in mortality when compared with our earlier study (1972-1982), which had a mortality rate of 12%, considering that more than 25% of the patients in that group were managed by colostomy and drainage alone. Factors identified univariately as predictors of mortality were age of more than 70 years ( P = .047), 2 or more comorbid conditions ( P P = .02), use of steroids ( P = .01), and perioperative sepsis ( P Conclusions Primary resection has become the standard practice for patients with generalized peritonitis complicating diverticulitis. Mortality rates have not significantly declined despite more aggressive surgical management of the septic source. Because advanced age, comorbid conditions, and perioperative sepsis predict mortality, it is suggested that further reduction in mortality will require improvement in medical management of perioperative sepsis and comorbid conditions.

Medical and Surgical Comanagement after Elective Hip and Knee Arthroplasty

Abstract: A hospitalist–orthopedic surgeon comanagement team model reduced minor postoperative complication rates. Length of stay, cost, and major complications did not change. The nurses and surgeons prefer...