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A A Pract ; 15(3): e01415, 2021 Mar 08.
Artigo em Inglês | MEDLINE | ID: mdl-33684090


This case describes a patient who underwent mitral valve replacement (MVR) surgery with preservation of the subvalvular apparatus who suffered anterolateral papillary muscle rupture (PMR) postseparation from cardiopulmonary bypass. This patient had no history of coronary artery disease (CAD); subsequent pathology of the papillary muscle showed evidence of amyloid deposition. Although most PMRs are caused by ischemia from CAD, cardiac amyloidosis must be considered in the absence of CAD and worked up appropriately as cardiac involvement of amyloidosis, especially the amyloid light-chain (AL) subtype, is prognostic of increased mortality that can be mitigated with therapy.

Amiloidose , Doenças das Valvas Cardíacas , Insuficiência da Valva Mitral , Amiloidose/complicações , Humanos , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/etiologia , Insuficiência da Valva Mitral/cirurgia , Músculos Papilares/diagnóstico por imagem , Músculos Papilares/cirurgia
Anesth Analg ; 130(5): 1415-1424, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31283617


BACKGROUND: We developed and implemented a perioperative guideline for obstructive sleep apnea (OSA), comprising a preoperative screening tool (BOSTN) and clinical management pathways. OSA was suspected with 2 or more of the following: body mass index ≥30 kg/m, observed apnea, loud snoring, daytime tiredness, and neck circumference ≥16.5 inches in women or ≥ 17.5 inches in men. The primary objective of this study was to assess the association between high BOSTN scores and the requirement of invasive mechanical ventilation after surgery. METHODS: In this hospital registry study, 169,662 noncardiac surgical cases performed at Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, between May 2008 and September 2017 were analyzed. We assessed the association between a high BOSTN Score (score ≥2) and the primary outcome of requirement of invasive mechanical ventilation within 7 days after surgery using multivariable logistic regression adjusted for patient-specific factors and case-specific surgical and anesthesiological confounders. Patients with a BOSTN Score ≥2 were assumed to have a high likelihood of suffering from OSA. Key secondary outcome was postoperative desaturation, defined as a peripheral oxygen saturation measurement <90% within 10 minutes of extubation. RESULTS: Invasive mechanical ventilation within 7 days of surgery was necessary in 3170 (2.3%) low-risk cases (BOSTN Score <2) and 664 (2.1%) high-risk cases (BOSTN Score ≥2). A score ≥2 was associated with significantly lower odds of requiring postoperative invasive ventilation (adjusted odds ratio [aOR], 0.89; 95% confidence interval [CI], 0.80-0.98; P = .017), but with an increased risk of postextubation desaturation (aOR, 1.34; 99.3% CI, 1.21-1.48; P < .001). Patients with a score ≥2 were hospitalized for an average of 3.71 days after surgery, compared to 4.27 days with a score <2 (adjusted incidence rate ratio [aIRR], 0.87; 99.3% CI, 0.84-0.91; P < .001). CONCLUSIONS: Patients at high risk of OSA required postoperative mechanical ventilation less frequently, had higher odds of postoperative desaturation, and were hospitalized for shorter periods of time.

Gerenciamento Clínico , Programas de Rastreamento/métodos , Assistência Perioperatória/métodos , Polissonografia/métodos , Sistema de Registros , Apneia Obstrutiva do Sono/diagnóstico , Adulto , Idoso , Feminino , Hospitais , Humanos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Apneia Obstrutiva do Sono/fisiopatologia , Apneia Obstrutiva do Sono/cirurgia , Ronco/diagnóstico , Ronco/fisiopatologia , Ronco/cirurgia
Surg Endosc ; 34(10): 1-12, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-31659507


BACKGROUND: Laparoscopy provides a minimally invasive alternative to open abdominal surgery. Current data describing its association with hospital readmission and costs in relation to surgeon laparoscopic case volume is limited to smaller databases and subsets of operations. METHODS: This retrospective cohort study of 23,285 adult abdominal operations from 2007 to 2015 compares 30-day readmission rate and costs between laparoscopic and open abdominal operations and examines effect modification by surgeon laparoscopic case volume. Outcomes were all-cause hospital readmission within 30 days after discharge and index hospital admission cost. RESULTS: All-cause hospital readmission rates were significantly lower after laparoscopic abdominal operations compared with open operations (adjusted odds ratio [aOR] 0.56, 95% CI 0.46-0.69, p < 0.001) with a difference in readmission risk attributable to laparoscopic approach of - 4.0% (95% CI - 5.4 to - 2.6%) in complete-case analysis. Among surgeons with a high laparoscopic case volume, the estimated difference in readmission risk through laparoscopy was magnified (- 5.8%, 95% CI - 7.5 to - 4.1%) compared to low surgeon laparoscopic case volume (- 2.9%, 95% CI - 4.8 to -1.1%, p for interaction = 0.005). The estimated difference in costs of the index hospital admission attributable to laparoscopic approach was - $3869 (95% CI - $4200 to - $3538; adjusted incidence rate ratio 0.77, 95% CI 0.75-0.79, p < 0.001). Laparoscopy was followed by significantly lower rates of readmissions related to gastrointestinal (aOR 0.68, 95% CI 0.55-0.85, p = 0.001), wound complications (infection: aOR 0.33, 95% CI 0.23-0.47, p < 0.001; non-infectious: aOR 0.47, 95% CI 0.30-0.74, p = 0.001), and malignancy (aOR 0.68, 95% CI 0.55-0.85, p < 0.001). The findings remain robust after multiple imputation and sensitivity analyses. CONCLUSIONS: Laparoscopy versus open abdominal surgery is associated with reduced hospital readmissions related to malignancy, gastrointestinal, and wound complications. Effect modification by higher laparoscopy case volume argues for continued proliferation of laparoscopy in abdominal surgeries.

Abdome/cirurgia , Custos Hospitalares , Laparoscopia/economia , Readmissão do Paciente/economia , Cirurgiões , Idoso , Fatores de Confusão Epidemiológicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco
Acta méd. costarric ; 58(1): 38-40, ene.-mar. 2016. tab
Artigo em Espanhol | LILACS | ID: lil-778051


La Kluyvera cryocrescens es una enterobacteria gram negativa que se ha aislado del esputo, orina, secreción biliar, líquido peritoneal y sangre en los seres humanos, raramente es causa de infección clínicamente significativa. Sin embargo hay varios casos descritos en la bibliografía, donde se ha manifestado con cuadros de sepsis severa y choque séptico, algunos con adecuada respuesta a diferentes terapias antibióticas. Se presenta un caso de sepsis severa, debido a bacteriemia por Kluyvera cryocrescens, en un masculino de 73 años, y se describe su diagnóstico, tratamiento y evolución. El paciente desarrolló la infección durante su estadía hospitalaria y recibió tratamiento 10 días con cefalosporinas de tercera generación, logrando una adecuada resolución de su cuadro.

Kluyvera cryocrescens is a gram-negative enterobacteria that has been isolated from sputum, urine, bile secretion, peritoneal fluid and blood in humans, but rarely causes clinically significant infections. However, there are several cases described in the literature that have presented with symptoms of severe sepsis and septic shock, some with adequate response to different antibiotic therapies. A case of severe sepsis due to Kluyvera cryocrescens bacteremia is described in a 73 year old male, regarding his diagnosis, treatment and outcome. He develops the infection while hospitalized and received a 10 day course of a third generation cephalosporin achieving adequate resolution of the infection.

Humanos , Masculino , Adulto , Bacteriemia , Cefalosporinas , Infecção Hospitalar , Bactérias Gram-Negativas , Kluyvera , Sepse , Choque Séptico