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1.
J Health Care Poor Underserved ; 31(1): 105-114, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32037320

RESUMO

We aim to evaluate the association between family income and mock multiple mini interview (MMI) performance for prospective medical school applicants. Each applicant participated in a three-station mock MMI and were scored on four items, each on a sevenpoint scale. Of the 48 prospective applicants participating, 29 (60% survey response rate) completed the survey. Hispanic applicants were significantly more likely to have a family income of less than or equal to $20,000 versus more than $20,000 (p<.05). The adjusted analysis suggested mock MMI total score was significantly lower for prospective medical school applicants with family incomes of less than or equal to $20,000 versus more than $20,000 (ß coefficient 5.37, 95% CI 0.05-10.69, p = .048). The mock MMI performance of prospective applicants with lower family incomes indicates the need for further interview skill preparation or new interview scoring protocols.

2.
Neurosurgery ; 86(2): 241-249, 2020 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-30873551

RESUMO

BACKGROUND: The "Volume Pledge" aims to centralize carotid artery stenting (CAS) to hospitals and surgeons performing ≥10 and ≥5 procedures annually, respectively. OBJECTIVE: To compare outcomes after CAS between hospitals and surgeons meeting or not meeting the Volume Pledge thresholds. METHODS: We queried the Nationwide Inpatient Sample for CAS admissions. Hospitals and surgeons were categorized as low volume and high volume (HV) based on the Volume Pledge. Multivariable hierarchical regression models were used to examine the impact of hospital volume (2005-2011) and surgeon volume (2005-2009) on perioperative outcomes. RESULTS: Between 2005 and 2011, 22 215 patients were identified. Most patients underwent CAS by HV hospitals (86.4%). No differences in poor outcome (composite endpoint of in-hospital mortality, postoperative neurological or cardiac complications) were observed by hospital volume but HV hospitals did decrease the likelihood of other complications, nonroutine discharge, and prolonged hospitalization. From 2005 to 2009, 9454 CAS admissions were associated with physician identifiers. Most patients received CAS by HV surgeons (79.2%). On multivariable analysis, hospital volume was not associated with improved outcomes but HV surgeons decreased odds of poor outcome (odds ratio [OR] 0.76, 95% confidence interval [CI] 0.59-0.97; P = .028), complications (OR 0.56, 95% CI 0.46-0.71, P < .001), nonroutine discharge (OR 0.70, 95% CI 0.57-0.87; P = .001), and prolonged hospitalization (OR 0.52, 95% 0.44-0.61, P < .001). CONCLUSION: Most patients receive CAS by hospitals and providers meeting the Volume Pledge threshold for CAS. Surgeons but not hospitals who met the policy's volume standards were associated with superior outcomes across all measured outcomes.


Assuntos
Doenças das Artérias Carótidas/cirurgia , Endarterectomia das Carótidas/tendências , Hospitais com Alto Volume de Atendimentos/tendências , Stents/tendências , Cirurgiões/tendências , Idoso , Artérias Carótidas/cirurgia , Doenças das Artérias Carótidas/epidemiologia , Endarterectomia das Carótidas/efeitos adversos , Feminino , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Stents/efeitos adversos , Cirurgiões/normas
3.
J Glob Oncol ; 5: 1-19, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31774711

RESUMO

PURPOSE: Limited information is available on multiple myeloma (MM), chronic lymphocytic leukemia (CLL), and non-Hodgkin lymphoma (NHL) management in Latin America. The primary objective of the Hemato-Oncology Latin America (HOLA) study was to describe patient characteristics and treatment patterns of Latin American patients with MM, CLL, and NHL. METHODS: This study was a multicenter, retrospective, medical chart review of patients with MM, CLL, and NHL in Latin America identified between January 1, 2006, and December 31, 2015. Included were adults with at least 1 year of follow-up (except in cases of death within 1 year of diagnosis) treated at 30 oncology hospitals (Argentina, 5; Brazil, 9; Chile, 1; Colombia, 5; Mexico, 6; Panama/Guatemala, 4). RESULTS: Of 5,140 patients, 2,967 (57.7%) had NHL, 1,518 (29.5%) MM, and 655 (12.7%) CLL. Median follow-up was 2.2 years for MM, 3.0 years for CLL, and 2.2 years for NHL, and approximately 26% died during the study observation period. Most patients had at least one comorbidity at diagnosis. The most frequent induction regimen was thalidomide-based chemotherapy for MM and chlorambucil with or without prednisone for CLL. Most patients with NHL had diffuse large B-cell lymphoma (DLBCL; 49.1%) or follicular lymphoma (FL; 19.5%). The majority of patients with DLBCL or FL received rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone. CONCLUSION: The HOLA study generated an unprecedented level of high-quality, real-world evidence on characteristics and treatment patterns of patients with hematologic malignancies. Regional disparities in patient characteristics may reflect differences in ethnoracial identity and level of access to care. These data provide needed real-world evidence to understand the disease landscape in Latin America and may be used to inform clinical and health policy decision making.


Assuntos
Leucemia Linfocítica Crônica de Células B/epidemiologia , Linfoma não Hodgkin/epidemiologia , Mieloma Múltiplo/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Humanos , América Latina/epidemiologia , Pessoa de Meia-Idade , Sistema de Registros , Adulto Jovem
4.
Onco Targets Ther ; 12: 8023-8031, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31632056

RESUMO

Objective: Approximately 40-50% of patients with acute myeloid leukaemia (AML) have been reported to present with a normal karyotype and a variable disease-free period, most likely due to the molecular heterogeneity presented by these patients. A variety of mutations have been identified at the molecular level, such as those in the IDH1/2 gene, which causes a gain of function of the isocitrate dehydrogenase enzyme, generating high levels of the (R)-2-hydroxyglutarate oncometabolite, which competitively inhibits dioxygenase enzymes. Therefore, the objective of this study was to evaluate the incidence of IDH1/2 gene mutations in AML patients and their impact on survival. Materials and methods: A total of 101 patients with a diagnosis of AML were included; mononuclear cells were obtained for DNA extraction and purification. Mutations were detected using TaqMan™ competitive allele-specific probes (castPCR™). Overall survival curves were plotted using IBM SPSS Statistics 23 software. Results: The frequency of IDH gene mutations was 19.8%. For the IDH1 gene, 13.8% of the mutations identified included R132H, V178I, G105G and R132C. The frequency of mutations of the IDH2 gene was 5.9%; the variants included R172K and R140Q. The mean survival time in patients without IDH1 gene mutations was 173.15 days (120.20-226.10), while the mean survival time for patients with mutations was 54.95 days (9.7-100.18), p = 0.001. Conclusion: The frequency of IDH1 and IDH2 gene mutations in the sample was similar to that reported in other studies. The analysis of these mutations in AML patients is of great importance as a prognostic factor due to their impact on survival and their use as potential therapeutic targets or as targets of inhibitors of IDH1(Ivosidenib, Tibsovo) and IDH2 (Enasidenib, Idhifa).

5.
Cureus ; 11(7): e5135, 2019 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-31523564

RESUMO

Philadelphia chromosome-positive Acute Myeloid Leukemia (AML) is a de novo acute leukemia in which patients show no evidence of Chronic Myeloid Leukemia (CML) before or after their treatment. This kind of leukemia has an aggressive clinical course, with poor response to traditional chemotherapy or monotherapy with Tyrosine Kinase Inhibitors (TKI), and a high risk of early relapse after induction therapy. We report a rare case of de novo ALM with t(9;22). A 26-year-old male patient was referred to our hospital for an examination of anemia, thrombocytopenia (hemoglobin 5.7 g/dL and platelets 110 000/L) and elevated White Blood Cell (WBC) count (11 600 µ/L, 24% segmented, 63% lymphocytes, 11% monocytes). Bone marrow smear was compatible with AML. Cytogenetic study revealed t(9;22)(q34;q11). Our patient was treated with chemotherapy for AML and a second-generation TKI and remains in complete remission pending a bone marrow transplant.

6.
World Neurosurg ; 130: e588-e597, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31260846

RESUMO

BACKGROUND: Most Americans consult the Internet to address their health concerns. Limited health literacy among the public highlights the need for patient education Web sites to deliver understandable health information. We assessed the understandability and actionability of online neurosurgical patient education materials (PEMs) provided by the American Association of Neurological Surgeons (AANS) and MedlinePlus. METHODS: Articles on neurosurgical conditions and treatments listed on both the AANS site and MedlinePlus were analyzed. Two reviewers scored articles using 2 validated health literacy tools, the Centers for Disease Control and Prevention Clear Communication Index (CCI) and the Agency for Healthcare Research and Quality (AHRQ) Patient Education Materials Assessment Tool (PEMAT). These tools evaluate the quality of written health information and assess for content, organization, and actionability of PEMs. RESULTS: One hundred and thirty-eight articles were evaluated from the AANS (n = 61) and MedlinePlus (n = 77). The median CCI score for MedlinePlus and AANS articles was 68.9 (interquartile range [IQR], 62.5-81.3) and 56.3 [IQR, 46.7-73.7], respectively (P < 0.001). Only 1 article scored ≥90%, which is the CCI threshold for PEMs to be considered easy to read. Although the AANS and Medline performed similarly on the understandability component of the PEMAT (66.7 [IQR, 53.8-69.2] vs. 69.2 [IQR, 66.7-83.3], respectively; P < 0.001), significant differences were observed for the actionability section of the PEMAT (Medline 60 [IQR, 60-60] vs. AANS 0 [IQR, 0-60]; P < 0.001). Less than 13% of articles provided summaries, visual aids, and tangible tools to aid patient action. CONCLUSIONS: Neurosurgical online PEMs may be difficult to understand and potentially act as barriers for patients' engagement with health systems. There is a need to deliver patient-centered health information that effectively informs patients, aiding in meaningful health decision making.


Assuntos
Compreensão , Internet , Procedimentos Neurocirúrgicos/educação , Educação de Pacientes como Assunto/normas , Materiais de Ensino/normas , Letramento em Saúde/normas , Humanos
7.
Radiology ; 291(3): 689-697, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30912721

RESUMO

Background Intraoperative MRI has been shown to improve gross-total resection of high-grade glioma. However, to the knowledge of the authors, the cost-effectiveness of intraoperative MRI has not been established. Purpose To construct a clinical decision analysis model for assessing intraoperative MRI in the treatment of high-grade glioma. Materials and Methods An integrated five-state microsimulation model was constructed to follow patients with high-grade glioma. One-hundred-thousand patients treated with intraoperative MRI were compared with 100 000 patients who were treated without intraoperative MRI from initial resection and debulking until death (median age at initial resection, 55 years). After the operation and treatment of complications, patients existed in one of three health states: progression-free survival (PFS), progressive disease, or dead. Patients with recurrence were offered up to two repeated resections. PFS, valuation of health states (utility values), probabilities, and costs were obtained from randomized controlled trials whenever possible. Otherwise, national databases, registries, and nonrandomized trials were used. Uncertainty in model inputs was assessed by using deterministic and probabilistic sensitivity analyses. A health care perspective was used for this analysis. A willingness-to-pay threshold of $100 000 per quality-adjusted life year (QALY) gained was used to determine cost efficacy. Results Intraoperative MRI yielded an incremental benefit of 0.18 QALYs (1.34 QALYs with intraoperative MRI vs 1.16 QALYs without) at an incremental cost of $13 447 ($176 460 with intraoperative MRI vs $163 013 without) in microsimulation modeling, resulting in an incremental cost-effectiveness ratio of $76 442 per QALY. Because of parameter distributions, probabilistic sensitivity analysis demonstrated that intraoperative MRI had a 99.5% chance of cost-effectiveness at a willingness-to-pay threshold of $100 000 per QALY. Conclusion Intraoperative MRI is likely to be a cost-effective modality in the treatment of high-grade glioma. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Bettmann in this issue.


Assuntos
Neoplasias Encefálicas/diagnóstico por imagem , Glioma/diagnóstico por imagem , Cuidados Intraoperatórios/economia , Imagem por Ressonância Magnética/economia , Cirurgia Assistida por Computador/economia , Encéfalo/diagnóstico por imagem , Neoplasias Encefálicas/economia , Análise Custo-Benefício , Glioma/economia , Humanos , Pessoa de Meia-Idade
8.
J Neurosurg ; : 1-9, 2019 Feb 22.
Artigo em Inglês | MEDLINE | ID: mdl-30797220

RESUMO

OBJECTIVESafety-net hospitals deliver care to a substantial share of vulnerable patient populations and are disproportionately impacted by hospital payment reform policies. Complex elective procedures performed at safety-net facilities are associated with worse outcomes and higher costs. The effects of hospital safety-net burden on highly specialized, emergent, and resource-intensive conditions are poorly understood. The authors examined the effects of hospital safety-net burden on outcomes and costs after emergent neurosurgical intervention for ruptured cerebral aneurysms.METHODSThe authors conducted a retrospective analysis of the Nationwide Inpatient Sample (NIS) from 2002 to 2011. Patients ≥ 18 years old who underwent emergent surgical clipping and endovascular coiling for aneurysmal subarachnoid hemorrhage (SAH) were included. Safety-net burden was defined as the proportion of Medicaid and uninsured patients treated at each hospital included in the NIS database. Hospitals that performed clipping and coiling were stratified as low-burden (LBH), medium-burden (MBH), and high-burden (HBH) hospitals.RESULTSA total of 34,647 patients with ruptured cerebral aneurysms underwent clipping and 23,687 underwent coiling. Compared to LBHs, HBHs were more likely to treat black, Hispanic, Medicaid, and uninsured patients (p < 0.001). HBHs were also more likely to be associated with teaching hospitals (p < 0.001). No significant differences were observed among the burden groups in the severity of subarachnoid hemorrhage. After adjusting for patient demographics and hospital characteristics, treatment at an HBH did not predict in-hospital mortality, poor outcome, length of stay, costs, or likelihood of a hospital-acquired condition.CONCLUSIONSDespite their financial burden, safety-net hospitals provide equitable care after surgical clipping and endovascular coiling for ruptured cerebral aneurysms and do not incur higher hospital costs. Safety-net hospitals may have the capacity to provide equitable surgical care for highly specialized emergent neurosurgical conditions.

9.
J Neurooncol ; 141(1): 159-166, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30460629

RESUMO

BACKGROUND: High-volume hospitals are associated with improved outcomes in glioblastoma (GBM). However, the impact of travel burden to high-volume centers is poorly understood. We examined post-operative outcomes between GBM patients that underwent treatment at local, low-volume hospitals with those that traveled long distances to high-volume hospitals. METHODS: The National Cancer Database was queried for GBM patients that underwent surgery (2010-2014). We established two cohorts: patients in the lowest quartile of travel distance and volume (Short-travel/Low-Volume: STLV) and patients in the highest quartile of travel and volume (Long-travel/High-Volume: LTHV). Outcomes analyzed were 30-day, 90-day mortality, overall survival, 30-day readmission, and hospital length of stay. RESULTS: Of 35,529 cases, STLV patients (n = 3414) traveled a median of 3 miles (Interquartile range [IQR] 1.8-4.2) to low-volume centers (5 [3-7] annual cases) and LTHV patients (n = 3808) traveled a median of 62 miles [44.1-111.3] to high-volume centers (48 [42-71]). LTHV patients were younger, had lower Charlson scores, largely received care at academic centers (84.4% vs 11.9%), were less likely to be minorities (8.1% vs 17.1%) or underinsured (6.9% vs 12.1), and were more likely to receive trimodality therapy (75.6% vs 69.2%; all p < 0.001). On adjusted analysis, LTHV predicted improved overall survival (HR 0.87, p = 0.002), decreased 90-day mortality (OR 0.72, p = 0.019), lower 30-day readmission (OR 0.42, p < 0.001), and shorter hospitalizations (RR 0.79, p < 0.001). CONCLUSIONS: Glioblastoma patients who travel farther to high-volume centers have superior post-operative outcomes compared to patients who receive treatment locally at low-volume centers. Strategies that facilitate patient travel to high-volume hospitals may improve outcomes.


Assuntos
Neoplasias Encefálicas/cirurgia , Glioblastoma/cirurgia , Acesso aos Serviços de Saúde , Idoso , Neoplasias Encefálicas/mortalidade , Feminino , Glioblastoma/mortalidade , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Viagem , Resultado do Tratamento
10.
J Neurosurg ; : 1-15, 2018 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-30215556

RESUMO

OBJECTIVEEpilepsy is one of the most common neurological disorders, yet its global surgical burden has yet to be characterized. The authors sought to compile the most current epidemiological data to quantify global prevalence and incidence, and estimate global surgically treatable epilepsy. Understanding regional and global epilepsy trends and potential surgical volume is crucial for future policy efforts and resource allocation.METHODSThe authors performed a systematic literature review and meta-analysis to determine the global incidence, lifetime prevalence, and active prevalence of epilepsy; to estimate surgically treatable epilepsy volume; and to evaluate regional trends by WHO regions and World Bank income levels. Data were extracted from all population-based studies with prespecified methodological quality across all countries and demographics, performed between 1990 and 2016 and indexed on PubMed, EMBASE, and Cochrane. The current and annual new case volumes for surgically treatable epilepsy were derived from global epilepsy prevalence and incidence.RESULTSThis systematic review yielded 167 articles, across all WHO regions and income levels. Meta-analysis showed a raw global prevalence of lifetime epilepsy of 1099 per 100,000 people, whereas active epilepsy prevalence is slightly lower at 690 per 100,000 people. Global incidence was found to be 62 cases per 100,000 person-years. The meta-analysis predicted 4.6 million new cases of epilepsy annually worldwide, a prevalence of 51.7 million active epilepsy cases, and 82.3 million people with any lifetime epilepsy diagnosis. Differences across WHO regions and country incomes were significant. The authors estimate that currently 10.1 million patients with epilepsy may be surgical treatment candidates, and 1.4 million new surgically treatable epilepsy cases arise annually. The highest prevalences are found in Africa and Latin America, although the highest incidences are reported in the Middle East and Latin America. These regions are primarily low- and middle-income countries; as expected, the highest disease burden falls disproportionately on regions with the fewest healthcare resources.CONCLUSIONSUnderstanding of the global epilepsy burden has evolved as more regions have been studied. This up-to-date worldwide analysis provides the first estimate of surgical epilepsy volume and an updated comprehensive overview of current epidemiological trends. The disproportionate burden of epilepsy on low- and middle-income countries will require targeted diagnostic and treatment efforts to reduce the global disparities in care and cost. Quantifying global epilepsy provides the first step toward restructuring the allocation of healthcare resources as part of global healthcare system strengthening.

11.
World Neurosurg ; 119: e294-e300, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30053566

RESUMO

BACKGROUND: Hospital readmission is a key surgical quality metric associated with financial penalties and greater healthcare costs. We examined the clinical risk factors and postoperative complications associated with 30-day unplanned hospital readmissions after cranial neurosurgery. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2016 for adult patients who had undergone a cranial neurosurgical procedure. Multivariable logistic regression with backward model selection was used to determine the predictors associated with 30-day unplanned hospital readmission. RESULTS: Of 40,802 cranial neurosurgical cases, 4147 (10.2%) required an unplanned readmission. Postoperative complications were greater in the readmission cohort (18.5% vs. 9.9%; P < 0.001). On adjusted analysis, the clinical factors predictive of unplanned readmission included hypertension, chronic obstructive pulmonary disease, diabetes, coagulopathy, chronic steroid use, and preoperative anemia, hyponatremia, and hypoalbuminemia (P ≤ 0.01 for all). Higher American Society of Anesthesiology class (III to V), operative time >216 minutes, and unplanned reoperation were also associated with an increased likelihood of readmission (P ≤ 0.001 for all). The postoperative complications predictive of unplanned readmissions were wound infection (odds ratio [OR], 4.90; P < 0.001), pulmonary embolus (OR, 3.94; P < 0.001), myocardial infarction or cardiac arrest (OR, 2.37; P < 0.001), sepsis (OR, 1.73; P < 0.001), deep venous thrombosis (OR, 1.50; P = 0.002), and urinary tract infection (OR, 1.45; P = 0.002). Female sex, transfer status, and postoperative pulmonary complications were protective of readmission (P < 0.05 for all). CONCLUSIONS: Unplanned hospital readmission after cranial neurosurgery is a common event. The identification of high-risk patients who undergo cranial procedures might allow hospitals to reduce unplanned readmissions and their associated healthcare costs.


Assuntos
Lesões Encefálicas/cirurgia , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Adolescente , Adulto , Distribuição por Idade , Idoso , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Adulto Jovem
12.
J Neurooncol ; 139(2): 389-397, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29691776

RESUMO

BACKGROUND: Safety-net hospitals (SNHs) provide disproportionate care for underserved patients. Prior studies have identified poor outcomes, increased costs, and reduced access to certain complex, elective surgeries at SNHs. However, it is unknown whether similar patterns exist for the management of glioblastoma (GBM). We sought to determine if patients treated at HBHs receive equitable care for GBM, and if safety-net burden status impacts post-treatment survival. METHODS: The National Cancer Database was queried for GBM patients diagnosed between 2010 and 2015. Safety-net burden was defined as the proportion of Medicaid and uninsured patients treated at each hospital, and stratified as low (LBH), medium (MBH), and high-burden (HBH) hospitals. The impact of safety-net burden on the receipt of any treatment, trimodality therapy, gross total resection (GTR), radiation, or chemotherapy was investigated. Secondary outcomes included post-treatment 30-day mortality, 90-day mortality, and overall survival. Univariate and multivariate analyses were utilized. RESULTS: Overall, 40,082 GBM patients at 1202 hospitals (352 LBHs, 553 MBHs, and 297 HBHs) were identified. Patients treated at HBHs were significantly less likely to receive trimodality therapy (OR = 0.75, p < 0.001), GTR (OR = 0.84, p < 0.001), radiation (OR = 0.73, p < 0.001), and chemotherapy (OR = 0.78, p < 0.001) than those treated at LBHs. Patients treated at HBHs had significantly increased 30-day (OR = 1.25, p = 0.031) and 90-day mortality (OR = 1.24, p = 0.001), and reduced overall survival (HR = 1.05, p = 0.039). CONCLUSIONS: GBM patients treated at SNHs are less likely to receive standard-of-care therapies and have increased short- and long-term mortality. Additional research is needed to evaluate barriers to providing equitable care for GBM patients at SNHs.


Assuntos
Neoplasias Encefálicas/terapia , Glioblastoma/terapia , Hospitais , Provedores de Redes de Segurança , Neoplasias Encefálicas/mortalidade , Feminino , Glioblastoma/mortalidade , Disparidades em Assistência à Saúde , Humanos , Masculino , Medicaid , Pessoas sem Cobertura de Seguro de Saúde , Pessoa de Meia-Idade , Qualidade da Assistência à Saúde , Análise de Sobrevida , Resultado do Tratamento , Estados Unidos
13.
Neurosurg Focus ; 44(4): E6, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29606044

RESUMO

OBJECTIVE Preoperative embolization of meningiomas can facilitate their resection when they are difficult to remove. The optimal use and timing of such a procedure remains controversial given the risk of embolization-linked morbidity in select clinical settings. In this work, the authors used a large national database to study the impact of immediate preoperative embolization on the immediate outcomes of meningioma resection. METHODS Meningioma patients who had undergone elective resection were identified in the National (Nationwide) Inpatient Sample (NIS) for the period 2002-2014. Patients who had undergone preoperative embolization were propensity score matched to those who had not, adjusting for patient and hospital characteristics. Associations between preoperative embolization and morbidity, mortality, and nonroutine discharge were investigated. RESULTS Overall, 27,008 admissions met the inclusion criteria, and 633 patients (2.34%) had undergone preoperative embolization and 26,375 (97.66%) had not. The embolization group was younger (55.17 vs 57.69 years, p < 0.001) with a lower proportion of females (63.5% vs 69.1%, p = 0.003), higher Charlson Comorbidity Index (p = 0.002), and higher disease severity (p < 0.001). Propensity score matching retained 413 embolization and 413 nonembolization patients. In the matched cohort, preoperative embolization was associated with increased rates of cerebral edema (25.2% vs 17.7%, p = 0.009), posthemorrhagic anemia or transfusion (21.8% vs 13.8%, p = 0.003), and nonroutine discharge (42.8% vs 35.7%, p = 0.039). There was no difference in mortality (≤ 2.4% vs ≤ 2.4%, p = 0.82). Among the embolization patients, the mean interval from embolization to resection was 1.49 days. On multivariate analysis, a longer interval was significantly associated with nonroutine discharge (OR 1.33, p = 0.004) but not with complications or mortality. CONCLUSIONS Relative to meningioma patients who do not undergo preoperative embolization in the same admission, those who do have higher rates of cerebral edema and nonroutine discharge but not higher rates of stroke or death. Thus, meningiomas requiring preoperative embolization represent a distinct clinical entity that requires prolonged, more complex care. Further, among embolization patients, the timing of resection did not affect the risk of in-hospital complications, suggesting that the timing of surgery can be determined according to surgeon discretion.


Assuntos
Tempo de Internação , Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Alta do Paciente/estatística & dados numéricos , Adulto , Idoso , Embolização Terapêutica/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
14.
Rev Med Chil ; 145(5): 579-584, 2017 May.
Artigo em Espanhol | MEDLINE | ID: mdl-28898333

RESUMO

BACKGROUND: The role of staging studies in patients with prostate cancer (PCa) is a topic of discussion. AIM: To evaluate the usefulness of imaging studies in patients with prostate cancer. MATERIAL AND METHODS: We reviewed the pathology service records to identify patients with prostate cancer diagnosed between 2003 and 2013. We reviewed the electronic medical records of those patients identified as having a prostate cancer. Patients were grouped according D’amico’s classification of cancer dissemination risk. We analized the frequency of imaging studies requested and their efficacy to detect metastases in each risk group. RESULTS: We identified 241 patients with a mean age of 67 years. Fifty two percent of patients were classified as low-risk, 32% as intermediate-risk and 16% as high risk. At least one imaging study was requested to 64% of patients (49, 78 and 87% of patients with low, intermediate and high risk respectively). Among the 155 patients in whom an imaging study was requested, no metastases were found in the low risk group. On the other hand, dissemination was found in 7% of the intermediate-risk group and 62% of the high-risk group. CONCLUSIONS: Half of patients with prostate cancer were classified as low risk. In half of this group of low risk patients, staging studies were requested and the probability of detecting metastases was low or nil. The odds of detecting metastases increased in higher risk groups.


Assuntos
Neoplasias da Próstata/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias/métodos , Neoplasias da Próstata/patologia , Estudos Retrospectivos , Medição de Risco
15.
Rev. méd. Chile ; 145(5): 579-584, mayo 2017. ilus, graf, tab
Artigo em Espanhol | LILACS-Express | LILACS | ID: biblio-902515

RESUMO

Background: The role of staging studies in patients with prostate cancer (PCa) is a topic of discussion. Aim: To evaluate the usefulness of imaging studies in patients with prostate cancer. Material and Methods: We reviewed the pathology service records to identify patients with prostate cancer diagnosed between 2003 and 2013. We reviewed the electronic medical records of those patients identified as having a prostate cancer. Patients were grouped according D’amico’s classification of cancer dissemination risk. We analized the frequency of imaging studies requested and their efficacy to detect metastases in each risk group. Results: We identified 241 patients with a mean age of 67 years. Fifty two percent of patients were classified as low-risk, 32% as intermediate-risk and 16% as high risk. At least one imaging study was requested to 64% of patients (49, 78 and 87% of patients with low, intermediate and high risk respectively). Among the 155 patients in whom an imaging study was requested, no metastases were found in the low risk group. On the other hand, dissemination was found in 7% of the intermediate-risk group and 62% of the high-risk group. Conclusions: Half of patients with prostate cancer were classified as low risk. In half of this group of low risk patients, staging studies were requested and the probability of detecting metastases was low or nil. The odds of detecting metastases increased in higher risk groups.

16.
Virulence ; 8(6): 782-796, 2017 08 18.
Artigo em Inglês | MEDLINE | ID: mdl-27652671

RESUMO

During long-term lung infection in cystic fibrosis (CF) patients, Burkholderia cenocepacia faces multiple selective pressures in this highly stressful and fluctuating environment. As a consequence, the initial infecting strain undergoes genetic changes that result in the diversification of genotypes and phenotypes. Whether this clonal expansion influences the pathogenic potential is unclear. The virulence potential of 39 sequential B. cenocepacia (recA lineage IIIA) isolates, corresponding to 3 different clones retrieved from 3 chronically infected CF patients was compared in this study using the non-mammalian infection hosts Galleria mellonella and Caenorhabditis elegans. The isolates used in this retrospective study were picked randomly from selective agar plates as part of a CF Center routine, from the onset of infection until patients' death after 3.5 and 7.5 y or the more recent isolation date after 12.5 y of chronic infection. The infection models proved useful to assess virulence potential diversification, but for some isolates the relative values diverged in C. elegans and G. mellonella. Results also reinforce the concept of the occurrence of clonal diversification and co-existence of multiple phenotypes within the CF lungs, also with respect to pathogenicity. No clear trend of decrease (or increase) of the virulence potential throughout long-term infection was found but there is an apparent tendency for a clone/patient-dependent decrease of virulence when the G. mellonella model was used. The sole avirulent variant in both infection hosts was found to lack the small third replicon previously associated to virulence. Although possible, the in vivo loss of this nonessential megaplasmid was found to be a rare event (1 among a total of 64 isolates examined).


Assuntos
Infecções por Burkholderia/microbiologia , Burkholderia cenocepacia/patogenicidade , Fibrose Cística/microbiologia , Pulmão/microbiologia , Animais , Infecções por Burkholderia/complicações , Burkholderia cenocepacia/genética , Caenorhabditis elegans/microbiologia , Doença Crônica , Fibrose Cística/complicações , Modelos Animais de Doenças , Genótipo , Humanos , Mariposas/microbiologia , Fenótipo , Infecções Respiratórias/complicações , Infecções Respiratórias/microbiologia , Estudos Retrospectivos , Virulência
17.
EMBO J ; 36(3): 346-360, 2017 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-27993935

RESUMO

Cell activation is a vital step for T-cell memory/effector differentiation as well as for productive HIV infection. To identify novel regulators of this process, we used next-generation sequencing to profile changes in microRNA expression occurring in purified human naive CD4 T cells in response to TCR stimulation and/or HIV infection. Our results demonstrate, for the first time, the transcriptional up-regulation of miR-34c-5p in response to TCR stimulation in naive CD4 T cells. The induction of this miR was further consistently found to be reduced by both HIV-1 and HIV-2 infections. Overexpression of miR-34c-5p led to changes in the expression of several genes involved in TCR signaling and cell activation, confirming its role as a novel regulator of naive CD4 T-cell activation. We additionally show that miR-34c-5p promotes HIV-1 replication, suggesting that its down-regulation during HIV infection may be part of an anti-viral host response.


Assuntos
Linfócitos T CD4-Positivos/imunologia , HIV/fisiologia , Interações Hospedeiro-Patógeno , Ativação Linfocitária , MicroRNAs/análise , Receptores de Antígenos de Linfócitos T/metabolismo , Replicação Viral , Linfócitos T CD4-Positivos/virologia , Perfilação da Expressão Gênica , HIV/imunologia , Humanos , Evasão da Resposta Imune
18.
Rev. chil. urol ; 82(2): 6-7, 2017.
Artigo em Espanhol | LILACS | ID: biblio-905945

RESUMO

INTRODUCCIÓN: El constante avance de la tecnología y el desarrollo de las técnicas mínimamente invasivas en cirugía robótica han dado mayores opciones de tratamiento quirúrgico a pacientes con Cáncer de Próstata. Debido a la complejidad anatómica y reducido espacio de la pelvis la cirugía robótica facilita realizar la prostatectomía . La superioridad técnica del sistema con robot en cuanto a visión, libertad de movimiento y precisión, permite una cirugía más segura además de mejorar resultados quirúrgicos, oncológicos y funcionales. El objetivo del presente video es demostrar la técnica utilizada en nuestro centro para prostatectomía radical robótica y mostrar una sistematización que simplifica el procedimiento. DESARROLLO: Se exponen las características del instrumento Madajet, así como su carga y armado. Se realiza el aislamiento y superficialización del conducto deferente derecho mediante técnica de tres dedos, en la cual el cirujano coloca sus dedos índice y medio en la cara posterior del escroto, fijando el deferente con el dedo pulgar en la cara anterior de la pared escrotal. Una vez aislado el deferente se realiza la anestesia local mediante del disparo del dispositivo sobre la pared anterior del escroto, repitiendo el proceso sobre el deferente izquierdo. Se realiza vasectomía sin bisturí mediante aislamiento del deferente en el rafe medio escrotal con clamp de anillo Li Brand®, con posterior punción y divulsión de la piel con pinza aguzada Li Brand® . Se efectúa la exteriorización del conducto deferente y posterior separación de éste de los vasos deferenciales, finalizando con la oclusión y sección del deferente. CONCLUSIONES: La vasectomía con técnica sin bisturí ­ sin aguja con dispositivo Madajet es una cirugía sencilla y reproducible que simplifica y disminuye los costos del procedimiento, lo que podría producir una mayor masificación de la vasectomía como método de control de fertilidad.(AU)


Assuntos
Masculino , Prostatectomia , Filme e Vídeo Educativo , Procedimentos Cirúrgicos Robóticos
19.
Oncotarget ; 7(4): 3993-4008, 2016 Jan 26.
Artigo em Inglês | MEDLINE | ID: mdl-26675257

RESUMO

The different prostate cancer (PCa) cell populations (bulk and cancer stem cells, CSCs) release exosomes that contain miRNAs that could modify the local or premetastatic niche. The analysis of the differential expression of miRNAs in exosomes allows evaluating the differential biological effect of both populations on the niche, and the identification of potential biomarkers and therapeutic targets. Five PCa primary cell cultures were established to originate bulk and CSCs cultures. From them, exosomes were purified by precipitation for miRNAs extraction to perform a comparative profile of miRNAs by next generation sequencing in an Illumina platform. 1839 miRNAs were identified in the exosomes. Of these 990 were known miRNAs, from which only 19 were significantly differentially expressed: 6 were overexpressed in CSCs and 13 in bulk cells exosomes. miR-100-5p and miR-21-5p were the most abundant miRNAs. Bioinformatics analysis indicated that differentially expressed miRNAs are highly related with PCa carcinogenesis, fibroblast proliferation, differentiation and migration, and angiogenesis. Besides, miRNAs from bulk cells affects osteoblast differentiation. Later, their effect was evaluated in normal prostate fibroblasts (WPMY-1) where transfection with miR-100-5p, miR-21-5p and miR-139-5p increased the expression of metalloproteinases (MMPs) -2, -9 and -13 and RANKL and fibroblast migration. The higher effect was achieved with miR21 transfection. As conclusion, miRNAs have a differential pattern between PCa bulk and CSCs exosomes that act collaboratively in PCa progression and metastasis. The most abundant miRNAs in PCa exosomes are interesting potential biomarkers and therapeutic targets.


Assuntos
Biomarcadores Tumorais/genética , Exossomos/genética , Fibroblastos/metabolismo , MicroRNAs/genética , Células-Tronco Neoplásicas/metabolismo , Próstata/metabolismo , Neoplasias da Próstata/genética , Apoptose , Biomarcadores Tumorais/metabolismo , Western Blotting , Movimento Celular , Proliferação de Células , Biologia Computacional , Progressão da Doença , Fibroblastos/patologia , Regulação Neoplásica da Expressão Gênica , Sequenciamento de Nucleotídeos em Larga Escala , Humanos , Masculino , Células-Tronco Neoplásicas/patologia , Próstata/patologia , Neoplasias da Próstata/metabolismo , Neoplasias da Próstata/secundário , RNA Mensageiro/genética , Reação em Cadeia da Polimerase em Tempo Real , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Células Tumorais Cultivadas
20.
Rev. chil. urol ; 81(1): 7-8, 2016.
Artigo em Espanhol | LILACS | ID: biblio-906279

RESUMO

La estenosis pieloureteral (EPU) puede predisponer al desarrollo de nefrolitiasis debido a estasis urinaria. Inicialmente la endopielotomía percutánea fue la alternativa mínimamente invasiva de elección frente a la cirugía abierta para la resolución de los casos de EPU con nefrolitiasis concomitante. Sin embargo, el bajo éxito de la endopielotomía percutánea ha favorecido el uso de la laparoscopía convencional o asistida por robot para el tratamiento de las EPU. Se han reportado casos de pieloplastías laparoscópicas en los cuales se ha introducido un nefroscopio flexible a través de un trócar para resolver la nefrolitiasis por vía transpiélica. Acá reportamos nuestra experiencia en un caso.(AU)


The pelvi-ureter stenosis may predispose to the development of nephrolithiasis due to urinary stasis. Initially, a percutaneous endopyelotomy was minimally invasive alternative of choice versus open surgery for resolving cases of EPU with concomitant nephrolithiasis. However, the low success of percutaneous endopyelotomy has favored the use of conventional laparoscopy or robot-assisted treatment of the pelvi-ureter stenosis. There have been reports of laparoscopic pyeloplasty in which a flexible nephroscope is inserted through a trocar to solve nephrolithiasis by a transpielic via. Here we report our experience in one case.(AU)


Assuntos
Feminino , Nefrolitíase , Laparoscopia , Constrição Patológica , Filme e Vídeo Educativo
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