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1.
Mayo Clin Proc ; 95(2): 355-369, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-32029088

RESUMO

Postsurgical neuropathies represent an infrequent but potentially devastating complication of surgery that may result in significant morbidity with medicolegal implications. Elucidation of this phenomenon has evolved over the past few decades, with emerging evidence for not only iatrogenic factors contributing to this process but also inflammatory causes. This distinction can be important; for instance, cases in which inflammatory etiologies are suspected may benefit from further investigations including nerve biopsy and may benefit from treatment in the form of immunotherapy. In contrast, postsurgical neuropathies due to perioperative causes including anesthesia, traction, compression, and transection will not benefit in the same manner. This article summarizes early and current literature surrounding the frequency of new neurologic deficits after various surgical types, potential causes including anatomical and inflammatory considerations, and roles for treatment. To capture the scope of the issue, a literature review was conducted for human studies in English via MEDLINE and EMBASE from January 1, 1988 to March 31, 2018. Search terms included anesthesia and/or surgical procedures, operative, peripheral nervous system diseases, trauma, mononeuropathy, polyneuropathy, peripheral nervous system, nerve compression, neuropathy, plexopathy, postoperative, postsurgical, perioperative, complication. We excluded case series with less than 10 patients and review papers. We then narrowed the studies to those presented highlighting key concepts in postsurgical neuropathy.

2.
Ann Thorac Surg ; 2020 Feb 20.
Artigo em Inglês | MEDLINE | ID: mdl-32088290

RESUMO

BACKGROUND: Obstructive sleep apnea (OSA) is associated with increased risk of postoperative complications in non-cardiac surgery, with limited literature on cardiac surgical patients. We compared perioperative outcomes of patients with OSA to those without OSA undergoing cardiac surgery. METHODS: This was a retrospective single center cohort study of adult patients who underwent cardiac surgery from January 2010 to April 2017. Our aim was to compare outcomes of patients with OSA to those without OSA including length of stay, readmissions, hospital mortality, and short-term outcomes. RESULTS: 8612 patients during the study period included 2636 (30.6%) with OSA. Patients with OSA had a higher median length-of-stay (6 vs 5 days, P < 0.001), higher incidence of prolonged (> 7 days) length of stay (26.3% vs 23.0%, P < 0.001), and less likely to discharge to home (78.2% vs 84.4%, P < 0.001). OSA patients also had a higher 30-day readmission rate (14.7% vs 10.4%, P < 0.001). Acute kidney injury was more common in OSA patients (25.2% vs 19.9%, P < 0.001). Our multivariable model found postoperative atrial fibrillation was associated with older age and not OSA status (age < 50 years compared to > 75 years odd ratio: 4.10, 95% confidence interval: 3.39-4.96). CONCLUSIONS: OSA patients had a higher mean length-of-stay, were more likely to have a prolonged length-of-stay, more likely to discharge to location other than home, and had a higher 30-day readmission rate. This suggests higher resource utilization is required to care for OSA patients following cardiac surgery.

3.
J Org Chem ; 85(5): 3757-3765, 2020 Mar 06.
Artigo em Inglês | MEDLINE | ID: mdl-31994396

RESUMO

The decarbonylative coupling of phthalimides with aryl boronic acids provides ready access to a broad range of ortho-substituted benzamides. This nickel-mediated methodology extends reactivity from previously described air-sensitive diorganozinc reagents of limited availability to easily handled and widely commercially available boronic acids. The decarbonylative coupling is tolerant of a broad range of functional groups and demonstrates little sensitivity to steric factors on either of the coupling partners.

4.
Pain ; 161(2): 237-243, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31613867

RESUMO

Postoperative pain is not adequately managed in greater than 40% of surgical patients and is a high priority for perioperative research. In this meta-analysis, we examined studies comparing postoperative opioid consumption and pain scores in surgical patients who received methadone by any route vs those who received another opioid by any route. Studies were identified from PubMed, Cochrane, Web of Science, EMBASE, and Scopus from January 1966 to November 2018. Pooled odds ratios were calculated for a primary outcome of postoperative opioid consumption and secondary outcomes of time-to-extubation, time-to-first postoperative analgesia request, satisfaction, hospital length-of-stay, and complications. Postoperative pain scores were assessed qualitatively. Ten studies (617 patients) were included. Postoperative opioid consumption at 24 hours was lower in the methadone group vs control (mean difference = -15.22 mg oral morphine equivalents, 95% confidence interval -27.05 to -3.38; P = 0.01). Patients in the methadone group generally reported lower postoperative pain scores in 7 of 10 studies. Meta-analysis revealed greater satisfaction scores with analgesia in the methadone group vs control (0-100 visual analog scale; mean difference = 7.16, 95% confidence interval 2.30-12.01; P = 0.004). There was no difference in time-to-extubation, time-to-first analgesia request, hospital length-of-stay, or complications (nausea, sedation, respiratory depression, and hypoxemia). The results demonstrate that surgical patients who received intraoperative methadone had lower postoperative opioid consumption, generally reported lower pain scores and experienced better satisfaction with analgesia. However, these advantages need to be weighed carefully against dangerous risks with perioperative methadone, specifically respiratory depression and arrhythmia. Future studies should explore logistics, safety, and cost effectiveness.

5.
Mayo Clin Proc ; 94(9): 1786-1798, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31486381

RESUMO

OBJECTIVE: To compare recall of complications and surgical details discussed during informed consent and perception of the consent process in patients undergoing emergent vs elective surgery. METHODS: Studies were identified from PubMed, Cochrane, Web of Science, and Scopus from January 1, 1966, through April 18, 2018. Included studies compared patient recall and perception regarding informed consent in those undergoing emergent vs elective surgery. Pooled odds ratios (ORs) were calculated for recall of complications and surgical details, patient satisfaction, perception of sufficient information being delivered on surgical risks, report of having read written consent, and factors that interfered with consent. RESULTS: Eleven observational studies (3178 patients) were included. The rate of recall of surgical complications (255 of 504 [50.6%] vs 321 of 446 [72.0%]; OR, 0.29; 95% CI, 0.11-0.80) was lower in patients undergoing emergent vs elective surgery. Meta-analysis revealed a decreased rate of patient satisfaction with the consent process (319 of 459 [69.5%] vs 882 of 1064 [82.9%]; OR. 0.53; 95% CI, 0.34-0.83) and fewer patients having read the consent form (130 of 395 [32.9%] vs 424 of 714 [59.4%]; OR, 0.35; 95% CI, 0.27-0.46) when undergoing emergent compared with elective surgery. Patients undergoing emergent surgery listed pain, analgesic medications, and fatigue as factors likely to interfere with consent. CONCLUSION: Patients undergoing emergent surgery have poor recall of the informed consent process and surgical complications. Furthermore, patients report lower rates of satisfaction, and with fewer patients reading written consent documentation, our findings illuminate problems with the current communication process. There is a need to develop effective tools to improve informed consent in emergency surgery.


Assuntos
Procedimentos Cirúrgicos Eletivos/métodos , Tratamento de Emergência/métodos , Consentimento Livre e Esclarecido , Rememoração Mental , Determinação de Necessidades de Cuidados de Saúde , Adulto , Idoso , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Tratamento de Emergência/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Observacionais como Assunto , Segurança do Paciente , Satisfação do Paciente , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Medição de Risco , Estados Unidos
6.
Orthopedics ; 42(6): 335-343, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31408522

RESUMO

This cohort study of adult (≥50 years) patients aimed to calculate a validated, preoperative frailty deficit index (FI) and used it to compare outcomes following total knee arthroplasty (TKA), primary and revision, from 2005 through 2016. Using multivariable logistic and Cox regression, the authors analyzed whether FI, adjusted for age, predicts outcomes prior to hospital discharge, within 90 days, and within 365 days. They classified 9818 patients undergoing TKA (7920 primary and 1898 revision; median age, 69 years) as frail (21%), vulnerable (39%), and non-frail (40%). Frail, relative to non-frail, patients were more often female with more systemic diseases (American Society of Anesthesiologists classification, ≥III). While in-hospital, frail patients were found to have increased odds of reoperation (odds ratio, 2.52) and wound complications/hematoma (odds ratio, 2.15). Within 90 days, there was increased risk for periprosthetic fracture (>4-fold) and mortality (>9-fold) following TKA after age adjustment. Within the first year, frail patients were at heightened risk for death (hazard ratio, 8.08), any patient infection (hazard ratio, 1.97), wound complications/hematoma (hazard ratio, 2.16), periprosthetic fracture (hazard ratio, 3.03), and reoperation (hazard ratio, 1.41). At no time point were significant associations found with arthrofibrosis, aseptic loosening, or patellar clunk syndrome. One-fifth of patients undergoing primary and revision TKAs are frail and at notable risk for complications. Calculating a preoperative FI should guide pre-habilitation efforts (eg, chronic disease management, wellness) before and postoperative surveillance after TKA. [Orthopedics. 2019; 42(6):335-343.].


Assuntos
Artroplastia do Joelho/efeitos adversos , Fragilidade/diagnóstico , Fraturas Periprotéticas/etiologia , Idoso , Idoso de 80 Anos ou mais , Artroplastia do Joelho/mortalidade , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fraturas Periprotéticas/mortalidade , Fraturas Periprotéticas/cirurgia , Período Pós-Operatório , Fatores de Risco , Taxa de Sobrevida
7.
J Shoulder Elbow Surg ; 28(10): e325-e338, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31353302

RESUMO

BACKGROUND: The ideal analgesic modality for total shoulder arthroplasty (TSA) remains controversial. We hypothesized that a multimodal analgesic pathway incorporating continuous interscalene blockade (ISB) provides better analgesic efficacy than both single-injection ISB and local infiltration analgesia. METHODS: This single-center, parallel, unblinded, randomized clinical trial evaluated 129 adults undergoing primary TSA. Patients were allocated to single-injection ISB, continuous ISB, or local infiltration analgesia. The primary outcome was the Overall Benefit of Analgesia Score (range, 0 [best] to 28 [worst]) on postoperative day 1. Additional outcomes included pain scores, opioid consumption, quality of life, and postoperative complications in the first 24 hours, at 3 months, and at 1 year. RESULTS: We analyzed 125 patients (42 with single-injection ISB, 41 with continuous ISB, and 42 with local infiltration analgesia). The Overall Benefit of Analgesia Score was significantly improved in the continuous group (median [25th percentile, 75th percentile], 0 [0, 2]) compared with the single-injection group (2 [1, 4]; P = .002) and local infiltration analgesia group (3 [2, 4]; P < .001). Pain scores were significantly lower in the continuous group compared with the local infiltration analgesia group (P < .001 for all time points) and after 12 hours from ward arrival compared with the single-injection group (median [25th percentile, 75th percentile], 1.0 [0.0, 2.8] vs. 2.5 [0.0, 4.0]; P = .016). After postanesthesia recovery discharge, opioid consumption (oral morphine equivalents) was significantly lower in the continuous group (median [25th percentile, 75th percentile], 7.5 mg [0.0, 25.0 mg]) than in the local infiltration analgesia group (30 mg [15.0, 52.5 mg]; P < .001) and single-injection group (17.6 mg [7.5, 45.5 mg]; P = .010). No differences were found across groups for complications, 3-month outcomes, and 1-year outcomes. CONCLUSION: Continuous ISB provides superior analgesia compared with single-injection ISB and local infiltration analgesia in the first 24 hours after TSA.


Assuntos
Analgesia/métodos , Anestésicos Locais/administração & dosagem , Artroplastia do Ombro , Bloqueio do Plexo Braquial/métodos , Dor Pós-Operatória/prevenção & controle , Idoso , Analgésicos Opioides/uso terapêutico , Artroplastia do Ombro/efeitos adversos , Bloqueio do Plexo Braquial/efeitos adversos , Feminino , Humanos , Injeções , Masculino , Pessoa de Meia-Idade , Manejo da Dor , Medição da Dor , Dor Pós-Operatória/etiologia , Período Pós-Operatório , Qualidade de Vida , Fatores de Tempo
8.
Am J Clin Pathol ; 152(5): 625-637, 2019 Oct 07.
Artigo em Inglês | MEDLINE | ID: mdl-31338515

RESUMO

OBJECTIVES: Hematopathology (HP) is a rapidly changing field with insufficient data to provide guidance to program directors (PDs), the Accreditation Council for Graduate Medical Education, or the American Board of Pathology. METHODS: Two surveys were performed-one for HP PDs and one, given twice, for HP diplomates doing Maintenance of Certification/Continuing Certification reporting in 2017 to 2018. RESULTS: Bone marrow (BM), lymph node (LN), and flow cytometry interpretations and peripheral blood/fluid reviews are performed by more than 80% of hematopathologists and are the areas with the greatest amount of training. A smaller proportion of hematopathologists is involved in other HP-related activities. Most PDs believed fellows should perform BM procedures. Interpretation of 400 or more LNs and 500 BMs was PDs' median expectations for fellows. PDs and HP diplomates considered coagulation and benign RBC disorders overemphasized on the certification examination. CONCLUSIONS: These results highlight how varied the practice of HP is and can provide guidance to HP PDs, those responsible for assessing HP programs, and the American Board of Pathology.

9.
Br J Anaesth ; 123(3): 269-287, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31351590

RESUMO

BACKGROUND: Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes. METHODS: The International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) systematic review, including randomised controlled and observational studies comparing neuraxial to general anaesthesia regarding major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, genitourinary, thromboembolic, neurological, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, from 1946 to May 17, 2018 were queried. Meta-analysis and Grading of Recommendations Assessment, Development and Evaluation approach was utilised to assess evidence quality and to develop recommendations. RESULTS: The analysis of 94 studies revealed that neuraxial anaesthesia was associated with lower odds or no difference in virtually all reported complications, except for urinary retention. Excerpt of complications for neuraxial vs general anaesthesia in hip/knee arthroplasty, respectively: mortality odds ratio (OR): 0.67, 95% confidence interval (CI): 0.57-0.80/OR: 0.83, 95% CI: 0.60-1.15; pulmonary OR: 0.65, 95% CI: 0.52-0.80/OR: 0.69, 95% CI: 0.58-0.81; acute renal failure OR: 0.69, 95% CI: 0.59-0.81/OR: 0.73, 95% CI: 0.65-0.82; deep venous thrombosis OR: 0.52, 95% CI: 0.42-0.65/OR: 0.77, 95% CI: 0.64-0.93; infections OR: 0.73, 95% CI: 0.67-0.79/OR: 0.80, 95% CI: 0.76-0.85; and blood transfusion OR: 0.85, 95% CI: 0.82-0.89/OR: 0.84, 95% CI: 0.82-0.87. CONCLUSIONS: Recommendation: primary neuraxial anaesthesia is preferred for knee arthroplasty, given several positive postoperative outcome benefits; evidence level: low, weak recommendation. RECOMMENDATION: neuraxial anaesthesia is recommended for hip arthroplasty given associated outcome benefits; evidence level: moderate-low, strong recommendation. Based on current evidence, the consensus group recommends neuraxial over general anaesthesia for hip/knee arthroplasty. TRIAL REGISTRY NUMBER: PROSPERO CRD42018099935.


Assuntos
Anestesia Epidural/efeitos adversos , Anestesia Geral/efeitos adversos , Raquianestesia/efeitos adversos , Artroplastia de Quadril/métodos , Artroplastia do Joelho/métodos , Anestesia Epidural/mortalidade , Anestesia Geral/mortalidade , Raquianestesia/mortalidade , Artroplastia de Quadril/mortalidade , Artroplastia do Joelho/mortalidade , Medicina Baseada em Evidências/métodos , Humanos , Complicações Pós-Operatórias/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
11.
Reg Anesth Pain Med ; 44(4): 447-451, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30914472

RESUMO

Manually delivered intermittent bolus (MIB) and programmable intermittent bolus (PIB), alternatives to continuous infusion (CI), involve administering a set volume of solution at a set interval of time. The benefits of intermittent bolus techniques in truncal and peripheral nerve blockade (TPNB) are unclear, and studies have largely demonstrated conflicting results. Using MEDLINE, Embase, Google Scholar, and the Cochrane Library, we conducted an evidenced-based review of published randomized controlled trials comparing intermittent bolus and CI methods in TPNB. In total, 13 randomized controlled trials were identified and evaluated. Outcomes data addressed in these studies included assessments of pain, opioid and local anesthetic consumption, patient satisfaction, adverse events, and physical therapy metrics. The overall quality of current evidence was found to be low given the small sample sizes, heterogeneity of data, and the variations in intermittent bolus techniques between studies. At this time, we found limited supportive data to endorse MIB or PIB over CI in TPNB. While unable to provide data-driven conclusions for local anesthetic delivery methods at this time, we propose that future studies and quantitative analysis between techniques should be on an anatomic, site-specific basis, with greater focus on evaluation of opioid use, adverse events, patient satisfaction, and rehabilitative metrics.


Assuntos
Analgesia Controlada pelo Paciente , Anestésicos Locais/administração & dosagem , Manejo da Dor/métodos , Anestesia Local , Humanos , Bombas de Infusão , Bloqueio Nervoso , Ensaios Clínicos Controlados Aleatórios como Assunto
12.
Muscle Nerve ; 59(6): 679-682, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30897216

RESUMO

INTRODUCTION: Neuropathy after total knee arthroplasty (TKA) can cause significant morbidity but is inconsistently reported. METHODS: We reviewed the clinical, electrodiagnostic and perioperative features of all patients who underwent primary TKA at our institution and developed a new neuropathy within 8 weeks postoperatively. RESULTS: Fifty-four cases were identified (incidence 0.37% [95% confidence interval, 0.28-0.49]) affecting the following nerve(s): peroneal (37), sciatic (11), ulnar (2), tibial (2), sural (1), and lumbosacral plexus (1). In all cases with follow-up data, motor recovery typically occurred within 1 year and was complete or near-complete. CONCLUSIONS: Post-TKA neuropathy is uncommon, typically does not require intervention and usually resolves within 1 year. Post-TKA neuropathy most often affects the nerves surgically at risk. Anesthesia type does not correlate with post-TKA neuropathy. An inflammatory etiology for post-TKA neuropathy is rare but should be considered in specific cases. Muscle Nerve 59:679-682, 2019.


Assuntos
Artroplastia do Joelho , Doenças do Sistema Nervoso Periférico/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Idoso , Feminino , Humanos , Plexo Lombossacral , Masculino , Pessoa de Meia-Idade , Condução Nervosa , Doenças do Sistema Nervoso Periférico/fisiopatologia , Neuropatias Fibulares/epidemiologia , Neuropatias Fibulares/fisiopatologia , Complicações Pós-Operatórias/fisiopatologia , Recuperação de Função Fisiológica , Estudos Retrospectivos , Neuropatia Ciática/epidemiologia , Neuropatia Ciática/fisiopatologia , Nervo Sural , Neuropatia Tibial/epidemiologia , Neuropatia Tibial/fisiopatologia , Neuropatias Ulnares/epidemiologia , Neuropatias Ulnares/fisiopatologia
14.
Cochrane Database Syst Rev ; 1: CD012819, 2019 01 16.
Artigo em Inglês | MEDLINE | ID: mdl-30650189

RESUMO

BACKGROUND: Spine surgery may be associated with severe acute postoperative pain. Compared with systemic analgesia alone, epidural analgesia may offer better pain control. However, epidural analgesia has sometimes been associated with rare but serious complications. Therefore, it is critical to quantify the real benefits of epidural analgesia over other modes of pain treatment. OBJECTIVES: To assess the effectiveness and safety of epidural analgesia compared with systemic analgesia for acute postoperative pain control after thoraco-lumbar spine surgery in children. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature on 14 November 2018, together with the references lists of related reviews and retained trials, and two trials registers. SELECTION CRITERIA: We included all randomized controlled trials performed in children undergoing any type of thoraco-lumbar spine surgery comparing epidural analgesia with systemic analgesia for postoperative pain. We applied no language or publication status restriction. DATA COLLECTION AND ANALYSIS: We assessed risk of bias of included trials using the Cochrane tool. We analysed data using random-effects models. We rated the quality of the evidence according to the GRADE scale. MAIN RESULTS: We included 11 trials (559 participants) in the review, and seven trials (249 participants) in the analysis: 140 participants received epidural analgesia and 109 received systemic analgesia.Most studies included adolescents. Three trials included in the analysis contained some participants older than 18 years. The types of surgery were posterior spinal fusion for idiopathic scoliosis (nine trials), anterior correction for idiopathic scoliosis (one trial), or selective dorsal rhizotomy in children with cerebral palsy (one trial). The mean numbers of vertebrae operated on were between nine and 14.5 and the mean numbers of spinal levels were between three and four and a half. The length of surgery varied between three and six and a half hours.Compared with systemic analgesia, epidural analgesia reduced pain at rest at all time points. At six to eight hours, the mean pain score on a 0 to 10 scale with systemic analgesia was 3.1 (standard deviation 0.7) and with epidural analgesia was -1.32 points (95% confidence interval (CI) -1.83 to -0.82; 4 studies, 116 participants; moderate-quality evidence). At 72 hours, the mean pain score with epidural analgesia was equivalent to a -0.8 point reduction on a 0 to 10 scale (standardized mean difference (SMD) -0.65, 95% CI -1.19 to -0.10; 5 studies, 157 participants; moderate-quality evidence).Return of gastrointestinal functionThere was no difference for nausea and vomiting between groups (risk ratio (RR) 0.87, 95% CI 0.58 to 1.30; 6 studies, 215 participants; low-quality evidence). One study found epidural analgesia with local anaesthetics may have increased the number of participants who had their first flatus within 48 hours (RR 1.63, 95% CI 1.08 to 2.47; 30 participants; very low-quality evidence). Two studies found epidural analgesia with local anaesthetics may have increased the number of participants in whom first bowel movement occurred within 48 hours (RR 11.52, 95% CI 2.36 to 56.26; 60 participants; low-quality evidence). It was uncertain whether epidural analgesia reduced the time to first bowel movement (MD 0.09 days, 95% CI -0.32 to 0.50; 1 study, 60 participants; very low-quality evidence) and time to first liquid ingestion following epidural infusion of an opioid alone or a local anaesthetic plus an opioid (mean difference (MD) -5.02 hours, 95% CI -13.15 to 3.10; 2 studies, 56 participants; very low-quality evidence). Epidural analgesia with local anaesthetics may have increased the risk of having first solid food ingestion within 48 hours (RR 7.00, 95% CI 1.91 to 25.62; 1 study, 30 participants; very low-quality evidence).Secondary outcomesIt was uncertain whether there was a difference in time to ambulate (MD 0.08 days, 95% CI -0.24 to 0.39; 1 study, 60 participants; very low-quality evidence) and hospital length of stay (MD -0.29 days, 95% CI -0.69 to 0.10; 2 studies, 89 participants; very low-quality evidence). Two studies found participants were more satisfied when treated with epidural analgesia (MD 1.62 on a scale from 0 to 10, 95% CI 1.26 to 1.97; 60 participants; very low-quality evidence). It was unclear whether there was a difference in parent satisfaction for epidural analgesia with an opioid alone (MD 0.60, 95% CI -0.81 to 2.01; 1 trial, 27 participants; very low-quality evidence).ComplicationsIt was uncertain whether there was a difference in the risk of complications such as: respiratory depression (risk difference (RD) -0.05, 95% CI -0.16 to 0.05; 4 studies, 126 participants; very low-quality evidence); wound infection (RD 0.01, 95% CI -0.05 to 0.08; 2 trials, 93 participants; very low-quality evidence); epidural abscess (RD 0, 95% CI -0.05 to 0.05; 3 trials, 120 participants; very low-quality evidence); and neurological complications (RD 0.01, 95% CI -0.04 to 0.06; 4 studies, 151 participants; very low-quality evidence). AUTHORS' CONCLUSIONS: There is moderate- and low-quality evidence that there may be a small additional reduction in pain up to 72 hours after surgery with epidural analgesia compared with systemic analgesia. Two very small studies showed epidural analgesia with local anaesthetic alone may accelerate the return of gastrointestinal function. The safety of this technique in children undergoing thoraco-lumbar surgery is uncertain due to the very low-quality of the evidence. The study in 'Studies awaiting classification' may alter the conclusions of the review once assessed.


Assuntos
Analgesia Epidural , Analgesia/métodos , Vértebras Lombares/cirurgia , Dor Pós-Operatória/tratamento farmacológico , Vértebras Torácicas/cirurgia , Analgesia/efeitos adversos , Analgesia Epidural/efeitos adversos , Deambulação Precoce/estatística & dados numéricos , Humanos , Duração da Cirurgia , Medição da Dor , Satisfação do Paciente , Ensaios Clínicos Controlados Aleatórios como Assunto , Vômito/induzido quimicamente
15.
Q J Exp Psychol (Hove) ; 72(4): 847-857, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29554832

RESUMO

Research exploring the processing of morphologically complex words, such as compound words, has found that they are decomposed into their constituent parts during processing. Although much is known about the processing of compound words, very little is known about the processing of lexicalised blend words, which are created from parts of two words, often with phoneme overlap (e.g., brunch). In the current study, blends were matched with non-blend words on a variety of lexical characteristics, and blend processing was examined using two tasks: a naming task and an eye-tracking task that recorded eye movements during reading. Results showed that blend words were processed more slowly than non-blend control words in both tasks. Blend words led to longer reaction times in naming and longer processing times on several eye movement measures compared to non-blend words. This was especially true for blends that were long, rated low in word familiarity, but were easily recognisable as blends.


Assuntos
Linguagem , Nomes , Leitura , Semântica , Vocabulário , Adulto , Atenção , Movimentos Oculares/fisiologia , Feminino , Humanos , Masculino , Tempo de Reação/fisiologia
16.
J Arthroplasty ; 34(1): 56-64.e5, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30340916

RESUMO

BACKGROUND: Frailty and disability from arthritis are closely intertwined and little is known about the impact of frailty on total hip arthroplasty (THA) outcomes. We hypothesized that higher preoperative frailty is associated with more adverse events following THA. METHODS: All patients (≥50 years) undergoing unilateral primary or revision THA at a single institution from 2005 through 2016 were included. We analyzed the association of frailty (measured by a frailty deficit index) with postoperative outcomes in hospital, within 90 days, and within 1 year using multivariable logistic and Cox regression, adjusting for age. RESULTS: Among 8640 patients undergoing THA (6502 primary and 2138 revisions; median age 68 years), 22.7%, 32.9%, and 44.4% were classified as frail, vulnerable, and nonfrail, respectively. Frail patients tended to be female, older, sicker (American Society of Anesthesiologists ≥3), and received general anesthesia more frequently. Relative to nonfrail patients, frail patients had significantly increased odds of wound complications/hematoma (odds ratio 2.01) and reoperation (odds ratio 2.74) while in hospital, and increased risks for mortality (1-year hazards ratio [HR] 5.65), infection (1-year HR 3.63), dislocation (1-year HR 2.10), wound complications/hematoma (1-year HR 2.61), and reoperation (1-year HR 2.22) within 90 days and 1 year. Frailty was also associated with >5.5-fold increased mortality risk 1 year following THA. No significant associations with aseptic loosening, periprosthetic fracture, or heterotopic ossification were observed. CONCLUSION: A higher preoperative frailty index is associated with increased mortality and perioperative complications following primary and revision THA. The proposed frailty deficit index provides clinically important information for healthcare providers to use when counseling patients prior to decision for surgery.


Assuntos
Artroplastia de Quadril/efeitos adversos , Fragilidade , Reoperação/efeitos adversos , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Ossificação Heterotópica , Fraturas Periprotéticas , Complicações Pós-Operatórias , Período Pós-Operatório , Período Pré-Operatório , Prevalência , Modelos de Riscos Proporcionais , Sistema de Registros , Fatores de Risco , Resultado do Tratamento
17.
Acta Psychol (Amst) ; 192: 1-10, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30388546

RESUMO

While recent research has explored the effect that positive and negative emotion words (e.g., happy or sad) have on the eye-movement record during reading, the current study examined the effect of positive and negative emotion-laden words (e.g., birthday or funeral) on eye movements. Emotion-laden words do not express a state of mind but have emotional associations and connotations. The current results indicated that both positive and negative emotion-laden words have a processing advantage over neutral words, although the relative time-course of processing differs between words of positive and negative valence. Specifically, positive emotion-laden words showed advantages in early, late, and post-target measures, while negative emotion-laden words showed effects only in late and post-target measures.


Assuntos
Emoções/fisiologia , Movimentos Oculares/fisiologia , Leitura , Adulto , Nível de Alerta/fisiologia , Feminino , Fixação Ocular , Humanos , Linguagem , Masculino
18.
Kidney Int Rep ; 3(6): 1294-1303, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30450456

RESUMO

Introduction: It is unknown whether patients receiving dialysis have a higher morbidity and mortality risk after hip fracture repair conferred by their kidney failure or by the high comorbidity burden often present. Methods: We examined associations of dialysis dependency with postoperative complications, death, and readmission in a matched cohort study of U.S. patients undergoing hip fracture repair, from January 2010 to December 2013, in the American College of Surgeons National Surgical Quality Improvement Program. Matching included sex, age, race, diabetes mellitus, operation year, primary surgery type, and anesthesia technique. Results: Among 22,621 patients, 377 dialysis-dependent patients were matched to 1508 nondialysis patients. Median age was 78 years (interquartile range = 68-85) years, 56% were men, 70% were white, 43% had diabetes, and 47% underwent fracture fixation under mostly (80%) general anesthesia. Dialysis-dependent patients had higher physical status classification, had more heart failure and hypoalbuminemia, and were less often smokers. After adjustment, a greater risk of prolonged postoperative stays beyond 7 days (odds ratio [OR] = 1.43, 95% confidence interval [CI] = 1.09-1.89), higher in-hospital mortality (OR = 3.13, CI = 1.72-5.7), and 30-day death (OR = 2.29, CI = 1.51-3.48) but not 30-day readmission (P = 0.09) was observed with dialysis dependency. Adjusted analyses in the original cohort (n = 22,621) were similar: the dialysis group had greater risk of prolonged postoperative stay (OR = 1.77, CI = 1.42-2.21), in-hospital mortality (OR = 2.65, CI = 1.74-4.05), and 30-day death (OR = 2.03, CI = 1.48-2.80) and 30-day readmission (OR = 1.62, CI = 1.66-2.26). Conclusion: Dialysis dependency is associated with an increased risk of death and postoperative complications after hip fracture repair. These findings have implications for case-mix adjustment and quality metrics.

19.
Mayo Clin Proc Innov Qual Outcomes ; 2(3): 234-240, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30225456

RESUMO

Objective: To test the hypothesis that patients dismissed alone in a sedation dismissal process (SDP) have no greater risk of adverse outcome compared with those who were dismissed with a responsible adult. Patients and Methods: We compared 2441 SDP patients undergoing 2703 procedures with 4923 unique control patients who underwent 5133 procedures between June 1, 2012, and March 31, 2017. Results: The rate of unplanned readmission related to the procedure was 0.11% (n=9), and there was no difference between SDP (0.07%) and controls (0.14%). Similarly, there was no difference in complication rates between SDP patients and controls when restricting to "all causes" unplanned readmissions within 24 hours and unplanned readmissions related to procedure. Conclusion: With proper preparation, short-acting anesthetic/sedation medications, and sound clinical judgment, the presence of a responsible adult escort is not associated with reduced risk following discharge after ambulatory anesthesia. This practice may lessen the hardships reported by patients in needing to obtain an escort and the inconveniences and delays experienced by ambulatory procedural facilities when patients arrive without a designated escort.

20.
Acad Pathol ; 5: 2374289518793988, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30186954

RESUMO

Autopsy has been a foundation of pathology training for many years, but hospital autopsy rates are notoriously low. At the 2014 meeting of the Association of Pathology Chairs, some pathologists suggested removing autopsy from the training curriculum of pathology residents to provide additional months for training in newer disciplines, such as molecular genetics and informatics. At the same time, the American Board of Pathology received complaints that newly hired pathologists recently certified in anatomic pathology are unable to perform an autopsy when called upon to do so. In response to a call to abolish autopsy from pathology training on the one hand and for more rigorous autopsy training on the other, the Association of Pathology Chairs formed the Autopsy Working Group to examine the role of autopsy in pathology residency training. After 2 years of research and deliberation, the Autopsy Working Group recommends the following:Autopsy should remain a component of anatomic pathology training.A training program must have an autopsy service director with defined responsibilities, including accountability to the program director to record every autopsy performed by every resident.Specific entrustable activities should be defined that a resident must master in order to be deemed competent in autopsy practice, as well as criteria for gaining the trust to perform the tasks without direct supervision.Technical standardization of autopsy performance and reporting must be improved.The current minimum number of 50 autopsies should not be reduced until the changes recommended above have been implemented.

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