Long-term results and complications following uvulopalatopharyngoplasty in 116 consecutive patients

A modified uvulopalatopharyngoplasty (UPPP) was carried out between January 1992 and December 2003 at the ENT Department of the Inselspital in Bern in 146 patients with habitual or complicated rhonchopathy. The operation consisted of a classical tonsillectomy or residual tonsil resection and additional shortening of the uvula. The natural mucosal fold between the uvula and the upper pole of the tonsils was carefully preserved. A wide opening to the rhinopharynx was created by asymmetric suturing of the glossopalantine and pharyngopalatine arches. A retrospective questionnaire with regard to rhonchopathy, phases of apnea, daytime drowsiness, obstruction of nasal breathing, long-term complications and patient satisfaction was used to evaluate the short-term and long-term effectiveness of the modified UPPP as well as the incidence of adverse side effects. Complete postoperative courses were evaluated in 116 patients. Surgical complications were restricted to one case with postoperative hemorrhage. A velum insufficiency or postoperative rhinopharyngeal stenosis did not occur. Eighty-three patients (72%) confirmed a persistent suppression or substantial improvement of the rhonchopathy. Disappearance or decrease of sleep apnea was confirmed in 12 (63%) out of 19 postoperative polysomnographic follow-up investigations. Long-term complications occurred in a total of 27 (23%) of 116 patients. They were confined to minor problems such as dryness of the mouth (n = 12), slight difficulty in swallowing (n = 7), discrete speech disturbances (n = 1), and slight pharyngeal dysesthesias (n = 7) with feeling of a lump in the throat and compulsive clearing of the throat. Eighty-five patients (73%) reported that they were satisfied with the postoperative result even several years after the operation. Looking back, 31 patients (27%) would no longer have the operation performed. The inadequate result of the rhonchopathy was specified as the reason by 21 patients. Ten patients had unpleasant memories of the operation because of intensive postoperative pain. Snoring and apneic phases are suppressed or improved by non-traumatic UPPP in the majority of patients. This effect persisted even years after the operation.

Mechanical thrombectomy for acute ischemic stroke: thrombus-device interaction, efficiency, and complications in vivo

BACKGROUND AND PURPOSE: Mechanical thrombectomy is a promising new modality of interventional stroke treatment. The various devices differ with regard to where they apply force on the thrombus, taking a proximal approach such as aspiration devices or a distal approach such as basket-like devices. The study compares the in vivo effectiveness and thrombus-device interaction of these 2 approaches. METHODS: Angiography and embolization with a radioopaque whole blood thrombus was performed in 10 swine. Mechanical thrombectomy was performed in 20 cranial vessels using a proximal aspiration device (Vasco35) and a distal basket-like device (Catch) with and without proximal balloon occlusion. Fifty-six retrieval attempts were made. RESULTS: The proximal device allowed fast repeated application with a low risk of thromboembolic events (3%) and vasospasm, but it had a significantly lower success rate (39.4%) in retrieving thrombotic material than the distal device (DD) (82.6%; odds ratio, 7.3; 95% CI, 2.0 to 26.4). The compaction of the thrombus during retrieval with DD increased the risk of vessel wall irritation significantly (P<0.01) and complicated retrieval into the guiding catheter. The number of embolic events was significantly higher with DD (26%; odds ratio, 11.3; 95% CI, 1.35 to 101.6) unless proximal balloon occlusion was used. CONCLUSIONS: The proximal and the distal approaches to mechanical thrombectomy proved to be effective at achieving recanalization of cranial vessels. The proximal device is faster in application and allowed repeated attempts with a low complication rate. The DD is more successful at removing thrombotic material, but its method of application and attendant thrombus compaction increase the risk of thromboembolic events and vasospasms.

Incidence of severe reproductive tract complications associated with diagnosed genital chlamydial infection: the Uppsala Women's Cohort Study

OBJECTIVE: To estimate the cumulative incidence of severe complications associated with genital chlamydia infection in the general female population. METHODS: The Uppsala Women's Cohort Study was a retrospective population based cohort study in Sweden, linking laboratory, hospital, and population registers. We estimated the cumulative incidence of hospital diagnosed pelvic inflammatory disease, ectopic pregnancy, and infertility, and used multivariable regression models to estimate hazard ratios according to screening status. RESULTS: We analysed complete data from 43 715 women in Uppsala aged 15-24 years between January 1985 and December 1989. Follow up until the end of 1999 included 709 000 woman years and 3025 events. The cumulative incidence of pelvic inflammatory disease by age 35 years was 3.9% (95% CI 3.7% to 4.0%) overall: 5.6% (4.7% to 6.7%) in women who ever tested positive for chlamydia, 4.0% (3.7% to 4.4%) in those with negative tests, and 2.9% (2.7% to 3.2%) in those who were never screened. The corresponding figures were: for ectopic pregnancy, 2.3% (2.2% to 2.5%) overall, 2.7% (2.1% to 3.5%), 2.0% (1.8% to 2.3%), and 1.9% (1.7% to 2.1%); and for infertility, 4.1% (3.9% to 4.3%) overall, 6.7% (5.7% to 7.9%), 4.7% (4.4% to 5.1%), and 3.1% (2.8% to 3.3%). Low educational attainment was strongly associated with the development of all outcomes. CONCLUSIONS: The incidence of severe chlamydia associated complications estimated from ours, and other population based studies, was lower than expected. Studies that incorporate data about pelvic inflammatory disease diagnosed in primary care and behavioural risk factors would further improve our understanding of the natural history of chlamydia. Our results provide reassurance for patients, but mean that the benefits of chlamydia screening programmes might have been overestimated.

Tubal sterilization: Complications of laparoscopy and minilaparotomy

OBJECTIVE: To evaluate whether intra- and post-operative morbidity varies according to the method used for female sterilization. STUDY DESIGN: The database of the Swiss obstetric study group was analyzed for a period of 9 years. After the exclusion of cases with extraneous factors that may have influenced the operative outcome, three groups of patients were identified: (1) interval laparoscopic sterilization unrelated to pregnancy (n=20,325); (2) postpartum laparoscopic sterilization (n=2233); (3) postpartum sterilization by minilaparotomy (n=5095). Intra-operative and post-operative complications were compared according to the surgical approach. RESULTS: A total of 27,653 patients were included in the study. The proportion of major complications was higher in group 3 than in group 1 (0.39% versus 0.10%, odds ratio 4.0, 95% CI 2.15-7.44, p<0.001) but not statistically different between groups 1 (0.10%) and 2 (0.18%). Minor complications were statistically significantly more frequent in group 3 (0.82%) than in group 1 (0.26%) or group 2 (0.27%). There was no case of intra-operative or post-operative death in the study population. CONCLUSION: When available, a laparoscopic approach should be chosen for female sterilization. After uneventful pregnancy course and delivery, it does not seem justified to delay the endoscopic sterilization to a later time.

[Conventional vs minimally invasive total hip arthroplasty. A prospective study of rehabilitation and complications]

BACKGROUND: In a prospective, nonrandomized study the outcome in terms of rehabilitation and complications of total hip arthroplasty (THA) through a superior capsulotomy exposure (study group) was compared to THA performed through a direct lateral exposure (control group). PATIENTS AND METHODS: The study group (106 THA) and the control group (107 THA) were controlled for complexity and had no significant differences in age, sex, diagnosis, or body mass index. RESULTS: The study group had improved recovery at 6 weeks after surgery which was statistically significant (p<0.001). In addition, the study group had a lower incidence of perioperative complications. CONCLUSION: The current study demonstrates the potential that less-invasive surgical techniques with the philosophy of maximally preserving the abductors, posterior capsule, and short rotators may result in a safer operation with an accelerated recovery.

Risk of adverse effects of intensified treatment in insulin-dependent diabetes mellitus: a meta-analysis

While the benefits of intensified insulin treatment in insulin-dependent (Type 1) diabetes mellitus (IDDM) are well recognized, the risks have not been comprehensively characterized. We examined the risk of severe hypoglycaemia, ketoacidosis, and death in a meta-analysis of randomized controlled trials. The MEDLINE database, reference lists, and specialist journals were searched electronically or by hand to identify relevant studies with at least 6 months of follow-up and the monitoring of glycaemia by glycosylated haemoglobin measurements. Logistic regression was used for calculation of combined odds ratios and 95% confidence intervals (95% CI). The influence of covariates was examined by including covariate-by-treatment interaction terms. Methodological study quality was assessed and sensitivity analyses were performed. Fourteen trials were identified. These contributed 16 comparisons with 1028 patients allocated to intensified and 1039 allocated to conventional treatment. A total of 846 patients suffered at least one episode of severe hypoglycaemia, 175 patients experienced ketoacidosis and 26 patients died. The combined odds ratio (95% CI) for hypoglycaemia was 2.99 (2.45-3.64), for ketoacidosis 1.74 (1.27-2.38) and for death from all causes 1.40 (0.65-3.01). The risk of severe hypoglycaemia was determined by the degree of normalization of glycaemia achieved (p=0.005 for interaction term), with the results from the Diabetes Control and Complications Trial (DCCT) in line with the other trials. Ketoacidosis risk depended on the type of intensified treatment used. Odds ratios (95% CI) were 7.20 (2.95-17.58) for exclusive use of pumps, 1.13 (0.15-8.35) for multiple daily injections and 1.28 (0.90-1.83) for trials offering a choice between the two (p = 0.004 for interaction). Mortality was significantly (p = 0.007) increased for causes potentially associated with acute complications (7 vs 0 deaths, 5 deaths attributed to ketoacidosis, and 2 sudden deaths), and non-significantly (p = 0.16) decreased for macrovascular causes (3 vs 8 deaths). We conclude that there is a substantial risk of severe adverse effects associated with intensified insulin treatment. Mortality from acute metabolic causes is increased; however, this is largely counterbalanced by a reduction in cardiovascular mortality. The excess of severe hypoglycemia in the DCCT is not exceptional. Multiple daily injection schemes may be safer than treatment with insulin pumps.

[Complications during and after surgical removal of mandibular third molars. Impact of patient related and anatomical factors]

The estimation of possible intra- and postoperative complications for surgical removal of third molars in the mandible poses a frequent dilemma in oral surgery. In the present study, the influence of the patient's age and gender, a reduced mouth opening, and the anatomical position of the tooth in the mandible on intra- and postoperative complications were evaluated. In a total of 120 surgically removed third molars, 9.2% intraoperative complications occurred, mainly bleeding. Factors influencing the risk for intraoperative complications were a male patient, a reduced mouth opening, and distally angulated teeth. Postoperative complications were encountered in 6.7%, mainly dry sockets. For this group, a female gender, a higher age, and distally angulated teeth were identified as risk parameters. As most of the patient- and anatomy-related factors are set parameters when evaluating possible risk factors for third molar surgery, only the timepoint of surgery can be influenced by the surgeon. Regarding the increase in intra- and postoperative complications for third molar removal in higher age groups, the prophylactic third molar surgery between the age of 18 and 25 seems justified.

[Childhood Henoch-Schönlein syndrome--common and uncommon features, complications, Finkelstein-Seidlmayer variant and management]

Although Henoch-Schönlein syndrome can occur at any age, it is overwhelmingly a disease of childhood. Indeed, Henoch-Schönlein syndrome is the most common vasculitis that affects children. The clinical features of this vasculitis are well documented, and the diagnosis is generally not difficult. This article briefly reviews both common and uncommon clinical aspects of the condition and information concerning therapy. A further focus of this review is recent information concerning abnormalities of immunoglobulin IgA1 glycosylation and the role of aberrantly glycosylated immunoglobulins in the development of Henoch-Schönlein syndrome. The final focus of the article is acute hemorrhagic edema, a benign vasculitis limited to the skin, which is characterized by circinate, medallion-like purpura, and ecchymoses and occurs in children younger than 4 years of age. The nosologic position of acute hemorrhagic edema, which has also been called Finkelstein-Seidlmayer syndrome, as a variant of Henoch-Schönlein syndrome is the subject of considerable debate, but most authors agree that there are sufficient clinical and prognostic differences to consider it a separate entity.