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2.
Ann Surg Oncol ; 28(5): 2438-2446, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33523364

RESUMO

AIMS: National studies have demonstrated disparities in the treatment and survival of pancreatic cancer patients based on socioeconomic status (SES). This study aimed to identify specific differences in perioperative management and outcomes based on patient SES and to study the role of a multidisciplinary clinic (MDC) in mitigating any variations. METHODS: The study analyzed patients undergoing pancreaticoduodenectomy for pancreatic ductal adenocarcinoma in a large hospital system. The patients were categorized into groups of high and low SES and whether they were managed by the authors' pancreatic cancer MDC or not. The study compared differences in disease characteristics, receipt of multimodality therapy, perioperative outcomes, and recurrence-free and overall survival. RESULTS: Of the 162 low-SES patients and 119 high-SES patients, 54% were managed in the MDC. Outside the MDC, low-SES patients were less likely to receive neoadjuvant chemotherapy and had less minimally invasive surgery, a longer OR time, less enhanced recovery participation, and more major complications (p < 0.05). No SES disparities were observed among the MDC patients. Despite similar tumor characteristics, the low-SES patients had inferior median overall survival (21 vs 32 months; p = 0.005), but the MDC appeared to eliminate this disparity. Low SES correlated with inferior survival for the non-MDC patients (17 vs 32 months; p < 0.001), but not for the MDC patients (24 vs 25 months; p = 0.33). These findings persisted in the multivariable analysis. CONCLUSION: A pancreatic cancer MDC standardizes treatment decisions, eliminates disparities in surgical outcomes, and improves survival for low-SES patients.


Assuntos
Carcinoma Ductal Pancreático , Neoplasias Pancreáticas , Carcinoma Ductal Pancreático/cirurgia , Disparidades em Assistência à Saúde , Humanos , Recidiva Local de Neoplasia , Pancreatectomia , Neoplasias Pancreáticas/cirurgia , Classe Social
3.
Ann Surg Oncol ; 28(7): 3779-3788, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33231769

RESUMO

BACKGROUND: Neoadjuvant therapy is increasingly used for patients with pancreatic ductal adenocarcinoma (PDAC). It is unknown whether neoadjuvant chemoradiotherapy is more effective than chemotherapy (NCRT vs. NAC). We aim to compare pathological and survival outcomes of NCRT and NAC in patients with PDAC. PATIENTS AND METHODS: Single-center analysis of PDAC patients treated with NCRT or NAC followed by resection between December 2008 and December 2018 was performed. Average treatment effect (ATE) was estimated after case-control matching using Mahalanobis distance nearest-neighbor matching. Inverse probability weighted estimates (IPWE)-based ATE was estimated for disease-free survival (DFS) and overall survival (OS). RESULTS: Among the 418 patients (mean age 66.8 years, 51% female) included in the study, 327 received NAC and 91 received NCRT. NCRT patients had higher rates of locally advanced disease, number of neoadjuvant chemotherapy cycles, more chemotherapy regimen crossover (gemcitabine and 5-FU based), and were more likely to undergo open surgical procedures and/or vascular resection (all p < 0.05). After matched analysis, NCRT was associated with a significant reduction in lymph node positive disease [ATE = (-)0.24, p = 0.007] and lymphovascular invasion [ATE = (-)0.20, p = 0.02]. While NCRT was associated with significantly improved DFS by 9.5 months (p = 0.006), it did not affect OS by IPWE-based ATE after adjusting for adjuvant therapy (ATE = 5.5 months; p = 0.32). CONCLUSION: Compared with NAC alone, NCRT is associated with improved pathologic surrogates and disease-free survival, but not overall survival in patients with PDAC.


Assuntos
Terapia Neoadjuvante , Neoplasias Pancreáticas , Idoso , Quimiorradioterapia , Intervalo Livre de Doença , Feminino , Humanos , Masculino , Estadiamento de Neoplasias , Neoplasias Pancreáticas/terapia , Estudos Retrospectivos
4.
BMC Vet Res ; 16(1): 223, 2020 Jun 30.
Artigo em Inglês | MEDLINE | ID: mdl-32605630

RESUMO

BACKGROUND: Free-ranging common bottlenose dolphins (Tursiops truncatus) can become entangled in fishing line and other marine debris. Infrequently, dolphins can be successfully disentangled, released back into the wild, and later examined postmortem to better understand the pathology and long-term effects of these entanglements. CASE PRESENTATION: An entangled common bottlenose dolphin (Tursiops truncatus) calf was observed in the Indian River Lagoon, Florida, USA, with monofilament fishing line wrapped tightly around its maxilla. A multi-agency team successfully disentangled the dolphin for immediate release back into its natural habitat. A year after disentanglement, photos and observations indicated that the now independent calf showed a decline in body condition, characterized by grossly visible ribs and a prominent post-nuchal depression. More than 2 years post-disentanglement, the freshly dead carcass of this juvenile dolphin was recovered with extensive predation wounds. Despite the forestomach being ~ 50% full of ingesta (fish), the dolphin was emaciated. During postmortem examination, we collected and evaluated photographs and measurements of the maxillary damage resulting from the entanglement. CONCLUSION: The monofilament entanglement caused permanent, bilateral deformation of the maxillary dental arcade, including a 4.0-4.2 cm long, 0.5 cm deep linear groove where the entanglement eroded the lateral edges of the maxilla. There was no evidence of maxillary fracture and the dolphin survived for more than 2 years after disentanglement. External evidence of propeller scars and a fishing hook discovered embedded in the laryngeal mucosa at necropsy indicated repeated human interactions.


Assuntos
Golfinho Nariz-de-Garrafa/lesões , Pesqueiros , Maxila/lesões , Animais , Florida , Atividades Humanas , Masculino , Comportamento Predatório , Ferimentos e Lesões/veterinária
5.
J Clin Psychol ; 69(12): 1305-14, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-23797951

RESUMO

OBJECTIVES: To examine the effect of proposed the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) changes to pathological gambling relative to DSM-IV criteria in a large gambling helpline sample (N = 2,750). Changes in prevalence rates, the diagnostic utility of the illegal acts criterion, and severity of alternative diagnostic formulation thresholds were examined. METHOD: Callers to the helpline completed a semistructured interview and DSM-IV criteria were assessed. RESULTS: Without lowering the diagnostic threshold, removal of the illegal acts criterion resulted in loss of diagnostic status in less than 2% of helpline callers. The DSM-IV prevalence rate in this sample was 81.2%, and DSM-5 formulations with lowered thresholds of 4, 3, and 2 symptoms increased prevalence rates by 9% to 17%. However, item-level symptom endorsement suggested that subclinical gamblers experience significant adverse consequences. CONCLUSIONS: Lowered thresholds may lead to earlier provision of treatment to gamblers and prevent escalation of the disorder, while being more consistent with diagnostic thresholds of other addiction disorders.


Assuntos
Sintomas Comportamentais/diagnóstico , Manual Diagnóstico e Estatístico de Transtornos Mentais , Jogo de Azar/diagnóstico , Adulto , Idoso , Sintomas Comportamentais/classificação , Sintomas Comportamentais/epidemiologia , Feminino , Jogo de Azar/classificação , Jogo de Azar/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Consulta Remota/estatística & dados numéricos , Índice de Gravidade de Doença , Telefone/estatística & dados numéricos , West Virginia/epidemiologia , Adulto Jovem
6.
Technol Cancer Res Treat ; 11(2): 105-15, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-22335404

RESUMO

The purpose of this study is to evaluate the difference in clinical outcomes for patients with metastatic spine disease treated with a whole versus partial vertebral body contouring approach. A retrospective study was performed for the clinical outcomes of 154 metastatic lesions to the spine in 117 patients treated with stereotactic body radiation therapy (SBRT) using the Cyberknife(TM) Robotic Radiosurgery System. Each patient was treated with a single session of radiotherapy using either a whole (WB) or a partial vertebral body contour approach (PB). The primary endpoint was re-treatment rate and the secondary endpoints were pain status, neurologic status, toxicity, tumor control, and survival. The WB group had a lower re-treatment rate (11% (WB) vs. 18.6% (PB), p=0.285). Prior surgery status (ß=1.953, OR=7.052, p<0.001) was correlated to the re-treatment rate. Trends for local tumor control were distinct for both treatment groups (X(2)=3.380, p-value=0.066). Treatment group (ß=-1.1017, OR=0.362, p=0.029) was significantly correlated to the local tumor control rate. The 2-year survival was 25.7% in WB and 20.9% in PB (p=0.741). Contouring the whole vertebral body for stereotactic body radiation therapy treatment of metastatic spinal lesions shows potential benefits by reducing the risk of recurrence, improving symptomatic relief and providing improved local tumor control.


Assuntos
Neoplasias Ósseas/cirurgia , Recidiva Local de Neoplasia/cirurgia , Neoplasias/cirurgia , Radiocirurgia , Neoplasias da Coluna Vertebral/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Ósseas/mortalidade , Neoplasias Ósseas/secundário , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Neoplasias/mortalidade , Neoplasias/patologia , Medição da Dor , Prognóstico , Estudos Retrospectivos , Neoplasias da Coluna Vertebral/mortalidade , Neoplasias da Coluna Vertebral/secundário , Taxa de Sobrevida
7.
J Forensic Sci ; 57(1): 270-2, 2012 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-21939444

RESUMO

While the use of psychological autopsies has at least a 50-year history in the investigation of equivocal deaths and suicides, we report a case where, after the discovery of a woman who died of natural causes, a subsequent search of her home found three deceased newborn infants. The infants were born on three separate occasions; the most recent was delivered approximately 2 weeks before the death of the mother. Using her own diaries and interviews with family and friends along with the physical autopsy and scene investigation data, we built a psychological autopsy that addressed the mother's mental state over the period of time when the infants' deaths took place. While the use of the psychological autopsy was not employed to distinguish the manner of death of the mother, it did provide explanatory power over circumstances of the crime scene and the behavioral disturbance of the mother.


Assuntos
Transtorno da Personalidade Borderline/psicologia , Psiquiatria Legal/métodos , Infanticídio/psicologia , Adulto , Transtorno da Personalidade Borderline/diagnóstico , Feminino , Humanos , Recém-Nascido
8.
Psychol Addict Behav ; 25(2): 372-9, 2011 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-21480678

RESUMO

Gambling help-lines are an essential access point, or frontline resource, for treatment seeking. This study investigated treatment engagement after calling a gambling help-line. From 2000-2007 over 2,900 unique callers were offered an in-person assessment appointment. Logistic regression analyses assessed predictors of (a) accepting the referral to the in-person assessment appointment and (b) attending the in-person assessment appointment. Over 76% of callers accepted the referral and 55% of all callers attended the in-person assessment appointment. This treatment engagement rate is higher than typically found for other help-lines. Demographic factors and clinical factors such as gender, severity of gambling problems, amount of gambling debt, and coercion by legal and social networks predicted engagement in treatment. Programmatic factors such as offering an appointment within 72 hr also aided treatment engagement. Results suggest gambling help-lines can be a convenient and confidential way for many individuals with gambling problems to access gambling-specific treatment. Alternative services such as telephone counseling may be beneficial for those who do not engage in treatment.


Assuntos
Comportamento Aditivo/psicologia , Jogo de Azar/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Adulto , Idoso , Comportamento Aditivo/terapia , Aconselhamento , Feminino , Jogo de Azar/terapia , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , West Virginia
9.
Technol Cancer Res Treat ; 9(5): 489-98, 2010 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-20815420

RESUMO

Endoscopic endonasal surgery (EES) has been shown to be a feasible approach to cranial base tumors while reducing post-operative morbidity. Using the endoscopic endonasal approach alone or in combination with open approaches may provide advantages over conventional approaches. However, the balance between maximal resection and minimal injury to neurovascular structures frequently precludes gross total resection (GTR). Consequently, adjuvant radiation therapy may be an important option to improve local control (LC) of residual disease. In this retrospective series, we report clinical outcomes, morbidity, and LC of 40 patients with cranial base tumors treated with EES +/- combined open approach followed by fSRS (CyberKnife, Accuray Inc.). 26 patients had benign disease, 7 had newly diagnosed malignant disease, and 7 had previously resected malignant disease. Surgical outcomes were evaluable in all patients. LC after fSRS was evaluable in 39 patients and defined as no evidence of regrowth by MRI, CT, & physical examination. GTR was achieved in 12/40. Median post-operative length of stay (LOS) was 3 days. In multivariable analysis controlling for anatomic location and malignant histology, post-operative complications (n = 10) were significantly associated with patients having combined open and EES (p < 0.01, OR = 16.9). SRS was delivered in 1-5 sessions to a median marginal dose of 24.9 Gy. Median follow-up was 24.7 months (range, 1.5 to 61 months). LC was achieved in 89.7% (35/39) of evaluable patients. LC was achieved in 11/12 patients who had GTR. Median progression-free survival was 19.7 months (21.0 months for benign tumors (n = 26), 5.8 months for previously resected malignant disease (n = 7), and 21.2 months for newly diagnosed malignant disease (n = 7). Of the 31 patients who had symptomatic disease at presentation, 18 (58%) reported complete symptom resolution, 9 partial, and 4 no improvement. One patient who received two prior courses of radiation therapy developed osteosclerosis (grade III). Other adverse events were erythema (grade I, n = 5), nausea (grade II, n = 2), conjunctivitis (grade II, n = 1). EES followed by fSRS is a safe and effective management strategy for selected cranial base tumors. EES combined with an open surgical approach may result in increased complications. However, initial follow-up offers encouraging results indicating shorter time to recovery, acceptable LC rates compared to conventional approaches, and similar median time to progression for benign and newly diagnosed malignant disease.


Assuntos
Endoscopia/métodos , Radiocirurgia/métodos , Neoplasias da Base do Crânio/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade , Complicações Pós-Operatórias/etiologia , Radiocirurgia/efeitos adversos , Resultado do Tratamento
11.
Int J Radiat Oncol Biol Phys ; 65(2): 554-60, 2006 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-16690437

RESUMO

PURPOSE: To measure respiration-induced abdominal organ motion using four-dimensional computed tomography (4D CT) scanning and to examine the organ paths. METHODS AND MATERIALS: During 4D CT scanning, consecutive CT images are acquired of the patient at each couch position. Simultaneously, the patient's respiratory pattern is recorded using an external marker block taped to the patient's abdomen. This pattern is used to retrospectively organize the CT images into multiple three-dimensional images, each representing one breathing phase. These images are analyzed to measure organ motion between each phase. The displacement from end expiration is compared to a displacement limit that represents acceptable dosimetric results (5 mm). RESULTS: The organs measured in 13 patients were the liver, spleen, and left and right kidneys. Their average superior to inferior absolute displacements were 1.3 cm for the liver, 1.3 cm for the spleen, 1.1 cm for the left kidney, and 1.3 cm for the right kidney. Although the organ paths varied among patients, 5 mm of superior to inferior displacement from end expiration resulted in less than 5 mm of displacement in the other directions for 41 of 43 organs measured. CONCLUSIONS: Four-dimensional CT scanning can accurately measure abdominal organ motion throughout respiration. This information may result in greater organ sparing and planning target volume coverage.


Assuntos
Abdome , Imageamento Tridimensional/métodos , Movimento , Respiração , Tomografia Computadorizada por Raios X/métodos , Feminino , Humanos , Rim/diagnóstico por imagem , Fígado/diagnóstico por imagem , Masculino , Radiografia Abdominal/métodos , Baço/diagnóstico por imagem , Tecnologia Radiológica/métodos
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