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1.
Ann Thorac Surg ; 2020 Mar 03.
Artigo em Inglês | MEDLINE | ID: mdl-32142814

RESUMO

As many as one third of patients undergoing minimally invasive thoracic surgery and one half undergoing thoracotomy develop chronic pain, defined as pain lasting 2-3 months. There is limited information regarding predictors of chronic pain and even less is known about its impact on health-related quality of life, known as pain interference. Currently, there is a focus on decreased opioid prescribing after surgery. Interestingly thoracic surgical patients are the least likely to be on opioids before surgery and have the highest rate of new persistent opioid use after surgery compared to other surgical cohorts. These studies of opioid use have identified important predictors of new persistent opioid use, but their findings are limited by failing to correlate opioid use with pain. The objectives of this invited review are to present the findings of pertinent studies of chronic pain and opioid use after thoracic surgery, "where we are", and to discuss gaps in our knowledge of these topics and opportunities for research to fill those gaps, "where we need to go".

2.
Ann Thorac Surg ; 109(3): 848-855, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31689407

RESUMO

BACKGROUND: The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD) has developed composite quality measures for lobectomy and esophagectomy. This study sought to develop a composite measure including all resections for lung cancer. METHODS: The STS lung cancer composite score is based on 2 outcomes: risk-adjusted mortality and morbidity. GTSD data were included from January 2015 to December 2017. "Star ratings" were created for centers with 30 or more cases by using 95% Bayesian credible intervals. The Bayesian model was performed with and without inclusion of the minimally invasive approach to assess the impact of approach on the composite measure. RESULTS: The study population included 38,461 patients from 256 centers. Overall operative mortality was 1.3% (495 of 38,461). The major complication rate was 7.9% (3045 of 38,461). The median number of nodes examined was 10 (interquartile range, 5 to 16); the median number of nodal stations sampled was 4 (interquartile range, 3 to 5). Positive resection margins were identified in 3.7% (1420 of 38,461). A total of 214 centers with 30 or more cases were assigned star ratings. There were 7 1-star, 194 2-star, and 13 3-star programs; 70.6% of resections were performed through a minimally invasive approach. Inclusion of minimally invasive approach, which was adjusted for in previous models, altered the star ratings for 3% (6 of 214) of the programs. CONCLUSIONS: Participants in the STS GTSD perform lung cancer resection with low morbidity and mortality. Lymph node data suggest that participants are meeting contemporary staging standards. There is wide variability among participants in application of minimally invasive approaches. The study found that risk adjustment for approach altered ratings in 3% of participants.

3.
IEEE Trans Pattern Anal Mach Intell ; 42(2): 502-508, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30802849

RESUMO

We present the Moments in Time Dataset, a large-scale human-annotated collection of one million short videos corresponding to dynamic events unfolding within three seconds. Modeling the spatial-audio-temporal dynamics even for actions occurring in 3 second videos poses many challenges: meaningful events do not include only people, but also objects, animals, and natural phenomena; visual and auditory events can be symmetrical in time ("opening" is "closing" in reverse), and either transient or sustained. We describe the annotation process of our dataset (each video is tagged with one action or activity label among 339 different classes), analyze its scale and diversity in comparison to other large-scale video datasets for action recognition, and report results of several baseline models addressing separately, and jointly, three modalities: spatial, temporal and auditory. The Moments in Time dataset, designed to have a large coverage and diversity of events in both visual and auditory modalities, can serve as a new challenge to develop models that scale to the level of complexity and abstract reasoning that a human processes on a daily basis.

4.
Can J Psychiatry ; : 706743719895342, 2019 Dec 13.
Artigo em Inglês | MEDLINE | ID: mdl-31835904

RESUMO

OBJECTIVES: To characterize the health-care utilization and economic burden associated with depression in Manitoba, Canada. METHODS: Patient-level data were retrieved from the Manitoba Centre for Health Policy administrative, clinical, and laboratory databases for the study period of January 1, 1996, through December 31, 2016. Patients were assigned to the depression cohort based on diagnoses recorded in hospitalizations and outpatient physician claims, as well as antidepressant prescription drug claims. A comparison cohort of nondepressed subjects, matched with replacement for age, gender, place of residence (urban vs. rural), and index date, was created. Demographics, comorbidities, intentional self-harm, mortality, health-care utilization, prescription drug utilization, and costs of health-care utilization and social services were compared between depressed patients and matched nondepressed patients, and incidence rate ratios and hazard ratios were reported. RESULTS: There were 190,065 patients in the depression cohort and 378,177 patients in the nondepression cohort. Comorbidities were 43% more prevalent among depressed patients. Intentional self-harm, all-cause mortality, and suicide mortality were higher among patients with depression than the nondepression cohort. Health-care utilization-including hospitalizations, physician visits, physician-provided psychotherapy, and prescription drugs-was higher in the depression than the nondepression cohort. Mean health-care utilization costs were 3.5 times higher among depressed patients than nondepressed patients ($10,064 and $2,832, respectively). Similarly, mean social services costs were 3 times higher ($1,522 and $510, respectively). Overall, depression adds a total average cost of $8,244 (SD = $40,542) per person per year. CONCLUSIONS: Depression contributes significantly to health burden and per patient costs in Manitoba, Canada. Extrapolation of the results to the entire Canadian health-care system projects an excess of $12 billion annually in health system spending.

5.
Artigo em Inglês | MEDLINE | ID: mdl-31740117

RESUMO

BACKGROUND: In 2018, the Leapfrog Group set minimum annual lung cancer surgery hospital and surgeon volume thresholds of 40 and 15, respectively. We examined whether outcomes associated with these Leapfrog Group volume thresholds are comparable for patients at the extremes of age and comorbidities. METHODS: We assessed lung cancer patients undergoing lobectomy or pneumonectomy in the New York and Florida State Inpatient Databases for 2007 to 2013. Multivariate logit models evaluated in-hospital mortality, complications, and prolonged length of stay. Median surgeon and hospital volumes were compared between "younger-healthier" (age 18-60 years, Elixhauser Comorbidity Index <1) and "older-sicker" patients (age >77 years, Elixhauser Comorbidity Index >3). RESULTS: The 27,841 patients included 13,277 men (48%). The median patient age was 69 years (interquartile range, 61-77), and mortality was 2.1%. Patients treated by both low-volume surgeons (<15 annual cases) and at low-volume hospitals (<40) had the greatest risk of mortality (2.5%), except for the cohort of younger-healthier patients (mortality <2%). Mortality for older-sicker patients was highest for high-volume surgeons (12%), although higher hospital volume was protective. Increasing hospital volume was associated with decreased mortality (odds ratio [OR], 0.997; 95% confidence interval [CI], 0.995-0.998; P = .0103), complications (OR, 0.998; 95% CI, 0.997-0.999; P < .001), and prolonged length of stay (OR, 0.998; 95% CI, 0.997-1.00; P = .01); similarly, higher surgeon volume was associated with decreased mortality (OR, 0.997; 95% CI, 0.99-1.00; P = .03), complications (OR, 0.997; 95% CI, 0.994-1.00; P = .02), and prolonged length of stay (OR, 0.991; 95% CI, 0.986-0.995; P < .01). CONCLUSIONS: Hospital volume has a greater effect on morbidity and mortality than surgeon volume especially for older-sicker patients, suggesting that Leapfrog Group volume guidelines should emphasize hospital volume over surgeon volume and may be less relevant for younger-healthier patients.

6.
Br J Clin Pharmacol ; 2019 Nov 23.
Artigo em Inglês | MEDLINE | ID: mdl-31758576

RESUMO

AIMS: Human genetic, tissue expression, proteomics, transcriptomics and nonclinical studies implicate tumour necrosis factor α-like ligand 1A (TL1A) as a novel target in inflammatory bowel disease (IBD). PF-06480605, a fully human immunoglobulin G1 monoclonal antibody, targets TL1A. This first-in-human, Phase 1, dose-escalation study assessed safety, tolerability, pharmacokinetics, pharmacodynamics and immunogenicity of intravenous (IV) and subcutaneous (SC) PF-06480605 in healthy subjects (NCT01989143). METHODS: Ninety-two subjects were randomized to single ascending doses (SAD), PF-06480605 1 mg, 3 mg, 10 mg, 30 mg, 100 mg, 300 mg, 600 mg or 800 mg IV, or multiple ascending doses (MAD), PF-06480605 3 × 500 mg IV, or 3 × 30 mg, 3 × 100 mg, or 3 × 300 mg SC every 2 weeks for three doses, or placebo. Safety, tolerability, pharmacokinetics, immunogenicity profiles and total TL1A, anti-drug antibody (ADA) and neutralizing antibody (NAb) levels were assessed at pre-determined times. RESULTS: PF-06480605 SAD up to 800 mg IV and MAD up to 300 mg ×3 SC and 500 mg ×3 IV were well tolerated. Overall, there were 45 and 44 treatment-emergent adverse events in SAD and MAD cohorts, respectively, and no deaths or serious adverse events. PF-06480605 exposure generally increased dose-dependently. ADA and NAb levels did not impact safety, pharmacokinetics, or pharmacodynamics at higher doses. Target engagement was demonstrated through dose-dependent differences in serum total soluble TL1A concentrations for PF-06480605 vs placebo cohorts. CONCLUSIONS: PF-06480605 was generally well tolerated, and binding of soluble TL1A was maintained throughout the dose interval, supporting further study of PF-06480605 in patients with IBD and other inflammatory conditions.

7.
Pharmacopsychiatry ; 2019 Sep 11.
Artigo em Inglês | MEDLINE | ID: mdl-31509860

RESUMO

INTRODUCTION: The use of pharmacogenomic (PGx) testing to guide decisions and improve patient outcomes has increased in recent years. PGx testing represents a decision support tool that may inform dosing, increase the likelihood of treatment response, and identify patients at risk for medication side effects. METHODS: This is a narrative review of utilization of PGx testing in psychiatry from stakeholders including, pharmacists, genetic counselors, implementation scientists, industry, and clinicians. RESULTS: While many limitations exist to streamline use of PGx testing in psychiatry, various stakeholders are crucial to clinical implementation. DISCUSSION: PGx testing can assist in medication selection and improve patient outcomes; however, more data are needed to understand when and how to incorporate PGx testing into psychiatric practice.

8.
J Thorac Dis ; 11(Suppl 12): S1633-S1642, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31489231

RESUMO

The morbidity and mortality benefits of performing high-risk operations in high-volume centers by high-volume surgeons are evident. Regionalization is a proposed strategy to leverage high-volume centers for esophagectomy to improve quality outcomes. Internationally, regionalization occurs under national mandates. Those mandates do not exist in the United States and spontaneous regionalization of esophagectomy has only modestly occurred in the U.S. Regionalization must strike a careful balance and not limit access to optimal oncologic care to our most vulnerable cancer patient populations in rural and disadvantaged socioeconomic areas. We reviewed the recent literature highlighting: the justification of hospital and surgeon annual esophagectomy volumes for regionalization; how safety performance metrics could influence regionalization; whether regionalization is occurring in the US; what impact regionalization may have on esophagectomy costs; and barriers to patients traveling to receive oncologic treatment at regionalized centers of excellence.

10.
Ann Surg ; 2019 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-31425294

RESUMO

OBJECTIVE: We examine how esophagectomy volume thresholds reflect outcomes relative to patient characteristics. SUMMARY BACKGROUND DATA: Esophagectomy outcomes are associated with surgeon and hospital operative volumes, leading the Leapfrog Group to recommend minimum annual volume thresholds of 7 and 20 respectively. METHODS: Patients undergoing esophagectomy for cancer were identified from the 2007-2013 New York and Florida Healthcare Cost and Utilization Project's State Inpatient Databases. Logit models adjusted for patient characteristics evaluated in-hospital mortality, complications, and prolonged length of stay (PLOS). Median surgeon and hospital volumes were compared between young-healthy (age 18-57, Elixhauser Comorbidity Index [ECI] <2) and older-sick patients (age ≥71, ECI >4). RESULTS: Of 4330 esophagectomy patients, 3515 (81%) were male, median age was 64 (interquartile range 58-71), and mortality was 4.0%. Patients treated by both low-volume surgeons and hospitals had the greatest mortality risk (5.0%), except in the case of older-sick patients mortality was highest at high-volume hospitals with high-volume surgeons (12%). For mortality <1%, annual hospital and surgeon volumes needed were 23 and 8, respectively; mortality rose to 4.2% when volumes dropped to the Leapfrog thresholds of 20 and 7, respectively. Complication rose from 53% to 63% when hospital and surgeon volumes decreased from 28 and 10 to 19 and 7, respectively. PLOS rose from 19% to 27% when annual hospital and surgeon volumes decreased from 27 and 8 to 20 and 7, respectively. CONCLUSIONS: Current Leapfrog Group esophagectomy volume guidelines may not predict optimal outcomes for all patients, especially at extremes of age and comorbidities.

11.
Arch Pathol Lab Med ; 2019 Aug 20.
Artigo em Inglês | MEDLINE | ID: mdl-31429605

RESUMO

CONTEXT.­: There is a wide disconnect between patients and the pathologists who make their diagnoses. Recent literature highlights successful programs in which patients meet with pathologists to review their pathology reports and see their tissue under a microscope. We do not know how many patients are interested in such a service, nor do we understand what drives interested patients to want to meet with their pathologist and what specific value it may provide. OBJECTIVE.­: To quantify patient interest in a patient-pathologist consultation program and qualitatively assess motivations for patient interest or disinterest. DESIGN.­: Subjects were recruited from an academic cancer center and a local community cancer support group to respond to a survey about their interest in a patient-pathologist consultation program. Both online forms and paper surveys were available. The online survey was promoted via social media. RESULTS.­: There was a high level of patient interest, with 75% of respondents indicating they were definitely interested in a patient-pathologist consultation program. Key themes of interest were enhanced understanding of the diagnosis and disease, an opportunity to demystify the diagnostic process, and the perception that additional knowledge would empower the patient. CONCLUSIONS.­: In a select group of cancer patients, there is a very high level of interest in a patient-pathologist consultation program. Pathologists, clinicians, and hospital leadership should work together to pilot these programs in diverse settings. Additional quantitative work to scale interventions for the interested population and qualitative work to design effective, patient-centered consultation programs and to assess value are needed.

12.
Ann Surg ; 2019 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-31469745

RESUMO

OBJECTIVE: The aim of this study was to identify independent predictors of hospital readmission for patients undergoing lobectomy for lung cancer. SUMMARY BACKGROUND DATA: Hospital readmission after lobectomy is associated with increased mortality. Greater than 80% of the variability associated with readmission after surgery is at the patient level. This underscores the importance of using a data source that includes detailed clinical information. METHODS: Using the Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD), we conducted a retrospective cohort study of patients undergoing elective lobectomy for lung cancer. Three separate multivariable logistic regression models were generated: the first included preoperative variables, the second added intraoperative variables, and the third added postoperative variables. The c statistic was calculated for each model. RESULTS: There were 39,734 patients from 277 centers. The 30-day readmission rate was 8.2% (n = 3237). In the final model, postoperative complications had the greatest effect on readmission. Pulmonary embolus {odds ratio [OR] 12.34 [95% confidence interval (CI),7.94-19.18]} and empyema, [OR 11.66 (95% CI, 7.31-18.63)] were associated with the greatest odds of readmission, followed by pleural effusion [OR 7.52 (95% CI, 6.01-9.41)], pneumothorax [OR 5.08 (95% CI, 4.16-6.20)], central neurologic event [OR 3.67 (95% CI, 2.23-6.04)], pneumonia [OR 3.13 (95% CI, 2.43-4.05)], and myocardial infarction [OR 3.16 (95% CI, 1.71-5.82)]. The c statistic for the final model was 0.736. CONCLUSIONS: Complications are the main driver of readmission after lobectomy for lung cancer. The highest risk was related to postoperative events requiring a procedure or medical therapy necessitating inpatient care.

13.
Ann Otol Rhinol Laryngol ; 128(11): 1054-1060, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31288548

RESUMO

OBJECTIVES: To present a systematic checklist to improve diagnosing otosclerosis (OS) on high-resolution computed tomography (HRCT) of the temporal bones and review this protocol's efficacy in diagnosing OS on HRCT. METHODS: A retrospective case series was performed at a University Referral Hospital in urban Chicago, Illinois. High-resolution computed tomographies of the temporal bone were reviewed including 17 ears in the test group with surgically confirmed OS and 21 ears in the control group surgically confirmed to not have OS. Preoperative HRCTs were evaluated by a single neuroradiologist using a systematic protocol created to assist in diagnosing OS. This looked for radiolucency at the fissula ante fenestram and pericochlear region, and new bone formation around the oval and round windows. RESULTS: The radiologist accurately diagnosed OS in all 17 test group ears and ruled out OS in all 21 control group ears using the protocol. All 17 test ears were read to have lucency at the fissula ante fenestram, 9 (53.0%) to have new bone formation, and 8 (47.1%) to have cochlear lucency. The radiologist was more confident in diagnosing OS when cochlear lucency was present with the fissula ante fenestram lucency. CONCLUSIONS: This HRCT checklist is a highly accurate tool for evaluating the presence of OS when images are reviewed in the systematic fashion described. Imaging prior to surgery aids in counseling patients, preparing surgically, and excluding other pathologies.


Assuntos
Cóclea/diagnóstico por imagem , Tomografia Computadorizada Multidetectores/métodos , Otosclerose/diagnóstico , Osso Temporal/diagnóstico por imagem , Adulto , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Otosclerose/cirurgia , Reprodutibilidade dos Testes , Estudos Retrospectivos , Cirurgia do Estribo/métodos
14.
Semin Pediatr Neurol ; 30: 68-78, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31235023

RESUMO

A complex diagnosis such as concussion requires a multidisciplinary patient-centered approach to maximize health outcomes. There is growing evidence to support the role of the Physical Therapist as a key member of the team of healthcare professionals managing children and adolescents with a protracted recovery following concussion. Symptoms such as headache, dizziness, neck pain, gaze instability, balance dysfunction, and fatigue can be addressed through a multimodel approach. This article provides an overview of the targeted pathways of examination and treatment of individuals with a concussion through vestibular rehabilitation, cervicogenic rehabilitation, exertional training, and patient education.

15.
Mhealth ; 5: 11, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31231666

RESUMO

Background: Adolescent death by suicide is an emergent health crisis in the United States of America. Although many suicide prevention programs have been created to address suicide in this population, rates continue to increase. Online interventions can disseminate treatments world-wide and reach large numbers of users. Thus, the purpose of the present study was to determine the effects of CATCH-IT, an Internet-based depression prevention intervention on risk factors for suicide (i.e., suicidal ideation, hopelessness, low self-esteem and social isolation). Methods: A total of 83 participants aged 14-21 years [mean =17.5; standard deviation (SD) =2.04] consented to take part in the intervention study. Results: Results indicated that suicidal ideation decreased from baseline to post-intervention. For those who completed the entire CATCH-IT program, the effect size was moderate (d =0.60, P<0.05). For those who partially completed the program the effect size was small (d =0.22, P<0.05). Interestingly, scales measuring hopelessness and social isolation were not associated with changes in suicidal ideation. Conclusions: The findings provide initial evidence that online depression prevention programs could be related to decreased suicidal ideation, and that those who complete the entire program may benefit more than those who complete only a part of CATCH-IT.

16.
Ann Thorac Surg ; 108(4): 1006-1012, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31181202

RESUMO

BACKGROUND: Cardiopulmonary assessment for lung resection is important for risk stratification, and the American College of Chest Physicians (ACCP) guidelines provide decision support. We ascertained the cardiopulmonary assessment practices of thoracic surgeons and determined whether they are guideline concordant. METHODS: An anonymous survey was emailed to 846 thoracic surgeons who participate in The Society of Thoracic Surgeons General Thoracic Surgery Database. We analyzed survey responses by practice type (general thoracic [GT] versus cardiothoracic [CT]) and years in practice (0-9, 10-19, and ≥20) with the use of contingency tables. We compared adherence of survey responses with the guidelines. RESULTS: The response rate was 24.0% (n = 203). Most surgeons (n = 121, 59.6%) cited a predicted postoperative forced expiratory volume in 1 second or diffusing capacity of lung for carbon monoxide threshold of 40% for further evaluation. Experienced surgeons (≥20 years) were more likely to have a threshold that varies by surgical approach (31.3% versus 23.5% with 10-19 years of experience and 15.9% for 0-9 years of experience, P = .007). Overall, 52.2% refer patients with cardiovascular risk factors to cardiology and 42.9% refer patients with abnormal stress testing. CT surgeons were more likely to refer all patients to cardiology than GT surgeons (17.6% versus 2.4%, P < .001). Only one respondent (0.5%) was 100% adherent to the ACCP guidelines, and 4.4% and 45.8% were 75% and 50% adherent, respectively. CONCLUSIONS: Among thoracic surgeons, there is variation in preoperative cardiopulmonary assessment practices, with differences by practice type and years in practice, and marked discordance with the ACCP guidelines. Further study of guideline adherence linked to postoperative morbidity and mortality is warranted to determine whether adherence affects outcomes.


Assuntos
Técnicas de Apoio para a Decisão , Fidelidade a Diretrizes , Pulmão/fisiopatologia , Pneumonectomia , Cuidados Pré-Operatórios/métodos , Testes de Função Respiratória/métodos , Cirurgiões/normas , Adulto , Idoso , Feminino , Humanos , Pulmão/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco
17.
Artigo em Inglês | MEDLINE | ID: mdl-31160943

RESUMO

As CRISPR (clustered regularly interspaced short palindromic repeats)-Cas9 technology becomes more mainstream in life science research, it becomes critical for undergraduate instructors to devise engaging ways to bring the technology into their classrooms. To help meet this challenge, the National Science Foundation sponsored a workshop for undergraduate instructors in June 2018 at The Ohio State University in conjunction with the annual Association of Biology Laboratory Educators meeting based on a workflow developed by the workshop's facilitators. Over the course of two and a half days, participants worked through a modular workflow for the use of CRISPR-Cas9 in a course-based (undergraduate) research experience (CURE) setting while discussing the barriers each of their institutions had to implementing such work, and how such barriers could be overcome. The result of the workshop was a team with newfound energy and confidence to implement CRISPR-Cas9 technology in their courses and the development of a community of undergraduate educators dedicated to supporting each other in the implementation of the workflow either in a CURE or modular format. In this article, we review the activities and discussions from the workshop that helped each participant devise their own tailored approaches of how best to bring this exciting new technology into their classes.

18.
Ecol Evol ; 9(10): 6082-6095, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31161020

RESUMO

Larval and adult mosquitoes mount immune responses against pathogens that invade their hemocoel. Although it has been suggested that a correlation exists between immune processes across insect life stages, the influence that an infection in the hemocoel of a larva has on the immune system of the eclosed adult remains unknown. Here, we used Anopheles gambiae to test whether a larval infection influences the adult response to a subsequent bacterial or malaria parasite infection. We found that for both female and male mosquitoes, a larval infection enhances the efficiency of bacterial clearance following a secondary infection in the hemocoel of adults. The adults that emerge from infected larvae have more hemocytes than adults that emerge from naive or injured larvae, and individual hemocytes have greater phagocytic activity. Furthermore, mRNA abundance of immune genes-such as cecropin A, Lysozyme C1, Stat-A, and Tep1-is higher in adults that emerge from infected larvae. A larval infection, however, does not have a meaningful effect on the probability that female adults will survive a systemic bacterial infection, and increases the susceptibility of females to Plasmodium yoelii, as measured by oocyst prevalence and intensity in the midgut. Finally, immune proficiency varies by sex; females exhibit increased bacterial killing, have twice as many hemocytes, and more highly express immune genes. Together, these results show that a larval hemocoelic infection induces transstadial immune activation-possibly via transstadial immune priming-but that it confers both costs and benefits to the emerged adults.

19.
Ann Thorac Surg ; 108(3): 859-865, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31059684

RESUMO

BACKGROUND: The role of sublobar resection in the treatment of pulmonary typical carcinoids is controversial. This study aims to compare long-term outcomes between sublobar and lobar resections in patients with peripheral typical carcinoid. METHODS: We retrospectively compared consecutive patients who underwent curative sublobar resection with patients who underwent lobectomy for cT1-3 N0 M0 peripheral pulmonary typical carcinoid in eight centers between 2000 and 2015. Primary outcomes were rates and patterns of recurrence and overall survival. Cox regression modeling was performed to identify factors influencing overall survival and recurrence. Propensity score analysis was done, and overall survival was compared between the two groups. RESULTS: In all, 177 patients were analyzed, consisting of 74 sublobar resections and 103 lobectomies, with a total of 857 person-years of follow-up. The R1 resection rates were 7% and 1% after sublobar resection and lobectomy, respectively (P = .08). One of 5 patients with sublobar R1 resection had recurrence. Recurrence rate was 0.02 (95% confidence interval [CI]: 0.009 to 0.044) per person-year of follow-up after sublobar resection and 0.008 (95% CI: 0.003 to 0.02) after lobectomy (P = .15). Five-year survival rates were 91.7% (95% CI: 78.5% to 96.9%) and 97.4% (95% CI: 90.1% to 99.4%) after sublobar and lobar resection, respectively (P = .08). Extent of resection was not a predictor of recurrence or survival. Propensity score analysis confirmed a similar survival and freedom from recurrence between the two groups. CONCLUSIONS: Sublobar resection of peripheral cT1-3 N0 M0 pulmonary typical carcinoid was not associated with worse short- or long-term outcomes compared with lobectomy. In select patients, sublobar resection may be considered for treatment of peripheral typical carcinoids if an R0 resection is obtained.


Assuntos
Tumor Carcinoide/mortalidade , Tumor Carcinoide/cirurgia , Causas de Morte , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/cirurgia , Pneumonectomia/métodos , Idoso , Tumor Carcinoide/patologia , Estudos de Coortes , Intervalo Livre de Doença , Feminino , Humanos , Internacionalidade , Estimativa de Kaplan-Meier , Neoplasias Pulmonares/patologia , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica/patologia , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/cirurgia , Estadiamento de Neoplasias , Pneumonectomia/mortalidade , Prognóstico , Pontuação de Propensão , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Análise de Sobrevida
20.
Int J Pediatr Otorhinolaryngol ; 122: 161-164, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31029951

RESUMO

OBJECTIVE: First branchial cleft anomalies (FBCAs) are rare and often misdiagnosed, which can delay proper management and increase surgical risks. Complete excision often requires parotidectomy with facial nerve dissection. The literature reports that younger patients more often have lesions deep to the nerve with higher rates of nerve injury. We hypothesized that the rate of nerve injury and complications in children with FBCAs was not different in those ≤2 years of age compared to those >2 years of age. METHODS: Retrospective review of pediatric patients who underwent resection of histopathologically confirmed FBCAs between 2007 and 2017 at a tertiary care, pediatric hospital. Presenting symptoms, lesion classification, prior procedures, imaging techniques, extent of surgery performed, facial nerve position, and complications were reviewed and compared between patients ≤2 years of age and >2 years of age at time of surgery. RESULTS: 43 cases of FBCAs were included in the study: 12 in the younger group and 31 in the older group. There was no difference between groups regarding the presenting symptoms, gender breakdown, lesion classification, prior procedures performed, or extent of surgery. Lesions were more commonly deep to or running between branches of the facial nerve in the younger group (33.3% vs 9.7%, p = .0496). Rates of postoperative complications and facial nerve weakness were comparable between the younger and older groups (8.3% vs 25.8%, p = .206; 25.0% vs 16.1%, p = .503). In combining the age groups, FBCAs located deep to the facial nerve had increased risk of nerve weakness postoperatively (RR 7.2) and those with a history of prior incision and drainage or resection had increased risk of postoperative complications (RR 2.36). Imaging was obtained on all subjects with accuracy rates of 80-100%. CONCLUSION: Presenting characteristics of FBCAs in patients ≤2 years of age and >2 years of age are comparable, but lesions in younger subjects had a greater likelihood of being deep to or coursing between branches of the facial nerve. However, the rates of facial nerve injury and postoperative complications are comparable in younger and older children, owing likely to accurate preoperative imaging and appropriate surgical planning.


Assuntos
Região Branquial/anormalidades , Anormalidades Craniofaciais/diagnóstico por imagem , Anormalidades Craniofaciais/cirurgia , Traumatismos do Nervo Facial/etiologia , Doenças Faríngeas/diagnóstico por imagem , Doenças Faríngeas/cirurgia , Fatores Etários , Região Branquial/diagnóstico por imagem , Região Branquial/cirurgia , Criança , Pré-Escolar , Dissecação , Drenagem , Músculos Faciais/fisiopatologia , Nervo Facial/cirurgia , Feminino , Humanos , Lactente , Masculino , Debilidade Muscular/etiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do Tratamento
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