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1.
Dermatitis ; 2020 Mar 21.
Artigo em Inglês | MEDLINE | ID: mdl-32209865

RESUMO

BACKGROUND: Contact dermatitis is a common disease that is associated with impaired quality of life. OBJECTIVE: We examined the effect of travel distance and other socioeconomic factors on duration of dermatitis before presentation at the Duke Contact Dermatitis and Patch Testing Center. METHODS: This is a retrospective study of patients who underwent patch testing from March 1, 2012, to August 1, 2018. Associations between duration of dermatitis, distance to clinic, and socioeconomic factors (age, race, payor group, county poverty rate, rural-urban status) were examined. RESULTS: The median duration of dermatitis was 14 months (Q1 = 7 months; Q3 = 36 months), and the median distance to clinic was 18 miles (Q1 = 7 miles; Q3 = 45.9 miles). For a 50-mile increase in the distance from the patient's zip code to the clinic, the median duration of dermatitis increased by 17.9% (P < 0.001). For every 5% increase in the county poverty rate, the median duration of dermatitis increased by 16.3% (n = 29; P = 0.032). Trends were noted for a longer duration of dermatitis based on insurance payor, rural-urban status, and race. CONCLUSIONS: Distance to patch test provider and county poverty status are important measures of access for patients with dermatitis.

2.
Cutis ; 105(1): 36-39, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32074145

RESUMO

Flipped and traditional classroom models were compared in the Duke University Medical Center (Durham, North Carolina) dermatology residency program for the 2014-2015 academic year. The residents participated in 12 lectures-6 traditional and 6 flipped-that were paired for similar content. Each lecture was followed by a survey comprised of 10 factual questions and 10 perception questions. Generalized linear regression models were used to study the differences in quiz scores between the 2 classroom models after adjusting for other baseline covariates. There was not a significant difference in mean factual quiz scores between the two classroom models. Results indicated significant perception differences in favor of the flipped classroom model, such as participation (P < .001), enjoyment (P=.038 and P=.026), efficiency (P=.033), and boards (P=.050) and clinical preparedness (P=.034).

3.
J Bone Joint Surg Am ; 102(2): 101-109, 2020 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-31743238

RESUMO

BACKGROUND: Financial burden for patients, providers, and payers can reduce access to physical therapy (PT) after total knee arthroplasty (TKA). The purpose of the present study was to examine the effect of a virtual PT program on health-care costs and clinical outcomes as compared with traditional care after TKA. METHODS: At least 10 days before unilateral TKA, patients from 4 clinical sites were enrolled and randomized 1:1 to the virtual PT program (involving an avatar [digitally simulated] coach, in-home 3-dimensional biometrics, and telerehabilitation with remote clinician oversight by a physical therapist) or to traditional PT care in the home or outpatient clinic. The primary outcome was total health-care costs for the 12-week post-hospital period. Secondary (noninferiority) outcomes included 6 and 12-week Knee injury and Osteoarthritis Outcome Score (KOOS); 6-week knee extension, knee flexion, and gait speed; and 12-week safety measures (patient-reported falls, pain, and hospital readmissions). All outcomes were analyzed on a modified intent-to-treat basis. RESULTS: Of 306 patients (mean age, 65 years; 62.5% women) who were randomized from November 2016 to November 2017, 290 had TKA and 287 (including 143 in the virtual PT group and 144 in the usual care group) completed the trial. Virtual PT had lower costs at 12 weeks after discharge than usual care (median, $1,050 compared with $2,805; p < 0.001). Mean costs were $2,745 lower for virtual PT patients. Virtual PT patients had fewer rehospitalizations than the usual care group (12 compared with 30; p = 0.007). Virtual PT was noninferior to usual PT in terms of the KOOS at 6 weeks (difference, 0.77; 90% confidence interval [CI], -1.68 to 3.23) and 12 weeks (difference, -2.33; 90% CI, -4.98 to 0.31). Virtual PT was also noninferior to usual care at 6 weeks in terms of knee extension, knee flexion, and gait speed and at 12 weeks in terms of pain and hospital readmissions. Falls were reported by 19.4% of virtual PT patients and 14.6% of usual care patients (difference, 4.83%; 90% CI, -2.60 to 12.25). CONCLUSIONS: Relative to traditional home or clinic PT, virtual PT with telerehabilitation for skilled clinical oversight significantly lowered 3-month health-care costs after TKA while providing similar effectiveness. These findings have important implications for patients, health systems, and payers. Virtual PT with clinical oversight should be considered for patients managed with TKA. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

5.
Artigo em Inglês | MEDLINE | ID: mdl-31721131

RESUMO

We evaluated the heterogeneity of outcomes among heart failure patients with ventricular recovery. The BEST trial studied patients with left ventricular ejection fraction (LVEF) ≤ 35%. Serial LVEF assessment was performed at baseline, 3 months, and 12 months. Heart failure with better ejection fraction (HFbEF) was defined as an LVEF > 40% at any point. Of the patients who survived to 1 year, 399 (21.3%) had HFbEF. Among subjects with HFbEF, 173 (43.4%) had "extended" recovery, 161 (40.4%) had "late" recovery, and 65 (16.3%) patients had "transient" recovery. Subjects with HFbEF had an improved event-free survival from death or first HF hospitalization compared to subjects without recovery (HR 0.50, 95% CI, 0.39-0.64, p < 0.001). Compared to "transient" recovery, "late" and "extended" recovery were associated with an improved event-free survival from all-cause death and HF hospitalization (HR 0.55, 95% CI, 0.34-0.90, p = 0.016). Our study shows patients with HFbEF to be a heterogeneous population with differing prognoses.

6.
Dermatitis ; 2019 Oct 11.
Artigo em Inglês | MEDLINE | ID: mdl-31609854

RESUMO

BACKGROUND: Patch testing is the criterion standard for diagnosis and management of allergic contact dermatitis. Limitations on the number of allergens tested can negatively impact patient care. OBJECTIVE: This study reports clinical practice patterns of American Contact Dermatitis Society (ACDS) members. METHODS: In October and November 2018, the US-based members of the ACDS received an electronic survey regarding their procedures and experiences with patch testing. We evaluated the type of practice, number of patients tested, type of screening and supplemental series, number of allergens tested, and billing and reimbursement concerns. RESULTS: There were 149 respondents; 62% use ACDS Core 80, 70% "sometimes" or "always" test with supplemental series, and 70% "sometimes" or "always" test patient products. Participants estimated that supplemental series identify relevant allergens 35% of the time. Approximately 66% most commonly test more than 81 allergens per patient, and 78% expressed concerns regarding fair reimbursement. CONCLUSIONS: Most ACDS members routinely test more than 81 allergens per patient. Barriers to fair payment for beyond a fixed number of patches at any one visit may impede the diagnosis of allergic contact dermatitis, prolong suffering, and worsen outcomes.

7.
J Electrocardiol ; 57S: S27-S33, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31627942

RESUMO

The electrocardiogram is often used as an efficacy endpoint for comparing new drugs or as an indicator for cardiovascular safety in both studies of arrhythmic and non-arrhythmic novel drugs. The FDA ECG Warehouse data are owned by the submitting entities, generally pharmaceutical company manufacturers. However, a subset of these ECG data was released with permission from the data owners to the CSRC for access by investigators, equipment manufacturers and algorithm developers for CSRC-approved research and development studies. This article provides an overview of the Cardiac Safety Research Consortium (CSRC) ECG Warehouse, including data availability, completed and ongoing projects, as well as future growth potential amidst an ever expanding FDA ECG Warehouse. Given that current ICH E14 guidelines request that sponsors submitting new drug applications assess the effects on the QT interval using a thorough QT (TQT) or dose-ranging study with concentration-QT analysis during early clinical development to assess cardiac risk, developing novel methods to determine cardiovascular safety, as well as understanding current ECG collection and analysis methods are prudent. The ability to utilize previously collected ECG data for secondary analyses improves cardiovascular safety by multiplying the scientific contribution of the original research.

8.
Bone Joint J ; 101-B(9): 1093-1099, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31474134

RESUMO

AIMS: Antifibrinolytic agents, including tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA), have been shown to be safe and effective for decreasing perioperative blood loss and transfusion following total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, there are few prospective studies that directly compare these agents. The purpose of this study was to compare the benefits of intraoperative intravenous TXA with EACA. PATIENTS AND METHODS: A total of 235 patients (90 THA and 145 TKA) were enrolled in this prospective, randomized controlled trial at a single tertiary-care referral centre. In the THA cohort, 53.3% of the patients were female with a median age of 59.8 years (interquartile range (IQR) 53.3 to 68.1). In the TKA cohort, 63.4% of the patients were female with a median age of 65.1 years (IQR 59.4 to 69.5). Patients received either TXA (n = 119) or EACA (n = 116) in two doses intraoperatively. The primary outcome measures included change in haemoglobin level and blood volume, postoperative drainage, and rate of transfusion. Secondary outcome measures included postoperative complications, cost, and length of stay (LOS). RESULTS: TKA patients who received EACA had greater drainage (median 320 ml (IQR 185 to 420) vs 158 ml (IQR 110 to 238); p < 0.001), increased loss of blood volume (891 ml (IQR 612 to 1203) vs 661 ml (IQR 514 to 980); p = 0.014), and increased haemoglobin change from the preoperative level (2.1 ml (IQR 1.7 to 2.8) vs 1.9 ml (IQR 1.2 to 2.4); p = 0.016) compared with patients who received TXA. For the THA cohort, no statistically significant differences were observed in any haematological outcome measure. One patient in the EACA group required transfusion. No patient in the TXA group required transfusion. There were no statistically significant differences in number or type of postoperative complications or LOS for either THA or TKA patients regardless of whether they received TXA or EACA. CONCLUSION: For hip and knee arthroplasty procedures, EACA is associated with increased perioperative blood loss compared with TXA. However, there is no significant difference in transfusion rate. While further prospective studies are needed to compare the efficacy of each agent, we currently recommend orthopaedic surgeons to select their antifibrinolytic based on cost and regional availability. Cite this article: Bone Joint J 2019;101-B:1093-1099.


Assuntos
Ácido Aminocaproico/administração & dosagem , Antifibrinolíticos/administração & dosagem , Artroplastia de Substituição/efeitos adversos , Perda Sanguínea Cirúrgica/prevenção & controle , Hemorragia Pós-Operatória/prevenção & controle , Ácido Tranexâmico/administração & dosagem , Administração Intravenosa , Idoso , Ácido Aminocaproico/uso terapêutico , Antifibrinolíticos/uso terapêutico , Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Transfusão de Sangue , Feminino , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/induzido quimicamente , Complicações Pós-Operatórias/etiologia , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/terapia , Estudos Prospectivos , Ácido Tranexâmico/uso terapêutico
9.
Pacing Clin Electrophysiol ; 42(11): 1440-1447, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31544956

RESUMO

BACKGROUND: Compared with medical therapy, catheter ablation of atrial fibrillation (AF) in patients with heart failure (HF) improves cardiovascular outcomes. Risk scores (CAAP-AF and APPLE) have been developed to predict the likelihood of AF recurrence after ablation, have not been validated specifically in patients with AF and HF. METHODS: We analyzed baseline characteristics, risk scores, and rates of AF recurrence 12 months postablation in a cohort of 230 consecutive patients with AF and HF undergoing PVI in the Duke Center for Atrial Fibrillation registry from 2009-2013. RESULTS: During a follow-up period of 12 months, 76 of 230 (33%) patients with HF experienced recurrent AF after ablation. The median APPLE and CAAP-AF scores were 1.5 ([Q1, Q3]: [1.0, 2.0]) and 4.0 ([Q1, Q3]: [3.0, 5.0]), respectively and were not different from those patients with and without recurrent AF. Freedom from AF was not different according to APPLE and CAAP-AF scores. Discrimination for recurrent AF with the CAAP-AF score was modest with a C-statistic of 0.60 (95% CI 0.52-0.67). Discrimination with the APPLE score was similarly modest, with a C-statistic of 0.54 (95% CI: 0.47-0.62). CONCLUSIONS: Validated predictive risk scores for recurrent AF after catheter ablation exhibit limited predictive ability in cohorts of AF and HF. Additional tools are needed to facilitate risk stratification and patient selection for AF ablation in patients with concomitant HF.

10.
Am Heart J ; 216: 136-142, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31434031

RESUMO

BACKGROUND: Although the high-risk acute pulmonary embolism (PE) population has been described, little is known about the contemporary inpatient experience and practice patterns of the PE population as a whole. METHODS: All patients with a diagnosis of acute PE from January 1, 2016, to June 30, 2017 within our academic, multihospital health system were retrospectively identified using International Classification of Diseases, 10th Revision, codes, and data were manually abstracted by 2 clinical investigators. Descriptive analyses were performed according to clinical risk stratification categories from the European Society of Cardiology. RESULTS: Of 829 total patients, 372 (44.8%) patients had intermediate or high-risk PE. Mean age was 62.1 years old, and 42.1% of patients had a history of malignancy. One hundred fifty-three (18.5%) patients had an acute PE during a hospitalization for another indication. A total of 6.0% underwent invasive PE therapies, 26.1% required intensive care unit admission, and 9.0% experienced in-hospital death or hospice discharge. In a subgroup description, patients who developed acute PE during a hospitalization for another indication had a higher incidence of incomplete risk stratification and a higher mortality (9.8%) than the primary cohort. Mortality was attributed to PE in 48.4% of cases. CONCLUSIONS: This contemporary description of acute PE managed at a single large, multihospital academic health system highlights substantial health care utilization and high mortality despite the available of advanced therapeutics. Additional work is needed to standardize care for the heterogeneous PE population to ensure appropriate allocation of resources and improved outcomes for all PE patients.

11.
Platelets ; : 1-10, 2019 Jul 17.
Artigo em Inglês | MEDLINE | ID: mdl-31311384

RESUMO

Platelets are central to thrombosis. However, it is unknown whether platelets slip at vascular or device surfaces. The presence of platelet slip at a surface would interrupt physical contact between the platelet and that surface, and therefore diminish adhesion and thrombosis. Unfortunately, no existing technology can directly measure platelet slip in a biological environment. The objective of this study was to explore whether microspheres-modeling platelets-slip at different vascular and device surfaces in an acrylic scaled-up model coronary artery. The microspheres (3.12 µm diameter) were suspended in a transparent glycerol/water experimental fluid, which flowed continuously at Reynolds numbers typical of coronary flow (200-400) through the model artery. We placed a series of axisymmetric acrylic stenoses (cross-sectional area reduction [CSAr], 20-90%) into the model artery, both without and with a central cylinder present (modeling a percutaneous interventional guide wire, and with a scaled-up Doppler catheter mounted upstream). We used laser Doppler velocimetry (LDV) to measure microsphere velocities within, proximal and distal to each stenosis, and compared to computer simulations of fluid flow with no-slip. For validation, we replaced the acrylic with paraffin stenoses (more biologically relevant from a surface roughness perspective) and then analyzed the signal recorded by the scaled-up Doppler catheter. Using the LDV, we identified progressive microsphere slip proportional to CSAr inside entrances for stenoses ≥60% and ≥40% without and with cylinder present, respectively. Additionally, microsphere slip occurred universally along the cylinder surface. Computer simulations indicated increased fluid shear rates (velocity gradients) at these particular locations, and logistic regression analysis comparing microsphere slip with fluid shear rate resulted in a c-index of 0.989 at a cut-point fluid shear rate of (10.61 [cm-1]×mean velocity [cm×sec-1]). Moreover, the presence of the cylinder caused disordering of microsphere shear rates distal to higher grade stenoses, indicating a disturbance in their flow. Finally, despite lower precision, the signal recorded by the scaled-up Doppler catheter nonetheless indicated slip at the entry into and at most locations distal to the 90% stenosis. Our validated model establishes proof of concept for platelet slip, and platelet slip explains several important basic and clinical observations. If technological advances allow confirmation in a true biologic environment, then our results will likely influence the development of shear-dependent antiplatelet drugs. Also, adding shear rate information, our results provide a direct experimental fluid dynamic foundation for antiplatelet-focused antithrombotic therapy during coronary interventions directed towards higher grade atherosclerotic stenoses.

12.
Shoulder Elbow ; 11(1 Suppl): 30-38, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31019560

RESUMO

Background: The modified Goutallier classification system describes the fatty infiltration of rotator cuff musculature (RCM) seen on magnetic resonance imaging (MRI) to assist with surgical decision-making for patients with rotator cuff tears (RCT). We describe the relationship between body mass index (BMI) and fatty infiltration in patients without RCT. Methods: Twenty-five patients from each of four different BMI ranges (< 25 kg/m2; 25 kg/m2 to 30 kg/m2; 30 kg/m2 to 35 kg/m2; > 35 kg/m2) were randomly selected from 1088 consecutive shoulder MRI scans (T1 parasagittal series). Four physician-readers evaluated MRI scans and assigned modified Goutallier grades (0 to 4) in each of the four rotator cuff muscles, as well as two adjacent muscles. Results: Grade distributions varied significantly based on BMI category for infraspinatus (p = 0.001), teres minor (p < 0.001), subscapularis (p = 0.025), teres major (p < 0.001) and deltoid (p < 0.001). Higher grades were evident with a diagnosis of diabetes mellitus in three of six muscles (p < 0.05), hyperlipidaemia in one muscle (p = 0.021) and greater patient age in three muscles (p < 0.05). Conclusions: Obese and severely obese patients without RCT have more fatty infiltration seen on MRI. Patient factors (older age and diagnosis of diabetes mellitus) can be predictive of fatty infiltration in RCM. Fatty infiltration of RCM is not solely attributable to the presence of a RCT.

13.
J Arthroplasty ; 34(7S): S168-S172, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30948289

RESUMO

BACKGROUND: Routine laboratory studies are generally obtained following total knee arthroplasty (TKA), and often continued daily until discharge. This study aims to investigate the utility and cost-effectiveness of complete blood count (CBC) tests following TKA. METHODS: Retrospective review identified 484 patients who underwent primary TKA under a tourniquet at a single institution. Preoperative and postoperative CBC values were collected along with demographic data, use of tranexamic acid (TXA), and transfusion rates. Logistic regression models were calculated for all variables. RESULTS: Twenty-five patients required transfusion following TKA (5.2%). Patients requiring transfusion had significantly lower preoperative hemoglobin compared to patients who did not require transfusion (11.47 vs 13.58 g/dL, P = .005). Risk of transfusion was 5.2 times higher in patients with preoperative anemia (95% confidence interval 2.90-9.35, P < .001). Without TXA, patients were 2.75 times more likely to receive transfusion (95% confidence interval 1.43-5.30, P < .001). An average of 2.9 CBC tests were collected per patient who did not receive medical intervention, costing a total of $144,773.80 in associated hospital charges ($316.10 per patient). CONCLUSION: Ensuring quality, cost-effective patient care following total joint arthroplasty is essential in the era of bundled payments. Routine postoperative CBCs do not add value for patients with normal preoperative hemoglobin who receive TXA during TKA performed under tourniquet. Patients who are anemic preoperatively or do not receive TXA should obtain a postoperative CBC test. Daily CBCs are unnecessary if the first postoperative CBC does not prompt intervention.

14.
Orthopedics ; 42(2): 103-109, 2019 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-30889256

RESUMO

Current antifibrinolytics have decreased perioperative blood loss; however, some patients still require transfusions postoperatively. The authors sought to determine the risk factors associated with postoperative transfusions and to establish a "cutoff" preoperative hemoglobin threshold value specific to total knee arthroplasty (TKA) that would identify patients who would benefit from blood conservation programs. The institutional database was queried for primary TKA patients. Preoperative patient demographics and hemoglobin values were determined in addition to intraoperative and postoperative variables, including transfusion rate. Patients were stratified by whether they received a transfusion perioperatively, and risk factors were identified through univariable and multivariable analysis. Optimal cutoff values for hemoglobin were identified by concurrently maximizing the sensitivity and specificity for predicting the risk of a postoperative transfusion event. Men and women were analyzed independently. A total of 532 primary TKAs were included for analysis, and 33 patients (6.2%) required a transfusion. Advanced age (P=.019), low pre-operative hemoglobin value (P<.001), and failure to receive tranexamic acid (P<.001) were associated with increased risk of postoperative transfusion. A preoperative hemoglobin value of 12.5 g/dL was identified as the optimal cutoff for predicting postoperative transfusion requirements across all patients, with a sensitivity of 84.8% and a specificity of 76.4%. Preoperative anemia remains predictive of transfusion following TKA despite current antifibrinolytics. Patients with a preoperative hemoglobin value of less than 12.5 g/dL who are not receiving intravenous tranexamic acid are particularly at risk and should be considered for blood conservation programs. [Orthopedics. 2019; 42(2):103-109.].


Assuntos
Antifibrinolíticos/uso terapêutico , Artroplastia do Joelho , Transfusão de Sangue/estatística & dados numéricos , Hemoglobinas/análise , Ácido Tranexâmico/uso terapêutico , Fatores Etários , Idoso , Anemia/epidemiologia , Feminino , Humanos , Masculino , Cuidados Pós-Operatórios , Período Pré-Operatório , Estudos Retrospectivos
15.
Am Heart J ; 211: 22-33, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30831331

RESUMO

Heart failure (HF) and diabetes mellitus (DM) are major public health issues that place significant burden on patients and health care systems. Patients with both HF and DM are at higher risk of adverse cardiovascular and HF outcomes than those with either disease in isolation. Different antihyperglycemic medications (even within the same medication class) have conflicting results of benefit or harm in patients with established and incident HF. Recent data highlight the importance of a renewed focus on optimal pharmacotherapy for this population with DM and HF (or at risk for HF). Both HF and DM require major lifestyle modification for optimal management, in terms of both optimizing health behaviors (eg, physical activity, diet) and adherence to complex medical and self-care regimens. Mobile health (mHealth) technologies (eg, apps, wearables) are widely available in the community and may play a role in optimizing the health status of patients; however, there is limited and conflicting information on whether such technologies are actually beneficial in at-risk populations. In this article, we summarize current strategies, including mobile health interventions, to improve physical activity levels, drug adherence, and outcomes in patients with DM, HF, or both and describe the design and rationale for the Technologies to improve drug Adherence and Reinforce Guideline based Exercise Targets in patients with heart Failure and Diabetes Mellitus trial, which is designed to test the efficacy of using mHealth technology to improve health behaviors and outcomes in this high-risk population.


Assuntos
Diabetes Mellitus/terapia , Exercício , Insuficiência Cardíaca/terapia , Adesão à Medicação , Telemedicina/métodos , Adulto , Diabetes Mellitus/tratamento farmacológico , Estilo de Vida Saudável , Insuficiência Cardíaca/tratamento farmacológico , Humanos , Hipoglicemiantes/uso terapêutico , Aplicativos Móveis , Dispositivos Eletrônicos Vestíveis
17.
Knee ; 26(3): 679-686, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30904327

RESUMO

BACKGROUND: There is a growing interest in avoiding discharging patients to rehab to maximize outcome and minimize complications after total knee arthroplasty (TKA). In addition, use of postoperative pain pathways that minimize opioid use is critical amidst the current opioid epidemic. However, the ideal pain regimen after TKA has yet to be determined. METHODS: From July 1, 2013 to October 1, 2014 two perioperative pathways were used to address surgical pain. These included either a single shot femoral nerve block plus liposomal bupivacaine pericapsular injection (FNB + LB-PAI) or adductor canal catheter plus posterior capsule single shot block (ACC + iPACK), each with an oral analgesic protocol. Little modification occurred with regard to surgical technique, postoperative medications, or postoperative physical therapy (PT). RESULTS: Overall, 264 unilateral, primary TKA patients (146 FNB + LB-PAI, 118 ACC + iPACK) were included. ACC + iPACK patients had a shorter median length of stay (LOS, 2.0 vs 3.0, p < 0.001), more discharges home (79.7% vs 67.8%, p = 0.002), and less median opioid consumption (IV morphine equivalents, IVME, 20.0 vs 44.1, p < 0.001) than the FNB + LB-PAI group. In multivariable analysis, use of ACC + iPACK remained independently associated with shorter LOS, increased discharge home, and less IVME consumed when controlling for confounding variables. ACC + iPACK patients also had fewer opioid related adverse events (0.8 vs 5.5, p = 0.045) and a lower rate of MUA (0.8% vs 6.2%, p = 0.026). CONCLUSIONS: We recommend ACC + iPACK with a multimodal oral analgesic protocol as the primary postoperative analgesia in enhanced recovery TKA protocols. This resulted in an easier recovery with fewer complications. LEVEL OF EVIDENCE: Level III.


Assuntos
Analgésicos Opioides/uso terapêutico , Artroplastia do Joelho , Bloqueio Nervoso/métodos , Dor Pós-Operatória/prevenção & controle , Alta do Paciente , Idoso , Anestésicos Locais/administração & dosagem , Uso de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Joelho/inervação , Tempo de Internação/estatística & dados numéricos , Masculino , Estudos Retrospectivos
18.
J Bone Joint Surg Am ; 101(4): e14, 2019 Feb 20.
Artigo em Inglês | MEDLINE | ID: mdl-30801382

RESUMO

BACKGROUND: Elements of competency-based training are being incorporated into surgical training. The primary objective of this study was to determine how the orientation of the arthroscope and the instruments relative to the standing position of the surgeon affects basic arthroscopic performance. The secondary objective was to determine how arthroscopic level of training affects performance. METHODS: Participants from a single academic institution were recruited and divided by level of training into 2 groups: novice and advanced. The Fundamentals of Arthroscopic Surgery Training (FAST) Workstation (Sawbones) was used in this study. Performance on the ring transfer module was evaluated based on the total number of ring transfers that were completed and the errors that were made in timed sessions. All participants performed the task with the arthroscope facing away from (position A) and facing toward (position B) their standing position. Two trials were completed for each position, followed by a survey. RESULTS: Fifty-seven subjects participated in this study. Overall, position A showed 2.7 times the amount of transfers compared with position B (p < 0.001). The advanced group had 1.6 times more transfers in position A than the novice group (p = 0.007), and there was no significant difference in transfers between training level in position B. The advanced group had 3.6 times more transfers in position A compared with position B (p < 0.001), while the novice group had 2.0 times more transfers in position A than in position B (p < 0.001). CONCLUSIONS: Performing an arthroscopic simulator task with the arthroscope directed toward the operator was found to be more difficult. An understanding of how the orientation of the operator, the arthroscope, and the instruments can strongly influence performance may be important for the primary surgeon, trainees, or assistants who may be standing opposite the arthroscope, and to optimize training to overcome this discrepancy.


Assuntos
Artroscópios , Artroscopia/educação , Competência Clínica/normas , Educação Médica/métodos , Adulto , Idoso , Artroscopia/instrumentação , Artroscopia/normas , Educação Baseada em Competências/métodos , Humanos , Internato e Residência , Pessoa de Meia-Idade , North Carolina , Cirurgiões Ortopédicos/educação , Cirurgiões Ortopédicos/normas , Medicina Esportiva/educação , Adulto Jovem
19.
Ultrastruct Pathol ; 43(1): 1-5, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30668206

RESUMO

Asbestos is well-recognized as the cause of a variety of disorders of the respiratory tract, including neoplastic as well as non-neoplastic conditions. Fiber dimensions and biopersistence are important determinants of the pathologic response, and analytical electron microscopy is a powerful technique for determining the fiber content of lung tissue samples. For decades our laboratory has examined lung tissue samples counting fibers measuring 5 µm or greater in length. More recent observations have indicated that fibers 10 µm or greater in length are pathogenic, and that a length of 10 µm and diameter less than 1.0 µm are useful features for distinguishing asbestiform fibers from cleavage fragments. We examined more than 570 fibers from more than 90 cases to determine the dimensions of fibers that might be classified as asbestos. The vast majority of fibers classified as amosite or crocidolite met the criteria for length greater than 10 µm and diameter less than 1.0 µm. However, a significant proportion of fibers classified as tremolite, actinolite, or anthophyllite did not meet these criteria. These findings have important implications for the identification and classification of elongated mineral particles, both in terms of pathogenicity as well as classification as asbestiform vs. cleavage fragments.


Assuntos
Amiantos Anfibólicos/farmacologia , Neoplasias Pulmonares/patologia , Pulmão/patologia , Minerais/metabolismo , Asbestos/metabolismo , Amiantos Anfibólicos/metabolismo , Humanos , Neoplasias Pulmonares/diagnóstico
20.
Foot Ankle Int ; 40(3): 307-317, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30381958

RESUMO

BACKGROUND:: Total ankle arthroplasty (TAA) is increasingly being recognized as an effective surgical option for end-stage ankle arthritis. Associated hindfoot arthrodesis procedures are at times needed to correct malalignment or to address adjacent joint arthritis. Results following TAA and associated hindfoot arthrodesis have at times been underwhelming and the devascularization of the talar blood supply has been postulated as a potential cause. This study explored the association between hindfoot arthrodesis fixation and talar component subsidence. METHODS:: The study included 81 consecutive patients who underwent a TAA with either an isolated subtalar arthrodesis or combined subtalar and talonavicular arthrodesis with a minimum of 2 years of follow-up. Radiographic and clinical evaluations including patient-reported outcomes were performed at each postoperative visit. The primary outcome measure was the presence of talar component subsidence while patient-reported outcomes were the secondary outcome measure. RESULTS:: 30.9% of patients had evidence of talar component subsidence. Subsidence was seen in 55.5% of patients with dorsal to plantar subtalar fixation compared to 11.1% of patients with plantar to dorsal screws ( P < .001) and in 44.4% of patients with screws violating the sinus tarsi compared to 3.7% of patients without screws in the sinus tarsi ( P < .001). Screws that were placed from dorsal to plantar were more likely to violate the sinus tarsi ( P < .001). Patients with evidence of talar subsidence reported higher pain scores and lower functional scores. There were 8 TAA failures, and the presence of dorsal to plantar screws was associated with failure ( P < .01). CONCLUSION:: Screws that are placed across the subtalar joint from a dorsal to plantar approach are more likely to violate the sinus tarsi, contributing to a significantly higher rate of talar component subsidence when associated with TAA. LEVEL OF EVIDENCE:: Level II, prospective comparative series.


Assuntos
Artrodese/métodos , Artroplastia de Substituição do Tornozelo/métodos , Parafusos Ósseos , Articulação Talocalcânea/cirurgia , Tálus/cirurgia , Adulto , Idoso , Avaliação da Deficiência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Estudos Prospectivos , Radiografia
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