Primary thyroid lymphoma is a rare disease that continues to produce diagnostic and therapeutic dilemmas. There was great difficulty in distinguishing thyroid lymphoma from anaplastic thyroid carcinoma but, because of new immunocytochemical staining techniques and increased cytopathologic knowledge, our ability to diagnose thyroid lymphoma has improved drastically over the past decade. Surgery that was once the mainstay of treatment for this disease, now plays a minimal role. Current treatment regimens for primary thyroid lymphoma consist of chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisone) and external beam radiation. The overall and distant relapse rates have been shown to be significantly lower in those patients receiving combined modality therapy compared to chemotherapy or radiation alone. Although the role of surgery has changed over time, it continues to play an important role, especially in confirming diagnoses through open biopsies, potentially providing local control in the more indolent subtypes, and may play a role in the palliation of symptoms for large obstructive lymphomas. The evolving classification of extranodal lymphomas has brought about a better understanding of the biologic behavior of these tumors. Most thyroid lymphomas are B-cell origin, with six different histologic subtypes, but there appears to be two distinct clinical and prognostic groupings of these rare tumors. The more indolent lymphomas are the subgroup of mucosa-associated lymphoid tissue (MALT) lymphomas comprising approximately 6% to 27% of thyroid lymphomas. This subgroup, when localized to the thyroid (stage IE), responds well to total thyroidectomy or radiation with a complete response rate of more than 90%, leading some authors to recommend surgery as primary therapy in the treatment of localized MALT lymphomas. Therefore, surgery as a primary treatment for thyroid lymphomas would only be recommended under ideal conditions, such as MALT subtype stage IE only, and completely resectable with minimal morbidity. Unfortunately, this scenario is rarely the case. The more common subtype, comprising up to 70% of cases, is diffuse large B-cell lymphoma. This subtype appears to have the most aggressive clinical course with almost 60% of these tumors diagnosed with disseminated disease. Up to 40% of all diffuse large cell lymphomas appear to have undergone transformation from a MALT lymphoma, but they behave in a similar fashion to diffuse large cell lymphomas. Treatment for these tumors should include chemotherapy and radiation. The overall 5-year survival for this aggressive group is less then 50%. Surgery is rarely beneficial in diffuse large cell lymphoma and the mixed large cell subtypes because the disease is generally disseminated and surgical excision of all disease is not possible or associated with increased morbidity. However, there may be a role for palliative surgical debulking to alleviate obstructive symptoms while the patient is undergoing standard chemotherapy and radiation.
Head of bed elevation results in clinically significant increases in measured IAP. Consistent body positioning from one IAP measurement to the next is necessary to allow consistent trending of IAP for accurate clinical decision making. Studies that involve IAP measurements should describe the patient's body position so that these values may be properly interpreted.
IntroductionWith the increasing aging population demographics and life expectancies the number of very elderly patients (age ≥ 80) undergoing emergency surgery is expected to rise. This investigation examines the outcomes in very elderly patients undergoing emergency general surgery, including predictors of in-hospital mortality and morbidity.MethodsA retrospective study of patients aged 80 and above undergoing emergency surgery between 2008 and 2010 at a tertiary care facility in Canada was conducted. Demographics, comorbidities, surgical indications, and perioperative risk assessment data were collected. Outcomes included length of hospitalization, discharge destination, and in-hospital mortality and morbidity. Multivariable logistic regression was used to identify predictors of in-hospital mortality and complications.ResultsOf the 170 patient admissions, the mean age was 84 years and the in-hospital mortality rate was 14.7%. Comorbidities were present in 91% of this older patient population. Over 60% of the patients required further services or alternate level of care on discharge. American Society of Anesthesiologist Physical Status (ASA) Classification (OR 5.30, 95% CI 1.774-15.817, p = 0.003) and the development of an in-hospital complications (OR 2.51, 95% CI 1.210-5.187, p = 0.013) were independent predictors of postoperative mortality. Chronological age or number of comorbidities was not predictive of surgical outcome.ConclusionsMortality, complication rates and post-discharge care requirements were high in very elderly patients undergoing emergency general surgery. Advanced age and medical comorbidities alone should not be the limiting factors for surgical referral or treatment. This study illustrates the importance of preventing an in-hospital complication in this very vulnerable population. ASA class is a robust tool which is predictive of mortality in the very elderly population and can be used to guide patient and family counseling in the emergency setting.
CT scanning in conjunction with plain films enhances the number of cervical spine injuries seen radiographically. Application of a protocol of plain radiographs and CT scanning may be used to clear cervical spines in the obtunded trauma patient. Ongoing evaluation of this protocol is required.
In this unique study, geographic differences in religion, practice composition, decision-maker viewpoint, and institutional resources resulted in significant variation in end-of-life care after injury. These disparities reflect competing concepts (patient autonomy, distributive justice, and religion).
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