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1.
Am Surg ; 85(10): 1139-1141, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657310

RESUMO

Decisions regarding whether to close the skin in trauma patients with hollow viscus injuries (HVIs) are based on surgeon discretion and the perceived risk for an SSI. We hypothesized that leaving the skin open would result in fewer wound complications in patients with HVIs. We performed a retrospective analysis of all adult patients who underwent operative repair of an HVI. The main outcome measure was superficial or deep SSIs. Of 141 patients, 38 (27%) had HVIs. Twenty-six patients developed SSIs, of which 13 (50%) were superficial or deep SSIs. On adjusted analysis, only female gender (P = 0.03) and base deficit were associated (P = 0.001) with wound infections Open wound management was not associated with a decreased incidence of SSIs (P = 0.19) in patients with HVIs. Further research is required to determine optimal strategies for reducing wound complications in patients sustaining HVIs.


Assuntos
Traumatismos Abdominais/cirurgia , Técnicas de Fechamento de Ferimentos Abdominais/efeitos adversos , Procedimentos Cirúrgicos Dermatológicos/efeitos adversos , Infecção da Ferida Cirúrgica/epidemiologia , Ferida Cirúrgica/cirurgia , Técnicas de Fechamento de Ferimentos Abdominais/estatística & dados numéricos , Adulto , Antibioticoprofilaxia/estatística & dados numéricos , Procedimentos Cirúrgicos Dermatológicos/métodos , Duodeno/lesões , Feminino , Humanos , Intestino Delgado/lesões , Jejuno/lesões , Masculino , Estudos Retrospectivos , Pele , Estatísticas não Paramétricas , Estômago/lesões , Infecção da Ferida Cirúrgica/classificação , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle
2.
Am Surg ; 85(10): 1146-1149, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657312

RESUMO

Cirrhosis is associated with adverse outcomes after emergency general surgery (EGS). The objective of this study was to determine the safety of laparoscopic cholecystectomy (LC) in EGS patients with cirrhosis. We performed a two-year retrospective cohort analysis of adult patients who underwent LC for symptomatic gallstones. The primary outcome was the incidence of intraoperative complications. Of 796 patients, 59 (7.4%) were cirrhotic, with a median model for end-stage liver disease (MELD) score of 15 (IQR, 7). On unadjusted analysis, patients with cirrhosis were older, more likely to be male (both P < 0.01), diabetic (P < 0.001), had a higher incidence of preadmission antithrombotic therapy use (P < 0.02), and experienced a longer time to surgery (3.2 vs 1.8 days, P < 0.001). Coarsened exact matching revealed no difference in intra- or postoperative complications between groups (P = 0.67). Operative duration was longer in patients with cirrhosis (162 vs 114 minutes, P = 0.001), who also had a nonsignificant increase in the rate of conversion to an open cholecystectomy (14% vs 4%, P = 0.07). The results of this study indicate that LC may be safely performed in EGS patients with cirrhosis.


Assuntos
Colecistectomia Laparoscópica/efeitos adversos , Tratamento de Emergência/efeitos adversos , Cálculos Biliares/cirurgia , Complicações Intraoperatórias/epidemiologia , Cirrose Hepática/complicações , Doença Aguda , Adulto , Fatores Etários , Ductos Biliares/lesões , Conversão para Cirurgia Aberta/estatística & dados numéricos , Tratamento de Emergência/métodos , Feminino , Fibrinolíticos/uso terapêutico , Cálculos Biliares/etiologia , Hemorragia/epidemiologia , Humanos , Incidência , Intestinos/lesões , Complicações Intraoperatórias/etiologia , Cirrose Hepática/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Segurança , Fatores Sexuais , Fatores de Tempo , Tempo para o Tratamento/estatística & dados numéricos
3.
Am J Surg ; 218(6): 1185-1188, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31551145

RESUMO

INTRODUCTION: The early identification of hemorrhagic shock may be challenging. The objective of this study was to examine the utility of a narrowed pulse pressure in identifying the need for emergent interventions following penetrating trauma. METHODS: In this 2.5-year retrospective study of adult patients with a penetrating mechanism, patients with a narrowed pulse pressure (<30 mmHg) were compared to those without. Main outcomes measures were the need for a massive transfusion or emergent operation. RESULTS: There were 957 patients, of which the majority were male (86%) and 55% presented with gunshot wounds. On multivariate analysis, a narrowed pulse pressure was associated with the need for massive transfusion (OR 3.74, 95% C.I. 1.8-7.7, p = 0.0003) and emergent surgery (OR 1.68, 95% C.I. 1.14-2.48, p = 0.009). CONCLUSIONS: A narrowed pulse pressure is associated with the presence of hemorrhagic shock and need for emergent interventions among patients with penetrating torso trauma.

5.
J Surg Case Rep ; 2017(5): rjw179, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28560016

RESUMO

Large cell neuroendocrine carcinoma (LCNEC) of the urinary bladder are rare. We present a case of a 72-year-old man who presented with back pain and acute renal failure. Ultrasound showed a soft tissue mass in the base of the bladder causing bilateral ureteric obstruction. Subsequent biopsy of this mass demonstrated neuroendocrine carcinoma. He was commenced on neoadjuvant chemotherapy (carboplatin/etoposide) and proceeded to a radical cysto-prostatectomy. Histology revealed a LCNEC involving the bladder, T4a with invasion through to adipose tissue and posteriorly at perivesical resection margins. In addition, there was a Gleason score 9 prostatic adenocarcinoma, distinct from the neuroendocrine carcinoma. Following surgery, the patient developed gross local-regional recurrence and refused further systemic therapy. However, 1 year following referral to palliative care, a further CT-PET showed complete spontaneous remission of his disease. There are only few case reports of LCNEC of the urinary bladder therefore the pathogenesis and treatment protocol are still unclear. This case report highlights the unpredictable nature of this disease.

6.
J Magn Reson Imaging ; 45(4): 998-1004, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-27648498

RESUMO

PURPOSE: To identify magnetic resonance imaging (MRI) features of sinonasal rhabdomyosarcoma in adults, including diffusion-weighted (DW) and dynamic contrast-enhanced (DCE) MRI features as compared with carcinomas. MATERIALS AND METHODS: Sixty-four patients were included in this study, including 12 sinonasal rhabdomyosarcomas and 52 sinonasal carcinomas. MRI was completed in all 64 patients with a 3T MR scanner. Conventional MR (nonenhanced and static contrast-enhanced) imaging features, DCE-MRI parameters, and the apparent diffusion coefficients (ADCs) were analyzed by two authors independently (X.Y.W. and Y.Z.W.). RESULTS: Compared with gray matter, sinonasal rhabdomyosarcomas appeared isointense on T1 -weighted images in 11 cases (91.7%, 11 of 12), and hyperintense on T2 -weighted images in 9 patients (75%, 9 of 12). After contrast, sinonasal rhabdomyosarcomas showed inhomogeneous enhancement in 10 cases (83.3%, 10 of 12). Skull involvement was found in eight patients (66.7%) with rhabdomyosarcomas. On T2 -weighted images, sinonasal carcinomas demonstrated isointense in 31 cases (59.6%, 31/52), hyperintense in 14 (26.9%, 14/52), and hypointense in 7 (13.5%, 7/52). Skull involvement was detected in 14 cases (14/52, 26.9%). There were significant differences in T2 signal intensity (P = 0.005) and skull involvement (P = 0.016) between sinonasal rhabdomyosarcoma and carcinomas. There was a marginal difference in time to peak enhancement (P = 0.061), while no difference in time to maximum enhancement (P = 0.403), maximum contrast index (P = 0.368), and time-intensity curve types (P = 0.138) between rhabdomyosarcoma and carcinomas. The ADCs of sinonasal rhabdomyosarcoma were significantly lower than those of sinonasal carcinomas (P < 0.001). CONCLUSION: A multiparametric approach using conventional MRI with added ADCs had the potential to improve the diagnostic accuracy of sinonasal rhabdomyosarcoma in adults. Evidence level: 4 J. Magn. Reson. Imaging 2017;45:998-1004.


Assuntos
Carcinoma/diagnóstico por imagem , Imagem por Ressonância Magnética/métodos , Neoplasias Nasais/diagnóstico por imagem , Seios Paranasais/diagnóstico por imagem , Rabdomiossarcoma/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Adulto Jovem
8.
Burns ; 43(4): 741-746, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28034668

RESUMO

INTRODUCTION: This study aimed to determine if a scar quality is associated with quality of life (QoL) at six months post-burn and beyond. METHODS: Quantile regression models adjusted for covariates were used to demonstrate the relationship of modified Vancouver Scar Scale (mVSS) total (with and without pigmentation) and the mVSS components, to the Burn Specific Health Scale-Brief (BSHS-B) scores (full scale, Affect and Relations domain, Skin Sensitivity domain). RESULTS: The sample (n=341) comprised 67% males, 83% with skin grafts with a median age 38 years, total body surface area (TBSA) 4%, length of stay seven days, mVSS total score of five and BSHS-B total score of 153. Between six and 12 months of injury, mVSS total, TBSA and female gender were significantly associated with the BSHS-B, a situation that was not affected by the presence or absence of pigmentation scores. The mVSS components did not individually influence QoL. DISCUSSION: mVSS total score, gender and burn size data may be a useful adjunct to experienced clinical judgment for identifying at risk patients and directing appropriate, timely resource allocation.


Assuntos
Queimaduras/cirurgia , Cicatriz/psicologia , Qualidade de Vida/psicologia , Transplante de Pele , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Imagem Corporal/psicologia , Superfície Corporal , Queimaduras/complicações , Cicatriz/etiologia , Cicatriz/patologia , Elasticidade , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Análise de Regressão , Estudos Retrospectivos , Medição de Risco , Autogestão , Fatores Sexuais , Pele/patologia , Pigmentação da Pele , Inquéritos e Questionários , Adulto Jovem
9.
N Z Med J ; 129(1446): 79-83, 2016 Dec 02.
Artigo em Inglês | MEDLINE | ID: mdl-27906922

RESUMO

INTRODUCTION: Radiation cystitis is one of the possible complications from pelvic radiotherapy. Hyperbaric oxygen (HBOT) improves tissue oxygenation and healing of scarred tissue. AIMS: To assess the efficacy of hyperbaric oxygen therapy (HBOT) in the management of radiation-induced haemorrhagic cystitis in patients with urological cancers. METHODS: This is a retrospective review on all patients with macroscopic haematuria secondary to radiation induced haemorrhagic cystitis who were treated with hyperbaric oxygen therapy (HBOT) between 2009 and 2013. The primary outcome is symptomatic assessment (either complete resolution, partial resolution or no change). RESULTS: A total of 12 patients with radiation-induced cystitis secondary to urological cancer were included in this study with a mean follow-up of 443 days. The mean age was 78 years. Complete resolution of haematuria was seen in six out of 12 patients. Partial response was achieved in two patients where one required two courses of HBOT and one required three courses of HBOT. As a result, the overall improvement of haematuria after HBOT was 67%. A total of four patients had no response to HBOT. CONCLUSION: Radiation-induced cystitis is a difficult clinical problem to treat. HBOT is not a magic bullet but it may be another alternative treatment option we have at this point in time.


Assuntos
Cistite/terapia , Hematúria/terapia , Oxigenação Hiperbárica/métodos , Lesões por Radiação/complicações , Neoplasias Urológicas/radioterapia , Idoso , Idoso de 80 Anos ou mais , Cistite/etiologia , Feminino , Seguimentos , Hematúria/etiologia , Humanos , Masculino , Lesões por Radiação/terapia , Estudos Retrospectivos , Resultado do Tratamento
10.
Injury ; 47(9): 2000-5, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-27324324

RESUMO

BACKGROUND: The precise role of thoracic CT in penetrating chest trauma remains to be defined. We hypothesized that thoracic CT effectively screens hemodynamically normal patients with penetrating thoracic trauma to surgery vs. expectant management (NOM). METHODS: A ten-year review of all penetrating torso cases was retrospectively analyzed from our urban University-based trauma center. We included hemodynamically normal patients (systolic blood pressure ≥90) with penetrating chest injuries that underwent screening thoracic CT. Hemodynamically unstable patients and diaphragmatic injuries were excluded. The sensitivity, specificity, positive predictive value and negative predictive value were calculated. RESULTS: A total of 212 patients (mean injury severity score=24, Abbreviated Injury Score for Chest=3.9) met inclusion criteria. Of these, 84.3% underwent NOM, 9.1% necessitated abdominal exploration, 6.6% underwent exploration for retained hemothorax/empyema, 6.6% underwent immediate thoracic exploration for significant injuries on chest CT, and 1.0% underwent delayed thoracic exploration for missed injuries. Thoracic CT had a sensitivity of 82%, specificity of 99%, positive predictive value of 90%, a negative predictive value of 99%, and an accuracy of 99% in predicting surgery vs. NOM. CONCLUSIONS: Thoracic CT has a negative predictive value of 99% in triaging hemodynamically normal patients with penetrating chest trauma. Screening thoracic CT successfully excludes surgery in patients with non-significant radiologic findings.


Assuntos
Serviço Hospitalar de Emergência , Hemotórax/diagnóstico por imagem , Derrame Pericárdico/diagnóstico por imagem , Pneumotórax/diagnóstico por imagem , Traumatismos Torácicos/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Centros de Traumatologia , Ferimentos Penetrantes/diagnóstico por imagem , Adulto , Feminino , Hemotórax/cirurgia , Humanos , Escala de Gravidade do Ferimento , Masculino , Derrame Pericárdico/cirurgia , Pneumotórax/cirurgia , Valor Preditivo dos Testes , Estudos Retrospectivos , Traumatismos Torácicos/epidemiologia , Traumatismos Torácicos/cirurgia , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Estados Unidos/epidemiologia , Revisão da Utilização de Recursos de Saúde , Ferimentos Penetrantes/epidemiologia , Ferimentos Penetrantes/cirurgia
11.
Int J Surg ; 25: 19-23, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26612527

RESUMO

INTRODUCTION: Acute lower gastrointestinal bleeding (LGIB) is a common acute presenting complaint to hospital. Unlike upper gastrointestinal bleeding, the diagnostic and therapeutic approach is not well-standardised. Intensive monitoring and urgent interventions are essential for patients with severe LGIB. The aim of this study is to investigate factors that predict severe LGIB and develop a clinical predictor tool to accurately triage LGIB in the emergency department of a busy metropolitan teaching hospital. METHODS: We retrospectively identified all adult patients who presented to Middlemore Hospital Emergency Department with LGIB over a one year period. We recorded demographic variables, Charlson Co-morbidities Index, use of anticoagulation, examination findings, vital signs on arrival, laboratory test results, treatment plans and further investigations results. We then identified a subgroup of patients who suffered severe LGIB. RESULTS: A total of 668 patients presented with an initial triage diagnosis of LGIB. 83 of these patients (20%) developed severe LGIB. Binary logistic regression analysis identified four independent risk factors for severe LGIB: use of aspirin, history of collapse, haemoglobin on presentation of less than 100 mg/dl and albumin of less than 38 g/l. CONCLUSIONS: We have developed a clinical prediction tool for severe LGIB in our population with a negative predictive value (NPV) of 88% and a positive predictive value (PPV) of 44% respectively. We aim to validate the clinical prediction tool in a further cohort to ensure stability of the multivariate model.


Assuntos
Hemorragia Gastrointestinal/etiologia , Triagem/métodos , Doença Aguda , Adulto , Idoso , Aspirina/efeitos adversos , Estudos de Coortes , Comorbidade , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hemorragia Gastrointestinal/sangue , Hemoglobina A/análise , Humanos , Masculino , Pessoa de Meia-Idade , Exame Físico , Inibidores da Agregação de Plaquetas/efeitos adversos , Valor Preditivo dos Testes , Análise de Regressão , Estudos Retrospectivos , Fatores de Risco , Albumina Sérica/análise , Triagem/normas
12.
Medicine (Baltimore) ; 94(35): e1452, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26334907

RESUMO

The primary malignant tumors of external auditory canal (EAC) are rare. The purpose of this study is to compare the imaging features of growth and recurrence pattern between 2 most common carcinomas namely squamous cell carcinoma (SCC) and adenocarcinoma of the EAC.This is a retrospective study involving 41 patients with primary EAC carcinomas of which 22 are SCC and 19 are adenocarcinoma. They were all scanned with high resolution computer tomography (HRCT) and magnetic resonance imaging. Follow-up clinical and imaging studies have also been collected and compared with a median follow-up time of 43 months (range 5-192 months). Necrosis was presented as hypodensity on computed tomography images, hyper-intense on T2WI and heterogeneous enhancement.Eighteen patients were diagnosed to be in T1 and T2 stage, it was found that SCC involved both the cartilaginous part and the bony part of the EAC (11/12), whereas adenocarcinoma involved only the cartilaginous part (6/6) (P < 0.01). Twenty-three patients were diagnosed to be in T3 and T4 stage showed bony involvement and adjacent tissue involvement for both SCC and adenocarcinoma. Parapharyngeal space involvement is much more common in recurrent SCC (P = 0.02). Lymph node metastasis was seen in 6 out of 22 patients with SCC, while 5 out of 19 patients of adenocarcinoma had lung metastasis, even at early stage (1/6; 1/5). Necrosis is more likely to occur in the patients with SCC (9/10) than that of adenocarcinoma (3/13) (P = 0.02).SCC and adenocarcinoma is seen to have different growth pattern at early stage but share similar patterns in the advanced stage. Lymph node metastasis is commonly seen in patients with SCC while adenocarcinoma shows lung metastasis even at early stage.


Assuntos
Adenocarcinoma/diagnóstico por imagem , Carcinoma de Células Escamosas/diagnóstico por imagem , Meato Acústico Externo/diagnóstico por imagem , Meato Acústico Externo/patologia , Neoplasias da Orelha/diagnóstico por imagem , Adenocarcinoma/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Escamosas/patologia , Proliferação de Células , Estudos Transversais , Progressão da Doença , Neoplasias da Orelha/patologia , Feminino , Seguimentos , Humanos , Metástase Linfática/patologia , Metástase Linfática/radioterapia , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/diagnóstico por imagem , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Estudos Retrospectivos , Tomografia Computadorizada por Raios X
13.
J Surg Case Rep ; 2015(7)2015 Jul 16.
Artigo em Inglês | MEDLINE | ID: mdl-26183574

RESUMO

We present a case on abdominal wall abscess from spilled stones post-cholecystectomy and describe laparoscopic drainage as our choice of management. Mr M is a 75-year-old male who presented on multiple occasions to the hospital with right upper quadrant pain and fever post-laparoscopic cholecystectomy. He also required multiple courses of antibiotics. Subsequent computed tomography and magnetic resonance imaging scan confirmed a number of retained stone with signs of chronic inflammation. Hence, 6 months after his initial laparoscopic cholecystectomy, he proceeded to an exploratory laparoscopy. We found an abscess cavity measuring 3 × 4 cm over the anterior abdominal wall. The cavity was de-roofed, drained and washed out. The tissue culture grew Klebsiella pneumoniae. Laparoscopic approach is optimal as the abscess cavity can be clearly identified, stones visualized and removed under direct vision. Patient does not require a laparotomy.

14.
JAMA Surg ; 150(8): 757-62, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26107381

RESUMO

IMPORTANCE: The care of most patients with pneumomediastinum (PNM) due to trauma can be managed conservatively; however, owing to aerodigestive tract injury and other associated injuries, there is a subset of patients with PNM who are at higher risk of mortality but can be difficult to identify. OBJECTIVE: To characterize computed tomographic (CT) findings associated with mortality in patients with PNM due to blunt trauma. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of medical records from January 1, 2002, to December 31, 2011, was conducted at a university-based urban trauma center. The patients evaluated were those injured by blunt trauma and found to have PNM on initial chest CT scanning. Data analysis was performed July 2, 2013, to June 18, 2014. MAIN OUTCOMES AND MEASURES: In-hospital mortality. RESULTS: During the study period, 3327 patients with blunt trauma underwent chest CT. Of these, 72 patients (2.2%) had PNM. Patients with PNM had higher Injury Severity Scores (P < .001) and chest Abbreviated Injury Scale scores (P < .001) compared with those without PNM. Pneumomediastinum was associated with higher mortality (9 [12.5%] vs 118 [3.6%] patients; P < .001) and longer mean (SD) hospital stays (11.3 [14.6] vs 5.1 [8.8] days; P < .001), intensive care unit stays (5.4 [10.2] vs 1.8 [5.7] days; P < .001), and ventilator days (1.7 [4.2] vs 0.6 [4.0] days; P < .03). We evaluated several chest CT findings that may have predictive value. Pneumomediastinum size was not associated with in-hospital mortality (P = .22). However, location of air in the posterior mediastinum was associated with increased mortality of 25% (7 of 28 patients; P = .007). Air in all mediastinal compartments was also associated with increased mortality of 40.0% (4 of 10 patients; P = .01). Presence of hemothorax along with PNM was associated with mortality of 22.2% (8 of 36 patients; P = .01). CONCLUSIONS AND RELEVANCE: Pneumomediastinum is uncommon in patients with injury from blunt trauma; however, CT findings of posterior PNM, air in all mediastinal compartments, and concurrent hemothorax are associated with increased mortality. These CT findings could be used as a triage tool to alert the trauma surgeon to a potentially lethal injury.


Assuntos
Enfisema Mediastínico/diagnóstico por imagem , Enfisema Mediastínico/mortalidade , Traumatismos Torácicos , Ferimentos não Penetrantes , Adulto , Mortalidade Hospitalar , Humanos , Enfisema Mediastínico/etiologia , Pessoa de Meia-Idade , Estudos Retrospectivos , Traumatismos Torácicos/complicações , Traumatismos Torácicos/diagnóstico por imagem , Traumatismos Torácicos/mortalidade , Tomografia Computadorizada por Raios X , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/mortalidade , Adulto Jovem
15.
J Neurosurg ; 123(3): 662-9, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26023999

RESUMO

OBJECT: Both the older and the recent extracranial-intracranial (EC-IC) bypass trials for symptomatic carotid occlusion failed to demonstrate a reduction in stroke recurrence. However, the role of superficial temporal artery (STA)-middle cerebral artery (MCA) bypass in patients with symptomatic intracranial stenoocclusive disease has been rarely evaluated. The authors evaluated serial changes in various cerebral hemodynamic parameters in patients with severe stenoocclusive disease of the intracranial internal carotid artery (ICA) or middle cerebral artery (MCA) and impaired cerebral vasodilatory reserve (CVR), treated by STA-MCA bypass surgery or medical treatment. METHODS: Patients with severe stenoocclusive disease of the intracranial ICA or MCA underwent transcranial Doppler (TCD) ultrasonography and CVR assessment using the breath-holding index (BHI). Patients with impaired BHI (< 0.69) were further evaluated with acetazolamide-challenge technitium-99m hexamethylpropyleneamine oxime ((99m)Tc HMPAO) SPECT. STA-MCA bypass surgery was offered to patients with impaired CVR on SPECT. All patients underwent TCD and SPECT at 4 ± 1 months and were followed up for cerebral ischemic events. RESULTS: A total of 112 patients were included. This total included 73 men, and the mean age of the entire study population was 56 years (range 23-78 years). (99m)Tc HMPAO SPECT demonstrated impaired CVR in 77 patients (69%). Of these 77 patients, 46 underwent STA-MCA bypass while 31 received best medical treatment. TCD and acetazolamide-challenge (99m)Tc HMPAO SPECT repeated at 4 ± 1 months showed significant improvement in the STA-MCA bypass group. During a mean follow-up of 34 months (range 18-39 months), only 6 (13%) of 46 patients in the bypass group developed cerebral ischemic events, as compared with 14 (45%) of 31 patients receiving medical therapy (absolute risk reduction 32%, p = 0.008). CONCLUSIONS: STA-MCA bypass surgery in carefully selected patients with symptomatic severe intracranial stenoocclusive disease of the intracranial ICA or MCA results in significant improvement in hemodynamic parameters and reduction in stroke recurrence.


Assuntos
Estenose das Carótidas/cirurgia , Revascularização Cerebral/métodos , Circulação Cerebrovascular/fisiologia , Doenças Arteriais Intracranianas/cirurgia , Artéria Cerebral Média/cirurgia , Artérias Temporais/cirurgia , Adulto , Idoso , Estenose das Carótidas/fisiopatologia , Feminino , Hemodinâmica/fisiologia , Humanos , Doenças Arteriais Intracranianas/fisiopatologia , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/fisiopatologia , Estudos Prospectivos , Resultado do Tratamento , Adulto Jovem
16.
J Surg Res ; 199(1): 177-82, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25986212

RESUMO

BACKGROUND: Measures of individual socioeconomic status correlate with recurrent violent injury; however, neighborhood socioeconomic status may also matter. We conducted a review of victims of interpersonal violence treated at our trauma center, hypothesizing that the percent of the population living under the poverty level in their neighborhood is associated with recurrent violent victimization. MATERIALS AND METHODS: We identified victims of interpersonal violence, ages 12-24, in our trauma registry from 2005-2010. Recurrent episodes of violent injury were identified through 2012. The percentage of the population living under the poverty level for the patient's zip code of residence was derived from United States census estimates and divided into quartiles. Multivariable logistic regression was conducted to evaluate predictors of violent injury recidivism. RESULTS: Our cohort consisted of 1890 patients. Multivariable logistic regression confirmed the following factors as independent predictors of violent injury recidivism: male sex (odds ratio [OR] = 2 [1.06-3.80]; P = 0.03), black race (OR = 2.1 [1.44-3.06]; P < 0.001), injury due to firearms (OR = 1.67 [1.12-2.50]; P = 0.01), and living in the lowest zip code socioeconomic quartile (OR = 1.59 [1.12-2.25]; P = 0.01). CONCLUSIONS: For young patients injured by violence, the socioeconomic position of their neighborhood of residence is independently correlated with their risk of violent reinjury. Low neighborhood socioeconomic status may be associated with a disrupted sense of safety after injury and also may alter a person's likelihood of engaging in behaviors correlated with recurrent violent injury. Programs aimed at reducing violent injury recidivism should address needs at the individual and neighborhood level.


Assuntos
Vítimas de Crime/estatística & dados numéricos , Pobreza , Características de Residência , Classe Social , Violência/estatística & dados numéricos , Ferimentos e Lesões/etiologia , Adolescente , Adulto , California/epidemiologia , Criança , Vítimas de Crime/economia , Feminino , Humanos , Modelos Logísticos , Masculino , Recidiva , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Violência/economia , Ferimentos e Lesões/epidemiologia , Adulto Jovem
17.
Am J Surg ; 209(4): 597-603, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25728889

RESUMO

BACKGROUND: Hospital-centered violence intervention programs (HVIPs) reduce violent injury recidivism. However, dedicated cost analyses of such programs have not yet been published. We hypothesized that the HVIP at our urban trauma center is a cost-effective means for reducing violent injury recidivism. METHODS: We conducted a cost-utility analysis using a state-transition (Markov) decision model, comparing participation in our HVIP with standard risk reduction for patients injured because of firearm violence. Model inputs were derived from our trauma registry and published literature. RESULTS: The 1-year recidivism rate for participants in our HVIP was 2.5%, compared with 4% for those receiving standard risk reduction resources. Total per-person costs of each violence prevention arm were similar: $3,574 for our HVIP and $3,515 for standard referrals. The incremental cost effectiveness ratio for our HVIP was $2,941. CONCLUSION: Our HVIP is a cost-effective means of preventing recurrent episodes of violent injury in patients hurt by firearms.


Assuntos
Hospitais , Violência/economia , Violência/prevenção & controle , Ferimentos por Arma de Fogo/economia , Ferimentos por Arma de Fogo/prevenção & controle , Adolescente , Criança , Análise Custo-Benefício , Feminino , Humanos , Masculino , Cadeias de Markov , Recidiva , Adulto Jovem
20.
Surgery ; 156(6): 1569-77; discussion 1577-8, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25444226

RESUMO

BACKGROUND: Papillary thyroid carcinoma (PTC) with BRAF mutation carries a poorer prognosis. Prophylactic central neck dissection (CND) reduces locoregional recurrences, and we hypothesize that initial total thyroidectomy (TT) with CND in patients with BRAF-mutated PTC is cost effective. METHODS: This cost-utility analysis is based on a hypothetical cohort of 40-year-old women with small PTC [2 cm, confined to the thyroid, node(-)]. We compared preoperative BRAF testing and TT+CND if BRAF-mutated or TT alone if BRAF-wild type, versus no testing with TT. This analysis took into account treatment costs and opportunity losses. Key variables were subjected to sensitivity analysis. RESULTS: Both approaches produced comparable outcomes, with costs of not testing being lower (-$801.51/patient). Preoperative BRAF testing carried an excess expense of $33.96 per quality-adjusted life-year per patient. Sensitivity analyses revealed that when BRAF positivity in the testing population decreases to 30%, or if the overall noncervical recurrence in the population increases above 11.9%, preoperative BRAF testing becomes the more cost-effective strategy. CONCLUSION: Outcomes with or without preoperative BRAF testing are comparable, with no testing being the slightly more cost-effective strategy. Although preoperative BRAF testing helps to identify patients with higher recurrence rates, implementing a more aggressive initial operation does not seem to offer a cost advantage.


Assuntos
Carcinoma/genética , Testes Genéticos/economia , Esvaziamento Cervical/economia , Proteínas Proto-Oncogênicas B-raf/genética , Neoplasias da Glândula Tireoide/genética , Tireoidectomia/economia , Adulto , Carcinoma/economia , Carcinoma/cirurgia , Carcinoma Papilar , Análise Custo-Benefício , Análise Mutacional de DNA/economia , Feminino , Humanos , Modelos Teóricos , Esvaziamento Cervical/métodos , Cuidados Pré-Operatórios/economia , Prognóstico , Câncer Papilífero da Tireoide , Neoplasias da Glândula Tireoide/economia , Neoplasias da Glândula Tireoide/cirurgia , Tireoidectomia/métodos
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