Articles: palliative-care.
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The records of 125 consecutive patients with unresectable pancreatic cancer treated between 1958 and 1979 were evaluated to determine the benefit or morbidity of gastroenterostomy performed on a routine basis. One hundred three patients had no evidence of gastric outlet obstruction from tumor extension as determined at the time of initial operation. Fifty-seven of these patients underwent biliary diversion as their only operative procedure. ⋯ Forty-six patients underwent both biliary and prophylactic gastric outlet diversion with a 15 percent mortality rate and a 46 percent incidence of morbidity. The most common complication in this group was delayed gastric emptying (14 percent). These findings, and the high incidence of delayed gastric emptying after gastroenterostomy and the relatively infrequent occurrence of gastric outlet obstruction (11 percent) after initial biliary diversion, suggest that gastroenterostomy should be performed on a selective basis only.
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One hundred and seventy-eight patients undergoing total hip replacement and 67 patients undergoing spinal surgery were given diamorphine intrathecally in varying doses. Doses in mg/kg were plotted against duration of analgesia and the absence of retention and emetic symptoms in each type of surgery. Analysis showed that these were not dose dependent within the therapeutic range of 0.005-0.015 mg/kg.
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Continuous infusion of drugs via an implantable infusion system offers advantages that are not available with other methods of drug delivery. For patients who require frequent drug injections, a continuous drug level, or high local concentrations, an implantable pump may assure compliance, comfort, and an improved therapeutic response. This method of drug delivery has been shown to be reliable and well tolerated by patients in numerous clinical trials. ⋯ At the present time regional infusion chemotherapy and intraspinal narcotic infusion for cancer pain seem to be most frequently encountered in a hospice setting. However, other uses for these implantable infusion systems are rapidly being developed, and this means of drug delivery probably will become more common in the next few years. One of the goals of continuous drug infusion by implantable pumps--optimal medical care without confining the patient to a hospital bed--is eminently compatible with the philosophy of hospice care.
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During a 6-year period, 24 patients, aged 7 days to 18 years, underwent palliative surgery for single-ventricle heart malformations; 22 has single-left ventricle with outlet chamber (14 with L-transposition); only two had type C malformation (van Praagh). They were subdivided according to physiology into two groups: the first included 15 patients with decreased pulmonary blood flow, whose main clinical feature was arterial desaturation; the second consisted of nine patients with increased pulmonary blood flow, who presented early with unmanageable heart failure. The first group was treated with a Blalock-Taussig shunt (typical or modified) in 12 cases (one death due to preoperative acute renal failure), with a Waterston or Potts shunt in two cases (both died early postoperatively), and by enlargement of the bulbo-ventricular foramen in one (who died at operation). ⋯ Patients of the second group received a pulmonary artery banding plus a number of associated procedures: coarctation repair (2), ligation of a patent ductus arteriosus (2), Blalock-Hanlon atrial septectomy (1), tricuspid valve replacement (1). There was only one early death due to critical subaortic stenosis produced by a restrictive outlet foramen; however, there were five late deaths and two cases of surgical failure with persistent pulmonary hypertension. An analysis of the best palliative approach in patients with single-ventricle heart malformations is made, based upon the results of this series and taking into consideration the possibility of future intracardiac repair.