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2.
Am Surg ; 86(9): 1169-1174, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32862663

RESUMO

BACKGROUND: Dehydration drives a significant proportion of readmissions following bariatric surgery. Routinely performed body composition testing and total body water (TBW) calculations may present a novel method for diagnosing dehydration for outpatient intervention. We sought to determine if a change in TBW from preoperative baseline could help identify bariatric patients requiring outpatient intravenous fluid (IVF) administration for dehydration. METHODS: The VUMC Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was retroactively queried for all patients undergoing bariatric surgery at an accredited bariatric surgery center from January 1, 2017 to May 31, 2018. Body composition test results presurgery and postsurgery were extracted from the electronic health record. Change in TBW was compared between patients requiring outpatient IVF and those who did not use multivariable logistic regression. RESULTS: 583 patients underwent surgery over the study period (388 laparoscopic Roux-en-Y gastric bypass, 195 sleeve). 62 (10.6%) required outpatient fluid administration for dehydration. After multivariable analysis, patients with an increased hospital length of stay at index operation were more likely to require outpatient IVF (odds ratio [OR] 1.65, 95% CI 1.22-2.2). Preexisting diabetes diagnosis was protective (OR 0.35, 95% CI 0.16-0.74). Neither 1-week nor 1-month change in TBW from preoperative baseline was significantly different between patients receiving outpatient IVF and those who did not. CONCLUSION: Increased hospital length of stay predicts patients at risk of postoperative dehydration requiring IVF administration. Body composition testing and TBW were not useful in distinguishing between populations. Further research is needed to examine the efficacy of outpatient IVF in preventing hospital readmissions for dehydration.


Assuntos
Cirurgia Bariátrica/métodos , Água Corporal/fisiologia , Hidratação/métodos , Laparoscopia/métodos , Obesidade Mórbida/cirurgia , Pacientes Ambulatoriais , Complicações Pós-Operatórias/terapia , Adulto , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/metabolismo , Complicações Pós-Operatórias/metabolismo , Período Pós-Operatório , Prognóstico , Estudos Retrospectivos
3.
J Wound Ostomy Continence Nurs ; 47(5): 456-457, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32925588

RESUMO

BACKGROUND: Surgical creation of a urostomy with or without radical cystectomy is a common urologic procedure. Despite advances in techniques, ostomy and surgical-related postoperative complications are prevalent and may impair physical recovery and health quality of life. Restrictions in face-to-face clinic visits created by the coronavirus disease-2019 (COVID-19) pandemic have dramatically altered care for patients with a new urostomy. CASE: This case report describes our management approaches using telemedicine and complementary communication strategies during the recent COVID-19 pandemic for a patient with multiple complex chronic conditions and multiple stoma and related postoperative complications. CONCLUSIONS: Despite challenges imposed during the COVID-19 pandemic, we were able to manage multiple surgical- and ostomy-related complications using a combination of telecommunication techniques that mitigated the need for routine and urgent postoperative clinic visits, hospital readmission, or unplanned visits to an emergency department. The new onset use of telemedicine approaches (telephone, televideo, and direct telemedicine) and various Health Insurance and Portability and Accountability Act-secure platforms due to pandemic conditions can improve access to care.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Estomia/efeitos adversos , Pneumonia Viral/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Telemedicina/organização & administração , Idoso , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Feminino , Humanos , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão
4.
J Wound Ostomy Continence Nurs ; 47(5): 456-457, 2020.
Artigo em Inglês | MEDLINE | ID: covidwho-760087

RESUMO

BACKGROUND: Surgical creation of a urostomy with or without radical cystectomy is a common urologic procedure. Despite advances in techniques, ostomy and surgical-related postoperative complications are prevalent and may impair physical recovery and health quality of life. Restrictions in face-to-face clinic visits created by the coronavirus disease-2019 (COVID-19) pandemic have dramatically altered care for patients with a new urostomy. CASE: This case report describes our management approaches using telemedicine and complementary communication strategies during the recent COVID-19 pandemic for a patient with multiple complex chronic conditions and multiple stoma and related postoperative complications. CONCLUSIONS: Despite challenges imposed during the COVID-19 pandemic, we were able to manage multiple surgical- and ostomy-related complications using a combination of telecommunication techniques that mitigated the need for routine and urgent postoperative clinic visits, hospital readmission, or unplanned visits to an emergency department. The new onset use of telemedicine approaches (telephone, televideo, and direct telemedicine) and various Health Insurance and Portability and Accountability Act-secure platforms due to pandemic conditions can improve access to care.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Estomia/efeitos adversos , Pneumonia Viral/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Telemedicina/organização & administração , Idoso , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Feminino , Humanos , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão
5.
Medicine (Baltimore) ; 99(31): e21430, 2020 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-32756150

RESUMO

INTRODUCTION: Most of the patients with bladder genital tract fistula recover with surgical treatment. In the present study, we aimed to assess conservative treatment strategies for bladder genital tract fistula. PATIENT CONCERNS: We reviewed 3 cases with bladder genital tract fistula who underwent treatment at our hospital from January to June 2017. Patient 1 underwent cesarean delivery, Patient 2 underwent total abdominal hysterectomy bilateral salpingo-oophorectomy (TAHBSO) and pelvic lymphadenectomy, and Patient 3 underwent extensive TAHBSO and pelvic lymphadenectomy. All 3 patients exhibited involuntary vaginal fluid outflow (average duration, 12.7 days; range, 7-21 days). DIAGNOSIS: Patient 1 was diagnosed as vesicouterine fistula by cystosonography and Patient 2, Patient 3 was diagnosed as vesicovaginal fistula by cystoscopy. INTERVENTIONS: All 3 patients underwent indwelling urinary catheterization. OUTCOMES: No vaginal fluid outflow could be observed after treatment of all 3 patients. CONCLUSION: Indwelling urinary catheterization should be administered for suitable patients as conservative treatment. If vesicouterine fistulas that are simple and have a diameter of <0.5 cm can be treated conservatively. If the condition does not resolve after 2 months, surgery should be considered.


Assuntos
Complicações Pós-Operatórias/terapia , Transtornos Puerperais/terapia , Fístula Vesicovaginal/terapia , Adulto , Cesárea/efeitos adversos , Tratamento Conservador , Diagnóstico Diferencial , Feminino , Humanos , Histerectomia/efeitos adversos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Gravidez , Cuidado Pré-Natal , Transtornos Puerperais/diagnóstico , Cateterismo Urinário , Fístula Vesicovaginal/diagnóstico
6.
J Pediatr Orthop ; 40(8): 380-386, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32776772

RESUMO

BACKGROUND: Pediatric ipsilateral supracondylar humerus and forearm fractures (floating elbow), are historically reported to have a high rate of complications, including pediatric acute compartment syndrome (PACS). As a result, treatment paradigms for these types of injuries differ in the urgency, extent of fixation, and type of immobilization than if each fracture were treated in isolation. We aimed to systematically review the literature on pediatric floating elbow injuries and assess the reported risk of PACS along with risk factors for poor outcomes. METHODS: A systematic review was performed in November 2019 in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. An exhaustive search of the PubMed and Embase databases was conducted for peer-reviewed literature between 1999 and 2019. Two reviewers filtered the results, looking for articles in English that reported >10 pediatric floating elbow cases. Primary outcomes were the rate and risk factors for developing PACS. Secondary outcomes included patient and injury characteristics, treatment strategies, other complications (eg, neurovascular injuries), and final outcomes. RESULTS: The initial search yielded a total of 150 studies. Following review, 11 studies were included, with 433 patients available for review. The mechanism of injury was a fall in 96% of cases. Closed reduction and percutaneous pinning was the most common treatment performed for both fractures. Only 8/433 patients (2%) developed PACS. The incidence of a pulseless limb at presentation was 4%, and all patients regained a pulse following reduction. Three cases of iatrogenic ulnar nerve injury were reported in the setting of medial pin placement. Good to excellent results were reported in 83% to 100% of patients, based on the modified Flynn criteria. CONCLUSIONS: Despite being limited to heterogenous and retrospective case series, the evidence reviewed in this study contradicts the current belief of a high risk of PACS or other complications in pediatric floating elbows. PACS is much more common with displaced fractures in the setting of delayed treatment. The rate of other complications is comparable to isolated supracondylar humerus fractures. Evidence supports treating these injuries in an urgent fashion in the setting of a displaced fracture, although fixation of both distal and proximal fractures is not supported by evidence. The outcomes of pediatric floating elbows are generally good and do not reflect the poor prognosis that adult floating elbows represent. LEVEL OF EVIDENCE: Level IV-systematic review of level IV studies.


Assuntos
Síndromes Compartimentais , Cotovelo/lesões , Traumatismos do Antebraço , Fixação de Fratura , Complicações Pós-Operatórias , Criança , Síndromes Compartimentais/etiologia , Síndromes Compartimentais/terapia , Traumatismos do Antebraço/complicações , Traumatismos do Antebraço/cirurgia , Fixação de Fratura/efeitos adversos , Fixação de Fratura/métodos , Humanos , Incidência , Avaliação de Processos e Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Fatores de Risco
7.
Plast Reconstr Surg ; 146(3): 258e-264e, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32842096

RESUMO

BACKGROUND: Multiple single-institution studies have revealed that breast free flap compromise usually occurs within the first 48 postoperative hours. However, national studies analyzing the rates and timing of breast free flap compromise are lacking. This study aimed to fill this gap in knowledge to better guide postoperative monitoring. METHODS: All women undergoing breast free flap reconstruction from the American College of Surgeons National Surgical Quality Improvement Program 2012 to 2016 database were analyzed to determine the rates and timing of free flap take-back. Take-backs were stratified by postoperative day through the first month. Multivariable modified Poisson regression analysis was used to determine the independent predictors of free flap take-back. RESULTS: A total of 6792 breast free flap patients were analyzed. Multivariable analysis revealed that body mass index of 40 kg/m or higher, hypertension, American Society of Anesthesiologists class of 3 or higher, steroid use, and smoking were independent predictors of take-back (p < 0.05). Take-back occurred at the highest rate during postoperative day 1, dropped significantly by postoperative day 2 (p < 0.001), and remained consistently low after postoperative day 2 (<0.6 percent daily). The identified risk factors significantly increased the likelihood of take-back on postoperative day 1 (p < 0.05), with a trend noted on postoperative day 2 (p = 0.06). Fewer than 0.4 percent of patients (n = 27) underwent take-back on postoperative day 2 without having risk factors. CONCLUSIONS: This is the first national study specifically analyzing rates, timing, and independent predictors of breast free flap take-back. The data support discontinuing breast free flap monitoring by the end of postoperative day 1 for patients without risk factors, given the very low rate of take-back for such patients during postoperative day 2 (≤0.4 percent). CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.


Assuntos
Retalhos de Tecido Biológico , Mamoplastia/métodos , Complicações Pós-Operatórias/terapia , Reoperação , Terapia de Salvação , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Pessoa de Meia-Idade , Monitorização Fisiológica , Fatores de Risco , Fatores de Tempo , Estados Unidos , Adulto Jovem
9.
Medicine (Baltimore) ; 99(34): e21725, 2020 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-32846791

RESUMO

Reports on lymphatic intervention for chylothorax complicating thoracic aortic surgery are limited. We aimed to evaluate technical and clinical outcomes of lymphangiography and thoracic duct embolization (TDE) for chylothorax complicating thoracic aortic surgery.Nine patients (mean age, 38.9 years) who underwent chylothorax interventions after thoracic aortic surgery (aorta replacement [n = 7] with [n = 2] or without [n = 5] lung resection, and vascular ring repair [n = 2]) were reviewed retrospectively. Magnetic resonance (MR) lymphangiograms were obtained in 5 patients. The median interval between surgery and conventional lymphangiography was 9 days (range, 4-28 days). TDE clinical success was defined as lymphatic leakage resolution with chest tube removal within 2 weeks.MR lymphangiograms revealed contrast leakage from the thoracic duct (n = 4) or no definite leakage (n = 1), which correlated well with conventional lymphangiogram findings. The technical success rate of conventional lymphangiography was 88.9% (8/9); 8 patients showed contrast leakage, while the patient without definite leakage on MR lymphangiography had small inguinal lymph nodes, and thoracic duct visualization by conventional lymphangiography failed. The technical success rates of antegrade and retrograde TDE via pleural access were 75% (6/8) and 100% (3/3), respectively. Clinical outcomes after embolization, as judged by the tube-removal day, were similar between low- (<500 mL/day) and high-output (≥500 mL/day) chylothorax patients. The drainage amount decreased significantly after lymphangiography/TDE, from 710.0 mL/day to 109.7 mL/day (p < .05). The clinical success rate of TDE was 87.8% (7/8).Conventional lymphangiography and TDE yielded high technical success rates and demonstrated encouraging clinical outcomes for chylothorax complicating thoracic aortic surgery.


Assuntos
Aorta Torácica/cirurgia , Quilotórax/terapia , Embolização Terapêutica/métodos , Linfografia/métodos , Complicações Pós-Operatórias/terapia , Adolescente , Adulto , Criança , Pré-Escolar , Quilotórax/diagnóstico por imagem , Quilotórax/etiologia , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Adulto Jovem
10.
Am Heart J ; 228: 57-64, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32828047

RESUMO

AIMS: Data regarding outcomes for patients with severe aortic stenosis (AS) with concomitant aortic insufficiency (AI), undergoing transcatheter aortic valve replacement (TAVR) are limited. This study aimed to analyze the prevalence of severe AS with concomitant AI among patients undergoing TAVR and outcomes of TAVR in this patient group. METHODS AND RESULTS: Using data from the STS/ACC-TVT Registry, we identified patients with severe AS with or without concomitant AI who underwent TAVR between 2011 and 2016. Patients were categorized based on the severity of pre-procedural AI. Multivariable proportional hazards regression models were used to examine all-cause mortality and heart failure (HF) hospitalization at 1-year. Among 54,535 patients undergoing TAVR, 42,568 (78.1%) had severe AS with concomitant AI. Device success was lower in patients with severe AS with concomitant AI as compared with isolated AS. The presence of baseline AI was associated with lower 1 year mortality (HR 0.94 per 1 grade increase in AI severity; 95% CI, 0.91-0.98, P < .001) and HF hospitalization (HR 0.87 per 1 grade increase in AI severity; 95% CI, 0.84-0.91, P < .001). CONCLUSIONS: Severe AS with concomitant AI is common among patients undergoing TAVR, and is associated with lower 1 year mortality and HF hospitalization. Future studies are warranted to better understand the mechanisms underlying this benefit. SHORT ABSTRACT: In this nationally representative analysis from the United States, 78.1% of patients undergoing TAVR had severe AS with concomitant AI. Device success was lower in patients with severe AS with concomitant AI as compared with isolated AS. The presence of baseline AI was associated with lower 1 year mortality (HR 0.94 per 1 grade increase in AI severity; 95% CI, 0.91-0.98, P < .001) and HF hospitalization (HR 0.87 per 1 grade increase in AI severity; 95% CI, 0.84-0.91, P < .001).


Assuntos
Insuficiência da Valva Aórtica , Estenose da Valva Aórtica , Valva Aórtica , Insuficiência Cardíaca , Complicações Pós-Operatórias , Substituição da Valva Aórtica Transcateter , Idoso , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/complicações , Insuficiência da Valva Aórtica/diagnóstico , Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/epidemiologia , Estenose da Valva Aórtica/cirurgia , Feminino , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Próteses Valvulares Cardíacas , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Sistema de Registros/estatística & dados numéricos , Índice de Gravidade de Doença , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/métodos , Estados Unidos/epidemiologia
11.
Br J Anaesth ; 125(4): 492-504, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32798069

RESUMO

Postoperative delirium is a relatively common and serious complication. It increases hospital stay by 2-3 days and is associated with a 30-day mortality of 7-10%. It is most prevalent in older patients, those with existing neurocognitive disorders, and those undergoing complex or emergency procedures. Preclinical and clinical research in recent years has uncovered more about the pathophysiology of postoperative delirium and may yield more potential therapeutic options. Using the enhanced recovery pathway framework of risk stratification, risk reduction, and rescue treatment, we have reviewed the current clinical evidence on the validity of delirium prediction scores for the surgical population, the effectiveness of perioperative delirium risk reduction interventions, and management options for established delirium. Effective perioperative interventions include depth of anaesthesia monitoring, intraoperative dexmedetomidine infusion, and multimodal analgesia. Choice of general anaesthetic agent may not be associated with significant difference in delirium risk. Several other factors, such as preoperative fasting, temperature control, and blood pressure management have some association with the risk of postoperative delirium; these will require further studies. Because of the limited treatment options available for established delirium, we propose that risk assessment and perioperative risk reduction may be the most effective approaches in managing postoperative delirium.


Assuntos
Delírio/terapia , Complicações Pós-Operatórias/terapia , Comportamento de Redução do Risco , Transfusão de Sangue , Delírio/prevenção & controle , Hidratação , Humanos , Manejo da Dor , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios , Medição de Risco
12.
Plast Reconstr Surg ; 146(2): 402-407, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32740596

RESUMO

BACKGROUND: Obesity is a risk factor for the development of secondary lymphedema after axillary lymphadenectomy and radiation therapy. The purpose of this study was to determine whether obesity influences the morbidity of lymphedema in patients who have the condition. METHODS: Two cohorts of patients were compared: group 1, normal weight (body mass index ≤25 kg/m); and group 2, obese (body mass index ≥30 kg/m). Inclusion criteria were patients aged 21 years or older with lymphedema confirmed by lymphoscintigraphy. Covariates included age, sex, lymphedema type (primary or secondary), location, comorbidities, lymph node dissection, radiation therapy, lymphoscintigram result, and disease duration. Outcome variables were infection, hospitalization, and degree of limb overgrowth. The cohorts were compared using the Mann-Whitney U test, Fisher's exact test, and multivariable logistic regression. RESULTS: Sixty-seven patients were included: group 1, n = 33; and group 2, n = 34. Disease duration did not differ between groups (p = 0.72). Group 2 was more likely to have an infection (59 percent), hospitalization (47 percent), and moderate or severe overgrowth (79 percent), compared to group 1 (18, 6, and 40 percent, respectively; p < 0.001). Multivariable logistic regression showed that obesity was an independent risk factor for infection (OR, 7.9; 95 percent CI, 2.5 to 26.3; p < 0.001), hospitalization (OR, 30.0; 95 percent CI, 3.6 to 150.8; p < 0.001), and moderate to severe limb overgrowth (OR, 6.7; 95 percent CI, 2.1 to 23.0; p = 0.003). CONCLUSIONS: Obesity negatively affects patients with established lymphedema. Obese individuals are more likely to have infections, hospitalizations, and larger extremities compared to subjects with a normal body mass index. Patients with lymphedema should be counseled about the negative effects of obesity on their condition. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.


Assuntos
Excisão de Linfonodo/efeitos adversos , Linfedema/epidemiologia , Mastectomia/efeitos adversos , Obesidade/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Axila , Índice de Massa Corporal , Neoplasias da Mama/terapia , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Linfedema/diagnóstico , Linfedema/etiologia , Linfedema/terapia , Linfocintigrafia , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Obesidade/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Radioterapia Adjuvante/efeitos adversos , Medição de Risco , Fatores de Risco , Adulto Jovem
13.
PLoS One ; 15(8): e0237133, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32760097

RESUMO

BACKGROUND: Accessory nerve shoulder dysfunction is common after neck dissection in oral cancer survivors. This study aimed to investigate the short-term effects of scapular muscle strengthening exercises with motor-control techniques on neck dissection-related shoulder dysfunction in oral cancer survivors before the initiation of radiotherapy. METHODS: Thirty-eight participants were randomly allocated into the motor-control and regular-exercise groups. Each group received conventional physical therapy and specific scapular muscle strengthening exercises for 1 month immediately after neck dissection. Motor control techniques were integrated with scapular strengthening exercises for the motor-control group. Shoulder pain, active range of motion (AROM) of shoulder abduction, and scapular muscle activities including upper trapezius (UT), middle trapezius (MT), lower trapezius (LT), and serratus anterior (SA) when performing maximal voluntary isometric contraction (MVIC) and scapular muscle exercises were evaluated at baseline and after 1 month of training. RESULTS: Both groups reduced shoulder pain and increased muscle activity of maximum voluntary isometric contraction (MVIC) of each muscle after the intervention. Increased AROM of shoulder abduction was only observed in the motor-control group (95% CI 3.80 to 20.51, p = 0.004). Relative to baseline evaluation, muscle activities of UT decreased in the motor-control group when performing shoulder shrug with 1-kg weight (95% CI -33.06 to -1.29, p = 0.034). Moreover, the SA activity decreased in the motor-control group (95% CI -29.73 to -27.68, p<0.001) but increased in the regular-exercise group (95% CI 28.16 to 30.05, p<0.001) when performing shoulder horizontal adduction and flexion. CONCLUSION: Early strengthening exercise with motor control techniques has greater benefits for improving AROM of shoulder abduction, muscle economy, and reducing compensatory scapular muscle activities in patients with neck dissection-related shoulder dysfunction before the initiation of radiotherapy.


Assuntos
Terapia por Exercício/métodos , Neoplasias Bucais/cirurgia , Força Muscular , Esvaziamento Cervical/efeitos adversos , Complicações Pós-Operatórias/terapia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Bucais/radioterapia , Contração Muscular , Amplitude de Movimento Articular , Ombro/fisiopatologia , Músculos Superficiais do Dorso/fisiopatologia
14.
Eur J Vasc Endovasc Surg ; 60(4): 519-530, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32624387

RESUMO

OBJECTIVE: Hospital and surgeon operative caseload is thought to be associated with peri-operative mortality following the non-elective repair of aortic aneurysms; however, whether such an association exists within the Australian healthcare setting is unknown. METHODS: The Australasian Vascular Audit was interrogated to identify patients undergoing non-elective (emergency [EMG] or semi-urgent [URG]) aortic aneurysm repair between 2010 and 2016, as well as their treating surgeon and hospital. Hierarchal logistic regression modelling was used to assess the impact of caseload on outcomes after both endovascular (EVAR) and open surgical repair (OSR). RESULTS: Volume counts were determined from 14 262 patients (4 121 OSR and 10 141 EVAR). After exclusion of elective procedures and duplicates, 1 153 EVAR (570 EMG and 583 URG) and 1 245 OSR (946 EMG and 299 URG) non-elective cases remained for the analysis. Crude mortality was 24.0% following OSR (EMG 29.2%; URG 7.7%) and 7.5% following EVAR (EMG 12.6%; URG 2.4%). Univariable analysis demonstrated an association between OSR mortality and hospital volume (quintile [Q] 1: 25.3%, Q2: 27.8%, Q3: 23.9%, Q4: 27.0%, Q5: 16.2%; p = .030), but not surgeon (Q1: 25.2%, Q2: 27.4%, Q3: 26.0%, Q4: 21.4%, Q5: 19.5%, p = .32). Multivariable analysis confirmed this association (odds ratio (OR) [95% CI]; Q1 vs 5: 1.91 [1.13-3.21], Q2 vs. 5: 2.01[1.24-3.25], Q3 vs. 5: 1.41 [0.86-2.29], Q4 vs. 5: 1.92 [1.17-3.15]; p = .020). The difference was most pronounced in the EMG OSR group [Q1 - 3 vs. 4-5] (OR 1.63 [1.07-2.48]; p = .020). Mortality after EVAR was not associated with either hospital (Q1: 6.3%, Q2: 10%, Q3: 6.8%, Q4: 4.5%, Q5: 10%; p = .14) or surgeon volume (Q1: 9.3%, Q2: 5.7%, Q3: 8.1%, Q4: 7.0%, Q5: 7.3%; p = .67). CONCLUSION: There is an inverse correlation between hospital volume and peri-operative mortality following EMG open repair of aortic aneurysm. These data support restructuring Australian pathways of care to direct suspected ruptured aneurysm to institutions that reach a minimum volume threshold.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Procedimentos Endovasculares , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Avaliação de Processos e Resultados em Cuidados de Saúde , Cirurgiões , Procedimentos Cirúrgicos Vasculares , Carga de Trabalho , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/mortalidade , Austrália/epidemiologia , Competência Clínica , Bases de Dados Factuais , Emergências , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade
17.
Orthopade ; 49(8): 691-701, 2020 Aug.
Artigo em Alemão | MEDLINE | ID: mdl-32642943

RESUMO

BACKGROUND: Pyogenic spondylodiscitis is a rare disease that is being diagnosed with increasing frequency in recent years. It is associated with a high morbidity and mortality. DIAGNOSIS: Often, because of its nonspecific symptoms, pyogenic spondylodiscitis is diagnose with some delay. In addition to pathogen detection, MRI is the gold standard to diagnose pyogenic spondylodiscitis. Also, x-ray imaging and CT can be carried out for surgical planning and for subsequent follow-up imaging. If blood or tissue cultures are negative, open surgical biopsies should be preferred over CT-guided biopsies. THERAPY: The therapy can be conservative, such as immobilization, as well as antibiotics and analgesics, or surgical. If, for example, neurological deficits, spinale instabilities or deformities, septic disease progression or extensive abscess formations are present, surgical therapy is indicated. The surgical treatment strategies depend on the severity of the disease. OUTLOOK: The prognosis is dependent on a rapid diagnosis and a swift start to therapy. There is no clear evidence with regard to treatment options (conservative vs. surgical therapy).


Assuntos
Antibacterianos/uso terapêutico , Desbridamento/métodos , Discite/diagnóstico por imagem , Imagem por Ressonância Magnética/métodos , Complicações Pós-Operatórias , Biópsia , Discite/tratamento farmacológico , Discite/microbiologia , Humanos , Complicações Pós-Operatórias/microbiologia , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Resultado do Tratamento
18.
Orthopade ; 49(8): 685-690, 2020 Aug.
Artigo em Alemão | MEDLINE | ID: mdl-32661896

RESUMO

The choice of implant in an infection of the spine depends on what type of infection it is: discitis, spondylodiscitis, early infection after spinal surgery, or a late infection. The appropriate treatment strategies vary. In spondylodiscitis, a titanium implant may be necessary. In implant-associated early infections, surgical sanitization is often sufficient without changing the implant. In late infections, implant exchange is necessary because of biofilm.


Assuntos
Antibacterianos/uso terapêutico , Discite/tratamento farmacológico , Degeneração do Disco Intervertebral/microbiologia , Complicações Pós-Operatórias/terapia , Próteses e Implantes/microbiologia , Traumatismos da Coluna Vertebral/cirurgia , Coluna Vertebral/cirurgia , Infecção da Ferida Cirúrgica/microbiologia , Discite/microbiologia , Humanos , Complicações Pós-Operatórias/microbiologia , Traumatismos da Coluna Vertebral/complicações , Infecção da Ferida Cirúrgica/terapia
19.
Orthopade ; 49(8): 702-709, 2020 Aug.
Artigo em Alemão | MEDLINE | ID: mdl-32671414

RESUMO

BACKGROUND: The high demands that fracture-related infections put on patients, physicians and the healthcare system have led to the establishment of a international group of experts called the Fracture-Related Infection (FRI) Consensus Group, whose aim is to develop evidence-based treatment recommendations. DIAGNOSIS: Fracture-related infections are classified according to the time of occurrence, extent and treatment options. The diagnostic algorithm distinguishes between confirmatory and suggestive diagnostic criteria. If there are indications of an infection, tissue biopsy with microbiological and histological workup is recommended to confirm the diagnosis. THERAPY: The primary objective of FRI treatment is to achieve fracture consolidation, while avoiding osteomyelitis. Therapeutic options are removal of the implant, eradication of the infection with implant retention or suppression of FRI. A multidisciplinary team is recommended to develop a patient-specific, optimized surgical and antimicrobial therapy.


Assuntos
Antibacterianos/uso terapêutico , Desbridamento/métodos , Fraturas Ósseas/complicações , Fraturas Ósseas/cirurgia , Osteomielite/tratamento farmacológico , Complicações Pós-Operatórias/microbiologia , Infecção da Ferida Cirúrgica/diagnóstico , Infecção da Ferida Cirúrgica/terapia , Algoritmos , Biofilmes , Fraturas Ósseas/microbiologia , Humanos , Osteomielite/diagnóstico , Osteomielite/microbiologia , Complicações Pós-Operatórias/terapia , Infecção da Ferida Cirúrgica/microbiologia , Traumatologia
20.
Orthopade ; 49(8): 737-748, 2020 Aug.
Artigo em Alemão | MEDLINE | ID: mdl-32710138

RESUMO

Gluteal insufficiency or hip abductor mechanism deficiency mainly following (revision) total hip replacement is associated with highly painful complaints and severe suffering of patients. It represents a great diagnostic and therapeutic challenge. Differentiated conservative treatment pathways, open surgical and endoscopic anatomic repair techniques with intact gluteal musculature and muscle transfer are available as salvage procedures for chronic not anatomically reconstructable mass ruptures. A stepwise diagnostic and therapeutic approach is required for restoration of the quality of life and painless or almost painless mobility of affected patients in occupation and daily life.


Assuntos
Artralgia/etiologia , Artroplastia de Quadril/métodos , Artroplastia de Quadril/psicologia , Nádegas/lesões , Músculo Esquelético/lesões , Músculo Esquelético/cirurgia , Qualidade de Vida , Procedimentos Cirúrgicos Reconstrutivos/métodos , Traumatismos dos Tendões/etiologia , Artralgia/diagnóstico , Artralgia/cirurgia , Nádegas/cirurgia , Endoscopia , Humanos , Traumatismos dos Nervos Periféricos/diagnóstico , Traumatismos dos Nervos Periféricos/epidemiologia , Traumatismos dos Nervos Periféricos/etiologia , Traumatismos dos Nervos Periféricos/terapia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Reoperação , Ruptura , Traumatismos dos Tendões/diagnóstico , Traumatismos dos Tendões/epidemiologia , Traumatismos dos Tendões/terapia , Resultado do Tratamento
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