RESUMO
PURPOSE: Subspecialization of adrenal surgery through regionalization has not been adequately evaluated. We assessed implementation of subspecialization and the association of regionalization with adrenalectomy outcomes in a community-based setting. METHODS: In this longitudinal retrospective cohort study, we used an interrupted time series analysis on consecutive adrenal surgeries at Kaiser Permanente Northern California, 2010-2019. The intervention was regionalization of surgery in 2016. Main outcomes include surgical volumes, operative time, length of stay, 30-day return-to-care, and 30-day complications obtained from the electronic medical record. t-Tests and multivariable models were used to analyze time trends in outcomes after accounting for changes in patient and disease characteristics. RESULTS: In total, 850 adrenal surgery cases were eligible. Between 2010 and 2019, the annual incidence of surgery (per 100,000 persons) increased from 2.4 (95% CI 1.9-3.1) to 4.1 (95% CI 3.5-4.8). Average annual surgeon volume increased from 2.4 (95% CI 1.6-3.1) to 9.9 (95% CI 4.9-14.9), while hospital volume increased from 3.5 (95% CI 2.3-4.6) to 15.4 (95% CI 6.9-24.0). Operative time was 34 (23-45) min faster in 2018-2019 compared with 2010-2011. After regionalization, same-day discharges increased to 64% in 2019 (p < 0.0001). The frequency of return-to-care (p = 0.69) and the overall complication rate (p = 0.31) did not change. CONCLUSIONS: Regionalizing adrenal surgery through surgical subspecialization and standardized care pathways was feasible and decreased operative time, and hospital stay, while increasing the frequency of same-day discharges without increasing return-to-care or complications.
Assuntos
Adrenalectomia , Encaminhamento e Consulta , Humanos , Tempo de Internação , Padrões de Referência , Estudos RetrospectivosRESUMO
AIMS: Following myocardial infarction (MI), the heart repairs itself via a fibrotic repair response. The degree of fibrosis is determined by the balance between deposition of extracellular matrix (ECM) by activated fibroblasts and breakdown of nascent scar tissue by proteases that are secreted predominantly by inflammatory cells. Excessive proteolytic activity and matrix turnover has been observed in human heart failure, and protease inhibitors in the injured heart regulate matrix breakdown. Serine protease inhibitors (Serpins) represent the largest and the most functionally diverse family of evolutionary conserved protease inhibitors, and levels of the specific Serpin, SerpinA3, have been strongly associated with clinical outcomes in human MI as well as non-ischaemic cardiomyopathies. Yet, the role of Serpins in regulating cardiac remodelling is poorly understood. The aim of this study was to understand the role of Serpins in regulating scar formation after MI. METHODS AND RESULTS: Using a SerpinA3n conditional knockout mice model, we observed the robust expression of Serpins in the infarcted murine heart and demonstrate that genetic deletion of SerpinA3n (mouse homologue of SerpinA3) leads to increased activity of substrate proteases, poorly compacted matrix, and significantly worse post-infarct cardiac function. Single-cell transcriptomics complemented with histology in SerpinA3n-deficient animals demonstrated increased inflammation, adverse myocyte hypertrophy, and expression of pro-hypertrophic genes. Proteomic analysis of scar tissue demonstrated decreased cross-linking of ECM peptides consistent with increased proteolysis in SerpinA3n-deficient animals. CONCLUSION: Our study demonstrates a hitherto unappreciated causal role of Serpins in regulating matrix function and post-infarct cardiac remodelling.
Assuntos
Modelos Animais de Doenças , Fibrose , Camundongos Knockout , Infarto do Miocárdio , Miocárdio , Remodelação Ventricular , Animais , Infarto do Miocárdio/metabolismo , Infarto do Miocárdio/patologia , Infarto do Miocárdio/genética , Infarto do Miocárdio/fisiopatologia , Miocárdio/metabolismo , Miocárdio/patologia , Matriz Extracelular/metabolismo , Matriz Extracelular/patologia , Camundongos Endogâmicos C57BL , Serpinas/metabolismo , Serpinas/genética , Função Ventricular Esquerda , Miócitos Cardíacos/metabolismo , Miócitos Cardíacos/patologia , Masculino , Proteínas de Fase AgudaRESUMO
In recent years, minimally invasive glaucoma surgery has emerged as a novel approach to lowering intraocular pressure. This technique, which is usually reserved for mild to moderate cases, is less invasive than classic filtration surgery and potentially offers a better safety profile. The XEN Gel Stent is implanted through a minimally invasive, ab interno procedure to create a subconjunctival pathway. Conjunctival tissue disruption is minimal, and flow is restricted to avoid hypotony. Data on the optimal approach to managing complications associated with this procedure are limited due to the relatively recent commercialization of this device. Here, we report a case of a persistent leaking bleb caused by XEN Stent exposure, which was managed by ab interno repositioning of the stent through the anterior chamber and direct suturing of the conjunctival defect.
Assuntos
Câmara Anterior/cirurgia , Túnica Conjuntiva/lesões , Implantes para Drenagem de Glaucoma/efeitos adversos , Glaucoma de Ângulo Aberto/cirurgia , Reoperação , Ruptura/etiologia , Deiscência da Ferida Operatória/etiologia , Túnica Conjuntiva/cirurgia , Feminino , Glaucoma de Ângulo Aberto/fisiopatologia , Humanos , Pressão Intraocular/fisiologia , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Stents , Deiscência da Ferida Operatória/cirurgia , Tonometria OcularRESUMO
Circumcision remains a controversial operation. Most procedures are performed in the neonatal period and avoid general anesthesia. Legislation driven by policy statements from the American Academy of Pediatrics led to significant changes in circumcisions in Florida with a shift to nonneonatal procedures as a result of costs. We sought to study the prevalence and financial implications of nonneonatal circumcisions in Florida. A retrospective population study was performed using the Florida Agency for Health Care Administration outpatient procedure database. We queried for patients 0 to 17 years of age undergoing circumcision between 2003 and 2008. Demographics, charges, and insurance status were analyzed. From 2003 to 2008, 31,741 outpatient circumcisions were performed. Publicly funded circumcisions accounted for 17,537 charging the state $6,263 on average for each circumcision at an expense of $111.8 million for the 5-year time period analyzed. Publicly funded circumcision procedures increased more than sixfold (P < 0.0001) than those covered by private insurance. Black circumcision procedures increased 77.3 per cent, whereas white circumcisions increased 28.7 per cent. There has been a significant increase in the number of nonneonatal circumcisions performed. This has resulted in an increase in economic health care. Public funding of neonatal circumcision could result in significant cost savings and avoid potential complications of general anesthesia.
Assuntos
Circuncisão Masculina/economia , Redução de Custos/economia , Pediatria/economia , Pré-Escolar , Alocação de Custos/métodos , Custos e Análise de Custo , Florida , Humanos , Lactente , Recém-Nascido , Masculino , Estudos RetrospectivosAssuntos
Neoplasias das Glândulas Suprarrenais/diagnóstico por imagem , Mielolipoma/diagnóstico por imagem , Neoplasias das Glândulas Suprarrenais/complicações , Neoplasias das Glândulas Suprarrenais/cirurgia , Hiperplasia Suprarrenal Congênita/complicações , Adulto , Feminino , Humanos , Mielolipoma/complicações , Mielolipoma/cirurgia , Tomografia Computadorizada por Raios X , Virilismo/etiologiaAssuntos
Neurilemoma/cirurgia , Neoplasias Gástricas/cirurgia , Diagnóstico Diferencial , Endossonografia , Gastrectomia/métodos , Tumores do Estroma Gastrointestinal/diagnóstico , Tumores do Estroma Gastrointestinal/cirurgia , Humanos , Imuno-Histoquímica , Achados Incidentais , Laparoscopia , Masculino , Pessoa de Meia-Idade , Neurilemoma/diagnóstico , Neurilemoma/metabolismo , Proteínas S100/metabolismo , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/metabolismo , Tomografia Computadorizada por Raios XRESUMO
Se hizo un estudio descriptivo, transversal y prospectivo de 1 200 pacientes con criterios para cirugía mayor ambulatoria, con el fin de determinar las características y beneficios de este método. En la serie predominaron las afecciones herniarias de la pared abdominal, generalmente intervenidas con anestesia local más sedación. Las enfermedades asociadas no constituyeron limitaciones en la muestra escogida, en tanto las complicaciones más frecuentes fueron: infección de la herida quirúrgica, seroma y hematoma. Se obtuvieron evidentes ventajas económicas con respecto al ahorro del recurso cama y la disminución del costo hospitalario, así como un elevado grado de satisfacción por parte de los operados, lo cual justifica que se recomiende incrementar la aplicación de este proceder y extenderlo al mayor número posible de afecciones quirúrgicas(AU)
We conducted a descriptive crosswise and prospective study of 1 200 patients who had undergone ambulatory major surgeries to determine the characteristics and benefits of this method. Abdominal hearnia, generallly operated with regional anesthesia plus sedatives prevailed in the group. Associated diseases were not restrictive factors in the selected sample whereas the most frequent complications were surgical wound infections, serone and hematomes. We observed obvious economic advantages regarding saving of beds and lower hospital costs as well as a high level of satisfaction on the part of the operated patients, which serves as a basis for recommending the increasing application of this method in a substantially higher number of surgeries(AU)