Symptom variability during repeated measurement among hospice patients with advanced cancer.

AIM: In this prospective study, we explored symptom variability in patients with cancer during repeated measurements. METHODS: Patients with cancer admitted to an inpatient hospice completed a daily questionnaire throughout their admission. The questionnaire consisted of 5 visual analogue scales (VAS) for anxiety, depression, nausea, pain, and sedation and 3 verbal rating scales (VRS) for depression, pain, and vomiting. Data from those who completed 5 consecutive days were used for the primary analysis. We used all available data points to compare VAS and VRS. An index was developed to assess for daily symptom variability. RESULTS/DISCUSSION: A total of 125 hospice inpatients were enrolled; 46 (38%) completed 3 consecutive daily questionnaires and 30 (24%), 5 days. We found (1) a statistically significant decrease in severity of symptoms present on admission, (2) new symptoms developed, (3) consequently overall symptom prevalence on days 1 and 5 appeared unchanged, (4) high daily symptom variability as demonstrated by the variability index and also changing daily symptom interrelationships, (5) demographic characteristics influenced symptom patterns on admission and subsequently, (6) severe pain predicted more frequent and severe symptom burden only on admission, (7) severe depression predicted more frequent and severe symptom burden on admission and thereafter, (8) VAS scores for depression and pain did not correspond with discrete VRS categories (mild, moderate, severe). CONCLUSIONS: (1) Symptom studies in advanced disease while difficult to conduct yield valuable information, (2) symptom relationships changed daily; strict timing of data collection is crucial for data analysis, (3) symptom monitoring following admission is an overlooked measure of risk assessment, (4) symptom prevalence studies alone for treatment follow-up may be misleading, (5) depression is an important predictor of symptoms and need to be more aggressively assessed and treated, (6) demographic characteristics may help identify symptom patterns and better direct treatment, (7) VRS rather than VAS was more reliable for assessing symptoms in hospice cancer patients.

Do echo-enhanced needles improve time to cannulate in a model of short-axis ultrasound-guided vascular access for a group of mostly inexperienced ultrasound users?

BACKGROUND: Vascular access is a critical skill for emergency physicians. However, it can be unpredictably challenging in some patients. While ultrasound-guided vascular access has been encouraged in emergency departments, there have been few studies evaluating echo-enhanced needles and their usefulness in performing vascular access. AIMS: Our purpose was to determine if the use of an echo-enhanced needle tip results in faster vascular access times, with fewer needle sticks, fewer redirections, and improved needle visualization in ultrasound-guided vascular access with the vessel in the short axis. METHODS: This is a prospective, randomized, observational study of ultrasound-guided vascular access on a vascular phantom comparing an echo-enhanced needle with a standard needle. Each participant viewed a teaching video demonstrating typical ultrasound-guided vascular access and then attempted ultrasound-guided vascular access using both a standard and an echo-enhanced needle with the vessel in the short axis. The numbers of needle sticks, redirections, and time to dye flash were measured. RESULTS: The 69 participants attempted 69 short-axis ultrasound-guided vascular cannulations with no difference in time to dye flash between needle types: the median time from needle stick to flash was 17.56 s [interquartile range (IQR): 12.37-33.15] for the standard needle and 19.22 s (IQR: 10.19-31.10) for the echo-enhanced needle. There was no difference between needle types for number of needle sticks or redirects. CONCLUSION: Echo-enhanced needles did not provide objective performance improvement compared to standard needles during ultrasound-guided vascular access with a vascular access model in the short axis.

A personal experience with the influence of diabetes and other factors on the outcome of infrainguinal bypass grafts for occlusive disease.

OBJECTIVE: To investigate the influence of diabetes mellitus and other factors on the outcome of all infrainguinal bypass grafts performed for occlusive disease by a single surgeon at a tertiary referral center. METHODS: The series includes 650 operations in 412 men and 238 women with median ages of 65 and 69 years, respectively. Critical ischemia was the indication for most procedures (n = 553, 85%), but 97 (15%) were done for claudication alone. Nearly half (n = 312, 48%) of the patients were diabetic, and 195 (30%) required insulin. All-autogenous vein was used for 389 grafts (60%). Synthetic or composite materials were employed for the remaining 261 grafts, 91 (35%) of which were entirely above the knee. Perioperative data were recorded contemporaneously and were supplemented by reviewing 558 of the 565 medical records and the Social Security Death Index. Survival, graft patency, and limb salvage were analyzed using logistic regression, Kaplan-Meier estimates and proportional hazards models. RESULTS: Diabetics were more likely to have critical preoperative limb ischemia (P < .001), elevated serum creatinine (P = .003) or a history of previous coronary intervention (P = .015), lower extremity revascularization (P < .001) or minor amputations (P = .002). The operative mortality rate was 4.8%, and there were 81 graft occlusions (12%) and 49 major amputations (7.5%) during the index hospital admission. Patency was immediately restored in 46 of the 81 occluded grafts, but their secondary patency rates were only 62 +/- 16% at 1 year and 26 +/- 18% at 5 years. Insulin-dependent diabetes was associated with a higher incidence of early amputation (odds ratio, 2.6; 95% confidence interval [CI], 1.4-4.8; P = .004). Overall survival was 52 +/- 4% at 5 years and 25 +/- 5% at 10 years, and there were 175 late graft occlusions (27%), a total of 198 related reoperations and 107 late amputations (16%). The risks for further occlusion and/or major amputation after three or more graft revisions were 65% and 71%, respectively. Insulin-dependent diabetes also was associated with higher late mortality (hazard ratio [HR], 1.5; 95% CI, 1.2-1.8; P = .001) and amputation rates (HR, 1.5; 95% CI, 1.0-2.1; P = .026), but other independent variables like age, elevated serum creatinine, critical preoperative ischemia, synthetic conduits, and previous ipsilateral bypass had at least as much influence as diabetes on survival, graft failure or limb loss. CONCLUSIONS: Diabetes was one of several factors influencing survival and limb preservation, but it did not adversely affect graft patency. The number of graft revisions was an important predictor of further occlusion or amputation.

A personal experience with direct reconstruction and extra-anatomic bypass for aortoiliofemoral occlusive disease.

OBJECTIVE: This study was conducted to investigate factors influencing the outcome of all open operations for aortoiliofemoral (AIF) revascularization performed by a single surgeon at a tertiary referral center. METHODS: The series included 355 direct reconstructions and 181 extra-anatomic bypass (EAB) grafts in 339 men (63%) and 197 women, with median ages of 61 and 62 years, respectively. These procedures were done for claudication alone in 267 patients (50%), for advanced ischemia in 258 (48%), and to facilitate other interventions in 11 (2.0%). Simultaneous infrainguinal bypass was necessary in 36 patients (6.7%). Survival and patency analyses were performed using logistic regression, Kaplan-Meier estimations, and proportional hazards models. RESULTS: Patients receiving EAB were older (P < .001) and were more likely to have advanced preoperative limb ischemia (P < .001), superficial femoral artery occlusions (P < .001), a history of previous lower extremity inflow operations (P < .001), elevated serum creatinine (P = .017), and clinically severe chronic obstructive pulmonary disease (P = .016). On multivariable analysis, EAB resulted in a higher incidence of postoperative death (8.8% vs 2.3%, P = .005) or graft thrombosis (8.8% vs 2.8%, P = .006) than direct reconstruction. Women were more likely to sustain graft thrombosis (P = .006) or require major amputation (P = .050), or both, during the early postoperative period. Overall late survival rates were 87% +/- 3% at 1 year, 64% +/- 5% at 5 years, 39% +/- 5% at 10 years, and 20% +/- 4% at 15 years. Late survival rates were significantly lower (P = .026) after EAB and also were unfavorably associated with advanced preoperative ischemia (P = .046) as well as with several medical comorbidities (P < .001). Primary limb-based patency rates were 95% +/- 2% at 1 year, 85% +/- 3% at 5 years, 77% +/- 5% at 10 years, and 69% +/- 7% at 15 years. Late occlusions occurred more frequently in patients who had undergone previous inflow procedures (P = .028) and were especially common after EAB (P < .001). Patients >65 years had higher early and late mortality rates than younger patients (P < .001), but younger patients had lower long-term patency rates (P < .001). CONCLUSIONS: The worse operative mortality and late survival rates for EAB in this series largely were preordained by the frequent selection of EAB for patients who represented poor medical risks for direct AIF reconstruction. However, the durability of aortofemoral, aortoiliac, or iliofemoral bypass compared with either femorofemoral or axillofemoral bypass makes direct reconstruction clearly superior for average or low-risk patients. Direct reconstruction should be used preferentially in such cases, especially in women and for younger patients of either gender.

Open infrarenal abdominal aortic aneurysm repair: the Cleveland Clinic experience from 1989 to 1998.

PURPOSE: The purpose of this study was to determine the safety and durability of traditional surgical treatment for asymptomatic infrarenal abdominal aortic aneurysms (AAAs) in a large series of patients who underwent open operations during the decade preceding the commercial availability of stent graft devices for endovascular AAA repair. METHODS: From 1989 to 1998, 1135 consecutive patients (985 men [87%], 150 women; mean age, 70 +/- 7 years) underwent elective graft replacement of infrarenal AAA. Computerized perioperative data have been supplemented with a retrospective review of hospital charts/outpatient records and a telephone canvass to calculate survival rates and the incidence rate of subsequent graft-related complications. Seventy-four patients (6.5%) were lost during a median follow-up period of 57 months for the entire series. RESULTS: The 30-day mortality rate was 1.2%. The hospital course was completely uneventful for 939 patients (83%), and the median length of stay for all patients was 8 days. A total of 196 patients had single (n = 150; 13%) or multiple (n = 46; 4%) postoperative complications, which were more likely to occur in men (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.1 to 5.2) and in patients with a history of congestive heart failure (OR, 3.7; 95% CI, 1.7 to 7.8), chronic pulmonary disease (OR, 1.9; 95% CI, 1.2 to 2.9), or renal insufficiency (OR, 2.5; 95% CI, 1.3 to 4.7). Kaplan-Meier method survival rate estimates were 75% at 5 years and 49% at 10 years. As was the case with early complications, the long-term mortality rate primarily was influenced by age of more than 75 years (risk ratio [RR], 2.2; 95% CI, 1.7 to 2.8) or previous history of congestive heart failure (RR, 2.1; 95% CI, 1.3 to 3.4), chronic pulmonary disease (RR, 1.5; 95% CI, 1.2 to 2.0), or renal insufficiency (RR, 3.2; 95% CI, 2.2 to 4.6). Of the 1047 patients who survived their operations and remained available for follow-up study, only four (0.4%) have had late complications that were related to their aortic replacement grafts. CONCLUSION: These results reconfirm the exemplary success of open infrarenal AAA repair. The future of endovascular AAA repair is exceedingly bright, but until the long-term outcome of the current generation of stent grafts is adequately documented, their use should be justified by the presence of serious surgical risk factors.