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1.
Ann Surg ; 272(4): e275-e279, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32932327

RESUMO

OBJECTIVE: The aim of this study was to describe the clinical course of a consecutive series of patients operated of urgent cardiac surgery during COVID-19 outbreak. BACKGROUND: In Italy, COVID outbreak has mostly occurred in the metropolitan area of Milan, and in the surrounding region of Lombardy, and previously "conventional" hospitals were converted into COVID spokes to increase ICU beds availability, and to allow only urgent CS procedures. METHODS: Among urgent CS patients (left main stenosis with unstable angina, acute endocarditis, valvular regurgitation with impending heart failure), 10 patients (mean age = 57 ± 9 years), despite a negative admission triage, developed COVID-pneumonia postoperatively, at a median of 7 days after CS. RESULTS: Patients showed typical lymphopenia, higher prothrombotic profile, and higher markers of inflammation (ferritin and interleukin-6 values). At the zenith of pulmonary distress, patients presented with severe hypoxia (median PaO2/FIO2 ratio = 116), requiring advanced noninvasive ventilation (Venturi mask and continuous positive airway pressure) in the majority of cases. All patients were treated with hydroxychloroquine, azithromycin, and low-molecular-weight heparin at anticoagulant dose. Overall in-hospital mortality was 10% (1/10), peaking 25% in patients who developed COVID pneumonia immediately after CS. The remaining patients, with late infection, were all discharged home without oxygen support, at a median of 25 days after symptom onset. CONCLUSIONS: As postoperative mortality in case of COVID pneumonia is not negligible, meticulous rules (precise triage, safe hospital path, high level of protection for health-care teams, prompt diagnosis of suspicious symptoms) should be strictly followed in patients undergoing CS during COVID pandemic. The role of therapies alternative to CS should be further assessed.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Infecções por Coronavirus/prevenção & controle , Infecção Hospitalar/prevenção & controle , Surtos de Doenças/estatística & dados numéricos , Mortalidade Hospitalar/tendências , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Idoso , Procedimentos Cirúrgicos Cardíacos/mortalidade , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Infecções por Coronavirus/epidemiologia , Emergências , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Controle de Infecções/métodos , Unidades de Terapia Intensiva/estatística & dados numéricos , Itália , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Pneumonia Viral/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Medição de Risco
2.
Pan Afr Med J ; 36: 170, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32952814

RESUMO

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It was first identified on 8thDecember 2019 in Wuhan, Hubei, China, and has since spread globally to become an emergency of international concern. Patients infected with SARS-CoV-2 may be asymptomatic or present with symptoms ranging from mild clinical manifestations: such as fever, cough, and sore throat to moderate and severe form of the disease such as pneumonia and acute respiratory distress syndrome (ARDS). In some patients, SARS-CoV-2 can affect the heart and cause myocardial injury which is evidenced either by electrocardiographic (ECG) changes or by a rise in serum troponin level. Patients with myocardial involvement are generally at risk of developing severe illness and tend to have a poor outcome. We hereby present a case of a hypertensive male patient with undiagnosed, asymptomatic COVID-19, who underwent an emergency urologic procedure for ureteric calculi. He eventually sustained a postoperative myocardial injury resulting in his demise. This case highlights the importance of detailed preoperative assessment and anticipation of complications during this global pandemic.


Assuntos
Infecções por Coronavirus/complicações , Traumatismos Cardíacos/fisiopatologia , Pneumonia Viral/complicações , Complicações Pós-Operatórias/fisiopatologia , Cálculos Ureterais/cirurgia , Doenças Assintomáticas , Infecções por Coronavirus/diagnóstico , Evolução Fatal , Traumatismos Cardíacos/etiologia , Humanos , Hipertensão/complicações , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/diagnóstico , Fatores de Risco
3.
Am Heart J ; 228: 27-35, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32745733

RESUMO

BACKGROUND: Limited data suggest that transcatheter (TAVR) as compared with surgical aortic valve replacement (SAVR) may be more effective in female than male patients. To date, most evidence is derived from subgroup analyses of large trials, and a dedicated randomized trial evaluating whether there is a difference in outcomes between these interventions in women is warranted. The RHEIA trial will compare the safety and efficacy of TAVR with SAVR in women with severe symptomatic aortic stenosis requiring aortic valve intervention, irrespective of surgical risk. METHODS/DESIGN: The RHEIA trial is a prospective, randomized, controlled study that will enroll up to 440 patients across 35 sites in Europe. Women with severe symptomatic aortic stenosis, with any but prohibitive surgical risk status, will be randomized 1:1 to undergo aortic valve intervention with either transfemoral TAVR with the SAPIEN 3 or SAPIEN 3 Ultra device or SAVR and followed up for 1 year. The objective is to determine whether TAVR is non-inferior to SAVR in this patient population and, if this is fulfilled whether TAVR is actually superior to SAVR. The primary safety/efficacy endpoint is a composite of all-cause mortality, all stroke, and re-hospitalization (for valve or procedure-related symptoms or worsening congestive heart failure) at 1 year post-procedure. Other outcomes (assessed at 30 days and/or 1 year) include all-cause mortality; bleeding, vascular, cardiac, cerebrovascular and renal complications; aortic valve prosthesis and left ventricular function; cognitive function, health status, and quality of life. DISCUSSION: The RHEIA study has been designed to evaluate the safety and efficacy of TAVR compared with SAVR specifically in women with severe symptomatic aortic stenosis, irrespective of the level of surgical risk. The results will be the first to provide specific randomized evidence to guide treatment selection in female patients with severe symptomatic aortic stenosis. TRIAL REGISTRATION: clinicaltrials.gov: NCT04160130.


Assuntos
Estenose da Valva Aórtica , Valva Aórtica , Próteses Valvulares Cardíacas , Complicações Pós-Operatórias , Qualidade de Vida , Risco Ajustado/métodos , Substituição da Valva Aórtica Transcateter , Idoso , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/psicologia , Estenose da Valva Aórtica/cirurgia , Feminino , Nível de Saúde , Próteses Valvulares Cardíacas/efeitos adversos , Próteses Valvulares Cardíacas/classificação , Humanos , Avaliação de Processos e Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/psicologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Índice de Gravidade de Doença , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/instrumentação , Substituição da Valva Aórtica Transcateter/métodos
4.
Br J Anaesth ; 125(2): 122-132, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32711724

RESUMO

BACKGROUND: Despite several clinical trials on haemodynamic therapy, the optimal intraoperative haemodynamic management for high-risk patients undergoing major abdominal surgery remains unclear. We tested the hypothesis that personalised haemodynamic management targeting each individual's baseline cardiac index at rest reduces postoperative morbidity. METHODS: In this single-centre trial, 188 high-risk patients undergoing major abdominal surgery were randomised to either routine management or personalised haemodynamic management requiring clinicians to maintain personal baseline cardiac index (determined at rest preoperatively) using an algorithm that guided intraoperative i.v. fluid and/or dobutamine administration. The primary outcome was a composite of major complications (European Perioperative Clinical Outcome definitions) or death within 30 days of surgery. Secondary outcomes included postoperative morbidity (assessed by a postoperative morbidity survey), hospital length of stay, mortality within 90 days of surgery, and neurocognitive function assessed after postoperative Day 3. RESULTS: The primary outcome occurred in 29.8% (28/94) of patients in the personalised management group, compared with 55.3% (52/94) of patients in the routine management group (relative risk: 0.54, 95% confidence interval [CI]: 0.38 to 0.77; absolute risk reduction: -25.5%, 95% CI: -39.2% to -11.9%; P<0.001). One patient assigned to the personalised management group, compared with five assigned to the routine management group, died within 30 days after surgery (P=0.097). There were no clinically relevant differences between the two groups for secondary outcomes. CONCLUSIONS: In high-risk patients undergoing major abdominal surgery, personalised haemodynamic management reduces a composite outcome of major postoperative complications or death within 30 days after surgery compared with routine care. CLINICAL TRIAL REGISTRATION: NCT02834377.


Assuntos
Abdome/cirurgia , Débito Cardíaco/fisiologia , Hidratação/métodos , Hemodinâmica/fisiologia , Cuidados Intraoperatórios/métodos , Complicações Pós-Operatórias/prevenção & controle , Idoso , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/fisiopatologia , Estudos Prospectivos , Risco
5.
Medicine (Baltimore) ; 99(29): e21201, 2020 Jul 17.
Artigo em Inglês | MEDLINE | ID: mdl-32702884

RESUMO

RATIONALE: We hypothesize that with the determination of lymph fistula location 3-dimensionally, application of appropriate pressure would promote fistula healing, and a secondary surgery may be avoided. Ga-labeled 1,4,7-triazacyclononane-N, N', N"-triacetic acid (NOTA) conjugated with truncated Evan blue (NEB) forms a complex with serum albumin in the interstitial fluid after it is locally injected and allows rapid visualization of the lymphatic system. PATIENT CONCERNS: A 44-year-old woman had a chief complaint of left nipple discharge. A 38-year-old woman came to the hospital after sensing a right breast mass. DIAGNOSES: The 2 patients were diagnosed with chylous fistula after breast cancer surgery based on the findings of a novel method, Ga-NOTA-Evans Blue (NEB) positron emission tomography/computed tomography. INTERVENTIONS: We successfully obtained clear images to locate the fistula using Ga-NEB positron emission tomography/computed tomography (PET/CT) for both patients. The lymphatic vessels and lymph nodes could be clearly visualized owing to the Ga-NEB activity during PET/CT. OUTCOMES: Three-dimensional positioning to locate the fistula could direct the application of the pressure dressing and reduce drainage markedly. LESSONS: Ga-NEB PET/CT may be a new method for diagnosing chylous fistula and providing guidance for treatment.


Assuntos
Axila/diagnóstico por imagem , Neoplasias da Mama/cirurgia , Fístula/etiologia , Mastectomia/efeitos adversos , Tomografia Computadorizada com Tomografia por Emissão de Pósitrons/normas , Adulto , Axila/anormalidades , Axila/cirurgia , Neoplasias da Mama/complicações , Feminino , Fístula/cirurgia , Humanos , Mastectomia/métodos , Derrame Papilar , Tomografia Computadorizada com Tomografia por Emissão de Pósitrons/métodos , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/cirurgia
6.
Bone Joint J ; 102-B(9): 1256-1260, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32627569

RESUMO

AIMS: The risk to patients and healthcare workers of resuming elective orthopaedic surgery following the peak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been difficult to quantify. This has prompted governing bodies to adopt a cautious approach that may be impractical and financially unsustainable. The lack of evidence has made it impossible for surgeons to give patients an informed perspective of the consequences of elective surgery in the presence of SARS-CoV-2. This study aims to determine, for the UK population, the probability of a patient being admitted with an undetected SARS-CoV-2 infection and their resulting risk of death; taking into consideration the current disease prevalence, reverse transcription-polymerase chain reaction (RT-PCR) testing, and preassessment pathway. METHODS: The probability of SARS-CoV-2 infection with a false negative test was calculated using a lower-end RT-PCR sensitivity of 71%, specificity of 95%, and the UK disease prevalence of 0.24% reported in May 2020. Subsequently, a case fatality rate of 20.5% was applied as a worst-case scenario. RESULTS: The probability of SARS-CoV-2 infection with a false negative preoperative test was 0.07% (around 1 in 1,400). The risk of a patient with an undetected infection being admitted for surgery and subsequently dying from the coronavirus disease 2019 (COVID-19) is estimated at approximately 1 in 7,000. However, if an estimate of the current global infection fatality rate (1.04%) is applied, the risk of death would be around 1 in 140,000, at most. This calculation does not take into account the risk of nosocomial infection. Conversely, it does not factor in that patients will also be clinically assessed and asked to self-isolate prior to surgery. CONCLUSION: Our estimation suggests that the risk of patients being inadvertently admitted with an undetected SARS-CoV-2 infection for elective orthopaedic surgery is relatively low. Accordingly, the risk of death following elective orthopaedic surgery is low, even when applying the worst-case fatality rate. Cite this article: Bone Joint J 2020;102-B(9):1256-1260.


Assuntos
Doenças Assintomáticas , Causas de Morte , Infecções por Coronavirus/epidemiologia , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Complicações Pós-Operatórias/mortalidade , Teorema de Bayes , Técnicas de Laboratório Clínico , Estudos de Coortes , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/prevenção & controle , Procedimentos Cirúrgicos Eletivos/mortalidade , Reações Falso-Negativas , Feminino , Humanos , Incidência , Masculino , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Complicações Pós-Operatórias/fisiopatologia , Medição de Risco , Taxa de Sobrevida , Resultado do Tratamento , Reino Unido
7.
Bone Joint J ; 102-B(9): 1136-1145, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32634023

RESUMO

AIMS: During the COVID-19 pandemic, many patients continue to require urgent surgery for hip fractures. However, the impact of COVID-19 on perioperative outcomes in these high-risk patients remains unknown. The objectives of this study were to establish the effects of COVID-19 on perioperative morbidity and mortality, and determine any risk factors for increased mortality in patients with COVID-19 undergoing hip fracture surgery. METHODS: This multicentre cohort study included 340 COVID-19-negative patients versus 82 COVID-19-positive patients undergoing surgical treatment for hip fractures across nine NHS hospitals in Greater London, UK. Patients in both treatment groups were comparable for age, sex, body mass index, fracture configuration, and type of surgery performed. Predefined perioperative outcomes were recorded within a 30-day postoperative period. Univariate and multivariate analysis were used to identify risk factors associated with increased risk of mortality. RESULTS: COVID-19-positive patients had increased postoperative mortality rates (30.5% (25/82) vs 10.3% (35/340) respectively, p < 0.001) compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status (hazard ratio (HR) 15.4 (95% confidence interval (CI) 4.55 to 52.2; p < 0.001) and greater than three comorbidities (HR 13.5 (95% CI 2.82 to 66.0, p < 0.001). COVID-19-positive patients had increased risk of postoperative complications (89.0% (73/82) vs 35.0% (119/340) respectively; p < 0.001), more critical care unit admissions (61.0% (50/82) vs 18.2% (62/340) respectively; p < 0.001), and increased length of hospital stay (mean 13.8 days (SD 4.6) vs 6.7 days (SD 2.5) respectively; p < 0.001), compared to COVID-19-negative patients. CONCLUSION: Hip fracture surgery in COVID-19-positive patients was associated with increased length of hospital stay, more admissions to the critical care unit, higher risk of perioperative complications, and increased mortality rates compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status and multiple (greater than three) comorbidities. Cite this article: Bone Joint J 2020;102-B(9):1136-1145.


Assuntos
Artroplastia de Quadril/efeitos adversos , Infecções por Coronavirus/epidemiologia , Fraturas do Quadril/cirurgia , Mortalidade Hospitalar , Pneumonia Viral/epidemiologia , Complicações Pós-Operatórias/mortalidade , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Artroplastia de Quadril/métodos , Causas de Morte , Estudos de Coortes , Feminino , Fraturas do Quadril/epidemiologia , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Pandemias , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/fisiopatologia , Valores de Referência , Medição de Risco , Reino Unido
8.
Methodist Debakey Cardiovasc J ; 16(2): 86-96, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32670468

RESUMO

Of the 100,000-plus valve surgeries performed each year in the United States, up to 6% of those develop complications from prosthetic valve dysfunction. Prosthetic valve dysfunction (PVD) can be life threatening and often challenging to diagnose. In this review, we discuss the prevalence and incidence of PVD, explore its different etiologies, and assess the role of multimodality imaging with an emphasis on cardiac multidetector computed tomography (MDCT) for evaluating patients with PVD. We also investigate the utility of MDCT in preprocedural planning for transcatheter devices and redo surgical planning and discuss management strategies for patients with PVD.


Assuntos
Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Valvas Cardíacas/cirurgia , Tomografia Computadorizada Multidetectores , Complicações Pós-Operatórias/diagnóstico por imagem , Falha de Prótese , Implante de Prótese de Valva Cardíaca/efeitos adversos , Valvas Cardíacas/diagnóstico por imagem , Valvas Cardíacas/fisiopatologia , Humanos , Incidência , Imagem Multimodal , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/cirurgia , Valor Preditivo dos Testes , Prevalência , Reoperação , Fatores de Risco , Resultado do Tratamento
9.
Ann Surg ; 272(2): 210-217, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32675483

RESUMO

OBJECTIVE: This trial aimed to provide randomized controlled data comparing Kono-S anastomosis and stapled ileocolic side-to-side anastomosis. BACKGROUND: Recently, a new antimesenteric, functional, end-to-end, hand-sewn ileocolic anastomosis (Kono-S) has shown a significant reduction in endoscopic recurrence score and surgical recurrence rate in Crohn disease (CD). METHODS: Randomized controlled trial (RCT) at a tertiary referral institution. Primary endpoint: endoscopic recurrence (ER) (Rutgeerts score ≥i2) after 6 months. Secondary endpoints: clinical recurrence (CR) after 12 and 24 months, ER after 18 months, and surgical recurrence (SR) after 24 months. RESULTS: In all, 79 ileocolic CD patients were randomized in Kono group (36) and Conventional group (43). After 6 months, 22.2% in the Kono group and 62.8% in the Conventional group presented an ER [P < 0.001, odds ratio (OR) 5.91]. A severe postoperative ER (Rutgeerts score ≥i3) was found in 13.8% of Kono versus 34.8% of Conventional group patients (P = 0.03, OR 3.32). CR rate was 8% in the Kono group versus 18% in the Conventional group after 12 months (P = 0.2), and 18% versus 30.2% after 24 months (P = 0.04, OR 3.47). SR rate after 24 months was 0% in the Kono group versus 4.6% in the Conventional group (P = 0.3). Patients with Kono-S anastomosis presented a longer time until CR than patients with side-to-side anastomosis (hazard ratio 0.36, P = 0.037). On binary logistic regression analysis, the Kono-S anastomosis was the only variable significantly associated with a reduced risk of ER (OR 0.19, P < 0.001). There were no differences in postoperative outcomes. CONCLUSIONS: This is the first RCT comparing Kono-S anastomosis and standard anastomosis in CD. The results demonstrate a significant reduction in postoperative endoscopic and clinical recurrence rate for patients who underwent Kono-S anastomosis, and no safety issues.ClinicalTrials.gov ID NCT02631967.


Assuntos
Anastomose Cirúrgica/efeitos adversos , Colectomia/métodos , Doença de Crohn/cirurgia , Endoscopia/efeitos adversos , Mesentério/patologia , Prevenção Secundária/métodos , Adulto , Idoso , Anastomose Cirúrgica/métodos , Colo/cirurgia , Doença de Crohn/diagnóstico , Endoscopia/métodos , Feminino , Seguimentos , Humanos , Íleo/cirurgia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Modelos de Riscos Proporcionais , Recidiva , Medição de Risco , Índice de Gravidade de Doença , Centros de Atenção Terciária , Resultado do Tratamento
11.
Ann Surg ; 272(2): 220-226, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32675485

RESUMO

OBJECTIVE: To develop and evaluate a novel instrument to measure SEVERE processes using video data. BACKGROUND: Surgical video data can serve an important role in understanding the relationship between intraoperative events and postoperative outcomes. However, a standard tool to measure severity of intraoperative events is not yet available. METHODS: Items to be included in the instrument were identified through literature and video reviews. A committee of experts guided item reduction, including pilot tests and revisions, and determined weighted scores. Content validity was evaluated using a validated sensibility questionnaire. Inter-rater reliability was assessed by calculating intraclass correlation coefficient. Construct validity was evaluated on a sample of 120 patients who underwent laparoscopic Roux-en-Y gastric bypass procedure, in which comprehensive video data was obtained. RESULTS: SEVERE index measures severity of 5 event types using ordinal scales. Each intraoperative event is given a weighted score out of 10. Inter-rater reliability was excellent [0.87 (95%-confidence interval, 0.77-0.92)]. In a sample of consecutive 120 patients undergoing gastric bypass procedures, a median of 12 events [interquartile range (IQR) 9-18] occurred per patient and bleeding was the most frequent type (median 10, IQR 7-14). The median SEVERE score per case was 11.3 (IQR 8.3-16.9). In risk-adjusted multivariable regression models, history of previous abdominal surgery (P = 0.02) and body mass index (P = 0.005) were associated with SEVERE scores, demonstrating construct validity evidence. CONCLUSION: The SEVERE index may prove to be a useful instrument in identifying patients with high risk of developing postoperative complications.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/métodos , Endoscopia Gastrointestinal/métodos , Complicações Intraoperatórias/diagnóstico , Monitorização Intraoperatória/métodos , Complicações Pós-Operatórias/prevenção & controle , Gravação em Vídeo , Centros Médicos Acadêmicos , Adulto , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Perda Sanguínea Cirúrgica/prevenção & controle , Estudos de Coortes , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Endoscopia Gastrointestinal/efeitos adversos , Feminino , Humanos , Complicações Intraoperatórias/prevenção & controle , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Variações Dependentes do Observador , Ontário , Projetos Piloto , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Prognóstico , Estudos Prospectivos , Reprodutibilidade dos Testes , Medição de Risco , Resultado do Tratamento
12.
Ann Surg ; 272(2): 266-276, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32675539

RESUMO

OBJECTIVE: To describe and critique tools used to assess frailty in vascular surgery patients, and investigate its associations with patient factors and outcomes. BACKGROUND: Increasing evidence shows negative impacts of frailty on outcomes in surgical patients, but little investigation of its associations with patient factors has been undertaken. METHODS: Systematic review and meta-analysis of studies reporting frailty in vascular surgery patients (PROSPERO registration: CRD42018116253) searching Medline, Embase, CINAHL, PsycINFO, and Scopus. Quality of studies was assessed using Newcastle-Ottawa scores (NOS) and quality of evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria. Associations of frailty with patient factors were investigated by difference in means (MD) or expressed as risk ratios (RRs), and associations with outcomes expressed as odds ratios (ORs) or hazard ratios (HRs). Data were pooled using random-effects models. RESULTS: Fifty-three studies were included in the review and only 8 (15%) were both good quality (NOS ≥ 7) and used a well-validated frailty measure. Eighteen studies (62,976 patients) provided data for the meta-analysis. Frailty was associated with increased age [MD 4.05 years; 95% confidence interval (CI) 3.35, 4.75], female sex (RR 1.32; 95% CI 1.14, 1.54), and lower body mass index (MD -1.81; 95% CI -2.94, -0.68). Frailty was associated with 30-day mortality [adjusted OR (AOR) 2.77; 95% CI 2.01-3.81), postoperative complications (AOR 2.16; 95% CI 1.55, 3.02), and long-term mortality (HR 1.85; 95% CI 1.31, 2.62). Sarcopenia was not associated with any outcomes. CONCLUSION: Frailty, but not sarcopenia, is associated with worse outcomes in vascular surgery patients. Well-validated frailty assessment tools should be preferred clinically, and in future research.


Assuntos
Causas de Morte , Idoso Fragilizado/estatística & dados numéricos , Fragilidade/mortalidade , Sarcopenia/epidemiologia , Procedimentos Cirúrgicos Vasculares/mortalidade , Idoso , Idoso de 80 Anos ou mais , Feminino , Avaliação Geriátrica , Humanos , Masculino , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/fisiopatologia , Medição de Risco , Sarcopenia/diagnóstico , Análise de Sobrevida , Resultado do Tratamento , Reino Unido , Procedimentos Cirúrgicos Vasculares/métodos
13.
Cerebrovasc Dis Extra ; 10(2): 66-75, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32726777

RESUMO

INTRODUCTION: Moyamoya disease (MMD) is a rare cerebrovascular disease associated with cerebral infarction or hemorrhage. Hyperperfusion is the most significant complication of direct bypass surgery. Previous research has shown that an increase in cerebral blood flow (CBF) is strongly related to symptomatic hyperperfusion and highlighted the importance of postoperative assessment of CBF. OBJECTIVE: The principal aims of this study were to quantitatively analyze the relationship between intraoperative graft flow and increase in CBF and to evaluate the effectiveness of intraoperative graft flow measurement during bypass surgery for patients with MMD. METHODS: This study included 91 surgeries in 67 consecutive adult patients with MMD who underwent direct revascularization surgery at our institution between November 2013 and September 2018. Intraoperative graft flow of the branches and main trunk was measured in all patients, after anastomosis had been established. Postoperative CBF measurements were performed under sedation, immediately after surgery. Radiological hyperperfusion was defined as focal high uptake, as determined by CBF imaging immediately after surgery. Patients were divided into two groups (radiological hyperperfusion and nonradiological hyperperfusion groups), and the relationship between intraoperative graft flow and radiological hyperperfusion was analyzed. RESULTS: Significant differences were observed between the radiological hyperperfusion and nonradiological hyperperfusion groups in terms of intraoperative graft flow of both the branch (median 72 vs. 42 mL/min, respectively; p < 0.01) and main trunk (median 113 vs. 68 mL/min, respectively; p < 0.01). A receiver-operating characteristic analysis was performed to test the utility of intraoperative flow as a quantitative measure. We set the cutoff values for the intraoperative branch and main trunk flow at 57 mL/min (sensitivity: 0.707, specificity: 0.702; area under the curve [AUC]: 0.773; 95% confidence interval [CI]: 0.675-0.871) and 84 mL/min (sensitivity: 0.667, specificity: 0.771; AUC: 0.78; 95% CI: 0.685-0.875), respectively. CONCLUSIONS: Measuring intraoperative graft flow during bypass surgery may be an effective means of predicting hyperperfusion and could serve to facilitate early therapeutic intervention such as strict blood pressure control.


Assuntos
Angiografia Cerebral , Revascularização Cerebral/efeitos adversos , Circulação Cerebrovascular , Angiografia por Ressonância Magnética , Monitorização Intraoperatória , Doença de Moyamoya/cirurgia , Complicações Pós-Operatórias/diagnóstico por imagem , Tomografia Computadorizada de Emissão de Fóton Único , Adolescente , Adulto , Idoso , Velocidade do Fluxo Sanguíneo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doença de Moyamoya/diagnóstico por imagem , Doença de Moyamoya/fisiopatologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
14.
Medicine (Baltimore) ; 99(26): e20874, 2020 Jun 26.
Artigo em Inglês | MEDLINE | ID: mdl-32590794

RESUMO

INTRODUCTION: Idiopathic necrotizing fasciitis (NF) is an infrequent, highly lethal skin infection that spreads rapidly, marked by fascia and subcutaneous tissue necrosis. It occurs in the absence of a known causative factor. Its emergence after sterile orthopedic fixation with unexpected spread to the abdomen may turn to be challenging both as a medical and surgical emergency. PATIENT CONCERNS: A 56-year-old diabetic female presented with multiple fractures. After open reduction and internal fixation (ORIF) with iliac crest grafting of hip fracture, she developed incisional NF which later spread to the abdomen. DIAGNOSIS: Post-ORIF of hip fracture complicated with idiopathic NF and abdominal spread. INTERVENTIONS: She underwent emergency débridements with negative pressure wound therapy and broad-spectrum intravenous antibiotic therapy. After granulation, the wounds were closed with skin flaps and grafts with antibiotic beads. When the NF spread to the abdomen, additional débridements during abdominal explorations were performed. OUTCOMES: The patient was initially stable with promising healings of the wounds. Later, the patient suddenly developed a high fever and severe abdominal pain. Ultrasound revealed that NF emerged unexpectedly in the right lower abdomen. The causative agent of the NF remained undetected. Despite all the extensive treatments, the patient's condition deteriorated rapidly. She died of septic shock and multiple organ failure. CONCLUSION: The idiopathic NF may still potentially occur after a clean ORIF of the hip region. The implementation of intensive guideline-based treatments may show improvements, but the risk of unexpected NF spread to the abdomen should be anticipated, which may increase the mortality rates in diabetic or immunocompromised patients.


Assuntos
Fasciite Necrosante/etiologia , Fraturas Ósseas/cirurgia , Acidentes de Trânsito , Antibacterianos/uso terapêutico , Desbridamento/métodos , Diabetes Mellitus , Feminino , Fraturas Ósseas/complicações , Quadril/cirurgia , Humanos , Pessoa de Meia-Idade , Tratamento de Ferimentos com Pressão Negativa/métodos , Redução Aberta/efeitos adversos , Redução Aberta/métodos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Cicatrização/efeitos dos fármacos , Cicatrização/fisiologia
15.
Br J Anaesth ; 125(1): 55-66, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32499013

RESUMO

BACKGROUND: Delirium frequently affects older patients, increasing morbidity and mortality; however, the pathogenesis is poorly understood. Herein, we tested the cognitive disintegration model, which proposes that a breakdown in frontoparietal connectivity, provoked by increased slow-wave activity (SWA), causes delirium. METHODS: We recruited 70 surgical patients to have preoperative and postoperative cognitive testing, EEG, blood biomarkers, and preoperative MRI. To provide evidence for causality, any putative mechanism had to differentiate on the diagnosis of delirium; change proportionally to delirium severity; and correlate with a known precipitant for delirium, inflammation. Analyses were adjusted for multiple corrections (MCs) where appropriate. RESULTS: In the preoperative period, subjects who subsequently incurred postoperative delirium had higher alpha power, increased alpha band connectivity (MC P<0.05), but impaired structural connectivity (increased radial diffusivity; MC P<0.05) on diffusion tensor imaging. These connectivity effects were correlated (r2=0.491; P=0.0012). Postoperatively, local SWA over frontal cortex was insufficient to cause delirium. Rather, delirium was associated with increased SWA involving occipitoparietal and frontal cortex, with an accompanying breakdown in functional connectivity. Changes in connectivity correlated with SWA (r2=0.257; P<0.0001), delirium severity rating (r2=0.195; P<0.001), interleukin 10 (r2=0.152; P=0.008), and monocyte chemoattractant protein 1 (r2=0.253; P<0.001). CONCLUSIONS: Whilst frontal SWA occurs in all postoperative patients, delirium results when SWA progresses to involve posterior brain regions, with an associated reduction in connectivity in most subjects. Modifying SWA and connectivity may offer a novel therapeutic approach for delirium. CLINICAL TRIAL REGISTRATION: NCT03124303, NCT02926417.


Assuntos
Encéfalo/fisiopatologia , Delírio/diagnóstico , Delírio/fisiopatologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/fisiopatologia , Biomarcadores/sangue , Encéfalo/diagnóstico por imagem , Estudos de Coortes , Citocinas/sangue , Delírio/sangue , Imagem de Tensor de Difusão/métodos , Eletroencefalografia/métodos , Humanos , Complicações Pós-Operatórias/sangue
16.
Am J Obstet Gynecol ; 223(2): 260.e1-260.e9, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32502559

RESUMO

BACKGROUND: Rates of postoperative incomplete bladder emptying vary significantly after pelvic reconstructive surgery. With enhanced recovery protocols the paradigm is shifting towards same-day discharge and the rates of incomplete bladder emptying are expected to increase. The optimal length of time for postoperative catheter drainage has not been clearly established. There are no current studies that assess the optimal timing of a repeat voiding trial in women who have unsuccessful same day voiding trials. OBJECTIVE: This study aimed to compare the outcomes of a second voiding trial performed 2-4 days (earlier group) vs 7 days (later group) postoperatively in women with incomplete bladder emptying after vaginal prolapse surgery. Secondary aims included postoperative urinary tract infection rates, total days with a catheter, and patient-reported catheter bother between groups. STUDY DESIGN: Across 2 sites, women undergoing multicompartment vaginal repair were enrolled. Within 6 hours postoperatively, subjects had an active retrograde voiding trial. Those who passed this voiding trial exited the study; those who had persistent incomplete bladder emptying (postvoid residual >100 mL) had a transurethral indwelling catheter placed and were randomized to return for an earlier (postoperative day 2-4) vs later (postoperative day 7) follow-up office voiding trial. Subjects were followed for 6 weeks after surgery. The primary outcome was the rate of unsuccessful repeat office voiding trial. Secondary outcomes included rates of urinary tract infection, total days with a catheter, and subjective catheter bother. A power calculation based on a projected 31% difference, a power of 0.8, and an alpha of 0.05 revealed that 30 subjects were needed in each group. RESULTS: A total of 102 subjects were enrolled; 38 exited on postoperative day 0, leaving 64 subjects for randomization (4 of whom withdrew after randomization). A comparison of data revealed that randomization was effective, with no differences between the earlier and later groups in terms of demographic data or surgical procedures. Using an intention-to-treat analysis, women in the earlier group were more likely to be unsuccessful in their follow-up office voiding trial (23.3%) than the later group (3.3%), with a risk difference of 20% (95% confidence interval, 3.56-36.44) and a relative risk of 7.00 (95% confidence interval, 0.92-53.47; P=.02). A number-needed-to-treat calculation found that for every 5 patients using a catheter for 7 days postoperatively, 1 case of persistent postoperative incomplete bladder emptying was prevented. Rates of catheter bother did not differ between groups at the time of the follow-up office voiding trial or at 6 weeks (P=.09 and P=.20, respectively). Urinary tract infection rates were higher in the earlier group but did not reach statistical significance (23% vs 7%, P=.07). Regression analysis revealed that subjects who required additional pain medication refills were 9.6 times (95% confidence interval, 1.24-73.77) more likely to have persistent incomplete bladder emptying after the follow-up office voiding trial. CONCLUSION: Women with incomplete bladder emptying after multicompartment prolapse repair had a 7-fold higher risk of an unsuccessful repeat office voiding trial if performed within 4 days of surgery than when performed within 7 days of surgery. In addition, requiring additional prescriptions for analgesia increased the risk of an unsuccessful follow-up office voiding trial.


Assuntos
Procedimentos Cirúrgicos em Ginecologia , Prolapso de Órgão Pélvico/cirurgia , Complicações Pós-Operatórias/fisiopatologia , Procedimentos Cirúrgicos Reconstrutivos , Recuperação de Função Fisiológica , Cateterismo Urinário , Retenção Urinária/fisiopatologia , Vagina/cirurgia , Idoso , Feminino , Humanos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Slings Suburetrais , Fatores de Tempo , Cateteres Urinários , Retenção Urinária/diagnóstico , Infecções Urinárias/epidemiologia
18.
BMC Surg ; 20(1): 108, 2020 May 19.
Artigo em Inglês | MEDLINE | ID: mdl-32430021

RESUMO

BACKGROUND: Breast cancer is the most common cancer in women worldwide. Major breast cancer surgery especially with axillary lymph node dissection (ALND), is associated with upper limb functional decline. Majority of studies are conducted in Western population and may not be applicable to Asians. This pilot study aims to evaluate whether major breast surgery results in upper limb functional impairment in a cohort of Asian women with breast cancer. METHODS: This is a prospective cohort study of 41 patients who underwent 44 major breast surgeries from April 2018 to August 2019. Main inclusion criteria were patients over 21 years of age undergoing major breast surgery for breast cancer. Major breast surgery was defined as wide local excision (WLE) or mastectomy. Main exclusion criteria were patients with pre-existing neurological or rheumatological co-morbidities affecting upper limb function or previous trauma with resulting deformities to the upper limbs. Patients underwent early rehabilitation from post-operative day 1. Shoulder flexion and abduction active range of motion (AROM) and QuickDASH disability score were assessed 1 week before surgery, post-operative week 2 and week 6. Baseline demographics and peri-operative data were also collected. RESULTS: Median age was 62.5 years. There were 16 (36.4%) wide local excisions and 28 (63.6%) simple mastectomies. Two (4.5%) cases had neoadjuvant chemotherapy. Fifteen (34.1%) cases had ALND. At post-operative week 6, shoulder flexion was comparable to baseline (p = 0.775), while abduction improved from baseline (p = 0.016). However, QuickDASH disability score was significantly worse at post-operative week 6 compared to baseline (median score 2.5 vs 0, p = 0.027). Subgroup analysis of patients with ALND demonstrated significantly worse QuickDASH disability score at post-operative week 6 (p = 0.010) but not for patients with only sentinel lymph node biopsy (p = 0.396). CONCLUSION: This pilot study in an Asian cohort found that patients were able to regain AROM of shoulder after major breast surgery at post-operative week 6 but had a worse QuickDASH disability score, especially in the subgroup with ALND. Aggressive and early rehabilitation should be encouraged. However, a longer follow-up is required to evaluate long term functional outcomes.


Assuntos
Neoplasias da Mama/cirurgia , Mastectomia/efeitos adversos , Extremidade Superior/fisiopatologia , Idoso , Grupo com Ancestrais do Continente Asiático , Axila/patologia , Axila/cirurgia , Neoplasias da Mama/terapia , Feminino , Humanos , Excisão de Linfonodo , Pessoa de Meia-Idade , Terapia Neoadjuvante , Medidas de Resultados Relatados pelo Paciente , Projetos Piloto , Complicações Pós-Operatórias/fisiopatologia , Estudos Prospectivos , Amplitude de Movimento Articular , Biópsia de Linfonodo Sentinela
19.
J Cardiothorac Surg ; 15(1): 105, 2020 May 20.
Artigo em Inglês | MEDLINE | ID: mdl-32434521

RESUMO

BACKGROUND: Surgical closure of atrial septal defect (ASD) is contraindicated in the condition with severe pulmonary arterial hypertension (PAH), whereas ASD closure in an effective intervention to normalize the structure and function of the right heart after previously experiencing volume overload due to shunting from the defect. This study aimed to evaluate normalization of the right heart and emergence of PAH after surgical closure of ASD. METHODS: This retrospective study was carried out in 45 patients over 18 years who had undergone surgical closure of ASD. The study has the aim to evaluate the morphological and functional parameters before and after the surgical approach and the preoperative factors that influenced the development of pulmonary arterial hypertension (PAP) after the ASD closure. RESULTS: The majority of subjects were female (73.3%) although there were no significant differences between males and females from the various parameters. The average of mPAP in the group that experienced PAH was higher than non-PAH group after ASD closure (p = 0.019, 31.23 ± 12.70 mmHg vs 24.07 ± 13.08 mmHg). Significant differences were found in the Right Atrium (RA) dimension, Right Ventricle (RV) dimension, Tricuspid Regurgitation Velocity (TRV) and Tricuspid Annular Plane Systolic Excursion (TAPSE) between before and at 6 months after ASD closure (p = 0.000, p = 0.000, p = 0.000, p = 000, respectively). The sensitivity of the predictive model to estimate PAH at 6 months after surgical closure of ASD was 58%, with a specificity of 62.5%. CONCLUSION: Structural and functional normalization of the right heart occurs at 6 months after surgical closure of ASD with the decrease of RA and RV dimensions and improvement from tricuspid regurgitation. Emergence of PAH after ASD closure was influenced by higher mPAP before surgical approach.


Assuntos
Comunicação Interatrial/cirurgia , Hipertensão Arterial Pulmonar/diagnóstico , Adulto , Ecocardiografia , Feminino , Comunicação Interatrial/complicações , Comunicação Interatrial/diagnóstico por imagem , Comunicação Interatrial/fisiopatologia , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Complicações Pós-Operatórias/fisiopatologia , Hipertensão Arterial Pulmonar/complicações , Hipertensão Arterial Pulmonar/diagnóstico por imagem , Hipertensão Arterial Pulmonar/fisiopatologia , Estudos Retrospectivos , Sensibilidade e Especificidade , Insuficiência da Valva Tricúspide/etiologia , Adulto Jovem
20.
Am J Med Sci ; 360(2): 146-152, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32466854

RESUMO

BACKGROUND: Transient hypocalcemia due to parathyroid gland or vessel manipulation is a common complication following thyroidectomy. Considering the role of 25-hydroxyvitamin D (25(OH)D) in calcium hemostasis, this study aimed to evaluate the effect of preoperative vitamin D supplementation on hypocalcemia incidence in thyroidectomy patients. METHODS: In this randomized clinical trial, 100 patients scheduled for total thyroidectomy and suffering from preoperative moderate or severe vitamin D deficiency were enrolled. Patients were randomly allocated to either study or control groups using the sealed envelope method. Patients in the study group received vitamin D3 50,000-unit pearl weekly for 4 weeks prior to the operation. The control group received placebo. Total and ionized serum calcium levels were checked before surgery, the day after surgery, and 2 weeks postoperatively. RESULTS: No significant difference was observed in terms of demographic data. During serial total calcium checks (5 episodes), total calcium levels changed significantly in patients who had received vitamin D supplements compared to the control group (P = 0.043). Symptomatic hypocalcemia incidence was significantly lower in patients supplemented with 25-hydroxyvitamin D (25(OH)D) (P = 0.04). Also, the requirement for intravenous calcium administration in order to treat the hypocalcemia symptoms was significantly lower in the study in comparison to the control group (P = 0.03). CONCLUSIONS: Vitamin D supplementation in patients with vitamin D deficiency might lead to a lower incidence of early-onset symptomatic hypocalcemia; hence, requiring less calcium supplementation for the management of hypocalcemia.


Assuntos
Colecalciferol/uso terapêutico , Hipocalcemia/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Cuidados Pré-Operatórios/métodos , Doenças da Glândula Tireoide/cirurgia , Tireoidectomia , Deficiência de Vitamina D/tratamento farmacológico , Vitaminas/uso terapêutico , Adenocarcinoma Folicular/cirurgia , Adulto , Cálcio/sangue , Feminino , Bócio Nodular/cirurgia , Humanos , Hipocalcemia/sangue , Hipocalcemia/fisiopatologia , Masculino , Complicações Pós-Operatórias/fisiopatologia , Câncer Papilífero da Tireoide/cirurgia , Neoplasias da Glândula Tireoide/cirurgia , Vitamina D/análogos & derivados , Vitamina D/sangue , Deficiência de Vitamina D/sangue , Deficiência de Vitamina D/diagnóstico
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