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1.
Dis Colon Rectum ; 64(11): 1417-1425, 2021 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-34192709

RESUMO

BACKGROUND: The emergency department plays a common and critical role in the treatment of postoperative patients. However, many quality improvement databases fail to record these interactions. As such, our understanding of the prevalence and etiology of postoperative emergency department visits in contemporary colorectal surgery is limited. Visits with potentially preventable etiologies represent a significant target for quality improvement, particularly in the current era of rapidly evolving postoperative and ambulatory care patterns. OBJECTIVE: We aimed to characterize postoperative emergency department visits and identify factors associated with these visits for potential intervention. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at an academic medical center. PATIENTS: Consecutive patients undergoing colectomy or proctectomy within the division of colorectal surgery at an academic medical center between 2014 and 2018 were included. MAIN OUTCOME MEASURES: Frequency and indication for emergency department visits, as well as clinical and sociodemographic factors associated with emergency department visits in the postoperative period, were included measures. RESULTS: From the 1763 individual operations, there were 207 emergency department visits from 199 patients (11%) within 30 days of discharge. Two thirds of emergency department visits led to readmission. Median (interquartile range) time to presentation was 8 days (4-16 d). Median time in the emergency department was 7.8 hours (6.0-10.1 h). One third of visits were identified as potentially preventable, most commonly for pain (17%) and stoma complications (excluding dehydration; 13%). A primary language other than English was associated with any postoperative emergency department visit risk ratio of 2.7 (95% CI, 1.3-5.3), as well as a preventable visit risk ratio of 3.6 (95% CI, 1.7-8.0). LIMITATIONS: This was a single-center study and a retrospective review. CONCLUSIONS: One third of emergency department visits after colorectal surgery are potentially preventable. Special attention should be directed toward those patients who do not speak English as a primary language. See Video Abstract at http://links.lww.com/DCR/B648. SE PUEDEN EVITAR LAS VISITAS AL SERVICIO DE URGENCIA DESPUS DE UNA CIRUGA COLORECTAL: ANTECEDENTES:Las unidades de emergencia tienen un rol fundamental en el periodo posterior a una cirugía. Sin embargo muchos de los registros en las bases de datos de estas secciones no son de buena calidad. Por esto analizar la prevalencia y etiología de las visitas postoperatorias en cirugía colorectal resulta ser bastante limitada. Para lograr una mejoría en la calidad es fundamental analizar las causas potencialmente evitables, especialmente al considerer la rapida evolucion de los parametros de medición actuales.OBJETIVO:Nuestro objetivo es caracterizar las visitas postoperatorias al servicio de urgencias e identificar los factores asociados potencialmente evitables.DISEÑO:Estudio de cohorte retrospectivo.AJUSTE:Centro médico académico, 2014-2018.PACIENTES:Pacientes consecutivos sometidos a colectomía o proctectomía dentro de la división de cirugía colorrectal en un centro médico académico entre 2014 y 2018.PRINCIPALES MEDIDAS DE RESULTADO:Frecuencia e indicación de las visitas al servicio de urgencias en el period postoperatorio: factores clínicos y sociodemográficos.RESULTADOS:De 1763 operaciones individuales, hubo 207 visitas al departamento de emergencias de 199 pacientes (11%) en los 30 días posteriores al alta. Dos tercios de las visitas al servicio de urgencias dieron lugar a readmisiones. La mediana [rango intercuartílico] de tiempo hasta la presentación fue de 8 [4-16] días. La mediana de tiempo en el servicio de urgencias fue de 7,8 [6-10,1] horas. Un tercio de las visitas se identificaron como potencialmente evitables, más comúnmente dolor (17%) y complicaciones del estoma (excluida la deshidratación) (13%). En los pacientes con poco manejo del inglés se asoció con una mayor frecuencia razón de visitas al departamento de emergencias posoperatorias [IC del 95%] 2,7 [1,3-5,3], así como opetancialmente evitables con un RR de 3,6 [1,7-8,0].LIMITACIONES:Estudio de un solo centro y revisión retrospectiva.CONCLUSIÓN:Al menos un tercio de las visitas al servicio de urgencias después de una cirugía colorrectal son potencialmente evitables. Se debe prestar especial atención a los pacientes que no hablan inglés como idioma materno. Consulte Video Resumen en http://links.lww.com/DCR/B648.

2.
Am J Med Qual ; 36(5): 320-327, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33967194

RESUMO

Enhanced Recovery after Surgery (ERAS) pathways in colorectal surgery improve outcomes and reduce disparities, but pathway adherence rates are variable. Sustainability of adherence following initial implementation, particularly in academic settings with trainee involvement, is underexplored. This study measures and describes ERAS adherence for 163 consecutive patients undergoing elective colorectal resection in an academic colorectal surgery department with a well-established ERAS pathway. Providers, including residents and nursing staff, were surveyed regarding pathway knowledge and obstacles to adherence. Adherence was higher preoperatively (80%) and intraoperatively (93%) than postoperatively (61%). Opioid-sparing analgesia and bowel motility agents were underdosed on up to 63% of hospital days, without clinical rationale in ≥50% of cases. Providers cited peer teaching (71%) as the primary source of pathway knowledge and identified individual surgeon preferences as an obstacle to adherence. Formalized ERAS pathway education, communication, and coordination among attending physicians are needed to reduce provider-driven deviation in an academic setting.


Assuntos
Recuperação Pós-Cirúrgica Melhorada , Procedimentos Cirúrgicos Eletivos , Hospitais , Humanos , Tempo de Internação , Complicações Pós-Operatórias
3.
Blood ; 138(13): 1182-1193, 2021 09 30.
Artigo em Inglês | MEDLINE | ID: mdl-33945603

RESUMO

Events mediated by the P-selectin/PSGL-1 pathway play a critical role in the initiation and propagation of venous thrombosis by facilitating the accumulation of leukocytes and platelets within the growing thrombus. Activated platelets and endothelium express P-selectin, which binds P-selectin glycoprotein ligand-1 (PSGL-1) that is expressed on the surface of all leukocytes. We developed a pegylated glycomimetic of the N terminus of PSGL-1, PEG40-GSnP-6 (P-G6), which proved to be a highly potent P-selectin inhibitor with a favorable pharmacokinetic profile for clinical translation. P-G6 inhibits human and mouse platelet-monocyte and platelet-neutrophil aggregation in vitro and blocks microcirculatory platelet-leukocyte interactions in vivo. Administration of P-G6 reduces thrombus formation in a nonocclusive model of deep vein thrombosis with a commensurate reduction in leukocyte accumulation, but without disruption of hemostasis. P-G6 potently inhibits the P-selectin/PSGL-1 pathway and represents a promising drug candidate for the prevention of venous thrombosis without increased bleeding risk.

4.
Acad Med ; 96(9): 1306-1310, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-33538475

RESUMO

PROBLEM: Health professions education does not routinely incorporate training in innovation or creative problem solving. Although some models of innovation education within graduate medical education exist, they often require participants' full-time commitment and removal from clinical training or rely upon participants' existing expertise. There is a need for curricula that teach innovation skills that will enable trainees to identify and solve unmet clinical challenges in everyday practice. To address this gap in surgical graduate education, the authors developed the Surgical Program in Innovation (SPIN). APPROACH: SPIN, a 6-month workshop-based curriculum, was established in 2016 in the Beth Israel Deaconess Medical Center Department of Surgery to teach surgical trainees the basics of the innovation process, focusing on surgeon-driven problem identification, product design, prototype fabrication, and initial steps in the commercialization process. Participating surgical residents and graduate students attend monthly workshops taught by medical, engineering, and medical technology (MedTech) industry faculty. Participants collaborate in teams to develop a novel device, fabricate a protype, and pitch their product to a panel of judges. OUTCOMES: From academic years 2015-2016 to 2017-2018, 49 trainees, including 41 surgical residents, participated in SPIN. Across this period, 13 teams identified an unmet need, ideated a solution, and designed and pitched a novel device. Ten teams fabricated prototypes. The 22 SPIN participants who responded to both pre- and postcourse surveys reported significant increases in confidence in generating problem statements, computer-aided design, fabrication of a prototype, and initial commercialization steps (product pitching and business planning). NEXT STEPS: Incorporating innovation education and design thinking into clinical training will prove essential in preparing future physicians to be lifelong problem finders and solvers. The authors plan to expand SPIN to additional clinical specialties, as well as to assess its impact in fostering future innovation and collaboration among program participants.


Assuntos
Currículo , Educação de Pós-Graduação em Medicina/métodos , Invenções , Aprendizagem Baseada em Problemas/métodos , Cirurgiões/educação , Difusão de Inovações , Humanos , Internato e Residência/métodos , Determinação de Necessidades de Cuidados de Saúde
5.
J Vasc Surg ; 72(2): 387-388, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32711903
9.
Sci Adv ; 6(3): eaay8230, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31998845

RESUMO

Aryl hydrocarbon receptor (AHR) is an essential regulator of gut immunity and a promising therapeutic target for inflammatory bowel disease (IBD). Current AHR agonists are inadequate for clinical translation due to low activity, inadequate pharmacokinetics, or toxicity. We synthesized a structurally diverse library and used integrated computational and experimental studies to discover mechanisms governing ligand-receptor interaction and to design potent drug leads PY109 and PY108, which display physiochemical drug-likeness properties, desirable pharmacokinetic profiles, and low toxicity. In a murine model of dextran sulfate sodium-induced colitis, orally administered compounds increase interleukin-22 (IL-22) production and accelerate mucosal healing by modulating mucosal adaptive and innate lymphoid cells. AHR and IL-22 pathway induction was confirmed using RNA sequencing and characterization of the lymphocyte protein-protein interaction network. Significant induction of IL-22 was also observed using human T cells from patients with IBD. Our findings support rationally designed AHR agonists for IBD therapy.


Assuntos
Desenho de Fármacos , Imunomodulação/efeitos dos fármacos , Linfócitos/efeitos dos fármacos , Linfócitos/metabolismo , Receptores de Hidrocarboneto Arílico/agonistas , Cicatrização/efeitos dos fármacos , Cicatrização/imunologia , Animais , Peptídeos Catiônicos Antimicrobianos/genética , Peptídeos Catiônicos Antimicrobianos/farmacologia , Colite/etiologia , Colite/metabolismo , Colite/patologia , Sulfato de Dextrana/efeitos adversos , Modelos Animais de Doenças , Estabilidade de Medicamentos , Expressão Gênica , Humanos , Interleucinas/biossíntese , Mucosa Intestinal/efeitos dos fármacos , Mucosa Intestinal/imunologia , Mucosa Intestinal/metabolismo , Mucosa Intestinal/patologia , Ligantes , Linfócitos/imunologia , Camundongos , Modelos Moleculares , Conformação Molecular , Receptores de Hidrocarboneto Arílico/química , Regeneração , Relação Estrutura-Atividade , Linfócitos T/imunologia , Linfócitos T/metabolismo , Cicatrização/genética
10.
Surg Endosc ; 34(7): 3011-3019, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31485929

RESUMO

BACKGROUND: The transversus abdominis plane (TAP) block is an important non-narcotic adjunct for post-operative pain control in abdominal surgery. Surgeons can use laparoscopic guidance for TAP block placement (LTAP), however, direct comparisons to conventional ultrasound-guided TAP (UTAPs) have been lacking. The aim of this study is to determine if surgeon placed LTAPs were non-inferior to anesthesia placed UTAPs for post-operative pain control in laparoscopic colorectal surgery. METHODS: This was a prospective, randomized, patient and observer blinded parallel-arm non-inferiority trial conducted at a single tertiary academic center between 2016 and 2018 on adult patients undergoing laparoscopic colorectal surgery. Narcotic consumption and pain scores were compared for LTAP vs. UTAP for 48 h post-operatively. RESULTS: 60 patients completed the trial (31 UTAP, 29 LTAP) of which 25 patients were female (15 UTAP, 10 LTAP) and the mean ages (SD) were 60.0 (13.6) and 61.5 (14.3) in the UTAP and LTAP groups, respectively. There was no significant difference in post-operative narcotic consumption between UTAP and LTAP at the time of PACU discharge (median [IQR] milligrams of morphine, 1.8 [0-4.5] UTAP vs. 0 [0-8.7] LTAP P = .32), 6 h post-operatively (5.4 [1.8-17.1] UTAP vs. 3.6 [0-12.6] LTAP P = .28), at 12 h post-operatively (9.0 [3.6-29.4] UTAP vs. 7.2 [0.9-22.5] LTAP P = .51), at 24 h post-operatively (9.0 [3.6-29.4] UTAP vs. 7.2 [0.9-22.5] LTAP P = .63), and 48 h post-operatively (39.9 [7.5-70.2] UTAP vs. 22.2 [7.5-63.8] LTAP P = .41). Patient-reported pain scores as well as pre-, intra-, and post-operative course were similar between groups. Non-inferiority criteria were met at all post-op time points up to and including 24 h but not at 48 h. CONCLUSIONS: Surgeon-delivered LTAPs are safe, effective, and non-inferior to anesthesia-administered UTAPs in the immediate post-operative period. TRIAL REGISTRY: The trial was registered at clinicaltrials.gov Identifier NCT03577912.


Assuntos
Cirurgia Colorretal/métodos , Laparoscopia/métodos , Bloqueio Nervoso/métodos , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Músculos Abdominais , Idoso , Anestesistas , Cirurgia Colorretal/efeitos adversos , Feminino , Humanos , Laparoscopia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Morfina/administração & dosagem , Morfina/uso terapêutico , Estudos Prospectivos , Cirurgiões , Ultrassonografia de Intervenção
11.
Gastroenterol Rep (Oxf) ; 7(2): 77-90, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30976420

RESUMO

Since the introduction of the first anti-tumor necrosis factor antibodies in the late 1990s, biologic therapy has revolutionized the medical treatment of patients with inflammatory bowel disease (IBD). Nevertheless, surgery continues to play a significant role in treating IBD patients. Rates of intestinal resection in patients with Crohn's disease or colectomy in ulcerative colitis are reducing but not substantially over the long term. An increasing variety of biologic medications are now available to treat IBD patients in various clinical situations. Consequently, a number of questions persist about how biologic medications affect the need for surgery and overall course in IBD patients. Given the trend for earlier and more frequent use of biologic medications in IBD patients, a working knowledge of the effects of these medications on surgical decision-making and outcomes is essential for the practicing colorectal surgeon and gastroenterologist. This review seeks to summarize the relevant literature surrounding biologic use and IBD surgery with a focus on the effect of biologics on the frequency, type and complications of surgery in this 'age of biologics'.

12.
ANZ J Surg ; 89(3): 165-170, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-29943881

RESUMO

BACKGROUND: To date, there are few studies comparing the outcomes of robotic hepatectomy (RH) versus open hepatectomy (OH). We report the first systematic review and meta-analysis comparing the outcomes of RH versus OH. METHODS: A systemic review was performed of all comparative studies of RH versus OH that reported the perioperative outcome(s) of interest. RESULTS: Seven retrospective cohort studies were included. There was no significant difference in patients' baseline characteristics. RH was associated with a longer operation time (mean difference (MD) 61.47 min; 95% confidence interval (CI) (7.03, 115.91); P = 0.03), shorter hospital stay (MD -2.57 days; 95% CI (-3.31, -1.82); P < 0.001), lower costs, less overall (risk ratio (RR) 0.63; 95% CI (0.46, 0.86); P = 0.004), minor (RR 0.64; 95% CI (0.43, 0.95); P = 0.03) and major (RR 0.45; 95% CI (0.22, 0.94); P = 0.03) post-operative complications compared to OH. CONCLUSION: RH had superior perioperative outcomes and was not cost prohibitive compared to OH, but had longer operation times.


Assuntos
Hepatectomia/efeitos adversos , Hepatectomia/estatística & dados numéricos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Hepatectomia/economia , Hepatectomia/tendências , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/economia , Laparoscopia/estatística & dados numéricos , Tempo de Internação/tendências , Razão de Chances , Duração da Cirurgia , Período Perioperatório/estatística & dados numéricos , Período Perioperatório/tendências , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/economia , Procedimentos Cirúrgicos Robóticos/tendências , Resultado do Tratamento
13.
Head Neck ; 40(4): 846-854, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29155470

RESUMO

BACKGROUND: Indications for treatment and outcomes after endovascular management of carotid blowout syndrome for patients with head and neck cancer are not well defined. We investigated the safety and effectiveness of endovascular embolization and stent-graft reconstruction. METHODS: A literature review was performed for studies published between 2001 and 2015 with relevance to treatment outcomes. Our institutional database was examined to identify patients treated with endovascular techniques. RESULTS: A total of 266 patients were included. Rates of procedural stroke were higher after embolization of internal carotid artery (ICA)/common carotid artery (CCA) compared to stent graft (embolization 10.3%; stent graft 2.5%; P < .02). Stent graft of ICA/CCA was associated with higher rates of recurrent bleeding (embolization 9.1%; stent graft 31.9%; P < .01). CONCLUSION: Both embolization and stent grafts are safe therapeutic options for acute carotid blowout syndrome. Embolization for ICA/CCA carotid blowout syndrome was associated with higher risks of procedural stroke and lower recurrent bleeding compared to stent grafts.


Assuntos
Doenças das Artérias Carótidas/terapia , Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Neoplasias de Cabeça e Pescoço/cirurgia , Esvaziamento Cervical/efeitos adversos , Stents , Doença Aguda , Adulto , Idoso , Doenças das Artérias Carótidas/etiologia , Artéria Carótida Primitiva/fisiopatologia , Artéria Carótida Interna/fisiopatologia , Feminino , Neoplasias de Cabeça e Pescoço/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Esvaziamento Cervical/métodos , Estudos Observacionais como Assunto , Medição de Risco , Ruptura Espontânea/etiologia , Ruptura Espontânea/terapia , Síndrome , Resultado do Tratamento
14.
J Vasc Surg ; 63(3): 795-804, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25446283

RESUMO

BACKGROUND: Vein bypass is an essential therapy for patients with advanced peripheral and coronary artery disease despite development of neointimal hyperplasia. We have shown that stimulation of the receptor tyrosine kinase ephrin type-B receptor 4 (Eph-B4) with its ligand ephrin-B2 prevents neointimal hyperplasia in murine vein grafts. This study determines whether Eph-B4 in adult human veins is capable of phosphorylation and activation of downstream signaling pathways, as well as functional to release nitric oxide (NO) and prevent neointimal hyperplasia in vitro. METHODS: Discarded human saphenous veins were taken from the operating room and placed in organ culture without or with ephrin-B2/Fc (2 µg/mL) for 14 days, and the neointima/media ratio was measured in matched veins. Primary human umbilical vein endothelial cells were treated with ephrin-B2/Fc (2 µg/mL) and examined with quantitative polymerase chain reaction, Western blot, immunoassays, and for release of NO. Ephrin-B2/Fc (2 µg/mL) was placed on the adventitia of saphenous veins treated with arterial shear stress for 24 hours in a bioreactor and activated Eph-B4 examined with immunofluorescence. RESULTS: The baseline intima/media ratio in saphenous vein rings was 0.456 ± 0.097, which increased to 0.726 ± 0.142 in untreated veins after 14 days in organ culture but only to 0.630 ± 0.132 in veins treated with ephrin-B2/Fc (n = 19, P = .017). Ephrin-B2/Fc stimulated Akt, endothelial NO synthase and caveolin-1 phosphorylation, and NO release (P = .007) from human umbilical vein endothelial cells (n = 6). Ephrin-B2/Fc delivered to the adventitia stimulated endothelial Eph-B4 phosphorylation after 24 hours of arterial stress in a bioreactor (n = 3). CONCLUSIONS: Eph-B4 is present and functional in adult human saphenous veins, with intact downstream signaling pathways capable of NO release and prevention of neointimal hyperplasia in vitro. Adventitial delivery of ephrin-B2/Fc activates endothelial Eph-B4 in saphenous veins treated with arterial shear stress in vitro. These results suggest that stimulation of Eph-B4 function may be a candidate strategy for translation to human clinical trials designed to inhibit venous neointimal hyperplasia.


Assuntos
Efrina-B2/farmacologia , Fragmentos Fc das Imunoglobulinas/farmacologia , Neointima , Receptor EphB4/agonistas , Veia Safena/efeitos dos fármacos , Reatores Biológicos , Caveolina 1/metabolismo , Proliferação de Células/efeitos dos fármacos , Células Cultivadas , Ativação Enzimática , Células Endoteliais da Veia Umbilical Humana/efeitos dos fármacos , Células Endoteliais da Veia Umbilical Humana/patologia , Humanos , Hiperplasia , Mecanotransdução Celular/efeitos dos fármacos , Óxido Nítrico/metabolismo , Óxido Nítrico Sintase Tipo III/metabolismo , Fosforilação , Cultura Primária de Células , Proteínas Proto-Oncogênicas c-akt/metabolismo , Receptor EphB4/genética , Receptor EphB4/metabolismo , Veia Safena/metabolismo , Veia Safena/patologia , Estresse Mecânico , Técnicas de Cultura de Tecidos/instrumentação
15.
Vascular ; 23(2): 183-7, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24903529

RESUMO

A 59-year-old woman was admitted three times over a six-month period with recurrent upper extremity deep venous thrombosis (UEDVT). It was determined that this patient was suffering from an unusual presentation of Paget-Schröetter syndrome secondary to a 20-year-old non-union of a midshaft clavicle fracture. Following thrombolysis the patient underwent resection and plate fixation of the clavicle fracture non-union. Despite the anatomic proximity of the subclavian vessels to the clavicle, vascular complications from fracture are rare. Treatment of midshaft clavicle fractures is often non-operative. Non-union rates are generally less than 10%, and easily treated secondarily without complication. Clavicular pseudo-arthroses from trauma have been implicated in the development of the thoracic outlet syndromes, however, onset 20 years after fracture has never before been reported.


Assuntos
Clavícula/cirurgia , Fraturas Ósseas/cirurgia , Síndrome do Desfiladeiro Torácico/cirurgia , Trombose Venosa/cirurgia , Placas Ósseas/efeitos adversos , Feminino , Humanos , Pessoa de Meia-Idade , Flebografia/métodos , Síndrome do Desfiladeiro Torácico/diagnóstico , Trombose Venosa Profunda de Membros Superiores/complicações , Trombose Venosa Profunda de Membros Superiores/diagnóstico , Trombose Venosa/diagnóstico
16.
Ann Thorac Surg ; 99(2): 393-8, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25497070

RESUMO

BACKGROUND: The aim of this study is to identify the predictors of hospital readmission or early unplanned return to clinic within 30 days of discharge after pulmonary lobectomy. METHODS: The medical records of patients undergoing lobectomy by the thoracic surgery service between January 2009 and July 2012 were reviewed. All lobectomies were included irrespective of the etiology of disease. Multivariate logistic regression methods were used to identify predictors of readmission and or early unplanned return to clinic. RESULTS: Two hundred thirteen patients underwent a pulmonary lobectomy during the study period (median age, 67 years). Pathologic diagnosis was malignant in 94% of the patients and benign in 6%. Minimally invasive approaches were used in 69% of the patients, whereas open thoracotomy was used in 31%. Median hospital length of stay was 4 days, and postoperative mortality occurred in 1 patient (0.5%). The Charlson comorbidity index was 1 ± 1. Predicted postoperative forced expiratory volume in 1 second and diffusing capacity of the lung for carbon monoxide were 68% ± 18% and 64% ± 17%, respectively. Postoperative complications occurred in 31% of patients; 13% required readmission to the hospital within 30 days of discharge or early unplanned return to clinic. Predictors of readmission or early unplanned return to clinic were unplanned transfer to the intensive care unit (odds ratio, 10.4; 95% confidence interval, 1.1 to 103.5; p = 0.04) and Charlson comorbidity index greater than 0 (odds ratio, 1.5; 95% confidence interval, 1.04 to 2.03; p = 0.03). Readmission or early unplanned return to clinic was independent of surgical approach (p = 0.32). CONCLUSIONS: Patients who require a postoperative transfer to the intensive care unit or with higher Charlson comorbidity index are at higher risk for hospital readmission after pulmonary lobectomy. Readmission was not affected by the surgical approach. Whether a different strategy to follow-up for these high-risk patients can prevent readmission remains to be determined.


Assuntos
Readmissão do Paciente/estatística & dados numéricos , Pneumonectomia/métodos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo
17.
Yale J Biol Med ; 87(3): 359-71, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25191151

RESUMO

Vein graft adaptation to the arterial environment is characterized by loss of venous identity, with reduced Ephrin type-B receptor 4 (Eph-B4) expression but without increased Ephrin-B2 expression. We examined changes of vessel identity of human saphenous veins in a flow circuit in which shear stress could be precisely controlled. Medium circulated at arterial or venous magnitudes of laminar shear stress for 24 hours; histologic, protein, and RNA analyses of vein segments were performed. Vein endothelium remained viable and functional, with platelet endothelial cell adhesion molecule (PECAM)-expressing cells on the luminal surface. Venous Eph-B4 expression diminished (p = .002), Ephrin-B2 expression was not induced (p = .268), and expression of osteopontin (p = .002) was increased with exposure to arterial magnitudes of shear stress. Similar changes were not found in veins placed under venous flow or static conditions. These data show that human saphenous veins remain viable during ex vivo application of shear stress in a bioreactor, without loss of the venous endothelium. Arterial magnitudes of shear stress cause loss of venous identity without gain of arterial identity in human veins perfused ex vivo. Shear stress alone, without immunologic or hormonal influence, is capable of inducing changes in vessel identity and, specifically, loss of venous identity.


Assuntos
Artérias/fisiologia , Receptor EphB4/metabolismo , Veia Safena/metabolismo , Resistência ao Cisalhamento , Estresse Mecânico , Adulto , Apoptose , Reatores Biológicos , Células Endoteliais/metabolismo , Imunofluorescência , Hemorreologia , Humanos , Modelos Biológicos , Pressão , Sobrevivência de Tecidos
18.
J Am Coll Surg ; 219(4): 771-7, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25158910

RESUMO

BACKGROUND: Carotid endarterectomy (CEA) is an effective surgical option for stroke prophylaxis for most patients. Restenosis after CEA can lead to additional interventions and adverse outcomes, but the factors that predict restenosis are poorly understood. This study examined which risk factors, such as metabolic syndrome (MetS), are associated with restenosis after CEA. STUDY DESIGN: This retrospective study examined the records of all patients who underwent CEA at the Veterans Affairs Connecticut Healthcare System during a 4-year period. Metabolic syndrome was defined as the presence of 3 or more of the following: hypertension (blood pressure ≥130 mmHg/≥85 mmHg); serum triglycerides ≥150 mg/dL; high-density lipoprotein ≤40 mg/dL; BMI ≥25 kg/m(2); and fasting blood glucose ≥110 mg/dL. Major adverse events were defined as death, stroke, or MI. Restenosis was defined as >50% stenosis on follow-up imaging. RESULTS: Seventy-eight patients underwent 79 CEAs during the study period. All patients were male and 76% were white. Mean patient age was 72.6 years. The mean duration of follow-up was 5.2 years. Sixty-seven percent of patients had MetS. Patients with MetS were comparable with those without MetS in demographics and preoperative comorbidities, except for increased hypertension and diabetes, as expected, and chronic renal insufficiency (p = 0.05). There was no significant difference in long-term survival or freedom from MAE between patients with and without MetS. Restenosis was significantly higher in patients with MetS (p = 0.02) and occurred 2 years after CEA in patients with MetS only, with a large increase in restenosis after 5 years (p = 0.018). MetS was an independent predictor of restenosis in multivariable analysis (p = 0.01). CONCLUSIONS: Metabolic syndrome is an independent predictor for restenosis after CEA in a high-risk population. More frequent and/or long-term surveillance might be warranted in patients with MetS after CEA.


Assuntos
Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Síndrome Metabólica/complicações , Medição de Risco/métodos , Idoso , Estenose das Carótidas/complicações , Connecticut/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Síndrome Metabólica/epidemiologia , Prognóstico , Recidiva , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
19.
N Am J Med Sci ; 6(7): 321-7, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25077080

RESUMO

BACKGROUND: Despite low peri-operative mortality after major lower extremity amputation, long-term mortality remains substantial. Metabolic syndrome is increasing in incidence and prevalence at an alarming rate in the USA. AIM: This study was to determine whether metabolic syndrome predicts outcome after major lower extremity amputation. PATIENTS AND METHODS: A retrospective review of charts between July 2005 and June 2010. RESULTS: Fifty-four patients underwent a total of 60 major lower extremity amputations. Sixty percent underwent below-knee amputation and 40% underwent above-knee amputation. The 30-day mortality was 7% with no difference in level (below-knee amputation, 8%; above-knee amputation, 4%; P = 0.53). The mean follow-up time was 39.7 months. The 5-year survival was 54% in the whole group, and was independent of level of amputation (P = 0.24) or urgency of the procedure (P = 0.51). Survival was significantly decreased by the presence of underlying chronic kidney disease (P = 0.04) but not by other comorbidities (history of myocardial infarction, P = 0.79; metabolic syndrome, P = 0.64; diabetes mellitus, P = 0.56). CONCLUSION: Metabolic syndrome is not associated with increased risk of adverse outcomes after lower extremity amputation. However, patients with chronic kidney disease constitute a sub-group of patients at higher risk of postoperative long-term mortality and may be a group to target for intervention.

20.
J Surg Res ; 188(1): 162-73, 2014 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-24582063

RESUMO

Veins are exposed to the arterial environment during two common surgical procedures, creation of vein grafts and arteriovenous fistulae (AVF). In both cases, veins adapt to the arterial environment that is characterized by different hemodynamic conditions and increased oxygen tension compared with the venous environment. Successful venous adaptation to the arterial environment is critical for long-term success of the vein graft or AVF and, in both cases, is generally characterized by venous dilation and wall thickening. However, AVF are exposed to a high flow, high shear stress, low-pressure arterial environment and adapt mainly via outward dilation with less intimal thickening. Vein grafts are exposed to a moderate flow, moderate shear stress, high-pressure arterial environment and adapt mainly via increased wall thickening with less outward dilation. We review the data that describe these differences, as well as the underlying molecular mechanisms that mediate these processes. Despite extensive research, there are few differences in the molecular pathways that regulate cell proliferation and migration or matrix synthesis, secretion, or degradation currently identified between vein graft adaptation and AVF maturation that account for the different types of venous adaptation to arterial environments.


Assuntos
Adaptação Fisiológica , Derivação Arteriovenosa Cirúrgica , Veias/fisiologia , Animais , Artérias/fisiologia , Velocidade do Fluxo Sanguíneo , Pressão Sanguínea , Humanos , Veias/transplante
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