Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 169
Filtrar
Mais filtros










Intervalo de ano de publicação
1.
Sci Rep ; 10(1): 867, 2020 Jan 21.
Artigo em Inglês | MEDLINE | ID: mdl-31964997

RESUMO

There is no clear study identifying the microbiome of the appendix. However, in other diverticular conditions, such as diverticulosis, methanogens appear important. We investigated whether patients who had undergone appendectomies had decreased levels of exhaled methane (CH4). Consecutive patients who underwent breath testing (BT) from November 2005 to October 2013 were deterministically linked to electronic health records. The numbers of patients with CH4 ≥ 1 ppm (detectable) and ≥ 3 and ≥ 10 ppm (excess) were compared between patients who did and did not undergo appendectomy using a multivariable model adjusted for age and sex. Of the 4977 included patients (48.0 ± 18.4 years, 30.1% male), 1303 (26.2%) had CH4 ≥ 10 ppm, and 193 (3.9%) had undergone appendectomy. Appendectomy was associated with decreased odds of CH4 ≥ 1, ≥ 3, and ≥ 10 ppm (ORs (95% CI) = 0.67 (0.47-0.93), p = 0.02; 0.65 (0.46-0.92), p = 0.01; and 0.66 (0.46-0.93), p = 0.02, respectively). Additionally, the percentage of CH4 producers increased 4-fold from the first to ninth decade of life. This is the first study to report that appendectomy is associated with decreased exhaled CH4. The appendix may play an active physiologic role as a reservoir of methanogens.

2.
J Surg Educ ; 77(1): 144-149, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31377203

RESUMO

OBJECTIVE: Few studies examine the impact of surgical trainee involvement on tumor-free margins in breast conserving surgery (BCS). Our objective was to investigate the impact of resident and fellow involvement on positive margins rates following BCS for invasive breast cancer (BC). DESIGN: We identified female patients who had BCS for BC between January 2005 to December 2015. SETTING: Tertiary care hospital. PARTICIPANTS: Around 1089 patients were identified from a prospectively maintained database. RESULTS: Of 1089 patients, mean age was 63 (range 43-99) years. Around 768 patients (70.1%) required preoperative localization, and 328 patients (29.9%) had a palpable cancer. Nonpalpable cancers had a smaller volume of specimen tissue excised (p = 0.0005) compared to palpable cancers, and no significant difference was observed in the positive margin rate between the nonpalpable group compared to the palpable group (24.7% nonpalpable vs. 25.3% palpable, p = 0.88). Nonpalpable cancer positive margin rates were 23.9% (n = 102/427) for cases performed by an attending surgeon, 25.0% (n = 15/60) with a junior resident (PGY 2-3), 28.6% (n = 8/28) with a senior resident (PGY 4-5), and 25.7% (n = 65/253) with a fellow, which were not statistically significant (p = 0.89). Palpable cancer positive margin rates were 27.6% (n = 47/170) for cases performed by an attending, 13.9% (n = 5/36) with an intern (PGY-1), 40.9% (n = 9/22) with a junior resident, 0% (n = 0/8) with a senior resident, and 23.9% (n = 22/92) with a fellow, which were also not significantly different (p = 0.07). CONCLUSION: Resident and fellow participation in BCS for BC does not appear to impact the rate of positive margins.

3.
Cytojournal ; 16: 21, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31741668

RESUMO

Background: The Paris System (TPS) acknowledges the need for more standardized terminology for reporting urine cytopathology results and minimizing the use of equivocal terms. We apply TPS diagnostic terminologies to assess interobserver agreement, compare TPS with the traditional method (TM) of reporting urine cytopathology, and evaluate the rate and positive predictive value (PPV) of each TPS diagnostic category. A survey is conducted at the end of the study. Materials and Methods: One hundred urine samples were reviewed independently by six cytopathologists. The diagnosis was rendered according to TPS categories: negative for high-grade urothelial carcinoma (NHGUC), atypical urothelial cells (AUC), low-grade urothelial neoplasm (LGUN), suspicious for high-grade urothelial carcinoma (SHGUC), and high-grade urothelial carcinoma (HGUC). The agreement was assessed using kappa. Disagreements were classified as high and low impacts. Statistical analysis was performed. Results: Perfect consensus agreement was 31%, with an overall kappa of 0.362. Kappa by diagnostic category was 0.483, 0.178, 0.258, and 0.520 for NHGUC, AUC, SHGUC, and HGUC, respectively. Both TM and TPS showed 100% specificity and PPV. TPS showed 43% sensitivity (38% by TM) and 70% accuracy (66% by TM). Disagreements with high clinical impact were 27%. Of the 100 cases, 52 were concurrent biopsy-proven HGUC. The detection rate of biopsy-proven HGUC was 43% by TPS (57% by TM). The rate of NHGUC was 54% by TPS versus 26% by TM. AUC rate was 23% by TPS (44% by TM). The PPV of the AUC category by TPS was 61% versus 43% by TM. The survey showed 33% overall satisfaction. Conclusions: TPS shows adequate precision for NHGUC and HGUC, with low interobserver agreement for other categories. TPS significantly increased the clinical significance of AUC category. Refinement and widespread application of TPS diagnostic criteria may further improve interobserver agreement and the detection rate of HGUC.

4.
Hypertension ; 74(5): 1192-1199, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31522619

RESUMO

Black Americans suffer disproportionately from hypertension and hypertensive heart disease. Out-of-office blood pressure (BP) is more predictive for cardiovascular complications than clinic BP; however, the relative abilities of clinic and out-of-office BP to predict left ventricular hypertrophy in black and white adults have not been established. Thus, we aimed to compare associations of out-of-office and clinic BP measurement with left ventricular hypertrophy by cardiac magnetic resonance imaging among non-Hispanic black and white adults. In this cross-sectional study, 1262 black and 927 white participants of the Dallas Heart Study ages 30 to 64 years underwent assessment of standardized clinic and out-of-office (research staff-obtained) BP and left ventricular mass index. In multivariable-adjusted analyses of treated and untreated participants, out-of-office BP was a stronger determinant of left ventricular hypertrophy than clinic BP (odds ratio per 10 mm Hg, 1.48; 95% CI, 1.34-1.64 for out-of-office systolic BP and 1.15 [1.04-1.28] for clinic systolic BP; 1.71 [1.43-2.05] for out-of-office diastolic BP, and 1.03 [0.86-1.24] for clinic diastolic BP). Non-Hispanic black race/ethnicity, treatment status, and lower left ventricular ejection fraction were also independent determinants of hypertrophy. Among treated Blacks, the differential association between out-of-office and clinic BP with hypertrophy was more pronounced than in treated white or untreated participants. In conclusion, protocol-driven supervised out-of-office BP monitoring provides important information that cannot be gleaned from clinic BP assessment alone. Our results underscore the importance of hypertension management programs outside the medical office to prevent hypertensive heart disease, especially in high-risk black adults. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00344903.


Assuntos
Afro-Americanos/estatística & dados numéricos , Monitorização Ambulatorial da Pressão Arterial/métodos , Hipertensão/complicações , Hipertensão/diagnóstico , Hipertrofia Ventricular Esquerda/etiologia , Imagem Cinética por Ressonância Magnética/métodos , Adulto , Fatores Etários , Anti-Hipertensivos/uso terapêutico , Teorema de Bayes , Determinação da Pressão Arterial/métodos , Estudos Transversais , Eletrocardiografia/métodos , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Seguimentos , Humanos , Hipertensão/tratamento farmacológico , Hipertensão/etnologia , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Hipertrofia Ventricular Esquerda/etnologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Medição de Risco , Índice de Gravidade de Doença , Fatores Sexuais , Texas
5.
J Surg Oncol ; 120(6): 926-931, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31396982

RESUMO

BACKGROUND: Resection of liver metastasis in small bowel neuroendocrine tumors (SBNET) may improve survival, however, factors influencing prognosis are unclear. We evaluated how the extent of resection influences outcomes. METHODS: Patients with SBNET with liver metastasis from 1990 to 2013 who underwent resection of the primary tumor were identified. Outcomes among patients undergoing complete resection (CR), partial resection (PR), or no resection (NR) of liver metastases with resection of the primary tumor only were compared. RESULTS: One hundred eleven patients met the criteria. The median number of liver lesions was seven and median lesions resected was one. Fifty (45%) patients had NR, 41 (36.9%) underwent CR, and 20 (18.1%) underwent PR. The 5-year overall survival (OS) was 79.4% for NR, 84.7% for PR, and 100% for CR, demonstrating a trend that CR was best, followed by PR then NR (P = .02). 10-year OS showed no significant differences (72.7% NR; 84.7% PR; 82.5% CR; P = .10). Greater than 10 liver lesions (hazard ratio [HR] 3.6; P = 0.04) or receiving chemotherapy (HR 3.7; P = .03) were negative predictors of survival. CONCLUSION: The extent of resection of liver disease in SBNET influenced survival at 5 years but not at 10 years. In addition, more than 10 liver lesions and chemotherapy were predictors of mortality.


Assuntos
Hepatectomia/mortalidade , Neoplasias Intestinais/mortalidade , Intestino Delgado/patologia , Neoplasias Hepáticas/mortalidade , Tumores Neuroendócrinos/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Neoplasias Intestinais/patologia , Neoplasias Intestinais/cirurgia , Intestino Delgado/cirurgia , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/cirurgia , Masculino , Pessoa de Meia-Idade , Tumores Neuroendócrinos/patologia , Tumores Neuroendócrinos/cirurgia , Prognóstico , Estudos Prospectivos , Taxa de Sobrevida , Adulto Jovem
6.
Eur Heart J Acute Cardiovasc Care ; : 2048872619872129, 2019 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-31452378

RESUMO

BACKGROUND: Limited data exists regarding sex differences in outcome and predictive accuracy of intensive care unit-based scoring systems when applied to cardiac intensive care unit patients. METHODS: We reviewed medical records of patients admitted to cardiac intensive care unit from 1 January 2011-31 December 2016. Sex differences in mortality rates and the performance of intensive care unit-based scoring systems in predicting in-hospital mortality were analyzed. Calibration was assessed by the Hosmer-Lemeshow test and locally weighted scatterplot smoothing curves. Discrimination was assessed using the c statistic and receiver-operating characteristic curve. RESULTS: Among 6963 patients, 2713 (39%) were women. Overall in-hospital and cardiac intensive care unit mortality rates were similar in women and men (9.1% vs 9.4%, p=0.67 and 5.9% vs 6%, p=0.88, respectively) and in age and major diagnosis subgroups. Of the scoring systems, Acute Physiology and Chronic Health Evaluation III and Sequential Organ Failure Assessment had poor calibration (Hosmer-Lemeshow p value <0.001), while Simplified Acute Physiology Score II performed better (Hosmer-Lemeshow p value 0.09), in both women and men. All scores had good discrimination (C statistics >0.8). In the subgroups of acute myocardial infarction and heart failure patients, all scores had good calibration (Hosmer-Lemeshow p>0.001) and discrimination (C statistic >0.8) while in diagnosis subgroups with highest mortality, the calibration varied among scores and by sex, and discrimination was poor. CONCLUSIONS: No sex differences in mortality were seen in cardiac intensive care unit patients. The mortality predictive value of intensive care unit-based scores is limited in both sexes and variable among different subgroups of diagnoses.

7.
Tex Heart Inst J ; 46(2): 115-119, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31236075

RESUMO

Venous thromboembolism is a leading cause of cardiovascular death. Historically, surgical intervention has been associated with high morbidity rates. Pharmacologic therapy alone can be inadequate for patients with substantial hemodynamic compromise, so minimally invasive procedures are being developed to reduce clot burden. We describe our initial experience with using the AngioVac system to remove thromboemboli percutaneously. We reviewed all suction thromboembolectomy procedures performed at our institution from March 2013 through August 2015. The main indications for the procedure were failed catheter-directed therapy, contraindication to thrombolysis, bleeding-related complications, and clot-in-transit phenomena. We collected details on patient characteristics, procedural indications, thrombus location, hemodynamic values, cardiac function, pharmacologic support, and survival to discharge from the hospital. The Wilcoxon signed-rank test was used for statistical analysis. Thirteen patients (mean age, 56 ± 15 yr; 10 men) underwent suction thromboembolectomy; 10 (77%) survived to hospital discharge. The median follow-up time was 74 days (interquartile range [IQR], 23-221 d). Preprocedurally, 8 patients (62%) had severe right ventricular dysfunction; afterwards, 11 (85%) had normal function or mild-to-moderate dysfunction, and only 2 (17%) had severe dysfunction (P=0.031). Percutaneous suction thromboembolectomy, a promising therapeutic option for patients, appears to be safe, and we found it to be associated with improved right ventricular function.


Assuntos
Ventrículos do Coração/fisiopatologia , Artéria Pulmonar/cirurgia , Embolia Pulmonar/cirurgia , Trombectomia/métodos , Função Ventricular Direita/fisiologia , Feminino , Seguimentos , Ventrículos do Coração/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Pulmonar/diagnóstico por imagem , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/fisiopatologia , Estudos Retrospectivos , Sucção/métodos , Tomografia Computadorizada por Raios X , Resultado do Tratamento
8.
Am J Kidney Dis ; 73(5): 605-614, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30929853

RESUMO

RATIONALE & OBJECTIVE: Increased access to transplantation for highly sensitized candidates following implementation of the kidney allocation system (KAS) has been mostly due to higher use of organs with a lower kidney donor profile index (KDPI; a quality metric for donated kidneys), although changes in allocation of these organs was not intended. It is unclear whether clinical outcomes have changed in association with these changes. We investigated the use of kidneys with low and high KDPI scores over time and whether KDPI score affects patient and graft survival differently across varying levels of allosensitization. STUDY DESIGN: Observational cohort study. SETTING & PARTICIPANTS: Adult (aged ≥18 years) recipients of a deceased donor kidney transplant between October 1, 2009, and September 30, 2017 (Organ Procurement and Transplantation Network/United Network for Organ Sharing database; n = 84,451). PREDICTORS: Calculated panel-reactive antibody (cPRA) level (0%, 1%-79%, 80%-89%, 90%-98%, and 99%-100%) and KDPI score (≤20%, 21%-85%, and >85%). OUTCOMES: Death, graft loss. ANALYTICAL APPROACH: Time to event. RESULTS: Allocation of kidneys with KDPI scores ≤ 20% and KDPI scores of 21% to 85% to recipients with cPRA levels ≥ 99% increased 4-fold following implementation of the KAS with little change in allocation of kidneys with KDPI scores > 85%. Patient survival and graft loss were strongly associated with KDPI score, whereas the association with cPRA level was minimal. There was no evidence of a differential effect of KDPI scores across the range of cPRA levels on patient survival (P for interaction=0.06-0.9) or graft loss (P for interaction=0.5-0.9). Patient survival at 5 years among the 5 cPRA groups ranged from 87.2% to 89.8% for recipients of kidneys with KDPI scores ≤ 20% (P=0.2), 82.8% to 85.5% for KDPI scores of 21% to 85% (P=0.04), and 70.2% to 79.2% for KDPI scores > 85% (P=0.2). Cumulative incidence of graft loss by cPRA level ranged from 7.7% to 10.6% for recipients of kidneys with KDPI scores ≤ 20% (P=0.2), 11.8% to 15.0% for KDPI scores of 21% to 85% (P < 0.001), and 19.8% to 29.7% for KDPI scores > 85% (P = 0.4). LIMITATIONS: Lack of data for crossmatches, donor-specific antibodies, and immunomodulation. CONCLUSIONS: Highly sensitized recipients received kidneys with lower KDPI scores following implementation of the KAS, reducing access to these kidneys by less-sensitized candidates. KDPI score has a stronger association with patient survival and graft loss than cPRA level. The association of KDPI score with these outcomes was not modified by the recipient's level of sensitization. The impact of the redistribution of kidneys with low KDPI scores on outcomes among less-sensitized recipients needs further evaluation.


Assuntos
Seleção do Doador/organização & administração , Transplante de Rim/métodos , Doadores de Tecidos , Obtenção de Tecidos e Órgãos/organização & administração , Transplantados , Adulto , Feminino , Seguimentos , Sobrevivência de Enxerto , Humanos , Masculino , Pessoa de Meia-Idade , Alocação de Recursos , Estudos Retrospectivos , Fatores de Risco , Estados Unidos
9.
J Am Heart Assoc ; 8(4): e010570, 2019 02 19.
Artigo em Inglês | MEDLINE | ID: mdl-30741603

RESUMO

Background Combined heart and kidney transplantation ( HKT x) is performed in patients with severe heart failure and advanced renal insufficiency. We analyzed the long-term survival after HKT x, the influence of age and dialysis status, the rates of cardiac rejection, and the influence of sensitization. Methods and Results From June 1992 to December 2016, we performed 100 HKT x procedures. We compared older (≥60 years, n=53) with younger (<60 years, n=47) recipients, and recipients on preoperative dialysis (n=49) and not on dialysis (n=51). We analyzed actuarial freedom from any cardiac rejection, acute cellular rejection, and antibody-mediated rejection, and survival rates by sensitized status with panel-reactive antibody levels <10%, 10% to 50%, and >50%, and compared these survival rates with those from the United Network for Organ Sharing database. There was no difference in 15-year survival between the 2 age groups (35±12.4% and 49±17.3%, ≥60 versus <60 years; P=0.45). There was no difference in 15-year survival between the dialysis and nondialysis groups (44±13.4% and 37±15.2%, P=0.95). Actuarial freedom from any cardiac rejection ( acute cellular rejection >0 or antibody-mediated rejection >0) was 92±2.8% and 84±3.8%, acute cellular rejection (≥2R/3A) 98±1.5% and 94±2.5%, and antibody-mediated rejection (≥1) 96±2.1% and 93±2.6% at 30 days and 1 year after HKT x. There was no difference in the 5-year survival among recipients by sensitization status with panel-reactive antibody levels <10%, 10% to 50%, and >50% (82±5.9%, 83±10.8%, and 92±8.0%; P=0.55). There was no difference in 15-year survival after HKT x between the United Network for Organ Sharing database and our center (38±3.2% and 40±10.1%, respectively; P=0.45). Conclusions HKT x is safe to perform in patients 60 years and older or younger than 60 years and with or without dialysis dependence, with excellent outcomes. The degree of panel-reactive antibody sensitization did not appear to affect survival after HKT x.

10.
Am J Transplant ; 19(6): 1663-1670, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30725531

RESUMO

Donor-derived cell-free DNA (dd-cfDNA) became Medicare reimbursable in the United States in October 2017 for the detection of rejection in kidney transplant recipients based on results from its pivotal validation trial, but it has not yet been externally validated. We assessed 63 adult kidney transplant recipients with suspicion of rejection with dd-cfDNA and allograft biopsy. Of these, 27 (43%) patients had donor-specific antibodies and 34 (54%) were found to have rejection by biopsy. The percentage of dd-cfDNA was higher among patients with antibody-mediated rejection (ABMR; median 1.35%; interquartile range [IQR]: 1.10%-1.90%) compared to those with no rejection (median 0.38%, IQR: 0.26%-1.10%; P < .001) and cell-mediated rejection (CMR; median: 0.27%, IQR: 0.19%-1.30%; P = .01). The dd-cfDNA test did not discriminate patients with CMR from those without rejection. The area under the ROC curve (AUC) for CMR was 0.42 (95% CI: 0.17-0.66). For ABMR, the AUC was 0.82 (95% CI: 0.71-0.93) and a dd-cfDNA ≥0.74% yielded a sensitivity of 100%, specificity 71.8%, PPV 68.6%, and NPV 100%. The dd-cfDNA test did not discriminate CMR from no rejection among kidney transplant recipients, although performance characteristics were stronger for the discrimination of ABMR.

11.
Dig Dis Sci ; 64(1): 182-188, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30324554

RESUMO

BACKGROUND: Irritable bowel syndrome (IBS) is a common chronic disorder of the gastrointestinal tract. Several treatments have been developed, including rifaximin for the treatment of IBS without constipation (non-IBS-C), but no studies have evaluated the effect of these therapies on patient referral rates to tertiary care gastroenterology clinics. AIM: To assess referral patterns for IBS patients at a tertiary motility clinic over a 10-year period. METHODS: Data from consecutive patients referred to the clinic during 2006-2016 were analyzed. Trends in the proportion of referrals and prior rifaximin use in IBS-C versus non-IBS-C groups were compared. RESULTS: A total of 814 adult patients were referred to a single physician panel for IBS-related symptoms. Of these, 776 were included in the study [528 females (68%), average age 45.7 ± 15.9 years), comprising 431 IBS-C (55.5%) and 345 non-IBS-C (44.5%) patients. The proportion of non-IBS-C referrals declined significantly from 53.0% in 2006 to 27.3% in 2016 (Chi-square, p < 0.0001, Cochran-Armitage trend test p = 0.0001), and the proportion of IBS-C referrals increased significantly from 46.9% in 2006 to 72.7% in 2016 (Chi-square, p < 0.0001, Cochran-Armitage trend test p = 0.0004). Non-IBS-C referrals with prior rifaximin use significantly increased from 22.7% in 2006 to 66.7% in 2016 (Cochran-Armitage trend test, p = 0.008). CONCLUSIONS: The results indicate a significantly declining tertiary care referral rate for non-IBS-C over the past decade. While not directly linked, there has been an increase in rifaximin use in the same population during the same time interval.


Assuntos
Fármacos Gastrointestinais/uso terapêutico , Síndrome do Intestino Irritável/tratamento farmacológico , Padrões de Prática Médica/tendências , Encaminhamento e Consulta/tendências , Rifaximina/uso terapêutico , Centros de Atenção Terciária/tendências , Adulto , Idoso , Revisão de Uso de Medicamentos/tendências , Feminino , Humanos , Síndrome do Intestino Irritável/diagnóstico , Síndrome do Intestino Irritável/epidemiologia , Los Angeles/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
12.
Dis Colon Rectum ; 62(2): 203-210, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30540660

RESUMO

BACKGROUND: Transversus abdominis plane block may improve analgesia after colorectal surgery; however, techniques remain unstandardized and results are conflicting. OBJECTIVE: The purpose of this study was to compare laparoscopic and ultrasound-guided transversus abdominis plane block with no block in minimally invasive colorectal surgery. DESIGN: This was a randomized controlled trial. SETTINGS: The study was conducted at an urban teaching hospital. PATIENTS: Patients undergoing laparoscopic colorectal surgery were included. INTERVENTIONS: The intervention included 2:2:1 randomization to laparoscopic, ultrasound-guided, or no transversus abdominis plane block. MAIN OUTCOME MEASURES: Morphine use in the first 24 hours after surgery was measured. RESULTS: The study cohort included 107 patients randomly assigned to laparoscopic (n = 41), ultrasound-guided (n = 45), or no transversus abdominis plane block (n = 21). Mean age was 50.4 years (SD ± 18 y), and 50 patients (47%) were men. Laparoscopic transversus abdominis plane block was superior to ultrasound-guided (p = 0.007) and no transversus abdominis plane block (p = 0.007), with median (interquartile range) total morphine used in the first 24 hours postoperatively of 17.6 mg (6.6-33.9 mg), 34.0 mg (16.4-44.4 mg), and 31.6 mg (18.4-44.4 mg). At 48 hours, laparoscopic transversus abdominis plane block remained superior to ultrasound-guided (p = 0.03) and no transversus abdominis plane block (p = 0.007) with median (interquartile range) total morphine used at 48 hours postoperatively of 26.8 mg (15.5-45.8 mg), 44.0 mg (27.6-70.0 mg), and 60.8 mg (34.8-78.8 mg). Mean hospital stay was 5.1 ± 3.1 days without any intergroup differences. Overall complications were similar between groups. LIMITATIONS: Treatment teams were not blinded and there was operator dependence of techniques and variable timing of the blocks. CONCLUSIONS: Laparoscopic transversus abdominis plane block is superior to ultrasound-guided and no transversus abdominis plane block in achieving pain control and minimizing opioid use in the first 24 hours after colorectal surgery. A large, multicenter, randomized trial is needed to confirm our findings. See Video Abstract at http://links.lww.com/DCR/A822.


Assuntos
Músculos Abdominais , Analgésicos Opioides/uso terapêutico , Colectomia/métodos , Laparoscopia/métodos , Morfina/uso terapêutico , Bloqueio Nervoso/métodos , Dor Pós-Operatória/tratamento farmacológico , Protectomia/métodos , Adulto , Idoso , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Feminino , Humanos , Intestino Delgado/cirurgia , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Método Simples-Cego , Cirurgia Assistida por Computador , Ultrassonografia
13.
Am J Surg Pathol ; 42(12): 1617-1624, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30273196

RESUMO

Liver biopsies are commonly performed in heart transplant candidates to confirm congestive hepatopathy (CH) and to assess the degree of fibrosis. Heterogeneity of fibrosis is frequent in CH, making it difficult to stage fibrosis. In this study, we evaluated the prevalence of heterogeneity of fibrosis and nodular regenerative hyperplasia (NRH) in liver biopsies with CH secondary to heart failure. Fifty liver biopsies with CH secondary to heart failure were reviewed. The fibrosis was scored on trichrome stain as follows: stage 0 for no fibrosis, stage 1 for zone 3 fibrosis, stage 2 for zone 3 and portal fibrosis, stage 3 for bridging fibrosis, and stage 4 for cirrhosis. Both stage 3 and stage 4 fibrosis were classified as advanced fibrosis. A predominant pattern of fibrosis and a secondary pattern of fibrosis, defined as a different stage of fibrosis seen in at least 10% of the biopsy material, if present, were recorded. A biopsy was considered to show heterogenous fibrosis if there was at least a 2 stage difference between the predominant and secondary patterns. Thirteen biopsies (26%) showed heterogenous fibrosis. Sixteen biopsies (32%) showed some evidence of advanced fibrosis: 5 had uniform advanced fibrosis, 4 had predominant pattern of advanced fibrosis, and advanced fibrosis was focal in 7 biopsies from 6 patients. NRH-type changes were seen in 9 of 50 biopsies (18%). In conclusion, our study showed heterogenous fibrosis in the liver biopsy of a quarter of patients with CH due to heart failure, highlighting the limitations of fibrosis assessment in the biopsies, and suggests that correlation with the complete clinical information is essential for management decisions.


Assuntos
Insuficiência Cardíaca/cirurgia , Transplante de Coração , Cirrose Hepática/patologia , Fígado/patologia , Adulto , Idoso , Biópsia , California/epidemiologia , Tomada de Decisão Clínica , Bases de Dados Factuais , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/epidemiologia , Humanos , Hiperplasia , Fígado/cirurgia , Cirrose Hepática/epidemiologia , Cirrose Hepática/cirurgia , Transplante de Fígado , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Prevalência , Fatores de Risco , Índice de Gravidade de Doença
14.
Breast J ; 24(6): 951-956, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30230113

RESUMO

Data from pathology reports of estrogen receptor positive (ER+) breast cancers with Ki67 < 14% (luminal-A; n = 128) and Ki67 ≥ 14% (luminal-B; n = 100) were entered into the automatic recurrence score (RS) calculator accessible at the University of Pittsburgh Department of Pathology website. Using RS obtained with Magee equations #1 and #3, an average modified Magee recurrence score (AMM RS) was calculated for each tumor. The AMM RS and the Oncotype DX RS (Onco RS) were compared per tumor and associated with follow-up. AMM RS and Onco RS agreed in 64.9% (148 of 228) breast cancers (70.3% luminal-A and 58% luminal-B). There was only one two-step (low risk by Onco/high risk by AMM) RS disagreement. This luminal-B patient is alive without recurrence and free of tumor at 46 months postdiagnosis. Low-risk/intermediate-risk disagreements comprised 94.7% (36 of 38) and 69% (29 of 42) of the RS disagreements in the luminal-A and luminal-B groups, respectively (P = 0.004). In luminal-A, there were only two intermediate/high-risk disagreements; both high-risk ratings were by Onco RS. In luminal-B, there were 12 intermediate/high-risk disagreements; 11 of the high-risk ratings were by Onco RS. 100% (3 of 3) luminal-A tumors and 75% (6 of 8) luminal-B tumors that were high risk by AMM RS were also high risk by Onco RS. Eight tumors recurred and/or metastasized. AMM RS and Onco RS disagreed in only two of these eight tumors. The high percentage of tumors scored as intermediate risk (50% by AMM RS and 39% by Onco RS) is a major limitation of both scoring algorithms.


Assuntos
Algoritmos , Neoplasias da Mama/patologia , Recidiva Local de Neoplasia/genética , Receptores Estrogênicos/metabolismo , Reação em Cadeia da Polimerase Via Transcriptase Reversa/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/genética , Neoplasias da Mama/metabolismo , Neoplasias da Mama/mortalidade , Feminino , Humanos , Linfonodos/patologia , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/patologia
15.
J Behav Med ; 41(5): 680-689, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29671167

RESUMO

Prenatal vitamin D deficiency and prenatal depression are both separately associated with adverse perinatal outcomes; however, to our knowledge no studies have investigated the effects of having both risk factors. Our objective was to determine to what extent vitamin D deficiency predicts adverse perinatal outcomes and whether elevated depressive symptoms in pregnancy places women at additional increased risk. This study was a secondary data analysis of prospective data collected from a cohort of pregnant women (N = 101) in an obstetric clinic of a large medical center. Maternal vitamin D deficiency (serum 25(OH)D ≤ 20 ng/ml) and depressive symptoms (Edinburgh Postnatal Depression Scale, EPDS) were assessed in early pregnancy. A composite of four adverse perinatal outcomes (low birth weight, preterm birth, small-for-gestational age, and preeclampsia) were abstracted from medical charts. Nineteen of the 101 women had one or more adverse perinatal outcome and 84% with an adverse outcome (16/19) were not White. Both prenatal and time of delivery vitamin D deficiency were associated with developing an adverse outcome compared to those vitamin D sufficient (prenatal relative risk 3.43; 95% CI 1.60-7.34, p = 0.004; delivery time relative risk 5.14, 95% CI 2.68-9.86, p = 0.004). These both remained significant after adjusting for BMI. A higher rate of adverse outcome was found when women had both prenatal vitamin D deficiency and elevated depressive symptoms (EPDS ≥ 10). Sixty percent with both risk factors had an adverse perinatal outcome versus 17% with only one or neither risk factor (relative risk 3.60; 95% CI 1.55-8.38, p = 0.045), worthy of investigation with larger samples. Together, prenatal vitamin D deficiency and elevated depressive symptoms in pregnancy may increase risk for adverse perinatal outcomes, especially in racial minorities. Obstetric providers should consider routine prenatal depression screening. The impact of vitamin D supplementation to reduce risk for adverse perinatal outcomes should be studied in prospective trials. Our results suggest that supplementation early in pregnancy might be especially beneficial for depressed women.


Assuntos
Depressão/sangue , Período Pós-Parto/sangue , Complicações na Gravidez/sangue , Deficiência de Vitamina D/sangue , Adulto , Depressão/prevenção & controle , Depressão Pós-Parto/sangue , Suplementos Nutricionais , Feminino , Humanos , Gravidez , Complicações na Gravidez/prevenção & controle , Diagnóstico Pré-Natal , Estudos Prospectivos , Vitamina D/sangue , Deficiência de Vitamina D/diagnóstico , Adulto Jovem
16.
Ann Surg Oncol ; 25(6): 1640-1645, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29626305

RESUMO

BACKGROUND: Postoperative venous thromboembolism (VTE) is a leading cause of in-hospital mortality for cancer patients; however, the prevalence of preoperative VTE remains unclear. OBJECTIVE: The aim of this study was to evaluate the prevalence and risk factors associated with preoperative VTE in asymptomatic patients undergoing major oncologic surgery. METHODS: Retrospective analysis of 346 patients identified from our prospectively maintained database of patients undergoing abdominopelvic oncologic surgery from 2009 to 2016. RESULTS: The prevalence of preoperative VTE found on screening venous duplex scan was 10.1%. Patients with a history of prior VTE were more likely to have a preoperative deep vein thrombosis (DVT) versus those with no prior VTE (42.9% vs. 4.5%, p < 0.01). Relative risk for prior VTE was 8.2 [95% confidence interval (CI) 4.7-14.3]. Older age was also associated with preoperative VTE. Regression modeling determined that patients were 1.24-fold as likely to have a preoperative DVT for every 5-year increase in age (relative risk 1.24, 95% CI 1.09-1.42). Patients with preoperative DVT were more likely to have been diagnosed with sepsis 1 month prior to surgery (8.6% vs. 1.6%, p = 0.04). There were no postoperative pulmonary emboli. The overall postoperative complication rate was higher in those with a preoperative DVT (25.7% vs. 13.2%, p = 0.071). CONCLUSION: Asymptomatic patients undergoing major oncologic surgery have a 10.1% prevalence of preoperative DVT. Increasing age, recent diagnosis of sepsis, and a history of prior VTE are significantly associated with preoperative DVTs. This suggests high-risk oncologic patients may benefit from screening lower extremity venous duplex ultrasound prior to Surgery.


Assuntos
Doenças Assintomáticas/epidemiologia , Neoplasias/cirurgia , Tromboembolia Venosa/epidemiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Período Pré-Operatório , Prevalência , Recidiva , Estudos Retrospectivos , Fatores de Risco , Sepse/epidemiologia , Ultrassonografia Doppler Dupla , Tromboembolia Venosa/diagnóstico por imagem
17.
J Bone Joint Surg Am ; 100(6): 449-458, 2018 Mar 21.
Artigo em Inglês | MEDLINE | ID: mdl-29557860

RESUMO

BACKGROUND: This study provides a comprehensive analysis of total hip arthroplasty (THA) revisions in the U.S. from 2007 to 2013. METHODS: International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes were used to identify all THA revisions in the Nationwide Inpatient Sample (NIS) from 2007 to 2013. The diagnoses leading to the revisions, types of revisions, major inpatient complications, and hospital and patient characteristics were compared between 2007 and 2013. Multivariable logistic regression models were used to calculate adjusted odds ratios (ORs) for complications in 2013 versus 2007. RESULTS: This study identified 320,496 THA revisions performed between 2007 and 2013. From 2007 to 2013, the THA revision rate adjusted for U.S. population growth increased by 30.4% in patients between 45 and 64 years of age and decreased in all other age groups. The rate of surgically treated THA dislocations decreased by 14.3% from 2007 to 2013 (p < 0.0001). The mean length of the hospital stay and hospital costs for THA revision were significantly lower in 2013 than in 2007 (4.6 versus 5.8 days and $20,463 versus $25,401 both p < 0.0001). A multivariable model showed that the odds of a patient undergoing THA revision having the following inpatient complications were significantly lower in 2013 than in 2007: deep vein thrombosis (OR = 0.57, p = 0.004), pulmonary embolism (OR = 0.45, p = 0.047), myocardial infarction (OR = 0.52, p = 0.003), transfusion (OR = 0.64, p < 0.0001), pneumonia (OR = 0.56, p < 0.0001), urinary tract infection (OR = 0.66, p < 0.0001), and mortality (OR = 0.50, p = 0.0009). Notably, the odds of being discharged to a skilled nursing facility were also lower in 2013 than in 2007 (OR = 0.71, p < 0.0001). CONCLUSIONS: The THA revision rate has significantly increased in patients between 45 and 64 years of age. However, the rate of surgically treated THA dislocations has decreased significantly. This may indicate that evolving techniques and implants are improving stability. The rate of inpatient complications following THA revision also decreased significantly from 2007 to 2013. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Artroplastia de Quadril/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Reoperação/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/estatística & dados numéricos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Utilização de Procedimentos e Técnicas , Estudos Retrospectivos , Estados Unidos/epidemiologia
18.
Ann Thorac Surg ; 105(3): 871-878, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29397102

RESUMO

BACKGROUND: Failure to rescue (FTR), defined as death after a major complication, is a metric increasingly being used to assess quality of care. Risk factors associated with FTR after esophagectomy have not been previously studied. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent esophagectomy with gastric conduit between 2010 and 2014. Patients with at least one major postoperative complication were grouped according to inhospital mortality (FTR group) and survival to discharge (SUR group). A stepwise logistic regression model was used to identify predictors of FTR. RESULTS: A total of 1,730 patients comprised the study group, with 102 (5.9%) in the FTR group and 1,628 (94.1%) in the SUR group. The FTR patients were older (69.0 versus 64.0 years, p < 0.0001) compared with the SUR patients. There were no differences in sex, body mass index, preoperative weight loss, smoking status, operation type, or surgeon specialty between the two groups. Age greater than 75 years (adjusted odds ratio 2.68, p < 0.0001), black race (adjusted odds ratio 2.75, p = 0.001), American Society of Anesthesiologists class 4 or 5 (adjusted odds ratio 1.82, p = 0.02), and the occurrence of pneumonia, respiratory failure, acute renal failure, sepsis, or acute myocardial infarction were predictive of FTR based on multivariable logistic regression. CONCLUSIONS: Nearly 6% of patients who have a major complication after esophagectomy do not survive to discharge. Age greater than 75 years, black race, American Society of Anesthesiologists class 4 or 5, and complications related to major infection or organ failure predict FTR. Further research is necessary to investigate how these factors affect survival after complications in order to improve rescue efforts.


Assuntos
Neoplasias Esofágicas/mortalidade , Neoplasias Esofágicas/cirurgia , Esofagectomia/efeitos adversos , Complicações Pós-Operatórias/mortalidade , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida
19.
Pituitary ; 21(1): 41-49, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29143885

RESUMO

PURPOSE: Remission from Cushing disease (CD) after pituitary adenoma resection may be predicted by a postoperative reduction in serum cortisol level. A 2008 consensus statement recommends assessing morning cortisol levels during the first postoperative week, and replacing glucocorticoid (GC) if cortisol nadir of < 2 or < 5 µg/dL is achieved. We sought to evaluate adherence to consensus recommendations following adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma resection at our tertiary medical center, and assess time to cortisol nadir to better define the window for assessment and intervention. METHODS: We retrospectively analyzed data extracted from in-hospital electronic medical records for CD surgeries between January 1991 and September 2015. We compared cortisol levels and collection times, ACTH measurement, and postoperative and discharge GC treatment before and after consensus statement publication in July 2008. RESULTS: 107 surgeries were performed in 92 patients with CD. After 2008, more surgeries had at least one cortisol value assessed (67.9% before vs. 91.3% after, p = 0.033), with median initial cortisol measurement at 14 h post-surgery. However, ACTH measurement remained unchanged (42.9% vs. 43.5%; p > 0.99). Cortisol collection during GC treatment tended to increase (32.7% vs. 57.1%; p = 0.068). Of surgeries performed without prior GC treatment, 31.7 and 55.0% had a cortisol nadir of < 2 and < 5 µg/dL, respectively, within 72 h postoperative. CONCLUSIONS: Our physicians were more diligent in measuring in-hospital postoperative cortisol levels consistent with 2008 consensus recommendations. Better management of cortisol measurements and their timing is an opportunity for improvement.


Assuntos
Adenoma Hipofisário Secretor de ACT/cirurgia , Adenoma/cirurgia , Testes de Função do Córtex Suprarrenal/normas , Insuficiência Adrenal/sangue , Hospitalização , Hidrocortisona/sangue , Hipofisectomia , Hipersecreção Hipofisária de ACTH/sangue , Adenoma Hipofisário Secretor de ACT/sangue , Adenoma Hipofisário Secretor de ACT/complicações , Adenoma Hipofisário Secretor de ACT/patologia , Adenoma/sangue , Adenoma/complicações , Adenoma/patologia , Adolescente , Insuficiência Adrenal/diagnóstico , Insuficiência Adrenal/tratamento farmacológico , Insuficiência Adrenal/etiologia , Adulto , Idoso , Biomarcadores/sangue , Ritmo Circadiano , Consenso , Registros Eletrônicos de Saúde , Feminino , Glucocorticoides/administração & dosagem , Fidelidade a Diretrizes , Humanos , Hipofisectomia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Hipersecreção Hipofisária de ACTH/diagnóstico , Hipersecreção Hipofisária de ACTH/etiologia , Guias de Prática Clínica como Assunto , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
20.
Pituitary ; 21(1): 65-75, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29218459

RESUMO

PURPOSE: Measuring IGF-1, a biomarker for GH activity, is critical to evaluating disordered hypothalamic-pituitary GH axis. Inconsistent IGF-1 measurements among different immunoassays are well documented. We switched from Immulite 2000 immunoassay to narrow-mass-extraction, high-resolution liquid chromatography mass-spectrometry (LC-MS) compliant with recent consensus recommendations on assay standardization. Comparability of these two assays in patients with pituitary disease in a clinical practice setting is not known. We sought to compare IGF-1 levels on Immulite 2000 and LC-MS in samples from naïve and treated patients with secretory and non-secretory pituitary masses. METHODS: We prospectively collected serum samples from 101 patients treated at the Cedars-Sinai Pituitary Center between February 2012 and March 2014. We intentionally recruited more patients with acromegaly or GH deficiency to ensure a clinically representative cohort. Samples were classified as in or out of the respective reference ranges. Bland-Altman analysis was used to assess agreement between assays. RESULTS: Twenty-four percent of samples were classified differently as below, in, or above range. Agreement between the assays was poor overall, with a significant bias for immunoassay reporting higher values than LC-MS. This pattern was also observed in patients with acromegaly and those with ≥ 2 pituitary hormone deficiencies. CONCLUSIONS: IGF-1 results may differ after switching from an older immunoassay to a consensus-compliant assay such as LC-MS. Clinicians should consider the potential impact of assay switching before altering treatment due to discrepant results, particularly in patients monitored over time, such as those with acromegaly and GH deficiency.


Assuntos
Cromatografia Líquida de Alta Pressão , Imunoensaio , Fator de Crescimento Insulin-Like I/análise , Espectrometria de Massas , Doenças da Hipófise/sangue , Doenças da Hipófise/diagnóstico , Acromegalia/sangue , Acromegalia/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Calibragem , Cromatografia Líquida de Alta Pressão/normas , Feminino , Humanos , Imunoensaio/normas , Los Angeles , Masculino , Espectrometria de Massas/normas , Pessoa de Meia-Idade , Neoplasias Hipofisárias/sangue , Neoplasias Hipofisárias/diagnóstico , Valor Preditivo dos Testes , Estudos Prospectivos , Padrões de Referência , Reprodutibilidade dos Testes , Adulto Jovem
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA