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1.
Med Care ; 57 Suppl 5 Suppl 1: S31-S37, 2019 05.
Artículo en Inglés | MEDLINE | ID: mdl-30985594

RESUMEN

INTRODUCTION: The collection of patient-reported outcomes (PROs) in routine clinical practice provides opportunities to "feed-forward" the patient's perspective to his/her clinical team to inform planning and management. This data can also be aggregated to "feedback" population-level analytics that can inform treatment decision-making, predictive modeling, population-based care, and system-level quality improvement efforts. METHODS AIDING INTERPRETATION AND ACTING ON RESULTS: Three case studies demonstrate a number of system-level features which aid effective PRO interpretation: (1) feed-forward and feedback information flows; (2) score interpretation aids; (3) cascading measurement; (4) registry-enabled learning health care systems; and (5) the maturational development of information systems. DISCUSSION: The case studies describe the developmental span of feed-forward PRO programs-from simple to mature applications. The Concord Hospital (CH) Multiple Sclerosis Neurobehavioral Clinic exemplifies a simple application in which PRO data are used before and during clinic visits by patients and clinicians to inform care. The Dartmouth-Hitchcock (D-H) Spine Center exemplifies a mature program which utilizes population-level analytics to provide decision support by predicting outcomes for different treatment options. The Swedish Rheumatology Quality (SRQ) Registry epitomizes an exceptional application which has spread to multiple systems across an entire country. KEY POINTS: Feed-forward and feedback PRO information systems can better inform, involve, and support clinicians, patients and families, and allow health systems to monitor and improve system performance and population health outcomes. Ideal systems have the capability for multilevel analyses at patient, system, and population levels, and an information technology infrastructure that is linked to associated workflows and a supportive practice culture. As systems mature, they progress beyond the ability to describe and inform towards higher level capabilities including prediction and decision support. Finally, there is additional promise for the integration of patient-reported information that is adjusted (or weighted) by preferences and values to guide shared decision-making and inform individualized precision health care in the future.


Asunto(s)
Retroalimentación , Medición de Resultados Informados por el Paciente , Desarrollo de Programa , Artritis Reumatoide/terapia , Recolección de Datos/métodos , Toma de Decisiones , Humanos , Esclerosis Múltiple/psicología , Estudios de Casos Organizacionales , Educación del Paciente como Asunto , Mejoramiento de la Calidad/organización & administración , Sistema de Registros , Traumatismos Vertebrales , Encuestas y Cuestionarios , Suecia
2.
Curr Protoc ; 2(10): e556, 2022 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-36200800

RESUMEN

Social Determinants of Health (SDOH) consider social, political, and economic factors that contribute to health disparities in patients and populations. The most common health-related SDOH exposures are food and housing insecurity, financial instability, transportation needs, low levels of education, and psychosocial stress. These domains describe risks that can impact health outcomes more than health care. Epidemiologic and translational research demonstrates that SDOH factors represent exposures that predict harm and impact the health of individuals. International and national guidelines urge health professionals to address SDOH in clinical practice and public health. The further implementation of these recommendations into basic and translational research, however, is lagging. Herein, we consider a precision health framework to describe how SDOH contributes to the exposome and exacerbates physiologic pathways that lead to chronic disease. SDOH factors are associated with various forms of stressors that impact physiological processes through epigenetic, inflammatory, and redox regulation. Many SDOH exposures may add to or potentiate the pathologic effects of additional environmental exposures. This overview aims to inform basic life science and translational researchers about SDOH exposures that can confound associations between classic biomedical determinants of disease and health outcomes. To advance the study of toxicology through either qualitative or quantitative assessment of exposures to chemical and biological substances, a more complete environmental evaluation should include SDOH exposures. We discuss common approaches to measure SDOH factors at individual and population levels and review the associations between SDOH risk factors and physiologic mechanisms that influence chronic disease. We provide clinical and policy-based motivation to encourage researchers to consider the impact of SDOH exposures on study results and data interpretation. With valid measures of SDOH factors incorporated into study design and analyses, future toxicological research may contribute to an evidence base that can better inform prevention and treatment options, to improve equitable clinical care and population health. © 2022 Wiley Periodicals LLC.


Asunto(s)
Biología , Determinantes Sociales de la Salud , Enfermedad Crónica , Escolaridad , Humanos , Factores de Riesgo
3.
Ann Plast Surg ; 66(3): 245-8, 2011 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-21042185

RESUMEN

BACKGROUND: Carpal tunnel surgery (CTS) can be performed in the clinic or operating room with similar outcomes. Our goals were to perform a total cost comparison, profit analysis, and assess efficiency of CTS in each setting. METHODS: A detailed cost analysis for all CTSs at a tertiary care academic center was done for the year 2007. We calculated the net revenues and profit margins for single endoscopic port and open CTS performed in each setting in the year 2007. For efficiency analysis, we assumed that the time saved by performing a procedure in the more efficient setting could accumulate and permit additional CTSs. This would be the opportunity cost of performing CTS in the less efficient setting. RESULTS: In general, the operating room was a costlier setting than the clinic. The total cost per case when performing single-port endoscopic CTS was more than double ($2273 vs. $985) when performed in the operating room versus the clinic. For open CTS, the operating room was more than 4 times as expensive than the clinic ($3469 vs. $670). For single endoscopic port cases, profits gained were greater than double in the clinic versus the operating room ($2710 vs. $1139). For open CTS, clinic cases had a profit margin per case of $1186; however, procedures in the operating room incurred a loss of $650 per case. The block time allowed for CTS in the clinic was 30 and 60 minutes in the operating room. To value this efficiency, we used the profit margin of CTS performed in the clinic ($2710) and divided it by the 30 minutes it took to perform. This provided us with a multiplier of $90/min. We multiplied the 30 minutes saved when operating in the clinic by the $90/min to give us an opportunity cost of $2700. CONCLUSION: Performing either single endoscopic port or open CTS in the operating room is more expensive and less efficient than in the clinic setting.


Asunto(s)
Instituciones de Atención Ambulatoria/economía , Síndrome del Túnel Carpiano/economía , Procedimientos Quirúrgicos Mínimamente Invasivos/economía , Quirófanos/economía , Instituciones de Atención Ambulatoria/organización & administración , Síndrome del Túnel Carpiano/cirugía , Análisis Costo-Beneficio , Costos de la Atención en Salud/estadística & datos numéricos , Costos de Hospital/estadística & datos numéricos , Humanos , Procedimientos Quirúrgicos Mínimamente Invasivos/estadística & datos numéricos , Quirófanos/organización & administración , Evaluación de Resultado en la Atención de Salud/economía , Estados Unidos
4.
Lancet ; 374(9695): 1074-81, 2009 Sep 26.
Artículo en Inglés | MEDLINE | ID: mdl-19782873

RESUMEN

BACKGROUND: A previous randomised controlled trial reported greater efficacy of surgery than of splinting for patients with carpal tunnel syndrome. Our aim was to compare surgical versus multi-modality, non-surgical treatment for patients with carpal tunnel syndrome without denervation. We hypothesised that surgery would result in improved functional and symptom outcomes. METHODS: In this parallel-group randomised controlled trial, we randomly assigned 116 patients from eight academic and private practice centres, using computer-generated random allocation stratified by site, to carpal tunnel surgery (n=57) or to a well-defined, non-surgical treatment (including hand therapy and ultrasound; n=59). The primary outcome was hand function measured by the Carpal Tunnel Syndrome Assessment Questionnaire (CTSAQ) at 12 months assessed by research personnel unaware of group assignment. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00032227. FINDINGS: 44 (77%) patients assigned to surgery underwent surgery. At 12 months, 101 (87%) completed follow-up and were analysed (49 of 57 assigned to surgery and 52 of 59 assigned to non-surgical treatment). Analyses showed a significant 12-month adjusted advantage for surgery in function (CTSAQ function score: Delta -0.40, 95% CI 0.11-0.70, p=0.0081) and symptoms (CTSAQ symptom score: 0.34, 0.02-0.65, p=0.0357). There were no clinically important adverse events and no surgical complications. INTERPRETATION: Symptoms in both groups improved, but surgical treatment led to better outcome than did non-surgical treatment. However, the clinical relevance of this difference was modest. Overall, our study confirms that surgery is useful for patients with carpal tunnel syndrome without denervation. FUNDING: NIH/NIAMS 5P60AR048093 and the Intramural Research Program of the NIH Clinical Center.


Asunto(s)
Síndrome del Túnel Carpiano/terapia , Antiinflamatorios no Esteroideos/uso terapéutico , Artroscopía , Síndrome del Túnel Carpiano/patología , Síndrome del Túnel Carpiano/cirugía , Descompresión Quirúrgica , Terapia por Ejercicio , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Recuperación de la Función , Férulas (Fijadores) , Resultado del Tratamiento , Terapia por Ultrasonido
5.
J Hand Surg Am ; 34(6): 997-1005, 2009.
Artículo en Inglés | MEDLINE | ID: mdl-19643287

RESUMEN

PURPOSE: Critics of U.S. health care cite both underuse and overuse of resources. With more than one third of Americans paying for medical care out of pocket, optimizing the cost-benefit ratio of care is a high priority. Clinical trials have established the success of the different treatment options for patients who present with trigger finger. The economic impact of these differing strategies has not been established. The aim of this study was to perform a cost-minimization analysis to identify the least costly strategy for effective treatment of trigger finger using existing evidence in the literature. METHODS: Five strategies for the treatment of trigger finger were identified: (1) a steroid injection followed by surgical release for failure or recurrence, (2) a steroid injection followed by a second injection for failures or recurrence, followed by definitive surgery if needed, (3) 3 steroid injections before definitive surgery if needed, (4) surgical release, and (5) percutaneous release with definitive open surgery if needed. To reflect the costs, we used 2 sources of data: our institution's billing charges to private payers and our institution's reimbursements from Medicare. A literature review identified median success rates of the different treatment strategies. We conducted a series of analyses to evaluate the effect of varying individual costs and success rates. RESULTS: The second strategy is the least costly treatment of those considered in this study. The most costly treatment, surgical release, costs between 248% and 340% more than the second strategy. For surgical or percutaneous release to cost less than the second strategy, the surgical billing charge would need to be lower than $742 for private payers or less than $305 of Medicare reimbursement. CONCLUSIONS: Trigger finger is a common problem with many acceptable treatment algorithms. Management of trigger finger with 2 steroid injections before surgery is the least costly treatment strategy. TYPE OF STUDY/LEVEL OF EVIDENCE: Decision Analysis II.


Asunto(s)
Técnicas de Apoyo para la Decisión , Costos de la Atención en Salud , Trastorno del Dedo en Gatillo/economía , Trastorno del Dedo en Gatillo/terapia , Análisis Costo-Beneficio , Árboles de Decisión , Articulaciones de los Dedos , Glucocorticoides/administración & dosificación , Glucocorticoides/economía , Humanos , Inyecciones Intraarticulares/economía , Procedimientos Ortopédicos/efectos adversos , Procedimientos Ortopédicos/economía , Recurrencia , Insuficiencia del Tratamiento , Trastorno del Dedo en Gatillo/cirugía
7.
Am Soc Clin Oncol Educ Book ; 38: 122-134, 2018 May 23.
Artículo en Inglés | MEDLINE | ID: mdl-30231381

RESUMEN

There is increasing interest to integrate collection of patient-reported outcomes (PROs) in routine practice to enhance clinical care. Multiple studies show that systematic monitoring of patients using PROs improves patient-clinician communication, clinician awareness of symptoms, symptom management, patient satisfaction, quality of life, and overall survival. The general approach includes a brief electronic survey, administered via the Web or an app or an automated telephone system, with alerts to clinicians for concerning or worsening issues. Patients have generally been asked to self-report on a regular basis (remotely between visits and/or at visits), with reminders prompting patients to self-report that are sent via email, text, or automated phone message. More recently, care management pathways for patients and clinicians have been triggered by PRO system alerts. PRO systems may be free-standing, integrated into electronic health record systems or patient portals, or native functionality of an electronic health record. Despite potential benefits, there are challenges with integrating PROs into practice for monitoring patient status, as there are with any modifications to existing clinical processes. These challenges range from administrative to technical to workflow. A session at the 2018 ASCO Annual Meeting was dedicated to the implementation of PROs in clinical practice. The session focused on practical examples of PRO implementations, with honest reflections on barriers and strategies that may be generalizable to other systems looking to implement PROs. Panelists for that session are the authors of this paper, which describes their respective experiences implementing PROs in practice settings.


Asunto(s)
Implementación de Plan de Salud , Medición de Resultados Informados por el Paciente , Calidad de la Atención de Salud , Atención a la Salud/métodos , Atención a la Salud/normas , Humanos , Mejoramiento de la Calidad
8.
Plast Reconstr Surg ; 139(5): 1046e-1055e, 2017 May.
Artículo en Inglés | MEDLINE | ID: mdl-28445351

RESUMEN

BACKGROUND: The BREAST-Q is a patient-reported outcome instrument used to evaluate outcomes in patients undergoing breast cancer surgery and reconstruction. Normative values for the BREAST-Q breast cancer modules have not been established, limiting data interpretation. METHODS: Participants were recruited by means of the Army of Women, an online community of women (with and without breast cancer), to complete Mastectomy, Breast Conserving Therapy, and Reconstruction preoperative BREAST-Q scales. Inclusion criteria were women aged 18 years or older without a history of breast surgery or breast cancer. Analysis included descriptive statistics, a linear multivariate regression, and a comparison of the generated normative data to previously published BREAST-Q findings. RESULTS: The BREAST-Q was completed by 1201 women. The mean patient age was 54 ± 13 years, mean body mass index 26 ± 6 kg/m, and 38 percent (n = 455) had a bra cup size of D or greater. Mean ± SD scores for BREAST-Q scales were as follows: Satisfaction with Breasts (58 ± 18), Psychosocial Well-being (71 ± 18), Sexual Well-being (56 ± 18), Physical Well-being-Chest (93 ± 11), and Physical Well-being Abdomen (78 ± 20). Women with a body mass index of 30 kg/m or greater, cup size of D or greater, age younger than 40 years, and annual income less than $40,000 reported lower scores. Comparing normative scores to published data in breast cancer patients, Satisfaction with Breasts scores were higher after autologous reconstruction and lower after mastectomy; Sexual Well-being scores were lower after mastectomy and breast conserving therapy; and Physical Well-being Chest scores were lower after mastectomy, breast conserving therapy, and reconstruction. CONCLUSION: These are the first published normative scores for the BREAST-Q breast cancer modules and provide a clinical reference point for the interpretation of data.


Asunto(s)
Neoplasias de la Mama/cirugía , Mamoplastia , Medición de Resultados Informados por el Paciente , Adulto , Femenino , Humanos , Mastectomía , Persona de Mediana Edad , Satisfacción del Paciente
9.
Plast Reconstr Surg ; 139(4): 846e-853e, 2017 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-28350653

RESUMEN

BACKGROUND: The BREAST-Q Reduction module evaluates outcomes in reduction mammaplasty. However, there are currently no published normative scores, limiting the interpretation of BREAST-Q data. METHODS: The BREAST-Q Reduction module was administered via the Army of Women, an online community of women (with and without breast cancer) engaged in breast-cancer related research. Normative data were generated from women aged 18 years and older, without a history of breast cancer or breast surgery. Data analysis was performed using descriptive statistics and a linear multivariate regression. Generated normative data were compared to published BREAST-Q Reduction findings. RESULTS: The preoperative version of the BREAST-Q Reduction module was completed by 1206 women. Participant mean age was 55 ± 13 years, mean body mass index was 27 ± 6 kg/m, and 40 percent (n = 481) had a bra cup size ≥ D. Mean normative scores were as follows: Satisfaction with Breasts, 57 ± 16; Psychosocial Well-being, 68 ± 19; Sexual Well-being, 55 ± 19; and Physical Well-being, 76 ± 11. Normative scores were lower in women with body mass index ≥ 30 and bra cup size ≥ D. In comparison to normative Army of Women scores, published BREAST-Q scores for women undergoing reduction mammaplasty were lower (worse) for preoperative patients and higher (better) for postoperative patients. CONCLUSION: These new Army of Women normative data provide insights into breast-related satisfaction and well-being in women not pursuing breast reduction, giving new clinical context to better understand the health burden of macromastia, and to demonstrate the value of reduction mammaplasty in certain patients.


Asunto(s)
Mama/anomalías , Costo de Enfermedad , Hipertrofia/cirugía , Mamoplastia , Evaluación de Resultado en la Atención de Salud , Mama/cirugía , Femenino , Humanos , Persona de Mediana Edad
10.
Plast Reconstr Surg ; 139(4): 846-853, 2017 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-28350657

RESUMEN

BACKGROUND: The BREAST-Q is a rigorously developed, well-validated, patient-reported outcome instrument with a module designed for evaluating breast augmentation outcomes. However, there are no published normative BREAST-Q scores, limiting interpretation. METHODS: Normative data were generated for the BREAST-Q Augmentation module by means of the Army of Women, an online community of women (with and without breast cancer) engaged in breast-cancer related research. Members were recruited by means of e-mail; women aged 18 years or older without a history of breast cancer or breast surgery were invited to participate. Descriptive statistics and a linear multivariate regression were performed. A separate analysis compared normative scores to findings from previously published BREAST-Q augmentation studies. RESULTS: The preoperative BREAST-Q Augmentation module was completed by 1211 women. Mean age was 54 ± 24 years, the mean body mass index was 27 ± 6 kg/m, and 39 percent (n = 467) had a bra cup size of D or greater. Mean scores were as follows: Satisfaction with Breasts, 54 ± 19; Psychosocial Well-being, 66 ± 20; Sexual Well-being, 49 ± 20; and Physical Well-being, 86 ± 15. Women with a body mass index of 30 kg/m or greater and bra cup size of D or greater had lower scores. In comparison with Army of Women scores, published BREAST-Q augmentation scores were lower before and higher after surgery for all scales except Physical Well-being. CONCLUSIONS: The Army of Women normative data represent breast-related satisfaction and well-being in women not actively seeking breast augmentation. These data may be used as normative comparison values for those seeking and undergoing surgery as we did, demonstrating the value of breast augmentation in this patient population.


Asunto(s)
Mamoplastia/normas , Medición de Resultados Informados por el Paciente , Interpretación Estadística de Datos , Femenino , Humanos , Persona de Mediana Edad
11.
Plast Reconstr Surg ; 137(2): 709-730, 2016 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-26818311

RESUMEN

UNLABELLED: The goal of this consensus conference, sponsored by the American Association of Plastic Surgeons, was to perform a systematic review and meta-analysis of controlled trials to examine both the benefits and risks of venous thromboembolism prophylaxis in plastic surgery patients. The panel sought to assess the safety and effectiveness of recognized venous thromboembolism prophylaxis strategies, including variation in anesthetic management, use of elastic compression stockings or intermittent pneumatic compression, and use of chemoprophylaxis. The authors also sought to examine effectiveness and safety of prophylaxis in patients risk-stratified by procedure type or 2005 Caprini score. The panel met face to face in March of 2015 to perform an exhaustive review of the existing literature. The panel subsequently created consensus recommendations using the GRADE criteria. Important directions for future research were also identified. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.


Asunto(s)
Ensayos Clínicos Controlados como Asunto , Procedimientos de Cirugía Plástica/efectos adversos , Embolia Pulmonar/etiología , Embolia Pulmonar/prevención & control , Trombosis de la Vena/etiología , Trombosis de la Vena/prevención & control , Humanos , Guías de Práctica Clínica como Asunto , Medición de Riesgo , Tromboembolia Venosa
12.
Med Decis Making ; 22(3): 208-17, 2002.
Artículo en Inglés | MEDLINE | ID: mdl-12058778

RESUMEN

The authors evaluated existing and new criteria for defining the medical necessity for breast reduction surgery. Two cohorts of women (those requesting breast reduction surgery [N = 266] and a group of controls [N = 184]) completed a questionnaire including breast-specific symptom severity, the Short Form 36, the EuroQol, the McGill Pain Questionnaire, and the Multidimensional Body Self Relations Questionnaire. To evaluate prediction validity, the most widely accepted decision criteria and a new definition of medical necessity were applied to the data set to determine whether women meeting the definition had more favorable outcomes than those who did not as measured by validated self-report instruments. For existing criteria, women not meeting and meeting the criterion gained equal benefit from surgery. Women meeting the new definition (> or = 2 of 7 physical symptoms all or most of the time) had significantly greater improvement scores on 4 of the 5 health burden measures compared to women not meeting this definition. The authors conclude that medical necessity for breast reduction surgery is better defined by self-report of symptoms than by existing criteria.


Asunto(s)
Mamoplastia/psicología , Selección de Paciente , Adulto , Estudios de Casos y Controles , Femenino , Estado de Salud , Humanos , Seguro de Salud , Periodo Posoperatorio , Encuestas y Cuestionarios
13.
Plast Reconstr Surg ; 109(1): 220-7, 2002 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-11786815

RESUMEN

In this study, the authors tested the hypothesis that there is a significant difference in spatial patterns of reflow in skin as opposed to skeletal muscle after an ischemic insult. The authors believe that this pathophysiologic difference between the two flap types has significant implications for flap salvage strategies. Bilateral buttock skin flaps (10 x 18 cm) and latissimus dorsi myocutaneous flaps (10 x 20 cm) were elevated in Landrace pigs (n = 7). Flaps on one side of the animal were randomly assigned to 6 hours of arterial occlusion, with the contralateral side acting as control. At 15 minutes, 1 hour, and 4 hours after reflow, radioactive microspheres (15 microm) were injected into the left ventricle. After 18 hours of reperfusion, skin and muscle viability were estimated by intravenous fluorescein and soaking in nitroblue tetrazolium, respectively. Flow rates in the skin with an ischemia-reperfusion injury were significantly reduced (30 to 53 percent), at all time intervals, compared with controls. The flow rate in the fluorescent skin with ischemia-reperfusion injury of the latissimus dorsi flaps (0.037 ml/min/g at 15 min) was greater than in that of the buttock flaps (0.018 ml/min/g). The muscle flaps with ischemia-reperfusion injury had significantly higher flow rates than control muscle flaps at all time intervals studied (at 1 hour, 0.32 ml/min/g compared with 0.16 ml/min/g, respectively). In flap skeletal muscle, an early hyperemic phase during reperfusion maintains a significant blood flow to all regions, including the area of the flap that is destined for necrosis. In flap skin, however, there is a marked decrease in flow rates. These differences have important implications for the intravascular delivery of therapeutic agents to the damaged portions of the flap. Transdermal drug delivery systems should be explored as an alternative to intravascular regimens for the salvage of flap skin with ischemia-reperfusion injury.


Asunto(s)
Músculo Esquelético/irrigación sanguínea , Daño por Reperfusión/fisiopatología , Piel/irrigación sanguínea , Colgajos Quirúrgicos/irrigación sanguínea , Animales , Velocidad del Flujo Sanguíneo , Nalgas , Colorantes , Femenino , Fluoresceína , Supervivencia de Injerto , Microesferas , Músculo Esquelético/patología , Músculo Esquelético/trasplante , Necrosis , Radioisótopos , Flujo Sanguíneo Regional , Piel/patología , Trasplante de Piel , Porcinos
14.
Plast Reconstr Surg ; 110(1): 169-76, 2002 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-12087248

RESUMEN

Ischemia-reperfusion injury causes tissue damage that leads to a decrease in bioavailability of nitric oxide. The authors hypothesized that an exogenous supply of nitric oxide will have beneficial effects on survival of skin and skeletal muscle subjected to ischemia-reperfusion injury. By using the nitric oxide donor SIN-1 (3-morpholino-sydnonimine) the effects of direct intraarterial infusion of an exogenous source of nitric oxide in reperfused flaps was studied. Bilateral island buttock skin flaps and latissimus dorsi myocutaneous flaps were elevated in eight pigs, for a total of 32 flaps. Flaps were subjected to 6 hours of ischemia followed by 18 hours of reperfusion. Flaps on one side of each animal were randomized to be treated with the nitric oxide donor (treatment group). The contralateral side was treated with an equivalent volume of saline vehicle (infusion control) SIN-1, or saline was administered as a continuous direct intraarterial infusion at the onset of reperfusion and continued during the observation period. Outcomes measured were tissue neutrophil accumulation by using myeloperoxidase assay and tissue survival (intravenous fluorescein and nitroblue tetrazolium for skin and muscle, respectively). In both skin and myocutaneous flaps, SIN-1 treatment caused a significant improvement in survival and a decrease in neutrophil accumulation. Nitric oxide may play an important role in the pathophysiologic process of ischemia-induced reperfusion injury in skin and skeletal muscle. Nitric oxide donors may be a promising family of therapeutic agents for the prevention of ischemia-induced reperfusion injury in cutaneous and myocutaneous flaps.


Asunto(s)
Molsidomina/farmacología , Donantes de Óxido Nítrico/farmacología , Daño por Reperfusión/patología , Colgajos Quirúrgicos/irrigación sanguínea , Animales , Supervivencia Celular/efectos de los fármacos , Femenino , Molsidomina/análogos & derivados , Neutrófilos/efectos de los fármacos , Neutrófilos/patología , Colgajos Quirúrgicos/patología , Porcinos
15.
Plast Reconstr Surg ; 109(5): 1638-45, 2002 Apr 15.
Artículo en Inglés | MEDLINE | ID: mdl-11932608

RESUMEN

Nitric oxide is produced from the amino acid L-arginine by nitric oxide synthase, which has three known isoforms: (1) endothelial nitric oxide synthase and (2) brain nitric oxide synthase, both of which are constitutive nitric oxide synthase; and (3) inducible nitric oxide synthase. The authors' hypothesis is that after reperfusion injury, endothelial cell dysfunction leads to disruption of nitric oxide synthase-mediated nitric oxide production and that this may in part explain the deleterious effects of ischemia-reperfusion injury on tissue survival and blood reflow in flaps. An experiment was designed to study the effects of ischemia-reperfusion injury on the bioactivity of all three isoforms of nitric oxide synthase. Buttock skin flaps and latissimus dorsi myocutaneous flaps were elevated in eight pigs. Flaps on one side of the animal were randomized to receive 6 hours of arterial ischemia, whereas flaps on the other side served as controls. At 6 hours of ischemia and at 1, 4, and 18 hours after reflow, tissue biopsy specimens were obtained and were processed for both constitutive nitric oxide synthase and inducible nitric oxide synthase enzyme activity on the basis of the L-citrulline assay. In addition, specimens were processed for Western blot analysis of the three isoforms. The authors' results revealed three key findings: first, there was a statistically significant (p < 0.001) decrease in constitutive nitric oxide synthase activity of ischemia-reperfusion-injured flaps as compared with controls in both skin and muscle for all time intervals measured. Second, Western blot analyses of endothelial nitric oxide synthase and brain nitric oxide synthase showed a significant decrease in the signal intensity in ischemic and reperfused tissue as compared with controls. Third, the inducible nitric oxide synthase isoform's activity and protein remained undetectable in both tissue types for all time points measured. The authors' data demonstrated that following ischemia-reperfusion injury in the pig flap model there was a disruption of constitutive nitric oxide synthase expression and activity, which may lead to decreased nitric oxide production. The significant decrease in nitric oxide synthase activity found in the current study may partly explain the mechanism of tissue damage in flaps subjected to ischemia-reperfusion injury. Knowledge of the kinetics of nitric oxide synthase activity under conditions of ischemia-reperfusion injury has important implications for the choice and timing of delivery of therapeutic agents whose goal is to increase the bioavailability of nitric oxide in reperfused tissue.


Asunto(s)
Óxido Nítrico Sintasa/metabolismo , Daño por Reperfusión/enzimología , Colgajos Quirúrgicos/irrigación sanguínea , Animales , Femenino , Isoenzimas/metabolismo , Porcinos
16.
Plast Reconstr Surg ; 109(5): 1556-66, 2002 Apr 15.
Artículo en Inglés | MEDLINE | ID: mdl-11932597

RESUMEN

In this report, the authors evaluate the effectiveness of breast reduction in alleviating the symptoms of macromastia by comparing baseline and postoperative health status using a series of well-validated self-report instruments. The study had a prospective design with a surgical intervention group and two control groups: a hypertrophy control group with bra cup sizes D or larger and a normal control group with bra cup sizes less than D. The effectiveness of nonsurgical interventions in relieving the symptoms of macromastia was also evaluated, both in the operative subjects and in the control groups. Surgical candidates and controls completed a self-administered baseline survey that consisted of the following validated and standardized instruments commonly used to evaluate outcomes: SF-36, EuroQol, Multidimensional Body-Self Relations Questionnaire (MBSRQ), and the McGill Pain Questionnaire (MPQ). A specially designed and validated instrument, the Breast-Related Symptoms (BRS), was also used. There were also questions about prior nonsurgical treatments, comorbid conditions, bra size, and a physical assessment. Additional information obtained on the operative subjects included surgical procedure data, resection weight, and complications. Approximately 6 to 9 months postoperatively, surgical subjects completed the same questionnaire as described above, and a final physical assessment was performed. The cohort included 179 operative subjects with matched preoperative and postoperative data sets, 96 normal controls and 88 hypertrophy controls. The women were predominantly Caucasian, middle-aged, well educated, and employed. Fifty percent of the operative subjects reported breast-related pain all or most of the time in the upper back, shoulders, neck, and lower back preoperatively compared with less than 10 percent postoperatively. Operative subjects and hypertrophy controls tried a number of conservative treatments, including weight loss, but none provided adequate permanent relief. Compared with population norms, the preoperative subjects had significantly lower scores (p < 0.05) in all eight health domains of the SF-36, and in the mental and physical component summary scores. After surgery, the operative subjects had higher means (better health) than national norms in seven of the eight domains and improved significantly from presurgical means in all eight domains (p < 0.05). Before surgery, the operative subjects reported high levels of pain with a Pain Rating Index (PRI) score from the MPQ of 26.6. After surgery, pain was significantly lower with a mean PRI score of 11.7, similar to that of our controls (mean PRI score, 11.2). Regression analysis was used to control for covariate effects on the main study outcomes. Among the operative subjects, benefits from breast reduction were not associated with body weight, bra cup size, or weight of resection, with essentially all patients benefiting from surgery.Breast hypertrophy has a significant impact on women's health status and quality of life as measured by validated and widely used self-report instruments including the SF-36, MPQ, and EuroQol. Pain is a significant symptom in this disease, and both pain and overall health status are markedly improved by breast reduction. In this population, conservative measures such as weight loss, physical therapy, special brassieres, and medications did not provide effective permanent relief of symptoms.


Asunto(s)
Enfermedades de la Mama/terapia , Mama/anomalías , Mamoplastia , Adulto , Mama/cirugía , Enfermedades de la Mama/complicaciones , Femenino , Humanos , Estudios Prospectivos , Análisis de Regresión
17.
Plast Reconstr Surg ; 132(6): 1670-1683, 2013 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-24281593

RESUMEN

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Accurately state the indications for breast imaging prior to breast reduction; 2. List the modifiable risk factors in a woman considering breast reduction. 3. Use perioperative antibiotics in an evidence based fashion. 4. Identify factors that are associated with higher rates of perioperative complications. 5. Describe the risks and benefits of breast infiltration with epinephrine. 6. Describe the pros and cons of using drains following breast reduction. 7. Describe the incidence of invasive breast cancer in surgical specimens compared to autopsy specimens. 8. Identify common questionnaires that can be used to track short and long-term outcomes following breast reduction. 9. List at least three current practices that are now evolving and changing based on evidence based medicine. SUMMARY: This paper is designed to summarize key evidence based steps in the care of women undergoing reduction mammaplasty. In addition, the authors identify gaps between how plastic surgeons practice breast reduction and what the best evidence supports. The article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification Program of the American Board of Plastic Surgery.


Asunto(s)
Mama/cirugía , Medicina Basada en la Evidencia , Mamoplastia/métodos , Mamografía , Educación Médica Continua , Femenino , Humanos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Factores de Riesgo
18.
Plast Reconstr Surg ; 132(1): 105-112, 2013 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-23508051

RESUMEN

BACKGROUND: The authors assessed the diagnostic potential of commonly used patient-reported measures, namely, the Boston Carpal Tunnel Questionnaire (function and symptom severity), QuickDASH (a shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire), and the Short Form-8. METHODS: Measure scores were extracted retrospectively from the records of 262 patients (397 hands) and compared using analysis of variance to determine statistical differences among diagnoses assigned by the same surgeon at the time of visit. Patients were grouped into one of two diagnostic groups: those with Dupuytren disease and those with carpal tunnel, osteoarthritis, and tenosynovitis conditions. Logistic regression analysis was performed, and a receiver operating characteristic curve was used in data analysis. RESULTS: Analysis of variance showed statistical differences among the five diagnoses for each patient-reported measure. Results showed that Dupuytren disease was significantly different from the other diagnoses. Carpal tunnel, osteoarthritis, and tenosynovitis conditions were statistically associated with higher Boston Carpal Tunnel Questionnaire function and symptom severity and QuickDASH scores compared with Dupuytren disease. Lower physical and mental summary Short Form-8 scores were associated with the carpal tunnel, osteoarthritis, and tenosynovitis conditions. QuickDASH scores of 25 or higher and Boston Carpal Tunnel Questionnaire symptom severity scores and function scores of 2.5 or higher and of 2 or higher, respectively, are the best patient-reported measure threshold values for distinguishing between the two diagnostic groups. CONCLUSIONS: The QuickDASH and Boston Carpal Tunnel Questionnaire patient-reported measures have diagnostic potential. Establishing threshold values for predicting a diagnostic group may prove to be a useful tool for referring providers. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.


Asunto(s)
Síndrome del Túnel Carpiano/diagnóstico , Autoinforme , Encuestas y Cuestionarios , Humanos , Persona de Mediana Edad , Curva ROC , Estudios Retrospectivos , Índice de Severidad de la Enfermedad
20.
Plast Reconstr Surg ; 128(4): 243e-249e, 2011 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-21921735

RESUMEN

BACKGROUND: The authors hypothesized that the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, Ohio) might outperform electrocautery in bilateral breast reduction surgery, possibly resulting in (1) shorter operative times, (2) lower postoperative fluid drainage rates, and (3) reduced postoperative pain scores. METHODS: Thirty-one patients were evaluated in a matched-pair design, with random (blinded) assignment of one side to the Harmonic Scalpel, with the other side defaulting to electrocautery. Main outcome measures were: (1) resection/hemostasis time, (2) drainage volume, and (3) postoperative pain. The authors also compared the learning curves, operative time versus specimen weights, complications, and costs for the devices. RESULTS: There was a statistically significant (but not clinically significant) difference between the median times for the Harmonic Scalpel (33 minutes) and electrocautery (31 minutes) (p=0.02). There was no statistical difference in drainage scores, and pain scores were equivalent. The analysis of specimen weight versus resection/hemostasis time showed no correlation. There were more complications on the breasts reduced with the Harmonic device, but due to the small sample size, the complication results were not statistically significant. Start-up costs for the devices were comparable, but the per-procedure cost for the Harmonic device was considerably higher. CONCLUSIONS: The Harmonic Scalpel is roughly equivalent to electrocautery in breast reduction surgery in terms of resection/hemostasis time, serous drainage, and postoperative pain. Though the Harmonic device may be excellent for other surgical procedures, its high cost suggests that surgeons and institutions can confidently forgo its use in breast reduction surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.


Asunto(s)
Electrocoagulación/métodos , Mamoplastia/métodos , Terapia por Ultrasonido/instrumentación , Adulto , Electrocoagulación/efectos adversos , Estética , Femenino , Estudios de Seguimiento , Humanos , Mamoplastia/instrumentación , Persona de Mediana Edad , Complicaciones Posoperatorias/fisiopatología , Medición de Riesgo , Método Simple Ciego , Instrumentos Quirúrgicos , Factores de Tiempo , Resultado del Tratamiento , Terapia por Ultrasonido/efectos adversos , Adulto Joven
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