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1.
Artículo en Inglés | MEDLINE | ID: mdl-33430189

RESUMEN

Targeting dementia prevention, first trials addressing multiple modifiable risk factors showed promising results in at-risk populations. In Germany, AgeWell.de is the first large-scale initiative investigating the effectiveness of a multi-component lifestyle intervention against cognitive decline. We aimed to investigate the recruitment process and baseline characteristics of the AgeWell.de participants to gain an understanding of the at-risk population and who engages in the intervention. General practitioners across five study sites recruited participants (aged 60-77 years, Cardiovascular Risk Factors, Aging, and Incidence of Dementia/CAIDE dementia risk score ≥ 9). Structured face-to-face interviews were conducted with eligible participants, including neuropsychological assessments. We analyzed group differences between (1) eligible vs. non-eligible participants, (2) participants vs. non-participants, and (3) between intervention groups. Of 1176 eligible participants, 146 (12.5%) dropped out before baseline; the study population was thus 1030 individuals. Non-participants did not differ from participants in key sociodemographic factors and dementia risk. Study participants were M = 69.0 (SD = 4.9) years old, and 52.1% were women. The average Montreal Cognitive Assessment/MoCA score was 24.5 (SD = 3.1), indicating a rather mildly cognitively impaired study population; however, 39.4% scored ≥ 26, thus being cognitively unimpaired. The bandwidth of cognitive states bears the interesting potential for differential trial outcome analyses. However, trial conduction is impacted by the COVID-19 pandemic, requiring adjustments to the study protocol with yet unclear methodological consequences.


Asunto(s)
Disfunción Cognitiva/prevención & control , Estilo de Vida , Selección de Paciente , Anciano , Femenino , Alemania , Envejecimiento Saludable , Humanos , Masculino , Persona de Mediana Edad , Pruebas Neuropsicológicas
3.
Cir. Esp. (Ed. impr.) ; 99(1): 4-10, ene. 2021. tab, ilus
Artículo en Español | IBECS | ID: ibc-192835

RESUMEN

La pandemia SARS-CoV-2 ha tenido un gran impacto en todo el mundo, siendo España uno de los países más afectados. La demora en la cirugía bariátrica puede tener consecuencias fatales, ya que hasta el 50% de los pacientes que se encuentran en lista de espera desarrollan una nueva comorbilidad durante el tiempo que permanecen en ella y el 1,5% de pacientes fallecen mientras esperan la intervención. Es por ello por lo que la cirugía bariátrica no debe demorarse en cuanto la ocupación del hospital por pacientes COVID-19+ disminuya de forma significativa y se disponga de recursos y seguridad suficiente para realizar la cirugía en pacientes con patología benigna. Este documento recoge las principales recomendaciones para los programas de cirugía bariátrica en nuestro país desde el punto de vista tanto de seguridad como de preparación y seguimiento del paciente bariátrico en el contexto de la pandemia SARS-CoV-2


The SARS-CoV-2 pandemic has a great impact worldwide, being Spain one of the most affected countries. The delay in bariatric surgery can have fatal consequences since up to 50% of the patients who are on the waiting list develop a new comorbidity during the time they remain on it and 1.5% of patients die while waiting for the intervention. That is why bariatric surgery should not be delayed, if the occupation of the hospital by COVID-19+ patients decreases significantly, and sufficient resources and safety are available to restart surgery in patients with benign pathology. This document contains the main recommendations for the bariatric surgery programs in our country from the point of view of safety, bariatric patient preparation and follow up during the SARS-CoV-2 pandemia


Asunto(s)
Humanos , Infecciones por Coronavirus/epidemiología , Neumonía Viral/epidemiología , Pandemias , Obesidad Mórbida/cirugía , Cirugía Bariátrica/normas , Prioridades en Salud/normas , Selección de Paciente , Estudios de Seguimiento , Seguridad del Paciente , Factores de Riesgo
4.
J Surg Oncol ; 123(1): 187-195, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-33002202

RESUMEN

BACKGROUND: While parenchymal hepatic metastases were previously considered a contraindication to cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC), liver resection (LR) is increasingly performed with CRS/HIPEC. METHODS: Patients from the US HIPEC Collaborative (2000-2017) with invasive appendiceal or colorectal adenocarcinoma undergoing primary, curative intent CRS/HIPEC with CC0-1 resection were included. LR was defined as a formal parenchymal resection. Primary endpoints were postoperative complications and overall survival (OS). RESULTS: A total of 658 patients were included. About 83 (15%) underwent LR of colorectal (58%) or invasive appendiceal (42%) metastases. LR patients had more complications (81% vs. 60%; p = .001), greater number of complications (2.3 vs. 1.5; p < .001) per patient and required more reoperations (22% vs. 11%; p = .007) and readmissions (39% vs. 25%; p = .014) than non-LR patients. LR patients had decreased OS (2-year OS 62% vs. 79%, p < .001), even when accounting for peritoneal carcinomatosis index and histology type. Preoperative factors associated with decreased OS on multivariable analysis in LR patients included age < 60 years (HR, 3.61; 95% CI, 1.10-11.81), colorectal histology (HR, 3.84; 95% CI, 1.69-12.65), and multiple liver tumors (HR, 3.45; 95% CI, 1.21-9.85) (all p < .05). When assigning one point for each factor, there was an incremental decrease in 2-year survival as the risk score increased from 0 to 3 (0: 100%; 1: 91%; 2: 58%; 3: 0%). CONCLUSIONS: As CRS/HIPEC + LR has become more common, we created a simple risk score to stratify patients considered for CRS/HIPEC + LR. These data aid in striking the balance between an increased perioperative complication profile with the potential for improvement in OS.


Asunto(s)
Neoplasias del Apéndice/terapia , Neoplasias Colorrectales/terapia , Procedimientos Quirúrgicos de Citorreducción/mortalidad , Hepatectomía/mortalidad , Hipertermia Inducida/mortalidad , Selección de Paciente , Neoplasias Peritoneales/terapia , Neoplasias del Apéndice/patología , Quimioterapia del Cáncer por Perfusión Regional/mortalidad , Neoplasias Colorrectales/patología , Terapia Combinada , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Neoplasias Peritoneales/secundario , Cuidados Preoperatorios , Pronóstico , Factores de Riesgo , Tasa de Supervivencia
5.
Neurology ; 96(1): e10-e18, 2021 01 05.
Artículo en Inglés | MEDLINE | ID: mdl-33046612

RESUMEN

OBJECTIVE: To determine whether the ABC/2 method could accurately and reliably measure infarct volume and guide thrombectomy decision in acute stroke cases presenting with late or unknown onset. METHODS: Four physicians who routinely use MRI for acute stroke imaging, blinded to the RAPID results, measured the diffusion-weighted imaging (DWI) infarct volume using the ABC/2 method. Measurements with ABC/2 (the index test) were compared with RAPID (the reference standard) to calculate sensitivity, specificity, and accuracy measures for various volume cutpoints. Thrombectomy decisions based on RAPID and raters' measurements using the criteria from the Diffusion-Weighted Imaging or Computerized Tomography Perfusion Assessment With Clinical Mismatch in the Triage of Wake-Up and Late-Presenting Strokes Undergoing Neurointervention With Trevo (DAWN) trial criteria were compared. Interrater and intrarater agreement was measured using kappa statistics. RESULTS: Accuracy with the ABC/2 method was greater than 80% for each rater and each volume cut point. Interrater and intrarater agreement was substantial to excellent for each volume cut point. Treatment decisions with ABC/2 volume estimations showed strong interrater and intrarater agreement, and led to similar thrombectomy decisions compared with RAPID in more than 85% of cases. CONCLUSION: DWI infarct volume measurement using ABC/2 method shows strong accuracy and reliability and may be an acceptable alternative to RAPID software for the application of DAWN criteria for thrombectomy decision-making.


Asunto(s)
Imagen de Difusión por Resonancia Magnética/métodos , Neuroimagen/métodos , Selección de Paciente , Accidente Cerebrovascular/diagnóstico por imagen , Trombectomía , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Interpretación de Imagen Asistida por Computador/métodos , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Accidente Cerebrovascular/cirugía , Tiempo de Tratamiento
6.
Vasc Endovascular Surg ; 55(1): 18-25, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-32909908

RESUMEN

OBJECTIVES: We sought to develop a prediction score with data from the Vascular Quality Initiative (VQI) EVAR in efforts to assist endovascular specialists in deciding whether or not a patient is appropriate for short-stay discharge. BACKGROUND: Small series describe short-stay discharge following elective EVAR. Our study aims to quantify characteristics associated with this decision. METHODS: The VQI EVAR and NSQIP datasets were queried. Patients who underwent elective EVAR recorded in VQI, between 1/2010-5/2017 were split 2:1 into test and analytic cohorts via random number assignment. Cross-reference with the Medicare claims database confirmed all-cause mortality data. Bootstrap sampling was employed in model. Deep learning algorithms independently evaluated each dataset as a sensitivity test. RESULTS: Univariate outcomes, including 30-day survival, were statistically worse in the DD group when compared to the SD group (all P < 0.05). A prediction score, SD-EVAR, derived from the VQI EVAR dataset including pre- and intra-op variables that discriminate between SD and DD was externally validated in NSQIP (Pearson correlation coefficient = 0.79, P < 0.001); deep learning analysis concurred. This score suggests 66% of EVAR patients may be appropriate for short-stay discharge. A free smart phone app calculating short-stay discharge potential is available through QxMD Calculate https://qxcalc.app.link/vqidis. CONCLUSIONS: Selecting patients for short-stay discharge after EVAR is possible without increasing harm. The majority of infrarenal AAA patients treated with EVAR in the United States fit a risk profile consistent with short-stay discharge, representing a significant cost-savings potential to the healthcare system.


Asunto(s)
Aneurisma de la Aorta/cirugía , Toma de Decisiones Clínicas , Técnicas de Apoyo para la Decisión , Aprendizaje Profundo , Procedimientos Endovasculares , Recuperación Mejorada Después de la Cirugía , Tiempo de Internación , Alta del Paciente , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta/diagnóstico , Aneurisma de la Aorta/mortalidad , Bases de Datos Factuales , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Investigación sobre Servicios de Salud , Humanos , Masculino , Aplicaciones Móviles , Análisis Multivariante , Selección de Paciente , Medición de Riesgo , Factores de Riesgo , Teléfono Inteligente , Factores de Tiempo , Resultado del Tratamiento
7.
Transplantation ; 105(1): 61-66, 2021 01 01.
Artículo en Inglés | MEDLINE | ID: mdl-33208691

RESUMEN

Coronavirus disease 2019 (COVID-19) outbreak has significantly upended solid organ transplant (SOT) practice around the world. Early reports confirmed the heavy burden of COVID-19 in SOT recipients with mortality rates reaching up to 35%. Because most transplant recipients harbored multiple comorbidities known to be associated with a severe course of COVID-19, the true impact of immunosuppression by itself remained an unsolved issue. Transplant societies have initially recommended to postpone nonurgent renal transplantations, while trying to maintain life-saving transplant programs, such as heart, lung, and liver transplantations. The pandemic thus resulted in an unprecedented and sudden drop of transplant activity worldwide. Moreover, the best treatment strategy in infected patients was challenging. Both reduction of immunosuppression and use of targeted therapies aiming at counteracting severe acute respiratory syndrome coronavirus 2 infection were the 2 faces of the therapeutic armamentarium. Recent controlled studies have better delineated the basis of mitigating and management strategies to improve patients' outcome. Nevertheless, and given the persistence of circulating virus, evidence-based recommendations in SOT recipients remain unclear. The resumption of transplant activity should be tailored with careful selection of both donors and recipients. Transplant decision should be made on a case-by-case basis after thorough assessment of the risks and benefits.


Asunto(s)
/epidemiología , Trasplante de Órganos , /mortalidad , Francia/epidemiología , Humanos , Tolerancia Inmunológica , Interleucina-6/antagonistas & inhibidores , Trasplante de Órganos/métodos , Trasplante de Órganos/estadística & datos numéricos , Selección de Paciente , Telemedicina
8.
Curr Opin Anaesthesiol ; 34(1): 1-6, 2021 Feb 01.
Artículo en Inglés | MEDLINE | ID: mdl-33315643

RESUMEN

PURPOSE OF REVIEW: The aim of this review is to provide an overview of the rationale and evidence for nonintubated thoracic surgery and guide clinicians, considering the implementation of nonintubated thoracic surgery, to find an anesthetic approach suitable for their department. RECENT FINDINGS: Based on physiologic considerations alone, nonintubated thoracic surgery would be expected to be an advantageous concept in thoracic anesthesia, especially in patients at high risk for pulmonary complications. Currently existing evidence, however, does not support these claims. Although the feasibility and safety have been repeatedly demonstrated, high-quality evidence showing a significant benefit regarding clinically relevant patient-centered outcomes is not available.Anesthetic approaches to nonintubated thoracic surgery differ significantly; however, they usually concentrate on six main aspects: maintenance of airway patency, respiratory support, analgesia, patient comfort, cough suppression, and conversion techniques. Given the lack of high-quality studies comparing different techniques, evidence-based guidance of clinical decision-making is currently not possible. Until further evidence is available, anesthetic management will depend mostly on local availability and expertise. SUMMARY: In select patients and with experienced teams, nonintubated thoracic surgery can be a suitable alternative to intubated thoracic surgery. Until more evidence is available, however, a general change in anesthetic management in thoracic surgery is not justified.


Asunto(s)
Anestesia General , Anestésicos , Guías como Asunto , Cirugía Torácica , Humanos , Evaluación de Resultado en la Atención de Salud , Selección de Paciente , Cirugía Torácica Asistida por Video
9.
J Card Surg ; 36(1): 199-202, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-33169430

RESUMEN

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has restructured the healthcare systems, prioritizing resources to treat COVID-19 patients. The aim of this study was to establish if patients affected by acute aortic syndrome (AAS) had unrestricted access to emergency treatment and evaluate outcome of these patients during the peak of the pandemic. METHODS: This is a retrospective analysis of prospectively collected data between March and June 2020 from 19 participating cardiac surgery centers in the United Kingdom. RESULTS: Among 95 patients who presented with an AAS in the participating centers; 85 (89%) underwent surgery, 7 (7%) were turned down for surgery because of their profile of comorbidities, and 3 (3%) died on transfer. Among the patients treated conservatively, three of them (43%) were alive at 30 days. We observed no significant restriction in access to treatment for AAS during the early months of the pandemic. CONCLUSION: Services for life-threatening aortic surgery patients were maintained during the COVID-19 period through patient selection and timing of surgery. The rate of surgical turn-down was comparable to published figures despite the challenges faced during the COVID-19 pandemic.


Asunto(s)
Enfermedades de la Aorta/etiología , Pandemias , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Enfermedades de la Aorta/epidemiología , Femenino , Humanos , Incidencia , Masculino , Selección de Paciente , Estudios Retrospectivos , Síndrome , Reino Unido/epidemiología
10.
Ear Nose Throat J ; 100(1): 19-25, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-32894699

RESUMEN

INTRODUCTION: During the COVID-19 pandemic, worldwide over 600,000 human beings died due to the cause of the disease. In order to deescalate the transmission rate and to avoid crush loading the countries medical health systems social distancing, face masks, and lockdowns have been considered essential by the majority of governments. Whereas some countries have highly reduced or completely stopped otorhinolaryngological procedures, other countries have continued selected surgeries. The objective of this study was to analyze procedures and outcomes of continuing semielective and emergency surgeries during the COVID-19 pandemic. METHODS: Retrospective analysis of n = 750 patients who received semi-elective or emergency surgery between March 26 and June 16, 2020, in the Otolaryngology Department of the Friedrich-Alexander-University of Erlangen-Nürnberg. All patients were screened for COVID symptoms and swabbed for SARS-CoV-2 prior to surgery. RESULTS: Of the n = 750 patients, n = 699 patients received semielective surgery and n = 51 emergency surgery. For 27 patients, the swab result could not be awaited due to a life-threatening condition. In these cases, surgery was performed in full protective equipment. No patient was tested positive during or after the surgery (follow-up 45 to 127 days). No member of the medical personnel showed symptoms or was tested positive after contact with patients. Due to the continuation of surgeries, patients' lives were saved and improvement of long-term quality-of-life and outcomes is anticipated. CONCLUSIONS: Continuing selected otorhinolaryngological surgeries is crucial for patients' health, survival, and long-time quality of life, yet, the protection of the medical personnel has to be granted.


Asunto(s)
/prevención & control , Control de Infecciones/organización & administración , Transmisión de Enfermedad Infecciosa de Paciente a Profesional/prevención & control , Procedimientos Quirúrgicos Otorrinolaringológicos , Selección de Paciente , Adulto , Anciano , /transmisión , Procedimientos Quirúrgicos Electivos , Femenino , Alemania , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos
12.
Oncologist ; 26(1): e66-e77, 2021 01.
Artículo en Inglés | MEDLINE | ID: mdl-33044007

RESUMEN

INTRODUCTION: The rapid spread of COVID-19 across the globe is forcing surgical oncologists to change their daily practice. We sought to evaluate how breast surgeons are adapting their surgical activity to limit viral spread and spare hospital resources. METHODS: A panel of 12 breast surgeons from the most affected regions of the world convened a virtual meeting on April 7, 2020, to discuss the changes in their local surgical practice during the COVID-19 pandemic. Similarly, a Web-based poll based was created to evaluate changes in surgical practice among breast surgeons from several countries. RESULTS: The virtual meeting showed that distinct countries and regions were experiencing different phases of the pandemic. Surgical priority was given to patients with aggressive disease not candidate for primary systemic therapy, those with progressive disease under neoadjuvant systemic therapy, and patients who have finished neoadjuvant therapy. One hundred breast surgeons filled out the poll. The trend showed reductions in operating room schedules, indications for surgery, and consultations, with an increasingly restrictive approach to elective surgery with worsening of the pandemic. CONCLUSION: The COVID-19 emergency should not compromise treatment of a potentially lethal disease such as breast cancer. Our results reveal that physicians are instinctively reluctant to abandon conventional standards of care when possible. However, as the situation deteriorates, alternative strategies of de-escalation are being adopted. IMPLICATIONS FOR PRACTICE: This study aimed to characterize how the COVID-19 pandemic is affecting breast cancer surgery and which strategies are being adopted to cope with the situation.


Asunto(s)
Neoplasias de la Mama/terapia , Mastectomía/tendencias , Pandemias/prevención & control , Pautas de la Práctica en Medicina/tendencias , Citas y Horarios , Neoplasias de la Mama/patología , /transmisión , Control de Enfermedades Transmisibles/organización & administración , Control de Enfermedades Transmisibles/normas , Progresión de la Enfermedad , Procedimientos Quirúrgicos Electivos/normas , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Procedimientos Quirúrgicos Electivos/tendencias , Femenino , Carga Global de Enfermedades , Asignación de Recursos para la Atención de Salud/normas , Asignación de Recursos para la Atención de Salud/estadística & datos numéricos , Asignación de Recursos para la Atención de Salud/tendencias , Humanos , Mastectomía/economía , Mastectomía/normas , Mastectomía/estadística & datos numéricos , Terapia Neoadyuvante/estadística & datos numéricos , Quirófanos/economía , Quirófanos/estadística & datos numéricos , Quirófanos/tendencias , Selección de Paciente , Admisión y Programación de Personal/economía , Admisión y Programación de Personal/estadística & datos numéricos , Admisión y Programación de Personal/tendencias , Pautas de la Práctica en Medicina/economía , Pautas de la Práctica en Medicina/organización & administración , Pautas de la Práctica en Medicina/estadística & datos numéricos , Derivación y Consulta/estadística & datos numéricos , Derivación y Consulta/tendencias , Cirujanos/estadística & datos numéricos , Encuestas y Cuestionarios/estadística & datos numéricos , Tiempo de Tratamiento
13.
Ann Vasc Surg ; 70: 481-490, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-32603844

RESUMEN

BACKGROUND: First-generation "off-the-shelf" branched endovascular stent grafts are in development for treatment of thoracoabdominal aortic aneurysms (TAAAs). Prior studies have assessed eligibility rates among highly selected cohorts of patients referred for endovascular treatment, and the broader applicability of these devices to all patients with TAAA is unknown. The aims of this study were to assess the overall suitability of the 3 commercial 4-branched devices with or without adjunct procedure(s) in an unselected cohort of patients with TAAA and to identify areas for improvement in the next generation of devices. METHODS: A retrospective review of three-dimensional centerline reconstructions of contrast-enhanced computed tomography (CT) imaging was performed in consecutive patients with TAAA seen between 2013 and 2017. All patients with contrast-enhanced CT imaging were included, regardless of prior evaluation for suitability for endovascular repair. Eligibility for a device was assessed based on instructions for use (IFU) from the device manufacturer along with prespecified anatomic criteria. Adjunct procedures were defined as carotid-subclavian revascularization, target vessel endovascular intervention, and iliac conduit/revascularization. RESULTS: Of 165 patients with TAAA, 122 had CT scans adequate for study inclusion. Eighteen patients (14.8%) were eligible for at least 1 device by IFU, and 41 (33.6%) could have been made eligible for at least 1 device by an adjunct procedure. Sixty-three (51.6%) were not eligible for any device within IFU even with adjunct procedures, including 31 of 32 patients with TAAA due to dissection. The most common reasons for ineligibility were perivisceral flow channel diameter <20 mm (n = 43) and an inadequate proximal seal zone (n = 29). Women were significantly less likely to be eligible for an off-the-shelf device (P = 0.03) and were more likely to require an iliac procedure to become eligible (P = 0.006). Almost none of the patients with dissection could receive a device even if adjunct procedures were used. CONCLUSIONS: Over half of patients with TAAA could not be made eligible for an off-the-shelf device based on manufacturers' criteria, even with adjunct procedures. Women and patients with TAAA due to dissection had higher rates of ineligibility. These data demonstrate that custom fenestrated devices and low-profile devices are needed to expand eligibility for endovascular repair of TAAA.


Asunto(s)
Aneurisma Disecante/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aortografía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Angiografía por Tomografía Computarizada , Determinación de la Elegibilidad , Procedimientos Endovasculares/instrumentación , Stents , Anciano , Anciano de 80 o más Años , Aneurisma Disecante/cirugía , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/efectos adversos , Toma de Decisiones Clínicas , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Selección de Paciente , Valor Predictivo de las Pruebas , Diseño de Prótesis , Estudios Retrospectivos
14.
Ann Vasc Surg ; 70: 190-196, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-32736022

RESUMEN

BACKGROUND: Local market competition has been previously associated with more aggressive surgical decision-making. For example, more local competition for organs is associated with acceptance of lower quality kidney offers in transplant surgery. We hypothesized that market competition would be associated with the size of an abdominal aortic aneurysm (AAA) at the time of elective endovascular aneurysm repair (EVAR). METHODS: We included all elective EVARs reported in the Vascular Quality Initiative database (2012-2018). Small AAAs were defined as a maximum diameter <5.5 cm in men or <5.0 cm in women. We calculated the Herfindahl-Hirschman Index (HHI), a measure of physician market concentration (higher HHI = less market competition), for each US census region. Multilevel regression was used to examine the association between the size of AAA at EVAR and HHI, clustering by region. RESULTS: Of 37,914 EVARs performed, 15,379 (40.6%) were for small AAAs. There was significant variation in proportion of EVARs performed for small AAAs across regions (P < 0.001). The South had both the highest proportion of EVARs for small AAAs (44.2%) as well as the highest market competition (HHI 50), whereas the West had the lowest proportion of EVARs for small AAAs (35.0%) and the lowest market competition (HHI 107). Adjusting for patient characteristics, each 10 unit increase in HHI was associated with a 0.1 mm larger maximum AAA diameter at the time of EVAR (95% CI 0.04-0.24 mm, P = 0.005). CONCLUSIONS: Physician market concentration is independently associated with AAA diameter at time of elective EVAR. These data suggest that physician decision-making for EVAR is impacted by market competition.


Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/tendencias , Competencia Económica/tendencias , Procedimientos Endovasculares/tendencias , Sector de Atención de Salud/tendencias , Disparidades en Atención de Salud/tendencias , Pautas de la Práctica en Medicina/tendencias , Cirujanos/tendencias , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/economía , Aneurisma de la Aorta Abdominal/epidemiología , Implantación de Prótesis Vascular/economía , Toma de Decisiones Clínicas , Bases de Datos Factuales , Procedimientos Endovasculares/economía , Femenino , Sector de Atención de Salud/economía , Disparidades en Atención de Salud/economía , Humanos , Masculino , Selección de Paciente , Pautas de la Práctica en Medicina/economía , Cirujanos/economía , Estados Unidos/epidemiología
15.
J Intensive Care Med ; 36(1): 9-17, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-32912049

RESUMEN

Infection with the novel 2019 coronavirus (SARS-CoV-2) is associated with the development of a viral pneumonia with severe hypoxemia and respiratory failure. In many cases these patients will require mechanical ventilation; but in others the severity of disease is significantly less and may not need invasive support. High flow nasal cannula (HFNC) is a widely used modality of delivering high concentrations of oxygen and airflow to patients with hypoxemic respiratory failure, but its use in patients with SARS-CoV-2 is poorly described. Concerns with use of HFNC have arisen including aerosolization of viral particles to healthcare workers (HCW) to delaying intubation and potentially worsening of outcomes. However, use of HFNC in other coronavirus pandemics and previous experimental evidence suggest HFNC is low risk and may be effective in select patients infected with SARS-CoV-2. With the significant increase in resource utilization in care of patients with SARS-CoV-2, identification of those that may benefit from HFNC allowing allocation of ventilators to those more critically ill is of significant importance. In this manuscript, we review pertinent literature regarding the use of HFNC in the current SARS-CoV-2 pandemic and address many concerns regarding its use.


Asunto(s)
Ventilación no Invasiva/métodos , Terapia por Inhalación de Oxígeno/métodos , Insuficiencia Respiratoria , /complicaciones , Humanos , Selección de Paciente , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapia
16.
Urol Clin North Am ; 48(1): 45-50, 2021 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-33218593

RESUMEN

"The robotic approach for radical cystectomy has become increasingly adopted by the urologic oncology community, as it has been shown to have equivalent oncologic outcomes with shorter hospital stay and fewer perioperative transfusions. Consensus guidelines from expert surgeons have been published to provide guidance on all aspects of how to implement the robotic approach in the urologic oncology clinic."


Asunto(s)
Cistectomía/métodos , Procedimientos Quirúrgicos Robotizados/métodos , Neoplasias de la Vejiga Urinaria/cirugía , Vejiga Urinaria/cirugía , Cistectomía/tendencias , Humanos , Selección de Paciente , Atención Perioperativa , Procedimientos Quirúrgicos Robotizados/tendencias
17.
J Urol ; 205(1): 241-247, 2021 01.
Artículo en Inglés | MEDLINE | ID: mdl-32716742

RESUMEN

PURPOSE: Resumption of elective urology cases postponed due to the COVID-19 pandemic requires a systematic approach to case prioritization, which may be based on detailed cross-specialty questionnaires, specialty specific published expert opinion or by individual (operating) surgeon review. We evaluated whether each of these systems effectively stratifies cases and for agreement between approaches in order to inform departmental policy. MATERIALS AND METHODS: We evaluated triage of elective cases postponed within our department due to the COVID-19 pandemic (March 9, 2020 to May 22, 2020) using questionnaire based surgical prioritization (American College of Surgeons Medically Necessary, Time Sensitive Procedures [MeNTS] instrument), consensus/expert opinion based surgical prioritization (based on published urological recommendations) and individual surgeon based surgical prioritization scoring (developed and managed within our department). Lower scores represented greater urgency. MeNTS scores were compared across consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization scores. RESULTS: A total of 204 cases were evaluated. Median MeNTS score was 50 (IQR 44, 55), and mean consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization scores were 2.6±0.6 and 2.2±0.8, respectively. Median MeNTS scores were 52 (46.5, 57.5), 50 (44.5, 54.5) and 48 (43.5, 54) for individual surgeon based surgical prioritization priority 1, 2 and 3 cases (p=0.129), and 55 (51.5, 57), 47.5 (42, 56) and 49 (44, 54) for consensus/expert opinion based surgical prioritization priority scores 1, 2, and 3 (p=0.002). There was none to slight agreement between consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization scores (Kappa 0.131, p=0.002). CONCLUSIONS: Questionnaire based, expert opinion based and individual surgeon based approaches to case prioritization result in significantly different case prioritization. Questionnaire based surgical prioritization did not meaningfully stratify urological cases, and consensus/expert opinion based surgical prioritization and individual surgeon based surgical prioritization frequently disagreed. The strengths and weaknesses of each of these systems should be considered in future disaster planning scenarios.


Asunto(s)
/prevención & control , Procedimientos Quirúrgicos Electivos/normas , Enfermedades Urológicas/cirugía , Procedimientos Quirúrgicos Urológicos/normas , Urología/normas , Adulto , Anciano , /transmisión , Toma de Decisiones Clínicas , Control de Enfermedades Transmisibles/normas , Consenso , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pandemias/prevención & control , Selección de Paciente , Medición de Riesgo/métodos , Medición de Riesgo/normas , Factores de Tiempo , Triaje/normas , Estados Unidos/epidemiología , Adulto Joven
18.
Ear Nose Throat J ; 100(1): 31-37, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-32804575

RESUMEN

The indications for cochlear implantation have gradually expanded as advancements in technology have evolved, resulting in improved audiologic outcomes for both adult and children. There remains a significant underutilization of cochlear implant technology in the United States, and recognition of the potential benefits of cochlear implantation for non-traditional indications is critical for encouraging the evolution of candidacy criteria. Adult cochlear implantation candidacy has progressed from patients with bilateral profound sensorineural hearing loss (SNHL) to include patients with greater degrees of residual hearing, single-sided deafness and asymmetric hearing, and atypical etiologies of hearing loss (eg, vestibular schwannoma, Ménière's disease, and otosclerosis). Indications for pediatric cochlear implantation have similarly evolved from children with bilateral severe to profound SNHL to implanting children at a younger age, including those with residual hearing, asymmetric hearing loss, inner ear malformations, as well as cochlear nerve deficiency. In this editorial, the literature investigating cochlear implantation for nontraditional indications is reviewed with an aim to use the best available evidence to encourage the evolution of candidacy criteria.


Asunto(s)
Implantación Coclear , Pérdida Auditiva/cirugía , Selección de Paciente , Adulto , Niño , Femenino , Humanos , Masculino , Estados Unidos
20.
Mayo Clin Proc ; 95(12): 2699-2703, 2020 12.
Artículo en Inglés | MEDLINE | ID: mdl-33276841

RESUMEN

Approval by the US Food and Drug Administration (FDA) of a drug for a given indication is thought to reassure clinicians, other health care providers, and patients that substantial evidence of effectiveness exists for specific indicated populations (patients and diseases). This study examines whether FDA approval of certain antibiotics should be so reassuring for all patient populations identified in the FDA-approved labels. Specifically, this study compared patient populations covered by FDA-approved labels for 21 novel antibiotics approved between 1999 and 2018 to the patient exclusion and inclusion criteria of pivotal trials that supported those approvals. We found that every FDA-approved label for these antibiotics included at least one identifiable patient population that was explicitly excluded from enrolling in the supporting pivotal trials. Two antibiotics, bedaquiline and ceftazidime-avibactam, were approved for use in populations that were fully excluded from enrolling in registration trials.


Asunto(s)
Antibacterianos , Infecciones Bacterianas , Aprobación de Drogas , Determinación de la Elegibilidad , Selección de Paciente , Adulto , Antibacterianos/clasificación , Antibacterianos/uso terapéutico , Infecciones Bacterianas/tratamiento farmacológico , Infecciones Bacterianas/epidemiología , Toma de Decisiones Clínicas , Ensayos Clínicos como Asunto , Aprobación de Drogas/métodos , Aprobación de Drogas/estadística & datos numéricos , Determinación de la Elegibilidad/métodos , Determinación de la Elegibilidad/organización & administración , Femenino , Humanos , Masculino , Pautas de la Práctica en Medicina , Vigilancia de Productos Comercializados/normas , Estados Unidos
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