1. Walters-Fischer, Patricia BS, RN

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A fourfold greater incidence among smokers.

A study released by a Danish hospital reports that there is a greater risk of incisional hernias after abdominal surgery among smokers.


From January 1997 to December 1998, data concerning 1,066 elective or emergency laparotomies (including relaparotomies) performed in 916 patients were collected. The procedures, which included open gastroduodenal, pancreatic, and biliary surgery, and operations on the small bowel, colon, and rectum, all took place at Bispebjerg Hospital at the University of Copenhagen in Denmark.


The data included variables relating to the patient's general and medical histories, the characteristics of the disease, the patient's preoperative clinical condition, operative severity and findings, and the surgeon's training. The patient's history of smoking also was obtained prior to surgery, and his weight and height, the fascial closure, and the location of the incision were recorded at follow-up.


Among patients who underwent elective surgery (n = 165), daily smokers accounted for 41.2%; among those who underwent emergency procedures (n = 145), they accounted for 42.8%, and the median ages of patients were 66 and 63, respectively. Additionally, among the patients who underwent elective surgery, 38.2% had diabetes, cardiovascular disease, or lung disease, 6.1% had cirrhosis or previous myocardial infarction or stroke, 3% had local or diffuse peritonitis, and 43% had a malignancy. In the emergency-procedure group, 40% of patients had diabetes, cardiovascular disease, or lung disease, 9% had cirrhosis or previous myocardial infarction or stroke, 30.3% had local or diffuse peritonitis, and 12.4% had a malignancy.


Any postoperative complications that occurred within 30 days of surgery were documented by the surgeon at either hospital discharge or readmission, so that only those necessitating hospitalization were recorded. Of the initial 916 patients, 310 were examined; 491 (53.6%) had died before examination, 22 (2.4%) were lost to follow-up, and 93 (10.2%) failed to return for examinations. In the study group, there was a 26% rate of incisional hernia on examination (defined as "a palpable defect of the fascia under or adjacent to an incision of the abdominal wall with a protrusion of tissue through the defect found on Valsalva maneuver"), with 81.5% of such hernias located in midline incisions.


The study revealed that there is a fourfold greater incidence of incisional hernia among smokers, independent of any other risk factors, with a higher rate among older male patients but not among obese patients.


The researchers concluded that smoking delays wound-healing, and that physicians might advise patients to cease the habit prior to any elective procedures. Long-term intervention studies are necessary to determine the effect of smoking cessation on incisional herniation.


Sorensen LT, et al. Arch Surg 2005;140(2): 119-23.



Attributable to severe, sudden emotional distress.

A study conducted at Johns Hopkins University reports that severe and sudden emotional distress can precipitate reversible left ventricular dysfunction in people without a history of coronary artery disease.


From November 1999 to September 2003, researchers evaluated 19 patients who presented to Johns Hopkins Hospital or Johns Hopkins Bayview Medical Center in Baltimore with left ventricular dysfunction (or "stress cardiomyopathy") after sudden emotional distress. All patients presented to the ED at a median of two hours after the onset of symptoms (severe chest pain and dyspnea) with chest pain, pulmonary edema, and cardiogenic shock. An initial electrocardiogram was performed, and creatine kinase, creatine kinase-MB, and troponin I levels were measured upon arrival. All patients underwent coronary angiography and serial echocardiography, and five of the 19 also underwent endomyocardial biopsy.


Half of the patients (among whom the median age was 63 and 18 [95%] were women) had received news of an unexpected death prior to the onset of symptoms, and among the other half a variety of emotionally stressful events had preceded them.


Upon evaluation of the results, 17 patients were found to have mildly elevated serum troponin I levels, but angiographic evidence of clinically significant coronary artery disease was manifested in only one of the 19. Within a median of four days of admission, all the patients showed signs of improvement, with left ventricular dysfunction rapidly resolving.


Acute emotional stress can precipitate the signs and symptoms of left ventricular dysfunction in patients, even in the absence of a history of coronary artery disease. Caregivers should be sure to take from the patient or family members a detailed account of how the symptoms emerged and of any traumatic or emotionally stressful events that have recently occurred, and not presume that the patient is being histrionic or having an anxiety attack. Stress cardiomyopathy is a real condition that warrants treatment.


Wittstein IS, et al. N Engl J Med 2005; 352(6):539-48.