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1.
J Clin Psychiatry ; 80(5)2019 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-31483958

RESUMO

BACKGROUND: Delirium is common and dangerous, yet underdetected and undertreated. Current screening questionnaires are subjective and ineffectively implemented in busy hospital workflows. Electroencephalography (EEG) can objectively detect the diffuse slowing characteristic of delirium, but it is not suitable for high-throughput screening due to size, cost, and the expertise required for lead placement and interpretation. This study hypothesized that an efficient and reliable point-of-care EEG device for high-throughput screening could be developed. METHODS: This prospective study, which measured bispectral EEG (BSEEG) from elderly inpatients to assess their outcomes, was conducted at the University of Iowa Hospitals and Clinics from January 2016 to October 2017. A BSEEG score was defined based on the distribution of 2,938 EEG recordings from the 428 subjects who were assessed for delirium; primary outcomes measured were hospital length of stay, discharge disposition, and mortality. RESULTS: A total of 274 patients had BSEEG score data available for analysis. Delirium and BSEEG score had a significant association (P < .001). Higher BSEEG scores were significantly correlated with length of stay (P < .001 unadjusted, P = .001 adjusted for age, sex, and Charlson Comorbidity Index [CCI] score) as well as with discharge not to home (P < .01). Hazard ratio for survival controlling for age, sex, CCI score, and delirium status was 1.35 (95% CI,1.04 to 1.76; P = .025). CONCLUSIONS: In BSEEG, an efficient and reliable device that provides an objective measurement of delirium status was developed. The BSEEG score is significantly associated with pertinent clinical outcomes of mortality, hospital length of stay, and discharge disposition. The BSEEG score better predicts mortality than does clinical delirium status. This study identified a previously unrecognized subpopulation of patients without clinical features of delirium who are at increased mortality risk.

2.
Iowa Orthop J ; 39(1): 29-35, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31413671

RESUMO

Background: Overlapping surgery is common in high-volume total knee arthroplasty (TKA) practices and has come under recent scrutiny in the press. The aim of this study was to evaluate differences in 6-week clinical and radiographic outcomes for primary TKA patients between single and overlapping operating room (OR) days. Methods: We retrospectively reviewed individual patient records of a consecutive series of primary TKAs with complete 6-week follow-up performed by a single academic surgeon between 2008-2016 (N= 452). Patients were stratified by single vs. overlapping OR days. 177 patients (39%) had an overlapping surgery. Age, body mass index (BMI), Charlson Comorbidity Index (CCI) and American Society of Anesthesiologists (ASA) class were recorded to assess for confounding variables. Outcomes included anesthesia time, 6-week readmission, unplanned return to OR, medical and surgical complication, and 6-week radiographic alignment. Results: There were no significant differences in anesthesiology time (165.5 vs 164.5 min, p=0.85), medical or surgical complication rates (10.5% vs 6.2%, p=0.11), 6-week readmissions (4.4% vs 1.7%, p=0.12), or return to OR (1.8% vs 1.7%, p=1.00) before or after adjusting for age, BMI, gender, ASA and CCI. There was no difference between overlapping and single OR cohorts in rate of neutral coronal alignment (2°-8° valgus) (98.3% vs 98.9%, respectively, p=0.68) or presence of periprosthetic lucency (p=0.43). Conclusions: This study demonstrates no differences in 6-week clinical or radiographic outcomes between patients undergoing primary TKA on single versus overlapping OR days. These results support the safe practice of overlapping surgical scheduling in high-volume primary TKA centers.Level of Evidence: III.

3.
J Vis Exp ; (150)2019 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-31424438

RESUMO

Cardiac transplantation demand is on the rise; nevertheless, organ availability is limited due to a paucity of suitable donors. Organ donation after circulatory death (DCD) is a solution to address this limited availability, but due to a period of prolonged warm ischemia and the risk of tissue injury, its routine use in cardiac transplantation is seldom seen. In this manuscript we provide a detailed protocol closely mimicking current clinical practices in the context of DCD with continuous monitoring of heart function, allowing for the evaluation of novel cardioprotective strategies and interventions to decrease ischemia-reperfusion injury. In this model, the DCD protocol is initiated in anesthetized Lewis rats by stopping ventilation to induce circulatory death. When systolic blood pressure drops below 30 mmHg, the warm ischemic time is initiated. After a pre-set warm ischemic period, hearts are flushed with a normothermic cardioplegic solution, procured, and mounted onto a Langendorff ex vivo heart perfusion system. Following 10 min of initial reperfusion and stabilization, cardiac reconditioning is continuously evaluated for 60 min using intraventricular pressure monitoring. A heart injury is assessed by measuring cardiac troponin T and the infarct size is quantified by histological staining. The warm ischemic time can be modulated and tailored to develop the desired amount of structural and functional damage. This simple protocol allows for the evaluation of different cardioprotective conditioning strategies introduced at the moment of cardioplegia, initial reperfusion and/or during ex vivo perfusion. Findings obtained from this protocol can be reproduced in large models, facilitating clinical translation.

4.
J Am Coll Cardiol ; 74(6): 729-740, 2019 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-31395122

RESUMO

BACKGROUND: Concerns remain for a greater risk of incomplete revascularization and reduced survival with off-pump coronary artery bypass grafting (CABG) surgery compared with on-pump surgery particularly in patients with left main disease and extensive underlying myocardial ischemia. OBJECTIVES: This study sought to compare outcomes following off-pump versus on-pump surgery for left main disease by performing a post hoc analysis from the multicenter, randomized EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial. METHODS: The EXCEL trial was designed to compare percutaneous coronary intervention with everolimus-eluting stents versus CABG in patients with left main disease. CABG was performed with or without cardiopulmonary bypass (on-pump vs. off-pump surgery) according to the discretion of the operator. The 3-year outcomes in the off-pump and on-pump groups were compared using inverse probability of treatment weighting (IPTW) for treatment effect estimation. RESULTS: Among 923 CABG patients, 652 and 271 patients underwent on-pump and off-pump surgery, respectively. Despite a similar extent of disease, off-pump surgery was associated with a lower rate of revascularization of the left circumflex coronary artery (84.1% vs. 90.0%; p = 0.01) and right coronary artery (31.1% vs. 40.6%; p = 0.007). After IPTW adjustment for baseline differences, off-pump surgery was associated with a significantly increased risk of 3-year all-cause death (8.8% vs. 4.5%; hazard ratio: 1.94; 95% confidence interval: 1.10 to 3.41; p = 0.02) and a nonsignificant difference in the risk for the composite endpoint of death, myocardial infarction, or stroke (11.8% vs. 9.2%; hazard ratio: 1.28; 95% confidence interval: 0.82 to 2.00; p = 0.28). CONCLUSIONS: Among patients with left main disease treated with CABG in the EXCEL trial, off-pump surgery was associated with a lower rate of revascularization of the coronary arteries supplying the inferolateral wall and an increased risk of 3-year all-cause death compared with on-pump surgery.

5.
Eval Health Prof ; : 163278719856406, 2019 Jun 13.
Artigo em Inglês | MEDLINE | ID: mdl-31195828

RESUMO

The patient-reported outcomes measurement information system (PROMIS) offers standardized assessment measures of clinically relevant patient-reported outcomes. This study evaluated the reliability and validity of select PROMIS measures with U.S. military veterans following orthopedic surgery. Data for the current study were collected as part of a pilot randomized control trial assessing the efficacy of a 1-day Acceptance and Commitment Therapy workshop on persistent postsurgical pain in at-risk veterans undergoing orthopedic surgery. Sixty-seven participants completed surveys 3 months after surgery. Participants completed the following PROMIS instruments: PROMIS Anxiety Short Form 8a, PROMIS Depression Short Form 8b, and PROMIS Pain Interference Short Form 8a. PROMIS measures were compared to the Generalized Anxiety Disorder 7-Item Scale, the Patient Health Questionnaire 9-Item Scale, and the Brief Pain Inventory Pain Interference subscale, respectively. All three PROMIS measures demonstrated excellent internal consistency (Cronbach's αs ranged from .93 to .96) and each loaded onto a single factor. The PROMIS measures were moderately correlated with their respective comparison measures (r = .69 to .76). The PROMIS anxiety and PROMIS depression measures were highly correlated to one another (r = .91). Findings highlight the potential utility of these PROMIS measures in veterans following orthopedic surgery and the overlap between the PROMIS depression and anxiety measures in this sample.

6.
Can J Cardiol ; 35(8): 967-982, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31229362

RESUMO

Coronary revascularization is done to alleviate the patient symptoms or to improve prognosis. Despite these clinical indications, significant variability exists in the risk assessment tools used to select patients for coronary revascularization, to the extent of revascularization performed and, in our approaches to define "optimal" revascularization. The goal of this review is to evaluate novel approaches that can assess coronary artery disease before and after revascularization, define the thresholds of these approaches that have been shown to improve morbidity and mortality, and highlight future directions for research in this area. The novel approaches defining coronary revascularization described in this review are split among quality of life metrics, risk scores, noninvasive imaging outcomes, invasive imaging outcomes, and physiological measurements.

7.
Life Sci ; 227: 8-19, 2019 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-30986447

RESUMO

AIMS: Cardiac ischemic conditioning has been shown to decrease ischemic injury in experimental models and clinically. Activation of survival pathways leading to heat shock proteins (HSP) modulation is an important contributor to this effect. We have previously shown that celastrol, an HSP90 modulator, achieves cardioprotection through activation of cytoprotective HSP's and heme-oxygenase-1 (HO-1). This is the first comparative evaluation of several modulators of HSP90 activity for cardioprotection. Furthermore, basic celastrol structure-activity relationship was characterized in order to develop novel potent infarct sparing agents suitable for clinical development. MAIN METHODS: Combining in vitro cell culture using rat myocardial cell line exposed to ischemic and ischemia/reperfusion (I/R) stresses, and ex vivo Langendorff rat heart perfusion I/R model, we evaluated cardioprotective effects of various compounds. Selected signalling pathways were evaluated by western blot and reporter gene activation. KEY FINDINGS: From a variety of HSP90 modulator chemotypes, the celastrol family was most efficient in inducing cytoprotective HSP70 and HO-1 protein overexpression and cell survival in vitro. Celastrol and two synthetic analogs were protective against ischemia and prevented ischemia/reperfusion (I/R) injury when given as pre-treatment or at time of reperfusion, increasing viability and reducing mitochondrial permeability transition pore opening. Ex vivo experiments demonstrated that the two synthetic analogs show cardioprotective activity at lower concentrations compared to celastrol, with activation of multiple survival pathways. SIGNIFICANCE: Celastrol backbone is essential for cardioprotection through HSP90 activity modulation. These compounds hold promise as novel adjunct treatment to improve outcome in the clinical management of I/R injury.


Assuntos
Cardiotônicos/metabolismo , Isquemia Miocárdica/tratamento farmacológico , Triterpenos/farmacologia , Animais , Cardiotônicos/uso terapêutico , Linhagem Celular , Proteínas de Choque Térmico HSP70/metabolismo , Proteínas de Choque Térmico HSP90/metabolismo , Coração , Proteínas de Choque Térmico/metabolismo , Masculino , Isquemia Miocárdica/metabolismo , Traumatismo por Reperfusão Miocárdica/metabolismo , Miocárdio/metabolismo , Ratos , Ratos Endogâmicos Lew , Transdução de Sinais/efeitos dos fármacos , Triterpenos/metabolismo
8.
JACC Cardiovasc Interv ; 12(8): 781-789, 2019 Apr 22.
Artigo em Inglês | MEDLINE | ID: mdl-31000014

RESUMO

OBJECTIVES: The authors sought to assess the distribution and prognostic significance of habitual physical activity (HPA) in older adults undergoing transcatheter aortic valve replacement (TAVR). BACKGROUND: Low HPA is associated with mortality and disability in community-dwelling older adults. In the setting of TAVR, it is unclear whether low HPA is a risk factor for downstream morbidity or a byproduct of severe aortic stenosis that improves following its correction. METHODS: Older adults undergoing TAVR in the prospective multicentre FRAILTY-AVR (Frailty in Aortic Valve Replacement) study were interviewed to quantify their HPA in kilocalories/week using a validated questionnaire at baseline and follow-up. The primary endpoint was all-cause mortality at 12 months. RESULTS: The cohort consisted of 755 patients with a median age of 84.0 years (interquartile range [IQR]: 80.0 to 87.0 years). At baseline, median HPA was 1,116 kcal/week (IQR: 227 to 2,715 kcal/week) with 73% of patients performing <150 min/week of moderate or vigorous HPA. Sedentary patients were more likely to be older, female, frail, cognitively impaired, depressed, and have multimorbidity, although they had similar left ventricular function and aortic stenosis severity. In the logistic regression model adjusting for these covariates, HPA was found to be associated with mortality at 12 months (odds ratio: 0.84/100 kcal; 95% confidence interval: 0.73 to 0.98). HPA was associated with longer length of stay, discharge to health care facilities, and disability. At 12 months, median HPA among survivors was 933 kcal/week (IQR: 0 to 2,334 kcal/week) with pre-existing frailty being independently predictive of worsening HPA following TAVR. CONCLUSIONS: Sedentary patients have a higher risk of mortality and functional decline following TAVR.

9.
J Am Coll Cardiol ; 73(13): 1616-1628, 2019 Apr 09.
Artigo em Inglês | MEDLINE | ID: mdl-30947913

RESUMO

BACKGROUND: The randomized EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial reported a similar rate of the 3-year composite primary endpoint of death, myocardial infarction (MI), or stroke in patients with left main coronary artery disease (LMCAD) and site-assessed low or intermediate SYNTAX scores treated with percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). Whether these results are consistent in high-risk patients with diabetes, who have fared relatively better with CABG in most prior trials, is unknown. OBJECTIVES: In this pre-specified subgroup analysis from the EXCEL trial, the authors sought to examine the effect of diabetes in patients with LMCAD treated with PCI versus CABG. METHODS: Patients (N = 1,905) with LMCAD and site-assessed low or intermediate CAD complexity (SYNTAX scores ≤32) were randomized 1:1 to PCI with everolimus-eluting stents versus CABG, stratified by the presence of diabetes. The primary endpoint was the rate of a composite of all-cause death, stroke, or MI at 3 years. Outcomes were examined in patients with (n = 554) and without (n = 1,350) diabetes. RESULTS: The 3-year composite primary endpoint was significantly higher in diabetic compared with nondiabetic patients (20.0% vs. 12.9%; p < 0.001). The rate of the 3-year primary endpoint was similar after treatment with PCI and CABG in diabetic patients (20.7% vs. 19.3%, respectively; hazard ratio: 1.03; 95% confidence interval: 0.71 to 1.50; p = 0.87) and nondiabetic patients (12.9% vs. 12.9%, respectively; hazard ratio: 0.98; 95% confidence interval: 0.73 to 1.32; p = 0.89). All-cause death at 3 years occurred in 13.6% of PCI and 9.0% of CABG patients (p = 0.046), although no significant interaction was present between diabetes status and treatment for all-cause death (p = 0.22) or other endpoints, including the 3-year primary endpoint (p = 0.82) or the major secondary endpoints of death, MI, or stroke at 30 days (p = 0.61) or death, MI, stroke, or ischemia-driven revascularization at 3 years (p = 0.65). CONCLUSIONS: In the EXCEL trial, the relative 30-day and 3-year outcomes of PCI with everolimus-eluting stents versus CABG were consistent in diabetic and nondiabetic patients with LMCAD and site-assessed low or intermediate SYNTAX scores.(Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization [EXCEL]; NCT01205776).

10.
J Arthroplasty ; 34(7S): S135-S139, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30890390

RESUMO

BACKGROUND: Orthopedic surgeons may overprescribe opioids postoperatively. Literature examining opioid prescribing guidelines following total joint arthroplasty (TJA) is limited. METHODS: Retrospective review was conducted of primary TJAs from June 2017 to February 2018, with 3-month follow-up. Patients were divided into those who underwent surgery before (historical cohort) and after (restrictive cohort) implementation of a strict postoperative opioid prescribing protocol. RESULTS: Three hundred ninety-nine total patients were included (282 in historical cohort, 117 in restrictive cohort). There was no significant difference in preoperative, perioperative, and postoperative inpatient opioid use. Historical cohort was given significantly larger initial prescriptions, received significantly more refills, and received significantly greater total quantity of opioids per patient. There were significantly fewer call-ins in the restrictive cohort. Clinical outcomes were not significantly different. CONCLUSION: Drastic reductions in opioid prescriptions following TJA are possible without an increase in refills, call-ins, or adverse clinical effects.

11.
CMAJ ; 191(9): E247-E256, 2019 Mar 04.
Artigo em Inglês | MEDLINE | ID: mdl-30833491

RESUMO

BACKGROUND: Perioperative corticosteroid use may reduce acute kidney injury. We sought to test whether methylprednisolone reduces the risk of acute kidney injury after cardiac surgery. METHODS: We conducted a prespecified substudy of a randomized controlled trial involving patients undergoing cardiac surgery with cardiopulmonary bypass (2007-2014); patients were recruited from 79 centres in 18 countries. Eligibility criteria included a moderate-to-high risk of perioperative death based on a preoperative score of 6 or greater on the European System for Cardiac Operative Risk Evaluation I. Patients (n = 7286) were randomly assigned (1:1) to receive intravenous methylprednisolone (250 mg at anesthetic induction and 250 mg at initiation of cardiopulmonary bypass) or placebo. Patients, caregivers, data collectors and outcome adjudicators were unaware of the assigned intervention. The primary outcome was postoperative acute kidney injury, defined as an increase in the serum creatinine concentration (from the preoperative value) of 0.3 mg/dL or greater (≥ 26.5 µmol/L) or 50% or greater in the 14-day period after surgery, or use of dialysis within 30 days after surgery. RESULTS: Acute kidney injury occurred in 1479/3647 patients (40.6%) in the methylprednisolone group and in 1426/3639 patients (39.2%) in the placebo group (adjusted relative risk 1.04, 95% confidence interval 0.96 to 1.11). Results were consistent across several definitions of acute kidney injury and in patients with preoperative chronic kidney disease. INTERPRETATION: Intraoperative corticosteroid use did not reduce the risk of acute kidney injury in patients with a moderate-to-high risk of perioperative death who had cardiac surgery with cardiopulmonary bypass. Our results do not support the prophylactic use of steroids during cardiopulmonary bypass surgery. Trial registration: ClinicalTrials.gov, no. NCT00427388.

12.
Circ Cardiovasc Qual Outcomes ; 12(3): e005363, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30879326

RESUMO

Background Women account for a large proportion of patients treated with transcatheter aortic valve replacement, yet there remain conflicting reports about the effect of sex on outcomes. Moreover, the sex-specific prevalence and prognostic impact of frailty has not been systematically studied in the context of transcatheter aortic valve replacement. Methods and Results A preplanned analysis of the FRAILTY-AVR study (Frailty Aortic Valve Replacement) was performed to analyze the determinants of outcomes in older women and men undergoing transcatheter aortic valve replacement. FRAILTY-AVR was a multinational, prospective, observational cohort assembled at 14 institutions in North America and Europe from 2012 to 2017. Multivariable logistic regression models were stratified by sex and adjusted for covariates. Interaction between sex and each of these covariates was assessed. The primary outcome was 12-month mortality, and the secondary outcome was 1-month composite mortality or major morbidity. The cohort consisted of 340 women and 419 men. Women were older and had higher predicted risk of mortality. Women were more likely to have physical frailty traits, but not cognitive or psychosocial frailty traits, and global indices of frailty were similarly associated with adverse events regardless of sex. Women were more likely to require discharge to a rehabilitation facility, particularly those with physical frailty at baseline, although their functional status was similar to men at 12 months. The risk of 1-month mortality or major morbidity was greater in women, particularly those treated with larger prostheses. The risk of 12-month mortality was not greater in women, with the exception of those with pulmonary hypertension, in whom, there was a significant interaction for increased mortality. Conclusions The present study highlights sex-specific differences in older adults undergoing transcatheter aortic valve replacement and draws attention to the impact of physical frailty in women and their potential risk associated with oversized prostheses and pulmonary hypertension.

13.
JACC Cardiovasc Interv ; 11(21): 2185-2192, 2018 Nov 12.
Artigo em Inglês | MEDLINE | ID: mdl-30343019

RESUMO

OBJECTIVES: The authors sought to determine whether frail older adults undergoing nonfemoral transcatheter aortic valve replacement (TAVR) procedures had a higher risk of 30-day and 12-month mortality. BACKGROUND: Frailty can help predict outcomes and guide therapy in older adults being considered for TAVR. Nonfemoral TAVR procedures are more invasive and impart a greater risk of adverse events, which may be less well tolerated in frail patients, compared with transfemoral TAVR procedures. METHODS: This study was a post hoc analysis of the FRAILTY-AVR (Frailty Assessment Before Cardiac Surgery & Transcatheter Interventions) prospective multicenter cohort that consisted of older adults undergoing TAVR from 2012 to 2017. Frailty was assessed using the Essential Frailty Toolset (EFT). Endpoints of interest were 30-day and 12-month all-cause mortality. Interaction tables and multivariable logistic regression models were used to investigate statistical interaction on the additive and multiplicative scales. RESULTS: The cohort consisted of 723 patients with a mean age of 84 ± 6 years, of which 556 (77%) had femoral access and 167 (23%) had nonfemoral access. In frail patients with EFT scores ≥3 (35%), nonfemoral access was associated with increased 30-day mortality (odds ratio [OR]: 3.91; 95% confidence interval [CI]: 1.48 to 10.31); whereas in nonfrail patients with EFT scores <3 (65%), nonfemoral access had no effect (OR: 1.29; 95% CI: 0.34 to 4.94). There was statistical evidence of interaction between frailty and access site on 30-day mortality on the additive scale (relative excess risk due to interaction = 5.95). Nonfemoral access was associated with increased 1-year mortality in frail patients (OR: 1.98; 95% CI: 1.00 to 3.93) but not in nonfrail patients (OR: 1.83; 95% CI: 0.90 to 3.74), although there was no statistical evidence of interaction. CONCLUSIONS: Frail patients undergoing TAVR via a more invasive nonfemoral access face a substantially higher risk of 30-day mortality, whereas nonfrail older adults tolerate the procedure with a low short-term risk irrespective of access route.

14.
Psychiatry Clin Neurosci ; 72(12): 856-863, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30246448

RESUMO

AIM: Delirium is common and dangerous among elderly inpatients; yet, it is underdiagnosed and thus undertreated. This study aimed to test the diagnostic characteristics of a noninvasive point-of-care device with two-channel (bispectral) electroencephalography (EEG) for the screening of delirium in the hospital. METHODS: Patients admitted to the University of Iowa Hospitals and Clinics were assessed for the presence of delirium with a clinical assessment, the Confusion Assessment Method for Intensive Care Unit and Delirium Rating Scale. Subsequently, we obtained a 10-min bispectral EEG (BSEEG) recording from a hand-held electroencephalogram device during hospitalization. We performed power spectral density analysis to differentiate between those patients with and without delirium. RESULTS: Initially 45 subjects were used as a test dataset to establish a cut-off. The BSEEG index was determined to be a significant indicator of delirium, with sensitivity 80% and specificity 87.7%. An additional independent validation dataset with 24 patients confirmed the validity of the approach, with a sensitivity of 83.3% and specificity of 83.3%. CONCLUSION: In this pilot study, the BSEEG method was able to distinguish delirious patients from non-delirious patients. Our data showed the feasibility of this technology for mass screening of delirium in the hospital.

15.
Iowa Orthop J ; 38: 203-208, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30104946

RESUMO

Background: Many clinical factors are known to increase an individual patient's risk of perioperative complications and hospital readmission. Several novel risk calculators have been created to predict the risk of postoperative complications for specific procedures that rely entirely on objective measurements. Our goal was to determine if surgeon intuition (an estimate of the percent likelihood of minor and major medical and surgical complications and 30-day readmission) could provide an additional source of data in the preoperative setting that may enhance the prediction of complications after surgery. Methods: We targeted the operative practices of three subspecialized orthopedic surgeons over a 6-month period (February 1 to July 31, 2015). We administered surveys to attending surgeons and assisting residents or nurse practitioners prior to each operation. Surgeons were asked to predict each patient's likelihood, on a scale from <1-100, for experiencing a complication. Following the procedure, we analyzed each patient's electronic medical record to determine any adverse events and readmissions. We then looked at levels of association between predictor variables and complications. Analysis of maximum likelihood estimates for complication outcome was performed comparing objective variables and surgeon prediction. Results: A total of 417 surveys in 270 patients were available for analysis. Defining the predicted likelihood of minor medical complications as <10% (low), 10-40% (intermediate), and >40% (high), provided discrimination of postoperative complications for a single observer in the first three month. These cutoff ranges showed inter-observer consistency and a trend towards intra-observer consistency. The only three variables predictive of minor medical complications were ASA class (OR=3.63, 95%CI=1.76-7.52, p=0.0005; comparing >2 vs ≤2), age (ß=0.034±0.012, p=0.0032) and surgeon prediction when comparing high to low risk (ß=0.034±0.008 (0.018-0.049), p<0.0001). Conclusions: Quantitative surgeon preoperative risk assessment was able to accurately discriminate between low- and high-risk groups of minor medical complications. We did not find a similar association between major complications and readmissions.Level of Evidence: IV.

16.
Artigo em Inglês | MEDLINE | ID: mdl-30165487

RESUMO

OBJECTIVES: Observational data suggest that the use of a single internal thoracic artery (SITA) may result in inferior outcomes compared with bilateral internal thoracic artery (BITA) use for coronary artery bypass grafting (CABG)-a finding not yet supported by randomized trial outcomes. However, the optimal number of internal thoracic artery grafts in patients with left main coronary artery disease has not been investigated. METHODS: The EXCEL trial randomized 1905 patients with left main coronary artery disease to percutaneous coronary intervention with everolimus-eluting stents versus CABG. Among the 905 patients undergoing CABG, 688 (76.0%) received SITA and 217 (24.0%) received BITA. Differences in clinical event rates were estimated using the Kaplan-Meier method and compared with the log-rank test. Multivariable Cox regression was used to adjust for differences in baseline covariates. RESULTS: Compared to SITA, patients treated with BITA were younger (66.1 ± 9.5 vs 64.5 ± 9.3 years, P = 0.020), were less likely female (24.3% vs 14.3%, P = 0.002) and diabetic (28.8% vs 15.2%, P < 0.001), and had a lower prevalence of peripheral vessel disease (10.2% vs 5.5%, P = 0.040). The unadjusted 3-year composite primary endpoint of death, stroke or myocardial infarction (MI) occurred in 15.6% of SITA vs 11.6% of BITA patients (P = 0.17). The SITA group tended to have a higher 3-year rate of all-cause death compared with the BITA group (6.7% vs 3.3%; P = 0.070). Stroke, MI and ischaemia-driven revascularization outcomes were not significantly different between groups. After adjusting for baseline differences, neither the composite of death, stroke or MI [hazard ratio (HR) 1.12, 95% confidence interval (CI) 0.71-1.78; P = 0.62] nor mortality (HR 1.36, 95% CI 0.60-3.12; P = 0.46) was significantly higher with SITA. The rehospitalization rate after 3 years was higher in the SITA group (35.8% vs 26.0%, P = 0.008), a difference which was no longer present after multivariable adjustment (HR 1.27, 95% CI 0.93-1.74; P = 0.13). Sternal wound dehiscence within 30 days did not occur more often in the BITA group compared to the SITA group (1.8% vs 2.2%, P > 0.99). CONCLUSIONS: In the EXCEL trial, there were no clinical differences at 3 years between SITA or BITA revascularization in patients with left main coronary artery disease.

17.
Circulation ; 2018 Jul 05.
Artigo em Inglês | MEDLINE | ID: mdl-29976568

RESUMO

Background -Older adults undergoing aortic valve replacement are at risk for malnutrition. The association between pre-procedural nutritional status and midterm mortality has yet to be determined. Methods -The FRAILTY-AVR prospective multi-center international cohort study was conducted between 2012-2017 in 14 centers in 3 countries. Patients ≥70 years of age who underwent transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) were eligible. The Mini Nutritional Assessment-Short Form (MNA-SF) was assessed by trained observers pre-procedure, with scores ≤7 of 14 considered malnourished and 8-11 of 14 considered at-risk for malnutrition. The Short Performance Physical Battery (SPPB) was simultaneously assessed to measure physical frailty, with scores ≤5 of 12 considered severely frail and 6-8 of 12 considered mildly frail. The primary outcome was 1-year all-cause mortality and the secondary outcome was 30-day composite mortality or major morbidity. Multivariable regression models were used to adjust for potential confounders. Results -There were 1,158 patients (727 TAVR and 431 SAVR) with 45% females, a mean age of 81.3 years, a mean body mass index of 27.5 kg/m2, and a mean Society of Thoracic Surgeons-Predicted Risk of Mortality (STS-PROM) of 5.1%. Overall, 8.7% of patients were classified as malnourished and 32.8% were at-risk for malnutrition. MNA-SF scores were moderately correlated with SPPB scores (Spearman R=0.31, P<0.001). There were 126 deaths in the TAVR group (19.1 per 100 patient-years) and 30 deaths in the SAVR group (7.5 per 100 patient-years). Malnourished patients had a nearly 3-fold higher crude risk of 1-year mortality compared with those with normal nutritional status (28% vs 10%, P<0.001). After adjustment for frailty, STS-PROM, and procedure type, pre-procedural nutritional status was a significant predictor of 1-year mortality (OR 1.08 per MNA-SF point, 95% CI 1.01-1.16) and of the 30-day composite safety endpoint (OR 1.06 per MNA-SF point, 95% CI 1.00 to 1.12). Conclusions -Pre-procedural nutritional status is associated with mortality in older adults following aortic valve replacement. Clinical trials are needed to determine whether pre- and post-procedural nutritional interventions can improve clinical outcomes in these vulnerable patients.

18.
Open Heart ; 5(1): e000780, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29682294

RESUMO

Introduction: Saphenous vein grafts (SVGs) remain the most often used conduits in coronary artery bypass grafting (CABG). However, they are prone to vein graft disease (VGD) during follow-up, which may compromise clinical outcomes. Injury to the SVG endothelium during harvesting and storage promotes neointimal hyperplasia that can advance to atherosclerosis characterised by SVG failure. This trial investigates the potential benefit of DuraGraft, a novel, one-time intraoperative graft treatment developed to efficiently protect the structural and functional integrity of the vascular endothelium, on the development and progression of VGD in CABG patients. Methods and analysis: This ongoing prospective randomised, double-blinded multicentre trial (NCT02272582/NCT02774824) includes patients undergoing isolated CABG requiring at least two SVGs. It compares the impact of DuraGraft, a novel treatment against VGD versus the standard-of-care (SOC; heparinised saline) using a within-patient randomisation (with one SVG treated with DuraGraft and the other treated with SOC). Besides clinical assessments, patients undergo longitudinal 64-slice or better multidetector CT (MDCT) angiography of paired grafts (within each patient) at 4-6 weeks, 3 months and 12 months. Primary endpoints will be the magnitude of change in mean wall thickness and lumen diameter (stenosis) of paired grafts, at 3 and 12 months, respectively. Besides the evaluation of overall safety, longitudinal assessment of each graft (secondary endpoint) is performed in order to obtain insight into graft behaviour after CABG. Enrolment of 119 patients was successfully completed, and analysis of MDCT angiography follow-up is ongoing with the completed analysis becoming available by end of first quarter of 2018. Ethics and dissemination: The regional ethics committees have approved the trial. Results will be submitted for publication. Clinical trial identifier: NCT02272582 and NCT02774824.

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