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1.
Arthroscopy ; 37(4): 1084-1085, 2021 04.
Artículo en Inglés | MEDLINE | ID: mdl-33812513

RESUMEN

Surgeons must rely on cost and charge data to inform a patient outcome-optimized value-based approach to arthroscopic rotator cuff repairs. Using biologic and regenerative procedures to augment repairs only when necessary and optimizing anchor number are 2 obvious ways surgeons can help control cost of these procedures. Addition of biologics, such as patches and tissue augmentation, nearly doubled the charges for the procedure.


Asunto(s)
Lesiones del Manguito de los Rotadores , Cirujanos , Procedimientos Quirúrgicos Ambulatorios , Artroscopía , Humanos , Manguito de los Rotadores/cirugía , Lesiones del Manguito de los Rotadores/cirugía
3.
Ann R Coll Surg Engl ; 103(3): 173-179, 2021 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-33557703

RESUMEN

INTRODUCTION: With the emergence of the COVID-19 pandemic, all elective surgery was temporarily suspended in the UK, allowing for diversion of resource to manage the anticipated surge of critically unwell patients. Continuing to deliver time-critical surgical care is important to avoid excess morbidity and mortality from pathologies unrelated to COVID-19. We describe the implementation and short-term surgical outcomes from a system to deliver time-critical elective surgical care to patients during the COVID-19 pandemic. MATERIALS AND METHODS: A protocol for the prioritisation and safe delivery of time-critical surgery at a COVID-19 'clean' site was implemented at the Nuffield Health Exeter Hospital, an independent sector hospital in the southwest of England. Outcomes to 30 days postoperatively were recorded, including unplanned admissions after daycase surgery, readmissions and complications, as well as the incidence of perioperative COVID-19 infection in patients and staff. RESULTS: A total of 128 surgical procedures were performed during a 31-day period by a range of specialties including breast, plastics, urology, gynaecology, vascular and cardiology. There was one unplanned admission and and two readmissions. Six complications were identified, and all were Clavien-Dindo grade 1 or 2. All 128 patients had preoperative COVID-19 swabs, one of which was positive and the patient had their surgery delayed. Ten patients were tested for COVID-19 postoperatively, with none testing positive. CONCLUSION: This study has demonstrated the implementation of a safe system for delivery of time-critical elective surgical care at a COVID-19 clean site. Other healthcare providers may benefit from implementation of similar methodology as hospitals plan to restart elective surgery.


Asunto(s)
Procedimientos Quirúrgicos Electivos/métodos , Neoplasias/cirugía , Procedimientos Quirúrgicos Operativos/métodos , Tiempo de Tratamiento , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Ambulatorios/métodos , Derivación Arteriovenosa Quirúrgica , Cateterismo Cardíaco , Prestación de Atención de Salud/organización & administración , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Histerectomía , Masculino , Tamizaje Masivo , Persona de Mediana Edad , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Reino Unido/epidemiología , Procedimientos Quirúrgicos Urológicos , Adulto Joven
4.
Zhonghua Yi Xue Za Zhi ; 101(6): 416-420, 2021 Feb 09.
Artículo en Chino | MEDLINE | ID: mdl-33611891

RESUMEN

Objective: To summarize the clinical effect of ultrasound-guided percutaneous transluminal angioplasty (PTA) in the treatment of arteriovenous fistula (AVF) immaturation under day surgery mode. Methods: The clinical data was retrospective analyzed of patients with AVF immaturation who were treated by ultrasound-guided PTA under day surgery mode from November 2016 to June 2019 in Renji Hospital. The basic information, lesion location, puncture approach, number and diameter of balloon used were counted. The primary and secondary patency rates were calculated at 6 and 12 months after operation. Results: In all of the 21 patients, 11 patients were male and 10 patients were female. The mean age was (52.6±12.9) years old. There were 20 of the 21 patients who were treated successfully. One patient had AVF reconstruction with vascular rupture, and the complication rate was 4.8% (1/21). The length of hospitalization was (1.05±0.71) days, and the cost was (11 487.7±4 401.4) yuan. The follow-up time was (19.7±8.3) months. The 6-month and 12-month primary patency rate were 70% and 55%, and the 6-month and 12-month secondary patency rate were both 90%. Conclusion: Ultrasound-guided PTA in the treatment of AVF immaturation under day surgery mode is safe and effective, which has a high technical success rate and good patency rate for AVF maturation.


Asunto(s)
Angioplastia de Balón , Fístula Arteriovenosa , Derivación Arteriovenosa Quirúrgica , Adulto , Anciano , Procedimientos Quirúrgicos Ambulatorios , Angioplastia , Fístula Arteriovenosa/diagnóstico por imagen , Fístula Arteriovenosa/terapia , Femenino , Oclusión de Injerto Vascular , Humanos , Masculino , Persona de Mediana Edad , Diálisis Renal , Estudios Retrospectivos , Resultado del Tratamiento , Ultrasonografía Intervencional , Grado de Desobstrucción Vascular
7.
J Perioper Pract ; 31(3): 62-70, 2021 03.
Artículo en Inglés | MEDLINE | ID: mdl-33544661

RESUMEN

BACKGROUND: The UK practice of laparoscopic cholecystectomy has reduced during the COVID-19 pandemic due to cancellation of non-urgent operations. Isolated day-case units have been recommended as 'COVID-cold' operating sites to resume surgical procedures. This study aims to identify patients suitable for day case laparoscopic cholecystectomy (DCLC) at isolated units by investigating patient factors and unexpected admission. METHOD: Retrospective analysis of 327 patients undergoing DCLC between January and December 2018 at Ysbyty Gwynedd (District General Hospital; YG) and Llandudno General Hospital (isolated unit; LLGH), North Wales, UK. RESULTS: The results showed that 100% of DCLCs in LLGH were successful; 71.4% of elective DCLCs were successful at YG. Increasing age (p = 0.004), BMI (p = 0.01), ASA Score (p = 0.006), previous ERCP (p = 0.05), imaging suggesting cholecystitis (p = 0.003) and thick-walled gallbladder (p = 0.04) were significantly associated with failed DCLC on univariate analysis. Factors retaining significance (OR, 95% CI) after multiple regression include BMI (1.82, 1.05-3.16; p = 0.034), imaging suggesting cholecystitis (4.42, 1.72-11.38; p = 0.002) and previous ERCP (5.25, 1.53-18.00; p = 0.008). Postoperative complications are comparable in BMI <35kg/m2 and 35-39.9kg/m2. CONCLUSIONS: Current patient selection for isolated day unit is effective in ensuring safe discharge and could be further developed with greater consideration for patients with BMI 35-39.9kg/m2. As surgical services return, this helps identify patients suitable for laparoscopic cholecystectomy at isolated COVID-free day units.


Asunto(s)
Procedimientos Quirúrgicos Ambulatorios/estadística & datos numéricos , Colecistectomía Laparoscópica/estadística & datos numéricos , Adulto , Colecistitis/cirugía , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Femenino , Vesícula Biliar/cirugía , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Gales
9.
Ulus Travma Acil Cerrahi Derg ; 27(1): 34-42, 2021 01.
Artículo en Inglés | MEDLINE | ID: mdl-33394479

RESUMEN

BACKGROUND: Acute cholecystitis (AC), a common complication of gallstones, is responsible for a significant part of emergency applications, and cholecystectomy is the only definitive treatment method for AC. Early cholecystectomy has many reported advantages. Operation-related morbidity and mortality have increased during the COVID-19 pandemic. In this study, our aim is to present our general clinical approach to patients who were diagnosed with AC during the pandemic and our percutaneous cholecystostomy experience during this period. METHODS: This study included 72 patients who were presented to our hospital's emergency room between March 11 and May 31, 2020, with AC. Patients were divided into three groups based on their treatment: outpatients (Group 1), inpatients (Group 2) and patients undergoing percutaneous cholecystostomy (Group 3). These three groups were compared by their demographic and clinical characteristics. RESULTS: There were 36 (50%) patients in Group 1, 25 (34.7%) patients in Group 2, and 11 (15.3%) patients in Group 3. The demographic characteristics of the patients were similar. The CRP and WBC levels of the patients in Group 3 were significantly higher compared to the other groups. Moreover, the wall of the gallbladder was thicker and the size of the gallbladder was larger in Group 3. Patients had percutaneous cholecystostomy at the median of 3.5 days and the length of hospital stay was longer compared to Group 2 (3.9 days versus 9.2 days, p=0.00). The rate of re-hospitalization after discharge was similar in Group 2 and Group 3, but none of the patients in Group 1 required hospitalization. None of 72 patients developed an emergency condition requiring surgery, and there was no death. CONCLUSION: Although many publications emphasize that laparoscopic cholecystectomy (LC) can be performed with low morbidity at the first admission in acute cholecystitis, it is a clinical condition that can be delayed in the COVID-19 pandemic and other similar emergencies. Thus, percutaneous cholecystostomy should be effectively employed, and its indications should be extended if necessary (e.g., younger patients, patients with lower CCI or ASA). This approach may enable us to protect both patients and healthcare professionals that perform the operation from the risk of COVID-19.


Asunto(s)
Procedimientos Quirúrgicos Ambulatorios/estadística & datos numéricos , Colecistectomía , Colecistitis Aguda , Hospitalización/estadística & datos numéricos , Colecistectomía/métodos , Colecistectomía/estadística & datos numéricos , Colecistitis Aguda/epidemiología , Colecistitis Aguda/cirugía , Servicio de Urgencia en Hospital , Humanos , Pandemias
11.
Medicine (Baltimore) ; 100(1): e23995, 2021 Jan 08.
Artículo en Inglés | MEDLINE | ID: mdl-33429761

RESUMEN

ABSTRACT: The Chinese government is attaching great importance to the development of ambulatory surgery in order to optimize the healthcare system in China. The study aims to examine the complications and quality indicators of patients who underwent gynecological ambulatory surgery at a tertiary hospital in China.This was a retrospective study of patients who underwent ambulatory surgery between July and September 2019 at the Department of Gynecology of the First Affiliated Hospital of Shandong First Medical University. The patients were followed by phone at 30 days after discharge. The postoperative complications, mortality, unplanned re-operation, delayed discharge, unplanned re-hospitalization, and patient satisfaction were collected. The patients who underwent conventional hysteroscopic resection of uterine lesions during the same period were collected as controls for the economics analysis.A total of 392 patients who underwent ambulatory gynecological surgery were included. Fifteen patients had postoperative complications, and the total complication rate was 3.8% (15/392). Eight (8/392, 2.0%) patients had delayed discharge. There were no unplanned re-operations and deaths. There were two (2/392, 0.5%) cases of unplanned re-hospitalization. At 30 days after discharge, two patients were dissatisfied, and 390 cases were satisfied, for an overall satisfaction rate of 99.5%. Compared with conventional hysteroscopic resection of uterine lesions, ambulatory hysteroscopic surgery had a shorter hospital stay and lower total costs (P < .05) but similar surgery-related costs.Ambulatory gynecological surgery is feasible in China, with an acceptable complication profile and obvious economic and social benefits. Nevertheless, hospital management shall be reinforced.


Asunto(s)
Procedimientos Quirúrgicos Ginecológicos/métodos , Adulto , Procedimientos Quirúrgicos Ambulatorios/métodos , Procedimientos Quirúrgicos Ambulatorios/normas , Procedimientos Quirúrgicos Ambulatorios/tendencias , China/epidemiología , Estudios de Factibilidad , Femenino , Procedimientos Quirúrgicos Ginecológicos/normas , Procedimientos Quirúrgicos Ginecológicos/tendencias , Humanos , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Desarrollo de Programa/métodos , Estudios Retrospectivos
12.
Spine (Phila Pa 1976) ; 46(3): 184-190, 2021 Feb 01.
Artículo en Inglés | MEDLINE | ID: mdl-33399438

RESUMEN

STUDY DESIGN: Retrospective review. OBJECTIVE: The aim of this study was to examine the association between preoperative depression and patient satisfaction in the outpatient spine clinic after lumbar surgery. SUMMARY OF BACKGROUND DATA: The Clinician and Group Assessment of Healthcare Providers and Systems (CG-CAHPS) survey is used to measure patient experience in the outpatient setting. CG-CAHPS scores may be used by health systems in physician incentive programs and quality improvement initiatives or by prospective patients when selecting spine surgeons. Although preoperative depression has been shown to predict poor patient-reported outcomes and less satisfaction with the inpatient experience following lumbar surgery, its impact on patient experience with spine surgeons in the outpatient setting remains unclear. METHODS: Patients who underwent lumbar surgery and completed the CG-CAHPS survey at postoperative follow-up with their spine surgeon between 2009 and 2017 were included. Data were collected on patient demographics, Patient Health Questionnaire 9 (PHQ-9) scores, and Patient-Reported Outcome Measurement Information System Global Health Physical Health (PROMIS-GPH) subscores. Patients with preoperative PHQ-9 scores ≥10 (moderate-to-severe depression) were included in the depressed cohort. The association between preoperative depression and top-box satisfaction ratings on several dimensions of the CG-CAHPS survey was examined. RESULTS: Of the 419 patients included in this study, 72 met criteria for preoperative depression. Depressed patients were less likely to provide top-box satisfaction ratings on CG-CAHPS metrics pertaining to physician communication and overall provider rating (OPR). Even after controlling for patient-level covariates, our multivariate analysis revealed that depressed patients had lower odds of reporting top-box OPR (odds ratio [OR]: 0.19, 95% confidence interval [CI]: 0.06-0.63, P = 0.007), feeling that their spine surgeon provided understandable explanations (OR: 0.32, 95% CI: 0.11-0.91, P = 0.032), and feeling that their spine surgeon provided understandable responses to their questions or concerns (OR: 0.19, 95% CI: 0.06-0.63, P = 0.007). CONCLUSION: Preoperative depression is independently associated with lower OPR and satisfaction with spine surgeon communication in the outpatient setting after lumbar surgery.Level of Evidence: 3.


Asunto(s)
Procedimientos Quirúrgicos Ambulatorios/psicología , Depresión/psicología , Vértebras Lumbares/cirugía , Medición de Resultados Informados por el Paciente , Satisfacción del Paciente , Cuidados Preoperatorios/psicología , Anciano , Procedimientos Quirúrgicos Ambulatorios/tendencias , Depresión/complicaciones , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios/psicología , Cuidados Posoperatorios/tendencias , Cuidados Preoperatorios/tendencias , Estudios Prospectivos , Estudios Retrospectivos , Cirujanos/psicología , Cirujanos/tendencias , Encuestas y Cuestionarios
13.
JMIR Mhealth Uhealth ; 9(1): e22846, 2021 01 26.
Artículo en Inglés | MEDLINE | ID: mdl-33496677

RESUMEN

BACKGROUND: Physical activity trackers such as the Fitbit can allow clinicians to monitor the recovery of their patients following surgery. An important issue when analyzing activity tracker data is to determine patients' daily compliance with wearing their assigned device, using an appropriate criterion to determine a valid day of wear. However, it is currently unclear as to how different criteria can affect the reported compliance of patients recovering from ambulatory surgery. Investigating this issue can help to inform the use of activity data by revealing factors that may impact compliance calculations. OBJECTIVE: This study aimed to understand how using different criteria can affect the reported compliance with activity tracking in ambulatory surgery patients. It also aimed to investigate factors that explain variation between the outcomes of different compliance criteria. METHODS: A total of 62 patients who were scheduled to undergo total knee arthroplasty (TKA, ie, knee replacement) volunteered to wear a commercial Fitbit Zip activity tracker over an 8-week perioperative period. Patients were asked to wear the Fitbit Zip daily, beginning 2 weeks prior to their surgery and ending 6 weeks after surgery. Of the 62 patients who enrolled in the study, 20 provided Fitbit data and underwent successful surgery. The Fitbit data were analyzed using 5 different daily compliance criteria, which consider patients as compliant with daily tracking if they either register >0 steps in a day, register >500 steps in a day, register at least one step in 10 different hours of the day, register >0 steps in 3 distinct time windows, or register >0 steps in 3 out of 4 six-hour time windows. The criteria were compared in terms of compliance outcomes produced for each patient. Data were explored using heatmaps and line graphs. Linear mixed models were used to identify factors that lead to variation between compliance outcomes across the sample. RESULTS: The 5 compliance criteria produce different outcomes when applied to the patients' data, with an average 24% difference in reported compliance between the most lenient and strictest criteria. However, the extent to which each patient's reported compliance was impacted by different criteria was not uniform. Some individuals were relatively unaffected, whereas others varied by up to 72%. Wearing the activity tracker as a clip-on device, rather than on the wrist, was associated with greater differences between compliance outcomes at the individual level (P=.004, r=.616). This effect was statistically significant (P<.001) in the first 2 weeks after surgery. There was also a small but significant main effect of age on compliance in the first 2 weeks after surgery (P=.040). Gender and BMI were not associated with differences in individual compliance outcomes. Finally, the analysis revealed that surgery has an impact on patients' compliance, with noticeable reductions in activity following surgery. These reductions affect compliance calculations by discarding greater amounts of data under strict criteria. CONCLUSIONS: This study suggests that different compliance criteria cannot be used interchangeably to analyze activity data provided by TKA patients. Surgery leads to a temporary reduction in patients' mobility, which affects their reported compliance when strict thresholds are used. Reductions in mobility suggest that the use of lenient compliance criteria, such as >0 steps or windowed approaches, can avoid unnecessary data exclusion over the perioperative period. Encouraging patients to wear the device at their wrist may improve data quality by increasing the likelihood of patients wearing their tracker and ensuring that activity is registered in the 2 weeks after surgery. TRIAL REGISTRATION: ClinicalTrials.gov NCT03518866; https://clinicaltrials.gov/ct2/show/NCT03518866.


Asunto(s)
Artroplastia de Reemplazo de Rodilla , Ejercicio Físico , Monitores de Ejercicio , Cooperación del Paciente/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Ambulatorios , Femenino , Humanos , Masculino , Persona de Mediana Edad , Recuperación de la Función
14.
Br J Anaesth ; 126(4): 862-871, 2021 04.
Artículo en Inglés | MEDLINE | ID: mdl-33390261

RESUMEN

BACKGROUND: Rebound pain is a common, yet under-recognised acute increase in pain severity after a peripheral nerve block (PNB) has receded, typically manifesting within 24 h after the block was performed. This retrospective cohort study investigated the incidence and factors associated with rebound pain in patients who received a PNB for ambulatory surgery. METHODS: Ambulatory surgery patients who received a preoperative PNB between March 2017 and February 2019 were included. Rebound pain was defined as the transition from well-controlled pain (numerical rating scale [NRS] ≤3) while the block is working to severe pain (NRS ≥7) within 24 h of block performance. Patient, surgical, and anaesthetic factors were analysed for association with rebound pain by univariate, multivariable, and machine learning methods. RESULTS: Four hundred and eighty-two (49.6%) of 972 included patients experienced rebound pain as per the definition. Multivariable analysis showed that the factors independently associated with rebound pain were younger age (odds ratio [OR] 0.98; 95% confidence interval [CI] 0.97-0.99), female gender (OR 1.52 [1.15-2.02]), surgery involving bone (OR 1.82 [1.38-2.40]), and absence of perioperative i.v. dexamethasone (OR 1.78 [1.12-2.83]). Despite a high incidence of rebound pain, there were high rates of patient satisfaction (83.2%) and return to daily activities (96.5%). CONCLUSIONS: Rebound pain occurred in half of the patients and showed independent associations with age, female gender, bone surgery, and absence of intraoperative use of i.v. dexamethasone. Until further research is available, clinicians should continue to use preventative strategies, especially for patients at higher risk of experiencing rebound pain.


Asunto(s)
Procedimientos Quirúrgicos Ambulatorios/efectos adversos , Bloqueo Nervioso Autónomo/métodos , Dimensión del Dolor/métodos , Dolor Postoperatorio/prevención & control , Nervios Periféricos/fisiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Ambulatorios/tendencias , Bloqueo Nervioso Autónomo/tendencias , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Dimensión del Dolor/tendencias , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/etiología , Nervios Periféricos/efectos de los fármacos , Estudios Retrospectivos , Adulto Joven
15.
Am J Sports Med ; 49(2): 505-511, 2021 02.
Artículo en Inglés | MEDLINE | ID: mdl-33332176

RESUMEN

BACKGROUND: Ambulatory surgeries have increased in recent decades to help improve efficiency and cost; however, there is a potential need for unplanned postoperative admission, clinic visits, or evaluation in the emergency department (ED). PURPOSE/HYPOTHESIS: The purpose was to determine the frequency, reasons, and factors influencing hospitalizations, return to clinic, and/or ED encounters within 24 hours of ambulatory surgery. The time frame for data collection was the first 2 years of operation of a university sports medicine ambulatory surgery center (ASC). We hypothesized that the percentage of encounters would be low and primarily because of pain or postoperative complication. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A retrospective review was performed of all patients undergoing ambulatory surgery at an ASC during the first 2 years of its operation (November 2016 to October 2018). Data including age, sex, Current Procedural Terminology code, procedure performed, American Society of Anesthesiologists classification, body mass index, medical history, and tobacco use were collected. Patients seeking care in the ED, inpatient, or outpatient setting within the first 24 hours after surgery were identified and the reasons for these encounters were categorized into 1 of 3 groups: (1) medical complication, (2) postoperative pain, or (3) other postoperative complication. Logistic regression models were used to assess risk factors for these encounters. RESULTS: A total of 4650 sports medicine procedures were performed at the university ASC during the study period. A total of 35 patients (0.75%) sought additional care within 24 hours of surgery. Medical complications were the primary reason for seeking care (n = 16; 45.7%). Patients who sought treatment within 24 hours of surgery tended to be older, had more medical comorbidities, and were more likely to have undergone upper extremity (particularly shoulder) procedures. In the multivariable analysis, patients with higher ASA scores were more likely to seek additional care (P < .005) and there was a trend toward increased risk of seeking additional care with upper extremity surgery (P = .077). CONCLUSION: Orthopaedic procedures performed in an ASC result in a relatively low percentage of patients seeking additional care within the first 24 hours after surgery, consistent with other reports in the literature. Upper extremity procedures, particularly those of the shoulder, may carry an increased risk of requiring medical treatment within 24 hours of surgery. Even in the first 2 years of operation of a university-based ASC, low rates of postoperative complications and unplanned admissions can be maintained.


Asunto(s)
Procedimientos Quirúrgicos Ambulatorios , Servicio de Urgencia en Hospital/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Procedimientos Ortopédicos , Complicaciones Posoperatorias , Procedimientos Quirúrgicos Ambulatorios/efectos adversos , Estudios de Casos y Controles , Humanos , Procedimientos Ortopédicos/efectos adversos , Estudios Retrospectivos , Universidades
16.
Int J Cardiol ; 322: 170-174, 2021 01 01.
Artículo en Inglés | MEDLINE | ID: mdl-33002522

RESUMEN

BACKGROUND: Catheter ablation for complex left-atrial arrhythmia is increasing worldwide with many centres admitting patients overnight. Same-day procedures using conscious sedation carry significant benefits to patients/healthcare providers but data are limited. We evaluated the safety and cost-effectiveness of same-day complex left-atrial arrhythmia ablation. METHOD: Multi-centre retrospective cohort study of all consecutive complex elective left-atrial ablation procedures performed between January 2011 and December 2019. Data were collected on planned same-day discharge versus overnight stay, baseline parameters, procedure details/success, ablation technology, post-operative complications, unplanned overnight admissions/outcomes at 4-months and mortality up to April 2020. A cost analysis of potential savings was also performed. RESULTS: A total of 967 consecutive patients underwent complex left-ablation using radiofrequency (point-by-point ablation aided by 3D-mapping or PVAC catheter ablation with fluoroscopic screening) or cryoballoon-ablation (mean age: 60.9 ± 11.6 years, range 23-83 yrs., 572 [59%] females). The majority of patients had isolation of pulmonary veins alone (n = 846, 87%) and most using conscious-sedation alone (n = 921, 95%). Of the total cohort, 414 (43%) had planned same-day procedure with 35 (8%) admitted overnight due to major (n = 5) or minor (n = 30) complications. Overall acute procedural success-rate was 96% (n = 932). Complications in planned overnight-stay/same-day cohorts were low. At 4-month follow-up there were 62 (6.4%) readmissions (femoral haematomas, palpitation, other reasons); there were 3 deaths at mean follow-up of 42.0 ± 27.6 months, none related to the procedure. Overnight stay costs £350; the same-day ablation policy over this period would have saved £310,450. CONCLUSIONS: Same-day complex left-atrial catheter ablation using conscious sedation is safe and cost-effective with significant benefits for patients and healthcare providers. This is especially important in the current financial climate and Covid-19 pandemic.


Asunto(s)
Procedimientos Quirúrgicos Ambulatorios/economía , Arritmias Cardíacas/cirugía , Ablación por Catéter/economía , Análisis Costo-Beneficio , Adulto , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Ambulatorios/efectos adversos , Ablación por Catéter/efectos adversos , Estudios de Cohortes , Femenino , Atrios Cardíacos/cirugía , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Adulto Joven
17.
J Urol ; 205(1): 264-270, 2021 01.
Artículo en Inglés | MEDLINE | ID: mdl-32749908

RESUMEN

PURPOSE: Postoperative opioids are overprescribed in the United States. In November 2016 the State of Pennsylvania required an opioid consent for minors. Our hypothesis is that this mandate decreased postoperative opioid prescriptions in our division. MATERIALS AND METHODS: All patients who received a urological outpatient or minor emergency procedure from August 2015 to August 2019 were identified. Surgeries performed within 6 months after mandate implementation were excluded to account for the transition period. Perioperative data including case type were extracted by a clinical data warehouse from preexisting fields within the health record. The frequencies of postoperative prescriptions, delayed prescriptions and emergency department encounters were assessed. A multivariable logistic regression to identify predictors of opioid prescription at discharge was performed. RESULTS: A total of 4,349 patients were analyzed. The frequency of postsurgical opioid prescriptions decreased from 45.3% to 2.6% (p <0.001). The median morphine milligram equivalent decreased by 22.5 among children prescribed an opioid (p <0.001). Rates of an emergency department visits (3% vs 2.7%) or delayed nonopioid prescriptions (0.8% vs 1.2%) within 30 days of discharge were unchanged (p >0.05). Fewer patients received a delayed opioid prescription after mandate implementation (0.03% vs 0.5%, p <0.001). Female patients were less likely (OR 0.309, 95% CI 0.195-0.491; p <0.001) to receive opioids prior to but not after the mandate (OR 0.309, 95% CI 0.544-2.035; p=0.122). Increasing age was predictive of receiving an opioid before (OR 1.187, 95% CI 1.157-1.218; p <0.001) and after (OR 1.241, 95% CI 1.186-1.299; p <0.001) the mandate. CONCLUSIONS: A state mandated opioid consent for minors greatly reduced post-urological surgery opioid prescription rates without increasing rates of readmission or delayed prescriptions.


Asunto(s)
Analgésicos Opioides/efectos adversos , Consentimiento Informado/legislación & jurisprudencia , Manejo del Dolor/normas , Dolor Postoperatorio/tratamiento farmacológico , Pautas de la Práctica en Medicina/estadística & datos numéricos , Procedimientos Quirúrgicos Urológicos/efectos adversos , Procedimientos Quirúrgicos Ambulatorios/efectos adversos , Analgésicos Opioides/normas , Niño , Preescolar , Utilización de Medicamentos/legislación & jurisprudencia , Utilización de Medicamentos/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Tratamiento de Urgencia/efectos adversos , Tratamiento de Urgencia/métodos , Femenino , Humanos , Lactante , Consentimiento Informado/normas , Masculino , Epidemia de Opioides/prevención & control , Manejo del Dolor/métodos , Dolor Postoperatorio/etiología , Readmisión del Paciente/estadística & datos numéricos , Pennsylvania , Pautas de la Práctica en Medicina/legislación & jurisprudencia , Pautas de la Práctica en Medicina/normas , Estudios Retrospectivos , Gobierno Estatal , Procedimientos Quirúrgicos Urológicos/métodos , Urólogos/legislación & jurisprudencia , Urólogos/normas , Urólogos/estadística & datos numéricos
18.
Am J Cardiol ; 143: 21-28, 2021 03 15.
Artículo en Inglés | MEDLINE | ID: mdl-33359193

RESUMEN

Prior studies in patients with noncomplex coronary artery disease have demonstrated the safety of percutaneous coronary intervention (PCI) in the outpatient setting. We sought to examine the outcomes of outpatient PCI in patients with unprotected left main coronary artery disease (LMCAD). In the EXCEL trial, 1905 patients with LMCAD and site-assessed low or intermediate SYNTAX scores were randomized to PCI with everolimus-eluting stents versus coronary artery bypass grafting. The primary end point was major adverse cardiovascular events (MACE; the composite of death, stroke, or myocardial infarction). In this sub-analysis, outcomes at 30 days and 5 years were analyzed according to whether PCI was performed in the outpatient versus inpatient setting. Among 948 patients with LMCAD assigned to PCI, 935 patients underwent PCI as their first procedure, including 100 (10.7%) performed in the outpatient setting. Patients who underwent outpatient compared with inpatient PCI were less likely to have experienced recent myocardial infarction. Distal left main bifurcation disease involvement and SYNTAX scores were similar between the groups. Comparing outpatient to inpatient PCI, there were no significant differences in MACE at 30 days (4.0% vs 5.0% respectively, adjusted OR 0.52 95% CI 0.12 to 2.22; p = 0.38) or 5 years (20.6% vs 22.1% respectively, adjusted OR 0.72, 95% CI 0.40 to 1.29; p = 0.27). Similar results were observed in patients with distal left main bifurcation lesions. In conclusion, in the EXCEL trial, outpatient PCI of patients with LMCAD was not associated with an excess early or late hazard of MACE. These data suggest that outpatient PCI may be safely performed in select patients with LMCAD.


Asunto(s)
Procedimientos Quirúrgicos Ambulatorios/métodos , Enfermedad de la Arteria Coronaria/cirugía , Hospitalización , Intervención Coronaria Percutánea/métodos , Anciano , Angina Estable/epidemiología , Angina Inestable/epidemiología , Puente de Arteria Coronaria , Femenino , Humanos , Masculino , Persona de Mediana Edad , Mortalidad , Infarto del Miocardio/epidemiología , Infarto del Miocardio sin Elevación del ST/epidemiología , Oportunidad Relativa , Ensayos Clínicos Controlados Aleatorios como Asunto , Infarto del Miocardio con Elevación del ST/epidemiología , Accidente Cerebrovascular/epidemiología
19.
Rev. Hosp. Ital. B. Aires (2004) ; 40(4): 164-170, dic. 2020. tab
Artículo en Español | LILACS | ID: biblio-1145436

RESUMEN

Introducción: como profesionales de la salud hemos observado distintas conductas en los pacientes pediátricos, sin psicoprofilaxis, que ingresan para ser intervenidos quirúrgicamente de urgencia; pacientes que, según su edad, su entorno social, familiar y cultural, podrán manifestar dichas conductas interpretadas como estrés, de distintas maneras. Objetivo: se midió el estrés prequirúrgico de los niños que fueron intervenidos quirúrgicamente de urgencia, los sábados y domingos por Guardia, en el Hospital de Niños Sor María Ludovica en la ciudad de La Plata. Materiales y métodos: hemos realizado un estudio piloto de diseño observacional, descriptivo, de corte transversal, aplicando para la recolección de datos la escala de YALE modificada (EAPY-m). Resultados: reclutamos 16 pacientes, de los cuales 10 fueron varones (62,50%), que ingresaron para ser tratados quirúrgicamente por las especialidades de traumatología y cirugía general en partes iguales. La mediana en edad fue de 7 años y la mediana en escolarización obligatoria de 6 años. Dentro de la muestra obtenida, un 56,25% concurrían a la escuela primaria y el 25% se encontraban en la etapa preescolar. La mitad de los niños tomaron como referente a su madre como la persona que lo calma y que les gustaría que estuviese presente en el momento previo a la cirugía. La conjunción de los resultados obtenidos ha superado los valores referenciales mínimos para la medición del estrés prequirúrgico: un 80% de los niños sufría de estrés prequirúrgico. Conclusiones: el estrés prequirúrgico es un hecho presente en los pacientes pediátricos que han sido incluidos en la realización del estudio, quedando en evidencia que la cirugía es un factor estresante para los niños. (AU)


Introduction: As health professionals, we have observed different behaviors in pediatric patients, without psychoprophylaxis, who are admitted for emergency surgery; patients who, according to their age, their social, family and cultural environment may manifest such behaviors interpreted as stress, in different ways. Objective: Therefore, the general objective of our research was to measure the presurgical stress of children who would undergo emergency surgery, on Saturdays and Sundays by guard, at the Sor María Ludovica children's hospital in the city of La Plata. Materials and methods: We have conducted a pilot study of observational, descriptive, cross-sectional design; applying the modified YALE scale (EArPY-m) for data collection. Results: We recruited 16 patients of which 10 were male (62.50%), who were admitted to be treated surgically by the specialties of traumatology and general surgery in equal parts. The median in age was 7 years and the median in compulsory schooling was 6 years. Within the sample obtained 56.25% attended primary school and 25% were in the preschool stage. 50% of the participants indicated that the mother was the one who calms them when they are nervous; while 43.75% was the mother who would like to be present at the time before surgery. The combination of the results obtained has exceeded the minimum reference values for the measurement of presurgical stress, 80% of children suffered from presurgical stress. Conclusions: We conclude that presurgical stress is a fact present in pediatric patients who have been included in the study, making it clear that surgery is a stressful factor for children. (AU)


Asunto(s)
Humanos , Masculino , Femenino , Niño , Estrés Psicológico/etiología , Procedimientos Quirúrgicos Operativos/psicología , Ansiedad/diagnóstico , Ansiedad/etiología , Argentina , Estrés Psicológico/diagnóstico , Cuidados Preoperatorios/psicología , Estudios Transversales , Procedimientos Quirúrgicos Ambulatorios/psicología
20.
Curr Opin Anaesthesiol ; 33(6): 753-759, 2020 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-33027075

RESUMEN

PURPOSE OF REVIEW: Postoperative pain is frequent while, on the other hand, there is a grooving general concern on using effective opioid pain killers in view of the opioid crisis and significant incidence of opioid abuse. The present review aims at describing nonopioid measures in order to optimize and tailor perioperative pain management in ambulatory surgery. RECENT FINDINGS: Postoperative pain should be addressed both preoperatively, intraoperatively and postoperatively. The management should basically be multimodal, nonopioid and procedure-specific. Opioids should only be used when needed on top of multimodal nonopioid prophylaxis, and then limited to a few days at maximum, unless strict control is applied. The individual patient should be screened preoperatively for any risk factors for severe postoperative pain and/or any abuse potential. SUMMARY: Basic multimodal analgesia should start preoperatively or peroperatively and include paracetamol, cyclo-oxygenase (COX)-2 specific inhibitor or conventional nonsteroidal anti-inflammatory drug (NSAID) and in most cases dexamethasone and local anaesthetic wound infiltration. If any of these basic analgesics are contraindicated or there is an extra risk of severe postoperative pain, further measures may be considered: nerve-blocks or interfascial plane blocks, gabapentinnoids, clonidine, intravenous lidocaine infusion or ketamine infusion. In the abuse-prone patient, a preferably nonopioid perioperative approach should be aimed at.


Asunto(s)
Procedimientos Quirúrgicos Ambulatorios , Analgésicos Opioides/efectos adversos , Manejo del Dolor , Dolor Postoperatorio/prevención & control , Humanos , Epidemia de Opioides , Dimensión del Dolor , Dolor Postoperatorio/tratamiento farmacológico
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