Institutional Outcomes of Leech Therapy for Venous Congestion in 87 Patients

Background We aimed to report the outcomes associated with leech therapy and to identify risk factors associated with reconstructive failure. Methods We retrospectively reviewed cases of flap reconstruction or replanted appendages that required leech therapy over an 8-year period at the Duke University Medical Center. Using logistic regression, we assessed the association of risk factors with reconstructive failure. Results The study cohort included 87 patients which correspond to 2.1% of 4,115 cases done during the study period. The most common flap recipient site was the lower extremity (n = 33, 37.9%) followed by the upper extremity (n = 30, 34.5%), head and neck (n = 13, 14.9%), and trunk (n = 11, 12.6%). Flap types were pedicled in 44 (50.5%) cases and free in 24 (27.5%) cases. Fifteen (17.2%) were digital replantation, and four (4.5%) were replanted appendages. The average duration of therapy was 4.6 days (range: 1–11). The overall leech therapy success rate was 60.9% (53/87) and accounted for cases without flap loss (n = 45, 51.7%) and with partial flap loss in which the original reconstructive goal was achieved without further reconstructive procedures (n = 8, 9.2%). Postoperative blood transfusion was administered in 32 (36.7%) cases, and infectious complications occurred in 7 cases in spite of the administration of prophylactic antibiotics (8%). Conclusions This study represents the largest single-institution series evaluating the outcomes after leech therapy. Our data support the use of leeches as an adjunct for the management of venous congestion after reconstructive surgery. However, the morbidity associated with it should be considered, particularly the need for a blood transfusion.

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Increase of major complications with a longer ischemia time in breast reconstruction with a free deep inferior epigastric perforator (DIEP) flap

European Journal of Plastic Surgery ◽

10.1007/s00238-019-01584-0 ◽

2019 ◽

Vol 43 (2) ◽

pp. 133-138

Author(s):

Nadine S. Hillberg ◽

Jop Beugels ◽

Sander M. J. van Kuijk ◽

René R. J. W. van der Hulst ◽

Stefania M. H. Tuinder

Keyword(s):

Breast Reconstruction ◽

Medical Center ◽

Major Complication ◽

P Value ◽

Diep Flap ◽

Level Of Evidence ◽

Recipient Site ◽

Ischemia Time ◽

Flap Loss ◽

Major Complications

Abstract Background The deep inferior epigastric artery perforator (DIEP) flap is one of the most used free flaps for postmastectomy breast reconstruction. Prolonged ischemia can result in (partial) flap loss. The aim of this study was to evaluate the association between ischemia time and postoperative complications of DIEP flap breast reconstruction. Methods A retrospective study of all patients who received a breast reconstructionwith aDIEP flap atMaastricht University Medical Center in theNetherlands, between January 2010 and June 2017 (n = 677). The flaps were divided into two groups: flaps with an ischemia time less than 60 min and those with 60 min or more. Recipient site complications, in particular major complications equal to re-exploration, and partial or total flap loss were the primary outcome measures. Results In 23.9% of the 677 included DIEP flaps, the ischemia time was 60 min or longer. Within this group, a complication of the recipient site occurred in 30.9% of the flaps. A major complication occurred in 17.3% of the flaps with 60 min or more ischemia time.With regard to the flaps with less than 60-min ischemia time, a complication occurred in 22.1% of the cases of which 8.9%would be considered amajor complication. A significant association was found between ischemia time and major complications on univariate (p value = 0.003) and multivariate analyses (p value = 0.016). Conclusions This study demonstrates that an ischemia time less than 60 min is associated with a significantly lower risk of major recipient site complications compared to an ischemia time of 60 min or more. Level of evidence: Level III, therapeutic, risk/prognostic study.

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Should postoperative haemoglobin and potassium levels be checked routinely following blood-conserving primary total joint arthroplasty?

The Bone & Joint Journal ◽

10.1302/0301-620x.101b1.bjj-2018-0554.r1 ◽

2019 ◽

Vol 101-B (1_Supple_A) ◽

pp. 25-31 ◽

Cited By ~ 18

Author(s):

N. J. Greco ◽

A. G. Manocchio ◽

A. V. Lombardi ◽

S. L. Gao ◽

J. Adams ◽

...

Keyword(s):

Risk Factors ◽

Blood Transfusion ◽

Total Joint Arthroplasty ◽

Laboratory Data ◽

Joint Arthroplasty ◽

Renal Diseases ◽

Study Cohort ◽

Blood Conservation ◽

Potassium Supplementation ◽

History Of

Aims Despite declining frequency of blood transfusion and electrolyte supplementation following total joint arthroplasty, postoperative blood analyses are still routinely ordered for these patients. This study aimed to determine the rate of blood transfusion and electrolyte restoration in arthroplasty patients treated with a perioperative blood conservation protocol and to identify risk factors that would predict the need for transfusion and electrolyte supplementation. Patients and Methods Patients undergoing primary total joint arthroplasty of the hip or knee between July 2016 and February 2017 at a single institution were included in the study. Standard preoperative and postoperative laboratory data were collected and reviewed retrospectively. A uniform blood conservation programme was implemented for all patients. Need for blood transfusion or potassium supplementation was determined through a coordinated decision by the care team. Rates of transfusion and supplementation were observed, and patient risk factors were noted. Results The overall rate of blood transfusion was 1.06% in the study population of 1132 total joint arthroplasties performed in 1023 patients. Of the 12 patients requiring transfusion, 11 were female, ten occurred in patients undergoing total hip arthroplasty, and all 12 patients had a preoperative haemoglobin level less than 130 g/l. Operative duration and surgical blood loss were significantly greater in those patients requiring blood transfusion. Nearly all patients requiring transfusion had a history of, or risk factors for, cardiovascular disease. Potassium supplementation was required in 15.5% of the study cohort; 72% of these patients receiving potassium presented with a potassium level less than 4 mmol/l during preoperative testing, while the remaining 28% had a past medical history of either significant anaemia, cardiopulmonary, cardiovascular, or renal diseases that had required substantial medical management. Conclusion A consistent blood-conserving perioperative strategy effectively minimized need for blood transfusion in total joint arthroplasty patients below previously reported rates in the literature. We suggest that postoperative full blood counts and basic metabolic panels should not routinely be ordered in these patients unless their preoperative haemoglobin and potassium is below 130 g/dl or 4 mmol/l respectively, and they have medical comorbidities.

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Hidden Blood Loss in Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Spinal Fusion Surgery: A Retrospective Study of 765 Cases in a Single Center

10.21203/rs.3.rs-523705/v1 ◽

2021 ◽

Author(s):

Lipeng Wang ◽

Jiangli Liu ◽

Xiaoxiao Song ◽

Muhui Luo ◽

Yongquan Chen

Keyword(s):

Risk Factors ◽

Regression Analysis ◽

Adolescent Idiopathic Scoliosis ◽

Blood Transfusion ◽

Blood Loss ◽

Idiopathic Scoliosis ◽

Spinal Fusion ◽

Posterior Spinal Fusion ◽

Postoperative Blood Transfusion ◽

Independent Risk Factors

Abstract Purpose: To investigate Hidden blood loss (HBL) and its potential risk factors in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion surgery and elucidate the influence of HBL on postoperative blood transfusion. Methods: We retrospectively studied 765 patients undergoing posterior spine fusion for adolescent idiopathic scoliosis from January 2014 to December 2018. The patient’s demographics, blood loss related parameters, operation and blood loss information were extracted. The association between patient’s characteristics and HBL was analyzed by Pearson or Spearman correlation analysis. Multivariate linear regression analysis was used to determine independent risk factors associated with HBL. Binary logistic regression analysis was used to analyze the influence of HBL on postoperative blood transfusion.Results: A total of 765 patients including 128 males and 637 females (age range 10-18 years) were included in this study. The mean amount of HBL was 693.5±473.4 ml, accounting for 53.9% of the total blood loss. In multivariate linear regression analysis, we found that preoperative Hct (p=0.003) and allogeneic blood transfusion (p<0.0001) were independent risk factors for HBL, while tranexamic acid (p=0.003) was negatively related to HBL. Binary logistic regression analysis showed that HBL > 850 ml ( P < 0.001, OR: 8.845, 95%CI: 5.806-13.290) was the independent risk factor for postoperative blood transfusion.Conclusion: a large amount of HBL was incurred in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion surgeries. Allogeneic blood transfusion and preoperative Hct were independent risk factors for HBL, while tranexamic acid was negatively related to HBL. HBL and its influential factors should be taken into account when considering the perioperative transfusion management. These patients with HBL greater than 850 ml should be paid more attention in case of postoperative anemia.Level of evidence: Level III

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Blood Transfusion is Associated with Infection and Increased Resource Utilization in Combat Casualties

The American Surgeon ◽

10.1177/000313480607200709 ◽

2006 ◽

Vol 72 (7) ◽

pp. 619-626 ◽

Cited By ~ 14

Author(s):

James R. Dunne ◽

Mark S Riddle ◽

Janine Danko ◽

Rich Hayden ◽

Kyle Petersen

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Blood Transfusion ◽

Resource Utilization ◽

Independent Risk Factor ◽

Study Cohort ◽

Icu Admission ◽

Independent Risk Factors ◽

Combat Casualties ◽

Injured Patients

Combat casualty care has made significant advances in recent years, including administration of blood products in far-forward locations. However, recent studies have shown blood transfusion to be a significant risk factor for infection and increased resource utilization in critically injured patients. We therefore sought to investigate the incidence of blood transfusion and its association with infection and resource utilization in combat casualties. Prospective data were collected and retrospectively reviewed on 210 critically injured patients admitted to the USNS Comfort over a 7-week period during the 2003 assault phase of Operation Iraqi Freedom. Patients were stratified by age, gender, and injury severity score (ISS). Multivariate regression analyses were used to assess blood transfusion and hematocrit (HCT) as independent risk factors for infection and intensive care unit (ICU) admission controlling for age, gender, and ISS. The study cohort had a mean age of 30 ± 2 years, a mean ISS of 14 ± 3, 84 per cent were male, and 88 per cent sustained penetrating trauma. Blood transfusion was required in 44 per cent (n = 93) of the study cohort. Transfused patients had a higher ISS (18 ± 4 vs. 10 ± 3, P < 0.01), a higher pulse rate (105 ± 4 vs. 93 ± 3, P < 0.0001), and a lower admission HCT (27 ± 1 vs. 33 ± 2, P < 0.0001) compared with patients not transfused. Patients receiving blood transfusion had an increased infection rate (69% vs. 18%, P < 0.0001), ICU admission rate (52% vs. 21%, P < 0.0001), and ICU length of stay (6.7 ± 2.1 days vs. 1.4 ± 0.5 days, P < 0.0001) compared with nontransfused patients. However, there was no significant difference in mortality between transfused and nontransfused patients. Multivariate binomial regression analysis identified blood transfusion and HCT as independent risk factors for infection (P < 0.01) and blood transfusion as an independent risk factor for ICU admission (P < 0.05). Combat casualties have a high incidence of blood transfusion. Blood transfusion is an independent risk factor for infection and increased resource utilization. Therefore, consideration should be given to the use of alternative blood substitutes and recombinant human erythropoietin in the treatment and management of combat casualties.

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Hidden blood loss in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion surgery: a retrospective study of 765 cases at a single centre

BMC Musculoskeletal Disorders ◽

10.1186/s12891-021-04681-z ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Lipeng Wang ◽

Jiangli Liu ◽

Xiaoxiao Song ◽

Muhui Luo ◽

Yongquan Chen

Keyword(s):

Risk Factors ◽

Regression Analysis ◽

Adolescent Idiopathic Scoliosis ◽

Blood Transfusion ◽

Blood Loss ◽

Idiopathic Scoliosis ◽

Posterior Spinal Fusion ◽

Hidden Blood Loss ◽

Postoperative Blood Transfusion ◽

Independent Risk Factors

Abstract Background In scoliosis corrective surgery, total blood loss is composed of visible blood loss, including intraoperative haemorrhage and drainage, and hidden blood loss in which blood extravasates into the tissues and accumulates in the surgical field. The purpose of this study was to investigate hidden blood loss (HBL) and its potential risk factors in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion surgery and elucidate the influence of HBL on the necessity for postoperative blood transfusion. Methods We retrospectively studied adolescent idiopathic scoliosis patients undergoing posterior spine fusion for adolescent idiopathic scoliosis from January 2014 to December 2018 at our hospital. The patients’ demographics, blood loss-related parameters, surgeries and blood loss data were extracted. The association between patient characteristics and HBL was analyzed by Pearson or Spearman correlation analyses. Multivariate linear regression analysis was used to determine independent risk factors associated with HBL. Binary logistic regression analysis was used to analyze the influence of HBL on the necessity for postoperative blood transfusion. Results A total of 765 patients, of whom 128 were male and 637 were female (age range 10–18 years), were included in this study. The mean volume of HBL was 693.5 ± 473.4 ml, accounting for 53.9 % of the total blood loss. The multivariate linear regression analysis revealed that preoperative Hct (p = 0.003) and allogeneic blood transfusion (p < 0.001) were independent risk factors for HBL, while tranexamic acid (p = 0.003) was negatively correlated with HBL. Binary logistic regression analysis showed that HBL > 850 ml (P < 0.001, OR: 8.845, 95 % CI: 5.806–13.290) was an independent risk factor for the necessity for postoperative blood transfusion. Conclusions Substantial HBL occurred in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion surgeries. Allogeneic blood transfusion and preoperative Hct were independent risk factors for HBL, while tranexamic acid was negatively related to HBL. HBL and its influencing factors should be considered when planning perioperative transfusion management. Patients with HBL greater than 850 ml should be closely monitored in cases of postoperative anaemia. Level of evidence Level III.

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Blood transfusion rates and predictors following geriatric hip fracture surgery

Hip International ◽

10.1177/1120700019897878 ◽

2020 ◽

pp. 112070001989787 ◽

Cited By ~ 1

Author(s):

Armin Arshi ◽

Wilson C Lai ◽

Brenda C Iglesias ◽

Edward J McPherson ◽

Erik N Zeegen ◽

...

Keyword(s):

Risk Factors ◽

Hip Fracture ◽

Blood Transfusion ◽

Hip Fractures ◽

Improvement Program ◽

Hip Fracture Surgery ◽

Femur Fractures ◽

Postoperative Blood Transfusion ◽

Geriatric Hip Fracture ◽

Fracture Surgery

Background: Postoperative blood product transfusions in elderly hip fracture patients cause concern for morbidity and mortality. The purpose of this study was to identify predictors and short-term sequelae of postoperative transfusion following geriatric hip fracture surgery. Methods: We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to identify geriatric (⩾65 years) patients who sustained operative femoral neck, intertrochanteric, and subtrochanteric hip fractures in 2016. Multivariate regression was used to determine risk-adjusted odds ratios (OR) of associated perioperative risk factors and sequelae of postoperative transfusion. Results: In total, 8416 geriatric hip fracture patients were identified of whom 28.3% had documented postoperative transfusion. In multivariate analysis, age (OR 1.03 [1.02–1.04], p < 0.001), preoperative anaemia (OR 4.69 [3.99–5.52], p = 0.001), female sex (OR 1.61 [1.39–1.87], p < 0.001), lower BMI (OR 0.97 [0.96–0.98], p < 0.001), American Society of Anesthesiologists (ASA) classification (OR 1.14 [1.01–1.27], p = 0.031), COPD (OR 1.30 [1.06–1.59], p = 0.011), hypertension (OR 1.17 [1.01–1.35], p = 0.038), increased OR time (OR 1.02 [1.01–1.03], p < 0.001), and intertrochanteric (OR 2.99 [2.57–3.49], p < 0.001) and subtrochanteric femur fractures (OR 5.07 [3.84–6.69], p < 0.001) were independent risk factors for receiving postoperative blood transfusion. Patients with postoperative transfusion had a significantly higher risk-adjusted 30-day mortality (8.4% vs. 6.4%, OR 1.29 [1.02–1.64], p = 0.035), hospital readmission rate (9.4% vs. 7.7%, OR 1.27 [1.04–1.55], p = 0.018), and total hospital LOS (7.3 vs. 6.3 days, p < 0.001). Conclusions: Postoperative transfusion is a common occurrence in geriatric fragility hip fractures with multiple risk factors. Careful preoperative planning and multidisciplinary management efforts are warranted to reduce use of postoperative transfusions.

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Incidence and Predicted Risk Factors of Pressure Ulcers in Surgical Patients: Experience at a Medical Center in Taipei, Taiwan

BioMed Research International ◽

10.1155/2014/416896 ◽

2014 ◽

Vol 2014 ◽

pp. 1-9 ◽

Cited By ~ 6

Author(s):

Ling Fu Shaw ◽

Pao-Chu Chang ◽

Jung-Fen Lee ◽

Huei-Yu Kung ◽

Tao-Hsin Tung

Keyword(s):

Risk Factors ◽

Pressure Ulcers ◽

Medical Center ◽

Signs And Symptoms ◽

Nursing Intervention ◽

Initial Study ◽

Surgical Patients ◽

Study Cohort ◽

Associated Risk Factors ◽

Type Of Surgery

Purpose. To explore the context of incidence of and associated risk factors for pressure ulcers amongst the population of surgical patients.Methods. The initial study cohort was conducted with a total of 297 patients admitted to a teaching hospital for a surgical operation from November 14th to 27th 2006 in Taipei, Taiwan. The Braden scale, pressure ulcers record sheet, and perioperative patient outcomes free from signs and symptoms of injury related to positioning and related nursing interventions and activities were collected.Results. The incidence of immediate and thirty-minute-later pressure ulcers is 9.8% (29/297) and 5.1% (15/297), respectively. Using logistic regression model, the statistically significantly associated risk factors related to immediate and thirty-minute-later pressure ulcers include operation age, type of anesthesia, type of operation position, type of surgery, admission Braden score, and number of nursing intervention after adjustment for confounding factors.Conclusion. Admission Braden score and number of nursing intervention are well-established protected factors for the development of pressure ulcers. Our study shows that older operation age, type of anesthesia, type of operation position, and type of surgery are also associated with the development of pressure ulcers.

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Blood Transfusion during Aneurysm Surgery

Neurosurgery ◽

10.1097/00006123-200111000-00009 ◽

2001 ◽

Vol 49 (5) ◽

pp. 1068-1075 ◽

Cited By ~ 1

Author(s):

Peter D. Le Roux ◽

J. Paul Elliott ◽

H. Richard Winn

Keyword(s):

Blood Transfusion ◽

Medical Center ◽

Median Number ◽

Aneurysm Rupture ◽

Intracerebral Hematoma ◽

Aneurysm Surgery ◽

Aneurysm Neck ◽

Poor Grade ◽

Computed Tomographic ◽

Postoperative Blood Transfusion

ABSTRACT INTRODUCTION Increasing costs and concerns about blood supply safety have led to a reevaluation of blood transfusion practices. This study was undertaken to examine blood use during aneurysm surgery. METHODS We performed a retrospective analysis of hospital records including operative, anesthetic, and nursing notes, computed tomographic scans, and four-vessel angiographic films of 547 patients undergoing surgery for ruptured and unruptured cerebral aneurysms at Harborview Medical Center in Seattle. During the review period, the transfusion threshold was not altered. RESULTS A total of 134 patients (24.5%) received an intraoperative blood transfusion (median number of units, 2; range, 1–17). Preoperative factors associated with intraoperative blood use included older patient age (P < 0.001), lower hematocrit level on admission (P = 0.007), ruptured rather than unruptured aneurysm (P = 0.004), severe intraventricular hemorrhage (P = 0.03), and larger aneurysm size (P = 0.004). Factors not associated with intraoperative blood transfusion included past medical history (including cardiac or pulmonary disease), admission clinical grade after aneurysm rupture, findings such as hydrocephalus on computed tomographic scanning, and aneurysm location and aneurysm neck-to-fundus ratio. Also associated with blood transfusion during surgery were intraoperative aneurysm rupture (P < 0.0001), intracerebral hematoma evacuation (P = 0.02), and obliteration of multiple aneurysms (P = 0.002). Among patients who received an intraoperative transfusion, those who experienced an aneurysm rupture required an average of 3.6 ± 0.35 units, whereas patients who did not have a rupture required 1.9 ± 0.12 units (P = 0.001). Postoperatively, a total of 244 patients (44.6%), including 77 who received blood intraoperatively, required a blood transfusion (median number of units, 2; range, 1–31). Postoperative blood transfusion was associated with the treatment of patients with subarachnoid hemorrhage (P < 0.0001), particularly among poor-grade patients who developed medical complications. CONCLUSION Blood transfusion can be expected in one in five patients undergoing aneurysm surgery. Reducing intraoperative rupture may reduce the need for blood products.

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The use of machine learning for predicating complications of free flap head and neck reconstruction.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.e18633 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. e18633-e18633

Author(s):

Malke Asaad ◽

Sheng-Chieh Lu ◽

Praneeth Kambhampati ◽

Jun Liu ◽

Edward I Chang ◽

...

Keyword(s):

Machine Learning ◽

Head And Neck ◽

Free Flap ◽

Surgical Outcomes ◽

Study Cohort ◽

Head And Neck Reconstruction ◽

Recipient Site ◽

Neck Reconstruction ◽

Routinely Collected Data ◽

Flap Loss

e18633 Background: The use of machine learning (ML) in plastic and reconstructive surgery has increased over the last decade. However, its use to predict surgical outcomes in head and neck reconstruction has not been well studied. The goal of this study is to assess the performance of ML algorithms trained to predict surgical outcomes of head and neck free flap reconstruction. Methods: Our study cohort included routinely collected data from 4000 patients who underwent free flaps for reconstruction of head and neck defects between January 2005 and December 2018. We developed and tested nine supervised ML algorithms to predict three outcomes of a.) any complication, b.) any major recipient-site complication, and c.) total flap loss. Results: In our sample, 33.7% of patients experienced any complication, 26.5% experienced a major complication at the recipient site and 1.7% experienced total flap loss. The k-nearest neighbors algorithm demonstrated the best overall performance for predicting any complication (AUROC = .61, sensitivity = .60). Regularized regression had the best performance for predicting major recipient site complication (AUROC=.68, sensitivity = .66), and decision trees were the best predictors of total flap loss (AUROC = .66, sensitivity = .50). Conclusions: We demonstrated that ML models trained using routinely collected data can make clinical useful predictions about who will experience complications. Our models correctly identified between half and two-thirds of patients who experienced post-surgical complications including total flap loss. These models can be applied to readily available clinical and perioperative data to facilitate decision making. Further performance improvements are likely possible with the inclusion of additional variables related to patient health and behavior.

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Venous Thromboembolism and High Grade Gliomas

Thrombosis and Haemostasis ◽

10.1055/s-0038-1649592 ◽

1993 ◽

Vol 70 (03) ◽

pp. 393-396 ◽

Cited By ~ 38

Author(s):

Mandeep S Dhami ◽

Robert D Bona ◽

John A Calogero ◽

Richard M Hellman

Keyword(s):

Risk Factors ◽

Venous Thromboembolism ◽

Medical Center ◽

Significant Risk ◽

Bleeding Complications ◽

Fisher Exact Test ◽

High Grade ◽

Chi Square ◽

Exact Test ◽

High Grade Gliomas

SummaryA retrospective study was done to determine the incidence of and the risk factors predisposing to clinical venous thromboembolism (VTE) in patients treated for high grade gliomas. Medical records of 68 consecutive patients diagnosed and treated at Saint Francis Hospital and Medical Center from January 1986 to June 1991 were reviewed. The follow up was to time of death or at least 6 months (up to December 1991). All clinically suspected episodes of VTE were confirmed by objective tests. Sixteen episodes of VTE were detected in 13 patients for an overall episode rate of 23.5%. Administration of chemotherapy (p = 0.027, two tailed Fisher exact test) and presence of paresis (p = 0.031, two tailed Fisher exact test) were statistically significant risk factors for the development of VTE. Thrombotic events were more likely to occur in the paretic limb and this difference was statistically significant (p = 0.00049, chi square test, with Yates correction). No major bleeding complications were seen in the nine episodes treated with long term anticoagulation.We conclude that venous thromboembolic complications are frequently encountered in patients being treated for high grade gliomas and the presence of paresis and the administration of chemotherapy increases the risk of such complications.

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