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2.
Ann Surg ; 271(2): 283-289, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30048320

RESUMO

OBJECTIVE: To compare the accuracy of the modified Fried Index (mFI) and the Clinical Frailty Scale (CFS) to predict death or patient-reported new disability 90 days after major elective surgery. BACKGROUND: The association of frailty with patient-reported outcomes, and comparisons between preoperative frailty instruments are poorly described. METHODS: This was a prospective multicenter cohort study. We determined frailty status in individuals ≥65 years having elective noncardiac surgery using the mFI and CFS. Outcomes included death or patient-reported new disability (primary); safety incidents, length of stay (LOS), and institutional discharge (secondary); ease of use, usefulness, benefit, clinical importance, and feasibility (tertiary). We measured the adjusted association of frailty with outcomes using regression analysis and compared true positive and false positive rates (TPR/FPR). RESULTS: Of 702 participants, 645 had complete follow up. The CFS identified 297 (42.3%) with frailty, the mFI 257 (36.6%); 72 (11.1%) died or experienced a new disability. Frailty was significantly associated with the primary outcome (CFS adjusted odds ratio, OR, 2.51, 95% confidence interval, CI, 1.50-4.21; mFI adjusted-OR 2.60, 95% CI 1.57-4.31). TPR and FPR were not significantly different between instruments. Frailty was the only significant predictor of death or new disability in a multivariable analysis. Need for institutional discharge, costs and LOS were significantly increased in individuals with frailty. The CFS was easier to use, required less time and had less missing data. CONCLUSIONS: Older people with frailty are significantly more likely to die or experience a new patient-reported disability after surgery. Clinicians performing frailty assessments before surgery should consider the CFS over the mFI as accuracy was similar, but ease of use and feasibility were higher.

4.
J Thorac Dis ; 10(Suppl 32): S3761-S3772, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30505563

RESUMO

Enhanced recovery after surgery (ERAS) programs include a variety of pre-, intra- and post-operative interventions that seek to decrease the stress response to surgery and facilitate the recovery of surgical patients. There are a number of patient factors that may increase the risk of postoperative complications (POC) after lung cancer surgery and delay recovery. Some of these factors may be amenable to optimization preoperatively and potentially decrease the incidence of these complications. We have chosen to discuss the incidence and complications associated with factors we felt were both relatively common and significant contributors to POCs. For each of these factors we discuss potential avenues for optimization and the evidence for the resulting decrease in complications.

5.
BMJ Open ; 8(6): e022057, 2018 06 22.
Artigo em Inglês | MEDLINE | ID: mdl-29934394

RESUMO

INTRODUCTION: Exercise prehabilitation may improve outcomes after surgery. Frailty is a key predictor of adverse postoperative outcomes in older people; the multidimensional nature of frailty makes this a population who may derive substantial benefit from exercise prehabilitation. The objective of this trial is to test the efficacy of exercise prehabilitation to improve postoperative functional outcomes for people living with frailty having cancer surgery with curative intent. METHODS AND ANALYSIS: We will conduct a single-centre, parallel-arm randomised controlled trial of home-based exercise prehabilitation versus standard care among consenting patients >60 years having elective cancer surgery (intra-abdominal and intrathoracic) and who are frail (Clinical Frailty Scale >4). The intervention consists of > 3 weeks of exercise prehabilitation (strength, aerobic and stretching). The primary outcome is the 6 min walk test at the first postoperative clinic visit. Secondary outcomes include the short physical performance battery, health-related quality of life, disability-free survival, complications and health resource utilisation. The primary outcome will be analysed by intention to treat using analysis of covariance. Outcomes up to 1 year after surgery will be ascertained through linkage to administrative data. ETHICS AND DISSEMINATION: Ethical approval has been granted by our ethics review board (Protocol Approval #2016009-01H). Results will be disseminated through presentation at scientific conferences, through peer-reviewed publication, stakeholder organisations and engagement of social and traditional media. TRIAL REGISTRATION NUMBER: NCT02934230; Pre-results.


Assuntos
Terapia por Exercício/métodos , Fragilidade/reabilitação , Neoplasias/cirurgia , Cuidados Pré-Operatórios , Procedimentos Cirúrgicos Eletivos , Humanos , Tempo de Internação , Modelos Lineares , Modelos Logísticos , Cooperação do Paciente , Complicações Pós-Operatórias , Estudos Prospectivos , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto
6.
Gynecol Oncol ; 146(2): 228-233, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28532856

RESUMO

OBJECTIVE(S): To evaluate the frequency of surgical site infections before and after implementation of a comprehensive, multidisciplinary perioperative glycemic control initiative. STUDY METHODS: As part of a CUSP (Comprehensive Unit-based Safety Program) initiative, between January 5 and December 18, 2015, we implemented comprehensive, multidisciplinary glycemic control initiative to reduce SSI rates in patients undergoing major pelvic surgery for a gynecologic malignancy ('Group II'). Key components of this quality of care initiative included pre-operative HbA1c measurement with special triage for patients meeting criteria for diabetes or pre-diabetes, standardization of available intraoperative insulin choices, rigorous pre-op/intra-op/post-op glucose monitoring with control targets set to maintain BG ≤10mmol/L (180mg/dL) and communication/notification with primary care providers. Effectiveness was evaluated against a similar control group of patients ('Group I') undergoing surgery in 2014 prior to implementation of this initiative. RESULTS: We studied a total of 462 patients. Subjects in the screened (Group II) and comparison (Group I) groups were of similar age (avg. 61.0, 60.0years; p=0.422) and BMI (avg. 31.1, 32.3kg/m2; p=0.257). Descriptive statistics served to compare surgical site infection (SSI) rates and other characteristics across groups. Women undergoing surgery prior to implementation of this algorithm (n=165) had an infection rate of 14.6%. Group II (n=297) showed an over 2-fold reduction in SSI compared to Group I [5.7%; p=0.001, adjRR: 0.45, 95% CI: (0.25, 0.81)]. Additionally, approximately 19% of Group II patients were newly diagnosed with either prediabetes (HbA1C 6.0-6.4) or diabetes (HbA1C≥6.5) and were referred to family or internal medicine for appropriate management. CONCLUSION(S): Implementation of a comprehensive multidisciplinary glycemic control initiative can lead to a significant reduction in surgical site infections in addition to early identification of an important health condition in the gynecologic oncology patient population.


Assuntos
Diabetes Mellitus Tipo 2/diagnóstico , Neoplasias dos Genitais Femininos/cirurgia , Hemoglobina A Glicada/metabolismo , Procedimentos Cirúrgicos em Ginecologia , Hiperglicemia/tratamento farmacológico , Complicações Pós-Operatórias/tratamento farmacológico , Estado Pré-Diabético/diagnóstico , Infecção da Ferida Cirúrgica/prevenção & controle , Idoso , Estudos de Casos e Controles , Diabetes Mellitus Tipo 2/metabolismo , Diabetes Mellitus Tipo 2/terapia , Feminino , Humanos , Programas de Rastreamento , Pessoa de Meia-Idade , Estado Pré-Diabético/metabolismo , Estado Pré-Diabético/terapia , Encaminhamento e Consulta , Estudos Retrospectivos , Medição de Risco
7.
Sci Total Environ ; 579: 557-568, 2017 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-27871751

RESUMO

There is growing concern worldwide about the exposure of groundwater resources to pharmaceutically active compounds (PhACs) and agricultural contaminants, such as pesticides, nitrate, and Escherichia coli. For regions with a low population density and an abundance of water, regional contamination assessments are not carried out systematically due to the typically low concentrations and high costs of analyses. The objectives of this study were to evaluate regional-scale contaminant distributions in untreated groundwater in a rural region of Quebec (Canada). The geological and hydrogeological settings of this region are typical of post-glacial regions around the world, where groundwater flow can be complex due to heterogeneous geological conditions. A new spatially distributed Anthropogenic Footprint Index (AFI), based on land use data, was developed to assess surface pollution risks. The Hydrogeochemical Vulnerability Index (HVI) was computed to estimate aquifer vulnerability. Nine wells had detectable concentrations of one to four of the 13 tested PhACs, with a maximum concentration of 116ng·L-1 for benzafibrate. A total of 34 of the 47 tested pesticides were detected in concentrations equal to or greater than the detection limit, with a maximum total pesticide concentration of 692ng·L-1. Nitrate concentrations exceeded 1mg·L-1 N-NO3 in 15.3% of the wells, and the Canadian drinking water standard was exceeded in one well. Overall, 13.5% of the samples had detectable E. coli. Including regional-scale sources of pollutants to the assessment of aquifer vulnerability with the AFI did not lead to the identification of contaminated wells, due to the short groundwater flow paths between recharge and the sampled wells. Given the occurrence of contaminants, the public health concerns stemming from these new data on regional-scale PhAC and pesticide concentrations, and the local flow conditions observed in post-glacial terrains, there is a clear need to investigate the sources and behaviours of local-scale pollutants.


Assuntos
Monitoramento Ambiental , Escherichia coli/crescimento & desenvolvimento , Nitratos/análise , Preparações Farmacêuticas/análise , Poluentes Químicos da Água/análise , Água Subterrânea/química , Água Subterrânea/microbiologia , Quebeque
8.
BMC Anesthesiol ; 16(1): 111, 2016 11 14.
Artigo em Inglês | MEDLINE | ID: mdl-27842511

RESUMO

BACKGROUND: Frailty is an aggregate expression of susceptibility to poor outcomes, owing to age-, and disease-related deficits that accumulate within multiple domains. Older patients who are frail before surgery are at an increased risk of morbidity and mortality, and use a disproportionately high amount of healthcare resources. While frailty is now a well-established risk factor for adverse postoperative outcomes, the perioperative literature lacks studies that: 1) compare the predictive accuracy of different frailty instruments; 2) consider the impact of frailty on patient-reported outcome measures; and 3) consider the acceptability and feasibility of using frailty instruments in clinical practice. METHODS: We will conduct a multicenter prospective cohort study comparing the predictive accuracy of the modified Fried Index (mFI) with the Clinical Frailty Scale (CFS) among consenting patients aged 65 years and older having elective major non-cardiac surgery. The primary outcome will be disability free survival at 90 days after surgery, a patient-reported outcome measure. Secondary outcomes will include complications, length of stay, discharge disposition, readmission and total health system costs. We will compare the accuracy of frailty instruments using the relative true positive rate and relative false positive rate. These measures can be interpreted as the relative difference in the probability of one instrument identifying a true case of death or new disability compared to another instrument, or the relative difference in the probability of one instrument identifying a false case of death or new disability, respectively. We will also assess the acceptability and feasibility of each instrument. DISCUSSION: Frailty is an important prognostic factor in the growing population of older patients having surgery. This study will provide novel findings regarding the choice of an accurate, clinically useable frailty instrument in predicting patient reported outcomes, as well as morbidity, mortality and resource use. These findings will inform current practice and future research.


Assuntos
Idoso Fragilizado , Avaliação Geriátrica/métodos , Complicações Pós-Operatórias/epidemiologia , Idoso , Estudos de Coortes , Avaliação da Deficiência , Reações Falso-Positivas , Humanos , Medidas de Resultados Relatados pelo Paciente , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Medição de Risco/métodos , Fatores de Risco , Análise de Sobrevida
9.
J Environ Radioact ; 164: 344-353, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27552658

RESUMO

Peatlands can play an important role in the hydrological dynamics of a watershed. However, interactions between groundwater and peat water remain poorly understood. Here, we present results of an exploratory study destined to test radon (222Rn) as a potential tracer of groundwater inflows from fluvioglacial landform aquifers to slope peatlands in the Amos region of Quebec, Canada. 222Rn occurs in groundwater but is expected to be absent from peat water because of its rapid degassing to the atmosphere. Any 222Rn activity detected in peat water should therefore derive from groundwater inflow. 222Rn activity was measured in groundwater from municipal, domestic wells and newly drilled and instrumented piezometers from the Saint-Mathieu-Berry and Barraute eskers (n = 9), from the Harricana Moraine (n = 4), and from the fractured bedrock (n = 3). Forty measurements of 222Rn activity were made from piezometers installed in five slope peatlands, along six transects oriented perpendicular to the fluvioglacial deposits. The relationship between 222Rn and total dissolved solids (TDS) measured in water from the mineral deposits underlying the peat layer suggests that 222Rn is introduced by lateral inflow from eskers and moraine together with salinity. This input is then diluted by peat water, depleted in both TDS and 222Rn. The fact that a relationship between TDS and 222Rn is visible calls for a continuous inflow of groundwater from lateral eskers/moraines, being 222Rn rapidly removed from the system by radioactive decay. Although more research is required to improve the sampling and tracing techniques, this work shows the potential of 222Rn tracer to identify groundwater inflow areas from granular aquifers found in eskers and moraines to slope peatlands.


Assuntos
Água Subterrânea/química , Monitoramento de Radiação , Radônio/análise , Poluentes Radioativos da Água/análise , Quebeque , Solo , Poços de Água
10.
Can J Anaesth ; 54(11): 882-90, 2007 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-17975232

RESUMO

PURPOSE: Patient-controlled epidural analgesia (PCEA) with meperidine provides effective analgesia following thoracotomy. Accumulation of normeperidine, a meperidine metabolite with neuroexcitatory effects, has led to recommendations to limit the use of meperidine postoperatively. The purpose of this study was to determine if the addition of adrenaline to PCEA meperidine decreased meperidine consumption, reduced serum normeperidine levels, and improved analgesia following thoracotomy. METHODS: Following Research Ethics approval consenting patients were randomly assigned to PCEA with either meperidine (2 mgxmL(-1)) + adrenaline (2 microgxmL(-1)) or meperidine alone (2 mgxmL(-1)). All patients received a standardized anesthetic and similar perioperative care. Visual analogue pain scores (at rest and with activity), quality of recovery (QoR) scores, and side effects were documented six, 24, and 48 hr postoperatively. Serum levels of meperidine and normeperidine were measured at the same time points. RESULTS: Forty-six patients completed the study protocol. Meperidine consumption (mean+/-SD) was similar in the meperidine + adrenaline and the meperidine groups (601+/-211 mg vs 580+/-211 mg over 48 hr, respectively; P=0.744). Serum meperidine levels were similar at all study time points. Serum normeperidine was not detected in any sample. Pain scores, QoR scores, and adverse events were comparable in both study groups. CONCLUSION: The addition of adrenaline did not influence PCEA meperidine consumption, analgesia outcomes, or QoR. Normeperidine did not accumulate in patients of either study group during the 48-hr study period. Meperidine for patient controlled epidural analgesia, with or without adrenaline, provides effective post-thoracotomy analgesia in selected patients.


Assuntos
Analgesia Epidural , Analgesia Controlada pelo Paciente , Epinefrina/administração & dosagem , Meperidina/administração & dosagem , Dor Pós-Operatória/tratamento farmacológico , Toracotomia , Adolescente , Adulto , Idoso , Humanos , Meperidina/sangue , Pessoa de Meia-Idade
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