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1.
Am Surg ; 86(1): 8-14, 2020 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-32077410

RESUMO

Studies demonstrate a significant variation in decision-making regarding withdrawal of life-sustaining treatment (WLST) practices for patients with severe traumatic brain injury (TBI). We investigated risk factors associated with WLST in severe TBI. We hypothesized age ≥65 years would be an independent risk factor. In addition, we compared survivors with patients who died in hospital after WLST to identify potential factors associated with in-hospital mortality. The Trauma Quality Improvement Program (2010-2016) was queried for patients with severe TBI of the head. Patients were compared by age (age < 65 and age ≥ 65 years) and survival after WLST (survivors versus non-survivors) at hospitalization discharge. A multivariable logistic regression model was used for analysis. From 1,403,466 trauma admissions, 328,588 (23.4%) patients had severe TBI. Age ≥ 65 years was associated with increased WLST (odds ratio: 1.76, confidence interval: 1.59-1.94, P < 0.001), whereas nonwhite race was associated with decreased WLST (odds ratio: 0.60, confidence interval: 0.55-0.65, P < 0.001). Compared with non-survivors of WLST, survivors were older (74 vs 61 years, P < 0.001) and more likely to have comorbidities such as hypertension (57% vs 38.5%, P < 0.001). Age ≥ 65 years was an independent risk factor for WLST, and nonwhite race was associated with decreased WLST. Patients surviving until discharge after WLST decision were older (≥74 years) and had multiple comorbidities.

2.
Vasc Endovascular Surg ; 54(1): 36-41, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31570064

RESUMO

OBJECTIVES: Although traumatic injuries to the superior mesenteric vein (SMV), portal vein (PV), and hepatic vein (HV) are rare, their impact is significant. Small single center reports estimate mortality rates ranging from 29% to 100%. Our aim is to elucidate the incidence and outcomes associated with each injury due to unique anatomic positioning and varied tolerance of ligation. We hypothesize that SMV injury is associated with a lower risk of mortality compared to HV and PV injury in adult trauma patients. METHODS: The Trauma Quality Improvement Program database (2010-2016) was queried for patients with injury to either the SMV, PV, or HV. A multivariable logistic regression model was used for analysis. RESULTS: From 1,403,466 patients, 966 (0.07%) had a single major hepatoportal venous injury with 460 (47.6%) involving the SMV, 281 (29.1%) involving the PV, and 225 (23.3%) involving the HV. There was no difference in the percentage of patients undergoing repair or ligation between SMV, PV, and HV injuries (P > .05). Compared to those with PV and HV injuries, patients with SMV injury had a higher rate of concurrent bowel resection (38.5% vs 12.1% vs 7.6%, P < .001) and lower mortality (33.3% vs 45.9% vs 49.3%, P < .01). After controlling for covariates, traumatic SMV injury increased the risk of mortality (odds ratio [OR] 1.59, confidence interval [CI] = 1.00-2.54, P = .05) in adult trauma patients; however, this was less than PV injury (OR = 2.77, CI = 1.56-4.93, P = .001) and HV injury (OR = 2.70, CI = 1.46-4.99, P = .002). CONCLUSION: Traumatic SMV injury had a lower rate of mortality compared to injuries of the HV and PV. SMV injury increased the risk of mortality by 60% in adult trauma patients, whereas PV and HV injuries nearly tripled the risk of mortality.


Assuntos
Veias Hepáticas/lesões , Veia Porta/lesões , Lesões do Sistema Vascular/epidemiologia , Adolescente , Adulto , Criança , Bases de Dados Factuais , Feminino , Veias Hepáticas/diagnóstico por imagem , Veias Hepáticas/cirurgia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Veia Porta/diagnóstico por imagem , Veia Porta/cirurgia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade , Lesões do Sistema Vascular/cirurgia , Adulto Jovem
3.
Ann Vasc Surg ; 2019 Oct 31.
Artigo em Inglês | MEDLINE | ID: mdl-31678543

RESUMO

Aortocaval fistulas following endovascular repair of ruptured abdominal aortic aneurysms (rAAA) are rare. We herein describe repair using an Amplatzer Septal Occluder in a 68-year-old male who presented to the emergency department 6 months after ruptured endovascular aneurysm repair (rEVAR) with right heart failure. With the assistance of diagnostic angiography and intravascular ultrasound, the patient was found to have a 1.2 cm diameter aortocaval fistula and a type-II endoleak. His aortocaval fistula was successfully closed using an Amplatzer septal occluder device after failure of attempted closure with an Amplatzer plug and coiling of the aneurysm sac. His symptoms of heart failure improved, and he was discharged to an acute rehabilitation unit. Follow-up at 3 months demonstrated continued improvement in heart failure symptoms, and a small persistent type II endoleak. Aortocaval fistulae are a potentially fatal complication of rAAA. We discuss the sequelae and treatment strategies of aortocaval fistulas following rEVAR including the use of the Amplatzer Septal Occluder.

4.
Am Surg ; 85(10): 1134-1138, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657309

RESUMO

Traumatic esophageal injury is a highly lethal but rare injury with minimal data in the trauma population. We sought to provide a descriptive analysis of esophageal trauma (ET) to identify the incidence, associated injuries, interventions, and outcomes. We hypothesized that blunt trauma is associated with higher risk of death than penetrating trauma. The Trauma Quality Improvement Program (2010-2016) was queried for patients with ET. Patients with blunt and penetrating trauma were compared using chi-square and Mann-Whitney U tests. A multivariable logistic regression model was used to determine risk of mortality. Of 1,403,466 adult patients, 651 (<0.01%) presented with ET. The most common associated thoracic injuries were rib fractures (38.7%) and pneumothorax (26.7%). More patients with a penetrating mechanism underwent open repair of the esophagus than those with blunt mechanism (46.2% vs 11.7%, P < 0.001). After controlling for covariates, there was no difference in risk of mortality between blunt and penetrating trauma (P = 0.65). The mortality rate for patients with esophageal injury surviving greater than 24 hours was 7.5 per cent. In this large national database analysis, ET was rare and most commonly associated with rib fractures and pneumothorax. Contrary to our hypothesis, the risk of mortality was equivalent between blunt and penetrating ET.


Assuntos
Esôfago/lesões , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/mortalidade , Adulto , Distribuição de Qui-Quadrado , Esôfago/cirurgia , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Tempo de Internação , Modelos Logísticos , Masculino , Morbidade , Pneumonia/epidemiologia , Pneumonia/etiologia , Pneumotórax/complicações , Pneumotórax/epidemiologia , Melhoria de Qualidade , Estudos Retrospectivos , Fraturas das Costelas/complicações , Fraturas das Costelas/epidemiologia , Fatores de Risco , Estatísticas não Paramétricas , Stents/estatística & dados numéricos , Taxa de Sobrevida , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/epidemiologia , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/epidemiologia , Ferimentos Penetrantes/cirurgia
5.
Surg Endosc ; 2019 Aug 05.
Artigo em Inglês | MEDLINE | ID: mdl-31385074

RESUMO

BACKGROUND: Initial adoption of minimally invasive esophagectomy (MIE) began in the late 1990s but its surgical technique, perioperative management, and outcome continues to evolve. METHODS: The aim of this study was to examine the evolving changes in the technique, outcome, and new strategies in management of postoperative leaks after MIE was performed at a single institution over a two-decade period. A retrospective chart review of 75 MIE operations was performed between November 2011 and September 2018 and this was compared to the initial series of 104 MIE operations performed by the same group between 1998 and 2007. Operative technique, outcomes, and management strategies of leaks were compared. RESULTS: There were 65 males (86.7%) with an average age of 61 years. The laparoscopic/thoracoscopic Ivor Lewis esophagectomy became the preferred MIE approach (49% of cases in the initial vs. 95% in the current series). Compared to the initial case series, there was no significant difference in median length of stay (8 vs. 8 days), major complications (12.5% vs. 14.7%, p = 0.68), incidence of leak (9.6% vs. 10.6%, p = 0.82), anastomotic stricture (26% vs. 32.0%, p = 0.38), or in-hospital mortality (2.9% vs. 2.6%, p = 0.47). Management of esophageal leaks has changed from primarily thoracotomy ± diversion initially (50% of leak cases) to endoscopic stenting ± laparoscopy/thoracoscopy currently (87.5% of leak cases). CONCLUSION: In a single-institutional series of MIE over two decades, there was a shift toward a preference for the laparoscopic/thoracoscopic Ivor Lewis approach with similar outcomes. The management of postoperative leaks drastically changed with predilection toward minimally invasive option with endoscopic drainage and stenting.

6.
J Intensive Care Med ; : 885066619870153, 2019 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-31455142

RESUMO

OBJECTIVES: To determine whether, similar to adults, early tracheostomy in pediatric patients with severe traumatic brain injury (TBI) improves inhospital outcomes including ventilator days, intensive care unit (ICU) length of stay (LOS), and total hospital LOS when compared to late tracheostomy. DESIGN: Retrospective cohort analysis. SETTING: The Pediatric Trauma Quality Improvement Program (TQIP) database. PATIENTS: One hundred twenty-seven pediatric patients <16 years old with severe (>3) abbreviated injury scale TBI who underwent early (days 1-6) or late (day ≥7) tracheostomy between 2014 and 2016. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: The Pediatric TQIP database was queried for patients <16 years old with severe TBI, who underwent tracheostomy. Patient demographics and outcomes of early versus late tracheostomy were compared using Student t test, Mann-Whitney U test, and χ2 analysis. Sixteen patients underwent early tracheostomy while 111 underwent late tracheostomy. The groups had similar distributions of age, gender, mechanism of injury, and mean injury severity scores (P > .05). Early tracheostomy was associated with decreased ICU LOS (early: 17 vs late: 32 days, P < .05) and ventilator days (early: 9.7 vs late: 27.1 days, P < .05). There was no difference in total LOS (early: 26.7 vs late: 41.3 days, P = .06), the incidence of acute respiratory distress syndrome (early: 6.3% vs late: 2.7%, P = .45), pneumonia (early: 12.5% vs late: 29.7%, P = .15), or mortality (early: 0% vs late: 2%, P = .588) between the 2 groups. CONCLUSION: Similar to adults, early tracheostomy in pediatric patients with severe TBI is associated with decreased ICU LOS and ventilator days. Future prospective trials are needed to confirm these findings. ARTICLE TWEET: Early tracheostomy in pediatric patients with severe TBI is associated with decreased ICU LOS and ventilator days.

7.
Surg Endosc ; 2019 Jun 18.
Artigo em Inglês | MEDLINE | ID: mdl-31214801

RESUMO

BACKGROUND: Hiatal Hernia Repairs (HHR) are performed by both general surgeons (GS) and thoracic surgeons (TS). However, there are limited literature with respect to outcomes of HHR based on specialty training. The objective of this study was to compare the utilization, perioperative outcomes, and cost for HHR performed by GS versus TS. METHODS: The Vizient database was used to identify patients who underwent elective laparoscopic HHR between October 2014 and June 2018. Patients were grouped according to surgeon's specialty (GS vs. TS). Patient demographics and outcomes including in-hospital mortality were compared between groups. RESULTS: During the study period 13,764 patients underwent HHR by either GS or TS. GS performed 9930 (72%) cases while TS performed 3834 (28%) cases. There was no significant difference between GS versus TS with regard to serious morbidity (1.28% vs. 1.30%, p = 0.97) or mortality (0.10% vs. 0.21%, p = 0.19). The mortality index was 0.24 for GS versus 0.45 for TS. Compared to TS, laparoscopic HHR performed by GS was associated with a shorter LOS (2.57 days vs. 2.72 days, p < 0.001) and lower mean hospital costs ($7139 vs. $8032, p < 0.0001). CONCLUSIONS: Within the context of academic centers, laparoscopic HHRs are mostly performed by GS with comparable outcome between general versus thoracic surgeons.

9.
Ann Gastroenterol ; 28(4): 475-80, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26423597

RESUMO

BACKGROUND: Postoperative ileus (POI) remains a major impediment in patient recovery and leads to longer lengths of stay at the hospital, readmission rates, and hospital costs. Alvimopan, a mu-opioid receptor antagonist, lowers POI incidence following open gastrointestinal surgery, however, little is known about its role on POI prevention among patients undergoing laparoscopic gastrointestinal surgery. METHODS: A comprehensive search of PubMed/MEDLINE, Scopus, CINAHL, and Cochrane databases was performed (December 2014). Meta-analysis was performed using the Mantel-Haenszel (fixed effects) model with odds ratio (OR) to assess prevention of POI and hospital readmission. RESULTS: Five studies were included in the final analysis. Pooling 4 of 5 studies, there was over a 75% relative risk reduction in POI development when patients were given alvimopan compared to placebo (OR 0.24, 95%CI 0.12-0.51, P=0.02). The number needed to treat with alvimopan to prevent one POI episode was 11 patients. There was a modest reduction in the length of hospitalization between 0.2 and 1.6 days. There did not appear to be a difference in frequency of 30-day readmission rate among the alvimopan group compared to placebo (OR 1.15, 95%CI 0.54-2.45, P=0.62). CONCLUSION: Overall, there was a 75% relative risk reduction in POI development among patients undergoing laparoscopic gastrointestinal surgery. However, there did not appear to be a significant reduction in all-cause 30-day readmission rate or length of hospitalization. Future studies will need to address which subset of patients undergoing laparoscopic gastrointestinal surgery will benefit most from alvimopan.

10.
Eukaryot Cell ; 14(12): 1217-27, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26432634

RESUMO

Proper functioning of intracellular membranes is critical for many cellular processes. A key feature of membranes is their ability to adapt to changes in environmental conditions by adjusting their composition so as to maintain constant biophysical properties, including fluidity and flexibility. Similar changes in the biophysical properties of membranes likely occur when intracellular processes, such as vesicle formation and fusion, require dramatic changes in membrane curvature. Similar modifications must also be made when nuclear pore complexes (NPCs) are constructed within the existing nuclear membrane, as occurs during interphase in all eukaryotes. Here we report on the role of the essential nuclear envelope/endoplasmic reticulum (NE/ER) protein Brl1 in regulating the membrane composition of the NE/ER. We show that Brl1 and two other proteins characterized previously-Brr6, which is closely related to Brl1, and Apq12-function together and are required for lipid homeostasis. All three transmembrane proteins are localized to the NE and can be coprecipitated. As has been shown for mutations affecting Brr6 and Apq12, mutations in Brl1 lead to defects in lipid metabolism, increased sensitivity to drugs that inhibit enzymes involved in lipid synthesis, and strong genetic interactions with mutations affecting lipid metabolism. Mutations affecting Brl1 or Brr6 or the absence of Apq12 leads to hyperfluid membranes, because mutant cells are hypersensitive to agents that increase membrane fluidity. We suggest that the defects in nuclear pore complex biogenesis and mRNA export seen in these mutants are consequences of defects in maintaining the biophysical properties of the NE.


Assuntos
Proteínas de Membrana/metabolismo , Complexo de Proteínas Formadoras de Poros Nucleares/metabolismo , Biogênese de Organelas , Proteínas de Saccharomyces cerevisiae/metabolismo , Saccharomyces cerevisiae/metabolismo , Adaptação Fisiológica/efeitos dos fármacos , Álcool Benzílico/farmacologia , Epistasia Genética/efeitos dos fármacos , Homeostase/efeitos dos fármacos , Lipídeos de Membrana/metabolismo , Mutação/genética , Membrana Nuclear/efeitos dos fármacos , Membrana Nuclear/metabolismo , Transporte de RNA/efeitos dos fármacos , RNA Mensageiro/genética , RNA Mensageiro/metabolismo , Saccharomyces cerevisiae/efeitos dos fármacos , Saccharomyces cerevisiae/crescimento & desenvolvimento , Esteróis/metabolismo , Viscosidade
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