Paravertebral block: an alternative to general anesthesia in breast cancer surgery.

Alternative forms of anesthesia in breast cancer patients have been sought to reduce the untoward effects of general anesthesia. The purpose of this study was to compare paravertebral block (PVB) and general anesthesia (GA) in terms of pain control, postoperative nausea and vomiting, and resumption of diet in patients undergoing operations for breast cancer. A retrospective chart review was performed on all patients (289) undergoing breast cancer surgery from May 1, 1999 through December 31, 2000 with PVB or GA. The PVB (n = 128) and GA (n = 100) groups had similar demographics. Postoperative narcotics were given to 80.8 and 93 per cent of PVB and GA patients, respectively (P < 0.01), after an average of 216 and 122 minutes from the end of surgery (P = 0.028). The PVB group received 6.2 narcotic units compared with 10.1 in the GA group (P = 0.04). Postoperative nausea and vomiting was present in 16.8 and 24 per cent of patients in the PVB and GA groups, respectively (P = 0.12). A diet was tolerated on the same day of surgery by 98.4 and 82 per cent of PVB and GA patients, respectively (P < 0.01). The complication rate of PVB was 1.8 per cent. PVB resulted in better postoperative pain control and earlier resumption of diet compared with GA. The good success rate and low complication rate of PVB make it well suited for breast cancer surgery and can eliminate the need for GA in patients with serious comorbidities.

Patient outcomes and dysphagia after laparoscopic antireflux surgery performed without use of intraoperative esophageal dilators.

Esophageal dilators (EDs) are commonly used during antireflux surgery but are a known cause of esophageal perforation. We hypothesized that the usage of ED during laparoscopic fundoplications (LFs) would not improve dysphagia rates or outcome. A retrospective review of 268 consecutive patients and a postoperative patient survey were performed to compare outcomes in patients undergoing LF. Eighty-nine patients had an ED placed and 179 did not. Significant postoperative dysphagia occurred in seven (8%) and six (3%), respectively (P = 0.123) and postoperative heartburn in five (6%) and three (2%), respectively (P = 0.865), in a mean 26.8-month follow-up. Patient survey results demonstrated good to excellent satisfaction in 89 per cent of patients in both groups. We conclude that the results of LF are equivalent with respect to control of heartburn and risk of dysphagia regardless of ED usage. Selective rather than routine use of EDs is recommended.

Improving care for patients with chronic heart failure in the community: the importance of a disease management program.

STUDY OBJECTIVE: Utilizing a comparison group of patients with congestive heart failure (CHF) discharged to their primary care physicians, we sought to determine if disease management in a short-term, aggressive-intervention heart failure clinic (HFC) following hospital discharge is associated with improved outcomes. DESIGN: Chart review. SETTING: An integrated health-care center serving a tristate area. PATIENTS: Inclusion criteria were discharge from the hospital with a primary diagnosis of CHF, outpatient follow-up within the hospital system, and the presence of left ventricular systolic dysfunction as the basis for CHF. Patients were categorized into group 1 if they were referred to the HFC after hospital discharge, and into group 2 if follow-up care was provided by their primary care physician. MEASUREMENTS AND RESULTS: There were 38 patients in group 1 and 63 patients in group 2. There was a trend toward a shorter time to the first outpatient visit following discharge (11 days vs 15 days, p = 0.09), more outpatient visits within 90 days (10 visits vs 2 visits, p < 0.001), and more patient-initiated contacts (four contacts vs one contact, p = < 0.001) in group 1 compared to group 2, respectively. The combined hospital readmission and mortality rate at 90 days (10% vs 30%, p < 0.018) and 1 year (21% vs 43%, p < 0.02) was lower in group 1. There was a 77% relative risk reduction for 30-day hospital readmission in favor of group 1, and a statistically lower rate of readmissions at 90 days and 1 year. Utilization and maintenance of standardized CHF medications were significantly higher in patients who attended the HFC. CONCLUSIONS: A comprehensive disease management program for patients discharged with a diagnosis of CHF resulted in fewer rehospitalizations and improved event-free survival compared to patients followed up by their primary care physicians.