RESUMO
BACKGROUND: Surgical resection of colorectal liver metastasis (CRLM) provides the best opportunity for prolonged survival. Eligibility for metastasectomy has expanded with technical advancements including parenchymal-sparing hepatectomy (PSH). Meanwhile, enthusiasm for minimally invasive surgery (MIS) has increased, though this approach may be preferentially utilized for technically straightforward cases. The purpose of this study is to characterize modern trends in open versus MIS approaches to partial hepatectomy and anatomic hepatectomy for CRLM within a nationwide cohort. METHODS: The American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) was used to investigate trends in MIS versus open hepatectomy for CRLM from 2015 to 2019. We examined baseline clinicopathologic and disease-related characteristics and compared trends in treatments over the study period. RESULTS: A total of 7457 patients undergoing hepatectomy for CRLM were identified (1367 MIS, 6090 open). Patients had similar clinicopathologic features between the two groups. Patients undergoing MIS resection less frequently received neoadjuvant therapy (51.1% vs 64.0%, p < 0.001) or concurrent intraoperative ablation (15.0% vs 21.3%, p < 0.001). Patients with tumors < 2 cm (34.9% vs 26.8%, p < 0.001) or only one to two tumors (82.8% vs 65.0%, p < 0.001) more commonly underwent MIS. MIS and open partial hepatectomies both significantly increased over the study period, but open partial hepatectomy increased at a greater rate than MIS (p < 0.001). Rates of anatomic resections have remained the same, with a greater proportion performed using an open approach (34.9% vs 16.4%, p < 0.001). Rates of operations consisting of > 1 concurrent partial hepatectomy are stable, but significantly more likely to be performed open (p < 0.001). CONCLUSIONS: Hepatectomy for CRLM has increased from a rise in partial hepatectomy, potentially translating to increased use of PSH. Current trends suggest MIS approaches appear to be increasing, but selectively implemented for patients with less technically demanding disease characteristics. Educational efforts should be directed towards increased dissemination of parenchymal-sparing MIS techniques for more complex resections.
Assuntos
Neoplasias Colorretais , Neoplasias Hepáticas , Humanos , Hepatectomia/métodos , Melhoria de Qualidade , Neoplasias Hepáticas/secundário , Procedimentos Cirúrgicos Minimamente Invasivos , Complicações Pós-Operatórias/cirurgia , Neoplasias Colorretais/cirurgia , Neoplasias Colorretais/patologia , Estudos RetrospectivosRESUMO
BACKGROUND: Most persons who are infected with human immunodeficiency virus type 1 (HIV-1) are also infected with herpes simplex virus type 2 (HSV-2), which is frequently reactivated and is associated with increased plasma and genital levels of HIV-1. Therapy to suppress HSV-2 reduces the frequency of reactivation of HSV-2 as well as HIV-1 levels, suggesting that suppression of HSV-2 may reduce the risk of transmission of HIV-1. METHODS: We conducted a randomized, placebo-controlled trial of suppressive therapy for HSV-2 (acyclovir at a dose of 400 mg orally twice daily) in couples in which only one of the partners was seropositive for HIV-1 (CD4 count, > or = 250 cells per cubic millimeter) and that partner was also infected with HSV-2 and was not taking antiretroviral therapy at the time of enrollment. The primary end point was transmission of HIV-1 to the partner who was not initially infected with HIV-1; linkage of transmissions was assessed by means of genetic sequencing of viruses. RESULTS: A total of 3408 couples were enrolled at 14 sites in Africa. Of the partners who were infected with HIV-1, 68% were women, and the baseline median CD4 count was 462 cells per cubic millimeter. Of 132 HIV-1 seroconversions that occurred after randomization (an incidence of 2.7 per 100 person-years), 84 were linked within couples by viral sequencing: 41 in the acyclovir group and 43 in the placebo group (hazard ratio with acyclovir, 0.92, 95% confidence interval [CI], 0.60 to 1.41; P=0.69). Suppression with acyclovir reduced the mean plasma concentration of HIV-1 by 0.25 log(10) copies per milliliter (95% CI, 0.22 to 0.29; P<0.001) and the occurrence of HSV-2-positive genital ulcers by 73% (risk ratio, 0.27; 95% CI, 0.20 to 0.36; P<0.001). A total of 92% of the partners infected with HIV-1 and 84% of the partners not infected with HIV-1 remained in the study for 24 months. The level of adherence to the dispensed study drug was 96%. No serious adverse events related to acyclovir were observed. CONCLUSIONS: Daily acyclovir therapy did not reduce the risk of transmission of HIV-1, despite a reduction in plasma HIV-1 RNA of 0.25 log(10) copies per milliliter and a 73% reduction in the occurrence of genital ulcers due to HSV-2. (ClinicalTrials.gov number, NCT00194519.)
Assuntos
Infecções Oportunistas Relacionadas com a AIDS/tratamento farmacológico , Aciclovir/uso terapêutico , Antivirais/uso terapêutico , Infecções por HIV/transmissão , HIV-1 , Herpes Genital/tratamento farmacológico , Herpesvirus Humano 2 , Aciclovir/efeitos adversos , Adolescente , Adulto , Antivirais/efeitos adversos , Contagem de Linfócito CD4 , Feminino , Seguimentos , Infecções por HIV/complicações , HIV-1/genética , HIV-1/isolamento & purificação , Herpes Genital/complicações , Humanos , Análise de Intenção de Tratamento , Estimativa de Kaplan-Meier , Masculino , Cooperação do Paciente , Gravidez , RNA Viral/sangue , Sexo sem Proteção/estatística & dados numéricos , Adulto JovemRESUMO
Ureteric tumours are rare and most of them are malignant. Of benign tumours, ureteral fibroepithelial polyps are the most common but are still considered clinical rarities. In the past, most benign ureteric tumours were only diagnosed after surgical removal. With technological advance, magnetic resonance imaging has become an effective means of assessing ureteric lesions. Non-contrast enhanced magnetic resonance urography can produce an image comparable to an intravenous urogram without use of intravenous water-soluble contrast. A polyp can be diagnosed on imaging if there is an elongated filling defect inside the ureter. Nevertheless, a definitive diagnosis relies on ureteroscopic examination with biopsy. When a non-obstructive polyp is being managed conservatively, imaging is helpful for monitoring. Equally, the information obtained from imaging can be used to plan operative treatment.
Assuntos
Imageamento por Ressonância Magnética , Pólipos/patologia , Neoplasias Ureterais/patologia , Adulto , Biópsia , Feminino , Humanos , Hidronefrose/diagnóstico , Neurilemoma/patologia , Neurilemoma/cirurgia , Pólipos/cirurgia , Neoplasias da Coluna Vertebral/patologia , Neoplasias da Coluna Vertebral/cirurgia , Neoplasias Ureterais/cirurgiaRESUMO
Salmonella mycotic aneurysm is a rare but potentially fatal condition. Mortality is high without timely intervention. The clinical presentation is protean and early diagnosis requires a high degree of clinical alertness. Prompt surgical intervention and prolonged antimicrobial therapy are keys to successful treatment. We report an 81-year-old man with an atypical presentation of Salmonella mycotic aneurysm in the aortic arch. The case highlights the need to evaluate all patients over 50 years with non-typhoid Salmonella bacteraemia for possible endovascular infections. Contrast-enhanced computed tomography is useful for making an early diagnosis of this disease.
Assuntos
Aneurisma Infectado/diagnóstico , Aneurisma Infectado/microbiologia , Aorta Torácica/microbiologia , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/microbiologia , Infecções por Salmonella/diagnóstico , Salmonella/isolamento & purificação , Idoso de 80 Anos ou mais , Aneurisma Infectado/terapia , Aorta Torácica/patologia , Aneurisma da Aorta Torácica/terapia , Angiografia Coronária , Microbiologia de Alimentos , Hong Kong , Humanos , Masculino , Infecções por Salmonella/terapiaRESUMO
Social forces shaping a region can also affect behaviors that facilitate the transmission of sexually transmitted diseases (STDs), including HIV. We sought to understand the social forces underlying high rates of infection, particularly among blacks, in a rural county of North Carolina in which 40% of the county is black. In the context of ongoing research on STDs we collected information from archival data on the county since the 1940s and interviewed local residents knowledgeable about the county's history. We present local data in the context of national economic and demographic trends. Successive changes in the national economy and farming policies disproportionately affected black farmers. A rural ghetto formed when poor blacks left their farms to seek work in the central town of the county. Segregationist housing policies and race-based differentials in employment opportunities exacerbated the concentration of poverty. Migration to northern industrial cities, predominantly by skilled black men, decreased the social capital of the community and lowered the ratio of men to women. Poverty, income disparity, social capital and the ratio of men to women can all affect the behaviors that facilitate transmission of STDs. Knowledge of social forces and their effects is critical for designing and evaluating interventions to prevent STDs and to decrease extreme racial disparities in rates of disease.
Assuntos
Negro ou Afro-Americano , Comportamentos Relacionados com a Saúde , População Rural , Infecções Sexualmente Transmissíveis/epidemiologia , Adulto , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , North Carolina/epidemiologia , Pobreza , Fatores SocioeconômicosRESUMO
A six-month interval (baseline) during which methadone doses above 99 mg required individual approval by the clinic's physician was compared with the subsequent 16-month period in which a policy of patient-regulated methadone dosing with no preset upper limit was implemented. During the later phase, all patients were required to remain at each selected dose for a minimum of four days, and standard compliance-based take-home dosing procedures were followed. For patients in the study sample (n=57), the daily maximum methadone dose increased from 165 mg during baseline to 300 mg during the self-regulation period, while their average daily methadone dose increased from 76.84 mg to 80.04 mg (W=473, n=57, p=0.01). Monthly percent of opiate-positive urine specimens decreased significantly from 5.26% during baseline to 1.64% during the self-regulated dose period (W=169, n=57, p<0.01), and use of other drugs remained unchanged. No patient failed to show possession of recalled take-home doses, and no instances of liquid methadone diversion were reported by law enforcement agencies in the area.
Assuntos
Metadona/administração & dosagem , Centros de Tratamento de Abuso de Substâncias , Transtornos Relacionados ao Uso de Substâncias/tratamento farmacológico , Administração Oral , Adulto , Feminino , Humanos , Masculino , Metadona/uso terapêutico , Metadona/urina , Autoadministração , Fatores de TempoRESUMO
OBJECTIVE: To develop and evaluate an evidence-based clinical practice guideline for assessment and routine care of neonatal skin, educate nurses about the scientific basis for practices recommended in the guideline, and design procedures that facilitate implementation of the project guideline into clinical practice. DESIGN: Descriptive report of the collaborative neonatal skin care research-based practice project of the Association of Women's Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses. SETTING: Neonatal intensive-care unit (NICU) and special-care nurseries and well-baby nurseries in 51 hospitals located throughout the United States. PARTICIPANTS: Member site coordinators (N = 51), nurses who work at the selected sites, and the neonates observed during both the pre- and postimplementation phases of the project (N = 2,820). METHOD: An evidence-based clinical practice guideline was developed, sites were selected from all respondents of the call for sites, site coordinator training was provided, data collection was facilitated by project-specific data collection tools, and the project was evaluated by the science team. MAIN OUTCOME MEASURES: Diversity and numbers of sites represented, patient representation, site coordinator knowledge of neonatal skin care pre- and postimplementation, use of project-designed implementation tools, satisfaction with project guideline and the data collection process, changes in practices and product use, and site coordinators' experiences during guideline implementation. RESULTS: Fifty-one sites completed the project, representing NICU, special-care, and well-baby nurseries in both academic and community hospital settings in 27 states. Registered nurses working in these sites totaled 4,754 full-time equivalent positions (FTEs) (in NICU/special-care and well-baby nurseries). Site coordinators demonstrated increased knowledge of research-based neonatal skin care and satisfaction with the implementation tools and data collection process. Product use changed, reflecting acquisition of new knowledge. Barriers to implementation of the guideline were identified. CONCLUSIONS: The AWHONN/NANN Neonatal Skin Care Research-Based Practice Project demonstrated increased knowledge among site coordinators who received training, facilitated changes in neonatal skin care as defined by the practice guideline, and thus advanced evidence-based clinical practice.
Assuntos
Medicina Baseada em Evidências , Enfermagem Neonatal/normas , Guias de Prática Clínica como Assunto/normas , Higiene da Pele/enfermagem , Higiene da Pele/normas , Pesquisa em Enfermagem Clínica , Educação Continuada em Enfermagem , Avaliação Educacional , Humanos , Recém-Nascido , Terapia Intensiva Neonatal/métodos , Terapia Intensiva Neonatal/normas , Conhecimento , Enfermagem Neonatal/educação , Enfermagem Neonatal/métodos , Avaliação em Enfermagem/métodos , Recursos Humanos de Enfermagem Hospitalar/educação , Higiene da Pele/métodos , Sociedades de Enfermagem , Estados UnidosRESUMO
Approximately 20% of women ages 25-64 years experience urinary incontinence. The symptoms increase during perimenopause, when 31% of women report that they experience incontinent episodes at least once per month. Bladder training and pelvic muscle exercise are the recommended initial treatment and can be taught effectively in the ambulatory care setting. Bladder training enables women to accommodate greater volumes of urine and extend between-voiding intervals. Pelvic muscle exercise increases muscle strength and reduces unwanted urine leakage. Accumulated research results provide evidence-based guidelines for nursing practice. The Association of Women's Health, Obstetric and Neonatal Nurses has identified continence for women as the focus of its third research utilization project. This article presents the rationale, evidence base, and educational strategies compiled by the Research Utilization 3 Nurse Scientist Team. Nurses can enable women to incorporate these noninvasive techniques into self-care.
Assuntos
Medicina Baseada em Evidências/métodos , Equipe de Enfermagem/organização & administração , Incontinência Urinária/epidemiologia , Incontinência Urinária/terapia , Adulto , Distribuição por Idade , Feminino , Humanos , Incidência , Pessoa de Meia-Idade , Pesquisa em Enfermagem , Fatores de Risco , Estados Unidos/epidemiologia , Incontinência Urinária/diagnóstico , Incontinência Urinária por Estresse/diagnóstico , Incontinência Urinária por Estresse/epidemiologia , Incontinência Urinária por Estresse/terapiaRESUMO
Approximately 20% of women ages 25-64 years experience urinary incontinence. The symptoms increase during perimenopause, when 31% of women report that they experience incontinent episodes at least once per month. Bladder training and pelvic muscle exercise are the recommended initial treatment and can be taught effectively in the ambulatory care setting. Bladder training enables women to accommodate greater volumes of urine and extend between-voiding intervals. Pelvic muscle exercise increases muscle strength and reduces unwanted urine leakage. Accumulated research results provide evidence-based guidelines for nursing practice. The Association of Women's Health, Obstetric, and Neonatal Nurses has identified continence for women as the focus of its third research utilization project. This article presents the rationale, evidence base, and educational strategies compiled by the Research Utilization 3 Nurse Scientist Team. Nurses can enable women to incorporate these noninvasive techniques into self-care.
Assuntos
Pesquisa em Enfermagem Clínica , Terapia por Exercício , Educação de Pacientes como Assunto , Diafragma da Pelve , Incontinência Urinária/reabilitação , Adulto , Idoso , Medicina Baseada em Evidências , Feminino , Humanos , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Pré-Menopausa , Autocuidado , Grupos de Autoajuda , Incontinência Urinária/etiologiaRESUMO
OBJECTIVE: To test the effectiveness of an evidence-based protocol for urinary incontinence in increasing identification of women with the condition and improving their outcomes. DESIGN: Prospective formative evaluation study. SETTING: Twenty-one public, private, and other women's health care sites. PARTICIPANTS: Women in ambulatory care settings (N = 1,474) provided descriptive statistics. Clinical outcomes were tested in 132 cases for whom pre- and posttreatment data were available. INTERVENTIONS: Standardized screening and baseline follow-up forms were used to minimize time burden on clinicians; bladder and pelvic floor muscle training materials were provided to clinicians for distribution. MAIN OUTCOME MEASURES: Self-reported frequency, volume, and quality of life related to incontinence and cost of self-management were used to assess protocol effectiveness. RESULTS: Frequency of incontinence episodes, estimated volume lost per episode, and the cost of self-management decreased. Quality of life improved, as reflected in decreased bother attributed to incontinence and in the number of women avoiding activities such as shopping, exercising, or travel because of incontinence. CONCLUSIONS: This simple program of pelvic floor muscle and bladder training, as it has been systematically implemented in a variety of ambulatory women's health care settings, has benefited women's continence status. The results of this project strongly support widespread application.
Assuntos
Incontinência Urinária/diagnóstico , Incontinência Urinária/terapia , Adulto , Medicina Baseada em Evidências , Terapia por Exercício , Feminino , Humanos , Pessoa de Meia-Idade , Diafragma da Pelve , Estudos Prospectivos , Fatores de Risco , Inquéritos e Questionários , Resultado do Tratamento , Revelação da Verdade , Incontinência Urinária/enfermagemRESUMO
OBJECTIVE: To develop an evidence-based protocol for initial evaluation and treatment of urinary incontinence and to design procedures that would facilitate the protocol's implementation into clinical practice. DESIGN: Descriptive report of the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) Continence for Women Project. SETTING: Twenty-one public, private, and other women's health sites. PARTICIPANTS: Women in ambulatory care settings (N = 1,474) provided demographic statistics. METHODS: The protocol was developed, sites were selected, site coordinator training was provided, data collection was facilitated by project-specific teleforms, and the overall process was evaluated by the science team. MAIN OUTCOME MEASURES: Site representation, patient representation, site coordinator feedback on the training program, and site coordinator experience during project implementation. RESULTS: The process yielded a representative mix of site and patient diversity appropriate for testing of the protocol. Site coordinators felt well-prepared to implement the protocol and experienced increased professional satisfaction because of therapeutic benefits achieved for patients and positive collaboration with physicians. CONCLUSIONS: The Continence for Women Project demonstrated the potential for developing and testing evidence-based protocols for clinical practice when the resources of an organization such as AWHONN and the research community are combined.
Assuntos
Implementação de Plano de Saúde/organização & administração , Avaliação em Enfermagem/métodos , Incontinência Urinária , Adulto , Idoso , Protocolos Clínicos , Medicina Baseada em Evidências , Feminino , Humanos , Pessoa de Meia-Idade , Pesquisa em Avaliação de Enfermagem , Inquéritos e Questionários , Incontinência Urinária/diagnóstico , Incontinência Urinária/enfermagem , Incontinência Urinária/terapiaAssuntos
Hemolinfa/metabolismo , Insetos/metabolismo , Metabolismo dos Lipídeos , Animais , MasculinoAssuntos
Atitude do Pessoal de Saúde , Medicina Baseada em Evidências , Pesquisa em Enfermagem/organização & administração , Pesquisadores/psicologia , Incontinência Urinária/enfermagem , Saúde da Mulher , Feminino , Humanos , Enfermagem Materno-Infantil , Avaliação de Programas e Projetos de Saúde , Sociedades de Enfermagem , Estados UnidosRESUMO
Submicrometric sulfuric acid (H2SO4) aerosol can affect mucociliary clearance without eliciting irritative symptoms or changes in pulmonary function. The effect of larger fog droplets containing H2SO4 on mucociliary clearance is unknown. We quantified mucociliary clearance from the trachea (n = 4) and small airways (n = 7) of young healthy male adults after an acute exposure to H2SO4 fog (MMAD = 10.3 microns; pH = 2.0; liquid water content = 481 +/- 65 mg/m3; osmolarity = 30 mOsm). Acid fog (AF) or saline fog (SF) (10.9 microns; 492 +/- 116 mg/m3; 30 mOsm) was administered for 40 min of unencumbered breathing (no mouth-piece) at rest and for 20 min of exercise sufficient to produce oronasal breathing. Fog exposures were followed by a methacholine (MCh) challenge (a measure of airway reactivity) or inhalation of technetium-99M radioaerosol (MMAD = 3.4 microns) on 2 study days each. Changes in symptoms and forced ventilatory function were also assessed. Clearance was quantified from computer-assisted analyses of gamma camera images of the lower respiratory tract in terms of %removal/min of the radiolabel from the trachea 25 min after inhalation and from the outer zone of the right lung after 1.9 to 3 h. Symptoms, forced ventilatory function, and MCh response were unaffected by either fog. Tracheal clearance was more rapid in four of four subjects after AF (0.83 +/- 1.58% removal/min) compared with that after SF (-0.54 +/- 0.85% removal/min). Outer zone clearance was more rapid in six of seven subjects after AF (0.22 +/- 0.15% removal/min) compared with that after SF (0.01 +/- 0.09% removal/min).(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Poluentes Atmosféricos/farmacologia , Depuração Mucociliar/efeitos dos fármacos , Ácidos Sulfúricos/farmacologia , Adulto , Aerossóis , Brônquios/fisiologia , Testes de Provocação Brônquica , Humanos , Concentração de Íons de Hidrogênio , Masculino , Cloreto de Metacolina , Tamanho da Partícula , Mecânica Respiratória/efeitos dos fármacos , Traqueia/fisiologia , Tempo (Meteorologia)RESUMO
Specialty nursing associations were queried about issues and challenges facing advanced practice nurses (APNs) today. APNs can seize opportunities to participate in shaping public policy that will advance advanced practice nursing and ultimately improve client well-being.
Assuntos
Enfermeiros Clínicos , Sociedades de Enfermagem , Especialidades de Enfermagem , Enfermagem em Emergência , Humanos , Recém-Nascido , Enfermagem Neonatal , Enfermeiros AnestesistasRESUMO
Coinfection with multiple types of genital human papillomavirus (HPV) has been reported, but how frequently it occurs and whether prior infection with specific HPV types inhibits subsequent infection by related types are not known. To address this, 518 women were followed for an average of 2.9 years, and behavioral information and cervical and vulvovaginal swabs for HPV DNA assay were obtained at 4-month intervals. A polymerase chain reaction-based method was used to detect types frequently found in cervical cancers (HPV 16, 18, 31, and 45) and in genital warts (HPV 6 and 11). Concurrent acquisition of multiple types occurred more often than expected by chance. However, no 2 types were more or less likely to be acquired concurrently than any other 2 types. When considering sequential acquisition of HPV types, we found that risk of acquiring a new HPV type was not decreased among those with prior infection by a phylogenetically related or unrelated type (hazard ratio [95% confidence interval], 1.0 [0.4-3.0] and 1.3 [0.8-2.1], respectively).