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1.
Br J Anaesth ; 124(3): 314-323, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32000978

RESUMO

BACKGROUND: In surgical patients undergoing general anaesthesia, coughing at the time of extubation is common and can result in potentially dangerous complications. We performed a systematic review and meta-analysis to assess the efficacy and safety of i.v. lidocaine administration during the perioperative period to prevent cough and other airway complications. METHODS: We searched Medical Literature Analysis and Retrieval System, Excerpta Medica database, and Cochrane Central Register of Controlled Trials for RCTs comparing the perioperative use of i.v. lidocaine with a control group in adult patients undergoing surgery under general anaesthesia. The RCTs were assessed using risk-of-bias assessment, and the quality of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE). RESULTS: In 16 trials (n=1516), the administration of i.v. lidocaine compared with placebo or no treatment led to large reductions in post-extubation cough (risk ratio [RR]: 0.64; 95% confidence interval [CI]: 0.48-0.86) and in postoperative sore throat at 1 h (RR: 0.46; 95% CI: 0.32-0.67). There was no difference in incidence of laryngospasm (risk difference [RD]: 0.02; 95% CI: -0.07 to 0.03) or incidence of adverse events related to the use of lidocaine. CONCLUSIONS: The use of i.v. lidocaine perioperatively decreased airway complications, including coughing and sore throat. There was no associated increased risk of harm.

2.
Ann Thorac Surg ; 2020 Jan 23.
Artigo em Inglês | MEDLINE | ID: mdl-31982438

RESUMO

BACKGROUND: Limited data exist for pectus excavatum repair in adults. We reviewed outcomes in adult patients undergoing Ravitch or Nuss pectus excavatum repairs to determine if there was a statistical difference in postoperative complications and recurrence between primary and redo operations. METHODS: Patients undergoing pectus excavatum repair between 2001-2018 were excluded if they were receiving a concurrent unrelated operation, <18 years old, or had less than 1-year follow-up (for recurrence analysis). Postoperative complications were recorded based on procedure type (Ravitch/Nuss) and iteration of repair (primary/redo). Continuous patient data were compared using student's t-tests for variables such as age, length of stay, estimated blood loss, body mass index, and number of bars inserted. Chi-square or Fisher Exact tests were performed for postoperative complications and recurrence rates between groups. RESULTS: Of 290 patients, there were no significant differences in postoperative complications or recurrence rates between: all Nuss repairs (n=237) and all Ravitch repairs (n=53) (p=0.59 and p=0.48, respectively), redo Nuss repairs (n=53) and redo Ravitch repairs (n=26) (p=0.26, p=0.99), and primary and redo Nuss repairs (p=0.26, p=0.10) or primary and redo Ravitch repairs (p=0.99, p=0.99). There were significant differences in age, length of stay, follow-up, bars inserted, and estimated blood loss between all Nuss and Ravitch repairs (p<0.05). CONCLUSIONS: Postoperative complication and recurrence rates were not statistically different between Nuss and Ravitch procedures of all types, suggesting either procedure may have utility in recurrent pectus excavatum. Further research may look to expand sample size and a prospective study investigating long-term outcomes.

4.
J Cardiovasc Pharmacol ; 75(1): 21-30, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31633584

RESUMO

Perivascular sympathetic-sensory interactions have been shown to regulate calcitonin gene-related peptide (CGRP)-mediated vasodilation in rats. We investigated whether perivascular adipose tissue (PVAT) modulates the neurogenic vasorelaxation of isolated rat mesenteric arteries. Mesenteric arterial rings were prepared with or without PVAT (PVAT+ or PVAT-) and with either an intact or denuded endothelium (EC+ or EC-). The results of myography analysis revealed that vasocontraction to phenylephrine was highest in EC-PVAT-, lowest in EC+PVAT+, and intermediate in EC-PVAT+ and EC+PVAT-. Transmural nerve stimulation (TNS) induced the tetrodotoxin-sensitive relaxation of the phenylephrine-precontracted mesenteric arteries. However, nicotine induced minor relaxation in EC-PVAT+, whereas vasorelaxation was significantly enhanced in EC-PVAT-. Nicotine-induced vasorelaxation was insensitive to propranolol and also significantly lower in sympathetically-denervated and guanethidine-treated EC-PVAT-, whereas TNS-induced vasorelaxation persisted. In EC-PVAT- depleted of CGRP via capsaicin, nicotine- and TNS-induced vasorelaxation was almost absent. Lowering the pH of Krebs' solution using HCl led to pH-dependent vasorelaxation that was sensitive to CGRP8-37. Furthermore, nicotine-induced relaxation of EC-PVAT-, which was not affected by leptin, was blocked by methyl palmitate. Methyl palmitate did not affect TNS- or HCl-induced vasorelaxation. These results suggest that PVAT plays a modulatory role in regulating sympathetic-sensory interaction-mediated CGRPergic vasorelaxation via the release of methyl palmitate.

5.
Int J Urol ; 2019 Dec 07.
Artigo em Inglês | MEDLINE | ID: mdl-31812157

RESUMO

Penile erection implicates arterial inflow, sinusoidal relaxation and corporoveno-occlusive function. By far the most widely recognized vascular etiologies responsible for organic erectile dysfunction can be divided into arterial insufficiency, corporoveno-occlusive dysfunction or mixed type, with corporoveno-occlusive dysfunction representing the most common finding. In arteriogenic erectile dysfunction, corpora cavernosa show lower oxygen tension, leading to a diminished volume of cavernosal smooth muscle and consequential corporoveno-occlusive dysfunction. Current studies support the contention that corporoveno-occlusive dysfunction is an effect rather than the cause of erectile dysfunction. Surgical interventions have consisted primarily of penile revascularization surgery for arterial insufficiency and penile venous surgery for corporoveno-occlusive dysfunction, whatever the mechanism. However, the surgical effectiveness remained debatable and unproven, mostly owing to the lack of consistent hemodynamic assessment, standardized select patient and validated outcome measures, as well as various surgical procedures. Penile vascular surgery has been disclaimed to be the treatment of choice based on the currently available guidelines. However, reports on penile revascularization surgery support its utility in treating arterial insufficiency in otherwise healthy patients aged <55 years with erectile dysfunction of late attributable to arterial occlusive disease. Furthermore, it is noteworthy that penile venous surgery might be beneficial for selected patients with corporoveno-occlusive dysfunction, especially with a better understanding of the innovated venous anatomy of the penis. Penile vascular surgery might remain a viable alternative for the treatment of erectile dysfunction, and could have found its niche in the possibility of obtaining spontaneous, unaided and natural erection.

6.
J Natl Compr Canc Netw ; 17(12): 1464-1472, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31805526

RESUMO

The NCCN Guidelines for Non-Small Cell Lung Cancer (NSCLC) address all aspects of management for NSCLC. These NCCN Guidelines Insights focus on recent updates in immunotherapy. For the 2020 update, all of the systemic therapy regimens have been categorized using a new preference stratification system; certain regimens are now recommended as "preferred interventions," whereas others are categorized as either "other recommended interventions" or "useful under certain circumstances."

7.
Artigo em Inglês | MEDLINE | ID: mdl-31732692

RESUMO

For manufacturers of both sterile and non-sterile pharmaceuticals alike, there is an expectation that the manufacturing process is performed in an aseptic manner in which the products are provided in a safe, integral, pure, and unadulterated form. As part of that process, cleaning and disinfection are an absolute necessity. While cleaning and disinfection maintain control of microbial contamination preventatively and through corrective action, they do not have specific compendial obligations. The intent of this paper is to provide a general guidance on how to perform cleaning and disinfection efficacy testing. This includes how to make sure the concepts are understood, how to interpret facility data and utilize it to demonstrate control awareness for your facilities, and how to leverage the data to reduce redundancies in validation or verification.

8.
J Thorac Cardiovasc Surg ; 158(6): 1675-1677, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31627944
9.
Front Mol Neurosci ; 12: 217, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31607857

RESUMO

Oral cancer patients report severe function-induced pain; severity is greater in females. We hypothesize that a neutrophil-mediated endogenous analgesic mechanism is responsible for sex differences in nociception secondary to oral squamous cell carcinoma (SCC). Neutrophils isolated from the cancer-induced inflammatory microenvironment contain ß-endorphin protein and are identified by the Ly6G+ immune marker. We previously demonstrated that male mice with carcinogen-induced oral SCC exhibit less nociceptive behavior and a higher concentration of neutrophils in the cancer microenvironment compared to female mice with oral SCC. Oral cancer cells secrete granulocyte colony stimulating factor (G-CSF), a growth factor that recruits neutrophils from bone marrow to the cancer microenvironment. We found that recombinant G-CSF (rG-CSF, 5 µg/mouse, intraperitoneal) significantly increased circulating Ly6G+ neutrophils in the blood of male and female mice within 24 h of administration. In an oral cancer supernatant mouse model, rG-CSF treatment increased cancer-recruited Ly6G+ neutrophil infiltration and abolished orofacial nociceptive behavior evoked in response to oral cancer supernatant in both male and female mice. Local naloxone treatment restored the cancer mediator-induced nociceptive behavior. We infer that rG-CSF-induced Ly6G+ neutrophils drive an endogenous analgesic mechanism. We then evaluated the efficacy of chronic rG-CSF administration to attenuate oral cancer-induced nociception using a tongue xenograft cancer model with the HSC-3 human oral cancer cell line. Saline-treated male mice with HSC-3 tumors exhibited less oral cancer-induced nociceptive behavior and had more ß-endorphin protein in the cancer microenvironment than saline-treated female mice with HSC-3 tumors. Chronic rG-CSF treatment (2.5 µg/mouse, every 72 h) increased the HSC-3 recruited Ly6G+ neutrophils, increased ß-endorphin protein content in the tongue and attenuated nociceptive behavior in female mice with HSC-3 tumors. From these data, we conclude that neutrophil-mediated endogenous opioids warrant further investigation as a potential strategy for oral cancer pain treatment.

10.
Ann Thorac Surg ; 108(6): 1895-1900, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31336069

RESUMO

BACKGROUND: Previous "high-stakes" examinations by the American Board of Thoracic Surgery (ABTS) required remote testing, were noneducational, and were not tailored to individual practices. Given the ABTS mission of public safety and diplomate education, the ABTS Maintenance of Certification (MOC) examination was revised in 2015 to improve the educational experience and validate knowledge acquired. METHODS: The ABTS-MOC Committee developed a web-based, secure examination tailored to the specialty-specific practice profile (cardiac, general thoracic, cardiothoracic, congenital) of the individual surgeon. After an initial answer to each question, an educational critique was reviewed before returning to the initial question and logging a second (final) response. Intraexam learning was assessed by comparing scores before and after reading the critique. Diplomate feedback was obtained. RESULTS: A total of 988 diplomates completed the 10-year MOC examination between 2015 and 2017. Substantive learning was demonstrated with an 18%, 17%, 20%, and 9% improvement in cardiac, general thoracic, cardiothoracic, and congenital final scores, respectively. This improvement was most notable among diplomates with the lowest initial scores. Fewer diplomates failed the new exam (<1% vs 2.3%). Diplomate postexam survey highlighted marked improvements in clinical relevance (35% vs 78%), convenience (37% vs 78%), and learning (15% vs 45%). Over 80% acknowledged educational value, and 97% preferred the new format. CONCLUSIONS: The new MOC process demonstrates increased knowledge acquisition through a convenient, secure, web-based practice-focused examination. This approach provides feedback, identifies baseline knowledge gaps for individual diplomates, and validates new knowledge attained.

11.
CMAJ ; 191(30): E830-E837, 2019 07 29.
Artigo em Inglês | MEDLINE | ID: mdl-31358597

RESUMO

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

13.
Thorac Surg Clin ; 29(3): 291-301, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31235298

RESUMO

Surgical training has focused on the development of technical competency. Interpersonal and cognitive skills are essential to working as an interdisciplinary team, which translates into safety for the patient and well-being for the surgeon and colleagues. This article offers an "alternative" surgical curriculum topic list to augment the technical skill sets traditionally taught to trainees.


Assuntos
Currículo , Cirurgia Geral/educação , Equipe de Assistência ao Paciente , Adaptação Psicológica , Conscientização , Competência Clínica , Comunicação , Tomada de Decisões , Inteligência Emocional , Processos Grupais , Humanos , Relações Interprofissionais , Liderança , Negociação , Resiliência Psicológica
14.
Ann Thorac Surg ; 108(3): 960, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30986419
15.
BMJ Open ; 9(2): e022995, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30826789

RESUMO

INTRODUCTION: Approximately 400 000 Americans and 36 000 Canadians undergo cardiac surgery annually, and up to 56% will develop chronic postsurgical pain (CPSP). The primary aim of this study is to explore the association of pain-related beliefs and gender-based pain expectations on the development of CPSP. Secondary goals are to: (A) explore risk factors for poor functional status and patient-level cost of illness from a societal perspective up to 12 months following cardiac surgery; and (B) determine the impact of CPSP on quality-adjusted life years (QALYs) borne by cardiac surgery, in addition to the incremental cost for one additional QALY gained, among those who develop CPSP compared with those who do not. METHODS AND ANALYSES: In this prospective cohort study, 1250 adults undergoing cardiac surgery, including coronary artery bypass grafting and open-heart procedures, will be recruited over a 3-year period. Putative risk factors for CPSP will be captured prior to surgery, at postoperative day 3 (in hospital) and day 30 (at home). Outcome data will be collected via telephone interview at 6-month and 12-month follow-up. We will employ generalised estimating equations to model the primary (CPSP) and secondary outcomes (function and cost) while adjusting for prespecified model covariates. QALYs will be estimated by converting data from the Short Form-12 (version 2) to a utility score. ETHICS AND DISSEMINATION: This protocol has been approved by the responsible bodies at each of the hospital sites, and study enrolment began May 2015. We will disseminate our results through CardiacPain.Net, a web-based knowledge dissemination platform, presentation at international conferences and publications in scientific journals. TRIAL REGISTRATION NUMBER: NCT01842568.

16.
HPB (Oxford) ; 21(8): 998-1008, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30777697

RESUMO

BACKGROUND: The literature suggests favorable survival for patients with isolated pulmonary recurrence after resection of pancreatic ductal adenocarcinoma (PDAC) as compared to other recurrence patterns. Within this cohort, it remains unclear what factors are associated with improved survival. METHODS: Patients who developed pulmonary recurrence after pancreatectomy were selected from a prospective database. Predictors for post-recurrence survival (PRS) were analyzed using a multivariable Cox regression model. RESULTS: Ninety-six patients were included. Median recurrence-free survival (RFS), PRS and overall survival (OS) were 16.3, 18.8 and 39.6 months, respectively. Further systemic treatment and/or metastasectomy (n = 64, 67%) was associated with significantly improved PRS and OS when compared to best supportive care (n = 35, 22%) (26.3 vs. 5.3 and 48.1 vs. 18.4, respectively; both P < 0.001). Patients who were able to undergo metastasectomy (n = 19) achieved a PRS and OS of 35.0 and 68.9 months, respectively. More than 5 pulmonary lesions, symptoms and CA 19-9 ≥100 U/mL at time of recurrence were predictive of decreased PRS. A recurrence-free interval of >16 months and treatment for recurrence were independently associated with improved PRS. CONCLUSIONS: Isolated pulmonary recurrence occurs in 13% of patients with recurrent PDAC and is associated with a median OS of 40 months. Aggressive treatment in highly selected patients was correlated with improved survival.

17.
J Thorac Cardiovasc Surg ; 158(1): 269-276, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30718052

RESUMO

OBJECTIVE: We conducted a phase I trial of neoadjuvant nivolumab, a monoclonal antibody to the programmed cell death protein 1 checkpoint receptor, in patients with resectable non-small cell lung cancer. We analyzed perioperative outcomes to assess the safety of this strategy. METHODS: Patients with untreated stage I-IIIA non-small cell lung cancer underwent neoadjuvant therapy with 2 cycles of nivolumab (3 mg/kg), 4 and 2 weeks before resection. Patients underwent invasive mediastinal staging as indicated and post-treatment computed tomography. Primary study end points were safety and feasibility of neoadjuvant nivolumab followed by pulmonary resection. Data on additional surgical details were collected through chart review. RESULTS: Of 22 patients enrolled, 20 underwent resection. One was unresectable; another had small cell histologic subtype. There were no delays to surgical resection. Median time from first treatment to surgery was 33 (range, 17-43) days. There were 15 lobectomies, 2 pneumonectomies, 1 bilobectomy, 1 sleeve lobectomy, and 1 wedge resection. Of 13 procedures attempted via a video-assisted thoracoscopic surgery or robotic approach, 7 (54%) required thoracotomy. Median operative time was 228 (range, 132-312) minutes; estimated blood loss was 100 (range, 25-1000) mL; length of hospital stay was 4 (range, 2-17) days. There was no operative mortality. Morbidity occurred in 10 of 20 patients (50%). The most common postoperative complication was atrial arrhythmia (6/20; 30%). Major pathologic response was identified in 9 of 20 patients (45%). CONCLUSIONS: Neoadjuvant therapy with nivolumab was not associated with unexpected perioperative morbidity or mortality. More than half of the video-assisted thoracoscopic surgery/robotic cases were converted to thoracotomy, often because of hilar inflammation and fibrosis.

18.
Ann Thorac Surg ; 107(6): 1854-1859, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30710523

RESUMO

BACKGROUND: With the impending shortage of cardiothoracic (CT) surgeons, much focus has been on increasing trainee interest, particularly at the medical student level. We aimed to determine the effect of participation in our Cardiothoracic Surgery Interest Group (CTSIG) on medical student attitudes regarding surgery, and especially CT surgery. METHODS: An anonymous survey was administered at two time points to the current member list of our 2015 to 2016 CTSIG and repeated for the 2016 to 2017 academic year. A set CTSIG event schedule was developed with current CT faculty and included events every 1 to 2 months. Total CTSIG membership was 101 students. Descriptive analysis was performed on quantitative data. RESULTS: Of 73 preclinical students completing both pre/postsurveys, 62% (45) were male. Postsurveys demonstrated increased interest in surgery and CT surgery as a career, which was significantly greater than those reporting no change (p < 0.01 for both). Common factors mentioned as deterrents for a CT surgery career included lifestyle, length of training, and associated personality/culture. Events hosted by the CTSIG most frequently reported as increasing interest included lunches/dinners with CT surgery faculty (89%), a "Leadership in Surgery" event (58%), and an "Intro to CT Surgery and Q/A Session" hosted by a CT surgeon (51%). CONCLUSIONS: Establishing a CTSIG that includes preset events with exposure to CT surgery by shadowing and interaction with faculty in a relaxed setting has the ability to increase preclinical interest in CT surgery. More emphasis on advocacy is needed to clear up misconceptions about CT surgery to maintain recruitment of outstanding students in our CT surgery heritage.


Assuntos
Atitude , Escolha da Profissão , Processos Grupais , Opinião Pública , Estudantes de Medicina/psicologia , Cirurgia Torácica , Feminino , Humanos , Masculino
20.
J Formos Med Assoc ; 118(6): 965-972, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29779924

RESUMO

Nocturnal enuresis causes significant psychological distress to affected children and their family and requires appropriate management. A 12-member expert committee of pediatric urologists and pediatric nephrologists in Taiwan with extensive experience in treating enuresis was established to develop consensus statements and a recommended treatment algorithm for the management of patients with nocturnal enuresis in Taiwan after careful consideration of current evidence, existing guidelines, and expert opinion as well as local practice and culture. The finalized consensus statements were reviewed by and have received endorsement from the Taiwan Urological Association and the Taiwan Pediatric Association. Patients with suspected enuresis should undergo a thorough initial assessment to fully evaluate urinary signs and symptoms and to rule out underlying causes of diurnal and nocturnal incontinence. Behavioral therapy is recommended throughout the course of management. Desmopressin in the fast-melting formulation is the recommended first-line pharmacological treatment. Combination therapy may be effective in patients who have failed first-line treatment. These consensus statements and a recommended treatment algorithm were created by the expert committee to provide practical support for clinical decision making by physicians in Taiwan.


Assuntos
Enurese Noturna/diagnóstico , Enurese Noturna/terapia , Antidiuréticos/uso terapêutico , Terapia Comportamental/métodos , Criança , Pré-Escolar , Consenso , Desamino Arginina Vasopressina/uso terapêutico , Humanos , Guias de Prática Clínica como Assunto , Sociedades Médicas , Taiwan
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