Concept: Recurrence relation
Patients who have had a first episode of unprovoked venous thromboembolism have a high risk of recurrence after anticoagulants are discontinued. Aspirin may be effective in preventing a recurrence of venous thromboembolism.
Background The distribution of malpractice claims among physicians is not well understood. If claim-prone physicians account for a substantial share of all claims, the ability to reliably identify them at an early stage could guide efforts to improve care. Methods Using data from the National Practitioner Data Bank, we analyzed 66,426 claims paid against 54,099 physicians from 2005 through 2014. We calculated concentrations of claims among physicians. We used multivariable recurrent-event survival analysis to identify characteristics of physicians at high risk for recurrent claims and to quantify risk levels over time. Results Approximately 1% of all physicians accounted for 32% of paid claims. Among physicians with paid claims, 84% incurred only one during the study period (accounting for 68% of all paid claims), 16% had at least two paid claims (accounting for 32% of the claims), and 4% had at least three paid claims (accounting for 12% of the claims). In adjusted analyses, the risk of recurrence increased with the number of previous paid claims. For example, as compared with physicians who had one previous paid claim, the 2160 physicians who had three paid claims had three times the risk of incurring another (hazard ratio, 3.11; 95% confidence interval [CI], 2.84 to 3.41); this corresponded in absolute terms to a 24% chance (95% CI, 22 to 26) of another paid claim within 2 years. Risks of recurrence also varied widely according to specialty - for example, the risk among neurosurgeons was four times as great as the risk among psychiatrists. Conclusions Over a recent 10-year period, a small number of physicians with distinctive characteristics accounted for a disproportionately large number of paid malpractice claims.
Background In a randomized trial comparing mitral-valve repair with mitral-valve replacement in patients with severe ischemic mitral regurgitation, we found no significant difference in the left ventricular end-systolic volume index (LVESVI), survival, or adverse events at 1 year after surgery. However, patients in the repair group had significantly more recurrences of moderate or severe mitral regurgitation. We now report the 2-year outcomes of this trial. Methods We randomly assigned 251 patients to mitral-valve repair or replacement. Patients were followed for 2 years, and clinical and echocardiographic outcomes were assessed. Results Among surviving patients, the mean (±SD) 2-year LVESVI was 52.6±27.7 ml per square meter of body-surface area with mitral-valve repair and 60.6±39.0 ml per square meter with mitral-valve replacement (mean changes from baseline, -9.0 ml per square meter and -6.5 ml per square meter, respectively). Two-year mortality was 19.0% in the repair group and 23.2% in the replacement group (hazard ratio in the repair group, 0.79; 95% confidence interval, 0.46 to 1.35; P=0.39). The rank-based assessment of LVESVI at 2 years (incorporating deaths) showed no significant between-group difference (z score=-1.32, P=0.19). The rate of recurrence of moderate or severe mitral regurgitation over 2 years was higher in the repair group than in the replacement group (58.8% vs. 3.8%, P<0.001). There were no significant between-group differences in rates of serious adverse events and overall readmissions, but patients in the repair group had more serious adverse events related to heart failure (P=0.05) and cardiovascular readmissions (P=0.01). On the Minnesota Living with Heart Failure questionnaire, there was a trend toward greater improvement in the replacement group (P=0.07). Conclusions In patients undergoing mitral-valve repair or replacement for severe ischemic mitral regurgitation, we observed no significant between-group difference in left ventricular reverse remodeling or survival at 2 years. Mitral regurgitation recurred more frequently in the repair group, resulting in more heart-failure-related adverse events and cardiovascular admissions. (Funded by the National Institutes of Health and Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT00807040 .).
Ankle sprain is the most common sports-related injury with a high rate of recurrence and associated costs. Recent studies have emphasised the effectiveness of both neuromuscular training and bracing for the secondary prevention of ankle sprains.
BACKGROUND: Transabdominal preperitoneal (TAPP) repair is widely used to treat bilateral or recurrent inguinal hernias. Recently a self-gripping mesh has been introduced into clinical practice. This mesh does not need staple fixation and thus might reduce the incidence of chronic pain. This prospective study aimed to compare two groups of patients with bilateral (BIH) or monolateral (MIH) primary or recurrent inguinal hernia treated with TAPP using either a self-gripping polyester and polylactic acid mesh (SGM) or a polypropylene and poliglecaprone mesh fixed with four titanium staples [standard technique (ST)]. METHODS: In this study, 96 patients (mean age, 58 years) with BIH (73 patients with primary and recurrent hernia) or MIH (22 patients with recurrent hernia) underwent a TAPP repair. For 49 patients, the repairs used SGM, and for 46 patients, ST was used. The patients were clinically evaluated 1 week and then 30 days postoperatively. After at least 6 months, a phone interview was conducted. The short-form McGill Pain Questionnaire was administered to all the patients at the 6-month follow-up visit. RESULTS: The mean length of the procedure was 83 min in the SGM group and 77.5 min in the ST group. The mean follow-up period was 13.8 months (range 1.3-42.0 months) for the SGM group and 18.2 months (range 1.9-27.1 months) for the ST group. The recurrence rate at the last follow-up visit was 0 % in the SGM group and 2.2 % (1 patient) in the ST group. The incidence of mild chronic pain at the 6-month follow-up visit was 4.1 % in the SGM group and 9.1 % in the ST group, and the incidence of moderate or severe pain was respectively 2.1 and 6.8 %. CONCLUSIONS: The study population was not large enough to obtain statistically significant results. However, the use of SGM for TAPP repairs appeared to give good results in terms of chronic pain, and the incidence of recurrences was not higher than with ST. In our unit, SGM during TAPP repair of inguinal hernias has become the standard.
Object Previous studies of systemic and intralesional administration of nonpegylated interferon have shown efficacy against craniopharyngioma. Pegylaion of interferon-α-2b (PI) prolongs the half-life, allowing sustained exposure of the drug over time, and enhances efficacy. The authors report the results of the use of PI in 5 children with recurrent craniopharyngiomas. Methods Five children, ranging in age from 9 to 15 years, with recurrent craniopharyngiomas were treated for up to 2 years with subcutaneous injections of PI at a dose of 1-3 μg/kg/week. Tumor response was assessed using MRI. Results All patients had stable disease or better in response to PI. One patient experienced a recurrence after gross-total resection (GTR). She initially showed an increase in the predominantly cystic tumor after 3 months of treatment, followed by a complete response. She required no further intervention and remains without evidence of disease 10 years after starting treatment. Another patient experienced recurrence 3.3 years after subtotal resection (STR) and radiation therapy. He had complete disappearance of the predominantly cystic component after 4 months of treatment, and a small residual calcified mass remains 5 years later. The third patient experienced recurrence after 3 GTRs. He had a complete response after 7 months of treatment and remains without evidence of disease 19 months after starting treatment. The fourth patient experienced recurrence after 2 STRs. He had a 30% decrease in tumor size after 4 months of treatment, which was maintained for 12 months at which point the cyst began to increase in size. The final patient experienced recurrence after GTR and has stable disease 6 months after starting treatment with PI. Conclusions The use of PI in children with recurrent craniopharyngiomas can result in significant and durable responses and potentially delay or avoid the need for radiation therapy.
PURPOSE: Chemical denervation is not recommended as part of the routine care of chronic non-cancer pain. Physicians face a dilemma when it comes to repeated interventions in cases of recurrent thoracolumbar facet joint pain after successful thermal radiofrequency ablation (RFA) in medial branch neurotomy. This study was performed to compare the effects of alcohol ablation (AA) with thermal RFA in patients with recurrent thoracolumbar facet joint pain after thermal RFA treatment. METHODS: Forty patients with recurrent thoracolumbar facet joint pain after successful thermal RFA defined as a numeric rating scale (NRS) score of ≥7 or a revised Oswestry disability index (ODI) of ≥22 % were randomly allocated to two groups receiving either the same repeated RFA (n = 20) or AA (n = 20). The recurrence rate was assessed with NRS and ODI during the next 24 months, and adverse events in each group were recorded. RESULTS: During the 24-month follow-up after RFA and AA, one and 17 patients, respectively, were without recurring thoracolumbar facet joint pain. The median effective periods in the RFA and AA groups were 10.7 (range 5.4-24) and 24 (range 16.8-24) months, respectively (p < 0.000). No significant complications were observed with the exception of injection site pain, which occurred in both groups. CONCLUSION: In our patient cohort, alcohol ablation in medial branch neurotomy provided a longer period of pain relief and better quality of life than repeated radiofrequency medial branch neurotomy in the treatment of recurrent thoracolumbar facet joint pain syndrome after successful thermal RFA without significant complications during the 24-month follow-up.
To evaluate the influence of pterygium morphology on the efficacy and safety of fibrin glue in pterygium surgery with conjunctival autografting. A prospective case series. During a period of 15 months, 45 patients (51 eyes) were recruited from the General Hospital for pterygium surgery. Seven eyes (13.73 %) were operated on for a recurrent pterygium. Autologous conjunctiva was harvested from the superior bulbar conjunctiva and fixed with fibrin glue. The pterygia were preoperatively divided into atrophic/grade 1 (n = 18; 35.29 %), intermediate/grade 2 (n = 22; 43.14 %) or fleshy/grade 3 (n = 11; 21.57 %) according to clinical morphology. Patients were evaluated for intraoperative and postoperative complications and recurrence rates. The success rate was defined by no pterygium recurrences. Patients with 2-year follow-ups were included in this study. Fifty-one patients (21 females/30 males) with a mean age of 60-65 years (range 24-87 years) took part in the study. All patients completed the study. No intraoperative complications were noted. Postsurgical complications included graft edema (n = 4; 7.8 %), graft hyperemia (n = 2; 3.8 %), and graft dislocation (n = 3; 5.9 %); these complications were transient. One graft unfastened completely (2 %) and five pterygium recurrences occurred (n = 5; 9.8 %). The overall success rate was 90 % after 2 years. In grade I group there were no recurrences, in grade 2 group there were two recurrences, and in grade 3 group there were three recurrences. There were significantly more recurrences in grade 3 group than in grade 2 group. There were more recurrences in both groups than in group 1 (60 vs 40 vs 0 % of all recurrences, p ≤ 0.05). The use of fibrin glue is a safe, easy and effective technique for attaching the conjunctival autograft in pterygium surgery. The morphology of pterygium influences recurrence rates, without significance for intraoperative and postoperative complications.
Objective: To present and evaluate the use of nasal dermoplasty for control of recurrent nasal polyps. Study design: Prospective case series. Method: The mucosa of the fovea ethmoidalis and the lamina papyracea was replaced by a split-thickness skin graft. The follow-up period ranged from 2 to 12 months. Results: Five patients underwent nasal dermoplasty for recurrent nasal polyposis. In three cases, the graft uptake was successful. Post-operatively, four patients reported they were in better condition than at the same interval after their previous operation. Recurrence of polyps was noted in all patients but not in the grafted areas. Conclusion: In this study, there was a high prevalence of successful graft uptake following nasal dermoplasty. This technique may have potential for the control of recurrent nasal polyps. Although it is demanding and time-consuming, it may reduce the need for multiple operations. Further research is justified to establish its efficacy.