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1.
Blood Adv ; 4(1): 47-54, 2020 Jan 14.
Artigo em Inglês | MEDLINE | ID: mdl-31899797

RESUMO

Patients with classic Hodgkin lymphoma (cHL) who relapse after autologous hematopoietic cell transplantation (auto-HCT) historically have had poor outcomes. We hypothesized that, post-auto-HCT relapse, overall survival (PR-OS) has improved in recent years as a result of more widespread use of novel therapies and allogeneic HCT (allo-HCT). We conducted a retrospective study in 4 US academic centers, evaluating 215 patients who underwent auto-HCT from 2005 to 2016 and relapsed thereafter. Patients were divided into 2 cohorts based on timing of auto-HCT, 2005 through 2010 (cohort 1; n = 118) and 2011 to 2016 (cohort 2; n = 97), to compare differences in clinical outcomes. The median age and disease status at auto-HCT were similar in cohorts 1 and 2. The proportions of patients who received brentuximab vedotin (Bv; 55% vs 69%; P = .07), checkpoint inhibitors (CPIs; 3% vs 36%; P ≤ .001), and allogeneic-HCT (22% vs 35%, P = .03) were significantly different between cohorts 1 and 2, respectively. At the 5-year follow-up after auto relapse, 32% and 50% of patients were alive in cohorts 1 and 2, respectively (P = .01). In multivariate analysis for PR-OS, cohort 1 vs 2 (hazard ratio [HR], 2.3; 95% confidence interval [CI], 1.14-4.60; P = .01), age at auto-HCT (HR, 1.48; 95% CI, 1.18-1.87; P ≤ .001), and time to relapse from auto-HCT (HR, 0.59; 95% CI, 0.47-74; P ≤ .0001), retained independent prognostic significance for PR-OS. Our study supports the hypothesis that survival of cHL patients after auto-HCT failure has significantly improved in recent years, most likely because of incorporation of novel therapies and more widespread use of allo-HCT.

2.
J Healthc Qual ; 2020 Jan 07.
Artigo em Inglês | MEDLINE | ID: mdl-31917712

RESUMO

PURPOSE: The quality of visual acuity (VA) measurement in emergency department (ED) settings can be affected by patient immobility and lack of standardized testing conditions. We implemented a previously validated, novel VA chart, the Runge Sloan letter near card, in a hospital ED and evaluated its impact on frequency and consistency of VA testing. METHODS: Two hundred seventeen hospital ED ophthalmology consult records from December 1, 2016, to November 15, 2017, were evaluated in an IRB-approved protocol. Frequency of VA measurement and agreement between nonophthalmic ED technicians and ophthalmology physicians-in-training were assessed. RESULTS: Implementation of the Runge card saw missed technician VA evaluations decrease from 36% (43/120) to 21% (20/97) of ophthalmic consults (p = .01), without significant change in agreement of VA measurements. After implementation, the proportion of VA measurements differing between technicians and residents by ≤2 lines was 51%; with pinhole testing, it improved to 64% (p < .05). In patients with good VA of >20/80, pinhole increased agreement from 58% to 73% (p < .05). CONCLUSIONS: Implementation of the Runge card was associated with improved frequency of VA measurement and, when combined with pinhole testing, increased agreement rates. Our findings suggest utility of training in the use of the Runge card in ED settings.

3.
Nutr Clin Pract ; 35(1): 133-141, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31172570

RESUMO

BACKGROUND: Computed tomography (CT) methods to estimate sarcopenia in obesity do not differentiate high-attenuating from low-attenuating muscle. The primary purpose of this study was to determine agreement between a CT method using general workstation-derived total and high-attenuating psoas muscle cross-sectional area (CSA) and a commercially available segmentation software-derived value. Secondary purpose was to explore the relationship between quantity of high-attenuating muscle to physical functioning in a pilot cohort of obese medical intensive care unit (MICU) patients. METHODS: We conducted a prospective observational cross-sectional study. CT images of obese MICU patients were reconstructed to calculate total psoas muscle, low-attenuating muscle, and high-attenuating muscle within the third lumbar psoas CSA using a CT method and commercial software. We performed blinded outcome measures of CSA, physical function, and muscle strength in 28 patients. RESULTS: Concordance correlation coefficient for identifying total psoas muscle was 0.96 (95% confidence interval: 0.93-0.98, P-value < 0.0001) between CT method and commercial software. There was moderate correlation between modified Medical Research Council muscle strength scores and high-attenuating psoas muscle CSA (r = 0.47, P = 0.01) and lower extremity strength and high-attenuating psoas muscle CSA (r = 0.40, P = 0.04). CONCLUSION: There was strong agreement between our CT method and a commercial software method to identify total psoas muscle CSA in obesity. Greater total high-attenuating psoas CSA moderately correlated with muscle strength. Additional studies using more objective markers of muscle strength validating these findings are needed.

4.
Blood ; 2019 Dec 27.
Artigo em Inglês | MEDLINE | ID: mdl-31880771

RESUMO

Gastrointestinal (GI) tract involvement is the major cause of morbidity and mortality in acute graft versus host disease (GVHD) and pathological damage is largely attributable to inflammatory cytokine production. Recently, GM-CSF has been identified as a cytokine that mediates inflammation in the GI tract, but the transcriptional program that governs GM-CSF production and the mechanism by which GM-CSF links adaptive to innate immunity within this tissue site have not been defined. In the current study, we identified Bhlhe40 as a key transcriptional regulator that governs GM-CSF production by CD4+ T cells and mediates pathological damage in the GI tract during GVHD. In addition, we observed that GM-CSF was not regulated by either IL-6 or IL-23 which are both potent inducers of GVHD-induced colonic pathology, indicating that GM-CSF constitutes a nonredundant inflammatory pathway in the GI tract. Mechanistically, GM-CSF had no adverse effect on regulatory T cell reconstitution, but linked adaptive to innate immunity by enhancing the activation of donor-derived dendritic cells in the colon and subsequent accumulation of these cells in the mesenteric lymph nodes. In addition, GM-CSF promoted indirect alloantigen presentation resulting in the accumulation of donor-derived T cells with a proinflammatory cytokine phenotype in the colon. Thus, Bhlhe40+ GM-CSF+ CD4+ T cells constitute a colitogenic T cell population that promotes indirect alloantigen presentation and pathological damage within the GI tract, positioning GM-CSF as a key regulator of GVHD in the colon and a potential therapeutic target for amelioration of this disease.

5.
Am J Surg ; 2019 Nov 13.
Artigo em Inglês | MEDLINE | ID: mdl-31739980

RESUMO

BACKGROUND: Trauma readmissions have been well studied but little data exists regarding Emergency Department (ED) utilization following an injury. This study was performed to determine the factors associated with a return to the ED after trauma. METHODS: A retrospective review of all adult trauma patients evaluated between January and December of 2014 was performed. Demographics, follow-up plan, and characteristics of ED visits within 30 days of discharge were recorded. Predictive factors of ED utilization were identified using univariate analysis and multi-logistic regression. RESULTS: Fourteen percent of 1836 consecutive patients returned to the ED within 30 days of initial trauma. On multi-logistic regression, penetrating trauma (OR 2.15 p = 0.001), and scheduled follow-up (OR 1.81 p = 0.046) remained significant predictors. CONCLUSIONS: Penetrating trauma victims are at increased risk of returning to the ED, most often because of wound or pain issues. Recognizing these factors allows for targeted interventions to decrease ED resource utilization.

6.
J Pediatr Urol ; 2019 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-31761695

RESUMO

INTRODUCTION: Augmenting the bladder with a seromuscular gastrointestinal flap is a promising alternative approach aiming for a mucus-free bladder augmentation; however, the contraction (shrinkage) of the flaps remains a major concern. Enteric nervous system (ENS) abnormalities cause a failure of relaxation of the intestinal muscle layers in motility disorders such as Hirschsprung's disease and intestinal neuronal dysplasia. In mammals, the submucosal enteric nervous plexus contains nitrergic inhibitory motor neurons responsible for muscle relaxation. The authors hypothesize that mucosectomy disconnects the submucosal nervous plexus from the myenteric plexus resulting in flap shrinkage. STUDY DESIGN: After ethical approval, mucosectomy was performed on vascularized flaps from the ileum, colon, and stomach in five anesthetized pigs. In Group (I), only the mucosa was scraped off with forceps, creating a sero-musculo-submucosal flap, while in Group (II), the mucosa and submucosa were peeled off as one layer, leaving a seromuscular flap. Isolated and detubularized segments served as control. The width of each flap was measured before and after the mucosectomy. The ENS was assessed by neurofilament immunohistochemistry in conventional sections and by acetylcholinesterase and NADPH-diaphorase enzyme histochemistry in whole-mount preparations. RESULTS: The stomach contracted to a lesser extent of its original width, 92.82 ± 7.86% in Group (I) and 82.24 ± 6.96% in Group (II). The ileum contracted to 81.68 ± 4.25% in Group (I) and to 72.675 ± 5.36% in Group (II). The shrinkage was most noticeable in the colon: 83.89 ± 15.73% in Group (I) and to 57.13 ± 11.51% in Group (II). One-way equal variance test showed significant difference (P < 0,05) between Group (I) and (II), comparing stomach with ileum and ileum with colon. The histochemistry revealed that the submucosal nervous plexus containing nitrergic inhibitory neurons was disconnected from the myenteric plexus in Group (II) of all specimens. CONCLUSION: Mucosectomy resulted in significant immediate shrinkage of the flaps. This was more expressed when also the submucosa was peeled off, thus fully disrupting the ENS. The shrinkage affected the stomach the least and the colon the greatest. This phenomenon should be taken into consideration when planning mucus-free bladder augmentation.

7.
J Clin Apher ; 34(6): 686-691, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31566813

RESUMO

The use of granulocyte-colony stimulating factor (G-CSF) with or without chemotherapy to mobilize hematopoietic progenitor cells (HPCs) can result in significant morbidity in light chain (AL) amyloidosis patients. Plerixafor, a strong inducer and mobilizer of HPCs, can be used as an adjunct to G-CSF to improve mobilization efficiency. We describe the outcomes for combined G-CSF/plerixafor mobilized patients with AL amyloidosis. We reviewed data of 53 consecutive AL amyloidosis patients who underwent combined G-CSF/plerixafor HPC mobilization between May 2011 and October 2017 at our institution. We evaluated patients for HPC collection efficiency, perimobilization toxicity and postautologous hematopoietic cell transplantation (autoHCT) outcomes. Median CD34+ cell collection was 12.4 × 106 cells/kg (range 2.5 × 106 to 34.1 × 106 cells/kg) and 45 (85%) patients had collections of ≥5.0 × 106 CD34+ cells/kg. There were no mobilization failures or perimobilization mortality. During mobilization, 37 (70%) patients had weight gain (median 1.3 kg, range 0.1-4) but none >10% body weight, 5 (10%) patients had diarrhea, and one patient each had hypotension and cardiac arrhythmia. Among the 31 patients analyzed for CD34 collection efficiency (CE), the median CD34 CE was 47% (range 36-62). At 5 years follow-up 82% and 84% of patients were progression-free and alive, respectively. Our results suggest that G-CSF/plerixafor mobilization is safe, well tolerated, and effective in AL amyloidosis.

8.
J Pediatr Surg ; 54(12): 2539-2545, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31519359

RESUMO

BACKGROUND/PURPOSE: Surgical management of appendicitis accounts for ~30% of total expenditure in the practice of pediatric surgery and is associated with high cost variation. We hypothesize that incorporating single-incision laparoscopy (SILS) and the resultant by-product dual-incision laparoscopy (DILS) into a historically three-incision laparoscopic (TILS) appendectomy practice affords equal outcomes at lower cost. METHODS: Appendectomies performed at a large-volume tertiary care children's hospital from 1/2015-12/2017 were retrospectively reviewed. Appendectomy technique and appendicitis severity were stratified against operative and admission direct variable (DV) costs. Secondary outcomes included perioperative time course and 30-day postoperative outcomes. RESULTS: A total of 970 appendectomies were analyzed during the study period (61% acute, 39% complex appendicitis). SILS and DILS had significantly lower mean DV costs and OR times compared to TILS for both acute and complex appendicitis while maintaining equivalent outcomes. CONCLUSIONS: SILS and DILS appendectomy techniques can be incorporated into pediatric surgical practice at lower cost than TILS appendectomy while maintaining equivalent outcomes. Further, the introduction of a tiered approach to laparoscopic appendectomy, in which all cases are started as SILS with additional incisions added based on operative difficulty, is estimated to save $74,580 annually in operative DV costs at a pediatric surgical center averaging 314 laparoscopic appendectomies per year. TYPE OF STUDY: Treatment Study. LEVEL OF EVIDENCE: Level III.

9.
Artigo em Inglês | MEDLINE | ID: mdl-31535394

RESUMO

BACKGROUND: The optimal dose and timing of enteral nutrition (EN) in septic shock are unclear. METHODS: We conducted a phase 3 single-center randomized controlled pilot trial comparing early trophic EN with "no EN" in mechanically ventilated adults with septic shock, with the hypothesis that implementing a protocol comparing early trophic EN with "no EN" in patients with septic shock would be feasible. Patients were randomized to early trophic EN or "no EN" until off vasopressor for 3 hours. The primary outcome was feasibility in achieving >75% consent and compliance rate and <10% contamination rate. RESULTS: One hundred thirty-one patients were eligible for enrollment, and 49 were available for consent. Thirty-one (86%) consented and were randomized and 100% of patients in the early EN arm and 94% in the "no EN" arm completed their protocols. While on vasopressors, early EN group received median 384 kcal, and the "no EN" group received median 0 kcal. Contamination rate was 0 in the early trophic EN arm and 6% in the "no EN" arm. The early EN group had median 25 intensive care unit-free days, as compared with 12 in the "no EN" arm (P = .014). The early EN arm had median 27 ventilator-free days, compared with 14 in "no EN" arm (P = .009). CONCLUSION: Our protocol comparing early trophic EN with "no EN" in septic shock was feasible. Early trophic EN may be beneficial, but a larger multicenter trial is warranted to confirm the observed clinical benefits seen in this trial.

10.
Oncologist ; 24(11): 1488-1495, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31467178

RESUMO

BACKGROUND: Advanced-stage Hodgkin lymphoma (HL) is a curable malignancy, although outcomes remain poor in certain patients. It remains unclear if recent advances have improved their population-level survival over time. MATERIALS AND METHODS: Using the Surveillance, Epidemiology, and End Results database, we identified patients aged ≥18 years with stage III or IV classical HL as the first primary malignancy, diagnosed between 2000 and 2014 and treated with chemotherapy. Patients were stratified by date of diagnosis into three groups (2000-2004, 2005-2009, 2010-2014) to assess the trends in overall survival (OS). RESULTS: A total of 9,042 patients with a median age of 41 years were included. The use of frontline radiation therapy decreased in each period (21.3% [2000-2004] vs. 15.5% [2005-2009] vs. 10.7% [2010-2014]; p < .001). Three-year OS was significantly higher for patients diagnosed between 2010 and 2014 (81.8%) and 2005 and 2009 (80.6%) compared with 2000 and 2004 (78.5%; p = .0008 and .02, respectively). Whereas outcomes were poorest in the age >60 cohort, similar improvements were also seen in 3-year OS over the three time periods within this patient population. On multivariate analysis, diagnosis in the earlier period and minority race were associated with higher mortality. Females and married patients had significantly lower mortality risk. CONCLUSION: Survival of patients with advanced-stage HL has continued to improve over time, suggesting the impact of evolving treatment approaches. Three-year OS in the contemporary period remains inadequate at 81.8%, highlighting the need for continued research to improve their outcomes. IMPLICATIONS FOR PRACTICE: This article evaluates contemporary outcomes for advanced-stage Hodgkin lymphoma (HL) in the U.S. using the Surveillance, Epidemiology, and End Results database. Although overall survival (OS) has improved in each 5-year period since 2000, the 3-year OS from 2010 to 2014 remains inadequate at 81.8% and is limited by patient demographics. New therapies are indicated to improve clinical outcomes in advanced-stage HL.

11.
J Surg Res ; 243: 447-452, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31376796

RESUMO

BACKGROUND: Current treatment for locally advanced rectal cancer includes neoadjuvant chemoradiation followed by surgery and adjuvant chemotherapy. With neoadjuvant chemotherapy (NC), both chemoradiation and chemotherapy are given in the neoadjuvant setting. This study aims to assess patterns of NC utilization and differences in treatment response compared with standard treatment at our institution. MATERIALS AND METHODS: We performed a retrospective review of patients treated for stage II-III rectal cancer at our institution between 2008 and 2018, examining patient demographics, tumor characteristics, and treatment modality. The primary outcome of interest was complete response (CR) to treatment, including both pathologic and clinical CR. RESULTS: Of 184 patients, 134 (72.8%) received standard therapy, and 50 (27.2%) received NC. In the standard treatment group, 70.1% were node positive, and 9.0% had T4-disease, compared with 92.0% and 26.0% in the NC group, respectively (both P < 0.01). NC utilization increased over time, with 3.4% of patients receiving NC between 2008 and 2012, compared with 48.5% in 2013-2018 (P < 0.01). CR was achieved in 19.4% versus 34.0% (P < 0.01) of patients in standard versus NC groups. With multivariate analysis, NC (odds ratio = 3.02 [95% confidence interval 1.37-6.67], P = 0.01) was associated with increased likelihood of achieving CR, whereas higher T-stage was associated with decreased likelihood of CR (for cT4, odds ratio = 0.06 [95% confidence interval 0.01-0.56], P = 0.01). CONCLUSIONS: Use of NC was increasingly used at our institution from 2008 to 2018. Patients who received NC achieved higher rates of CR compared with those undergoing standard therapy, despite having more advanced disease. These data support trends from other institutions and provides rationale for further study regarding use of NC for locally advanced rectal cancer.

12.
J Trauma Acute Care Surg ; 87(5): 1181-1188, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31425468

RESUMO

BACKGROUND: Rib fractures are associated with increased mortality, particularly in the elderly. While opiate-based pain regimens remain the cornerstone of rib fracture management, issues related to opioids have driven research into alternative analgesics. Adjunctive ketamine use in lieu of opioids continues to increase but little evidence exists to support its efficacy or safety within the elderly trauma population. METHODS: A prospective, randomized, double-blind placebo-controlled trial of elderly patients (age, ≥65 years) with three or more rib fractures admitted to a Level I trauma center was conducted. Exclusion criteria included Glasgow Coma Scale score less than 14, and chronic opiate use. Groups were randomized to either low-dose ketamine (LDK) at 2 µg·kg·min or an equivalent rate of 0.9% normal saline. The primary outcome was reduction in numeric pain scores (NPS). Secondary outcomes included oral morphine equivalent (OME) utilization, epidural rates, pulmonary complications, and adverse events. RESULTS: Thirty (50.8%) of 59 were randomized to the experimental arm. Groups were similar in makeup. Low-dose ketamine failed to reduce 24-hour NPS or OME totals. Subgroup analysis of 24 patients with Injury Severity Score greater than 15 demonstrated that LDK was associated with a reduction in OME utilization the first 24-hours (25.6 mg vs. 42.6 mg, p = 0.04) but at no other time points. No difference in other secondary outcomes or adverse events was noted. CONCLUSION: Low-dose ketamine failed to affect NPS or OME within the overall cohort, but a decrease in OME was observed in those with an Injury Severity Score greater than 15. Additional studies are necessary to confirm whether LDK benefits severely injured elderly patients. LEVEL OF EVIDENCE: Therapeutic, level I.

13.
Amyloid ; 26(4): 210-215, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31347424

RESUMO

Engraftment syndrome (ES), a complication of autologous hematopoietic cell transplantation (auto-HCT), can occur around the time of neutrophil recovery. We sought to identify the incidence of ES in light chain (AL) amyloidosis patients undergoing auto-HCT at our centre by evaluating 72 consecutive amyloidosis patients transplanted between 1999 and 2017. To assess trends in ES over time, patients were divided into two Eras (Era 1 = 1999-2008 and Era 2 = 2009-2017) based on year of auto-HCT. Twenty-two (31%) patients developed ES; three (16%) and 19 (36%) in Era 1 and 2, respectively (p = .1). Three (16%) and 51 (96%) patients in Era 1 and 2 received chemotherapy before auto-HCT (p = <.001). The most common symptoms observed with ES in addition to fever was diarrhoea (73%), rash (68%), weight gain (56%) and non-cardiogenic pulmonary oedema (23%). Day 100 post-auto-HCT haematological response (19.5% vs. 14%, p = .7) or post-transplant best organ response (23% vs. 36%, p = .2) were not significantly different in patients who did not or did develop ES, respectively. In this single centre series, we define the incidence and characteristics of ES in AL amyloidosis patients undergoing auto-HCT.

14.
Dig Liver Dis ; 51(8): 1086-1095, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31278016

RESUMO

BACKGROUND: Despite the high rate of postoperative recurrence (POR) in Crohn's disease (CD), there is no widely accepted consensus on its prevention. AIM: To compare the efficacy of biological and conventional therapies in preventing POR of CD. METHODS: We searched four electronic databases up to April 2019 for articles that examined the efficacy of different preventive therapies against POR. Our PICO was: (P) adults with CD who underwent intestinal resection, (I) biological agents, (C) conventional therapies or a placebo, and (O) clinical, endoscopic, and histological POR. RESULTS: Anti-TNFα agents were significantly better in preventing clinical, endoscopic, severe endoscopic and histological POR compared to conventional therapies (OR: 0.508, 95% CI: 0.309-0.834, P = 0.007; OR: 0.312, 95% CI: 0.199-0.380, P < 0.001; OR: 0.195, 95% CI: 0.107-0.356, P < 0.001; and OR: 0.255, 95% CI: 0.106-0.611, P = 0.002, respectively), as well as in the subgroup of nonselected CD patients (OR: 0.324, 95% CI: 0.158-0.664, P = 0.002; OR: 0.225, 95% CI: 0.124-0.409, P < 0.001; and OR: 0.248, 95% CI: 0.070-0.877, P = 0.031, respectively). Infliximab and adalimumab proved to be equally effective in preventing endoscopic POR. CONCLUSION: Anti-TNFα agents are more effective in preventing clinical, endoscopic and histological POR than conventional therapies, even in nonselected CD patients.

15.
Clin Cosmet Investig Dent ; 11: 157-162, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31354361

RESUMO

Objective: This study compared attendees at Wisconsin Mission of Mercy (MoM) events with and without prior emergency department (ED) visits for dental care in terms of demographic characteristics and dental procedures received. Methods: De-identified archival data available from the America's Dentists Care Foundation (2013-2016) were analyzed. Summary statistics were calculated based on prior ED visit status for county-level characteristics and type of dental procedures received. Generalized estimating equation models with logistic links were fitted to examine associations between the predictor and independent variables. Results: Most attendees were White, adult females (mean age 37 years). Current dental pain was reported by 61% vs 33% of attendees with and without prior ED visit. Cleaning (57%) was the most common procedure received by attendees with no prior ED visits, while extractions (47%) were the most common for those with prior ED visits. Among MoM attendees, males had higher odds of prior ED visits compared to females. Compared to White, Black had higher odds and Hispanic had lower odds of having prior ED visits. In the multivariable analysis, dental pain (OR: 3.32; 95% CI: 2.75, 4.02) had the strongest association with prior ED visits. Attendees with prior ED visit history had higher odds of receiving extractions and restorative care, compared to cleaning after adjustment for person and county-level characteristics. Conclusion: Among MoM attendees, prior ED visits were associated with not being Hispanic, being male, and having dental pain. Compared to attendees with no prior ED visit, those with prior ED visits had higher odds of receiving restorative care and extractions.

16.
Surgery ; 166(4): 483-488, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31345565

RESUMO

BACKGROUND: Alvimopan has been shown to reduce length of stay after bowel resection. Use remains variable among institutions due to cost and efficacy concerns in laparoscopic surgery. Additionally, alvimopan's effects have not been isolated from other medications within enhanced recovery protocols. The aim of this study was to distinguish the relationship between alvimopan use, length of stay, and cost in both open and laparoscopic segmental colectomies. METHODS: The Vizient dataset was queried to identify patients undergoing open and laparoscopic colectomies from 2015 to 2017. Patient demographics and treatment details were collected. Primary outcomes of interest included duration of stay and total direct costs. RESULTS: In the study, 12,727 patients met inclusion criteria and 3,358 (26.4%) received alvimopan. For both open and laparoscopic groups, alvimopan was associated with decreased length of stay in unadjusted (4.0 vs 6.0 days, P < .01 and 3.0 vs 4.0 days, P < .01, respectively) and adjusted analysis (effect ratio 0.79, P < .01 and 0.85, P < .01, respectively). Alvimopan was associated with a 7% decrease in direct cost after adjustment (effect ratio 0.93, P = .04), with no cost difference in laparoscopic procedures (effect ratio 0.99, P = .71). CONCLUSION: Alvimopan use is associated with decreased length of stay for both open and laparoscopic colon resections, decreased cost in open procedures, and no cost difference for laparoscopic procedures.

17.
JAMA Netw Open ; 2(7): e196476, 2019 Jul 03.
Artigo em Inglês | MEDLINE | ID: mdl-31276175

RESUMO

Importance: Hematopoietic cell transplantation (HCT) is a therapeutic strategy in the management of several hematological cancers. Limited data exist on the incidence and predictors of 30-day readmission after HCT. Objective: To measure the incidence of and risk factors associated with 30-day readmission following HCT in the United States. Design, Setting, and Participants: This cohort study examined patient data from the US population-based Nationwide Readmissions Database. All adults (age ≥18 years) who underwent autologous (auto-) or allogenic (allo-) HCT in US hospitals between January 1, 2012, and November 30, 2014, were included. The analysis was performed from June 2018 to February 2019. Main Outcomes and Measures: The main outcome was 30-day readmission rates for auto-HCT and allo-HCT. Factors associated with readmission, including baseline demographic characteristics and disease- and hospital-related characteristics (including annual case volume), were measured. Results: A total of 28 356 index admissions for auto-HCT in 244 centers (191 low-volume, 38 medium-volume, and 15 high-volume centers) and 17 217 index admissions for allo-HCT in 211 centers (161 low-volume, 37 medium-volume, and 13 high-volume centers) were identified during the study period. The overall 30-day readmission rates were 11.6% for auto-HCT and 24.4% for allo-HCT. The odds of readmission were significantly higher in low-volume hospitals compared with high-volume hospitals (adjusted odds ratio [aOR], 1.69; 95% CI, 1.08-2.64 for auto-HCT and aOR, 1.41; 95% CI, 1.09-1.82 for allo-HCT) but comparable to medium-volume hospitals (aOR, 1.06; 95% CI, 0.62-1.83 for auto-HCT and aOR, 1.19; 95% CI, 0.90-1.57 for allo-HCT). Other factors associated with readmission for auto-HCT included younger age (aOR for age ≥50 vs <49 years, 0.82; 95% CI, 0.68-0.98), female sex (aOR, 1.21; 95% CI, 1.06-1.36), disease type (aOR for other vs myeloma, 1.37; 95% CI, 1.06-1.77), and Elixhauser comorbidity index score (aOR for ≥20 vs 0, 1.5; 95% CI, 1.17-1.93). For allo-HCT, factors associated with readmission included disease type (aOR for acute lymphoblastic leukemia vs acute myelogenous leukemia, 1.30; 95% CI, 1.04-1.62), insurance (aOR for Medicare vs private, 1.18; 95% CI, 1.02-1.36), and Elixhauser comorbidity index score (aOR for 1-9 vs 0, 1.2; 95% CI, 1.04-1.39). Infections, neutropenic fever, and gastrointestinal symptoms were the most common reasons for readmission for both types of HCT. Conclusions and Relevance: This study found substantial rates of readmission for both types of HCT and an inverse association between hospital HCT volume and 30-day readmission. These results may provide guidance when developing quality indicators and policies penalizing hospitals for HCT readmission.

18.
Blood Adv ; 3(11): 1661-1669, 2019 Jun 11.
Artigo em Inglês | MEDLINE | ID: mdl-31167818

RESUMO

Outcomes for diffuse large B-cell lymphoma (DLBCL) patients relapsing after autologous hematopoietic cell transplantation (auto-HCT) have been historically poor. We studied outcomes of such patients using data from 4 transplantation centers. Eligibility criteria included adult patients (age ≥18 years) with DLBCL experiencing disease relapse after auto-HCT performed during 2006 to 2015. The time period was stratified into 2 eras (era 1, 2006-2010; era 2, 2011-2015). The primary end point was postrelapse overall survival (PR-OS). Secondary end points were factors prognostic of PR-OS. Of the 700 patients with DLBCL who underwent auto-HCT, 248 (35%) relapsed after auto-HCT. Median PR-OS of all relapsed DLBCL patients after auto-HCT (n = 228) was 9.8 months (95% confidence interval [CI], 7-15). Median PR-OS was significantly better for patients in complete (17.8 months; 95% CI, 7.9-41.6) vs partial remission at auto-HCT (7.1 months; 95% CI, 5.4-11; P = .01), those undergoing auto-HCT >1 year (12.8 months; 95% CI, 7.6-24.9) vs ≤1 year after DLBCL diagnosis (6.3 months; 95% CI, 4.5-9.2; P = .01), and those with late (56.4 months; 95% CI, 23.7-∞) vs early relapse (5.9 months; 95% CI, 4.5-8.8; P < .0001). On multivariate analysis, although late relapse (hazard ratio [HR], 0.21; 95% CI, 0.13-0.34; P < .0001) was associated with significantly lower mortality, the risk of mortality increased with age (HR, 1.25 per decade; 95% CI, 1.06-1.48; P = .009). This is the largest study to date to evaluate outcomes of DLBCL patients relapsing after auto-HCT. Our study provides benchmarking for future trials of chimeric antigen receptor T cells and other promising agents evaluating PR-OS after auto-HCT.

19.
Neurogastroenterol Motil ; 31(9): e13668, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31236998

RESUMO

BACKGROUND: The Chicago Classification of esophageal motility includes a group of patients who show evidence of esophagogastric junction outflow obstruction (EGJOO) as demonstrated by elevated integrated relaxation pressure (IRP) and preserved peristalsis. Our aim is to classify EGJOO patients based on response to amyl nitrite (AN) during high-resolution manometry. METHODS: Patients were considered to have true EGJOO if elevated IRP during supine swallow persisted in the upright position and was associated with high intrabolus pressure. The EGJ response to AN was compared between patients with achalasia type 2 (A2) and normal esophageal motility. Based on the relaxation gain (deglutitive IRP-AN IRP) value that best discriminated these two groups (10 mm Hg), patients with true EGJOO were categorized as being in either the AN-responsive (AN-R) or AN-unresponsive (AN-U) subgroups. KEY RESULTS: In the group of 49 patients with true EGJOO, the AN response classified 27 patients (IRP = 25 ± 10 mm Hg) with AN-R and 22 patients (IRP = 20 ± 5 mm Hg) with AN-U (P = 0.2). In AN-R, AN produced a relaxation gain and rebound after-contraction response at the EGJ comparable to A2 patients. AN-U patients had an elevated IRP after AN and a relaxation gain similar to normal esophageal motility patients. AN-U patients were obese and had higher prevalence of sleep apnea (P < 0.05). CONCLUSIONS: Among patients with true EGJOO, only half have pharmacologic evidence of impaired LES relaxation. Pharmacologic interrogation of the EGJ is thus necessary to identify the subgroup of EGJOO patients who could be expected to benefit from LES ablative therapies.

20.
Pancreatology ; 19(4): 488-499, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31068256

RESUMO

BACKGROUND: Unwarranted administration of antibiotics in acute pancreatitis presents a global challenge. The clinical reasoning behind the misuse is poorly understood. Our aim was to investigate current clinical practices and develop recommendations that guide clinicians in prescribing antibiotic treatment in acute pancreatitis. METHODS: Four methods were used. 1) Systematic data collection was performed to summarize current evidence; 2) a retrospective questionnaire was developed to understand the current global clinical practice; 3) five years of prospectively collected data were analysed to identify the clinical parameters used by medical teams in the decision making process, and finally; 4) the UpToDate Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was applied to provide evidence based recommendations for healthcare professionals. RESULTS: The systematic literature search revealed no consensus on the start of AB therapy in patients with no bacterial culture test. Retrospective data collection on 9728 patients from 22 countries indicated a wide range (31-82%) of antibiotic use frequency in AP. Analysis of 56 variables from 962 patients showed that clinicians initiate antibiotic therapy based on increased WBC and/or elevated CRP, lipase and amylase levels. The above mentioned four laboratory parameters showed no association with infection in the early phase of acute pancreatitis. Instead, procalcitonin levels proved to be a better biomarker of early infection. Patients with suspected infection because of fever had no benefit from antibiotic therapy. CONCLUSIONS: The authors formulated four consensus statements to urge reduction of unjustified antibiotic treatment in acute pancreatitis and to use procalcitonin rather than WBC or CRP as biomarkers to guide decision-making.


Assuntos
Antibacterianos/uso terapêutico , Gestão de Antimicrobianos , Pancreatite/tratamento farmacológico , Doença Aguda , Infecções Bacterianas/complicações , Infecções Bacterianas/tratamento farmacológico , Biomarcadores , Tomada de Decisão Clínica , Consenso , Medicina Baseada em Evidências , Fidelidade a Diretrizes , Humanos , Pancreatite/complicações , Pancreatite/microbiologia , Padrões de Prática Médica , Ensaios Clínicos Controlados Aleatórios como Assunto , Inquéritos e Questionários
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