RESUMO
BACKGROUND: This study compared the efficacy and safety of apixaban and warfarin in patients with nonvalvular atrial fibrillation (NVAF) and end-stage renal disease (ESRD) on hemodialysis (HD). Apixaban decreased incidence of stroke and bleeding compared with warfarin in major clinical trials that excluded patients with severe renal dysfunction. Apixaban is no longer contraindicated in patients with ESRD on HD with NVAF based on pharmacokinetic studies. Limited clinical data exist for patients with ESRD on HD on apixaban. METHODS: A retrospective chart review was performed on patients with a diagnosis of NVAF and ESRD on HD who were prescribed apixaban or warfarin for stroke prevention in the years 2018 through 2019. Patients' charts were reviewed for up to a 2-year period. Patients on renal replacement therapy other than HD, those using anticoagulation for reasons other than NVAF, patients with Child-Pugh Class C cirrhosis, and those with severe mitral valve stenosis were excluded. The primary outcome was emergency department visits or hospital admissions for ischemic stroke or transient ischemic attack. Secondary outcomes included major or minor bleeding and adverse effects. RESULTS: A total of 181 patients were screened; 110 patients met eligibility criteria and were included in the analysis. Four patients (7.5%) in the apixaban group and 6 patients (10.5%) in the warfarin group met the primary outcome of hospitalization or emergency department visit for stroke (P = 0.742). Symptomatic bleeding occurred in 39.6% of patients in the apixaban group and 36.8% in the warfarin group (P = 0.918). A trend in major bleeding occurred more often in the warfarin group, 52.4% versus 49.2% (P = 0.758). CONCLUSIONS: There were no statistically significant differences in efficacy and safety outcomes between apixaban and warfarin in patients with NVAF and ESRD on HD in the intention-to-treat analysis of our study. Larger trials are needed to further analyze this patient population.
RESUMO
BACKGROUND: This study compared the efficacy and safety of apixaban and warfarin in patients with nonvalvular atrial fibrillation (NVAF) and end-stage renal disease (ESRD) on hemodialysis (HD). Apixaban decreased incidence of stroke and bleeding compared with warfarin in major clinical trials that excluded patients with severe renal dysfunction. Apixaban is no longer contraindicated in patients with ESRD on HD with NVAF based on pharmacokinetic studies. Limited clinical data exist for patients with ESRD on HD on apixaban. METHODS: A retrospective chart review was performed on patients with a diagnosis of NVAF and ESRD on HD who were prescribed apixaban or warfarin for stroke prevention in the years 2018 through 2019. Patients' charts were reviewed for up to a 2-year period. Patients on renal replacement therapy other than HD, those using anticoagulation for reasons other than NVAF, patients with Child-Pugh Class C cirrhosis, and those with severe mitral valve stenosis were excluded. The primary outcome was emergency department visits or hospital admissions for ischemic stroke or transient ischemic attack. Secondary outcomes included major or minor bleeding and adverse effects. RESULTS: A total of 181 patients were screened; 110 patients met eligibility criteria and were included in the analysis. Four patients (7.5%) in the apixaban group and 6 patients (10.5%) in the warfarin group met the primary outcome of hospitalization or emergency department visit for stroke (P = 0.742). Symptomatic bleeding occurred in 39.6% of patients in the apixaban group and 36.8% in the warfarin group (P = 0.918). A trend in major bleeding occurred more often in the warfarin group, 52.4% versus 49.2% (P = 0.758). CONCLUSIONS: There were no statistically significant differences in efficacy and safety outcomes between apixaban and warfarin in patients with NVAF and ESRD on HD in the intention-to-treat analysis of our study. Larger trials are needed to further analyze this patient population.
Assuntos
Fibrilação Atrial , Falência Renal Crônica , Pirazóis , Acidente Vascular Cerebral , Humanos , Varfarina/efeitos adversos , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/epidemiologia , Anticoagulantes/efeitos adversos , Estudos Retrospectivos , Piridonas/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/complicações , Hemorragia/epidemiologia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Diálise Renal/efeitos adversos , Falência Renal Crônica/complicações , Falência Renal Crônica/terapia , Falência Renal Crônica/induzido quimicamenteRESUMO
BACKGROUND: Data registries facilitate knowledge acquisition and quality improvement. ImageGuide is a registry developed by the American Society of Nuclear Cardiology collecting data since 2015, providing insight into current nuclear cardiology practice. METHODS AND RESULTS: HIPAA de-identified data on > 100 practice- and patient-related variables from 19 US practices were obtained from ImageGuide. Continuous variables are reported as the mean ± standard deviation; discrete variables are reported as N (%). Practices were from 12 states; 9520 studies were submitted. The average patient was a 66-year-old man. Chest pain was the most common indication; 96% of studies were appropriate. Rest/stress 1-day studies were most common; stress/rest 1- and 2-day studies comprised < 5%. Tc-99 m was the most common radiopharmaceutical. Tl-201 was used in 14% of rest studies. Most studies were not corrected for attenuation. 89% were of good or better quality. 62% of studies were normal. CONCLUSIONS: Practice diversity is limited, but patient demographics are reflective of reported current practice. Most studies are appropriate and may obviate the need for invasive testing. Radiation dosimetry could be decreased with wider adoption of stress/rest studies and avoidance of Tl-201. ImageGuide will be an important tool to guide non-invasive cardiac imaging in the future.
Assuntos
Cardiologia , Radioisótopos de Tálio , Idoso , Coração , Humanos , Masculino , Sistema de Registros , Estados UnidosRESUMO
BACKGROUND: Delayed gastric emptying (DGE) remains common after pancreaticoduodenectomy (PD). Risk factors for DGE have been difficult to identify due to a lack of a standard definition. The purpose of this study was to identify factors associated with DGE using a standard definition across a national cohort of patients. METHODS: A retrospective cohort study of patients who underwent PD from 2014 to 2016 within the ACS-NSQIP pancreatectomy-specific module was performed. Multivariable (MV) regression was used to determine perioperative risk factors for DGE. RESULTS: Of 10,249 patients undergoing PD, 16.6% developed DGE and were older (65.3 vs. 64.3 years), more often male (62.5% vs. 51.9%), overweight/obese (66.7% vs. 61.3%), and American Society of Anesthesiologist (ASA) class 3 (80.0% vs. 76.0%). Rates of pylorus preservation (41.4% vs. 38.7%) were higher, and median operative time (373 vs. 354 min) longer. On MV analysis, age≥65 years [OR 1.26 (95%CI 1.13-1.41)], male sex [OR 1.54 (95%CI 1.38-1.72), body mass index (BMI) > 30 [OR 1.22 (95%CI 1.06-1.40)], ASA class≥3 [OR 1.24 (95%CI 1.08-1.42)], pylorus preservation [OR 1.08 (95%CI 1.02-1.14)], and longer operative time [OR 1.26 (95%CI 1.13-1.40)] remained associated with DGE. Preoperative chemotherapy was associated with decreased risk of DGE [OR 0.77 (95%CI 0.64-0.93)]. CONCLUSION: In this national, multicenter cohort of patients undergoing PD, 16.6% of patients developed DGE based on a standardized definition. Perioperative factors including age, BMI, ASA class, pylorus preservation, and operative time were associated with increased risk of DGE. Further research is warranted to identify opportunities for prevention via preoperative rehabilitation strategies and treatment.
Assuntos
Esvaziamento Gástrico , Pancreaticoduodenectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Idoso , Índice de Massa Corporal , Estudos de Coortes , Tratamento Farmacológico , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Neoplasias Pancreáticas/tratamento farmacológico , Neoplasias Pancreáticas/cirurgia , Piloro/cirurgia , Melhoria de Qualidade , Estudos Retrospectivos , Fatores de RiscoRESUMO
OBJECTIVE: To determine the association between the physical activity vital sign (PAVS) and markers of cardiometabolic disease. DESIGN: Patients were assessed through the PAVS, a validated tool self-reporting the frequency and duration of physical activity. Patients were categorized into 3 groups: inactive (0 minutes per week), underactive (1-149 minutes per week), and active (>150 minutes per week). Associations were tested between the PAVS and the cardiometabolic disease biomarkers of body mass index, hemoglobin A1c (A1c), blood pressure, and low-density lipoprotein (LDL) using one-way analyses of variance. SETTING: High-risk family medicine residency clinic. PARTICIPANTS: Two thousand three hundred twenty-one adult patients (age ≥ 18 years). RESULTS: Participants reported a mean of 97.87 (SD = 149.35) minutes per week of exercise. Overall, 50.1% reported physical inactivity, 25.7% were underactive, and 24.3% were active. Younger individuals (P < 0.001) and men (P < 0.05) reported more physical activity than older individuals and women. Patients who reported being active were significantly less likely to be overweight (P < 0.05), obese (P < 0.05), or hypertensive (P < 0.05), but there was no association with A1c or LDL levels. CONCLUSIONS: This is the first investigation to examine the PAVS in a high-risk population. In these patients, reported levels of physical inactivity are 150% higher than other clinical settings, and the PAVS is only associated with improvements in 2 of 4 major cardiometabolic risk factors. For this group, self-reported levels of physical activity may need to be higher for cardiovascular benefits to be realized in all 4 cardiometabolic domains. The PAVS offers health professionals an opportunity to encourage lifestyle-based interventions to reduce cardiovascular risk, but refinements may be necessary to address this population.
Assuntos
Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/fisiopatologia , Exercício Físico/fisiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Pressão Sanguínea , Índice de Massa Corporal , Doenças Cardiovasculares/prevenção & controle , LDL-Colesterol/sangue , Comorbidade , Feminino , Hemoglobinas Glicadas/metabolismo , Humanos , Hipertensão/epidemiologia , Masculino , Pessoa de Meia-Idade , Obesidade/epidemiologia , Fatores de Risco , Comportamento Sedentário , Autorrelato , Adulto JovemRESUMO
BACKGROUND: Burnout and depression are prevalent among resident physicians, though the supportive role of the program director (PD) is not well defined. OBJECTIVE: To understand the residents' view of the residency program director's role in assessing and promoting resident wellness. METHODS: A single institution survey of all house staff was conducted in 2017. Rates of burnout and depression were identified via the 2-item Maslach Burnout Inventory (MBI) and the Patient Health Questionaire-2 (PHQ-2), respectively. Residents then qualified their preferences for various assistance services and for the role of their program directors in assisting them. RESULTS: One-hundred sixty-one of 202 (79.7%) residents completed the survey. The rate of depression was 28%. Rates of emotional exhaustion and depersonalization (2-item MBI) were 44 and 62%, respectively. Only 4% of respondents had used the Employee Assistance Program (EAP) in the prior 12 months. Eighty-two percent of residents were in favor of PDs inquiring about wellness regardless of their job performance and only 1% of residents stated the PD should not inquire about wellness at all. Thirty-three percent of residents reported that they would be likely to contact EAP on their own if they felt unwell. Significantly more residents (62%) reported being more likely to contact EAP if recommended by their PD (33 vs 62%, p < 0.001%). Important perceived barriers to seeking assistance were lack of time (65%), lack of knowledge of how to contact EAP (41%), and concerns about appearing weak (35%). CONCLUSIONS: Despite a high prevalence of burnout and depression, residents are unlikely to seek help on their own. Program directors have an important role in assessing and promoting the wellness of their residents. The majority of residents wants their PD to inquire about wellness and may be more likely to seek and receive help if recommended and facilitated by their PD.
Assuntos
Esgotamento Profissional/terapia , Comportamento de Busca de Ajuda , Internato e Residência , Liderança , Médicos/psicologia , Adulto , Esgotamento Profissional/epidemiologia , Estudos Transversais , Despersonalização/diagnóstico , Despersonalização/epidemiologia , Depressão/diagnóstico , Depressão/epidemiologia , Feminino , Humanos , Masculino , Serviços de Saúde do Trabalhador/estatística & dados numéricos , Inquéritos e QuestionáriosRESUMO
BACKGROUND: The aim of this study was to evaluate reporting compliance of laboratories applying for serial accreditation by the Intersocietal Accreditation Commission (IAC) and compare compliance based on laboratory characteristics. METHODS: All laboratories applying for IAC accreditation for the first time in 2008 and then twice more (2011-2014) were evaluated for compliance with 18 reporting elements. The elements were ranked into three severity groups (high/moderate/low). RESULTS: Reports from 523 laboratories were evaluated. The percentage of laboratories with reporting issues by cycle was 66.2% for cycle 1, 36.7% for cycle 2, and 43.8% for cycle 3 (p < .001). For most of the 18 elements, there was a significant decrease in the percentage of labs with issues. Less moderate and high severity errors were seen over time. Also, the mean non-compliant elements per laboratory decreased from 5.78 ± 2.72 at cycle 1, down to 1.25 ± 1.77 at cycle 3. CONCLUSIONS: In facilities applying for 3 consecutive IAC accreditation cycles, reporting compliance with IAC Standards improved between cycles 1-2 and 1-3. No significant improvement occurred between cycles 2-3. Although the quality of reports improved overall, problems remain in quantifying myocardial perfusion defects, documenting report approval date, and integrating stress and imaging reports.
Assuntos
Acreditação , Cardiologia/normas , Fidelidade a Diretrizes , Medicina Nuclear/normas , Humanos , Laboratórios/normas , Estudos RetrospectivosRESUMO
BACKGROUND: In 2011, Tilkemeier et al reported significant nuclear cardiology laboratory noncompliance with reporting standards. The aim of this study was to identify and examine noncompliant reporting elements with the Intersocietal Accreditation Commission Nuclear/PET (IAC) Reporting Standards and to compare compliance between 2008 and 2014. METHODS: This was a retrospective study of compliance with 18 reporting elements utilizing accreditation findings from all laboratories applying for accreditation in 2008 and 2014. RESULTS: 1816 labs applying for initial or subsequent accreditation were analyzed for compliance. The mean reporting noncompliance per lab decreased from 2008 to 2014 (2.48 ± 2.67 to 1.24 ± 1.79, P < .001). Noncompliance decreased across lab types, labs with Certification Board of Nuclear Cardiology physicians on staff, and by geographic region (P < .001). Overall severity of reporting issues decreased. Facilities with compliant reports increased from 35.0% in 2008 to 57.1% in 2014 (P < .001). CONCLUSION: Continuing medical education, accreditation, and other instructional activities aimed at improving nuclear cardiology reporting appear to have made a positive impact over time with the number and severity of noncompliance decreased. More labs are now compliant with the IAC Standards and, thus, reporting guidelines. However, the need for continued educational efforts remains.
Assuntos
Acreditação , Técnicas de Imagem Cardíaca , Cardiologia , Fidelidade a Diretrizes , Cintilografia , Guias como Assunto , Humanos , Estudos Retrospectivos , Estados UnidosRESUMO
BACKGROUND: Catheter-directed thrombolysis (CDT) and/or pharmacomechanical thrombectomy (PMT) can dissolve/remove thrombus; PMT alone, however, may require the adjunctive use of CDT. The aim of this study was to compare the use of CDT with and without PMT for the treatment of acute lower extremity ischemia (ALI). METHODS: We retrospectively reviewed all patients with ALI who underwent CDT with or without PMT between January 2008 and April 2014 (n = 99). Patients with incomplete medical charts were excluded (n = 16). Remaining patients were divided into 2 cohorts: group 1 included patients who underwent PMT + CDT (n = 54); group 2 included those who underwent CDT alone (n = 29). Lesions were further characterized by anatomic location: iliac disease (n = 14), femoropopliteal disease (n = 53), tibial disease (n = 2), and multilevel disease (n = 14). Data collection included patient and limb characteristics, duration of treatment, complications, clinical outcomes, adjunctive interventions, and follow-up. RESULTS: No significant differences were seen between treatment groups in terms of patient characteristics, occlusion length and location, Rutherford class, median duration of ischemia time (P = 0.22), or mean lysis time (P = 0.58). Treatment groups were also similar with regard to outcomes, including periprocedure complications, patency, reintervention, limb salvage, and amputation-free survival. CONCLUSIONS: There was no different between PMT + CDT and CDT alone in terms of periprocedural complications or outcomes. In the quest to resolve ALI, initial thrombus extraction with PMT may not reduce the need, duration, or efficacy of CDT.
Assuntos
Cateterismo Periférico , Fibrinolíticos/administração & dosagem , Isquemia/terapia , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/terapia , Trombectomia/métodos , Terapia Trombolítica/métodos , Doença Aguda , Idoso , Amputação Cirúrgica , Cateterismo Periférico/efeitos adversos , Terapia Combinada , Intervalo Livre de Doença , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intra-Arteriais , Isquemia/diagnóstico , Isquemia/fisiopatologia , Estimativa de Kaplan-Meier , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/fisiopatologia , Fluxo Sanguíneo Regional , Estudos Retrospectivos , Fatores de Risco , Trombectomia/efeitos adversos , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
BACKGROUND: Laparoscopic ventral hernia repair (LVHR) demonstrates comparable recurrence rates, but lower incidence of surgical site infection (SSI) than open repair. Delayed complications can occur with intraperitoneal mesh, particularly if a subsequent abdominal operation is required, potentially resulting in bowel injury. Robotic retromuscular ventral hernia repair (RRVHR) allows abdominal wall reconstruction (AWR) and extraperitoneal mesh placement previously only possible with open repair, with the wound morbidity of LVHR. METHODS: All LVHR and RRVHR performed in our institution between June 2013 and May 2015 contained in the Americas Hernia Society Quality Collaborative database were analyzed. Continuous bivariate analysis was performed with Student's t test. Continuous nonparametric data were compared with Chi-squared test, or Fisher's exact for small sample sizes. p values <0.05 were considered significant. RESULTS: We compared 103 LVHR with 53 RRVHR. LVHR patients were older (60.2 vs. 52.9 years; p = 0.001), but demographics were otherwise similar between groups. Hernia width was similar (6.9 vs. 6.5 cm, p = 0.508). Fascial closure was achieved more often with RRVHR (96.2 vs. 50.5 %; p < 0.001) and aided by myofascial release in 43.4 %. Mesh was placed in an intraperitoneal position in 90.3 % of LVHR and extraperitoneal in 96.2 % of RRVHR. RRVHR operative time was longer (245 vs. 122 min, p < 0.001). Narcotic requirement was similar between LVHR and RRVHR (1.8 vs. 1.4 morphine equivalents/h; p = 0.176). Seroma was more common after RRVHR (47.2 vs. 16.5 %, p < 0.001), but SSI was similar (3.8 vs. 1 %, p = 0.592). Median length of stay was shorter after RRVHR (1 vs. 2 days, p = 0.004). Direct hospital cost was similar (LVHR $13,943 vs. RRVHR $19,532; p = 0.07). CONCLUSION: RRVHR enables true AWR, with myofascial release to offset tension for midline fascial closure, and obviates the need for intraperitoneal mesh. Perioperative morbidity of RRVHR is comparable to LVHR, with shorter length of stay despite a longer operative time and extensive tissue dissection.
Assuntos
Hérnia Ventral/cirurgia , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Feminino , Hérnia Ventral/economia , Custos Hospitalares , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias , Seroma/etiologia , Telas Cirúrgicas , Infecção da Ferida Cirúrgica/etiologia , Estados UnidosRESUMO
INTRODUCTION: Laparoscopic ventral hernia repair (LVHR) with intraperitoneal mesh placement is well established; however, the fate of patients requiring future abdominal operations is not well understood. This study identifies the characteristics of LVHR patients undergoing reoperation and the sequelae of reoperation. METHODS: A retrospective review of a prospectively maintained database at a hernia referral center identified patients who underwent LVHR between 2005 and 2014 and then underwent a subsequent abdominal operation. The outcomes of those reoperations were collected. Data are presented as a mean with ranges. RESULTS: A total of 733 patients underwent LVHR. The average age was 56.5 years, BMI 33.9 kg/m2, hernia size 115 cm2 (range 1-660 cm2), and mesh size 411 cm2 (range 17.7-1360 cm2). After a mean follow-up of 19.4 months, the overall hernia recurrence rate was 8.4 %. Subsequent abdominal operations were performed in 17 % (125 patients) at a mean 2.2 years. The most common indication for reoperation was recurrent hernia (33 patients, 26.4 %), followed by bowel obstruction (18 patients, 14.4 %), hepatopancreaticobiliary (17 patients, 13.6 %) and infected mesh removal (15 patients, 12 %), gynecologic (10 patients, 8 %), colorectal (8 patients, 6.4 %), bariatric (4 patients, 3 %), trauma (1 patient, 0.8 %), and other (19 patients, 15 %). The overall incidence of enterotomy or unplanned bowel resection (EBR) at reoperation was 4 %. This occurred exclusively in those reoperated for complete bowel obstruction, and the reason for EBR was mesh-bowel adhesions. No other indication for reoperation resulted in EBR. The incidence of secondary mesh infection after subsequent operation was 2.4 %. CONCLUSION: In a large consecutive series of LVHR, the rate of abdominal reoperation was 17 %. Generally, these reoperations can be performed safely. A reoperation for bowel obstruction, however, may carry an increased risk of EBR as a direct result of mesh-bowel adhesions. Secondary mesh infection after reoperation, although rare, may also occur. Surgeons should discuss with their patients the potential long-term implications of having an intraperitoneal mesh and how it may impact future abdominal surgery.
Assuntos
Cirurgia Bariátrica , Procedimentos Cirúrgicos do Sistema Digestório , Procedimentos Cirúrgicos em Ginecologia , Hérnia Ventral/cirurgia , Herniorrafia , Hérnia Incisional/cirurgia , Laparoscopia , Reoperação/estatística & dados numéricos , Telas Cirúrgicas , Adulto , Idoso , Doenças Biliares/cirurgia , Bases de Dados Factuais , Remoção de Dispositivo , Feminino , Humanos , Obstrução Intestinal/cirurgia , Hepatopatias/cirurgia , Masculino , Pessoa de Meia-Idade , Pancreatopatias/cirurgia , Infecções Relacionadas à Prótese/cirurgia , Recidiva , Estudos Retrospectivos , RiscoRESUMO
PURPOSE: Determine the psychological impact of false-positive ECG screening in National Collegiate Athletic Association (NCAA) athletes. METHODS: Athletes representing seven NCAA institutions received a standardised history, physical examination and ECG interpreted using the 2013 Seattle Criteria. Assessments of health attitudes, anxiety and impact of screening on sport were conducted using validated prescreen and postscreen measurements. RESULTS: 1192 student-athletes participated (55.4% male, median age 19 years, 80.4% Caucasian). 96.8% of athletes had a normal cardiovascular screen, 2.9% had a false-positive ECG and 0.3% were diagnosed with a serious cardiac condition. Prior to screening, 4.5% worried about potentially harbouring cardiac disease and 70.1% preferred knowing about an underlying condition, rather than play sports without this knowledge. There was no difference in anxiety described by athletes with a normal versus false-positive screen (p=0.369). Reported anxiety levels during screening also did not differ when analysed by different gender, race, division of play or sport. Athletes with normal and false-positive screens had similar levels of satisfaction (p=0.714) and would recommend ECG screening to other athletes at similar rates (p=0.322). Compared with athletes with a normal screen, athletes with false-positive results also reported feeling safer during competition (p>0.01). In contrast, athletes with false-positive screens were more concerned about the possibility of sports disqualification (p<0.001) and the potential for developing a future cardiac condition (p<0.001). CONCLUSIONS: Athletes with a false-positive ECG do not experience more anxiety than athletes with a normal screen but do express increased concern regarding sports disqualification and the development of a cardiac disorder. These findings do not justify avoiding advanced cardiovascular screening protocols. Further understanding of athlete experiences could better prepare the practising physician to counsel athletes with an abnormal ECG.
Assuntos
Ansiedade , Atletas/psicologia , Eletrocardiografia/psicologia , Cardiopatias/diagnóstico , Estudos Transversais , Morte Súbita Cardíaca/prevenção & controle , Reações Falso-Positivas , Feminino , Humanos , Masculino , Exame Físico , Medicina Esportiva/métodos , Estudantes , Universidades , Adulto JovemRESUMO
BACKGROUND: With the increasing application of fenestrated and physician-modified endografting for aneurysm repair, there is increasing concern about the accuracy of vessel position measurements based on computed tomography scans. Inaccuracies in measurements may result in a "window-shutter" or "eclipsing" phenomenon whereby the fenestration may not overlie the vessel ostium completely. We hypothesized that vessel position measurements from reconstructed imaging do not represent the true vessel position as obtained from a three-dimensional (3D) printed physical model of the visceral aortic segment. METHODS: Medical 3D modeling software was used to develop the 3D reconstructions, which were then exported to the 3D printing software. This allowed 3D models to be physically generated. The distances to the top and bottom and the angle of each of the celiac, superior mesenteric, right renal, and left renal arteries were recorded. These same measurements were obtained by each of the blinded reviewers in addition to the aortic diameter at the midpoint of each of these vessels. Measurements were compared with intraclass correlation coefficient, nonparametric Spearman rank correlation test, and one-sample t-test to assess accuracy and precision. Statistical significance was set at P < .05 for all tests. RESULTS: Both the individual measurements and the average of the measurements were statistically accurate (significant) for the bottom of the superior mesenteric artery and the top and bottom of both the right and left renal arteries. There was variability and inaccuracy in all visceral vessel angles and in the bottom of the celiac artery (the top and the angle of the celiac artery were the arbitrary referents). CONCLUSIONS: Whereas the visceral vessel orifices are largely accurately assessed and measured, the vessel angles are not. This may lead to an eclipsing phenomenon, which may contribute to branch or fenestrated vessel failure and therefore reintervention. Further efforts should assess the clinical significance of the eclipsing phenomenon and should target accurate and appropriate fenestration construction to prevent long-term morbidity.
Assuntos
Aorta Abdominal/diagnóstico por imagem , Aorta Abdominal/cirurgia , Aortografia/métodos , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Angiografia por Tomografia Computadorizada , Desenho Assistido por Computador , Procedimentos Endovasculares/instrumentação , Médicos , Impressão Tridimensional , Desenho de Prótese , Bases de Dados Factuais , Humanos , Modelos Anatômicos , Variações Dependentes do Observador , Modelagem Computacional Específica para o Paciente , Valor Preditivo dos Testes , Interpretação de Imagem Radiográfica Assistida por Computador , Reprodutibilidade dos Testes , Estudos RetrospectivosRESUMO
Sarcopenia, also known as a reduction of skeletal muscle mass, is a patient-specific risk factor for vascular and cancer patients. However, there are no data on abdominal aortic aneurysm (AAA) patients treated with endovascular aneurysm repair (EVAR) who have sarcopenia. To determine the impact of sarcopenia on mortality following EVAR, we retrospectively reviewed 200 patients treated with EVAR by estimating muscle mass on abdominal computed tomography (CT) scans. Mortality was analyzed according to its presence (n=25) or absence (n=175). Sarcopenia was more common in women than men (32.0% vs 9.7%; p=0.005). Patients with sarcopenia had an increased risk of mortality compared to those without (76% vs 48%; p=0.016). Of note, the overall mortality rate was 51% with a median follow up of 8.4 years (interquartile range, 5.3-11.7). In conclusion, the presence of sarcopenia on a CT scan is an important predictor of long-term mortality in patients treated for AAA with EVAR. Pending further study, these data suggest that sarcopenia may aid in pre-procedural long-term survival assessment of patients undergoing EVAR.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/mortalidade , Sarcopenia/mortalidade , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Músculo Esquelético/diagnóstico por imagem , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Sarcopenia/diagnóstico por imagem , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: There is no evidence that insurance-mandated weight loss before bariatric surgery affects outcomes. OBJECTIVE: This retrospective study evaluated the relationship between insurance-mandated weight management program (WMP) completion before primary bariatric surgery and postoperative outcomes. SETTING: Suburban academic medical center. METHODS: Patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB, n = 572) or sleeve gastrectomy (SG, n = 484) from 2014 to 2019 were dichotomized to presence (LRYGB n = 431, SG n = 348) or absence (LRYGB n = 141, SG n = 136) of insurance-mandated WMP completion. Primary endpoints included follow-up rate, percent total weight loss (%TWL), and percent excess weight loss (%EWL) through 60 months after surgery. The Mann-Whitney U test compared between-group means with significance at P < .05. RESULTS: Follow-up rate, %TWL, and %EWL were not different (P = NS) up to 60 months postoperation between groups for either surgery. Both LRYGB and SG patients without WMP completion maintained greater %TWL (LRYGB: 34.4 ± 11.1% versus 29.8 ± 11.0%, P = .159; SG: 21.4 ± 10.0% versus 18.2 ± 10.5%, P = .456) and %EWL (LRYGB: 71.3 ± 26.3% versus 67.6 ± 26.5%, P = .618; SG: 49.2 ± 18.8% versus 47.5 ± 28.8%, P = .753) at 36 months after surgery. Secondarily, duration of time to get to surgery was significantly greater among yes-WMP patients (LRYGB: 178 days versus 121 days, P < .001; SG: 169 days versus 95 days, P < .001). CONCLUSION: Insurance-mandated WMP completion before bariatric surgery delays patient access to surgery without improving postoperative weight loss potential and must be abandoned.
Assuntos
Cirurgia Bariátrica , Derivação Gástrica , Seguro , Laparoscopia , Obesidade Mórbida , Programas de Redução de Peso , Humanos , Obesidade Mórbida/cirurgia , Estudos Retrospectivos , Gastrectomia , Redução de Peso , Resultado do TratamentoRESUMO
To investigate a potential role for galectins as biomarkers that enable diagnosis or prognostication of breast or non-small cell lung cancer, the serum levels of galectins -1, -3, -7, -8, and -9 of cancer patients determined by ELISA assays were compared to the mutation status of 50 known cancer-critical genes, which were determined using multiplex PCR in tumors of the same patients. Mutations in the KIT proto-oncogene, which codes for the c-Kit protein, a receptor tyrosine kinase, correlated with higher levels of galectins -1, -3, -8, and -9 in breast cancer patients and galectin-1 in non-small cell lung cancer patients. Mutations in the KIT gene were more likely found in brain metastases from both of these primary cancers. The most common KIT mutation in our panel was p.M541L, a missense mutation in the transmembrane domain of the c-Kit protein. These results demonstrate an association between KIT oncogenic signaling and elevated serum galectins in patients with metastatic disease. Changes in protein trafficking and the glycocalyx composition of cancer cells may explain the observed alterations in galectin expression. This study can be useful for the targeted selection of receptor tyrosine kinase and galectin inhibitor anti-cancer treatments.
RESUMO
OBJECTIVES: Helicopter transport of trauma patients remains controversial. We examined the survival rates of patients undergoing helicopter versus ground transport to a Level 1 trauma center. METHODS: Retrospective analysis was performed on trauma patients treated between 2014 and 2017. Student's t-test was used to compare air versus ground transport times. A logistic regression was then used to examine the association of transportation type on survival controlling for demographics, mechanism of injury, transport time, field intubation, and injury severity. RESULTS: Of 3967 patients identified, 69.6% (2762) were male, and the average age was 40 years. Most patients suffered blunt injuries (86.8%, 3445), while the remaining had penetrating injuries (11.6%, 459) or burns (1.6%, 63). The majority of patients were transferred by ground (3449) with only 13% (518) transferred by air. Patients transported by air had increased Injury Severity Score (ISS) with a median of 17 (IQR 9-24) versus 9 (IQR 5-14), increased length of stay (LOS) at 6 days versus 3 (P < .001), and increased mortality at 12.6% vs 6.5% (P < .001). Patients transported by air arrived 16.6 ± 6.7 minutes faster compared with ground for the zip codes examined. When adjusting for the mechanism of injury, ISS, age, gender, intubation status, and transport time, air transport was associated with an increased likelihood of survival (odds ratio [OR] = 1.57, 95% CI = 1.06-2.40). CONCLUSION: In our analysis of 3967 patients, those transported by air had a significant improvement in the likelihood of survival compared with those transported by ground even when adjusting for both ISS and time.
Assuntos
Resgate Aéreo , Ferimentos e Lesões/mortalidade , Adulto , Ambulâncias , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida , Fatores de TempoRESUMO
INTRODUCTION: Obesity is an epidemic in the United States, known to be associated with comorbidities. However, some data show that obesity may be a protective factor in some instances. The purpose of this study is to determine if there are differences in morbidity and mortality when comparing the obese and non-obese critically ill trauma patient populations. MATERIALS AND METHODS: This was a retrospective study conducted at Prisma Health Upstate in Greenville, South Carolina, an Adult Level 1 Trauma Center. Patients over the age of 18 years admitted due to trauma from February 6, 2016 to February 28, 2019 were included in this study. Burn patients were excluded. An online trauma database was used to obtain age, sex, body mass index, Glasgow coma score (GCS), injury severity score (ISS), revised trauma score (RTS), days on mechanical ventilation, hospital length of stay (LOS), and intensive care unit (ICU) LOS. RESULTS: There were 2365 critically ill trauma patients who met inclusion criteria for this study. 1570 patients were men (66.38%) and mean age was 53.2 ± 20.9. Of the patients, 2166 patients had blunt trauma (91.59%). Median GCS was 15 (interquartilerange [IQR]: 12, 15), median RTS was 12 (IQR: 11, 12), and median ISS was 17 (IQR: 9, 22). Obese critically ill trauma patients had significantly lower odds of mortality than nonobese (OR .686, CI 0.473-.977). Penetrating traumas (OR: 4.206, CI: 2.478, 6.990), increased ISS (OR: 1.095, CI: .473, 1.112), and increased age (OR: 1.036, CI: 1.038, 1.045) were associated with significantly increased odds of mortality. DISCUSSION: The obesity paradox is observed in the obese critically ill trauma patient population.
Assuntos
Obesidade/complicações , Ferimentos e Lesões/mortalidade , Feminino , Escala de Coma de Glasgow , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , South Carolina/epidemiologia , Centros de TraumatologiaRESUMO
BACKGROUND: Direct aspiration thrombectomy techniques use large bore aspiration catheters for mechanical thrombectomy. Several aspiration catheters are now available. We report a bench top exploration of a novel beveled tip catheter and our experience in treating large vessel occlusions (LVOs) using next-generation aspiration catheters. METHODS: A retrospective analysis from a prospectively maintained database comparing the bevel shaped tip aspiration catheter versus non-beveled tip catheters was performed. Patient demographics, periprocedural metrics, and discharge and 90-day modified Rankin Scale (mRS) scores were collected. Patients were divided into two groups based on which aspiration catheter was used. RESULTS: Our data showed no significant difference in age, gender, IV tissue plasminogen activator administration, admission NIH Stroke Scale score, baseline mRS, or LVO location between the beveled tip and flat tip groups. With the beveled tip, Thrombolysis in Cerebral Infarction (TICI) 2C or better recanalization was more frequent overall (93.2% vs 74.2%, p=0.017), stent retriever usage was lower (9.1% vs 29%, p=0.024), and patients had lower mRS on discharge (median 3 vs 4, p<0.001) and at 90 days (median 2 vs 4, p=0.008). CONCLUSION: Patients who underwent mechanical thrombectomy with the beveled tip catheter had a higher proportion of TICI 2C or better and had a significantly lower mRS score on discharge and at 90 days.
Assuntos
Isquemia Encefálica , AVC Isquêmico , Acidente Vascular Cerebral , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/cirurgia , Catéteres , Humanos , Estudos Retrospectivos , Stents , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Trombectomia , Ativador de Plasminogênio Tecidual , Resultado do TratamentoRESUMO
BACKGROUND: Preoperative portal vein embolization (PVE) is selectively performed to induce hypertrophy of the future liver remnant prior to major liver resection. The primary aim of this study was to determine the association of PVE with liver-specific and overall postoperative morbidity. METHODS: A retrospective cohort study of patients who underwent major hepatectomy from 2014 to 2016 within the ACS-NSQIP hepatectomy-specific module was performed. RESULTS: Of the 3912 patients identified, 9.9% (N = 388) underwent PVE. Patients who underwent PVE were older (59.1 vs. 57.7 years). Most patients in the PVE cohort underwent right hepatectomy (51.8%, N = 201) or trisectionectomy (46.1%, N = 179), compared with right (49.3%, N = 1738) and left hepatectomy (29.6%, N = 1042) in the non-PVE cohort (p < 0.001). Median operative time was longer in the PVE group (310 vs. 276 min, p < 0.001). Post-hepatectomy liver failure was more common among patients undergoing PVE (18.6% (N = 72) vs. 9.9% (N = 350), p < 0.001), as was bile leak (17.3% (N = 67) vs. 12.2% (N = 428), p = 0.005). Overall complication rates were higher among patients who underwent PVE (45.9% (N = 178) vs. 34.0% (N = 1199), p < 0.001). However, on multivariable analysis controlling for patient and technical factors, PVE remained associated with an increased risk of liver-specific complications (OR 1.33, 95% CI 1.01-1.74) but not with overall complications (OR 1.17, 95% CI 0.92-1.50). CONCLUSION: Within a national cohort, patients treated with PVE are older and undergo a more extensive liver resection. When controlling for patient and technical factors, PVE is neither associated with an increase in overall morbidity nor mortality, suggesting that PVE can be safely used in appropriate patients undergoing major hepatectomy.