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1.
Am Surg ; 88(5): 953-958, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-35275764

RESUMO

BACKGROUND: The American Association for the Surgery of Trauma (AAST) has developed a grading system for emergency general surgery (EGS) conditions. We sought to validate the AAST EGS grades for patients undergoing urgent/emergent colorectal resection. METHODS: Patients enrolled in the "Eastern Association for the Surgery of Trauma Multicenter Colorectal Resection in EGS-to anastomose or not to anastomose" study undergoing urgent/emergent surgery for obstruction, ischemia, or diverticulitis were included. Baseline demographics, comorbidity severity as defined by Charlson comorbidity index (CCI), procedure type, and AAST grade were prospectively collected. Outcomes included length of stay (LOS) in-hospital mortality, and surgical complications (superficial/deep/organ-space surgical site infection, anastomotic leak, stoma complication, fascial dehiscence, and need for further intervention). Multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication or mortality. RESULTS: There were 367 patients, with a mean (± SD) age of 62 ± 15 years. 39% were women. The median interquartile range (IQR) CCI was 4 (2-6). Overall, the pathologies encompassed the following AAST EGS grades: I (17, 5%), II (54, 15%), III (115, 31%), IV (95, 26%), and V (86, 23%). Management included laparoscopic (24, 7%), open (319, 87%), and laparoscopy converted to laparotomy (24, 6%). Higher AAST grade was associated with laparotomy (P = .01). The median LOS was 13 days (8-22). At least 1 surgical complication occurred in 33% of patients and the mortality rate was 14%. Development of at least 1 surgical complication, need for unplanned intervention, mortality, and increased LOS were associated with increasing AAST severity grade. On multivariable analysis, factors predictive of in-hospital mortality included AAST organ grade, CCI, and preoperative vasopressor use (odds ratio (OR) 1.9, 1.6, 3.1, respectively). The American Association for the Surgery of Trauma emergency general surgery grade was also associated with the development of at least 1 surgical complication (OR 2.5), while CCI, preoperative vasopressor use, respiratory failure, and pneumoperitoneum were not. CONCLUSION: The American Association for the Surgery of Trauma emergency general surgery grading systems display construct validity for mortality and surgical complications after urgent/emergent colorectal resection. These results support incorporation of AAST EGS grades for quality benchmarking and surgical outcomes research.


Assuntos
Neoplasias Colorretais , Cirurgia Geral , Laparoscopia , Idoso , Feminino , Humanos , Tempo de Internação , Pessoa de Meia-Idade , Estudos Retrospectivos , Índice de Gravidade de Doença , Resultado do Tratamento , Estados Unidos
2.
Am J Physiol Heart Circ Physiol ; 320(5): H1786-H1801, 2021 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-33635167

RESUMO

Thoracic aortic aneurysm and dissection (TAAD) is a deadly disease characterized by intimal disruption induced by hemodynamic forces of the circulation. The effect of exercise in patients with TAAD is largely unknown. ß-Aminopropionitrile (BAPN) is an irreversible inhibitor of lysyl oxidase that induces TAAD in mice. The objective of this study was to investigate the effect of aerobic exercise on BAPN-induced TAAD. Upon weaning, mice were given either BAPN-containing water or standard drinking water and subjected to either conventional cage activity (BAPN-CONV) or forced treadmill exercise (BAPN-EX) for up to 26 wk. Mortality was 23.5% (20/85) for BAPN-CONV mice versus 0% (0/22) for BAPN-EX mice (hazard ratio 3.8; P = 0.01). BAPN induced significant elastic lamina fragmentation and intimal-medial thickening compared with BAPN-untreated controls, and aneurysms were identified in 50% (5/10) of mice that underwent contrast-enhanced CT scanning. Exercise significantly decreased BAPN-induced wall thickening, calculated circumferential wall tension, and lumen diameter, with 0% (0/5) of BAPN-EX demonstrating chronic aortic aneurysm formation on CT scan. Expression of selected genes relevant to vascular diseases was analyzed by qRT-PCR. Notably, exercise normalized BAPN-induced increases in TGF-ß pathway-related genes Cd109, Smad4, and Tgfßr1; inflammation-related genes Vcam1, Bcl2a1, Ccr2, Pparg, Il1r1, Il1r1, Itgb2, and Itgax; and vascular injury- and response-related genes Mmp3, Fn1, and Vwf. Additionally, exercise significantly increased elastin expression in BAPN-treated animals compared with controls. This study suggests that moderate aerobic exercise may be safe and effective in preventing the most devastating outcomes in TAAD.NEW & NOTEWORTHY Moderate aerobic exercise was shown to significantly reduce mortality, extracellular matrix degradation, and thoracic aortic aneurysm and dissection formation associated with lysyl oxidase inhibition in a mouse model. Gene expression suggested a reversal of TGF-ß, inflammation, and extracellular matrix remodeling pathway dysregulation, along with augmented elastogenesis with exercise.


Assuntos
Aneurisma Dissecante/terapia , Aorta Torácica/patologia , Aneurisma da Aorta Torácica/terapia , Ruptura Aórtica/prevenção & controle , Terapia por Exercício , Matriz Extracelular/patologia , Remodelação Vascular , Aminopropionitrilo , Aneurisma Dissecante/induzido quimicamente , Aneurisma Dissecante/metabolismo , Aneurisma Dissecante/patologia , Animais , Aorta Torácica/metabolismo , Aorta Torácica/fisiopatologia , Aneurisma da Aorta Torácica/induzido quimicamente , Aneurisma da Aorta Torácica/metabolismo , Aneurisma da Aorta Torácica/patologia , Ruptura Aórtica/induzido quimicamente , Ruptura Aórtica/metabolismo , Ruptura Aórtica/patologia , Dilatação Patológica , Modelos Animais de Doenças , Progressão da Doença , Matriz Extracelular/metabolismo , Proteínas da Matriz Extracelular/metabolismo , Regulação da Expressão Gênica , Hemodinâmica , Masculino , Camundongos Endogâmicos C57BL , Proteólise , Transdução de Sinais
3.
J Trauma Acute Care Surg ; 90(3): 557-564, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33507026

RESUMO

BACKGROUND: The Emergency Surgery Score (ESS) was recently validated as an accurate mortality risk calculator for emergency general surgery. We sought to prospectively evaluate whether ESS can predict the need for respiratory and/or renal support (RRS) at discharge after emergent laparotomies (EL). METHODS: This is a post hoc analysis of a 19-center prospective observational study. Between April 2018 and June 2019, all adult patients undergoing EL were enrolled. Preoperative, intraoperative, and postoperative variables were systematically collected. In this analysis, patients were excluded if they died during the index hospitalization, were discharged to hospice, or transferred to other hospitals. A composite variable, the need for RRS, was defined as the need for one or more of the following at hospital discharge: tracheostomy, ventilator dependence, or dialysis. Emergency Surgery Score was calculated for all patients, and the correlation between ESS and RRS was examined using the c-statistics method. RESULTS: From a total of 1,649 patients, 1,347 were included. Median age was 60 years, 49.4% were men, and 70.9% were White. The most common diagnoses were hollow viscus organ perforation (28.1%) and small bowel obstruction (24.5%); 87 patients (6.5%) had a need for RRS (4.7% tracheostomy, 2.7% dialysis, and 1.3% ventilator dependence). Emergency Surgery Score predicted the need for RRS in a stepwise fashion; for example, 0.7%, 26.2%, and 85.7% of patients required RRS at an ESS of 2, 12, and 16, respectively. The c-statistics for the need for RRS, the need for tracheostomy, ventilator dependence, or dialysis at discharge were 0.84, 0.82, 0.79, and 0.88, respectively. CONCLUSION: Emergency Surgery Score accurately predicts the need for RRS at discharge in EL patients and could be used for preoperative patient counseling and for quality of care benchmarking. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.


Assuntos
Serviço Hospitalar de Emergência , Hospitalização , Laparotomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Diálise Renal , Respiração Artificial , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Determinação de Necessidades de Cuidados de Saúde , Complicações Pós-Operatórias/terapia , Valor Preditivo dos Testes , Medição de Risco
4.
Ann Vasc Surg ; 70: 386-392, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32634563

RESUMO

BACKGROUND: Endovascular treatment of mesenteric lesions has become increasingly prevalent. Mesenteric bypass, however, remains the optimal treatment in the cases of chronic mesenteric ischemia (CMI) in young, medically fit patients given its durability. Endarterectomy has gone by the wayside, but in certain situations, this technique remains surgically relevant and should still be used. Herein, we present 2 cases of distal superior mesenteric artery (SMA) endarterectomy for mesenteric revascularization. METHODS/RESULTS: Case 1 is a 40-year-old male with history of antithrombin III deficiency, myocardial infarction, bilateral pulmonary embolism, acute aortic thrombus, and mesenteric ischemia status after placement of a proximal SMA stent and was transferred to our institution because of concern for ischemic bowel. Intraoperative angiography showed mid to distal SMA chronic thromboembolism with narrow lumen of recanalization and distal flow. No intervention was performed at that time. He developed worsening abdominal pain and weight loss over several months which required initiation of total parenteral nutrition, complicated by line-associated sepsis. Subsequent distal SMA endarterectomy was performed. He recovered well and had improved enteral intake at 1-month follow-up, and radiographic imaging at 2 months showed patent vessels. Case 2 is a 50-year-old female with extensive smoking history and hyperlipidemia and gastroesophageal reflux who presented with postprandial abdominal pain and a forty-pound weight loss over the past year. Attempted angiographic cannulation with a stent was not successful because of flush occlusion of the SMA approximately 1 centimeter distal to the ostium that was unable to be crossed. Computed tomography angiography confirmed that the SMA origin was free of atherosclerotic disease with a distal focal segment of occlusion. She underwent successful endarterectomy of this occlusion. The postoperative course was uneventful, and at 1-month follow-up, she reported continued improvement in pain and appetite. CONCLUSIONS: SMA endarterectomy can be successfully performed on mid to distal lesions of the SMA. This operation should remain a viable option in the management of CMI.


Assuntos
Endarterectomia , Artéria Mesentérica Superior/cirurgia , Isquemia Mesentérica/cirurgia , Oclusão Vascular Mesentérica/cirurgia , Adulto , Endarterectomia/efeitos adversos , Feminino , Humanos , Masculino , Artéria Mesentérica Superior/diagnóstico por imagem , Artéria Mesentérica Superior/fisiopatologia , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/fisiopatologia , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/fisiopatologia , Pessoa de Meia-Idade , Circulação Esplâncnica , Resultado do Tratamento , Grau de Desobstrução Vascular
5.
Am J Surg ; 221(5): 1069-1075, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-32917366

RESUMO

INTRODUCTION: We sought to evaluate whether the Emergency Surgery Score (ESS) can accurately predict outcomes in elderly patients undergoing emergent laparotomy (EL). METHODS: This is a post-hoc analysis of an EAST multicenter study. Between April 2018 and June 2019, all adult patients undergoing EL in 19 participating hospitals were prospectively enrolled, and ESS was calculated for each patient. Using the c-statistic, the correlation between ESS and mortality, morbidity, and need for ICU admission was assessed in three patient age cohorts (65-74, 75-84, ≥85 years old). RESULTS: 715 patients were included, of which 52% were 65-74, 34% were 75-84, and 14% were ≥85 years old; 51% were female, and 77% were white. ESS strongly correlated with postoperative mortality (c-statistic:0.81). Mortality gradually increased from 0% to 20%-60% at ESS of 2, 10 and 16 points, respectively. ESS predicted mortality, morbidity, and need for ICU best in patients 65-74 years old (c-statistic:0.81, 0.75, 0.83 respectively), but its performance significantly decreased in patients ≥85 years (c-statistic:0.72, 0.64, 0.67 respectively). CONCLUSION: ESS is an accurate predictor of outcome in the elderly EL patient 65-85 years old, but its performance decreases for patients ≥85. Consideration should be given to modify ESS to better predict outcomes in the very elderly patient population.


Assuntos
Tratamento de Emergência/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Tratamento de Emergência/efeitos adversos , Tratamento de Emergência/mortalidade , Feminino , Humanos , Laparotomia/efeitos adversos , Laparotomia/mortalidade , Masculino , Medição de Risco , Índice de Gravidade de Doença , Resultado do Tratamento , Estados Unidos
6.
J Trauma Acute Care Surg ; 89(6): 1023-1031, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32890337

RESUMO

OBJECTIVE: Evidence comparing stoma creation (STM) versus anastomosis after urgent or emergent colorectal resection is limited. This study examined outcomes after colorectal resection in emergency general surgery patients. METHODS: This was an Eastern Association for the Surgery of Trauma-sponsored prospective observational multicenter study of patients undergoing urgent/emergent colorectal resection. Twenty-one centers enrolled patients for 11 months. Preoperative, intraoperative, and postoperative variables were recorded. χ, Mann-Whitney U test, and multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication/mortality. RESULTS: A total of 439 patients were enrolled (ANST, 184; STM, 255). The median (interquartile range) age was 62 (53-71) years, and the median Charlson Comorbidity Index (CCI) was 4 (1-6). The most common indication for surgery was diverticulitis (28%). Stoma group was older (64 vs. 58 years, p < 0.001), had a higher CCI, and were more likely to be immunosuppressed. Preoperatively, STM patients were more likely to be intubated (57 vs. 15, p < 0.001), on vasopressors (61 vs. 13, p < 0.001), have pneumoperitoneum (131 vs. 41, p < 0.001) or fecal contamination (114 vs. 33, p < 0.001), and had a higher incidence of elevated lactate (149 vs. 67, p < 0.001). Overall mortality was 13%, which was higher in STM patients (18% vs. 8%, p = 0.02). Surgical complications were more common in STM patients (35% vs. 25%, p = 0.02). On multivariable analysis, management with an open abdomen, intraoperative blood transfusion, and larger hospital size were associated with development of a surgical complication, while CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion were independently associated with mortality. CONCLUSION: This study highlights a tendency to perform fecal diversion in patients who are acutely ill at presentation. There is a higher morbidity and mortality rate in STM patients. Independent predictors of mortality include CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion. Following adjustment by clinical factors, method of colon management was not associated with surgical complications or mortality. LEVEL OF EVIDENCE: Therapeutic study, level IV.


Assuntos
Colectomia/métodos , Cirurgia Colorretal/educação , Doença Diverticular do Colo/cirurgia , Cirurgia Geral/educação , Idoso , Anastomose Cirúrgica , Colectomia/educação , Colectomia/estatística & dados numéricos , Emergências , Feminino , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Padrões de Prática Médica/estatística & dados numéricos , Estudos Prospectivos , Resultado do Tratamento , Estados Unidos
7.
J Trauma Acute Care Surg ; 89(1): 118-124, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32176177

RESUMO

BACKGROUND: The Emergency Surgery Score (ESS) was recently developed and retrospectively validated as an accurate mortality risk calculator for emergency general surgery. We sought to prospectively validate ESS, specifically in the high-risk nontrauma emergency laparotomy (EL) patient. METHODS: This is an Eastern Association for the Surgery of Trauma multicenter prospective observational study. Between April 2018 and June 2019, 19 centers enrolled all adults (aged >18 years) undergoing EL. Preoperative, intraoperative, and postoperative variables were prospectively and systematically collected. Emergency Surgery Score was calculated for each patient and validated using c-statistic methodology by correlating it with three postoperative outcomes: (1) 30-day mortality, (2) 30-day complications (e.g., respiratory/renal failure, infection), and (3) postoperative intensive care unit (ICU) admission. RESULTS: A total of 1,649 patients were included. The mean age was 60.5 years, 50.3% were female, and 71.4% were white. The mean ESS was 6, and the most common indication for EL was hollow viscus perforation. The 30-day mortality and complication rates were 14.8% and 53.3%; 57.0% of patients required ICU admission. Emergency Surgery Score gradually and accurately predicted 30-day mortality; 3.5%, 50.0%, and 85.7% of patients with ESS of 3, 12, and 17 died after surgery, respectively, with a c-statistic of 0.84. Similarly, ESS gradually and accurately predicted complications; 21.0%, 57.1%, and 88.9% of patients with ESS of 1, 6, and 13 developed postoperative complications, with a c-statistic of 0.74. Emergency Surgery Score also accurately predicted which patients required intensive care unit admission (c-statistic, 0.80). CONCLUSION: This is the first prospective multicenter study to validate ESS as an accurate predictor of outcome in the EL patient. Emergency Surgery Score can prove useful for (1) perioperative patient and family counseling, (2) triaging patients to the intensive care unit, and (3) benchmarking the quality of emergency general surgery care. LEVEL OF EVIDENCE: Prognostic study, level III.


Assuntos
Emergências , Cirurgia Geral , Medição de Risco/métodos , Ferimentos e Lesões/cirurgia , Adulto , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Pontuação de Propensão , Estudos Prospectivos , Ferimentos e Lesões/mortalidade
8.
Ann Vasc Surg ; 65: 240-246, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-31726200

RESUMO

BACKGROUND: Surgical exposure of a high carotid bifurcation (HCB) for carotid endarterectomy (CEA) can be technically challenging due to the presence of bony structures in the most cranial portion of the neck and is associated with significant morbidity making carotid artery stenting (CAS) a common alternative. However, a high transverse neck incision with subplatysmal flaps facilitates CEA in these patients without additional exposure techniques. We present a high transverse neck incision with subplatysmal flaps as an alternative to the standard surgical exposure of the carotid bifurcation to facilitate CEA in patients with HCB. METHODS: Four patients with carotid bifurcations located cranial to the C3-4 vertebral interspace (identified on preoperative imaging) requiring intervention underwent CEA using a high transverse neck incision through an existing skin crease with subplatysmal flap elevation. CEA was performed in a standard fashion with bovine pericardial patch. RESULTS: Two male and 2 female patients with an average age of 65 years successfully underwent CEA using this incision. One patient underwent concurrent carotid body tumor excision. None of the patients required mandibulotomy or hyoid bone resection. Two patients required division of the posterior belly of the digastric muscle. There were no perioperative complications. Primary patency was 100% in the 4 patients with surveillance studies, and mean follow-up of 160 days (range 54-369 days). There were no significant cranial nerve injuries. No patient required conversion to an endovascular procedure due to inaccessibility of the lesion or subsequent interventions for incomplete endarterectomy. CONCLUSIONS: A high transverse incision with subplatysmal flaps is a safe, effective, and cosmetically preferable surgical approach in patients with HCB requiring carotid artery intervention and may be an alternative to CAS.


Assuntos
Artéria Carótida Primitiva/cirurgia , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/métodos , Pericárdio/transplante , Retalhos Cirúrgicos , Idoso , Animais , Artéria Carótida Primitiva/diagnóstico por imagem , Artéria Carótida Primitiva/fisiopatologia , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/fisiopatologia , Bovinos , Endarterectomia das Carótidas/efeitos adversos , Feminino , Xenoenxertos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Retalhos Cirúrgicos/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
9.
J Vasc Nurs ; 37(2): 78-85, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31155166

RESUMO

As the cost of care for patients with specific diagnoses becomes fixed, hospitals must develop systems to reduce length of stay and optimize the use of hospital resources while maintaining a high quality of care. The goal of this study is to evaluate the implementation and efficacy of a system designed to reduce average length of stay on a vascular surgery service. To effectively reduce the average length of stay in our center, we restructured patient rounds, implemented multidisciplinary rounds, introduced clinical pathways to postoperative care, and expanded outpatient management of postoperative patients. A total of 1697 adult vascular surgery patients discharged while under the medical direction of a vascular surgeon between July 1, 2013, and June 30, 2016, were included in the study. Improving communication with critical staff and using procedural space outside of the main operating rooms led to a 2.8-day reduction in the length of stay (10.8 vs 8.0, P < .001). There was a trend toward a reduction in the 30-day readmission rate (12% vs 10%, respectively; P = .01) and no significant difference in the case-mix index as a measure of illness severity (2.5 vs 2.4, respectively; P = .15). Length of stay reductions were heterogeneous among the types of vascular diseases studied, with greater improvements seen in patients undergoing lower extremity amputation, lower extremity angiogram, and endovascular aneurysm repair for nonruptured abdominal aortic aneurysms. Less pronounced differences were observed in patients undergoing carotid artery endarterectomy or stenting and lower extremity bypasses. In conclusion, restructuring team rounds and instituting a multidisciplinary approach to discharge planning produced significant reductions in length of stay without a deleterious effect on patient care which may impact hospital profitability.


Assuntos
Procedimentos Clínicos , Pacientes Internados/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Procedimentos Cirúrgicos Vasculares , Idoso , Feminino , Hospitais , Humanos , Tempo de Internação/economia , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente/organização & administração , Alta do Paciente , Readmissão do Paciente/economia , Readmissão do Paciente/tendências , Estudos Retrospectivos , Fatores de Risco
10.
Ann Vasc Surg ; 60: 221-228, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31077769

RESUMO

BACKGROUND: Free-floating thrombus (FFT) of the carotid artery is an uncommon condition that can present with neurologic symptoms, often in the setting of ischemic stroke. The literature pertaining to the incidence and optimal treatment of this condition is limited. Herein, we report our contemporary experience with FFT across a range of degrees of carotid stenosis. METHODS: Medical records and imaging studies from a single academic medical center from January 2016 to July 2018 were retrospectively reviewed. Patient demographics, presentation, treatment, and follow-up were abstracted. RESULTS: Six cases of FFT of the carotid artery with and without hemodynamically significant atherosclerotic disease were identified. All cases presented with ischemic stroke; one case had a hemorrhagic conversion. In each case, the FFT was visualized by at least one imaging modality including computed tomography angiography, magnetic resonance angiography, and duplex ultrasound. Three patients had >50% carotid stenosis and three had <50%. All cases were treated with endarterectomy. Four of the six patients received preoperative anticoagulation. There were no postoperative complications. Median follow-up was 252 days, with one case lost to follow-up. Four of the six patients have been without restenosis, recurrence of the thrombus, nor worsening or recurrent stroke on follow-up. The fifth patient developed restenosis but remained clinically stable. CONCLUSIONS: Although current society guidelines do not recommend carotid endarterectomy as first-line treatment for symptomatic patients with <50% stenosis, it may be indicated in the context of FFT.


Assuntos
Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas , Trombose/cirurgia , Adulto , Idoso , Anticoagulantes/administração & dosagem , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/fisiopatologia , Tomada de Decisão Clínica , Endarterectomia das Carótidas/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Trombose/diagnóstico por imagem , Trombose/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
11.
J Vis Exp ; (137)2018 07 16.
Artigo em Inglês | MEDLINE | ID: mdl-30059027

RESUMO

Aortic aneurysm and dissection is associated with significant morbidity and mortality in the population and can be highly lethal. While animal models of aortic disease exist, in vivo imaging of the vasculature has been limited. In recent years, micro-computerized tomography (micro-CT) has emerged as a preferred modality for imaging both large and small vessels both in vivo and ex vivo. In conjunction with a method of vascular casting, we have successfully used micro-CT to characterize the frequency and distribution of aortic pathology in ß-aminopropionitrile-treated C57/Bl6 mice. Technical limitations of this method include variations in the quality of the perfusion introduced by poor animal preparation, the application of proper methodologies for vessel size quantification, and the non-survivability of this procedure. This article details a methodology for the intravascular perfusion of a lead-based radiopaque silicone rubber for the quantitative characterization of aortopathy in a mouse model of aneurysm and dissection. In addition to visualizing aortic pathology, this method may be used for examining other vascular beds in vivo or vascular beds removed post-mortem.


Assuntos
Aneurisma Aórtico/induzido quimicamente , Dissecação/métodos , Microtomografia por Raio-X/métodos , Animais , Aneurisma Aórtico/terapia , Modelos Animais de Doenças , Humanos , Masculino , Camundongos
12.
Vasc Endovascular Surg ; 52(8): 641-647, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29898647

RESUMO

We describe the cases of 2 patients who had septic thrombophlebitis and were successfully managed with endovascular thrombectomy. Patient A developed septic thrombophlebitis of the inferior vena cava after several retroperitoneal resections for metastatic renal cell carcinoma. The thrombus was successfully removed via endovascular mechanical balloon thrombectomy. Patient B was a patient with pancreatic adenocarcinoma involving the portal vein who developed a septic inferior vena cava thrombus extending from the level and beyond the renal veins, for which she underwent endovascular thrombectomy. We argue that this approach is safe and feasible. It should be considered as a supplemental treatment modality for select decompensating patients who require lifesaving interventions and have contraindications to traditional management of surgical thrombectomy or excision of the involved venous segment.


Assuntos
Procedimentos Endovasculares , Sepse/cirurgia , Trombectomia/métodos , Tromboflebite/cirurgia , Veia Cava Inferior/cirurgia , Idoso , Angiografia por Tomografia Computadorizada , Feminino , Humanos , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Flebografia/métodos , Sepse/diagnóstico , Sepse/microbiologia , Tromboflebite/diagnóstico por imagem , Tromboflebite/microbiologia , Resultado do Tratamento , Veia Cava Inferior/diagnóstico por imagem , Veia Cava Inferior/microbiologia
13.
Vasc Endovascular Surg ; 52(3): 212-217, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29554863

RESUMO

We report a case of a complex chronic type B aortic dissection treated by thoracic endovascular aortic repair and laser fenestration of the false septum to preserve flow to branch vessels originating from both the true and false lumen. Dissections complicated by thoracoabdominal aneurysmal degeneration with critical organs being perfused by branches arising from both true and false lumens are rare and leave limited options for repair. Despite advancements in endovascular techniques, fenestration remains one of the only means of preserving flow to both the true and false lumens and thus was necessary in the management of our patient. This novel procedure allows complex aortic dissections to be addressed endovascularly, which increases the flexibility and management of this challenging problem that previously required an open repair with significant morbidity.


Assuntos
Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Procedimentos Endovasculares/métodos , Terapia a Laser/métodos , Idoso , Aneurisma Dissecante/complicações , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/fisiopatologia , Aneurisma da Aorta Torácica/complicações , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/fisiopatologia , Aortografia/métodos , Doença Crônica , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/instrumentação , Humanos , Terapia a Laser/instrumentação , Masculino , Fluxo Sanguíneo Regional , Resultado do Tratamento , Ultrassonografia de Intervenção , Grau de Desobstrução Vascular
14.
Ann Thorac Surg ; 105(3): e99-e101, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29455831

RESUMO

We report a patient with refractory electrical storm after coronary artery bypass grafting who was successfully treated with thoracoscopic sympathectomy. Cardiac arrest with ventricular tachycardia occurred on postoperative day 2, and the patient required emergency support with venoarterial extracorporeal membrane oxygenation. Frequent episodes of ventricular tachycardia prevented cardiac recovery and weaning from mechanical circulatory support. A percutaneous left stellate ganglion block initially demonstrated successful prevention of ventricular tachycardia, and definitive sympathetic denervation was achieved by a left thoracoscopic sympathectomy. The patient remained in normal sinus rhythm and gained recovery of baseline ventricular function, permitting successful decannulation and weaning of inotropic support.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Simpatectomia , Taquicardia Ventricular/etiologia , Taquicardia Ventricular/cirurgia , Toracoscopia , Fibrilação Ventricular/cirurgia , Oxigenação por Membrana Extracorpórea , Humanos , Masculino , Pessoa de Meia-Idade
15.
J Vasc Nurs ; 35(3): 146-156, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28838590

RESUMO

Surgical site infections (SSIs) have always complicated recovery after surgery, being associated with increased cost of hospitalization, length of stay, and mortality. The most significant measure to reduce the incidence of SSI was the standardization of prophylactic antibiotic administration in patients undergoing surgical procedures. Since then, countless measures have been proposed to improve rates of SSI and patient outcome, but few have been as efficacious as prophylactic antibiotics. Therefore, SSI continues to plague clinicians and patients in modern health care. This review focuses on current and future efforts at SSI control.


Assuntos
Antibioticoprofilaxia , Infecção da Ferida Cirúrgica/terapia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Virilha , Humanos , Incidência , Fatores de Risco , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle
16.
Cardiol Rev ; 24(6): 261-267, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27548689

RESUMO

In many parts of the world, electronic cigarettes (ECs) are marketed as a tool to assist users in attempts to quit smoking and are perceived to be a safer alternative to tobacco cigarettes. Numerous studies have suggested ECs may not be effective in achieving this goal and that the illusive "safety" of ECs can be enticing to consumers. The composition of the liquid solutions vaporized by these devices has not been fully disclosed and may not contain the actual advertised ingredients in the fractions reported. As this market has developed largely outside the oversight of an appropriate regulatory body, we are left to evaluate how ECs as a form of nicotine replacement therapy fit in the existing regulatory framework of conventional cigarettes and what the role of nicotine is in our society.


Assuntos
Sistemas Eletrônicos de Liberação de Nicotina , Abandono do Uso de Tabaco , Adolescente , Comportamento do Adolescente , Sistemas Eletrônicos de Liberação de Nicotina/legislação & jurisprudência , Humanos , Testes de Função Respiratória , Poluição por Fumaça de Tabaco , Dispositivos para o Abandono do Uso de Tabaco
17.
Obesity (Silver Spring) ; 20(10): 2057-62, 2012 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-22402736

RESUMO

Diet-induced weight loss in women may be associated with decreases not only in plasma levels of low-density lipoprotein cholesterol (LDL-C), but also in high-density lipoprotein cholesterol (HDL-C). Whether a decrease in HDL-C is associated with altered HDL function is unknown. One hundred overweight or obese women (age 46 ± 11 years, 60 black; 12 diabetic) were enrolled in the 6-month program of reduced fat and total energy diet and low-intensity exercise. Serum cholesterol efflux capacity was measured in (3)H-cholesterol-labeled BHK cells expressing ABCA1, ABCG1, or SR-B1 transporters and incubated with 1% apolipoprotein B (apoB)-depleted serum. Antioxidant properties of HDL were estimated by paraoxonase-1 (PON1) activity and oxygen radical absorbance capacity (ORAC). Endothelial nitric oxide synthase (eNOS) activation was measured by conversion of L-arginine to L-citrulline in endothelial cells incubated with HDL from 49 subjects. Participants achieved an average weight loss of 2.2 ± 3.9 kg (P < 0.001), associated with reductions in both LDL-C (-6 ± 21 mg/dl, P = 0.004) and HDL-C (-3 ± 9 mg/dl, P = 0.016). Cholesterol efflux capacity by the ABCA1 transporter decreased by 10% (P = 0.006); efflux capacities by the ABCG1 and SR-B1 transporters were not significantly altered. ORAC decreased by 15% (P = 0.018); neither PON1 activity nor eNOS activation was significantly altered by reduction in HDL-C. Findings were similar for diabetic and nondiabetic subjects. Diet-induced weight loss in overweight or obese women is associated with a decrease in HDL-C levels, but overall HDL function is relatively spared, suggesting that decrease in HDL-C in this setting is not deleterious to cardiovascular risk.


Assuntos
HDL-Colesterol/sangue , Doença da Artéria Coronariana/sangue , Dieta com Restrição de Gorduras , Endotélio Vascular/metabolismo , Exercício Físico , Obesidade/sangue , Perda de Peso , Absorciometria de Fóton , Adiposidade , Adulto , Arildialquilfosfatase/sangue , Índice de Massa Corporal , LDL-Colesterol/sangue , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/fisiopatologia , Endotélio Vascular/fisiopatologia , Feminino , Humanos , Resistência à Insulina , Pessoa de Meia-Idade , Óxido Nítrico Sintase Tipo III/sangue , Obesidade/epidemiologia , Obesidade/fisiopatologia , Medição de Risco , Estados Unidos/epidemiologia
18.
Am J Cardiol ; 109(4): 527-32, 2012 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-22105786

RESUMO

Subjects at risk of atherosclerosis might have dysfunctional high-density lipoprotein (HDL) despite normal cholesterol content in the plasma. We considered whether the efflux of excess cellular cholesterol to HDL from obese subjects is associated with impaired arterial endothelial function, a biomarker of cardiovascular risk. A total of 54 overweight (body mass index [BMI] 25 to 29.9 kg/m(2)) or obese (BMI ≥30 kg/m(2)) women, aged 46 ± 11 years, were enrolled in a worksite wellness program. The HDL cholesterol averaged 57 ± 17 mg/dl and was inversely associated with the BMI (r = -0.419, p = 0.002). Endothelial function was assessed using brachial artery flow-mediated dilation. Cholesterol efflux from (3)H-cholesterol-labeled baby hamster kidney cells transfected with the adenosine triphosphate-binding cassette transporter 1 showed 8.2% to 22.5% cholesterol efflux within 18 hours when incubated with 1% serum and was positively correlated with brachial artery flow-mediated dilation (p <0.05), especially in the 34 subjects with BMI ≥30 kg/m(2) (r = 0.482, p = 0.004). This relation was independent of age, HDL or low-density lipoprotein cholesterol concentrations in plasma, blood pressure, or insulin resistance on stepwise multiple regression analysis (ß = 0.31, R(2) = 0.21, p = 0.007). Nitration of apolipoprotein A-I tyrosine residues (using sandwich enzyme-linked immunosorbent assay) was significantly greater in women with a BMI ≥30 kg/m(2) and the lowest cholesterol efflux than in women with a BMI of 25 to 29.9 kg/m(2) and the greatest cholesterol efflux (p = 0.01). In conclusion, we have shown that decreased cholesterol efflux by way of the adenosine triphosphate-binding cassette transporter 1 is associated with increased nitration of apolipoprotein A-I in HDL and is an independent predictor of impaired endothelial function in women with a BMI of ≥30 kg/m(2). This finding suggests that the functional measures of HDL might be better markers for cardiovascular risk than the HDL cholesterol levels in this population.


Assuntos
Apolipoproteína A-I/metabolismo , HDL-Colesterol/metabolismo , Obesidade/metabolismo , Transportadores de Cassetes de Ligação de ATP/metabolismo , Trifosfato de Adenosina/metabolismo , Adulto , Idoso , Apolipoproteína A-I/química , Pressão Sanguínea/fisiologia , Índice de Massa Corporal , Artéria Braquial/fisiologia , Endotélio Vascular/metabolismo , Feminino , Humanos , Pessoa de Meia-Idade , Análise de Regressão , Tirosina/metabolismo
19.
Pediatrics ; 128(1): e1-8, 2011 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-21690117

RESUMO

BACKGROUND: Sudden deaths of young competitive athletes are highly visible events that have a substantial effect on families and communities. Recent attention has focused predominantly on cardiovascular causes, and less on traumatic organ damage. OBJECTIVE: To define the clinical profile, epidemiology, and frequency of trauma-related deaths in young US athletes. METHODS: We analyzed the 30-year US National Registry of Sudden Death in Young Athletes (1980-2009) by using systematic identification and tracking strategies. RESULTS: Of 1827 deaths of athletes aged 21 years or younger, 261 (14%) were caused by trauma-related injuries, usually involving the head and/or neck (mean: 16 ± 2 years; 90% male) in 22 sports. The highest number of events in a single year was 16 (1986), with an average of 9 per year throughout 30 years. The mortality rate was 0.11 in 100 000 participations (95% confidence interval: 0.08-0.15). The largest number of deaths was in football (148 [57%]), including 17 high school athletes who sustained concussions shortly before fatal head trauma ("second-impact syndrome"). Football deaths were more frequent in defensive players, although the single most common position involved was running back (61% of offensive players). CONCLUSIONS: In a large community-based national registry, sudden deaths caused by blunt trauma in young athletes aged 21 years or younger were relatively uncommon with 16 or fewer per year, about fourfold less than cardiovascular deaths. These fatalities were most frequent in football, and an important proportion of deaths after head blows in high school football were associated with a recent history of symptomatic concussion.


Assuntos
Atletas , Morte Súbita/epidemiologia , Morte Súbita/etiologia , Ferimentos não Penetrantes/complicações , Adolescente , Feminino , Humanos , Masculino , Estudos Prospectivos , Estudos Retrospectivos
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