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1.
CMAJ ; 192(49): E1715-E1722, 2020 Dec 07.
Artigo em Inglês | MEDLINE | ID: mdl-33288505

RESUMO

BACKGROUND: Postoperative atrial fibrillation (POAF) is associated with clinically significant short- and long-term complications after noncardiac surgery. Our aim was to describe the incidence of clinically important POAF after noncardiac surgery and establish the prognostic value of N-terminal pro-brain-type natriuretic peptide (NT-proBNP) in this context. METHODS: The Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Study was a prospective cohort study involving patients aged 45 years and older who had inpatient noncardiac surgery that was performed between August 2007 and November 2013. We determined 30-day incidence of clinically important POAF (i.e., resulting in angina, congestive heart failure, symptomatic hypotension or requiring treatment) using logistic regression models to analyze the association between preoperative NT-proBNP and POAF. RESULTS: In 37 664 patients with no history of atrial fibrillation, we found that the incidence of POAF was 1.0% (95% confidence interval [CI] 0.9%-1.1%; 369 events); 3.2% (95% CI 2.3%-4.4%) in patients undergoing major thoracic surgery, 1.3% (95% CI 1.2%-1.5%) in patients undergoing major nonthoracic surgery and 0.2% (95% CI 0.1%-0.3%) in patients undergoing low-risk surgery. In a subgroup of 9789 patients with preoperative NT-proBNP measurements, the biomarker improved the prediction of POAF risk over conventional prognostic factors (likelihood ratio test p < 0.001; fraction of new information from NT-proBNP was 16%). Compared with a reference NT-proBNP measurement set at 100 ng/L, adjusted odds ratios for the occurrence of POAF were 1.31 (95% CI 1.15-1.49) at 200 ng/L, 2.07 (95% CI 1.27-3.36) at 1500 ng/L and 2.39 (95% CI 1.26-4.51) at 3000 ng/L. INTERPRETATION: We determined that the incidence of clinically important POAF after noncardiac surgery was 1.0%. We also found that preoperative NT-proBNP levels were associated with POAF independent of established prognostic factors. Trial registration: ClinicalTrials.gov, no. NCT00512109.

2.
Eur Respir J ; 2020 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-32883680

RESUMO

RATIONALE: Oxidised phosphatidylcholines (OxPC) are produced under conditions of elevated oxidative stress and can contribute to human disease pathobiology. However, their role in allergic asthma is unexplored. OBJECTIVES: Characterise the OxPC profile in the airways after allergen challenge of people with airway hyperresponsiveness (AHR) or mild-asthma. Determine the capacity of OxPC to contribute to pathobiology associated with asthma. METHODS: Using bronchoalveolar lavage (BAL) from two human cohorts, OxPC species were quantified using ultra high performance liquid chromatography tandem mass spectrometry. Murine thin cut lung slices (TCLS) were used to measure airway narrowing caused by OxPCs. Human airway smooth muscle (HASM) cells were exposed to OxPCs to assess concentration-associated changes in inflammatory phenotype and activation of signalling networks. MEASUREMENTS AND MAIN RESULTS: OxPC profiles were different in the airways of people with or without AHR and correlated with methacholine responsiveness. Exposure of mild-asthmatics to allergens produced unique OxPC signatures that were associated with the late asthma response severity. OxPCs dose-dependently induced 15% airway narrowing in murine TCLS. In HASM, OxPCs dose-dependently increased the biosynthesis of cyclooxygenase-2, IL-6, IL-8, GM-CSF, and the production of oxylipins via protein kinase C-dependent pathways. CONCLUSIONS: Data from human cohorts and primary HASM culture we show that OxPCs are present in the airways, increase after allergen challenge, and correlate with metrics of a dysfunction. Furthermore, OxPCs may contribute to asthma pathobiology by promoting airway narrowing and inducing a pro-inflammatory phenotype and contraction of airway smooth muscle. OxPCs represent a potential novel target for treating oxidative stress-associated pathobiology in asthma.

3.
Pilot Feasibility Stud ; 6: 104, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32699643

RESUMO

Background: Surgical bleeding is associated with postoperative cardiovascular complications. The efficacy and safety of tranexamic acid (TXA) in noncardiac surgery are still uncertain. Statins may prevent perioperative cardiovascular complications. We conducted a pilot to assess the feasibility of a perioperative trial of TXA and rosuvastatin. Methods: Using a factorial design, we randomized patients at cardiovascular risk undergoing noncardiac surgery to intravenous TXA (1 g at the start and end of surgery) or placebo, and oral rosuvastatin (40 mg before and 20 mg daily for 30 days after surgery) or placebo. Feasibility outcomes included recruitment rates, follow-up, and compliance to interventions. Clinical outcomes were secondarily explored. Results: After 3 months, we changed the design to a partial factorial due to the difficult recruitment of statin-naive patients. Over 6 months, 100 patients were randomized in the TXA trial (49 TXA, 51 placebo), 34 in the rosuvastatin trial (18 rosuvastatin, 16 placebo). Ninety-two percent (95% CI 80-98) of TXA and 86% (95% CI 74-94) of TXA-placebo patients received the 2 study doses. Thirty-three percent (95% CI 13-59) of rosuvastatin patients and 37% (95% CI 15-65) of rosuvastatin-placebo patients discontinued the study drug. A major cardiovascular complication occurred at 30 days in 1 TXA and 6 TXA-placebo patients, and 1 rosuvastatin and no rosuvastatin-placebo patients. Conclusions: Our pilot study supports the feasibility of a perioperative TXA trial in noncardiac surgery. Feasibility of a perioperative rosuvastatin trial is uncertain because of a high prevalence of statin use in the target population and concerns about compliance. Trial registration: ClinicalTrials.govNCT02546648.

4.
J Thorac Cardiovasc Surg ; 160(4): 1112-1122.e3, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32276803

RESUMO

BACKGROUND: It is unclear how positive end-expiratory pressure (PEEP) and recruitment maneuvers impact patients during one-lung ventilation (OLV). We conducted a systematic review and meta-analysis of the effect of lung recruitment and PEEP on ventilation and oxygenation during OLV. METHODS: A systematic review and random-effects meta-analysis were performed. Mean difference with standard deviation was calculated. Included studies were evaluated for quality and risk of bias using the Cochrane Risk of Bias tool and the modified Newcastle-Ottawa Score where appropriate. RESULTS: In total, 926 articles were identified, of which 16 were included in meta-analysis. Recruitment maneuvers increased arterial oxygen tension (PaO2) by 82 mm Hg [20, 144 mm Hg] and reduced dead-space by 5.9% [3.8, 8.0%]. PEEP increased PaO2 by 30.3 mm Hg [11.9, 48.6 mm Hg]. Subgroup analysis showed a significant increase in PaO2 (P = .0003; +35.4 mm Hg [16.2, 54.5 mm Hg]) with PEEP compared with no PEEP but no such difference in comparisons with PEEP-treated controls. No significant difference in PaO2 was observed between "high" and "low" PEEP-treated subgroups (P = .29). No significant improvement in PaO2 was observed for subgroups coadministered PEEP, lung recruitment, and low tidal volumes. PEEP was associated with a modest but statistically significant increase in compliance (P = .03; 4.33 mL/cmH2O [0.33, 8.32]). High risk of bias was identified in the majority of studies. Considerable heterogeneity was observed. CONCLUSIONS: Recruitment maneuvers and PEEP have physiologic advantages during OLV. The optimal use of PEEP is yet to be determined. The evidence is limited by heavy use of surrogate outcomes. Future studies with clinical outcomes are necessary to determine the impact of recruitment maneuvers and PEEP during OLV.


Assuntos
Pulmão/fisiopatologia , Ventilação Monopulmonar , Respiração com Pressão Positiva , Procedimentos Cirúrgicos Torácicos , Lesão Pulmonar Induzida por Ventilação Mecânica/prevenção & controle , Humanos , Ventilação Monopulmonar/efeitos adversos , Respiração com Pressão Positiva/efeitos adversos , Fatores de Risco , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Resultado do Tratamento , Lesão Pulmonar Induzida por Ventilação Mecânica/etiologia
5.
J Bone Joint Surg Am ; 102(10): 880-888, 2020 May 20.
Artigo em Inglês | MEDLINE | ID: mdl-32118652

RESUMO

BACKGROUND: Myocardial injury after noncardiac surgery (MINS) is common and of prognostic importance. Little is known about MINS in orthopaedic surgery. The diagnostic criterion for MINS was a level of ≥0.03 ng/mL on a non-high-sensitivity troponin T (TnT) assay due to myocardial ischemia. METHODS: We undertook an international, prospective study of 15,103 patients ≥45 years of age who had inpatient noncardiac surgery; 3,092 underwent orthopaedic surgery. Non-high-sensitivity TnT assays were performed on postoperative days 0, 1, 2, and 3. Among orthopaedic patients, we determined (1) the prognostic relevance of the MINS diagnostic criteria, (2) the 30-day mortality rate for those with and without MINS, and (3) the probable proportion of MINS cases that would go undetected without troponin monitoring because of a lack of an ischemic symptom. RESULTS: Three hundred and sixty-seven orthopaedic patients (11.9%) had MINS. MINS was associated independently with 30-day mortality including among those who had had orthopaedic surgery. Orthopaedic patients without and with MINS had a 30-day mortality rate of 1.0% and 9.8%, respectively (odds ratio [OR], 11.28; 95% confidence interval [CI], 6.72 to 18.92). The 30-day mortality rate was increased for patients with MINS who had an ischemic feature (i.e., symptoms, or evidence of ischemia on electrocardiography or imaging) (OR, 18.25; 95% CI, 10.06 to 33.10) and for those who did not have an ischemic feature (OR, 7.35; 95% CI, 3.37 to 16.01). The proportion of orthopaedic patients with MINS who were asymptomatic and in whom the myocardial injury would have probably gone undetected without TnT monitoring was 81.3% (95% CI, 76.3% to 85.4%). CONCLUSIONS: One in 8 orthopaedic patients in our study had MINS, and MINS was associated with a higher mortality rate regardless of symptoms. Troponin levels should be measured after surgery in at-risk patients because most MINS cases (>80%) are asymptomatic and would go undetected without routine measurements. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

6.
Anesthesiology ; 132(4): 692-701, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32022771

RESUMO

BACKGROUND: The authors previously reported that perioperative aspirin and/or clonidine does not prevent a composite of death or myocardial infarction 30 days after noncardiac surgery. Moreover, aspirin increased the risk of major bleeding and clonidine caused hypotension and bradycardia. Whether these complications produce harm at 1 yr remains unknown. METHODS: The authors randomized 10,010 patients with or at risk of atherosclerosis and scheduled for noncardiac surgery in a 1:1:1:1 ratio to clonidine/aspirin, clonidine/aspirin placebo, clonidine placebo/aspirin, or clonidine placebo/aspirin placebo. Patients started taking aspirin or placebo just before surgery; those not previously taking aspirin continued daily for 30 days, and those taking aspirin previously continued for 7 days. Patients were also randomly assigned to receive clonidine or placebo just before surgery, with the study drug continued for 72 h. RESULTS: Neither aspirin nor clonidine had a significant effect on the primary 1-yr outcome, a composite of death or nonfatal myocardial infarction, with a 1-yr hazard ratio for aspirin of 1.00 (95% CI, 0.89 to 1.12; P = 0.948; 586 patients [11.8%] vs. 589 patients [11.8%]) and a hazard ratio for clonidine of 1.07 (95% CI, 0.96 to 1.20; P = 0.218; 608 patients [12.1%] vs. 567 patients [11.3%]), with effect on death or nonfatal infarction. Reduction in death and nonfatal myocardial infarction from aspirin in patients who previously had percutaneous coronary intervention at 30 days persisted at 1 yr. Specifically, the hazard ratio was 0.58 (95% CI, 0.35 to 0.95) in those with previous percutaneous coronary intervention and 1.03 (95% CI, 0.91to 1.16) in those without (interaction P = 0.033). There was no significant effect of either drug on death, cardiovascular complications, cancer, or chronic incisional pain at 1 yr (all P > 0.1). CONCLUSIONS: Neither perioperative aspirin nor clonidine have significant long-term effects after noncardiac surgery. Perioperative aspirin in patients with previous percutaneous coronary intervention showed persistent benefit at 1 yr, a plausible sub-group effect.


Assuntos
Analgésicos/administração & dosagem , Anti-Inflamatórios não Esteroides/administração & dosagem , Aspirina/administração & dosagem , Clonidina/administração & dosagem , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/diagnóstico , Idoso , Analgésicos/efeitos adversos , Anti-Inflamatórios não Esteroides/efeitos adversos , Aspirina/efeitos adversos , Clonidina/efeitos adversos , Feminino , Seguimentos , Humanos , Internacionalidade , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/prevenção & controle , Assistência Perioperatória/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Fatores de Tempo
7.
Ann Thorac Surg ; 109(5): e339-e341, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31604094

RESUMO

Herpes simplex virus is an uncommon cause of esophagitis and particularly so in immunocompetent individuals. Although the common presentation tends to be odynophagia and/or dysphagia, fever, and retrosternal chest pain, there are variations and rarely it can present more ominously as esophageal rupture. We report a rare case of esophageal perforation with penetration into the vertebral space secondary to chronic herpes simplex virus esophagitis in a 71-year-old immunocompetent woman. This is the second known such occurrence. The patient had a long stay in the hospital but recovered from the condition and was followed up for 1 year after initial presentation.


Assuntos
Perfuração Esofágica/etiologia , Perfuração Esofágica/cirurgia , Esofagite/complicações , Esofagite/cirurgia , Herpes Simples/complicações , Herpes Simples/cirurgia , Idoso , Fístula Brônquica/diagnóstico por imagem , Fístula Brônquica/etiologia , Fístula Brônquica/cirurgia , Doença Crônica , Endoscopia do Sistema Digestório , Fístula Esofágica/diagnóstico por imagem , Fístula Esofágica/etiologia , Fístula Esofágica/cirurgia , Perfuração Esofágica/diagnóstico por imagem , Esofagite/diagnóstico por imagem , Extravasamento de Materiais Terapêuticos e Diagnósticos/diagnóstico por imagem , Extravasamento de Materiais Terapêuticos e Diagnósticos/etiologia , Extravasamento de Materiais Terapêuticos e Diagnósticos/cirurgia , Feminino , Seguimentos , Herpes Simples/diagnóstico por imagem , Humanos , Tempo de Internação , Stents , Vértebras Torácicas/diagnóstico por imagem , Tomografia Computadorizada por Raios X
9.
Anesthesiology ; 132(1): 121-130, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31651439

RESUMO

BACKGROUND: Low 25-hydroxyvitamin D is associated with cardiovascular, renal, and infectious risks. Postsurgical patients are susceptible to similar complications, but whether vitamin D deficiency contributes to postoperative complications remains unclear. We tested whether low preoperative vitamin D is associated with cardiovascular events within 30 days after noncardiac surgery. METHODS: We evaluated a subset of patients enrolled in the biobank substudy of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) study, who were at least 45 yr with at least an overnight hospitalization. Blood was collected preoperatively, and 25-hydroxyvitamin D was measured in stored samples. The primary outcome was the composite of cardiovascular events (death, myocardial injury, nonfatal cardiac arrest, stroke, congestive heart failure) within 30 postoperative days. Secondary outcomes were kidney injury and infectious complications. RESULTS: A total of 3,851 participants were eligible for analysis. Preoperative 25-hydroxyvitamin D concentration was 70 ± 30 nmol/l, and 62% of patients were vitamin D deficient. Overall, 26 (0.7%) patients died, 41 (1.1%) had congestive heart failure or nonfatal cardiac arrest, 540 (14%) had myocardial injury, and 15 (0.4%) had strokes. Preoperative vitamin D concentration was not associated with the primary outcome (average relative effect odds ratio [95% CI]: 0.93 [0.85, 1.01] per 10 nmol/l increase in preoperative vitamin D, P = 0.095). However, it was associated with postoperative infection (average relative effect odds ratio [95% CI]: 0.94 [0.90, 0.98] per 10 nmol/l increase in preoperative vitamin D, P adjusted value = 0.005) and kidney function (estimated mean change in postoperative estimated glomerular filtration rate [95% CI]: 0.29 [0.11, 0.48] ml min 1.73 m per 10 nmol/l increase in preoperative vitamin D, P adjusted value = 0.004). CONCLUSIONS: Preoperative vitamin D was not associated with a composite of postoperative 30-day cardiac outcomes. However, there was a significant association between vitamin D deficiency and a composite of infectious complications and decreased kidney function. While renal effects were not clinically meaningful, the effect of vitamin D supplementation on infectious complications requires further study.


Assuntos
Doenças Transmissíveis/epidemiologia , Cardiopatias/epidemiologia , Nefropatias/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Período Pré-Operatório , Deficiência de Vitamina D/sangue , Deficiência de Vitamina D/epidemiologia , Idoso , Doenças Transmissíveis/sangue , Comorbidade , Feminino , Cardiopatias/sangue , Humanos , Nefropatias/sangue , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/sangue , Vitamina D/análogos & derivados , Vitamina D/sangue
10.
Ann Intern Med ; 172(2): 96-104, 2020 01 21.
Artigo em Inglês | MEDLINE | ID: mdl-31869834

RESUMO

Background: Preliminary data suggest that preoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP) may improve risk prediction in patients undergoing noncardiac surgery. Objective: To determine whether preoperative NT-proBNP has additional predictive value beyond a clinical risk score for the composite of vascular death and myocardial injury after noncardiac surgery (MINS) within 30 days after surgery. Design: Prospective cohort study. Setting: 16 hospitals in 9 countries. Patients: 10 402 patients aged 45 years or older having inpatient noncardiac surgery. Measurements: All patients had NT-proBNP levels measured before surgery and troponin T levels measured daily for up to 3 days after surgery. Results: In multivariable analyses, compared with preoperative NT-proBNP values less than 100 pg/mL (the reference group), those of 100 to less than 200 pg/mL, 200 to less than 1500 pg/mL, and 1500 pg/mL or greater were associated with adjusted hazard ratios of 2.27 (95% CI, 1.90 to 2.70), 3.63 (CI, 3.13 to 4.21), and 5.82 (CI, 4.81 to 7.05) and corresponding incidences of the primary outcome of 12.3% (226 of 1843), 20.8% (542 of 2608), and 37.5% (223 of 595), respectively. Adding NT-proBNP thresholds to clinical stratification (that is, the Revised Cardiac Risk Index [RCRI]) resulted in a net absolute reclassification improvement of 258 per 1000 patients. Preoperative NT-proBNP values were also statistically significantly associated with 30-day all-cause mortality (less than 100 pg/mL [incidence, 0.3%], 100 to less than 200 pg/mL [incidence, 0.7%], 200 to less than 1500 pg/mL [incidence, 1.4%], and 1500 pg/mL or greater [incidence, 4.0%]). Limitation: External validation of the identified NT-proBNP thresholds in other cohorts would reinforce our findings. Conclusion: Preoperative NT-proBNP is strongly associated with vascular death and MINS within 30 days after noncardiac surgery and improves cardiac risk prediction in addition to the RCRI. Primary Funding Source: Canadian Institutes of Health Research.


Assuntos
Biomarcadores/sangue , Doenças Cardiovasculares/sangue , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Complicações Pós-Operatórias/sangue , Procedimentos Cirúrgicos Operatórios , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Período Pré-Operatório , Estudos Prospectivos , Troponina T/sangue
11.
Eur Heart J ; 41(5): 645-651, 2020 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-31237939

RESUMO

AIMS: To determine the 1-year risk of stroke and other adverse outcomes in patients with a new diagnosis of perioperative atrial fibrillation (POAF) after non-cardiac surgery. METHODS AND RESULTS: The PeriOperative ISchemic Evaluation (POISE)-1 trial evaluated the effects of metoprolol vs. placebo in 8351 patients, and POISE-2 compared the effect of aspirin vs. placebo, and clonidine vs. placebo in 10 010 patients. These trials included patients with, or at risk of, cardiovascular disease who were undergoing non-cardiac surgery. For the purpose of this study, we combined the POISE datasets, excluding 244 patients who were in atrial fibrillation (AF) at the time of randomization. Perioperative atrial fibrillation was defined as new AF that occurred within 30 days after surgery. Our primary outcome was the incidence of stroke at 1 year of follow-up; secondary outcomes were mortality and myocardial infarction (MI). We compared outcomes among patients with and without POAF using multivariable adjusted Cox proportional hazards models. Among 18 117 patients (mean age 69 years, 57.4% male), 404 had POAF (2.2%). The stroke incidence 1 year after surgery was 5.58 vs. 1.54 per 100 patient-years in patients with and without POAF, adjusted hazard ratio (aHR) 3.43, 95% confidence interval (CI) 2.00-5.90; P < 0.001. Patients with POAF also had an increased risk of death (incidence 31.37 vs. 9.34; aHR 2.51, 95% CI 2.01-3.14; P < 0.001) and MI (incidence 26.20 vs. 8.23; aHR 5.10, 95% CI 3.91-6.64; P < 0.001). CONCLUSION: Patients with POAF have a significantly increased risk of stroke, MI, and death at 1 year. Intervention studies are needed to evaluate risk reduction strategies in this high-risk population.

12.
Artigo em Inglês | MEDLINE | ID: mdl-33518385

RESUMO

BACKGROUND: The selection of tidal volumes for 1-lung ventilation remains unclear, because there exists a trade-off between oxygenation and risk of lung injury. We conducted a systematic review and meta-analysis to determine how oxygenation, compliance, and clinical outcomes are affected by tidal volume during 1-lung ventilation. METHODS: A systematic search of MEDLINE and EMBASE was performed. A systematic review and random-effects meta-analysis was conducted. Pooled mean difference estimated arterial oxygen tension, compliance, and length of stay; pooled odds ratio was calculated for composite postoperative pulmonary complications. Risk of bias was determined using the Cochrane risk of bias and Newcastle-Ottawa tools. RESULTS: Eighteen studies were identified, comprising 3693 total patients. Low tidal volumes (5.6 [±0.9] mL/kg) were not associated with significant differences in partial pressure of oxygen (-15.64 [-88.53-57.26] mm Hg; P = .67), arterial oxygen tension to fractional intake of oxygen ratio (14.71 [-7.83-37.24]; P = .20), or compliance (2.03 [-5.22-9.27] mL/cmH2O; P = .58) versus conventional tidal volume ventilation (8.1 [±3.1] mL/kg). Low versus conventional tidal volume ventilation had no significant impact on hospital length of stay (-0.42 [-1.60-0.77] days; P = .49). Low tidal volumes are associated with significantly decreased odds of pulmonary complications (pooled odds ratio, 0.40 [0.29-0.57]; P < .0001). CONCLUSIONS: Low tidal volumes during 1-lung ventilation do not worsen oxygenation or compliance. A low tidal volume ventilation strategy during 1-lung ventilation was associated with a significant reduction in postoperative pulmonary complications.

13.
Contemp Clin Trials Commun ; 16: 100445, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31650068

RESUMO

Background: Lung cancer is a major cause of global morbidity and mortality. Current low dose CT screening is invasive and its role remains contentious. There are no known biomarkers to monitor treatment response, detect disease recurrence and patient selection for adjuvant treatment after curative surgical resection. Hence there is an urgent need to explore non-conventional and non-invasive tools to develop novel biomarkers to improve the outcome of this lethal cancer. Methods: This is an ongoing exploratory and translational study involving collection of bio fluids from 50 patients with early stage non-small cell lung cancer before and after surgical resection. The primary objective is to identify cancer specific metabolome in body fluids - sputum, exhaled breath condensate, blood and urine of the patients with early stage non-small cell lung cancer using Magnetic Resonance Spectroscopy and Mass Spectroscopy. Conclusion: The trajectory of change in metabolic profile of body fluids before and after surgical resection may have potential clinical applications in lung cancer screening, as biomarkers for disease recurrence and exploration of novel targets for therapeutic intervention.

14.
CMAJ ; 191(30): E830-E837, 2019 07 29.
Artigo em Inglês | MEDLINE | ID: mdl-31358597

RESUMO

BACKGROUND: Among adults undergoing contemporary noncardiac surgery, little is known about the frequency and timing of death and the associations between perioperative complications and mortality. We aimed to establish the frequency and timing of death and its association with perioperative complications. METHODS: We conducted a prospective cohort study of patients aged 45 years and older who underwent inpatient noncardiac surgery at 28 centres in 14 countries. We monitored patients for complications until 30 days after surgery and determined the relation between these complications and 30-day mortality using a Cox proportional hazards model. RESULTS: We included 40 004 patients. Of those, 715 patients (1.8%) died within 30 days of surgery. Five deaths (0.7%) occurred in the operating room, 500 deaths (69.9%) occurred after surgery during the index admission to hospital and 210 deaths (29.4%) occurred after discharge from the hospital. Eight complications were independently associated with 30-day mortality. The 3 complications with the largest attributable fractions (AF; i.e., potential proportion of deaths attributable to these complications) were major bleeding (6238 patients, 15.6%; adjusted hazard ratio [HR] 2.6, 95% confidence interval [CI] 2.2-3.1; AF 17.0%); myocardial injury after noncardiac surgery [MINS] (5191 patients, 13.0%; adjusted HR 2.2, 95% CI 1.9-2.6; AF 15.9%); and sepsis (1783 patients, 4.5%; adjusted HR 5.6, 95% CI 4.6-6.8; AF 12.0%). INTERPRETATION: Among adults undergoing noncardiac surgery, 99.3% of deaths occurred after the procedure and 44.9% of deaths were associated with 3 complications: major bleeding, MINS and sepsis. Given these findings, focusing on the prevention, early identification and management of these 3 complications holds promise for reducing perioperative mortality. Study registration: ClinicalTrials.gov, no. NCT00512109.


Assuntos
Complicações Pós-Operatórias/mortalidade , Procedimentos Cirúrgicos Operatórios/mortalidade , Idoso , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/mortalidade , Estudos Prospectivos , Sepse/mortalidade
15.
J Thorac Dis ; 11(12): 5664-5665, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32030295
16.
Lancet ; 391(10137): 2325-2334, 2018 06 09.
Artigo em Inglês | MEDLINE | ID: mdl-29900874

RESUMO

BACKGROUND: Myocardial injury after non-cardiac surgery (MINS) increases the risk of cardiovascular events and deaths, which anticoagulation therapy could prevent. Dabigatran prevents perioperative venous thromboembolism, but whether this drug can prevent a broader range of vascular complications in patients with MINS is unknown. The MANAGE trial assessed the potential of dabigatran to prevent major vascular complications among such patients. METHODS: In this international, randomised, placebo-controlled trial, we recruited patients from 84 hospitals in 19 countries. Eligible patients were aged at least 45 years, had undergone non-cardiac surgery, and were within 35 days of MINS. Patients were randomly assigned (1:1) to receive dabigatran 110 mg orally twice daily or matched placebo for a maximum of 2 years or until termination of the trial and, using a partial 2-by-2 factorial design, patients not taking a proton-pump inhibitor were also randomly assigned (1:1) to omeprazole 20 mg once daily, for which results will be reported elsewhere, or matched placebo to measure its effect on major upper gastrointestinal complications. Research personnel randomised patients through a central 24 h computerised randomisation system using block randomisation, stratified by centre. Patients, health-care providers, data collectors, and outcome adjudicators were masked to treatment allocation. The primary efficacy outcome was the occurrence of a major vascular complication, a composite of vascular mortality and non-fatal myocardial infarction, non-haemorrhagic stroke, peripheral arterial thrombosis, amputation, and symptomatic venous thromboembolism. The primary safety outcome was a composite of life-threatening, major, and critical organ bleeding. Analyses were done according to the intention-to-treat principle. This trial is registered with ClinicalTrials.gov, number NCT01661101. FINDINGS: Between Jan 10, 2013, and July 17, 2017, we randomly assigned 1754 patients to receive dabigatran (n=877) or placebo (n=877); 556 patients were also randomised in the omeprazole partial factorial component. Study drug was permanently discontinued in 401 (46%) of 877 patients allocated to dabigatran and 380 (43%) of 877 patients allocated to placebo. The composite primary efficacy outcome occurred in fewer patients randomised to dabigatran than placebo (97 [11%] of 877 patients assigned to dabigatran vs 133 [15%] of 877 patients assigned to placebo; hazard ratio [HR] 0·72, 95% CI 0·55-0·93; p=0·0115). The primary safety composite outcome occurred in 29 patients (3%) randomised to dabigatran and 31 patients (4%) randomised to placebo (HR 0·92, 95% CI 0·55-1·53; p=0·76). INTERPRETATION: Among patients who had MINS, dabigatran 110 mg twice daily lowered the risk of major vascular complications, with no significant increase in major bleeding. Patients with MINS have a poor prognosis; dabigatran 110 mg twice daily has the potential to help many of the 8 million adults globally who have MINS to reduce their risk of a major vascular complication [corrected]. FUNDING: Boehringer Ingelheim and Canadian Institutes of Health Research.


Assuntos
Dabigatrana/farmacologia , Hemorragia/complicações , Infarto do Miocárdio/tratamento farmacológico , Doença Arterial Periférica/complicações , Acidente Vascular Cerebral/complicações , Tromboembolia Venosa/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Antitrombinas/farmacologia , Dabigatrana/administração & dosagem , Dabigatrana/efeitos adversos , Feminino , Hemorragia/tratamento farmacológico , Hemorragia/prevenção & controle , Humanos , Masculino , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/mortalidade , Omeprazol/administração & dosagem , Omeprazol/uso terapêutico , Período Perioperatório/mortalidade , Doença Arterial Periférica/tratamento farmacológico , Doença Arterial Periférica/prevenção & controle , Efeito Placebo , Inibidores da Bomba de Prótons/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/prevenção & controle , Trombose/patologia , Resultado do Tratamento , Troponina/efeitos dos fármacos , Troponina/metabolismo , Tromboembolia Venosa/prevenção & controle
17.
Can J Surg ; 61(3): 185-194, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29806816

RESUMO

BACKGROUND: Myocardial injury after noncardiac surgery (MINS) is a mostly asymptomatic condition that is strongly associated with 30-day mortality; however, it remains mostly undetected without systematic troponin T monitoring. We evaluated the cost and consequences of postoperative troponin T monitoring to detect MINS. METHODS: We conducted a model-based cost-consequence analysis to compare the impact of routine troponin T monitoring versus standard care (troponin T measurement triggered by ischemic symptoms) on the incidence of MINS detection. Model inputs were based on Canadian patients enrolled in the Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) study, which enrolled patients aged 45 years or older undergoing inpatient noncardiac surgery. We conducted probability analyses with 10 000 iterations and extensive sensitivity analyses. RESULTS: The data were based on 6021 patients (48% men, mean age 65 [standard deviation 12] yr). The 30-day mortality rate for MINS was 9.6%. We determined the incremental cost to avoid missing a MINS event as $1632 (2015 Canadian dollars). The cost-effectiveness of troponin monitoring was higher in patient subgroups at higher risk for MINS, e.g., those aged 65 years or more, or with a history of atherosclerosis or diabetes ($1309). CONCLUSION: The costs associated with a troponin T monitoring program to detect MINS were moderate. Based on the estimated incremental cost per health gain, implementation of postoperative troponin T monitoring seems appealing, particularly in patients at high risk for MINS.


Assuntos
Análise Custo-Benefício , Isquemia Miocárdica , Avaliação de Resultados em Cuidados de Saúde , Cuidados Pós-Operatórios , Complicações Pós-Operatórias , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Troponina T/sangue , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/sangue , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/economia , Isquemia Miocárdica/mortalidade , Avaliação de Resultados em Cuidados de Saúde/economia , Cuidados Pós-Operatórios/economia , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/normas , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/mortalidade , Risco
18.
Ann Transl Med ; 6(4): 84, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29666807

RESUMO

Esophagectomy is the mainstay of curative therapy for esophageal cancer; however, it is associated with significant morbidity and mortality, with subsequent major impact on quality of life. This paper reviews the evaluation of health-related quality of life (HRQOL) in esophageal cancer patients undergoing curative intent therapy, the relationship between postoperative HRQOL and survival as well the potential utility of pre-treatment HRQOL as a prognostic tool. HRQOL assessment is valuable in helping clinicians understand the impact on patients of esophageal cancer and the various treatments thereof. HRQOL is also valuable as an end-point in studies of esophageal cancer and esophageal cancer treatment. Given the morbidity and mortality associated with the various treatments for esophageal cancer, it could be argued that HRQOL is as important an endpoint as survival, if not more so. Patient-reported pre-treatment HRQOL assessment appears to predict survival better than clinician-derived performance status assessment period. HRQOL assessment also appears to be responsive to surgical and non-surgical therapy and thus could potentially be used in trials and in practice to serve that function. Thus, HRQOL assessment could be a potentially important adjunct in shared decision-making and guiding treatment planning as well as monitoring the progress of treatment.

19.
J Surg Oncol ; 117(5): 977-984, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29473958

RESUMO

BACKGROUND: Histologic confirmation of malignancy has been indicated for a suspicious lung nodule prior to resection. The purpose of this study was to determine whether or not foregoing routine tissue biopsy increased the incidence of lobectomy for benign lesions. METHODS: Retrospective cohort of 256 patients who underwent thoracoscopic or open lobectomy for a confirmed or suspected pulmonary malignancy, with or without tissue diagnosis. Clinical, radiographic, and pathologic data were compared. RESULTS: Among 256 patients, 127 had attempted biopsy (group A) and 129 had no biopsy procedure (group B). There was no significant difference in the incidence of benign resections between the groups (Group A = 4 (3.2%) benign pathology vs group B = 9 (7.0%; P = 0.16). Group B had significantly lower operative time (127.1 vs 112.3 minutes; P = 0.004) and intraoperative complications (23 vs 37 patients; P = 0.03). There was a trend toward longer hospital stay and surgical waiting time in group A (6.6 vs 5.2 days, P = 0.24; 92.4 vs 66.2 days; P = 0.14, respectively). CONCLUSION: Foregoing biopsies and proceeding to lobectomy in selected patients with suspicious lung nodules is safe, did not increase the incidence of resected benign pathology, and may decrease surgical wait time. Patients should be carefully evaluated and counseled.


Assuntos
Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/cirurgia , Seleção de Pacientes , Pneumonectomia , Nódulo Pulmonar Solitário/patologia , Nódulo Pulmonar Solitário/cirurgia , Idoso , Biópsia , Diagnóstico por Imagem/métodos , Feminino , Seguimentos , Custos de Cuidados de Saúde , Humanos , Neoplasias Pulmonares/diagnóstico por imagem , Masculino , Prognóstico , Estudos Retrospectivos , Nódulo Pulmonar Solitário/diagnóstico por imagem
20.
J Cardiothorac Vasc Anesth ; 32(4): 1750-1755, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29402627

RESUMO

OBJECTIVES: To determine the preferences and perceptions regarding analgesic options for video-assisted thoracic surgery (VATS) among thoracic anesthesiologists in Canada. DESIGN: A cross-sectional survey of thoracic anesthesiologists with 30 multiple choice questions was e-mailed through an online survey tool called FluidSurveys was performed to members of the Canadian Anesthesiologists' Society. SETTING: A nationwide survey. PARTICIPANTS: Members of Canadian Anesthesiologists' Society who provide thoracic anesthesia INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Participant characteristics and outcomes are described using counts and percentages. The frequency of use of each technique for each surgical category is described in percentages and 95% confidence intervals. Based on the responses obtained from individual centers, approximately 469 anesthesiologists provided thoracic care in Canada at the time of the survey. The response rate to the survey was 19% (n = 89). Epidural analgesia was preferred by 93.42% (95% CI 85-98) for open surgeries compared with 41% (30-52) for VATS lobectomies. The difference was statistically significant-52% (37-67). Patient-controlled analgesia was preferred by 27% (19-39) for VATS lobectomies and 46% (35-57) for VATS minor resections. Only 14% preferred paravertebral block for any VATS surgeries. CONCLUSIONS: The use of analgesic techniques for VATS surgeries is variable and largely dictated by provider preferences. The majority still prefer epidural analgesia compared with paravertebral catheter (placed either by the anesthesiologist or surgeon). A broadly acceptable choice that is effective, safe, and technically less demanding requires comparative effectiveness studies and more uniform training for physicians.


Assuntos
Analgesia/tendências , Anestesiologistas/tendências , Dor Pós-Operatória/tratamento farmacológico , Inquéritos e Questionários , Toracoscopia/efeitos adversos , Toracoscopia/tendências , Analgesia Epidural/tendências , Analgesia Controlada pelo Paciente/tendências , Anestesia por Condução/tendências , Canadá/epidemiologia , Estudos Transversais , Humanos , Bloqueio Nervoso/tendências , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/epidemiologia , Cirurgia Torácica Vídeoassistida/efeitos adversos , Cirurgia Torácica Vídeoassistida/tendências
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