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1.
Am J Ophthalmol ; 2021 Dec 20.
Artigo em Inglês | MEDLINE | ID: mdl-34942111

RESUMO

PURPOSE: Test the hypothesis that macular ganglion cell complex (GCC) thickness from optical coherence tomography (OCT) provides a stronger change signal regardless of glaucoma severity compared to other macular measures. DESIGN: Prospective cohort study. SETTING: Tertiary glaucoma center. SUBJECTS: 112 eyes with moderate to severe glaucoma at baseline. OBSERVATION PROCEDURE: In each 3°×3° macular superpixel, a hierarchical Bayesian random intercept and slope model with random residual variance was fit to longitudinal full macular thickness (FMT), outer retina layers (ORL), GCC, ganglion cell/inner plexiform layer (GCIPL), and ganglion cell layer (GCL) measurements. We estimated population- and individual-level slopes and intercepts. MAIN OUTCOME MEASURES: Proportions of significant worsening and improving superpixel slopes were compared between layers and in superpixels with mild/moderate vs. severe damage (total deviation of corresponding visual field location ≥-8 vs. <-8dB). RESULTS: Average (SD) follow-up time and baseline 10-2 visual field mean deviation were 3.6 (0.4) years and -8.9 (5.9) dB. FMT (54.9%) displayed the highest proportion of significant negative slopes followed by GCC (36.5%), ORL (35.6%), GCIPL (30.6%), and GCL (19.8%). Inner macular measures detected less worsening in the severe glaucoma group; yet GCC (22.6%) identified the highest proportion (GCIPL:18.6%; GCL:10.8%). Proportions of positive rates were small and comparable among all measures. CONCLUSIONS: GCC is the optimal macular measure for detection of structural change in eyes with moderate to severe glaucoma. Although a higher proportion of worsening superpixels was observed for FMT, a large portion of FMT change could be attributed to changes in ORL.

3.
JAMA Pediatr ; 175(10): 1009-1016, 2021 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-34251435

RESUMO

Importance: There are conflicting accounts about the risk for attention-deficit/hyperactivity disorder (ADHD) following traumatic brain injury (TBI), possibly owing to variations between studies in acute TBI severity or when ADHD was assessed postinjury. Analysis of these variations may aid in identifying the risk. Objective: To conduct a meta-analysis of studies assessing ADHD diagnoses in children between ages 4 and 18 years following concussions and mild, moderate, or severe TBI. Data Sources: PubMed, PsycInfo, and Cochrane Central Register of Controlled Trials (1981-December 19, 2019) were searched including the terms traumatic brain injury, brain injuries, closed head injury, blunt head trauma, concussion, attention deficit disorders, ADHD, and ADD in combination with childhood, adolescence, pediatric, infant, child, young adult, or teen. Study Selection: Limited to English-language publications in peer-reviewed journals and patient age (4-18 years). Differences about inclusion were resolved through consensus of 3 authors. Data Extraction and Synthesis: MOOSE guidelines for abstracting and assessing data quality and validity were used. Odds ratios with 95% credible intervals (CrIs) are reported. Main Outcomes and Measures: The planned study outcome was rate of ADHD diagnoses. Results: A total of 12 374 unique patients with TBI of all severity levels and 43 491 unique controls were included in the 24 studies in this review (predominantly male: TBI, 61.8%; noninjury control, 60.9%; other injury control, 66.1%). The rate of pre-TBI ADHD diagnoses was 16.0% (95% CrI, 11.3%-21.7%), which was significantly greater than the 10.8% (95% CrI, 10.2%-11.4%) incidence of ADHD in the general pediatric population. Compared with children without injuries, the odds for ADHD were not significantly increased following concussion (≤1 year: OR, 0.32; 95% CrI, 0.05-1.13), mild TBI (≤1 year: OR, 0.56; 0.16-1.43; >1 year: OR, 1.07; 95% CrI, 0.35-2.48), and moderate TBI (≤1 year: OR, 1.28; 95% CrI, 0.35-3.34; >1 year: OR, 3.67; 95% CrI, 0.83-10.56). The odds for ADHD also were not significantly increased compared with children with other injuries following mild TBI (≤1 year: OR, 1.07; 95% CrI, 0.33-2.47; >1 year: OR, 1.18; 95% CrI, 0.32-3.12) and moderate TBI (≤1 year: OR, 2.34; 95% CrI, 0.78-5.47; >1 year: OR, 3.78; 95% CrI, 0.93-10.33). In contrast, the odds for ADHD following severe TBI were increased at both time points following TBI compared with children with other injuries (≤1 year: OR, 4.81; 95% CrI, 1.66-11.03; >1 year: OR, 6.70; 95% CrI, 2.02-16.82) and noninjured controls (≤1 year: OR, 2.62; 95% CrI, 0.76-6.64; >1 year: OR, 6.25; 95% CrI, 2.06-15.06), as well as those with mild TBI (≤1 year OR, 5.69; 1.46-15.67: >1 year OR, 6.65; 2.14-16.44). Of 5920 children with severe TBI, 35.5% (95% CrI, 20.6%-53.2%) had ADHD more than 1 year postinjury. Conclusions and Relevance: This study noted a significant association between TBI severity and ADHD diagnosis. In children with severe but not mild and moderate TBI, there was an association with an increase in risk for ADHD. The high rate of preinjury ADHD in children with TBI suggests that clinicians should carefully review functioning before a TBI before initiating treatment.

4.
J Surg Res ; 266: 421-429, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34102512

RESUMO

INTRODUCTION: This study aims to characterize longitudinal care management and evaluate the relationship between various patient factors and the likelihood of choosing risk-reducing behaviors in women with increased risk of developing breast cancer. METHODS: A retrospective study was conducted to evaluate all adult female patients who had at least one clinic visit with a surgical provider for discussion of breast cancer risk assessment between January, 2017 to July, 2020 at an academic center. Patients with prior history of breast cancer were excluded. Patient details and strategies pursued at clinic visits were recorded. A time-to-event analysis was performed, and hazard ratios were determined to characterize associations between patient characteristics and time to pursuing risk-reducing care management. RESULTS: There were 283 participants with at least one follow-up visit and 48 (17.0%) ultimately changed their initial strategy to either chemoprevention or prophylactic mastectomy. Patients with gene mutations were 6 times more likely to engage in risk-reducing management compared to those without (hazard ratio (HR) 5.99, P < 0.001). Those with histories of high-risk proliferative changes (HR 7.62, P < 0.001) and hysterectomy (HR 2.99, P = 0.019) were also more likely to engage in risk-reducing management. Age, race, and increased predicted risk of developing breast cancer (estimated by various calculators) were not associated with increased likelihood of engaging in risk-reducing strategies. CONCLUSION: Known gene mutations, history of high-risk proliferative changes, and prior hysterectomy were factors associated with women who were more likely to engage in risk-reducing strategies. These findings, when paired with patient reported outcome measures, may help guide shared decision-making.


Assuntos
Neoplasias da Mama/psicologia , Quimioprevenção/estatística & dados numéricos , Mastectomia Profilática/estatística & dados numéricos , Adulto , Neoplasias da Mama/diagnóstico por imagem , Neoplasias da Mama/genética , Neoplasias da Mama/prevenção & controle , Quimioprevenção/psicologia , Feminino , Humanos , Imageamento por Ressonância Magnética , Mamografia , Pessoa de Meia-Idade , Mastectomia Profilática/psicologia , Estudos Retrospectivos
5.
Transl Vis Sci Technol ; 10(4): 15, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-34003991

RESUMO

Purpose: Develop a hierarchical longitudinal regression model for estimating local rates of change of macular ganglion cell complex (GCC) measurements with optical coherence tomography (OCT). Methods: We enrolled 112 eyes with four or more macular OCT images and ≥2 years of follow-up. GCC thickness measurements within central 6 × 6 superpixels were extracted from macular volume scans. We fit data from each superpixel separately with several hierarchical Bayesian random-effects models. Models were compared with the Watanabe-Akaike information criterion. For our preferred model, we estimated population and individual slopes and intercepts (baseline thickness) and their correlation. Results: Mean (SD) follow-up time and median (interquartile range) baseline 24-2 visual field mean deviation were 3.6 (0.4) years and -6.8 (-12.2 to -4.3) dB, respectively. The random intercepts and slopes model with random residual variance was the preferred model. While more individual and population negative slopes were observed in the paracentral and papillomacular superpixels, superpixels in the superotemporal and inferior regions displayed the highest correlation between baseline thickness and rates of change (r = -0.43 to -0.50 for the top five correlations). Conclusions: A Bayesian linear hierarchical model with random intercepts/slopes and random variances is an optimal initial model for estimating GCC slopes at population and individual levels. This novel model is an efficient method for estimating macular rates of change and probability of glaucoma progression locally. Translational Relevance: The proposed Bayesian hierarchical model can be applied to various macular outcomes from different OCT devices and to superpixels of variable sizes to estimate local rates of change and progression probability.


Assuntos
Glaucoma , Células Ganglionares da Retina , Teorema de Bayes , Humanos , Pressão Intraocular , Tomografia de Coerência Óptica , Campos Visuais
6.
Crit Pathw Cardiol ; 19(4): 206-212, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33009074

RESUMO

BACKGROUND: Rapid reperfusion reduces infarct size and mortality for acute coronary syndrome (ACS), but efficacy is time dependent. The aim of this study was to determine if transportation factors and clinical presentation predicted prehospital delay for suspected ACS, stratified by final diagnosis (ACS vs. no ACS). METHODS: A heterogeneous sample of emergency department (ED) patients with symptoms suggestive of ACS was enrolled at 5 US sites. Accelerated failure time models were used to specify a direct relationship between delay time and variables to predict prehospital delay by final diagnosis. RESULTS: Enrolled were 609 (62.5%) men and 366 (37.5%) women, predominantly white (69.1%), with a mean age of 60.32 (±14.07) years. Median delay time was 6.68 (confidence interval 1.91, 24.94) hours; only 26.2% had a prehospital delay of 2 hours or less. Patients presenting with unusual fatigue [time ratio (TR) = 1.71, P = 0.002; TR = 1.54, P = 0.003, respectively) or self-transporting to the ED experienced significantly longer prehospital delay (TR = 1.93, P < 0.001; TR = 1.71, P < 0.001, respectively). Predictors of shorter delay in patients with ACS were shoulder pain and lightheadedness (TR = 0.65, P = 0.013 and TR = 0.67, P = 0.022, respectively). Predictors of shorter delay for patients ruled out for ACS were chest pain and sweating (TR = 0.071, P = 0.025 and TR = 0.073, P = 0.032, respectively). CONCLUSION: Patients self-transporting to the ED had prolonged prehospital delays. Encouraging the use of EMS is important for patients with possible ACS symptoms. Calling 911 can be positively framed to at-risk patients and the community as having advanced care come to them because EMS capabilities include 12-lead ECG acquisition and possibly high-sensitivity troponin assays.


Assuntos
Síndrome Coronariana Aguda , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/epidemiologia , Síndrome Coronariana Aguda/terapia , Idoso , Dor no Peito/diagnóstico , Dor no Peito/epidemiologia , Dor no Peito/etiologia , Eletrocardiografia , Serviço Hospitalar de Emergência , Fadiga , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
7.
J Acquir Immune Defic Syndr ; 84(4): 387-395, 2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32598118

RESUMO

BACKGROUND: In March of 2013, the Los Angeles County (LAC) Division of HIV and STD Programs implemented a clinic-based Medical Care Coordination (MCC) Program to increase viral suppression (VS) (<200 c/mL) among people living with HIV (PLWH) at high risk for poor health outcomes. OBJECTIVE: This study aimed to estimate trajectories of VS and to assess whether these trajectories differed by stimulant use, housing instability, and depressive symptom severity as reported by PLWH participating in MCC. METHODS: Data represent 6408 PLWH in LAC receiving services from the MCC Program and were obtained from LAC HIV surveillance data matched to behavioral assessments obtained across 35 Ryan White Program clinics participating in MCC. Piecewise mixed-effects logistic regression with a random intercept estimated probabilities of VS from 12 months before MCC enrollment through 36 months after enrollment, accounting for time by covariate interactions for 3 comorbid conditions: housing instability, stimulant use, and depressive symptoms. RESULTS: The overall probability of VS increased from 0.35 to 0.77 within the first 6 months in the MCC Program, and this probability was maintained up to 36 months after enrollment. Those who reported housing instability, stimulant use, or multiple comorbid conditions did not achieve the same probability of VS by 36 months as those with none of those comorbidities. CONCLUSIONS: Findings suggest that MCC improved the probability of VS for all patient groups regardless of the presence of comorbidities. However, those with comorbid conditions will still require increased support from patient-centered programs to address disparities in VS.


Assuntos
Instituições de Assistência Ambulatorial/estatística & dados numéricos , Infecções por HIV/diagnóstico , Infecções por HIV/tratamento farmacológico , Avaliação de Programas e Projetos de Saúde , Adulto , Comorbidade , Feminino , Infecções por HIV/psicologia , Pessoas em Situação de Rua/estatística & dados numéricos , Humanos , Estudos Longitudinais , Los Angeles , Masculino , Minorias Sexuais e de Gênero/estatística & dados numéricos , Fatores Socioeconômicos , Resultado do Tratamento
8.
J Emerg Med ; 59(2): 193-200, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32291127

RESUMO

BACKGROUND: McKesson's InterQual criteria are widely used in hospitals to determine if patients should be classified as observation or inpatient status, but the accuracy of the criteria is unknown. OBJECTIVE: We sought to determine whether InterQual criteria accurately predicted length of stay (LOS) in older patients with syncope. METHODS: We conducted a secondary analysis of a cohort study of adults ≥60 years of age who had syncope. We calculated InterQual criteria and classified the patient as observation or inpatient status. Outcomes were whether LOS were less than or greater than 2 midnights. RESULTS: We analyzed 2361 patients; 1227 (52.0%) patients were male and 1945 (82.8%) were white, with a mean age of 73.2 ± 9.0 years. The median LOS was 32.6 h (interquartile range 24.2-71.8). The sensitivity of InterQual criteria for LOS was 60.8% (95% confidence interval 57.9-63.6%) and the specificity was 47.8% (95% confidence interval 45.0-50.5%). CONCLUSIONS: In older adults with syncope, those who met InterQual criteria for inpatient status had longer LOS compared with those who did not; however, the accuracy of the criteria to predict length of stay over 2 days is poor, with a sensitivity of 60% and a specificity of 48%. Future research should identify criteria to improve LOS prediction.


Assuntos
Pacientes Internados , Síncope , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Síncope/diagnóstico
10.
JAMA Facial Plast Surg ; 21(5): 440-445, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31343668

RESUMO

Importance: Nasal base view is important for rhinoplasty analysis. Although some descriptors of nasal base shape exist, they are largely subjective and qualitative. Objective: To evaluate a parametric model of nasal base shape and compare it with categorization by surgeons to create an objective classification system for clinical evaluation and communication. Design, Setting, and Participants: Retrospective cohort review of deidentified photographs of 420 patients evaluated for possible facial plastic surgery at a tertiary care academic medical center between January 2013 and June 2017. The nasal bases were classified into 6 shape categories (equilateral, boxy, cloverleaf, flat, round, and narrow) via visual inspection. The contour of each nasal base was traced using MATLAB software (MathWorks Inc). The software then performed a curve fit to the parametric model with output of values for 5 parameters: projection-to-width ratio, the anterior-posterior positioning of the tip bulk, symmetry, degree of lateral recurvature of the nasal base, and size. The differences among shape categories for each parameter were analyzed using 1-way analysis of variance. Pairwise comparisons were then performed to ascertain how the various shapes differed. Finally, a multinomial logistic regression model was used to predict nasal base shape using parameter values. Data were analyzed between April 2017 and January 2018. Main Outcomes and Measures: An algorithm that categorized nasal base shapes into 6 categories. Results: The 420 nasal base photographs of patients evaluated for possible plastic surgery were categorized into 1 of 6 categories; 305 photographs were readily classified, and the remaining 115 were termed unclassified and were categorized. For both the classified and unclassified nasal base groups, there were statistically significant differences between projection-to-width ratio (classified, F5,299 = 21.51; unclassified, F4,100 = 10.59; P < .001), the anterior-posterior positioning of the tip bulk (classified, F5,299 = 3.76; P = .003; unclassified, F4,110 = 4.54; P = .002), and degree of lateral recurvature of the nasal base (classified, F5,299 = 24.14; unclassified, F4,100 = 7.21; P < .001). A multinomial logistic regression model categorization was concordant with surgeon categorization in 201 of 305 (65.9%) cases of classified nasal bases and 38 of 115 (33.0%) unclassified nasal bases. Conclusions and Relevance: The parametric model may provide an objective and numerical approach to analyzing nasal base shape. Level of Evidence: NA.


Assuntos
Modelos Anatômicos , Nariz/anatomia & histologia , Nariz/cirurgia , Rinoplastia , Algoritmos , Humanos , Fotografação , Estudos Retrospectivos , Software
11.
Ann Emerg Med ; 74(2): 260-269, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31080027

RESUMO

STUDY OBJECTIVE: Many adults with syncope are hospitalized solely for observation and testing. We seek to determine whether hospitalization versus outpatient management for older adults with unexplained syncope is associated with a reduction in postdisposition serious adverse events at 30 days. METHODS: We performed a propensity score analysis using data from a prospective, observational study of older adults with unexplained syncope or near syncope who presented to 11 emergency departments (EDs) in the United States. We enrolled adults (≥60 years) who presented with syncope or near syncope. We excluded patients with a serious diagnosis identified in the ED. Clinical and laboratory data were collected on all patients. The primary outcome was rate of post-ED serious adverse events at 30 days. RESULTS: We enrolled 2,492 older adults with syncope and no serious ED diagnosis from April 2013 to September 2016. Mean age was 73 years (SD 8.9 years), and 51% were women. The incidence of serious adverse events within 30 days after the index visit was 7.4% for hospitalized patients and 3.19% for discharged patients, representing an unadjusted difference of 4.2% (95% confidence interval 2.38% to 6.02%). After propensity score matching on risk of hospitalization, there was no statistically significant difference in serious adverse events at 30 days between the hospitalized group (4.89%) and the discharged group (2.82%) (risk difference 2.07%; 95% confidence interval -0.24% to 4.38%). CONCLUSION: In our propensity-matched sample of older adults with unexplained syncope, for those with clinical characteristics similar to that of the discharged cohort, hospitalization was not associated with improvement in 30-day serious adverse event rates.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Síncope/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Feminino , Hospitalização/tendências , Humanos , Incidência , Masculino , Sintomas Inexplicáveis , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Pontuação de Propensão , Estudos Prospectivos , Medição de Risco , Síncope/complicações , Síncope/epidemiologia , Estados Unidos/epidemiologia
12.
Am J Emerg Med ; 37(12): 2215-2223, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-30928476

RESUMO

BACKGROUND: Syncope is a common chief complaint among older adults in the Emergency Department (ED), and orthostatic vital signs are often a part of their evaluation. We assessed whether abnormal orthostatic vital signs in the ED are associated with composite 30-day serious outcomes in older adults presenting with syncope. METHODS: We performed a secondary analysis of a prospective, observational study at 11 EDs in adults ≥ 60 years who presented with syncope or near syncope. We excluded patients lost to follow up. We used the standard definition of abnormal orthostatic vital signs or subjective symptoms of lightheadedness upon standing to define orthostasis. We determined the rate of composite 30-day serious outcomes, including those during the index ED visit, such as cardiac arrhythmias, myocardial infarction, cardiac intervention, new diagnosis of structural heart disease, stroke, pulmonary embolism, aortic dissection, subarachnoid hemorrhage, cardiopulmonary resuscitation, hemorrhage/anemia requiring transfusion, with major traumatic injury from fall, recurrent syncope, and death) between the groups with normal and abnormal orthostatic vital signs. RESULTS: The study cohort included 1974 patients, of whom 51.2% were male and 725 patients (37.7%) had abnormal orthostatic vital signs. Comparing those with abnormal to those with normal orthostatic vital signs, we did not find a difference in composite 30-serious outcomes (111/725 (15.3%) vs 184/1249 (14.7%); unadjusted odds ratio, 1.05 [95%CI, 0.81-1.35], p = 0.73). After adjustment for gender, coronary artery disease, congestive heart failure (CHF), history of arrhythmia, dyspnea, hypotension, any abnormal ECG, physician risk assessment, medication classes and disposition, there was no association with composite 30-serious outcomes (adjusted odds ratio, 0.82 [95%CI, 0.62-1.09], p = 0.18). CONCLUSIONS: In a cohort of older adult patients presenting with syncope who were able to have orthostatic vital signs evaluated, abnormal orthostatic vital signs did not independently predict composite 30-day serious outcomes.


Assuntos
Síncope/epidemiologia , Sinais Vitais , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Eletrocardiografia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Cardiopatias/diagnóstico , Cardiopatias/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Exame Físico , Estudos Prospectivos
13.
Am J Emerg Med ; 37(4): 685-689, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30017687

RESUMO

BACKGROUND: Syncope is a common chief complaint in the ED, and the electrocardiogram (ECG) is a routine diagnostic tool in the evaluation of syncope. We assessed whether increasingly prolonged QTc intervals are associated with composite 30-day serious outcomes in older adults presenting to the ED with syncope. METHODS: This is a secondary analysis of a prospective, observational study at 11 EDs in adults 60 years or older who presented with syncope or near syncope. We excluded patients presenting without an ECG, measurement of QTc, non-sinus rhythm, bundle branch block or those without 30-day follow-up. We categorized QTc cutoffs into values of <451; 451-470; 471-500, and >500 ms. We determined the rate of composite 30-day serious outcomes including ED serious outcomes and 30-day arrhythmias not identified in ED. RESULTS: The study cohort included 2609 patients. There were 1678 patients (64.3%) that had QTc intervals <451 ms; 544 (20.8%) were 451-470 ms; 302 (11.6%) were 471-500 ms, and 85 (3.3%) had intervals >500 ms. Composite 30-day serious outcomes was associated with increasingly prolonged QTc intervals (13.0%, 15.3%, 18.2%, 22.4%, p = 0.01), but this association did not persist in multivariate analysis. CONCLUSIONS: In a cohort of older patients presenting with syncope, increased QTc interval was a marker of but was not independently predictive of composite 30-day serious outcomes.


Assuntos
Eletrocardiografia , Sistema de Condução Cardíaco/fisiopatologia , Síndrome do QT Longo/diagnóstico , Síncope/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Valor Preditivo dos Testes , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Estados Unidos
14.
Ann Emerg Med ; 73(3): 274-280, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30529112

RESUMO

STUDY OBJECTIVE: Controversy remains in regard to the risk of adverse events for patients presenting with syncope compared with near-syncope. The purpose of our study is to describe the difference in outcomes between these groups in a large multicenter cohort of older emergency department (ED) patients. METHODS: From April 28, 2013, to September 21, 2016, we conducted a prospective, observational study across 11 EDs in adults (≥60 years) with syncope or near-syncope. A standardized data extraction tool was used to collect information during their index visit and at 30-day follow-up. Our primary outcome was the incidence of 30-day death or serious clinical events. Data were analyzed with descriptive statistics and multivariate logistic regression analysis adjusting for relevant demographic or historical variables. RESULTS: A total of 3,581 patients (mean age 72.8 years; 51.6% men) were enrolled in the study. There were 1,380 patients (39%) presenting with near-syncope and 2,201 (61%) presenting with syncope. Baseline characteristics revealed a greater incidence of congestive heart failure, coronary artery disease, previous arrhythmia, nonwhite race, and presenting dyspnea in the near-syncope compared with syncope cohort. There were no differences in the primary outcome between the groups (near-syncope 18.7% versus syncope 18.2%). A multivariate logistic regression analysis identified no difference in 30-day serious outcomes for patients with near-syncope (odds ratio 0.94; 95% confidence interval 0.78 to 1.14) compared with syncope. CONCLUSION: Near-syncope confers risk to patients similar to that of syncope for the composite outcome of 30-day death or serious clinical event.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Síncope/mortalidade , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Medição de Risco , Síncope/diagnóstico
15.
Lasers Surg Med ; 51(2): 150-160, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30051633

RESUMO

OBJECTIVES: Adenotonsillectomy (AT) is commonly used to treat upper airway obstruction in children, but selection of patients who will benefit most from AT is challenging. The need for diagnostic evaluation tools without sedation, radiation, or high costs has motivated the development of long-range optical coherence tomography (LR-OCT), providing real-time cross-sectional airway imaging during endoscopy. Since the endoscope channel location is not tracked in conventional LR-OCT, airway curvature must be estimated and may affect predicted airway resistance. The study objective was to assess effects of three realistic airway curvatures on predicted airway resistance using computational fluid dynamics (CFD) in LR-OCT reconstructions of the upper airways of pediatric patients, before and after AT. METHODS: Eight subjects (five males, three females, aged 4-9 years) were imaged using LR-OCT before and after AT during sedated endoscopy. Three-dimensional (3D) airway reconstructions included three airway curvatures. Steady-state, inspiratory airflow simulations were conducted under laminar conditions, along with turbulent simulations for one subject using the k-ω turbulence model. Airway resistance (pressure drop/flow) was compared using two-tailed Wilcoxon signed rank tests. RESULTS: Regardless of the airway curvatures, CFD findings corroborate a surgical end-goal with computed post-operative airway resistance significantly less than pre-operative (P < 0.01). The individual resistances did not vary significantly for different airway curvatures (P > 0.25). Resistances computed using turbulent simulations differed from laminar results by less than ∼5%. CONCLUSIONS: The results suggest that reconstruction of the upper airways from LR-OCT imaging data may not need to account for airway curvature to be predictive of surgical effects on airway resistance. Lasers Surg. Med. 51:150-160, 2019. © 2018 Wiley Periodicals, Inc.


Assuntos
Obstrução das Vias Respiratórias/diagnóstico por imagem , Obstrução das Vias Respiratórias/cirurgia , Esofagoscopia , Procedimentos Cirúrgicos Reconstrutivos , Tomografia de Coerência Óptica , Tonsila Faríngea/patologia , Obstrução das Vias Respiratórias/etiologia , Resistência das Vias Respiratórias , Criança , Pré-Escolar , Simulação por Computador , Feminino , Humanos , Hidrodinâmica , Hipertrofia , Masculino , Tonsila Palatina/patologia
16.
Am J Emerg Med ; 37(5): 869-872, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30361153

RESUMO

Almost 20% of patients with syncope will experience another event. It is unknown whether recurrent syncope is a marker for a higher or lower risk etiology of syncope. The goal of this study is to determine whether older adults with recurrent syncope have a higher likelihood of 30-day serious clinical events than patients experiencing their first episode. METHODS: This study is a pre-specified secondary analysis of a multicenter prospective, observational study conducted at 11 emergency departments in the US. Adults 60 years or older who presented with syncope or near syncope were enrolled. The primary outcome was occurrence of 30-day serious outcome. The secondary outcome was 30-day serious cardiac arrhythmia. In multivariate analysis, we assessed whether prior syncope was an independent predictor of 30-day serious events. RESULTS: The study cohort included 3580 patients: 1281 (35.8%) had prior syncope and 2299 (64.2%) were presenting with first episode of syncope. 498 (13.9%) patients had 1 prior episode while 771 (21.5%) had >1 prior episode. Those with recurrent syncope were more likely to have congestive heart failure, coronary artery disease, previous diagnosis of arrhythmia, and an abnormal ECG. Overall, 657 (18.4%) of the cohort had a serious outcome by 30 days after index ED visit. In multivariate analysis, we found no significant difference in risk of events (adjusted odds ratio 1.09; 95% confidence interval 0.90-1.31; p = 0.387). CONCLUSION: In older adults with syncope, a prior history of syncope within the year does not increase the risk for serious 30-day events.


Assuntos
Síncope/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/epidemiologia , Estudos de Casos e Controles , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recidiva , Medição de Risco , Fatores de Risco , Síncope/epidemiologia
17.
JAMA Facial Plast Surg ; 20(2): 160-165, 2018 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-29222563

RESUMO

Importance: The nasal base view is often overlooked in rhinoplasty analysis and, unlike lateral and frontal views, lacks detailed quantitative analysis and descriptors. While shape-category analysis of the nasal base is well established, these descriptive methods remain subjective and do not facilitate quantitative analysis. Objective: To establish a simple and quantitative classification scheme using a multiple-parameter numerical model for analyzing and describing the shape of the nasal base. Design, Setting, and Participants: Deidentified photographs of the nasal base view were analyzed without knowledge of patients' pathology or medical history. Each nose was classified into 1 of 6 categories derived from literature (equilateral, narrow, flat, cloverleaf, boxy, and round). Finite parametric modeling was performed on each nose, and the correlations between the resulting parameters and the 6 categories were analyzed. Photographs for this study were acquired from the practice of a single facial plastic surgeon (B.J.F.W.) at a tertiary care academic medical center. One hundred twenty-one consecutive patients who had nasal base view photographs taken were included in the study. Main Outcomes and Measures: All of the 121 images were classified into 1 of the 6 categories by 1 reviewer (C.H.B.). The contour of each nasal base was curve fit to a 5-parameter numerical model. The 5 parameters controlled base size, deviation from the midline, projection-to-width ratio, degree of nasal alar recurvature, and anterior-posterior positioning of nasal base bulk. A numerical value for each nasal base shape type was predicted by the parametric model. Results: In 121 patient photographs, the parametric model generated shapes that accurately matched the tracing of the actual nasal base contours with an average correlation coefficient of greater than 0.98. This finding indicates close approximation of the nasal base shape with the curve fit constructed by the PM. Parameters b (projection-to-width ratio) and e (roundedness) were shown to have significant differences among the groups (F statistic, 8.88; P < .001 and F statistic, 13.05; P < .001, respectively). These two curve-fit parameters alone could be used to classify nasal shape into 1 of the 6 clinically determined base geometries. Conclusions and Relevance: A numerical approach to classify nasal base shape was developed using a 5-parameter model and tested against subjective analysis. This model may aid in the advancement of algorithm-driven objective nasal analysis techniques, preoperative modeling, intraoperative guidance, and surgical outcome measures beyond using Likert scales. Level of Evidence: NA.


Assuntos
Tamanho Corporal , Modelos Anatômicos , Nariz/anatomia & histologia , Rinoplastia , Algoritmos , Humanos , Nariz/cirurgia , Fotografação , Cuidados Pré-Operatórios
18.
JAMA Facial Plast Surg ; 19(6): 502-509, 2017 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-28654968

RESUMO

Importance: The classic management of burn scars and other injuries to the skin has largely relied on soft-tissue transfer to resurface damaged tissue with local tissue transfer or skin graft placement. In situ generation of electrochemical reactions using needle electrodes and an application of current may be a new approach to treat scars and skin. Objective: To examine the changes in optical, mechanical, and acoustic impedance properties in porcine skin after electrochemical therapy. Design, Setting, and Participants: This preclinical pilot study, performed from August 1, 2015, to November 1, 2016, investigated the effects of localized pH-driven electrochemical therapy of ex vivo porcine skin using 24 skin samples. Platinum-plated needle electrodes were inserted into fresh porcine skin samples. A DC power supply provided a voltage of 4 to 5 V with a 3-minute application time. Specimens were analyzed using optical coherence tomography, optical coherence elastography, and ultrasonography. Ultrasonography was performed under 3 conditions (n = 2 per condition), optical coherence tomography was performed under 2 conditions (n = 2 per condition), and optical coherence elastography was performed under 2 conditions (n = 2 per condition). The remaining samples were used for the positive and negative control groups (n = 10). Exposures: Platinum-plated needle electrodes were inserted into fresh porcine skin samples. A DC power supply provided a voltage of 4 to 5 V with a 3-minute application. Main Outcomes and Measures: Tissue softening was observed at the anode and cathode sites as a result of electrochemical modification. Volumetric changes were noted using each optical and acoustic technique. Results: A total of 24 ex vivo porcine skin samples were used for this pilot study. Optical coherence tomography measured spatial distribution of superficial tissue changes around each electrode site. At 4 V for 3 minutes, a total volumetric effect of 0.47 mm3 was found at the anode site and 0.51 mm3 at the cathode site. For 5 V for 3 minutes, a total volumetric effect of 0.85 mm3 was found at the anode site and 1.05 mm3 at the cathode site. Conclusions and Relevance: Electrochemical therapy is a low-cost technique that is on par with the costs of suture and scalpel. The use of electrochemical therapy to create mechanical and physiologic changes in tissue has the potential to locally remodel the soft-tissue matrix, which ultimately may lead to an inexpensive scar treatment or skin rejuvenation therapy. Level of Evidence: NA.


Assuntos
Estimulação Acústica/métodos , Terapia por Estimulação Elétrica/métodos , Pele , Animais , Fenômenos Biomecânicos , Técnicas de Imagem por Elasticidade , Técnicas In Vitro , Modelos Animais , Agulhas , Projetos Piloto , Pele/diagnóstico por imagem , Suínos , Tomografia de Coerência Óptica
19.
Laryngoscope ; 127(1): 64-69, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27559721

RESUMO

OBJECTIVES/HYPOTHESIS: Current imaging modalities lack the necessary resolution to diagnose subglottic stenosis. The aim of this study was to use optical coherence tomography (OCT) to evaluate nascent subglottic mucosal injury and characterize mucosal thickness and structural changes using texture analysis in a simulated intubation rabbit model. STUDY DESIGN: Prospective animal study in rabbits. METHODS: Three-centimeter-long sections of endotracheal tubes (ETT) were endoscopically placed in the subglottis and proximal trachea of New Zealand White rabbits (n = 10) and secured via suture. OCT imaging and conventional endoscopic video was performed just prior to ETT segment placement (day 0), immediately after tube removal (day 7), and 1 week later (day 14). OCT images were analyzed for airway wall thickness and textural properties. RESULTS: Endoscopy and histology of intubated rabbits showed a range of normal to edematous tissue, which correlated with OCT images. The mean airway mucosal wall thickness measured using OCT was 336.4 µm (day 0), 391.3 µm (day 7), and 420.4 µm (day 14), with significant differences between day 0 and day 14 (P = .002). Significance was found for correlation and homogeneity texture features across all time points (P < .05). CONCLUSIONS: OCT is a minimally invasive endoscopic imaging modality capable of monitoring progression of subglottic mucosal injury. This study is the first to evaluate mucosal injury during simulated intubation using serial OCT imaging and texture analysis. OCT and texture analysis have the potential for early detection of subglottic mucosal injury, which could lead to better management of the neonatal airway and limit the progression to stenosis. LEVEL OF EVIDENCE: NA Laryngoscope, 127:64-69, 2017.


Assuntos
Intubação Intratraqueal/efeitos adversos , Laringoestenose/diagnóstico , Tomografia de Coerência Óptica/métodos , Animais , Modelos Animais de Doenças , Interpretação de Imagem Assistida por Computador , Laringoscopia , Estudos Prospectivos , Coelhos
20.
Sci Rep ; 6: 39443, 2016 12 19.
Artigo em Inglês | MEDLINE | ID: mdl-27991580

RESUMO

The upper airway is a complex tissue structure that is prone to collapse. Current methods for studying airway obstruction are inadequate in safety, cost, or availability, such as CT or MRI, or only provide localized qualitative information such as flexible endoscopy. Long range optical coherence tomography (OCT) has been used to visualize the human airway in vivo, however the limited imaging range has prevented full delineation of the various shapes and sizes of the lumen. We present a new long range OCT system that integrates high speed imaging with a real-time position tracker to allow for the acquisition of an accurate 3D anatomical structure in vivo. The new system can achieve an imaging range of 30 mm at a frame rate of 200 Hz. The system is capable of generating a rapid and complete visualization and quantification of the airway, which can then be used in computational simulations to determine obstruction sites.


Assuntos
Sistema Respiratório/anatomia & histologia , Tomografia de Coerência Óptica/métodos , Simulação por Computador , Humanos , Imageamento Tridimensional/métodos
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