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1.
J Foot Ankle Surg ; 59(3): 484-490, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32354505

RESUMO

AIMS: The optimal level of lower-extremity amputation, particularly in diabetic patients with ulceration, is debated. Proximal amputations more greatly decrease function versus distal amputations, but healing and complication rates may differ between the 2 types. This study compares early postoperative outcomes after transmetatarsal and other partial foot amputations and major leg amputations. METHODS: Data were derived from National Surgical Quality Improvement Program datasets covering 2012 to 2014. Outcomes studied include 30-day rates of readmission to hospital for wound complications. We matched the 2 types of amputation patients by propensity score to fairly compare between levels of amputation when either type of amputation might be indicated. The same analysis was then performed with emphasis on diabetic patients. RESULTS: Major amputation patients were more likely to have dependent functional status, although their surgeries tended to be more complicated. Minor amputation patients had 2.5 times the odds of irrigation and debridement compared with major amputation patients, but only 0.49 and 0.47 times the odds of urinary tract infection or transfusion, respectively. CONCLUSIONS: Although short-term complications, readmissions, and reoperations were more common in distal amputation, UTI and the need for transfusion were higher in major amputation.

2.
J Obes ; 2020: 3736504, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32185078

RESUMO

Successful lifestyle changes for weight reduction are heavily dependent on recognizing the importance of societal and cultural factors. Patients 13-19 years of age with a BMI ≥95th percentile are eligible for our multidisciplinary adolescent weight loss clinic. A behavioral questionnaire was administered at the initial visit. Patients were seen every 4-6 weeks. Bivariate analysis was used to identify sociodemographic factors associated with differences in weight loss. Overall, receiving reduced cost meals was associated with a lower likelihood of losing weight (kg) (p < 0.01). When stratified by race, White adolescents were more likely to lose weight if caretakers reported having enough money to buy healthy food (p < 0.05); in contrast, Black adolescents were less likely to lose weight (p < 0.05). However, Black patients were more likely to lose weight if they reported eating fruits and vegetables (p < 0.05). Female adolescents were more likely to lose weight if they felt unhappy about their appearance (p < 0.05). Interestingly, male adolescents were less likely to lose weight if they felt unhappy about their appearance (p < 0.05). Social and cultural norms influence weight loss in adolescents in unique and differing ways. Culturally competent individualized interventions could increase weight loss in diverse groups of adolescents with obesity.

3.
J Foot Ankle Surg ; 59(2): 239-245, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32130984

RESUMO

Although fractures of the ankle are common injuries treated by surgical podiatrists and orthopaedic surgeons specializing in foot and ankle surgery, postoperative complications can occur, often imposing an economic burden on the patient. As health care in the United States moves toward value-based care, cost reduction has primarily focused on reducing complications and unplanned episodes of care. We used a large modern database of insurance claims to examine patterns of complications after open reduction internal fixation of ankle fractures, identifying diabetes mellitus and history of myocardial infarction as risk factors for postoperative infection within 30 days of surgery. Lateral malleolar repair was less likely to lead to infection, or need for repeated surgery, than was medial malleolar fracture repair. Diabetes mellitus, neuropathy, and chronic obstructive pulmonary disease were associated with development of postoperative cellulitis. Patients with a history of cerebrovascular accident were more likely to return to the emergency department or to have a pulmonary embolism. Male sex, presence of lupus, and increased age were associated with repeat surgery.

4.
J Foot Ankle Surg ; 59(1): 75-85, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31753572

RESUMO

Histopathologic examination of bone specimens coupled with bone culture is considered the gold standard for the diagnosis of osteomyelitis (OM). Despite this, studies have demonstrated interpathologist agreement in the diagnosis of OM as low as 30%, largely stemming from a lack of specific definitions and diagnostic criteria. Review of the literature has provided insight into the lifecycle of OM, illustrating the histologic progression of OM phases from acute to chronic, and provides support for defining subcategories of OM. Using an algorithmic histopathologic tool consisting of 15 criteria, each with an associated score, we defined 5 categories of OM: (1) acute OM, (2) acute and chronic OM, (3) chronic OM, (4) chronic active OM, and (5) chronic inactive OM. We reviewed 462 microscopic slides from 263 patients with suspected OM, and for each slide, we determined an algorithm-derived diagnosis, which was then used to calculate a total histopathologic load score (Jupiter score). Algorithm-derived diagnoses recapitulated original clinical diagnoses and diagnosed cases as OM that had not been originally diagnoses. These novel cases were more likely to have subsequent clinical complications. Finally, pathologic load scores were assessed for association with the category of OM.

5.
Neurol India ; 67(6): 1539-1542, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31857556

RESUMO

Background: Cognitive impairment has emerged as an important concern in clinical practice in aging population. Several comorbid factors contribute to etiopathogenesis; one disease of interest is chronic respiratory disease. Aim: The aim of this study is to investigate the association of chronic respiratory disease with risk of cognitive impairment in older Mexicans. Materials and Methods: Data were obtained from 2782 Mexicans, aged ≥60 years, enrolled in waves I (2001) and III (2012) of the Mexican Health and Aging Study, a prospective cohort of nationally representative sample of older Mexicans. Participants' self-reported responses were used to categorize them into having respiratory disease or not. Study outcome included participants categorized into "cognitively impaired" or "cognitively normal" groups. Multivariable logistic regression models were used to investigate the relationship. Results: Overall, 16% of cohort participants reported cognitively impaired at Wave III. Compared with older Mexicans without chronic respiratory disease diagnosis, those diagnosed were not significantly associated with risk of cognitive impairment [adjusted odds ratio (OR): 0.94, 95% confidence interval (CI): 0.58-1.58]. Conclusion: Chronic respiratory disease is not significantly associated with risk of cognitive impairment in older Mexican adults.

6.
J Surg Orthop Adv ; 28(4): 260-267, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31886761

RESUMO

This study evaluates rater accuracy and variation for the purpose of using intraoperative ultrasound (US) imaging to detect dorsal screw protrusion during fixed-angle volar plating of distal radius fractures. Stabilizing volar plates and screws with varying lengths of dorsal protrusion were applied to 10 cadaver wrist pairs. After a brief training session, seven surgeons without prior ultrasound experience assessed screw protrusion on two separate occasions using a diagnostic ultrasound machine. Screw protrusions were visually confirmed after data collection was completed. Statistical analyses included percent agreement and Cohen's kappa for accuracy and intra- and inter-rater reliability, sensitivity, specificity, and positive and negative predictive values. Only two out of seven raters met acceptable levels of accuracy and consistency. Our findings inform us that accuracy and consistency of ultrasound-guided detection of dorsal screw protrusion are negatively impacted by rater variation. Further investigations are needed to improve rater effectiveness. (Journal of Surgical Orthopaedic Advances 28(4):260-267, 2019).


Assuntos
Placas Ósseas , Fraturas do Rádio , Parafusos Ósseos , Fixação Interna de Fraturas , Humanos , Rádio (Anatomia) , Reprodutibilidade dos Testes , Ultrassonografia
7.
J Foot Ankle Surg ; 58(6): 1203-1209, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31679673

RESUMO

The aim of the current study was to evaluate the effectiveness of intraoperative neuromonitoring (INM) as an adjunct in performing tarsal tunnel decompression surgery. We reviewed 38 patients who met inclusion criteria. INM was used to measure the voltage of the abductor hallucis and digiti quinti muscles both before and after decompression. Observed changes intraoperatively were acute and within minutes of the decompression performed by the surgeon. Patient outcomes were ascertained from clinical findings and classified as excellent, fair, or poor. Patient outcomes and the voltage change were measured and assessed for association, and statistically significant differences were found between outcome groups. Of the 38 patients, 29 (76%) had excellent outcomes, with a mean change in microvolts of 2088.28 ± 1172.44 (684%) (p = .0004) and 2173.24 ± 1228.39 (742%) (p = .0014) for abductor hallucis and abductor digiti quinti, respectively. The study supports INM as a useful adjunct in performing tarsal tunnel decompression.

8.
Med Care ; 57(11): 905-912, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31568165

RESUMO

BACKGROUND: It is unclear whether Medicare data can be used to identify type and degree of collaboration between primary care providers (PCPs) [medical doctors (MDs), nurse practitioners, and physician assistants] in a team care model. METHODS: We surveyed 63 primary care practices in Texas and linked the survey results to 2015 100% Medicare data. We identified PCP dyads of 2 providers in Medicare data and compared the results to those from our survey. Sensitivity, specificity, and positive predictive value (PPV) of dyads in Medicare data at different threshold numbers of shared patients were reported. We also identified PCPs who work in the same practice by Social Network Analysis (SNA) of Medicare data and compared the results to the surveys. RESULTS: With a cutoff of sharing at least 30 patients, the sensitivity of identifying dyads was 27.8%, specificity was 91.7%, and PPV 72.2%. The PPV was higher for MD-nurse practitioner/physician assistant pairs (84.4%) than for MD-MD pairs (61.5%). At the same cutoff, 90% of PCPs identified in a practice from the survey were also identified by SNA in the corresponding practice. In 5 of 8 surveyed practices with at least 3 PCPs, about ≤20% PCPs identified in the practices by SNA of Medicare data were not identified in the survey. CONCLUSIONS: Medicare data can be used to identify shared care with low sensitivity and high PPV. Community discovery from Medicare data provided good agreement in identifying members of practices. Adapting network analyses in different contexts needs more validation studies.


Assuntos
Assistência à Saúde/estatística & dados numéricos , Medicare/estatística & dados numéricos , Equipe de Assistência ao Paciente/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Interpretação Estatística de Dados , Assistência à Saúde/métodos , Humanos , Colaboração Intersetorial , Profissionais de Enfermagem/estatística & dados numéricos , Assistentes Médicos/estatística & dados numéricos , Médicos de Atenção Primária/estatística & dados numéricos , Atenção Primária à Saúde/métodos , Texas , Estados Unidos
9.
J Foot Ankle Surg ; 58(6): 1152-1162, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31543380

RESUMO

The data regarding rates of deep venous thrombosis and pulmonary embolism after foot and ankle trauma remain sparse. In this study of the National Trauma Data Bank Data set (2007-2009 and 2010-2016), these rates were reexamined and risk factors associated with these complications were assessed. Data quality is improved in the later data set; the incidence of deep venous thrombosis and pulmonary embolism was 0.28% and 0.21%, respectively, in the 2010-2016 data. Prophylaxis, male gender, treatment in a university hospital, open reduction, chronic obstructive pulmonary disease, and hypertension were notable significant risk factors for pulmonary embolism. For deep venous thrombosis, male gender, bleeding disorder, angina, and prophylaxis were risk factors. Careful, individualized assessment of the risk factors associated with deep venous thrombosis and pulmonary embolism is important, and the merits of routine prophylaxis remain in question.

10.
J Foot Ankle Surg ; 58(6): 1095-1099, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31562061

RESUMO

Relationships between hallux valgus (HV) and other measurements within the first ray have been extensively studied. It is becoming more popular to correct HV deformity with tarsometatarsal joint arthrodesis while internally (varus) rotating the first metatarsal. This, in turn, reduces the sesamoid position when viewed in the dorsoplantar projection on radiographs. However, it has been shown that not all HV deformities have pathological external (valgus) rotation of the first metatarsal. In this study, we explored the relationships between frontal-plane rotations of the first metatarsal as well as the sesamoids, and other factors not limited to the first ray, to better understand the pathological process of HV deformity and to assist in surgical planning. We found that when adjusting for these covariates, the only factor associated with first metatarsal external rotation was having less metatarsus adductus. Sesamoid rotation, on the other hand, was independently associated with the HV angle, tibial sesamoid position, and medial column collapse. When surgically treating HV, correction of sesamoid rotation may need to be prioritized.

11.
J Foot Ankle Surg ; 58(6): 1298, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31562063
12.
BMC Cancer ; 19(1): 778, 2019 Aug 07.
Artigo em Inglês | MEDLINE | ID: mdl-31391011

RESUMO

BACKGROUND: Adjunct testosterone therapy improves lean body mass, quality of life, and physical activity in patients with advanced cancers; however, the effects of testosterone on cardiac morphology and function are unknown. Accordingly, as an ancillary analysis of a randomized, placebo-controlled trial investigating the efficacy of testosterone supplementation on body composition in men and women with advanced cancers, we explored whether testosterone supplementation could prevent or reverse left ventricular (LV) atrophy and dysfunction. METHODS: Men and women recently diagnosed with late stage (≥IIB) or recurrent head and neck or cervical cancer who were scheduled to receive standard of care chemotherapy or concurrent chemoradiation were administered an adjunct 7 week treatment of weekly intramuscular injections of either 100 mg testosterone (T, n = 1 M/5F) or placebo (P, n = 6 M/4F) in a double-blinded randomized fashion. LV morphology (wall thickness), systolic function (ejection fraction, EF), diastolic function (E/A; E'/E), arterial elastance (Ea), end-systolic elastance (Ees), and ventricular-arterial coupling (Ea/Ees) were assessed. RESULTS: No significant differences were observed in LV posterior wall thickness in placebo (pre: 1.10 ± 0.1 cm; post: 1.16 ± 0.2 cm; p = 0.11) or testosterone groups (pre: 0.99 ± 0.1 cm; post: 1.14 ± 0.20 cm; p = 0.22). Compared with placebo, testosterone significantly improved LVEF (placebo: - 1.8 ± 4.3%; testosterone: + 6.2 ± 4.3%; p < 0.05), Ea (placebo: 0.0 ± 0.2 mmHg/mL; testosterone: - 0.3 ± 0.2 mmHg/mL; p < 0.05), and Ea/Ees (placebo: 0.0 ± 0.1; testosterone: - 0.2 ± 0.1; p < 0.05). CONCLUSIONS: In patients with advanced cancers, testosterone was associated with favorable changes in left ventricular systolic function, arterial elastance, and ventricular-arterial coupling. Given the small sample size, the promising multisystem benefits of testosterone warrants further evaluation in a definitive randomized trial. TRIAL REGISTRATION: This study was prospectively registered on ClinicalTrials.gov (NCT00878995; date of registration: April 9, 2009).


Assuntos
Coração/efeitos dos fármacos , Neoplasias/fisiopatologia , Testosterona/uso terapêutico , Adulto , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Pressão Sanguínea/efeitos dos fármacos , Ecocardiografia , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/etiologia , Frequência Cardíaca/efeitos dos fármacos , Ventrículos do Coração/efeitos dos fármacos , Ventrículos do Coração/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/complicações , Neoplasias/tratamento farmacológico , Qualidade de Vida , Testosterona/administração & dosagem , Testosterona/efeitos adversos , Resultado do Tratamento , Função Ventricular Esquerda/efeitos dos fármacos
13.
J Am Acad Orthop Surg Glob Res Rev ; 3(5): e055, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31321373

RESUMO

Background: Scaphoid and radial head fractures are two injuries derived from the common fall on outstretched hand. How these injuries are related has not been fully investigated. The aim of this study was to evaluate risk factors for having concomitant proximal radius and scaphoid fractures. The goal was to identify at-risk patient populations and drive improvement in diagnosis and management of these injuries. Methods: A retrospective review of the National Trauma Data Bank from 2007 through 2012 identified 11,309 patients with proximal radius fracture, and, as a proxy for low-energy injury, an injury severity score of less than 15. These patients were then categorized by presence of concomitant scaphoid injury. Presence of scaphoid fracture was then analyzed based on age, sex, race, trauma type, mechanism, and injury severity score. Results: Three hundred seventy-eight (3%) scaphoid fractures among the 11,309 proximal radius fractures were identified. Both age and sex reached statistical significance as risk factors for concomitant scaphoid and radial head injury. There was an incremental increase in risk for concomitant injury with younger age. Subset analysis demonstrated a 10% incidence of concomitant fractures in men aged 18 to 30 years. Discussion: This study provides a better understanding of how these two fractures are related. There is a markedly higher risk for concomitant injuries in male and young patients, especially those whose mechanism is a fall. Close examination of the wrist should be performed for any proximal radius fracture, and any pain should be a cause for further investigation of scaphoid injury.

14.
PLoS One ; 14(6): e0217690, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31194764

RESUMO

INTRODUCTION: Long-term head-down bed rest (HDBR) results in musculoskeletal losses similar to those observed during long-term space flight. Agents such as testosterone, in addition to regular exercise, are effective countermeasures for reducing loss of skeletal muscle mass and function. OBJECTIVE: We investigated the skeletal muscle proteome of healthy men in response to long term HDBR alone (CON) and to HDBR with exercise (PEX) or exercise plus testosterone (TEX) countermeasures. METHOD: Biopsies were performed on the vastus lateralis before (pre) HDBR and on HDBR days 32 (mid) and 64 (post). Extracted proteins from these skeletal muscle biopsies were subjected to 2-dimensional gel electrophoresis (2DE), stained for phosphoproteins (Pro-Q Diamond dye) and total proteins (Sypro Ruby dye). Proteins showing significant fold differences (t-test p ≤ 0.05) in abundance or phosphorylation state at mid or post were identified by mass spectroscopy (MS). RESULTS: From a total of 932 protein spots, 130 spots were identified as potentially altered in terms of total protein or phosphoprotein levels due to HDBR and/or countermeasures, and 59 unique molecules emerged from MS analysis. Top canonical pathways identified through IPA included calcium signaling, actin cytoskeleton signaling, integrin linked kinase (ILK) signaling, and epithelial adherens junction signaling. Data from the pre-HDBR proteome supported the potential for predicting physiological post-HDBR responses such as the individual's potential for loss vs. maintenance of muscle mass and strength. CONCLUSIONS: HDBR resulted in alterations to skeletal muscle abundances and phosphorylation of several structural and metabolic proteins. Inclusion of exercise alone or in combination with testosterone treatment modulated the proteomic responses towards cellular reorganization and hypertrophy, respectively. Finally, the baseline proteome may aid in the development of personalized countermeasures to mitigate health risks in astronauts as related to loss of muscle mass and function.

15.
J Bone Joint Surg Am ; 101(11): e50, 2019 Jun 05.
Artigo em Inglês | MEDLINE | ID: mdl-31169583

RESUMO

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) Open Payments public database, resulting from the Physician Payments Sunshine Act of 2010, was designed to increase transparency of physicians' financial relationships with pharmaceutical manufacturers. We compared physician-reported conflict-of-interest (COI) disclosures in journal articles with this database to determine any discrepancies in physician-reported disclosures. METHODS: COIs reported by authors from 2014 through 2016 were analyzed in 3 journals: Foot & Ankle International (FAI), The Journal of Bone & Joint Surgery (JBJS), and The Journal of Arthroplasty (JOA). Payment information in the CMS Open Payments database was cross-referenced with each author's disclosure statement to determine if a disclosure discrepancy was present. RESULTS: We reviewed 3,465 authorship positions (1,932 unique authors) in 1,770 articles. Within this sample, 7.1% of authorships had a recorded undisclosed COI (disclosure discrepancy), and 13.2% of articles had first and/or last authors with a disclosure discrepancy. Additionally, we saw a great variation in the percentage of authorships with disclosure discrepancies among the journals (JBJS, 2.3%; JOA, 3.6%; and FAI, 23.7%). CONCLUSIONS: Discrepancies exist between payment disclosures made by authors and those published in the CMS Open Payments database. Although the percentage of articles with these discrepancies varies widely among the journals that were analyzed in this study, no trend was found when analyzing the number of discrepancies over the 3-year period. CLINICAL RELEVANCE: COI disclosures are important for the interpretation of study results and need to be accurately reported. However, COI disclosure criteria vary among orthopaedic journals, causing uncertainty regarding which conflicts should be disclosed.


Assuntos
Conflito de Interesses , Revelação , Indústria Farmacêutica/ética , Ortopedia/ética , Médicos/ética , Bases de Dados Factuais , Humanos , Ortopedia/economia , Médicos/economia , Estados Unidos
16.
J Oncol Pract ; 15(5): e447-e457, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30946640

RESUMO

PURPOSE: Health care costs are driven by a small proportion of patients, and it is important to identify their characteristics to effectively manage their health care needs. We examined characteristics associated with high-cost inpatient visits of elderly patients with cancer using a national sample. METHODS: We identified 574,367 inpatient visits of individuals age 65 years or older with a cancer diagnosis using the 2014 National Inpatient Sample data, an all-payer sample of inpatient stays in the United States. High-cost visits were defined as those with a total cost at or above the 90th percentile. The remaining visits were defined as the lower-cost group. We examined patients' clinical characteristics and hospital characteristics for both groups. Logistic regression was used to identify characteristics associated with being in the high-cost group. RESULTS: The median visit cost in the high-cost group was $38,194 (interquartile range, $31,405 to $51,802), which was nearly five times the cost of the lower-cost group (median, $8,257; interquartile range, $5,032 to $13,335). Hematologic malignancies were the most common cancer in the high-cost group. Those in the high-cost group were more likely to have metastatic cancer. Compared with patients with no comorbidities, those with five or more comorbidities were four times more likely to be in the high-cost group (odds ratio, 4.08; 95% CI, 3.74 to 4.46). Patients with a greater number of procedures were also more likely to be in the high-cost group (odds ratio, 1.57; 95% CI, 1.52 to 1.61). CONCLUSION: High-cost cancer visits were five times more expensive than the remaining visits. Identification of high-cost visits and the associated factors may help provide tailored strategies to effectively manage costly inpatient admissions.

17.
J Foot Ankle Surg ; 58(2): 403-404, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30850106

RESUMO

There are numerous possible goals for building statistical models. Those statistical goals, the associated model types, and each statistical tool involved in model building come with its own assumptions and requirements. In turn, these requirements must be met if we are to ensure that our models produce meaningful, interpretable results. However, beyond these technical details is the intuition, and the additional set of tools and algorithms, used by the statistician, to build the contextually appropriate model: not only must we build an interpretable model, we must build a model that answers the particular question at hand and addresses the particular goal we have in mind. In this column we discuss the methods by which statisticians build models for description, risk factor identification, and prediction.


Assuntos
Traumatismos do Pé/cirurgia , Fraturas Ósseas/cirurgia , Modelos Estatísticos , Algoritmos , Fraturas do Tornozelo/diagnóstico por imagem , Fraturas do Tornozelo/cirurgia , Tomada de Decisão Clínica , Traumatismos do Pé/diagnóstico por imagem , Fraturas Ósseas/diagnóstico por imagem , Humanos , Valor Preditivo dos Testes , Fatores de Risco
18.
Environ Res ; 172: 462-469, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30844571

RESUMO

The potential of system dynamics modeling to advance our understanding of cumulative risk in the service of optimal health is discussed. The focus is on exploring system dynamics modeling as a systems science methodology that can provide a framework for examining the complexity of real-world social and environmental exposures among populations-particularly those exposed to multiple disparate sources of risk. The discussion also examines how system dynamics modeling can engage a diverse body of key stakeholders throughout the modeling process, promoting the collective assessment of assumptions and systematic gathering of critical data. Though not a panacea, system dynamics modeling provides a promising methodology to complement traditional research methods in understanding cumulative health effects from exposure to multiple environmental and social stressors.


Assuntos
Exposição Ambiental , Medição de Risco , Exposição Ambiental/efeitos adversos , Medição de Risco/métodos
19.
J Cardiothorac Vasc Anesth ; 33(8): 2208-2215, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30738752

RESUMO

OBJECTIVE: Identifying fluid responsiveness is critical to optimizing perfusion while preventing fluid overload. An experimental study of hypovolemic shock resuscitation showed the importance of ventricular compliance and peripheral venous pressure (PVP) on fluid responsiveness. The authors tested the hypothesis that reduced ventricular compliance measured using transesophageal echocardiography results in decreased fluid responsiveness after a fluid bolus. DESIGN: Prospective observational study. SETTING: Two-center, university hospital study. PARTICIPANTS: The study comprised 29 patients undergoing elective coronary revascularization. INTERVENTION: Albumin 5%, 7 mL/kg, was infused over 10 minutes to characterize fluid responders (>15% increase in stroke volume) from nonresponders. MEASUREMENTS AND MAIN RESULTS: Invasive hemodynamics and the ratio of mitral inflow velocity (E-wave)/annular relaxation (e'), or E/e' ratio, were measured using transesophageal echocardiography to assess left ventricular (LV) compliance at baseline and after albumin infusion. Fifteen patients were classified as responders and 14 as nonresponders. The E/e' ratio in responders was 7.4 ± 1.9 at baseline and 7.1 ± 1.8 after bolus. In contrast, E/e' was significantly higher in nonresponders at baseline (10.7 ± 4.6; p = 0.04) and further increased after bolus (12.6 ± 5.5; p = 0.002). PVP was significantly greater in the nonresponders at baseline (14 ± 4 mmHg v 11 ± 3 mmHg; p = 0.02) and increased in both groups after albumin infusion. Fluid responsiveness was tested using the area under the receiver operating characteristic curve and was 0.74 for the E/e' ratio (95% confidence interval 0.55-0.93; p = 0.029) and 0.72 for the PVP (95% confidence interval 0.52-0.92; p = 0.058). CONCLUSION: Fluid responders had normal LV compliance and lower PVP at baseline. In contrast, nonresponders had reduced LV compliance, which worsened after fluid bolus. E/e,' more than PVP, may be a useful clinical index to predict fluid responsiveness.

20.
Foot Ankle Spec ; 12(6): 530-534, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30628467

RESUMO

Ultrasound-guided popliteal blocks for postoperative pain management have grown in popularity within foot and ankle surgery. The purpose of this study was to evaluate the efficacy of popliteal block in preventing postoperative emergency department visits after foot and ankle surgery. We compared rates of presentation to the emergency department for pain following foot and ankle surgery between surgeries with a popliteal block and those with local field block alone. We identified 101 charts, of which 26 presented to the emergency department for postoperative pain following popliteal block. Our results demonstrated that popliteal blocks did not perform better than local blocks, and that there is no statistically significant difference between the 2 methods of postoperative pain control in terms of rates of presentation to the emergency department for pain. Levels of Evidence: Level III, All statistical analyses were carried out using the R statistical package by the primary author (NS) (R Developmental, Core Team. R: A Language and Environment for Statistical Computing, 2012. http://www.R-project.org ).

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