RESUMO
OBJECTIVE: The optimal timing and modality of surveillance after endovascular intervention for peripheral arterial disease is controversial, and no randomized trial to assess the value of peripheral endovascular intervention has ever been performed. The aim of this systematic review was to examine the practice of surveillance after peripheral endovascular intervention in randomized trials. METHODS: We used the Medline, Embase, Cochrane Library, and WHO trial registry databases in this systematic review of the literature to capture surveillance strategies used in randomized trials comparing endovascular interventions. Surveillance protocols were assessed for completeness, modalities used, duration, and intensity. RESULTS: Ninety-six different surveillance protocols were reported in 103 trials comparing endovascular interventions. Protocol specification was incomplete in 32% of trials. The majority of trials used multiple surveillance modalities (mean of 3.46 modalities), most commonly clinical examination (96%), ankle-brachial index (80%), duplex ultrasound examination (75%), and digital subtraction angiography (51%). Trials involving infrapopliteal lesions used more angiographic surveillance than trials with femoropopliteal lesions (P = .006). The median number of surveillance visits in the first 12 months after intervention was three and the mean surveillance duration was 21 months. Trials treating infrapopliteal vessels had a higher surveillance intensity compared with those treating femoropopliteal lesions in the first 12 months after endovascular intervention (mean 5 vs 3 surveillance visits; P = .017). Trials with drug-eluting devices had longer surveillance duration compared with those without (mean 26 vs 19 months; P = .020). CONCLUSIONS: There is a high level of variation in the modality, duration, and intensity of surveillance protocols used in randomized trials comparing different types of peripheral endovascular arterial intervention. Further research is required to determine the value and impact of postprocedural surveillance on patient outcomes.
Assuntos
Oclusão de Enxerto Vascular/diagnóstico , Programas de Rastreamento/normas , Doença Arterial Periférica/cirurgia , Enxerto Vascular/efeitos adversos , Grau de Desobstrução Vascular , Índice Tornozelo-Braço , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/cirurgia , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/cirurgia , Humanos , Extremidade Inferior/irrigação sanguínea , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/cirurgia , Guias de Prática Clínica como Assunto , Reoperação , Stents/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler Dupla/normasRESUMO
A 69-year-old woman presented with a cortical hand syndrome progressing over several weeks. MRI brain showed characteristic appearances of progressive multifocal leukoencephalopathy (PML), confirmed by detection of the JC virus in CSF, despite the absence of any evidence of immunosuppression. Treatment with mirtazapine, mefloquine and cidofovir did not affect the progression of the disease, which was fatal within 7 months of presentation. This report adds to the small case literature that suggests that PML can occur in immunocompetent people, albeit extremely rarely.
Assuntos
Fenômeno do Membro Alienígena/fisiopatologia , Vírus JC/patogenicidade , Leucoencefalopatia Multifocal Progressiva/fisiopatologia , Idoso , Fenômeno do Membro Alienígena/complicações , Fenômeno do Membro Alienígena/tratamento farmacológico , Fenômeno do Membro Alienígena/virologia , Cidofovir/uso terapêutico , Progressão da Doença , Evolução Fatal , Feminino , Humanos , Imunocompetência , Vírus JC/fisiologia , Leucoencefalopatia Multifocal Progressiva/complicações , Leucoencefalopatia Multifocal Progressiva/tratamento farmacológico , Leucoencefalopatia Multifocal Progressiva/virologia , Mefloquina/uso terapêutico , Mirtazapina/uso terapêutico , Falha de TratamentoAssuntos
Abdome Agudo/etiologia , Hérnia Ventral/etiologia , Obesidade/complicações , Abdome Agudo/diagnóstico por imagem , Dor Abdominal/etiologia , Feminino , Hérnia Ventral/diagnóstico por imagem , Hérnia Ventral/cirurgia , Herniorrafia , Humanos , Pessoa de Meia-Idade , Obesidade/diagnóstico , Fatores de Risco , Tomografia Computadorizada por Raios X , Vômito/etiologiaRESUMO
BACKGROUND: Surgeons routinely care for patients with life-limiting illness, requiring communication and symptom management skills supported by appropriate training. The objective of this study was to appraise and synthesize studies that assessed surgeon-directed training interventions that aimed to optimize communication and symptom management for patients with life-limiting illness. METHODS: A PRISMA-concordant systematic review was undertaken. MEDLINE, Embase, Allied and Complementary Medicine Database (AMED), and the Cochrane Central Register of Controlled Trials were searched from inception until October 2022 for studies reporting on the evaluation of surgeon-training interventions intending to improve surgeons' communication or symptom management of patients with life-limiting disease. Data on the design, trainer and patient participants, and the intervention were extracted. Risk of bias was assessed. RESULTS: Of 7794 articles, 46 were included. Most studies employed a before-after approach (29 studies) and nine included control groups with five being randomized studies. General surgery was the most frequently included sub-specialty (22 studies). Trainers were described in 25 of 46 studies. Most training interventions aimed to improve communication skills (45 studies) and 13 different training interventions were described. Eight studies reported a measurable improvement in patient care, such as increased documentation of advance care discussions. Most study outcomes focused on surgeons' knowledge (12 studies), skills (21 studies), and confidence/comfort (18 studies) in palliative communication skills. Studies had a high risk of bias. CONCLUSION: Whilst interventions exist to improve the training of surgeons managing patients with life-threatening conditions, evidence is limited, and studies measure the direct impact on patient care insufficiently. Improved research is needed to lead to better methods for training surgeons to benefit patients.
Assuntos
Comunicação , Cirurgiões , HumanosRESUMO
Robot-assisted anti-reflux surgery (RA-ARS) is increasingly being used to treat refractory gastro-oesophageal reflux disease. The IDEAL (Idea, Development, Exploration, Assessment, Long-term follow up) Collaboration's framework aims to improve the evaluation of surgical innovation, but the extent to which the evolution of RA-ARS has followed this model is unclear. This study aims to evaluate the standard to which RA-ARS has been reported during its evolution, in relation to the IDEAL framework. A systematic review from inception to June 2020 was undertaken to identify all primary English language studies pertaining to RA-ARS. Studies of paraoesophageal or giant hernias were excluded. Data extraction was informed by IDEAL guidelines and summarised by narrative synthesis. Twenty-three studies were included: two case reports, five case series, ten cohort studies and six randomised controlled trials. The majority were single-centre studies comparing RA-ARS and laparoscopic Nissen fundoplication. Eleven (48%) studies reported patient selection criteria, with high variability between studies. Few studies reported conflicts of interest (30%), funding arrangements (26%), or surgeons' prior robotic experience (13%). Outcome reporting was heterogeneous; 157 distinct outcomes were identified. No single outcome was reported in all studies.The under-reporting of important aspects of study design and high degree of outcome heterogeneity impedes the ability to draw meaningful conclusions from the body of evidence. There is a need for further well-designed prospective studies and randomised trials, alongside agreement about outcome selection, measurement and reporting for future RA-ARS studies.
Assuntos
Laparoscopia , Procedimentos Cirúrgicos Robóticos , Robótica , Humanos , Fundoplicatura , Estudos Prospectivos , Resultado do Tratamento , Procedimentos Cirúrgicos Robóticos/métodosRESUMO
INTRODUCTION: Robotic cholecystectomy (RC) is a recent innovation in minimally invasive gallbladder surgery. The IDEAL (idea, development, exploration, assessment, long-term study) framework aims to provide a safe method for evaluating innovative procedures. This study aimed to understand how RC was introduced, in accordance with IDEAL guidelines. METHODS: Systematic searches were used to identify studies reporting RC. Eligible studies were classified according to IDEAL stage and data were collected on general study characteristics, patient selection, governance procedures, surgeon/centre expertise, and outcome reporting. RESULTS: Of 1425 abstracts screened, 90 studies were included (5 case reports, 38 case series, 44 non-randomized comparative studies, and 3 randomized clinical trials). Sixty-four were single-centre and 15 were prospective. No authors described their work in the context of IDEAL. One study was classified as IDEAL stage 1, 43 as IDEAL 2a, 43 as IDEAL 2b, and three as IDEAL 3. Sixty-four and 51 provided inclusion and exclusion criteria respectively. Ethical approval was reported in 51 and conflicts of interest in 34. Only 21 reported provision of training for surgeons in RC. A total of 864 outcomes were reported; 198 were used in only one study. Only 30 reported a follow-up interval which, in 13, was 1 month or less. CONCLUSION: The IDEAL framework was not followed during the adoption of RC. Few studies were conducted within a research setting, many were retrospective, and outcomes were heterogeneous. There is a need to implement appropriate tools to facilitate the incremental evaluation and reporting of surgical innovation.
Assuntos
Colecistectomia , Robótica , Humanos , Estudos Prospectivos , Projetos de Pesquisa , Estudos RetrospectivosRESUMO
The ubiquitous nature of social media has meant that its effects on fields outside of social communication have begun to be felt. The generation undergoing medical education are of the generation referred to as "digital natives", and as such routinely incorporate social media into their education. Social media's incorporation into medical education includes its use as a platform to distribute information to the public ("distributive education") and as a platform to provide information to a specific audience ("push education"). These functions have proved beneficial in many regards, such as enabling constant access to the subject matter, other learners, and educators. However, the usefulness of using social media as part of medical education is limited by the vast quantities of poor quality information and the time required to find information of sufficient quality and relevance, a problem confounded by many student's preoccupation with "efficient" learning. In this Perspective, the authors discuss whether social media has proved useful as a tool for medical education. The current growth in the use of social media as a tool for medical education seems to be principally supported by students' desire for efficient learning rather than by the efficacy of social media as a resource for medical education. Therefore, improvements in the quality of information required to maximize the impact of social media as a tool for medical education are required. Suggested improvements include an increase in the amount of educational content distributed on social media produced by academic institutions, such as universities and journals.