Paul Friedmann

Survival following moderate-dose preoperative radiation therapy for carcinoma of the rectum

We performed a retrospective study of patients with carcinoma of the rectum or rectosigmoid undergoing surgical resection. Forty‐two patients received adjuvant preoperative radiation therapy (4000–4500 rad). One hundred twenty patients underwent surgical resection alone. Survival of radiation patients was significantly improved over that of Surgery Only patients, even after adjusting for nontreatment factors using Cox regression. Crude 5‐year survival was 63% for radiation patients (74% adjusted) compared to 46% for surgery‐only patients (48% adjusted) (P < 0.025). Radiation patients also had longer disease‐free survival than surgery‐only patients (P < 0.05) and fewer recurrences (14% versus 37%; P < 0.025). Fewer radiation patients had lymph nodes involved with tumor than surgery‐only patients (20% versus 35%; P = 0.07). Although 71% of radiation patients experienced radiation reactions, these were primarily mild and transitory. We believe that preoperative radiation is an effective and safe adjunct to surgery in the treatment of rectal cancer and that its use can lead to improved survival rates.

Synergistic effect of acute renal failure and respiratory failure in the surgical intensive care unit

A retrospective evaluation of the effect of renal and respiratory failure on mortality in our surgical intensive care unit was undertaken. The coexistence of combined renal and respiratory failure had a synergistic adverse effect on survival. Combined pulmonary and kidney failure appeared to develop simultaneously. A subset of patients with severe prerenal azotemia but without uremia had the highest mortality. These results are not consistent with the simple combination of single systems failure but rather suggest that renal and respiratory failure are makers of a generalized underlying defect.

A prospective comparison of two expanded polytetrafluoroethylene grafts for linear forearm hemodialysis access: does the manufacturer matter?

BACKGROUND The function and patency of standard 6-mm Goretex (W.L. Gore and Associates, Flagstaff, AZ) and Impra (Impra, Inc., Tempe, AZ) expanded polytetrafluoroethylene (e-PTFE) grafts for hemodialysis as radial-antecubital linear arteriovenous fistulae for dialysis are compared. STUDY DESIGN A randomized clinical trial was conducted in two community dialysis centers and in one hospital-based center serviced by one vascular surgical practice, that performed the access surgery. Selection of linear forearm access, as opposed to other hemodialysis graft configurations, was at the discretion of the surgeon. Candidates for linear grafts had palpable radial pulses with a normal Allen test and normal digital Doppler flow in the hand. Linear grafts were placed using end-to-side anastomoses to the artery and vein, and the graft type was determined by randomization. Primary patency was determined by first episode of thrombosis, first revision, or angioplasty of the graft. Secondary patency after thrombectomy, revision, or angioplasty was determined when the graft was no longer clinically usable, and a new graft needed to be placed as a parallel conduit in the forearm or in another site. Statistical analysis was by actuarial life-table methods. RESULTS There were 131 linear forearm grafts in 117 patients. The Impra and Goretex groups were equally matched for gender and major risk factors, except for smoking, which was more common in the Goretex group. Minimum followup was 24 months. Life table primary patencies at 1 year (Impra 43%, Goretex 47%) and at 2 years (Impra 30%, Goretex 26%) were not statistically different (p = 0.78); secondary patency was also equal at 1 year (Impra 49%, Goretex 69%) and at 2 years (Impra 33%, Goretex 41%) (p = 0.15). Discontinuance of use of a patent graft, complications, episodes of thrombosis, and the need to replace the original graft occurred in the two groups without a statistically significant difference. CONCLUSIONS In the linear forearm position from the radial artery to an antecubital vein, there is no difference in the performance of 6-mm standard e-PTFE grafts on the basis of manufacturer, whether Goretex or Impra. On the basis of performance, linear forearm dialysis grafts are an acceptable method for hemodialysis access.

Carotid endarterectomy. Clinical results in a community-based teaching hospital.

Since 1971, 688 consecutive carotid endarterectomies were performed in 612 patients in a community-based teaching hospital by 16 surgeons; 82% of the procedures were performed in patients who had suffered a transient ischemic attack, amaurosis fugax, or a previous stroke. Seven patients (1%) died, five of perioperative stroke and two of myocardial infarction. Thirty-one patients suffered a perioperative stroke (4.5% of the 688 endarterectomies); 20 patients (2.9% of 688) were left with moderate to severe neurologic deficits. The combined mortality/major neurologic deficit morbidity rate (number of patients divided by number of endarterectomies) is 3.2%. Both operative mortality and morbidity have progressively declined in successive 5-year periods, with no deaths and a 2.7% stroke rate in 148 endarterectomies performed after 1984. Our results indicate that carotid endarterectomy as practiced in a community-based teaching hospital can be performed without excessive risk.

The sequential femoropopliteal bypass graft: A five year experience☆

(1) A five year experience with sequential bypass grafts for femoropopliteal tibial reconstruction is presented. (2) Twenty-nine consecutive grafts were performed in twenty-eight patients in whom the saphenous vein was absent or inadequate for grafting purposes. (3) The series contains a high percentage of women (57 per cent), diabetics (39 per cent), and patients requiring surgery because of rest pain or tissue necrosis (83 per cent). (4) There was no operative mortality and no significant operative morbidity. (5) The overall graft patency rate is 71 per cent, which is comparable to that obtained with standard bypass technics. (6) There was no late failures in the ten grafts that survived one year or more. (7) This procedure appears to be a useful method for bypass grafting to the popliteal or tibial arteries below the knee when the saphenous vein is absent or inadequate.

Adjuvant radiation therapy in colorectal carcinoma

A series of sixty-five patients with adenocarcinoma of the rectum and rectosigmoid is reviewed. Thirty-two patients had surgery alone, fourteen patients underwent postoperative radiation therapy, and nineteen patients underwent preoperative radiation therapy. A moderate dose program of 4,000 to 4,500 r was used. The postoperative treatment group had a higher incidence of stage C lesions and a higher recurrence rate, but there were no statistically significant differences in survival. Postoperative radiation therapy in patients with stage C lesions did not prolong life and is of little benefit. The preoperative treatment group tolerated the radiation very well, and there were no major complications. Eight patients underwent anterior resections in irradiated fields. Two minor anastomotic leaks subsequently healed spontaneously. There were no pelvic recurrences in the preoperative treatment group, and the incidence of lymph node metastases was 26% as opposed to 41% in controls. We conclude that preoperative moderate dose radiation is not associated with increased risk of morbidity or mortality. It may be useful in reducing the incidence of lymph node metastases and pelvic recurrence. The effect on survival is not determined in this study.

Coumarin Skin Necrosis in a Patient with Heparin-Induced Thrombocytopenia — A Case Report

A patient with evidence of both heparin-related thrombocytopenia and coumarin-induced skin necrosis is presented. Etiology, diagnostic evaluation, histopathology, and therapeutic options are discussed.

The 2003 common duty hour limits: process, outcome, and lessons learned.

Long hours are a component of medical residency and a cultural symbol of a profession that requires hard work and dedication. The origins of residents’ long work hours, along with the term residency, are found in a traditional model of clinical education as a generally brief period of intense training, during which responsibility for patients rested with the residents 24 hours a day, 7 days a week. By the early 21st century, this has given way to a multiyear experience that combines participation in patient care with new learning modalities in a vastly changed delivery system. In the summer of 2002, the Accreditation Council for Graduate Medical Education (ACGME) granted preliminary approval to common duty hour limits for all specialties that became effective in July 2003. The establishment of common duty hour standards was prompted by 3 factors: a change in the delivery system, with increased patient acuity and demands on residents; a body of scientific knowledge showing negative effects of sleep loss on performance; and public attention on the number of hours worked by residents. In late 2001 this culminated in the introduction of legislation to limit resident hours and a petition to regulate duty hours as a workplace health hazard. In response, the ACGME charged a work group with the development of a blueprint for common duty hour limits. Setting duty hour standards across specialties was a watershed event for the ACGME, yet it built on 20 years of prior effort that had produced specialty-specific limits. The nuances of this approach made it difficult to explain its benefits to the public. The dialogue with the academic community and the public highlighted a gulf between these 2 stakeholder groups. From this emerged 2 concepts that served as guiding principles for the work group’s deliberations. The first was reaffirmation of the need for standards sensitive to the education and patient care needs of the 26 ACGMEaccredited specialties; the second was a need for the standards to reflect the science on sleep loss and performance. This led to a plan to develop common standards that would preserve an educational accreditation model that was flexible and sensitive to specialties, programs, and residents. At the same time, the standards should be easily explained to the public and viewed as comparable to the perceived safety and effectiveness of a legislative or regulatory approach.

The development of new medical specialties.

The development of new medical specialties has been an essential feature of the growth of modern scientific medicine. The time has long since passed when any individual could master the entire field of medical knowledge and practice. Perhaps Hermann Boerhaave of Leyden was the last of the great medical polymaths, but the course of medical education and practice since the early part of the eighteenth century has been one of progressive and inexorable specialization. For the most part, the medical specialties have developed in concert with scientific advances in a special area, although the history of specialization dates all the way back to ancient Egyptian practices, in which “one physician is confined to the study and management of one disease.” Sir William Osler recognized the necessity of specialization, but expressed his concern about the dangers of excessive fragmentation of the specialties themselves. “The incessant concentration of thought upon one subject, however interesting, tethers a man’s mind in a narrow field.” In the early part of the twentieth century, medical specialization was proceeding rapidly, but the educational systems were not in place to provide proper education and training. Organizations such as the American College of Surgeons and other specialty societies were formed in part to provide the educational basis for the development of special knowledge and skills. Nevertheless, physicians were able to practice in medical specialties without adequate training, and there was no assurance to the public that a physician had the requisite knowledge, training, and skills to practice safely in a specialty area. In his Presidential Address to the American Academy of Ophthalmology and Otolaryngology in 1908, Derrick T. Vail proposed the concept of the organization of a specialty board to set the standards for training in ophthalmology and to certify to the public that a physician had been found competent to practice in that specialty. “After a sufficiently long time of service in an ophthalmic institution in America or abroad, he should be permitted to appear before a proper examining board, similar to any State Board of Examination and Registration, for examination, and if he is found competent let him then be permitted and licensed to practice ophthalmology.” The American Board for Ophthalmic Examinations was created in 1917 to “arrange, control, and supervise examinations to test the preparation of those who design to enter on the special or exclusive practice of ophthalmology.” The second specialty Board, in Otolaryngology, was founded in 1924. The American Board of Surgery was a relative latecomer to the Board system, being organized in 1937. There are now 24 recognized specialty Boards, all of which are separately incorporated and financially independent organizations. The function of the Boards is to “provide assurance to the public that a physician specialist certified by a member Board of the American Board of Medical Specialties (ABMS) has successfully completed an educational program and an evaluation process which includes an examination designed to assess the knowledge, skills, and experience required to provide quality patient care in that specialty.” The American Board of Medical Specialties grew out of the Advisory Board for Medical Specialties, which was formed in 1933 for the purpose of providing coordination and advice to the member Boards, and to assume jurisdiction over those common processes expressly delegated to it by the participating Boards. The Advisory Council agreed not to interfere with the autonomy of any of the represented examining Boards. The Advisory Board became the American Board of Medical Specialties (ABMS) in 1970. One of the functions of the ABMS is to determine when a new or developing specialty can be recognized as such, and have its own examining Board. This function is delegated to the Liaison Committee for Specialty Boards (LCSB), which is a committee jointly formed by the ABMS and the Council on Medical Education (CME) of the American Medical Association (AMA). The ABMS and the AMA each appoint 4 voting members, under the chairmanship of the Chairman of the CME. The LCSB receives and evaluates applications for the formation of a new board, and it holds hearings. If the LCSB approves the application for a new Board, that recommendation is forwarded to the ABMS and the CME of the AMA. Each of these latter organizations must then act by a 2/3 majority in order to approve a new Board. If an application is not approved, it may be resubmitted after 12 months. Alternatively, the applicant may appeal the decision to an appeals committee, which makes a recommendation back to the LCSB. The LCSB then takes a final action. Correspondence: Inquiries to Paul Friedmann, MD, Department of Surgery, W3, Baystate Medical Center, Springfield, MA 01199; fax: (413) 794-0300; e-mail: paul.friedmann@bhs.org

Time-limited vs unlimited physician certification.

We also previously reported that among the 4282 participants who had been taking aspirin before study enrollment (ie, the continuation stratum), there was no benefit to continuing aspirin during the perioperative period for the outcome of mortality or nonfatal myocardial infarction (HR, 1.00; 95% CI, 0.81-1.23). A separate substudy will report the results of patients who had a prior stent. Although aspirin did not significantly affect the primary renal outcome (ie, an increase in serum creatinine concentration by either ≥0.3 mg/dL within 48 hours of surgery or an increase of ≥50% within 7 days of surgery), an outcome defined a priori demonstrated a higher risk of acute kidney injury in patients treated with dialysis and randomized to aspirin (HR, 2.20; 95% CI, 1.72-2.83). Few patients developed acute kidney injury requiring dialysis, but post hoc analyses demonstrated that major bleeding was independently associated with subsequent risk of acute kidney injury (adjusted HR, 2.20; 95% CI, 1.72-2.83). Our large international trial does not support the initiation or continuation of aspirin in patients having noncardiac surgery (including high-risk patients) because there was no demonstrated benefit and there was an increased risk of major bleeding (HR, 1.23; 95% CI, 1.01-1.49).2 In patients who have their aspirin held during the perioperative period and have an indication for long-term use, it is important to ensure aspirin is restarted 8 to 10 days after surgery when the risk of perioperative bleeding has passed. Further data are needed to elucidate the effects of perioperative aspirin use in patients with a prior coronary stent.