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1.
Artigo em Inglês | MEDLINE | ID: mdl-39030154

RESUMO

OBJECTIVES: Effective pain control after cardiac surgery may facilitate recovery. This study aimed to assess the use and association of ultrasound-guided single-injection chest wall blocks with liposomal bupivacaine on postoperative pain scores and short-term opioid requirements after cardiothoracic surgery at a single institution. DESIGN: Retrospective cohort study. SETTING: Midwestern academic hospital. PARTICIPANTS: Adult patients who underwent cardiothoracic surgery between July 1, 2020, and June 30, 2022. INTERVENTIONS: Ultrasound-guided single-injection chest wall block with liposomal bupivacaine. MEASUREMENTS AND MAIN RESULTS: Of the 1,038 patients included in this study, 301 (29%) received a perioperative nerve block for postoperative sternotomy pain, and 737 (71%) did not. Most of the single-shot blocks were bilateral parasternal intercostal plane blocks (n = 294 [98%]) performed after induction and before surgical incision (n = 280 [93%]). After adjusting for age, gender, American Society of Anesthesiologists status, select comorbidities, and surgical procedure type, mean postoperative pain scores were not significantly different between groups in the immediate postoperative period at all time points assessed (12 ± 2 hours, 24 ± 4 hours, 48 ± 8 hours, and 72 ± 12 hours). Similarly, there was no difference in mean opioid requirements (milligram morphine equivalents) at 72 hours between groups (68.6 [95% confidence interval, 56.3-83.4] vs 62.9 [95% confidence interval, 52.8-74.9], p = 0.195). CONCLUSIONS: In this retrospective study, the implementation of single-shot chest wall nerve blocks with liposomal bupivacaine was not associated with decreased postoperative pain scores or opioid consumption at 72 hours in select cardiac surgical patients at one institution.

2.
Ann Surg Oncol ; 29(5): 3337-3346, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-35211861

RESUMO

INTRODUCTION: The safety and efficacy of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in peritoneal metastasis in palliative settings remain poorly investigated and understood. Chemotherapy-refractory patients often present with symptomatic disease. This study investigated the safety and survival outcomes of optimal CRS/HIPEC performed primarily for palliation. METHODS: Palliative CRS/HIPEC was defined as asymptomatic patients who did not respond to three or more lines of chemotherapy, progression on current chemotherapy, and/or any symptomatic disease progression, including ascites, bowel obstruction, and pain. Data collected included demographics, histology, length of stay (LOS), perioperative complications, perioperative mortality, adjuvant chemotherapy use, peritoneal recurrence, overall recurrence, and overall survival. RESULTS: The median number of lines of chemotherapy received prior to CRS/HIPEC was 3.2, and 81% of patients were symptomatic. There were no postoperative deaths and the major complication rate was 22%. Ostomy creation and abdominal wall reconstruction were performed in 24% and 21% of patients, respectively. The median LOS was 11 days and successful palliation was achieved in 97% of patients. Overall survival was 13.5 months and factors associated with prolonged survival included optimal CRS (R1/R2a; p < 0.01) and the use of adjuvant chemotherapy (p < 0.001). Synchronous liver metastasis in the colon cancer subset did not negatively impact survival. CONCLUSION: CRS/HIPEC was performed safely in the palliative setting in patients with symptomatic progressive disease receiving multiple lines of chemotherapy. Median survival exceeded 1 year and factors associated with longer survival were optimal CRS and adjuvant chemotherapy. Liver metastasis did not preclude survival benefit in colon cancer patients. CRS/HIPEC can be considered for palliation but should be performed at high-volume centers.


Assuntos
Neoplasias do Colo , Hipertermia Induzida , Neoplasias Hepáticas , Neoplasias Peritoneais , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias do Colo/tratamento farmacológico , Terapia Combinada , Procedimentos Cirúrgicos de Citorredução/efeitos adversos , Humanos , Quimioterapia Intraperitoneal Hipertérmica , Neoplasias Hepáticas/tratamento farmacológico , Neoplasias Peritoneais/secundário , Estudos Retrospectivos , Taxa de Sobrevida
3.
J Surg Res ; 276: 235-241, 2022 08.
Artigo em Inglês | MEDLINE | ID: mdl-35395563

RESUMO

INTRODUCTION: Unintended perioperative hypothermia is associated with surgical site infection (SSI) in adults, prompting exhaustive efforts to maintain perioperative normothermia. Although these efforts are also made for pediatric patients, the association between hypothermia and SSI has not been demonstrated in children. We sought to determine whether perioperative hypothermia and other risk factors and clinical outcomes are associated with SSI in the pediatric population. MATERIALS AND METHODS: This case-control study took place from January 2014 through December 2016 and included patients at a National Surgical Quality Improvement Program-participant academic children's hospital. All surgical patients were included in this retrospective analysis. SSI rates were determined. A univariate analysis was performed to determine clinical factors associated with SSI. A multivariate regression analysis was then performed to determine the predictive effect of minimum perioperative temperature for SSI. RESULTS: This study included 3541 patients, of which 92 (2.6%) developed SSI. A univariate analysis showed associations among SSI and higher perioperative temperatures, surgical specialty of otolaryngology and general surgery, and wound classification (American Society of Anesthesiologists [ASA] classification III and IV). A multivariate analysis determined the odds of SSI increased by a factor of 1.6 for every 1°C increase in minimum perioperative temperature. CONCLUSIONS: Unintended perioperative hypothermia in our pediatric patients was inversely associated with SSI. This finding suggests that pediatric SSI prevention may not require the efforts made for adult patients to maintain normothermia.


Assuntos
Hipotermia , Adulto , Estudos de Casos e Controles , Criança , Humanos , Hipotermia/epidemiologia , Hipotermia/etiologia , Estudos Retrospectivos , Fatores de Risco , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle
4.
Ann Hematol ; 100(10): 2513-2519, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34279675

RESUMO

Richter's transformation (RT) is a rare complication arising in patients with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) and is associated with an overall dismal outcome. The rarity of this entity poses many challenges in understanding its biology and outcomes seen and the optimal treatment approach. We utilized the SEER (Surveillance, Epidemiology and End Results) database to identify patients diagnosed with CLL/SLL between 2000 and 2016 and subsequently had a diagnosis of diffuse large B-cell lymphoma (DLBCL) or Hodgkin lymphoma (HL), thus capturing those who experienced an RT event. We compared the outcomes of those patients to those of patients in the database diagnosed with DLBCL without a preceding CLL/SLL diagnosis. We identified 530 patients who developed RT out of 74,116 patients diagnosed with CLL/SLL in the specified period. The median age at RT diagnosis was 66 years, and the median time from CLL/SLL diagnosis to RT development was roughly 4 years. Patients with RT had a dismal outcome with median overall survival of 10 months. We identified advanced Ann Arbor stage (III/IV) and prior treatment for CLL as predictors of worse outcome in patients with RT. Our study represents the largest dataset of patients with CLL/SLL and RT and adds to the existing literature indicating the poor outcomes for those patients.


Assuntos
Leucemia Linfocítica Crônica de Células B/patologia , Idoso , Transformação Celular Neoplásica/patologia , Progressão da Doença , Feminino , Doença de Hodgkin/diagnóstico , Humanos , Leucemia Linfocítica Crônica de Células B/complicações , Leucemia Linfocítica Crônica de Células B/diagnóstico , Linfoma Difuso de Grandes Células B/diagnóstico , Masculino , Pessoa de Meia-Idade , Prognóstico
5.
J Surg Oncol ; 123(7): 1599-1609, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33667317

RESUMO

INTRODUCTION: Interrogation of cancers with next-generation sequencing (NGS) mutation panels has become widely utilized, identifying prognostic and actionable mutations. This study explored the value of expanded mutation analysis in appendix peritoneal metastases (APM). METHODS: Forty-eight APM patients treated 2013-2018 were retrospectively collected from a registry. Fifty-gene NGS analysis was performed in CLIA approved lab to obtain mutation profiles. All patients underwent cytoreductive surgery (CRS)/hyperthermic intraperitoneal chemotherapy (HIPEC) with mitomycin C. Peritoneal cancer index (PCI), optimal CRS, survival (overall survival [OS] and progression-free survival [PFS]) data were collected. Survival analyses were performed on all APM, high-grade (HG), and low grade (LG) subsets, evaluating the impact of specific mutations on the outcome. RESULTS: Eighty-three percent of APM had a mutation identified. KRAS was most frequent, 65% (88% LG 42% HG) with GNAS identified in 92% of LG-APM. SMAD4 and/or TP53 mutations occurred in 25% of APM with observed decreased OS (46 vs. 81 months p = .0029); worse in HG-APM (26 vs. 49 months p = .0451). SMAD4 was associated with the most significant reduction in PFS in APM (p = .0085). Actionable mutations were identified in 73% of APM patients. CONCLUSIONS: Most frequent mutations were KRAS, TP53, and SMAD4, and actionable mutation detection was common. SMAD4 and TP53 were associated with decreased OS. NGS mutation profiling has potential utility in APM.


Assuntos
Neoplasias do Apêndice/genética , Neoplasias do Apêndice/terapia , Quimioterapia Intraperitoneal Hipertérmica/métodos , Neoplasias Peritoneais/genética , Neoplasias Peritoneais/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias do Apêndice/patologia , Terapia Combinada , Procedimentos Cirúrgicos de Citorredução/métodos , Feminino , Sequenciamento de Nucleotídeos em Larga Escala/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Mitomicina/administração & dosagem , Neoplasias Peritoneais/secundário , Prognóstico , Proteínas Proto-Oncogênicas p21(ras)/genética , Estudos Retrospectivos , Proteína Smad4/genética , Proteína Supressora de Tumor p53/genética
6.
Pediatr Blood Cancer ; 68(4): e28921, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33522720

RESUMO

BACKGROUND: Children with terminal cancer and their families describe a preference for home-based end-of-life care. Inadequate support outside of the hospital is a limiting factor in home location feasibility, particularly in rural regions lacking pediatric-trained hospice providers. METHODS: The purpose of this longitudinal palliative telehealth support pilot study was to explore physical and emotional symptom burden and family impact assessments for children with terminal cancer receiving home based-hospice care. Each child received standard of care home-based hospice care from an adult-trained rural hospice team with the inclusion of telehealth pediatric palliative care visits at a scheduled minimum of every 14 days. RESULTS: Eleven children (mean age 11.9 years) received pediatric palliative telehealth visits a minimum of every 14 days, with an average of 4.8 additional telehealth visits initiated by the family. Average time from enrollment to death was 21.6 days (range 4-95). Children self-reported higher physical symptom prevalence than parents or hospice nurses perceived the child was experiencing at time of hospice enrollment with underrecognition of the child's emotional burden. At the time of hospice enrollment, family impact was reported by family caregivers as 46.4/100 (SD 18.7), with noted trend of improved family function while receiving home hospice care with telehealth support. All children remained at home for end-of-life care. CONCLUSION: Pediatric palliative care telehealth combined with adult-trained rural hospice providers may be utilized to support pediatric oncology patients and their family caregivers as part of longitudinal home-based hospice care.


Assuntos
Cuidados Paliativos , Telemedicina , Assistência Terminal , Adolescente , Criança , Serviços de Assistência Domiciliar , Humanos , Lactente , Recém-Nascido , Cuidados Paliativos/métodos , Projetos Piloto , População Rural , Telemedicina/métodos , Assistência Terminal/métodos
7.
Surg Endosc ; 35(6): 2724-2730, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-32556757

RESUMO

PURPOSE: Use of absorbable mesh in hiatal hernia (HH) repair has been shown to decrease recurrence rates. Our aim was to compare the efficiency of three meshes in relation to the surgical outcomes of patients undergoing HH repair. METHODS: A single-institution retrospective review was done for adult patients who underwent HH repair with mesh between 2004 and 2016. Demographics, intra-operative, and cost data were collected. Esophageal symptoms and medication use were assessed pre- and postoperatively. Surgical outcomes were evaluated at 6-, 12-months, and long-term follow-up. Three groups were created based on type of mesh: human tissue matrix (HTM), biosynthetic mesh (BIOS), or porcine tissue matrix (PTM). Comparisons were performed between groups using SPSS v.26.0 and PC SAS v9.4, α = 0.05. RESULTS: 292 patients were included (HTM:N = 162, BIOS:N = 83, PTM:N = 47). Majority were male (60.4%), Caucasian (93.2%), median age, and BMI of 59 years [25-90 years] and 29.19 kg/m2 [18.9-58.0 kg/m2], respectively. 69% had a large HH. Median follow-up time was 27 months [1-166 months]. Overall recurrence rate was 39%, being significantly lower in BIOS at long-term (HTM: 31%, BIOS: 17%, PTM: 19%, p = 0.038). All groups had a significant postoperative improvement of esophageal symptoms, all p < 0.001. 65-70% of the cost difference between the groups was incurred by the cost of mesh alone (HTM: $1072, BIOS: $548, PTM: $1295), with the remainder attributable to the surgery itself. CONCLUSION: While outcomes of the three mesh groups were similar in our data, there was a significant difference in mesh cost. Surgeon and hospital preference still play a role in choosing the type of mesh used; however, knowledge of the individual mesh cost will help surgeons make better informed decisions.


Assuntos
Hérnia Hiatal , Laparoscopia , Animais , Feminino , Hérnia Hiatal/cirurgia , Herniorrafia , Humanos , Masculino , Recidiva , Estudos Retrospectivos , Telas Cirúrgicas , Suínos , Resultado do Tratamento
8.
World J Surg Oncol ; 19(1): 118, 2021 Apr 14.
Artigo em Inglês | MEDLINE | ID: mdl-33853623

RESUMO

BACKGROUND: The optimal type of operative drainage following pancreaticoduodenectomy (PD) remains unclear. Our objective is to investigate risk associated with closed drainage techniques (passive [gravity] vs. suction) after PD. METHODS: We assessed operative drainage techniques utilized in patients undergoing PD in the ACS-NSQIP pancreas-targeted database from 2016 to 2018. Using multivariable logistic regression to adjust for characteristics of the patient, procedure, and pancreas, we examined the association between use of gravity drainage and postoperative outcomes. RESULTS: We identified 9665 patients with drains following PD from 2016 to 2018, of which 12.7% received gravity drainage. 61.0% had a diagnosis of adenocarcinoma or pancreatitis, 26.5% had a duct <3 mm, and 43.5% had a soft or intermediate gland. After multivariable adjustment, gravity drainage was associated with decreased rates of postoperative pancreatic fistula (odds ratio [OR] 0.779, 95% confidence interval [CI] 0.653-0.930, p=0.006), delayed gastric emptying (OR 0.830, 95% CI 0.693-0.988, p=0.036), superficial SSI (OR 0.741, 95% CI 0.572-0.959, p=0.023), organ space SSI (OR 0.791, 95% CI 0.658-0.951, p=0.012), and readmission (OR 0.807, 95% CI 0.679-0.958, p=0.014) following PD. CONCLUSIONS: Gravity drainage is independently associated with decreased rates of CR-POPF, DGE, SSI, and readmission following PD. Additional prospective research is necessary to better understand the preferred drainage technique following PD.


Assuntos
Drenagem , Fístula Pancreática , Humanos , Fístula Pancreática/epidemiologia , Fístula Pancreática/etiologia , Pancreaticoduodenectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Prognóstico , Estudos Prospectivos , Fatores de Risco
9.
J Surg Oncol ; 122(6): 1106-1113, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32662065

RESUMO

BACKGROUND AND OBJECTIVES: Outcomes for gastrointestinal peritoneal metastases (GI-PM) are worse compared to systemic metastases, with a paucity of data exploring extended mutation profiling. An exploratory mutation analysis in GI-PMs was performed as a "proof of concept" of potential predictive values of profiling in GI-PM and rates of actionable mutations. METHODS: The study included 40 GI-PM patients: 14 low-grade mucinous carcinoma peritonei and 26 HG-PM (12 colons, 10 appendix, 4 small bowels). Demographics, histologies, peritoneal cancer indexes, cytoreduction scores, and survival data were collected. NGS 50-gene mutation profiling was performed on 38 specimens. The association of mutations with survival was evaluated in high-grade PM. RESULTS: KRAS, TP53, and SMAD4 mutations were observed in 61%, 29%, and 8% of cases across all tumor histologies. In 66% cases >1 mutations occurred, associated with decreased survival in HG-PM: 32 vs 73 months, P = .03. TP53 or SMAD4 mutations were associated with decreased survival in HG-PM: 22 vs 48 months, P = .02. Actionable mutations were detected in 70%. CONCLUSION: Actionable mutations were detected at high rates. GI-PMs have similar mutational profiles and TP53, SMAD4, and/or >1 mutation were associate with decreased survival in HG-PM. This data supports the concept of the extended mutation profiling utility in GI-PM warranting further investigation.


Assuntos
Adenocarcinoma Mucinoso/patologia , Biomarcadores Tumorais/genética , Procedimentos Cirúrgicos de Citorredução/mortalidade , Análise Mutacional de DNA/métodos , Neoplasias Gastrointestinais/patologia , Mutação , Neoplasias Peritoneais/patologia , Adenocarcinoma Mucinoso/genética , Adenocarcinoma Mucinoso/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Neoplasias Gastrointestinais/genética , Neoplasias Gastrointestinais/cirurgia , Sequenciamento de Nucleotídeos em Larga Escala , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Peritoneais/genética , Neoplasias Peritoneais/cirurgia , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Adulto Jovem
10.
Transpl Infect Dis ; 22(2): e13225, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31785022

RESUMO

BACKGROUND: Autologous hematopoietic stem cell transplant (HSCT) recipients are not uniformly considered as "high risk" enough to receive fluoroquinolone (FQ) prophylaxis. The risks versus benefits of FQ prophylaxis in autologous HSCT require further investigation. METHODS: A retrospective chart review of patients > 19 years old who received an autologous HSCT at Nebraska Medicine analyzed two time periods (period 1: no prophylaxis [2013-2015] versus period 2: levofloxacin prophylaxis [2015-2016]) to characterize the clinical impact of levofloxacin prophylaxis on autologous HSCT recipients. RESULTS: A total of 224 autologous HSCT were screened with 214 included. Febrile neutropenia (FN) developed in 101/113 (89%) versus 60/101 (59%) patients in the no prophylaxis (NPx) versus prophylaxis (Px) group (P < .01). Time to onset of FN was a median 6 versus 7 days (P = .01), and total bloodstream infections (BSI) were 33/113 (29%) versus 7/101 (7%) (P < .01) in NPx and Px groups, respectively. Gram-negative BSI were absent in the Px group. Viridans group streptococci were the most common Gram-positive BSI overall, with FQ-resistance more common in Px recipients. Rates of Clostridium difficile infections, length of hospital stay, or death at 100 days post-HSCT did not differ between the groups. CONCLUSION: Fluoroquinolone prophylaxis introduced into autologous HSCT care at our institution in 2015 resulted in prevention of Gram-negative BSI, decreased rates of FN, microbiologically documented infections, and a delay in time to onset of FN compared with the prior NPx. FQ prophylaxis in autologous HSCT recipients should be evaluated per individual institution.


Assuntos
Antibacterianos/administração & dosagem , Antibioticoprofilaxia , Neutropenia Febril/etiologia , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Levofloxacino/administração & dosagem , Bacteriemia/prevenção & controle , Infecções por Clostridium/prevenção & controle , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Transplantados/estatística & dados numéricos , Transplante Autólogo/efeitos adversos , Transplante Homólogo/efeitos adversos
11.
World J Surg ; 44(5): 1478-1484, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31894357

RESUMO

PURPOSE: The American College of Surgeons' Rural Trauma Team Development Course (RTTDC) was designed to help rural hospitals optimize a team approach to trauma management recognizing the need for early transfer. Little literature exists on the success of RTTDC achieving its objectives. The purpose of this study was to determine the impact of RTTDC on rural trauma team members. METHODS: RTTDC was hosted at seven rural hospitals. A pre-course 30-question Likert survey gauging confidence managing trauma patients was administered to participants. Four weeks following, participants received a post-course survey with corresponding Likert questions and 11 trauma knowledge-based questions. Chi-square, Fisher's exact tests and general linear models were utilized. Statistical significance is set as p < 0.05. RESULTS: 111 participants completed the pre-course survey; 53 (48%) completed the post-course survey. Results presented on a 5-point Likert scale with 1 = "not at all comfortable" to 5 = "extremely comfortable." Participants knowing their role in the trauma team improved by 16% (p = 0.02). Familiarity with the roles of other trauma team members was significantly improved (3.4 vs. 4.15; p < 0.01). Participants comfort with resuscitating trauma patients and managing traumatic brain injury significantly improved (3.29 vs. 3.69; p = 0.01 and 2.62 vs. 3.14; p = 0.004, respectively). Comfortability communicating with the regional trauma center improved significantly (3.64 vs. 4.19; p = 0.004). Participant decision to transfer trauma patients within 15 min of arrival improved by 3.2%. Participants answered 82% of the knowledge-based questions correctly. CONCLUSION: RTTDC instills confidence in providers at rural hospitals. The information taught is well retained, allowing for quality care and timely patient transfer to the nearest trauma center.


Assuntos
Competência Clínica , Educação Continuada/métodos , Hospitais Rurais/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Autoimagem , Traumatologia/educação , Ferimentos e Lesões/terapia , Adulto , Feminino , Humanos , Masculino , Nebraska , Transferência de Pacientes/organização & administração , Recursos Humanos em Hospital/educação , Qualidade da Assistência à Saúde , Saúde da População Rural , Serviços de Saúde Rural/organização & administração , Centros de Traumatologia/organização & administração
12.
Br J Haematol ; 184(5): 744-752, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30520026

RESUMO

Relapsed or refractory non-Hodgkin lymphomas (NHLs) often carry poor prognosis and pose management challenges. We evaluated the safety and efficacy of dasatinib, a broad-spectrum multi-kinase inhibitor in relapsed/refractory NHL with correlative genomic analysis in a Phase I/II trial. The study included 33 patients with various sub-types of NHL who had received at least one prior therapy. The most common sub-types were diffuse large B-cell lymphoma (24%), follicular lymphoma, grade 1/2 (21%) and peripheral T-cell lymphoma not otherwise specified (PTCL-NOS; 21%). Most patients were heavily pre-treated, including 42% with more than four prior therapies, 67% with rituximab exposure and 24% with prior autologous transplant. In this cohort, dasatinib showed modest activity in evaluable patients with an objective response rate of 29% (7/24) and clinical benefit rate of 71% (17/24). In 32 patients with outcome data, median progression-free survival was 3 months and median overall survival was 22·4 months. There were two patients with sustained complete responses, both with PTCL-NOS histology. The side effect profile was consistent with prior studies, with pleural effusion being the most common non-haematological toxicity. Exploratory genomic analysis showed two cases of PTCL-NOS with sustained response had a common mutation in LRRK2 and high prevalence of FOXO1 mutation in relapsed/refractory follicular lymphoma.


Assuntos
Dasatinibe/administração & dosagem , Proteína Forkhead Box O1/genética , Serina-Treonina Proteína Quinase-2 com Repetições Ricas em Leucina/genética , Linfoma não Hodgkin , Proteínas de Neoplasias/genética , Adulto , Idoso , Idoso de 80 Anos ou mais , Intervalo Livre de Doença , Feminino , Genômica , Humanos , Linfoma não Hodgkin/tratamento farmacológico , Linfoma não Hodgkin/genética , Linfoma não Hodgkin/mortalidade , Masculino , Pessoa de Meia-Idade , Recidiva , Taxa de Sobrevida
13.
J Surg Oncol ; 120(4): 661-669, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31292967

RESUMO

BACKGROUND: Anastomotic leak is the most common major complication after esophagectomy. We investigated the 2016 American College of Surgeons National Surgical Quality Improvement Program esophagectomy targeted database to identify risk factors for anastomotic leak. METHODS: Patients who underwent esophagectomy for cancer were included. Patients experiencing an anstomotic leak were identified, and univariate and multivariable logistic regression was performed to identify variables independently associated with anastomotic leak. RESULTS: Of 915 patients included, 83% were male and the median age was 64 years. Patients with anastomotic leak more frequently had additional complications (87% vs 36%, P < .001). Rates of reoperation (64% vs 11%, P < .001) and mortality (8% vs 2%, P = .001) were higher in patients with anastomotic leak. After adjusting for patient and procedure characteristics, prolonged operative time (for each additional 30-minutes; adjusted odds ratios (AOR) 1.068, 95% CI, 1.022-1.115, P = .003), increased preoperative WBC count (for each 3000/µL increase; AOR 1.323, 95% CI, 1.048-1.670, P = .019), pre-existing diabetes (AOR 1.601, 95% CI, 1.012-2.534, P = .045), and perioperative transfusion (AOR 1.777, 95% CI, 1.064-2.965, P = .028) were independently associated with anastomotic leak. CONCLUSION: Both patient and procedure-related factors are associated with anastomotic leak. Though frequently non-modifiable, these findings could facilitate risk stratification and early detection of anastomotic leak to reduce associated morbidity.


Assuntos
Adenocarcinoma/cirurgia , Fístula Anastomótica/etiologia , Carcinoma de Células Escamosas/cirurgia , Neoplasias Esofágicas/cirurgia , Esofagectomia/efeitos adversos , Medição de Risco/métodos , Adenocarcinoma/patologia , Idoso , Fístula Anastomótica/patologia , Carcinoma de Células Escamosas/patologia , Neoplasias Esofágicas/patologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico
14.
Surg Endosc ; 32(4): 1834-1839, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29052065

RESUMO

BACKGROUND: Minimally invasive surgery (MIS) use for ventral hernia repair has increased over the last decade. Whether outcomes are improved by robotic assistance remains a subject of debate. The aim of this study is to evaluate outcomes (including cost, complications, length of stay (LOS), and pain medication utilization) in patients who underwent an open (OVHR), laparoscopic (LVHR), or robotic (RVHR) ventral hernia repair (VHR). METHODS: The Vizient database was queried using ICD-9 procedure and diagnosis codes for patients who underwent VHR from January 2013 to September 2015. Complications, 30-day readmission, mortality, LOS, cost, and intra-hospital opiate utilization were analyzed using IBM SPSS v.23.0.0.0. Median tests with post hoc pairwise comparisons, Fischer's exact, and Pearson's chi-squared test with Bonferroni correction were applied where appropriate, with α = 0.05. RESULTS: 46,799 patients (OVHR: N = 39,505, LVHR: N = 6829, RVHR: N = 465) met the criteria and patients in each group had similar demographics (Table 1). OVHR was associated with significant increased overall complications, 30-day readmission, LOS, and postoperative pain use compared to RVHR or LVHR. OVHR had higher mortality and postoperative infection rates than LVHR. RVHR had significantly higher rates of complications and postoperative infections compared to LVHR, although there was no difference in mortality, 30-day readmission, LOS, and postoperative pain medication use. Mean direct cost of surgery was significantly higher for RVHR, followed by OVHR and LVHR. CONCLUSIONS: Overall patient outcomes were improved in the LVHR and RVHR groups compared to the open approach. However, RVHR patients did not have significant improvement compared with the LVHR group in either short-term outcomes or opiate medication used. While RVHR surgery was the most expensive modality, OVHR was also significantly costlier than LVHR, which was the least expensive. Long-term data on recurrence could not be evaluated and should be studied to determine the role of robotic surgery in VHR and recurrence rates.


Assuntos
Hérnia Ventral/cirurgia , Herniorrafia/instrumentação , Laparoscopia , Complicações Pós-Operatórias/cirurgia , Procedimentos Cirúrgicos Robóticos , Adulto , Bases de Dados Factuais , Feminino , Herniorrafia/métodos , Humanos , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/etiologia
15.
Cancer ; 123(4): 688-696, 2017 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-27741355

RESUMO

BACKGROUND: Stereotactic body radiotherapy (SBRT) is the standard of care for patients with nonoperative, early-stage non-small cell lung cancer (NSCLC) measuring < 5 cm, but its use among patients with tumors measuring ≥5 cm is considerably less defined, with the existing literature limited to small, single-institution reports. The current multi-institutional study reported outcomes evaluating the largest such population reported to date. METHODS: Clinical/treatment characteristics, outcomes, toxicities, and patterns of failure were assessed in patients with primary NSCLC measuring ≥5 cm without evidence of distant/lymph node metastasis who underwent SBRT using ≤5 fractions. Statistics included Kaplan-Meier survival analyses and univariate/multivariate Cox proportional hazards models. RESULTS: A total of 92 patients treated from 2004 through 2016 were analyzed from 12 institutions. The median follow-up was 12 months (15 months in survivors). The median age and tumor size among the patients were 73 years (range, 50-95 years) and 5.4 cm (range, 5.0-7.5 cm), respectively. The median dose/fractionation was 50 Gray/5 fractions. The actuarial local control rates at 1 year and 2 years were 95.7% and 73.2%, respectively. The disease-free survival rate was 72.1% and 53.5%, respectively, at 1 year and 2 years. The 1-year and 2-year disease-specific survival rates were 95.5% and 78.6%, respectively. The median, 1-year, and 2-year overall survival rates were 21.4 months, 76.2%, and 46.4%, respectively. On multivariate analysis, lung cancer history and pre-SBRT positron emission tomography maximum standardized uptake value were found to be associated with overall survival. Posttreatment failures were most commonly distant (33% of all disease recurrences), followed by local (26%) and those occurring elsewhere in the lung (23%). Three patients had isolated local failures. Grade 3 to 4 toxicities included 1 case (1%) and 4 cases (4%) of grade 3 dermatitis and radiation pneumonitis, respectively (toxicities were graded according to the Common Terminology Criteria for Adverse Events [version 4.0]). Grades 2 to 5 radiation pneumonitis occurred in 11% of patients. One patient with a tumor measuring 7.5 cm and a smoking history of 150 pack-years died of radiation pneumonitis. CONCLUSIONS: The results of the current study, which is the largest study of patients with NSCLC measuring ≥5 cm reported to date, indicate that SBRT is a safe and efficacious option. Cancer 2017;123:688-696. © 2016 American Cancer Society.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/radioterapia , Recidiva Local de Neoplasia/radioterapia , Radiocirurgia , Idoso , Idoso de 80 Anos ou mais , Carcinoma Pulmonar de Células não Pequenas/epidemiologia , Carcinoma Pulmonar de Células não Pequenas/patologia , Intervalo Livre de Doença , Fracionamento da Dose de Radiação , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/epidemiologia , Recidiva Local de Neoplasia/patologia , Resultado do Tratamento
16.
Am J Hematol ; 92(8): 764-771, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28437868

RESUMO

Cancer health disparities may exist based on the facility type. We aimed to determine the association between the academic status of centers and outcomes of patients with acute myeloid leukemia (AML). Using the National Cancer Data Base, we compared 1-month mortality and long-term overall survival (OS) of 60 738 patients with AML, who received first course treatment between 2003 and 2011 at academic or nonacademic centers (community cancer program, comprehensive community cancer program, and others). Multivariate analysis was done using logistic regression for one-month mortality and Cox regression with backward elimination approach for OS. Patients treated at academic centers differed from those at nonacademic centers in that they were younger with a median age of 62 versus 70 years (P < .0001), more often an ethnic minority (P < .0001), had lower education level (P = .005), lower co-morbidity score (P < .0001), a different income (P < .0001), and insurance profile (P < .0001), and more often received chemotherapy (P < .0001) and transplant (P < .0001). Receipt of care at nonacademic centers was associated with worse 1-month mortality (29% vs. 16%, P < .0001) and 5-year OS (15% vs. 25%; P < .0001). After adjusting for prognostic covariates, the 1-month mortality (odds ratio, 1.52; 95% confidence interval, CI 1.46-1.59; P < .0001) and OS were significantly worse in nonacademic centers, compared to academic centers. Our large database study suggests that the receipt of initial therapy at academic centers is associated with lower 1-month mortality and higher long-term OS. Investigation of the underlying reasons may allow reducing this disparity.


Assuntos
Institutos de Câncer , Leucemia Mieloide Aguda/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Análise Fatorial , Feminino , Humanos , Leucemia Mieloide Aguda/terapia , Masculino , Pessoa de Meia-Idade , Mortalidade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Fatores Socioeconômicos , Análise de Sobrevida , Estados Unidos/epidemiologia , Adulto Jovem
17.
J Surg Res ; 207: 190-197, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27979476

RESUMO

BACKGROUND: Surgical education is witnessing a surge in the use of simulation. However, implementation of simulation is often cost-prohibitive. Online shopping offers a low budget alternative. The aim of this study was to implement cost-effective skills laboratories and analyze online versus manufacturers' prices to evaluate for savings. MATERIALS AND METHODS: Four skills laboratories were designed for the surgery clerkship from July 2014 to June 2015. Skills laboratories were implemented using hand-built simulation and instruments purchased online. Trademarked simulation was priced online and instruments priced from a manufacturer. Costs were compiled, and a descriptive cost analysis of online and manufacturers' prices was performed. Learners rated their level of satisfaction for all educational activities, and levels of satisfaction were compared. RESULTS: A total of 119 third-year medical students participated. Supply lists and costs were compiled for each laboratory. A descriptive cost analysis of online and manufacturers' prices showed online prices were substantially lower than manufacturers, with a per laboratory savings of: $1779.26 (suturing), $1752.52 (chest tube), $2448.52 (anastomosis), and $1891.64 (laparoscopic), resulting in a year 1 savings of $47,285. Mean student satisfaction scores for the skills laboratories were 4.32, with statistical significance compared to live lectures at 2.96 (P < 0.05) and small group activities at 3.67 (P < 0.05). CONCLUSIONS: A cost-effective approach for implementation of skills laboratories showed substantial savings. By using hand-built simulation boxes and online resources to purchase surgical equipment, surgical educators overcome financial obstacles limiting the use of simulation and provide learning opportunities that medical students perceive as beneficial.


Assuntos
Estágio Clínico/economia , Estágio Clínico/métodos , Comércio/métodos , Análise Custo-Benefício , Cirurgia Geral/educação , Internet , Treinamento por Simulação/economia , Comércio/economia , Cirurgia Geral/economia , Humanos , Laparoscopia/economia , Laparoscopia/educação , Laparoscopia/instrumentação , Satisfação Pessoal , Estados Unidos
18.
Nutr Cancer ; 68(1): 105-12, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26699517

RESUMO

A reported linkage between processed (nitrite-treated) meat products and the incidence of colon cancer could be due to sodium nitrite (NaNO2) itself or to N-nitroso compounds produced from the nitrite. Exposure to nitrite occurs due to residual nitrite in processed meat and to salivary nitrite arising by reduction of nitrate in vegetables and drinking water. Here we tested whether NaNO2 could induce colonic aberrant crypts (ABC) or ABC foci (ACF), which are putative precursors of colon cancer. We fed NaNO2 in drinking water for 20-25 wk to groups of 8-20 adult female mice. After sacrifice, ABC and ACF were counted in 2-cm distal colonic segments. In Experiment 1, no significant differences in ABC/ACF induction were seen between groups of 13-14 A/J mice fed 0, 0.5, or 1.0 g NaNO2/l drinking water. NaNO2 also did not affect fasting blood glucose levels. In Experiment 2, we fed 0, 1.0, 1.25, or 1.5 g NaNO2/l water to groups of 15 CF-1 mice. Five of the mice fed 1.5 g NaNO2/l showed ABC, whereas all other groups showed only 0-2 ABC/group, including 0 ABC for the group fed 1.25 g NaNO2/l. Overall statistical analysis indicated a dose-response p trends of 0.04. Pairwise comparison of ABC between groups fed 1.25 and 1.5 g NaNO2/l showed p 0.02 for both ABC and ACF, but a similar comparison between the untreated and 1.5 g/l groups showed no significant effects. In Experiment 3, hot dogs (18% of diet), which were fed to CF-1 mice previously treated with azoxymethane, inhibited ABC and ACF induction, but this effect was not significant (P = 0.10-0.12). In conclusion, these results support the view that NaNO2 may be a risk factor for colon carcinogenesis.


Assuntos
Focos de Criptas Aberrantes/induzido quimicamente , Neoplasias Colorretais/induzido quimicamente , Nitrito de Sódio/toxicidade , Animais , Azoximetano/toxicidade , Feminino , Hemina/toxicidade , Camundongos
19.
J Card Fail ; 21(10): 792-7, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25937146

RESUMO

BACKGROUND: Proven strategies to reduce right ventricular (RV) dysfunction after continuous-flow left ventricular assist device (CF-LVAD) implantation are lacking. We sought to evaluate the tolerability, feasibility, efficacy, and pharmacokinetics of inhaled milrinone (iMil) delivery after CF-LVAD implantation. METHODS AND RESULTS: We prospectively evaluated fixed-dose nebulized iMil delivered into a ventilator circuit for 24 hours in 10 postoperative CF-LVAD (Heartmate-II) patients. Tolerability (arrhythmias, hypotension, and hypersensitivity reaction), efficacy (hemodynamics), pharmacokinetics (plasma milrinone levels), and cost data were collected.Mean age was 56 ± 9 years, 90% were male, and mean INTERMACS profile was 2.5 ± 0.8. No new atrial arrhythmia events occurred, although 3 (30%) ventricular tachycardia (1 nonsustained, 2 sustained) events occurred. Sustained hypotension, drug hypersensitivity, death, or need for right ventricular assist device were not observed. Invasive mean pulmonary arterial pressure from baseline to during iMil therapy was improved (P = .017). Mean plasma milrinone levels (ng/mL) at baseline, and 1, 4, 8, 12, and 24 hours were 74.2 ± 35.4, 111.3 ± 70.9, 135.9 ± 41.5, 205.0 ± 86.7, 176.8 ± 61.3 187.6 ± 105.5, respectively. Reduced institutional cost was observed when iMil was compared with nitric oxide therapy over 24 hours ($165.29 vs $1,944.00, respectively). CONCLUSIONS: iMil delivery after CF-LVAD implantation was well tolerated, feasible, and demonstrated favorable hemodynamic, pharmacokinetic, and cost profiles. iMil therapy warrants further study in larger clinical trials.


Assuntos
Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/cirurgia , Coração Auxiliar/tendências , Milrinona/administração & dosagem , Administração por Inalação , Idoso , Análise Custo-Benefício , Feminino , Insuficiência Cardíaca/diagnóstico , Ventrículos do Coração , Hemodinâmica/efeitos dos fármacos , Hemodinâmica/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Milrinona/economia , Cuidados Pós-Operatórios/economia , Cuidados Pós-Operatórios/métodos , Resultado do Tratamento , Vasodilatadores/administração & dosagem , Vasodilatadores/economia , Disfunção Ventricular Direita/prevenção & controle
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