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Circ Cardiovasc Interv ; 11(9): e006664, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30354591


BACKGROUND: The Society of Thoracic Surgeons (STS) scores are used to screen patients for transcatheter aortic valve replacement (TAVR). The STS scores were also used to risk stratify patients in major TAVR trials. This study evaluates the reclassification of predicted risk of mortality by the currently available online STS score calculator compared with the 2008 STS risk model in patients undergoing TAVR. METHODS AND RESULTS: All patients who underwent TAVR from 2006 to 2016 were included in the study. The STS scores for all included patients were calculated by applying the 2008 STS risk model and again using the current STS online calculator. Among 1209 patients who underwent TAVR, 30-day mortality was 27 (2.2%). The overall predicted risk of mortality estimated by using the current online STS risk calculator was significantly lower than the 2008 STS risk model (6.3±4.4 vs 7.3±4.9; P<0.001). A total of 235 (19%) patients were reclassified into a lower risk category per the current STS risk model. In a multivariable logistic regression analysis, patients with persistent atrial fibrillation (odds ratio, 1.4; 95% CI, 1.0-1.9; P=0.03), chronic heart failure (odds ratio, 6.0; 95% CI, 3.8-10.1; P<0.001), and New York Heart Association class IV heart failure (odds ratio, 2.4; 95% CI, 1.3-4.4; P=0.007) were more likely to be reclassified into a lower risk category per the current STS risk model. CONCLUSIONS: The current STS calculation method produces significantly lower predicted risk of mortality than the 2008 calculator, more pronounced in patients with certain comorbid conditions. These results should be considered while evaluating data from prior studies of TAVR.

Valva Aórtica/cirurgia , Técnicas de Apoio para a Decisão , Doenças das Valvas Cardíacas/cirurgia , Substituição da Valva Aórtica Transcateter/mortalidade , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisão Clínica , Comorbidade , Feminino , Doenças das Valvas Cardíacas/diagnóstico , Doenças das Valvas Cardíacas/mortalidade , Humanos , Masculino , Seleção de Pacientes , Valor Preditivo dos Testes , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do Tratamento
PLoS One ; 11(4): e0153675, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27082959


Epidural analgesia is considered the standard of care but cannot be provided to all patients Liposomal bupivacaine has been approved for field blocks such as transversus abdominis plane (TAP) blocks but has not been clinically compared against other modalities. In this retrospective propensity matched cohort study we thus tested the primary hypothesis that TAP infiltration are noninferior (not worse) to continuous epidural analgesia and superior (better) to intravenous opioid analgesia in patients recovering from major lower abdominal surgery. 318 patients were propensity matched on 18 potential factors among three groups (106 per group): 1) TAP infiltration with bupivacaine liposome; 2) continuous Epidural analgesia with plain bupivacaine; and; 3) intravenous patient-controlled analgesia (IV PCA). We claimed TAP noninferior (not worse) over Epidural if TAP was noninferior (not worse) on total morphine-equivalent opioid and time-weighted average pain score (10-point scale) within first 72 hours after surgery with noninferiority deltas of 1 (10-point scale) for pain and an increase less of 20% in the mean morphine equivalent opioid consumption. We claimed TAP or Epidural groups superior (better) over IV PCA if TAP or Epidural was superior on opioid consumption and at least noninferior on pain outcome. Multivariable linear regressions within the propensity-matched cohorts were used to model total morphine-equivalent opioid dose and time-weighted average pain score within first 72 hours after surgery; joint hypothesis framework was used for formal testing. TAP infiltration were noninferior to Epidural on both primary outcomes (p<0.001). TAP infiltration were noninferior to IV PCA on pain scores (p = 0.001) but we did not find superiority on opioid consumption (p = 0.37). We did not find noninferiority of Epidural over IV PCA on pain scores (P = 0.13) and nor did we find superiority on opioid consumption (P = 0.98). TAP infiltration with liposomal bupivacaine and continuous epidural analgesia were similar in terms of pain and opioid consumption, and not worse in pain compared with IV PCA. TAP infiltrations might be a reasonable alternative to epidural analgesia in abdominal surgical patients. A large randomized trial comparing these techniques is justified.

Analgesia Epidural/métodos , Analgésicos Opioides/administração & dosagem , Bupivacaína/administração & dosagem , Músculos Abdominais/efeitos dos fármacos , Adulto , Idoso , Algoritmos , Analgesia Controlada pelo Paciente/métodos , Anti-Inflamatórios não Esteroides/uso terapêutico , Feminino , Fentanila/administração & dosagem , Humanos , Tempo de Internação , Lipossomos , Masculino , Pessoa de Meia-Idade , Morfina/administração & dosagem , Manejo da Dor/métodos , Medição da Dor , Dor Pós-Operatória/terapia , Sistema de Registros , Estudos Retrospectivos , Esteroides/uso terapêutico
Case Rep Endocrinol ; 2015: 864719, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26236513


A young healthy postpartum mother presented with intermittent high fevers and tachycardia. Appropriate testing was done to rule out infectious causes including pan cultures but no identifiable infectious source was found. A CT of the abdomen showed a retroperitoneal mass with two small pulmonary nodules and a bony metastatic lesion. She was found to have stage 4 extra-adrenal paraganglioma with metastases to the lungs and spine. She underwent resection of the mass and is currently undergoing palliative radiation to the spine for pain control. Subsequent genetic testing identified a likely pathogenic variant in SDHB, confirming a diagnosis of Hereditary Paraganglioma-Pheochromocytoma syndrome.

J Community Support Oncol ; 13(10): 374-7, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26862913


Zoledronic acid is a parenteral long-acting bisphosphonate that has been shown to be more effective than other bisphosphonates in treating hypercalcemia of malignancy. It is important to be aware of its ability to induce prolonged and severe hypocalcemia (hypoCa) following administration, which can be difficult to control despite aggressive calcium replacement. We report on a patient with metastatic breast cancer who presented with severe symptomatic hypoCa after receiving zoledronic acid for hypercalcemia of malignancy.

Indian J Psychol Med ; 36(2): 201-3, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24860227


We present a case of depression with panic disorder, which did not respond to adequate psychiatric interventions over a period of several months. However, it improved completely with the diagnosis and treatment of diabetes mellitus. Hence, we infer that comorbid diabetes mellitus can render depression resistant to psychiatric interventions and must always be ruled out when treating patients who show poor response to adequate interventions for an adequate period of time. The role of antidepressants should also be considered in poor glycemic control.