RESUMO
CONTEXT: The use of p16 in cervical biopsies improves the accuracy of cervical intraepithelial neoplasia (CIN) diagnosis and grading and decreases its interpathologist variability. OBJECTIVE: To determine the impact of the frequency of use of p16 immunostains in cervical biopsies on pathologists' diagnoses of CIN grade 1 and grade 2 or above (CIN1 and CIN2+) and on cytohistologic correlations. DESIGN: We identified all cervical biopsy specimens with cytologic correlations subjected or not to p16 staining from January 1, 2005, to September 30, 2010; calculated each pathologist's percentage of p16 use; and correlated it with their major cytohistologic discrepancy rates, CIN2+ diagnoses, and CIN1/CIN2+ ratios. RESULTS: During the study period, each of the 23 pathologists interpreted 59 to 1811 (mean, 518) of 11 850 cervical biopsy specimens, used p16 for 0% to 21.31% (mean, 10.14%) of these, had CIN2+ detection rates of 9.5% to 24.1% (mean, 18.9%), and CIN1/CIN2+ ratios of 0.7 to 4.5 (mean, 1.5). Compared to the 12 "low users" of p16, who used p16 fewer times than the institution's mean for p16 use, the 11 "high users" of p16 diagnosed more biopsies (8391 versus 3459), had a lower rate of major cytohistologic discrepancies (12.62% versus 14.92%, P < .001), a higher rate of CIN2+ diagnoses (19.9% versus 16.4%, P < .001), a lower range of CIN2+ rates (15.0%-23.1% versus 9.5%-24.1%), and lower CIN1/CIN2+ ratios (1.2 versus 2.3). CONCLUSIONS: We found a high intrainstitutional variability of p16 use in cervical biopsies, CIN2+ rates, and CIN1/CIN2+ ratios. Use of p16 for greater than 10% of cervical biopsies was associated with improved cytohistologic correlation rates and with lower variability in the frequencies of histologic diagnoses.
Assuntos
Inibidor p16 de Quinase Dependente de Ciclina/análise , Imuno-Histoquímica/estatística & dados numéricos , Antígeno Ki-67/análise , Displasia do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/diagnóstico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores Tumorais/análise , Biópsia , Citodiagnóstico/métodos , Feminino , Humanos , Imuno-Histoquímica/métodos , Pessoa de Meia-Idade , Neoplasias do Colo do Útero/metabolismo , Adulto Jovem , Displasia do Colo do Útero/metabolismoRESUMO
Recruitment of participants to clinical trials remains a significant challenge, especially for research addressing topics of a sensitive nature such as fecal incontinence (FI). In the Fiber Study, a randomized controlled trial on symptom management for FI, we successfully enrolled 189 community-living adults through collaborations with specialty-based and community-based settings, each employing methods tailored to the organizational characteristics of their site. Results show that using the two settings increased racial and ethnic diversity of the sample and inclusion of informal caregivers. There were no differential effects on enrollment, final eligibility, or completion of protocol by site. Strategic collaborations with complementary sites can achieve sample recruitment goals for clinical trials on topics that are sensitive or known to be underreported.
Assuntos
Incontinência Fecal , Fundações/organização & administração , Sistemas Pré-Pagos de Saúde/organização & administração , Seleção de Pacientes , Prática Privada/organização & administração , Ensaios Clínicos Controlados Aleatórios como Assunto , Academias e Institutos , Publicidade , Idoso , Análise de Variância , Distribuição de Qui-Quadrado , Cirurgia Colorretal , Bases de Dados Factuais , Fibras na Dieta/uso terapêutico , Incontinência Fecal/prevenção & controle , Feminino , Humanos , Relações Interinstitucionais , Masculino , Pessoa de Meia-Idade , Minnesota , Pesquisa em Avaliação de Enfermagem/métodos , Avaliação de Resultados em Cuidados de Saúde , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Projetos de Pesquisa , Escolas de Enfermagem , Método Simples-CegoRESUMO
BACKGROUND: Cystic fibrosis (CF) patients commonly use a high-frequency chest-wall compression (HFCWC) device for airway clearance that generates oscillatory flow with a sine-wave configuration. Typical HFCWC settings combine a lower Vest inflation pressure setting (eg, 5 on the Vest's arbitrary 1-10 scale for the setting that controls the background pressure of the inflatable vest) with mid-range frequency (14-16 Hz) (lower-pressure/mid-frequency HFCWC). OBJECTIVE: To determine whether HFCWC with higher pressure settings (6-10 on the Hill-Rom Vest's arbitrary 1-10 scale) combined with variable mid-frequencies (8, 9, and 10 Hz, plus 18, 19, and 20 Hz) (higher-pressure/variable-frequency HFCWC) results in greater sputum expectoration than lower-pressure/mid-frequency HFCWC. METHODS: This was a controlled randomized crossover study. Sixteen clinically stable, adult CF patients participated. Patients performed airway clearance with HFCWC, once each with lower-pressure/mid-frequency HFCWC and higher-pressure/variable-frequency HFCWC, on separate occasions. All sputum produced during each session was collected. Patients completed pulmonary function tests before and after each session. RESULTS: Median sputum wet weight was greater with higher-pressure/variable-frequency HFCWC than with lower-pressure/mid-frequency HFCWC (6.4 g, range 0.49-22.0 g, versus 4.8 g, range 0.24-15.0 g, P = .02). Dry sputum weight differences did not reach statistical significance (higher-pressure/variable-frequency HFCWC 0.20 g, range 0.009-0.62 g, lower-pressure/mid-frequency HFCWC 0.12 g, range 0.0001-1.0 g, P = .23). Higher-pressure/variable-frequency HFCWC and lower-pressure/mid-frequency HFCWC resulted in similar increases in FEV(1) (70 mL vs 90 mL, P = .21) and forced vital capacity (80 mL vs 80 mL, P = .94). Post-therapy sputum viscoelastic properties did not differ. Patients perceived the 2 regimens as equally comfortable and effective (P = .35 and P = .35, respectively). CONCLUSIONS: In adult CF patients, single-session higher-pressure/variable-frequency HFCWC resulted in greater sputum expectoration by wet weight, but not other differences, compared to the commonly used lower-pressure/mid-frequency settings. Longer-term comparisons are needed in a larger, more diverse population to determine whether sustained use of the higher-pressure/variable-frequency settings results in clinically important differences in outcomes.
Assuntos
Oscilação da Parede Torácica/métodos , Fibrose Cística/terapia , Adulto , Oscilação da Parede Torácica/instrumentação , Estudos Cross-Over , Feminino , Humanos , Masculino , Escarro , Resultado do TratamentoRESUMO
Federal and state initiatives are aligning around the goal that by 2014 all Americans will have electronic health records to support access to their health information any time and anywhere. As a key healthcare provider, nursing data must be included to enhance patient safety, effectiveness, and efficiency of care that is patient-centric. The purpose of this study was to test the feasibility of abstracting, integrating, and comparing the effective use of a standardized terminology, the Omaha System, across software vendors and 15 home care agencies. Results showed that the 2900 patients in this study had an average of four problems on care plans, with interventions most frequently addressing surveillance (39%) and teaching (30%). Findings in this study support the feasibility of integrating data across software vendors and agencies as well as the usefulness for describing care provided in home care. However, before exchanging data across systems, data quality issues found in this study need attention. There were missing data for 10.8% of patients as well as concerns about the validity of using the problem rating scale for outcomes. Strategies for effective use of standardized nursing terminologies are recommended.
Assuntos
Serviços Contratados/organização & administração , Agências de Assistência Domiciliar/organização & administração , Integração de Sistemas , Estudos de Viabilidade , Sistemas Computadorizados de Registros MédicosRESUMO
BACKGROUND: Blood product transfusion has been known for immunosuppressive effects, and over-transfusion is linked with adverse outcomes. In cardiac surgery, the risk of non-transfusion can be poor postoperative oxygen delivery and hemorrhage. We hypothesized that infectious complications, organ dysfunction, and mortality result after a given threshold of blood product transfusion is exceeded. METHODS: Retrospectively, a prospectively maintained institutional database was analyzed from April 1, 2004 through December 31, 2006. All patients undergoing coronary artery bypass and/or valve operations were evaluated for bivariate and multivariate associations of blood-product transfusion with postoperative complications and mortality. Additionally, risk factors associated with transfusion were assessed. Receiver operator characteristic (ROC) curves analyses were employed to determine transfusion thresholds associated with complications. RESULTS: During the study period, 741 patients met inclusion criteria. Fifty-four percent received postoperative blood-product transfusions. Previous cardiac intervention, renal dysfunction, stroke, and immunosuppression were some of the risks associated with transfusion (P < 0.05). Specific complications independently (P < 0.05) associated with total blood product transfusion identified from the multivariate analysis were infectious, neurologic, organ dysfunction, cardiac, and death. From ROC curve analyses, 5.5 units of total blood product transfusion was the inflection point for infectious complications (sensitivity 73%, specificity 64%) and organ dysfunction (sensitivity 73%, specificity 64%). For mortality, the inflection point was a transfusion of 7.5 units of total blood-products (sensitivity 73%, specificity 71%). CONCLUSION: Bloodless cardiac surgery is associated with a decreased morbidity and mortality. Limiting transfusion is advisable. Transfusion of less than 5.5 units of total blood-products may not have deleterious effects on outcomes.
Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Reação Transfusional , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Curva ROC , Estudos Retrospectivos , Fatores de RiscoRESUMO
Infectious complications remain an important cause of death in hematopoietic stem cell transplant (HSCT) recipients. We undertook a 20-year (1988-2007) retrospective review of all autopsies performed on HSCT recipients in our institution, with emphasis on infections, especially fungal infections, as the cause of death. Of the 2,943 autopsies performed in our institution from 1988 to 2007, 395 (13.4%) involved HSCT recipients (117 pediatric; 278 adult). Of the patients, 298 had received allogeneic, 46 autologous, 41 umbilical cord blood, and 3 autologous plus allogeneic types, and 7 were unknown HSCT types. The most common causes of death were pulmonary complications, occurring in 247 (62.5%) of 395 cases. In 178 cases (45.1%), microorganisms (viral, bacterial, and/or fungal) were documented at autopsy in one or more organs and contributed to the cause of death. Fungal infections were found in 23.5% of cases, but their frequency as a cause of death decreased throughout this study, from 30.3% in the 1988-1992 period to 10.9% in the 2003-2007 period.
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Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Micoses/mortalidade , Adolescente , Adulto , Idoso , Autopsia , Causas de Morte , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Micoses/etiologia , Micoses/microbiologia , Estudos Retrospectivos , Tempo , Adulto JovemRESUMO
BACKGROUND: The introduction of liquid-based Papanicolaou (Pap) tests (LBPTs) has reduced the incidence of unsatisfactory Pap tests (UPTs), but little is known about their causes and significance, especially in the case of SurePath LBPTs. METHODS: All unsatisfactory LBPTs from January 1, 2003 to December 31, 2006 were retrieved. The characteristics of patients, providers, and LBPTs; the reason for UPTs; and any cytologic or histologic follow-up within 24 months were recorded. Negative Pap tests that were evaluated immediately after a UPT served as a control group. RESULTS: Of 243,006 Pap tests (95.5% SurePath LBPTs), 0.23% were unsatisfactory. Scant cellularity was the primary cause of SurePath UPT. Women in this UPT group were older, had more diagnostic Pap tests taken, less frequently were taking contraceptives or were pregnant, and were more likely to be menopausal or posthysterectomy. The 278 women who had UPTs had significantly higher rates of follow-up Pap tests (65.1% vs 22.2%), abnormal Pap tests (5.4% vs 1.4%), biopsies (10% vs 1%), and abnormal biopsies (5% vs 1%) than the 284 women in the control group, including 7 women with cervical intraepithelial neoplasia 1 (CIN-1), 1 woman with CIN-2, 4 women with CIN-3, and 2 women with endometrial hyperplasia. The UPT rates varied little between provider groups (physicians vs nonphysicians and gynecologists vs nongynecologists). CONCLUSIONS: The frequency of UPTs in a predominantly SurePath LBPT-screened population was very low and was caused mainly by low cellularity. Similar to conventional Pap smears, unsatisfactory SurePath LBPTs had a higher risk of significant histologic abnormalities on follow-up than negative satisfactory Pap tests and could have benefited from a repeat Pap test or other evaluation, according to current management guidelines.
Assuntos
Teste de Papanicolaou , Neoplasias do Colo do Útero/diagnóstico , Esfregaço Vaginal/métodos , Esfregaço Vaginal/normas , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Pessoa de Meia-Idade , Displasia do Colo do Útero/diagnósticoRESUMO
This pilot study aimed to determine the feasibility of providing massage to children with cancer to reduce symptoms in children and anxiety in parents. Twenty-three children/parent dyads were enrolled; 17 completed all data points. Children with cancer, ages 1 to 18 years, received at least 2 identical cycles of chemotherapy, and one parent, participated in the 2-period crossover design in which 4 weekly massage sessions alternated with 4 weekly quiet-time control sessions. Changes in relaxation (heart and respiratory rates, blood pressure, and salivary cortisol level) and symptoms (pain, nausea, anxiety, and fatigue) were assessed in children; anxiety and fatigue were measured in parents. Massage was more effective than quiet time at reducing heart rate in children, anxiety in children less than age 14 years, and parent anxiety. There were no significant changes in blood pressure, cortisol, pain, nausea, or fatigue. Children reported that massage helped them feel better, lessened their anxiety and worries, and had longer lasting effects than quiet time. Massage in children with cancer is feasible and appears to decrease anxiety in parents and younger children.
Assuntos
Massagem , Neoplasias/terapia , Adolescente , Criança , Pré-Escolar , Estudos Cross-Over , Estudos de Viabilidade , Humanos , Lactente , Neoplasias/fisiopatologia , Pais/psicologia , Resultado do TratamentoRESUMO
BACKGROUND: Apart from several subjective criteria, ASCUS and LSIL are defined by nuclear enlargement of 2.5x to 3x and > or = 3x the area of a normal intermediate squamous cell nucleus, respectively. The aim of this study was to assess the ability of observers with various degrees of experience to estimate nuclear area ratios. METHODS: Forty-five participants (5 anatomic pathologists, 5 cytopathologists, 2 cytopathology fellows, 16 pathology residents, 8 cytotechnologists, 6 medical students, and 3 cytopreparatory staff members) judged the area ratios of pairs of squamous cell nuclei imaged at x100 objective magnification. For Test 1 (T1), participants chose between 5 preset area ratios (1.0x to 1.4x, 1.5x to 1.9x, 2.0x to 2.4x, 2.5x to 2.9x, 3.0x to 3.4x) for 15 pairs of cells with ratios falling in the middle of these intervals. One week after T1, an instructional tutorial was given and T1 was repeated in different order of cell pairs as Test 2 (T2). RESULTS: The kappa values for all participants were 0.30 for T1 and 0.39 for T2. Accurate responses were given in 50.5% in T1 and 53.5% in T2. Both T1 and T2 responses failed to differentiate between area ratios corresponding to ASCUS and LSIL. There were no differences in accuracy according to sex, experience, or expertise in cytopathology. CONCLUSIONS: The overall accuracy of participants in estimating nuclear area ratios was low, especially for ratios in the range of ASCUS versus LSIL, with only minimal improvement after an instructional tutorial. Nuclear area ratio estimation may, therefore, contribute to the well-known substantial variability in ASCUS rates and ASC/squamous intraepithelial lesion ratios.
Assuntos
Núcleo Celular/ultraestrutura , Citodiagnóstico/normas , Variações Dependentes do Observador , Lesões Pré-Cancerosas/diagnóstico , Displasia do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/diagnóstico , Feminino , Humanos , Pessoal de Laboratório Médico , Patologia Cirúrgica/normas , Médicos , Lesões Pré-Cancerosas/epidemiologia , Neoplasias do Colo do Útero/epidemiologia , Esfregaço Vaginal , Displasia do Colo do Útero/epidemiologiaRESUMO
PURPOSE: We compared health-related quality of life (HRQL), including patient-perceived neurocognitive function at preoperative baseline and 3 months after coronary artery bypass (CABG) surgery. DESIGN: The design was prospective and comparative. SETTING: The study took place in the cardiovascular units at two large metropolitan Midwestern hospitals. SAMPLE: The study included a consecutive convenience sample of 64 patients who underwent CABG. METHODS: Preoperative baseline and mailed survey at 3 months post-CABG included the Short-Form 12 (subjective health-status), State Trait Anxiety Inventory (state anxiety), Center for Epidemiological Studies of Depression (depressive symptoms), and Cantril Ladder of Life Satisfaction (global life satisfaction). Investigator-developed questions assessed satisfaction in life domains, cardiac symptoms, and frequency of symptoms related to neurocognitive function. RESULTS: Significant improvements were demonstrated 3 months postoperatively, including the Physical Component Summary, Mental Component Summary, depression, anxiety, satisfaction with social and mental life domains, and patient-perceived neurocognitive function related to memory and concentration. CONCLUSIONS: Patients reported improvements in HRQL measures, including two of three subjective neurocognitive measures. Health care providers facilitate preparation for the CABG recovery trajectory by discussing expected post-hospital experience and potential postoperative variations in emotions and neurocognitive function.
Assuntos
Transtornos Cognitivos/etiologia , Ponte de Artéria Coronária/psicologia , Doença das Coronárias/psicologia , Qualidade de Vida , Idoso , Ansiedade/complicações , Doença das Coronárias/complicações , Doença das Coronárias/cirurgia , Depressão/complicações , Feminino , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Período Pós-Operatório , Cuidados Pré-Operatórios/psicologia , Estudos Prospectivos , Escalas de Graduação Psiquiátrica , Recuperação de Função Fisiológica , Estatísticas não ParamétricasRESUMO
BACKGROUND: The Bethesda 2001 (B2001) classification system raised the threshold for reporting atypical squamous cells. The category of Atypical Squamous Cells of Undetermined Significance (ASCUS)-favor reactive has been eliminated with a recommendation for cytologists to judiciously downgrade those Papanicolaou (Pap) tests that would formerly have been in this category to Negative for Intraepithelial Lesion or Malignancy (NILM). The effect of this change on sensitivity and specificity of the Pap test is not yet known. METHODS: A total of 535 consecutive SurePath Pap tests interpreted as ASCUS during a period from March 1 through December 31, 2001, with follow-up polymerase chain reaction(PCR)-based human papilloma virus (HPV) testing, were independently reviewed by 3 pathologists and 1 cytotechnologist who reinterpreted these tests according to Bethesda 2001 criteria. Follow-up HPV and biopsy results were compiled for a 5-year period. RESULTS: By consensus of the 4 observers, 169 (32%) of the ASCUS cases were downgraded to NILM. These cases showed a lower rate of underlying high-risk HPV infection (11% vs 30%) and cervical intraepithelial neoplasia of grades 2 to 3 (CIN 2/3) (5% vs 10%) on follow-up than those tests that were reinterpreted as ASCUS or higher. Nine women with follow-up CIN 2/3 would have had the Pap test interpreted as NILM instead of ASCUS under Bethesda 2001 (20% of all CIN 2/3 found). Individual reviewers downgraded 29% to 42% Pap tests to NILM including those of 5 to 10 women with follow-up CIN 2/3. CONCLUSIONS: The ASCUS threshold established by B2001 prevents a sizeable subset of women from having follow-up for ASC. However, as a consequence, a few women with CIN 2/3 are downgraded to NILM. The cost savings thus achieved must be weighed against the lost opportunities to detect CIN 2/3.
Assuntos
Teste de Papanicolaou , Esfregaço Vaginal/normas , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Neoplasias de Células Escamosas/patologia , Papillomaviridae , Infecções por Papillomavirus/patologia , Reação em Cadeia da Polimerase , Sensibilidade e Especificidade , Infecções Tumorais por Vírus/patologia , Neoplasias do Colo do Útero/patologiaRESUMO
OBJECTIVE: To assess the impact of the recommendation of the 2001 Bethesda System to report all benign-appearing endometrial cells seen in women aged > or = 40 years on the frequency with which endometrial carcinomas are potentially detected as a consequence of Pap test reports that mention endometrial cells. STUDY DESIGN: We identified all women diagnosed with endometrial adenocarcinoma who also had a Pap test during the preceding 6 months. The search was performed for 3-year periods before and after the date of implementation of Bethesda 2001. RESULTS: Benign endometrial cells were reported for 589 women in the 3 years before Bethesda 2001 and for 3,810 women in the 3 following years. The number of endometrial malignancies found on follow-up in these women decreased from 8 in the 3 years before Bethesda 2001 to only 4 subsequently. The frequency of reporting atypical or malignant glandular cells, as well as the likelihood of finding endometrial malignancy on follow-up, did not significantly change. CONCLUSION: Despite a 6.5-fold rise in the frequency of reporting benign endometrial cells after Bethesda 2001, the frequency of subsequent diagnosis of endometrial malignancies did not in-crease.
Assuntos
Adenocarcinoma/epidemiologia , Neoplasias do Endométrio/epidemiologia , Adenocarcinoma/diagnóstico , Adenocarcinoma/patologia , Adulto , Idoso , Neoplasias do Endométrio/diagnóstico , Neoplasias do Endométrio/patologia , Feminino , Humanos , Esfregaço VaginalRESUMO
OBJECTIVE: In order to define the preferred electromyographic monitoring method during spine surgery, (1) a porcine model of neurotonic generation after lumbar root compression was developed and (2) intraoperative use of deltoid muscle intramuscular needle, subdermal needle, and surface electrodes was retrospectively reviewed. METHODS: In pigs, an array of intramuscular needle, subdermal needle, and surface electrode derivations was differentially amplified at identical gain and filter settings. Nerve root compression generated neurotonic discharges whose amplitudes were compared at each derivation. Clinically, 25 deltoid muscles in 13 patients were simultaneously monitored (during cervical spine surgery at the C4-C5 level) with surface, subdermal needle, and intramuscular needle electrode pairs, differentially amplified at identical gain and filter settings. Non-repeating neurotonic discharges were assigned, by amplitude and morphology, to best derivation (intramuscular, subdermal, surface or combination); coincident amplitudes were measured at the maximum deflection among the three derivations. Actual voltage detected between clinical methods was analyzed with Friedman's test and any detection versus none by general estimating equations(GEE) using SAS. The advantage of two needles over one in detection of any voltage was assessed using McNemar's test. RESULTS: Compressed porcine lumbar roots generated neurotonics which were identifiable at intramuscular sites only. Clinically, 31 neurotonics were identified: 20/31 at intramuscular, 5/31 at subdermal, and 6/31 equally well at intramuscular and subdermal derivations. Intramuscular detected neurotonics better than subdermal derivations (z = 2.9, P < .004). No voltage was recorded at the surface in 16/31 neurotonics. For detection of any voltage, intramuscular was better than subdermal (z = -1.5, P = .04) or surface electrodes (z = -2.7, P < .001). CONCLUSIONS: Electromyographic moni- toring of spine surgery should not be done by surface electrodes. Because sensitive neurotonic detection requires near field recording, intramuscular electrodes are preferred. Monitoring of a myotome at particularly increased risk may suggest multiple intramuscular electrodes.
Assuntos
Eletrodos , Eletromiografia/instrumentação , Eletromiografia/métodos , Músculo Esquelético/inervação , Potenciais de Ação , Adulto , Idoso , Idoso de 80 Anos ou mais , Animais , Plexo Cervical/lesões , Plexo Cervical/cirurgia , Descompressão Cirúrgica/efeitos adversos , Potencial Evocado Motor , Feminino , Humanos , Região Lombossacral/inervação , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/instrumentação , Monitorização Intraoperatória/métodos , Agulhas/estatística & dados numéricos , Procedimentos Neurocirúrgicos/efeitos adversos , Ombro/fisiopatologia , Pele , Raízes Nervosas Espinhais/lesões , SuínosRESUMO
BACKGROUND: New immunosuppression protocols have resulted in decreased rates of biopsy-proven acute rejection; however, it is unclear whether recipients without biopsy-proven acute rejection are still at risk for immune complication and chronic allograft dysfunction. The aim of our studies was to determine whether pretransplant immune parameters were associated with posttransplant early acute rejection, unstable creatinine courses, and poor graft outcome. METHODS: Immune parameters, including human leukocyte antigen (HLA) mismatch, HLA-specific antibodies, global CD4+ cellular response as measured by intracellular adenosine triphosphate (iATP) synthesis, and IFN-gamma precursor frequencies to donor or third-party cells as measured by ELISPOT were determined for a total of 126 kidney recipients treated with a protocol, including rapid discontinuation of prednisone. RESULTS: The donor specific pretransplant parameters of HLA class I mismatches (P=0.04) and total HLA mismatches (P=0.04) with the donor as well as the pretransplant HLA-donor specific antibodies (P=0.002) were associated with biopsy-proven acute rejection. Higher pretransplant iATP levels, a donor nonspecific parameter, were found associated with biopsy proven acute rejection (P=0.04). Pretransplant iATP levels were significantly greater for recipients with early unstable creatinine levels (P=0.01). Recipients with a pretransplant iATP value greater than 375 ng/ml were 3.67 times more likely to experience acute rejection (P=0.03). CONCLUSIONS: Pretransplant assessment of donor specific and nonspecific immune parameters may identify recipients who can benefit from closer clinical and immunological surveillance to allow for tailored immunsuppression and selective intervention aimed at optimizing both short and long-term graft outcome.
Assuntos
Rejeição de Enxerto/imunologia , Transplante de Rim/imunologia , Doadores de Tecidos , Doença Aguda , Anticorpos/imunologia , Biópsia , Ensaios Clínicos como Assunto , Creatina/sangue , Feminino , Antígenos HLA/imunologia , Humanos , Interferon gama/biossíntese , Interferon gama/imunologia , Masculino , Pessoa de Meia-Idade , Modelos Imunológicos , Fatores de Risco , Sensibilidade e Especificidade , Resultado do TratamentoRESUMO
A review of our institution's Papanicolaou test records over an 11-yr period showed that liquid-based Papanicolaou tests (LBPTs) had a significantly higher frequency of diagnoses of Herpes simplex virus (HSV)-related cellular changes compared to conventional Papanicolaou smears (77/302,841, 0.026% vs. 56/376,173, 0.015%, P = 0.002). To investigate the accuracy of the diagnosis of HSV by LBPT, we performed conventional polymerase chain reaction (PCR) on the residual samples from 258 prospectively collected LBPT and real-time PCR using a different primer set on a subset of 40 LBPT. Conventional PCR was positive in 22 of 22 cases diagnosed of HSV, 1 of 2 cases diagnosed as suspicious for HSV, and none of 234 LBPT without a cytologic HSV diagnosis. Real-time PCR was positive in 8 of 8 cases diagnosed as HSV and none of the 32 controls. We conclude that LBPT allows an increased detection of HSV that is highly accurate.
Assuntos
Herpes Simples/diagnóstico , Teste de Papanicolaou , Reação em Cadeia da Polimerase/métodos , Simplexvirus/genética , Esfregaço Vaginal/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , DNA Viral/genética , Feminino , Herpes Simples/patologia , Humanos , Estudos Longitudinais , Programas de Rastreamento , Pessoa de Meia-Idade , Vagina/patologia , Vagina/virologiaRESUMO
BACKGROUND: Blood transfusion with cardiac surgery accounts for 20% of transfusions in the United States. The effect of perioperative transfusion on cardiac surgery outcomes is unknown. We hypothesized that cardiac surgery with perioperative blood transfusion was associated with worse outcomes. METHODS: A prospectively maintained (Society of Thoracic Surgeons) institutional database was analyzed from 2000 to 2005. All patients undergoing coronary artery bypass and/or valve operations were evaluated for the association of preoperative and intraoperative risk factors with blood transfusion. The association of transfusion with postoperative complications and mortality was evaluated. RESULTS: During the study period, 2691 patients met inclusion criteria. Sixty-four percent received transfusions. Preoperative risk factors associated with transfusion (p < 0.05) were lung disease, elevated creatinine, peripheral vascular disease, and previous cardiac interventions. Patients requiring transfusion were older (mean 65.2 vs. 61.2 years, p < 0.001). Transfusion was associated with longer cross-clamp (median 78 vs. 88 minutes, p < 0.001) and perfusion times (median 114 vs. 128 minutes, p < 0.001). Perioperative blood transfusion was associated with increased postoperative complications (53.5% vs. 30.5%, p < 0.001). Significant transfusion-associated complications were renal failure, prolonged ventilation time, pneumonia, cardiac arrest, gastrointestinal complications, atrial fibrillation, stroke, myocardial infarction, and bleeding requiring reoperation. Blood transfusion was associated with an increased operative mortality (3.4% vs. 1.7%, p = 0.005) and length of stay after surgery (median 6 vs. 5 days p < 0.001). CONCLUSION: Identification and management of risk factors associated with transfusion may reduce the transfusion requirement, minimize perioperative complications and improve outcomes. Bloodless cardiac surgery is associated with a decreased morbidity and mortality.
Assuntos
Transfusão de Sangue , Assistência Perioperatória , Complicações Pós-Operatórias/prevenção & controle , Cirurgia Torácica/métodos , Resultado do Tratamento , Idoso , Bases de Dados como Assunto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Instrumentos Cirúrgicos , Fatores de TempoRESUMO
BACKGROUND: Patients who undergo coronary artery bypass graft surgery often rely on spouses for care during recovery. Although often meaningful, caregiving may be stressful and affect spouses' ability to provide care to the patient. OBJECTIVES: The purpose of this study was to compare burden and caregiving outcomes across three groups of spouses. Spouse groups varied by the interval of time between surgery and follow-up, which may have been 3, 6, or 12 months. METHODS: This cross-sectional comparative study recruited a convenience sample of 166 spouses on the basis of a power analysis. A total of 166 spouses completed caregiver surveys on burden and other caregiving outcomes. RESULTS: Total, objective, and subjective burden levels were low to moderate. Although no burden differences were found between groups, men had higher total burden but more positive caregiving outcomes. Future outlook and social activities were less positive in the 6-month group. Burden levels were not lower, nor were caregiving outcomes higher, in the 12-month group, suggesting a steady caregiving demand across the first year after coronary artery bypass graft surgery. CONCLUSION: Longitudinal investigations are needed to understand burden and caregiving outcomes over time and the impact of burden on spousal and patient recovery outcomes.
Assuntos
Cuidadores/psicologia , Ponte de Artéria Coronária , Efeitos Psicossociais da Doença , Assistência Domiciliar/psicologia , Cônjuges/psicologia , Estresse Psicológico , Resultado do Tratamento , Idoso , Ponte de Artéria Coronária/enfermagem , Ponte de Artéria Coronária/reabilitação , Estudos Transversais , Feminino , Inquéritos Epidemiológicos , Hospitais Urbanos , Humanos , Avaliação de Estado de Karnofsky , Masculino , Pessoa de Meia-Idade , Meio-Oeste dos Estados Unidos , Psicometria , Fatores Sexuais , Fatores de TempoRESUMO
PURPOSE: We sought to identify perioperative factors associated with long-term adjustment to an incontinent ostomy. METHODOLOGY: The Ostomy Adjustment Scale (OAS), a demographic form, and a $5 gift certificate were mailed to 200 ostomates. Associations between items from the Survey of Perioperative Factors of Ostomy Adjustment, demographic forms, and total OAS scores were assessed using bivariate and multiple linear regression analysis. RESULTS: The survey response rate was 74%. About half (70/146, 49%) of the respondents were women, 99% (144/145) were Caucasian, and 74% (109/146) were married. Their mean age was 65+/-14 years. Fifty-six percent (79/141) of the respondents had an ileostomy, 28% (39/141) had a colostomy, and 15% (21/141) had a urostomy. The mean OAS score for all the respondents was 159.5+/-26.2, indicating a good overall adjustment to an incontinent ostomy. In bivariate analyses, the factor associated with a lower OAS score indicating poorer adjustment was distress related to affording and obtaining ostomy supplies. The more helpful the ostomates found the preoperative education provided by a wound, ostomy, and continence specialist nurse, the better was their adjustment as indicated by a higher OAS score. Having ongoing/recurrent illness and having an ostomy created by a specialty surgeon were also associated with better adjustment. When multiple factors were considered in a stepwise regression analysis, adjustment was lowered by distress about obtaining ostomy supplies. Adjustment was improved when preoperative education provided by a wound, ostomy, and continence specialist nurse was considered helpful for the ongoing/ recurrent illness. CONCLUSION: Many ostomates have a good long-term adjustment to ostomy surgery and value education provided by a wound, ostomy, and continence nurse. Perioperative patient education and addressing patient distress over obtaining supplies are areas that can benefit from wound, ostomy, and continence nurse intervention.
Assuntos
Adaptação Psicológica , Atitude Frente a Saúde , Colostomia/psicologia , Ileostomia/psicologia , Assistência Perioperatória/psicologia , Derivação Urinária/psicologia , Atividades Cotidianas/psicologia , Idoso , Colostomia/efeitos adversos , Colostomia/enfermagem , Análise Fatorial , Feminino , Necessidades e Demandas de Serviços de Saúde , Humanos , Ileostomia/efeitos adversos , Ileostomia/enfermagem , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Minnesota , Análise Multivariada , Enfermeiros Clínicos , Pesquisa Metodológica em Enfermagem , Educação de Pacientes como Assunto , Assistência Perioperatória/métodos , Assistência Perioperatória/enfermagem , Autoimagem , Ajustamento Social , Inquéritos e Questionários , Derivação Urinária/efeitos adversos , Derivação Urinária/enfermagemRESUMO
BACKGROUND: Coronary artery bypass (CAB) patients often rely on spouses for care and assistance during recovery after surgery. Caregiving can be stressful and meaningful depending upon the interplay of many factors not completely understood. These factors may affect the spouse caregiver's health-related quality of life (HRQL), which may impact ability to care for the CAB patient. OBJECTIVE: To investigate patient-spouse caregiver relationship and role variables associated with caregiver burden during the first year after CAB surgery. METHODS: Using a cross-sectional design, a convenience sample of CAB spouses was recruited at 3, 6, or 12 months. Spouses (n = 166) completed a survey that included perceptions of patient health status, caregiver burden and other caregiving variables, and caregiver HRQL. RESULTS: Higher burden scores were associated with patient's gender (female), poorer patient health status, lower caregiver mental HRQL, increased personal gain, and increased caregiver competence. These correlates explained 38% of the variance in caregiver burden. DISCUSSION: Only poorer patient health status and lower caregiver mental HRQL were supported by previous research in this population. Positive relationships between burden and caregiver competence and personal gain may be a reflection that spouse caregivers were invested and working hard. They felt satisfied from enhancement of self but were burdened from their caregiving role, providing support for a previously described two-domain caregiving model. Caregiver screening is essential to identify spouses at high risk for negative outcomes. Longitudinal research is needed to identify the correlates and predictors most likely to influence burden and caregiver gain over time, and to more fully understand caregiving in the CAB population.
Assuntos
Cuidadores , Ponte de Artéria Coronária , Efeitos Psicossociais da Doença , Nível de Saúde , Qualidade de Vida , Idoso , Cuidadores/psicologia , Ponte de Artéria Coronária/reabilitação , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Meio-Oeste dos Estados Unidos , Análise Multivariada , Análise de Regressão , Fatores Sexuais , Cônjuges/psicologia , Resultado do TratamentoRESUMO
OBJECTIVE: To examine cardiovascular disease risk factors among adult Native American women Inter-Tribal Heart Project participants. DESIGN: A secondary analysis used controllable risk factors identified by the American Heart Association as the framework to examine cardiovascular disease risk factors in this population. SETTING: Three Native American Reservations in Minnesota and Wisconsin. PARTICIPANTS: 866 adult Native American women who participated in the Inter-Tribal Heart Project cardiovascular health research study. MAIN OUTCOME MEASURES: Descriptive, correlational, bivariate, and multivariate analysis provided findings on cardiovascular disease risk factors in this population. RESULTS: Cardiovascular disease risk factors are high among this population. For every additional risk factor, the odds of self-reported cardiovascular disease increases 1.2 times (95% confidence interval: 1.1-1.3). Participants who self-reported cardiovascular disease were older, less educated, employed less, and reported more Indian ancestry (higher blood quantum) and had higher prevalence rates of diabetes, higher systolic blood pressure, and body mass index in comparison to women who self-reported an absence of cardiovascular disease. CONCLUSIONS: A key to decreasing cardiovascular disease lies in preventing and controlling cardiovascular disease risk factors with concerted efforts specific to the culture and life ways of the Native American woman.