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1.
JAMA ; 323(3): 225-236, 2020 01 21.
Artigo em Inglês | MEDLINE | ID: mdl-31961418

RESUMO

Importance: It is not known if use of colloid solutions containing hydroxyethyl starch (HES) to correct for intravascular deficits in high-risk surgical patients is either effective or safe. Objective: To evaluate the effect of HES 130/0.4 compared with 0.9% saline for intravascular volume expansion on mortality and postoperative complications after major abdominal surgery. Design, Setting, and Participants: Multicenter, double-blind, parallel-group, randomized clinical trial of 775 adult patients at increased risk of postoperative kidney injury undergoing major abdominal surgery at 20 university hospitals in France from February 2016 to July 2018; final follow-up was in October 2018. Interventions: Patients were randomized to receive fluid containing either 6% HES 130/0.4 diluted in 0.9% saline (n = 389) or 0.9% saline alone (n = 386) in 250-mL boluses using an individualized hemodynamic algorithm during surgery and for up to 24 hours on the first postoperative day, defined as ending at 7:59 am the following day. Main Outcomes and Measures: The primary outcome was a composite of death or major postoperative complications at 14 days after surgery. Secondary outcomes included predefined postoperative complications within 14 days after surgery, durations of intensive care unit and hospital stays, and all-cause mortality at postoperative days 28 and 90. Results: Among 826 patients enrolled (mean age, 68 [SD, 7] years; 91 women [12%]), 775 (94%) completed the trial. The primary outcome occurred in 139 of 389 patients (36%) in the HES group and 125 of 386 patients (32%) in the saline group (difference, 3.3% [95% CI, -3.3% to 10.0%]; relative risk, 1.10 [95% CI, 0.91-1.34]; P = .33). Among 12 prespecified secondary outcomes reported, 11 showed no significant difference, but a statistically significant difference was found in median volume of study fluid administered on day 1: 1250 mL (interquartile range, 750-2000 mL) in the HES group and 1500 mL (interquartile range, 750-2150 mL) in the saline group (median difference, 250 mL [95% CI, 83-417 mL]; P = .006). At 28 days after surgery, 4.1% and 2.3% of patients had died in the HES and saline groups, respectively (difference, 1.8% [95% CI, -0.7% to 4.3%]; relative risk, 1.76 [95% CI, 0.79-3.94]; P = .17). Conclusions and Relevance: Among patients at risk of postoperative kidney injury undergoing major abdominal surgery, use of HES for volume replacement therapy compared with 0.9% saline resulted in no significant difference in a composite outcome of death or major postoperative complications within 14 days after surgery. These findings do not support the use of HES for volume replacement therapy in such patients. Trial Registration: ClinicalTrials.gov Identifier: NCT02502773.


Assuntos
Abdome/cirurgia , Hidratação/métodos , Derivados de Hidroxietil Amido/uso terapêutico , Complicações Pós-Operatórias/prevenção & controle , Solução Salina/uso terapêutico , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Lesão Renal Aguda/prevenção & controle , Idoso , Método Duplo-Cego , Feminino , Humanos , Cuidados Intraoperatórios , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade , Estatísticas não Paramétricas
2.
Plast Reconstr Surg ; 145(2): 317-327, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31985612

RESUMO

BACKGROUND: This study investigated the risk of reconstruction failure after mastectomy, immediate breast reconstruction, and radiotherapy to either a temporary tissue expander or permanent implant. METHODS: Records of women treated at a single institution between June of 1997 and December of 2011 were reviewed. Two patient groups were identified based on type of immediate breast reconstruction: tissue expander followed by exchange with a permanent implant and permanent implant. The study endpoint was rate of reconstruction failure, defined as a replacement, loss of the implant, or conversion to flap. RESULTS: The tissue expander/permanent implant and the permanent implant groups consisted of 63 and 75 patients, respectively. The groups were well balanced for clinical and treatment characteristics. With a median follow-up of 116 months, eight implant losses, 50 implant replacements, and four flap conversions were recorded. Reconstruction failure occurred in 22 of 63 patients in the expander/implant group and in 40 of 75 patients in the permanent implant group. A traditional proportional hazards model showed a higher risk of reconstruction failure for the expander/implant group (hazard ratio, 2.01) and a significantly shorter time to reconstruction failure compared with the permanent implant group (109.2 months versus 157.7 months; p = 0.03); however, according to a competing risk model, the between-groups cumulative incidences were not significantly different (hazard ratio, 1.09). CONCLUSIONS: Radiotherapy to either a tissue expander or a permanent implant presented a fairly large risk of reconstruction failure over time. The expander/implant group was not more likely to develop reconstruction failure compared to permanent implant group, but the timing of onset was shorter. More complex techniques should be investigated to lower the risk of reconstruction failure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Assuntos
Neoplasias da Mama/cirurgia , Mastectomia/métodos , Expansão de Tecido/métodos , Adolescente , Adulto , Idoso , Antibacterianos/administração & dosagem , Implante Mamário/instrumentação , Implante Mamário/métodos , Neoplasias da Mama/radioterapia , Implantes de Medicamento , Feminino , Humanos , Mamoplastia/métodos , Pessoa de Meia-Idade , Polimetil Metacrilato/uso terapêutico , Cuidados Pós-Operatórios/métodos , Infecções Relacionadas à Prótese/prevenção & controle , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Terapia de Salvação/instrumentação , Terapia de Salvação/métodos , Expansão de Tecido/instrumentação , Dispositivos para Expansão de Tecidos , Resultado do Tratamento , Adulto Jovem
3.
Plast Reconstr Surg ; 145(2): 545-554, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31985657

RESUMO

BACKGROUND: Following bariatric surgery, patients develop problems related to lax abdominal skin that may be addressed by contouring procedures. Third-party insurers have subjective requirements for coverage of these procedures that can limit patient access. The authors sought to determine how well third-party payers cover abdominal contouring procedures in this population. METHODS: The authors conducted a cross-sectional analysis of insurance policies for coverage of panniculectomy, lower back excision, and circumferential lipectomy. Abdominoplasty was evaluated as an alternative to panniculectomy. Insurance companies were selected based on their market share and state enrolment. A list of medical necessity criteria was abstracted from the policies that offered coverage. RESULTS: Of the 55 companies evaluated, 98 percent had a policy that covered panniculectomy versus 36 percent who would cover lower back excision (p < 0.0001), and one-third provided coverage for circumferential lipectomy. Of the insurers who covered panniculectomy, only 30 percent would also cover abdominoplasty. Documentation of secondary skin conditions was the most prevalent criterion in panniculectomy policies (100 percent), whereas impaired function and secondary skin conditions were most common for coverage of lower back excision (73 percent and 73 percent, respectively). Frequency of criteria for panniculectomy versus lower back excision differed most notably for (1) secondary skin conditions (100 percent versus 73 percent; p = 0.0030), (2) weight loss (45 percent versus 7 percent; p = 0.0106), and (3) duration of weight stability (82 percent versus 53 percent; p = 0.0415). CONCLUSIONS: For the postbariatric population, panniculectomy was covered more often and had more standardized criteria than lower back excision or circumferential lipectomy. However, all have vast intracompany and interpolicy variations in coverage criteria that may reduce access to procedures, even among patients with established indications.


Assuntos
Abdominoplastia/economia , Cirurgia Bariátrica/economia , Contorno Corporal/economia , Cobertura do Seguro/economia , Seguro Saúde/estatística & dados numéricos , Abdominoplastia/estatística & dados numéricos , Dorso/cirurgia , Estudos Transversais , Humanos , Seguradoras/economia , Seguradoras/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/economia , Lipectomia/economia , Lipectomia/estatística & dados numéricos , Cuidados Pós-Operatórios/economia , Estados Unidos
5.
Medicine (Baltimore) ; 99(2): e18710, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31914080

RESUMO

The present study aimed to assess the effect of removing an indwelling urinary catheter at different times on urinary retention and urinary infection in patients undergoing gynecologic surgery.Electronic databases including PubMed, EMbase, the Cochrane Central Register of Controlled Trials, and Ovid from inception to June 2018 were searched. Relevant randomized controlled trials (RCTs) of removal the indwelling urinary catheter in different time were included.Eight RCTs were included. Data were analyzed by RevMan 5.3 version. There was significant difference in urinary retention (relative risk [RR] 2.46, 95% confidence intervals [CIs] 1.10-5.53), P = .03) between the ≤6 hours and >6 hours indwelling urinary catheter removal groups, while no significant differences were found in the gynecologic surgery excluded the vaginal surgery group and vaginal surgery group. When compared with >6 hours indwelling urinary catheter removal group, the incidence of urinary infection was significantly reduced at the ≤6 hours removal group (RR = 0.66, 95% CI 0.48-0.89, P = .007). The urinary catheter removal time at ≤6 hours also significantly reduced the incidence of urinary retention (RR = 5.06, 95%CI 1.74-14.69, P = .003), and did not statistically increase the incidence of urinary infection (RR = 0.30, 95%CI 0.08 to 1.20, P = .09), compared with immediate urinary catheter removal after surgery.Removal time of the urinary catheter at ≤6 hours postoperatively seems to be more beneficial than immediate or >6 hours for patients undergoing gynecologic surgery which excluded the vaginal surgery.


Assuntos
Remoção de Dispositivo/métodos , Procedimentos Cirúrgicos em Ginecologia/métodos , Cuidados Pós-Operatórios/métodos , Cateteres Urinários , Remoção de Dispositivo/efeitos adversos , Humanos , Cuidados Pós-Operatórios/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo , Retenção Urinária/etiologia , Infecções Urinárias/etiologia
7.
Plast Reconstr Surg ; 145(2): 403-406, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31985631

RESUMO

Humpectomy is one of the most common steps in reduction rhinoplasty among Caucasian patients. The most widespread procedures to address hump removal are both the "en bloc humpectomy" (with reconstruction of the middle third with spreader grafts) and the "split hump technique" (with confection of spreader flaps). The spare roof technique, for rhinoplasty reduction, has been developed over the past 4 years. In this technique, the upper lateral cartilages are completely preserved-even the hidden part under the caudal aspect of the nasal bones. It consists of five main steps: step 1, the upper lateral cartilages are released from the dorsal aspect of the nasal septum; step 2, a 1-mm strip of the dorsal septum is taken in each movement as required; step 3, ostectomy of the caudal aspect of nasal bones, keeping the upper lateral cartilages intact and releasing the "lateral" (left and right) pyriform aperture ligament; step 4, classic medial and lateral osteotomies (closing the open bony roof); and step 5, suturing the upper lateral cartilages to the dorsal septum and thus avoiding the natural spring effect. The outcomes of the first 100 patients have been validated by a prospective, interventional, and longitudinal study performed on patients undergoing primary rhinoplasty by means of the spare roof technique. This study confirms that the spare roof technique significantly improved patient quality of life regarding nose function and appearance. It is a reliable technique that can help deliver consistently good results in Caucasian and Mediterranean patients with a dorsal hump seeking rhinoplasty.


Assuntos
Septo Nasal/cirurgia , Rinoplastia/métodos , Humanos , Osso Nasal/cirurgia , Osteotomia/métodos , Cuidados Pós-Operatórios/métodos , Retalhos Cirúrgicos
8.
Ann R Coll Surg Engl ; 102(1): 14-17, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31155915

RESUMO

INTRODUCTION: Infra-inguinal vascular reconstruction with active groin infection is a concerning issue. Using resistant grafts to infection is the most adopted approach. However, in absence of these materials in acute situations, the trans-obturator approach allows for limb revascularisation avoiding the infected site. We evaluated the effectiveness of this approach in patients who needed lower limb revascularisation with an ipsilateral groin infection. MATERIALS AND METHODS: A retrospective study was conducted over a four-year period. RESULTS: Over this period, 13 patients underwent trans-obturator reconstructions (13 external iliac-popliteal above-knee and one aortobipopliteal above-knee bypass). Seven patients had been previously revascularised and were admitted for graft infection (six infra-inguinal bypasses, one axillo-bifemoral bypass). Four presented with acute limb ischaemia, three with groin haematoma and one with a groin abscess. The remaining cases consisted of drug-addicted patients with injury of femoral vessels due to self-injection of drugs. The patients underwent reconstructions with autologous grafts which complicated early with groin haematoma. After transobturator revascularisation, the groin underwent debridement with applying vacuum-assisted wound closure device. CONCLUSION: The transobturator approach could be considered as a chance for lower limb revascularisation in case of ipsilateral groin infection. Moreover, avoiding the infected site allowed us to focus separately and safely on the treatment of the inguinal wound.


Assuntos
Abscesso Abdominal/complicações , Infecções Bacterianas/complicações , Perna (Membro)/irrigação sanguínea , Reperfusão/métodos , Idoso , Amputação/estatística & dados numéricos , Anastomose Cirúrgica/métodos , Prótese Vascular , Feminino , Virilha , Humanos , Isquemia/cirurgia , Masculino , Cuidados Pós-Operatórios , Estudos Retrospectivos , Terapia de Salvação/estatística & dados numéricos
10.
Ann Otol Rhinol Laryngol ; 129(2): 181-190, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31631687

RESUMO

OBJECTIVES: Tracheostomy care in leading pediatric hospitals is both multidisciplinary and comprehensive, including generalized care protocols and thorough family training programs. This level of care is more difficult in resource-limited settings lacking developed healthcare infrastructure and tracheostomy education among nursing and resident staff. The objective of this study was to improve pediatric tracheostomy care in resource-limited settings. METHODS: In collaboration with a team of otolaryngologists, respiratory therapists, tracheostomy nurses, medical illustrators, and global health educators, image-based tracheostomy education materials and low-cost tracheostomy care kits were developed for use in resource-limited settings. In addition, a pilot study was conducted, implementing the image-based tracheostomy pamphlet, manual suctioning device and low-cost ambulatory supply kit ("Go-Bags"), within a low-fidelity simulated training course for nurses and residents in Kigali, Rwanda. RESULTS: An image-based language and literacy-independent tracheostomy care manual was created and published on OPENPediatrics, an open-access online database of clinician-reviewed learning content. Participants of the training program pilot study reported the course to be of high educational and practical value, and described improved confidence in their ability to perform tracheostomy care procedures. CONCLUSIONS: Outpatient tracheostomy care may be improved upon by implementing image-based tracheostomy care manuals, locally-sourced tracheostomy care kits, and tailored educational material into a low-fidelity simulated tracheostomy care course. These materials were effective in improving technical skills and confidence among nurses and residents. These tools are expected to improve knowledge and skills with outpatient tracheostomy care, and ultimately, to reduce tracheostomy-related complications.


Assuntos
Cuidados Pós-Operatórios/normas , Melhoria de Qualidade , Traqueostomia , Assistência Ambulatorial , Criança , Feminino , Recursos em Saúde , Humanos , Masculino , Projetos Piloto , Ruanda , Traqueostomia/educação , Traqueostomia/instrumentação
11.
Oncology ; 98(1): 16-22, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31514200

RESUMO

PURPOSE: Preclinical studies indicated that imatinib may have single-agent activity in glioblastoma through inhibition of tyrosine kinase activity and also that it might enhance the efficacy of radiotherapy. We therefore sought to investigate clinical efficacy in patients with newly diagnosed and recurrent glioblastoma in combination with radiotherapy. METHODS: We conducted a nonrandomized, 2-arm, open-label phase II trial including patients aged 18 years or older with an ECOG performance status of 0-2 that were either newly diagnosed (arm A) with a measurable tumor (i.e., after incomplete resection or biopsy) or that were diagnosed with progression of a glioblastoma after initial therapy (arm B). Patients in arm A received 600 mg/day imatinib in combination with hypofractionated radiotherapy (2.5 Gy per fraction, 22 fractions). Patients in arm B received 600 mg/day imatinib alone or in combination with re-irradiation at various doses. In case tumor progression occurred, CCNU was added (2 cycles, 100 mg/m2) to imatinib. The primary end point was progression-free survival (PFS). The secondary end point was safety, defined as per Common Terminology Criteria for Adverse Events (version 2.0). Overall survival (OS) was analyzed as an exploratory end point. RESULTS: Fifty-one patients were enrolled, of which 19 were included in arm A and 32 in arm B. The median follow-up was 4 (0.5-30) months in arm A and 6.5 (0.3-51.5) months in arm B. The median PFS was 2.8 months (95% CI 0-8.7) in arm A and 2.1 months (95% CI 0-11.8) in arm B. The median OS was 5.0 (0.8-30) months (95% CI 0-24.1) in arm A and 6.5 (0.3-51.5) months (95% CI 0-32.5) in arm B. The major grade 3 events were seizure (present in 17 patients), pneumonia (11 patients), and vigilance decrease (7 patients). CONCLUSIONS: Imatinib showed no measurable activity in patients with newly diagnosed or recurrent glioblastoma.


Assuntos
Antineoplásicos/uso terapêutico , Glioblastoma/tratamento farmacológico , Glioblastoma/patologia , Mesilato de Imatinib/uso terapêutico , Inibidores de Proteínas Quinases/uso terapêutico , Adulto , Idoso , Antineoplásicos/administração & dosagem , Antineoplásicos/efeitos adversos , Biópsia , Terapia Combinada , Progressão da Doença , Feminino , Seguimentos , Glioblastoma/mortalidade , Glioblastoma/cirurgia , Humanos , Mesilato de Imatinib/administração & dosagem , Mesilato de Imatinib/efeitos adversos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Cuidados Pós-Operatórios , Prognóstico , Inibidores de Proteínas Quinases/administração & dosagem , Inibidores de Proteínas Quinases/efeitos adversos , Retratamento , Resultado do Tratamento
12.
Ann R Coll Surg Engl ; 102(1): 28-35, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31232611

RESUMO

INTRODUCTION: Enhanced recovery programmes are established as an essential part of laparoscopic colorectal surgery. Optimal pain management is central to the success of an enhanced recovery programme and is acknowledged to be an important patient reported outcome measure. A variety of analgesia strategies are employed in elective laparoscopic colorectal surgery ranging from patient-controlled analgesia to local anaesthetic wound infiltration catheters. However, there is little evidence regarding the optimal analgesia strategy in this cohort of patients. The LapCoGesic study aimed to explore differences in analgesia strategies employed for patients undergoing elective laparoscopic colorectal surgery and to assess whether this variation in practice has an impact on patient-reported and clinical outcomes. MATERIALS AND METHODS: A prospective, multicentre, observational cohort study of consecutive patients undergoing elective laparoscopic colorectal resection was undertaken over a two-month period. The primary outcome measure was postoperative pain scores at 24 hours. Data analysis was conducted using SPSS version 22. RESULTS: A total of 103 patients undergoing elective laparoscopic colorectal surgery were included in the study. Thoracic epidural was used in 4 (3.9%) patients, spinal diamorphine in 56 (54.4%) patients and patient-controlled analgesia in 77 (74.8%) patients. The use of thoracic epidural and spinal diamorphine were associated with lower pain scores on day 1 postoperatively (P < 0.05). The use of patient-controlled analgesia was associated with significantly higher postoperative pain scores and pain severity. DISCUSSION: Postoperative pain is managed in a variable manner in patients undergoing elective colorectal surgery, which has an impact on patient reported outcomes of pain scores and pain severity.


Assuntos
Analgesia/métodos , Doenças do Colo/cirurgia , Laparoscopia/métodos , Padrões de Prática Médica/estatística & dados numéricos , Doenças Retais/cirurgia , Idoso , Analgesia/estatística & dados numéricos , Analgesia Controlada pelo Paciente/estatística & dados numéricos , Analgésicos Opioides/uso terapêutico , Conversão para Cirurgia Aberta/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Humanos , Cuidados Intraoperatórios/métodos , Cuidados Intraoperatórios/estatística & dados numéricos , Laparoscopia/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Medição da Dor , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/prevenção & controle , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/estatística & dados numéricos , Estudos Prospectivos , Reoperação/estatística & dados numéricos , Resultado do Tratamento
13.
Anaesthesia ; 75(2): 227-233, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31250430

RESUMO

Traditional methods used to disseminate educational resources to front-line healthcare staff have several limitations. Social media may increase the visibility of these resources among targeted groups and communities. Our project aimed to disseminate key clinical messages from the National Tracheostomy Safety Project to those caring for patients with tracheostomies or laryngectomies. We commissioned an external media company to design educational material and devise a marketing strategy. We developed videos to communicate recommendations from the safety project and used Facebook, Twitter, YouTube and LinkedIn to deliver these to our target users. We recorded 629,270 impressions over a paid 12-week campaign. Our YouTube channel registered more than a five-fold increase in views and watch time during the campaign as compared with the previous year. Around two-thirds of views across all platforms were from peer-to-peer sharing. We spent £4140 on social media advertising, with each view and click costing £0.02 and £0.67, respectively. This intelligence-led approach using social media is an effective and efficient method to disseminate knowledge on the principles of safe tracheostomy care to front-line clinical staff. Similar strategies may be effective for other patient safety topics, especially when targeting groups that do not use medical journals or other traditional means of dissemination.


Assuntos
Disseminação de Informação/métodos , Laringectomia , Sistemas Automatizados de Assistência Junto ao Leito , Cuidados Pós-Operatórios/métodos , Smartphone , Mídias Sociais/estatística & dados numéricos , Traqueostomia , Humanos , Segurança do Paciente , Reino Unido
14.
Eur J Ophthalmol ; 30(1): 119-124, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30378440

RESUMO

OBJECTIVES: Complete epithelial wound healing is a milestone in early postoperative care after penetrating keratoplasty. The re-epithelialization rate after penetrating keratoplasty was measured in patients receiving a new matrix therapy agent (regenerating agent, Cacicol®) that mimics heparan sulphates. METHODS: This was a prospective, open-label, uncontrolled, single-centre observational study. A total of 33 consecutive patients (33 eyes) who underwent an 8.25-mm diameter penetrating keratoplasty were treated with regenerating agent eye drops: one drop in the operating theatre immediately after graft, then on alternate days. Patients were divided into those at low risk (13 patients) and high risk (20 patients) of delayed wound healing, and follow-up was performed by digital slit lamp with fluorescein-dye testing repeated daily at a fixed time. Dye area was measured using ImageJ freeware. The main endpoint was epithelial healing after regenerating agent therapy. RESULTS: The mean ± standard deviation time to complete healing for all patients was 2.7 ± 1.1 (median: 3, range: 1-6) days. This was obtained on Day 1 for 15% of patients, Day 2 for 33%, Day 3 for 88%, Day 4 for 94% and Day 6 for 100%. There was no significant difference between low- and high-risk patients. The area of epithelial defect decreased by a mean ± standard deviation of 75% ± 22% between Day 1 and Day 2, corresponding to a mean ± standard deviation wound-healing rate of 11.5 ± 6.5 mm2/D. There were no systemic or local side effects related to regenerating agent. CONCLUSION: These preliminary data suggest that regenerating agent could be a useful, non-invasive therapeutic approach in postoperative management of penetrating keratoplasty with the potential to accelerate re-epithelialization.


Assuntos
Epitélio Anterior/patologia , Glicosaminoglicanos/administração & dosagem , Ceratoplastia Penetrante/métodos , Cuidados Pós-Operatórios/métodos , Cicatrização , Adulto , Idoso , Idoso de 80 Anos ou mais , Úlcera da Córnea/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Soluções Oftálmicas/administração & dosagem , Estudos Prospectivos , Resultado do Tratamento , Adulto Jovem
15.
Int J Radiat Oncol Biol Phys ; 106(1): 5-12, 2020 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-31404580

RESUMO

PURPOSE: In studies evaluating the benefit of adjuvant therapies, immortal time bias (ITB) can affect the results by incorrectly reporting a survival advantage. It does so by including all deceased patients who may have been planned to receive adjuvant therapy within the observation cohort. Given the increase in National Cancer Database (NCDB) analyses evaluating postoperative radiation therapy (PORT) as an adjuvant therapy, we sought to examine how often such studies accounted and adjusted for ITB. METHODS AND MATERIALS: A systematic review was undertaken to search MEDLINE and EMBASE from January 2014 until May 2019 for NCDB studies evaluating PORT. After appropriate exclusion criteria were applied, 60 peer-reviewed manuscripts in which PORT was compared with postoperative observation or maintenance therapy were reviewed. The manuscripts were reviewed to evaluate whether ITB was accounted for, the method with which it was adjusted for, impact factor, year of publication, and whether PORT was beneficial. RESULTS: Of the 60 publications reviewed, 23 studies (38.3%) did not include an adjustment for ITB. Most studies that did adjust for ITB employed a single landmark (LM) time (n = 31), 4 used a sequential landmark analyses, and 2 used a time-dependent Cox model. In 23 of 31 studies (74.2%) that did adjust for ITB via a single LM time, the rationale behind why the specified LM time was chosen was not clearly explained. There was no relationship between adjusting for ITB and year of publication (P = .074) or whether the study was published in a high-impact journal (P = .55). CONCLUSIONS: Studies assessing adjuvant radiation therapy by analyzing the NCDB are susceptible to ITB, which overestimates the effect size of adjuvant therapies and can provide misleading results. Adjusting for this bias is essential for accurate data representation and to better quantify the impact of adjuvant therapies such as PORT.


Assuntos
Viés , Bases de Dados Factuais/estatística & dados numéricos , Neoplasias/mortalidade , Neoplasias/radioterapia , Radioterapia Adjuvante/mortalidade , Humanos , Fator de Impacto de Revistas , Modelos Logísticos , Neoplasias/cirurgia , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/mortalidade , Modelos de Riscos Proporcionais , Análise de Sobrevida , Fatores de Tempo , Conduta Expectante
16.
Br J Radiol ; 93(1106): 20190733, 2020 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-31868524

RESUMO

OBJECTIVE: To compare the diagnostic performance of breast MRI with abbreviated protocol (AB-MRI) and full ddiagnostic protocol (FDP-MRI) for surveillance of females with a personal history of breast cancer. METHODS: In this retrospective study, we analyzed the outcomes of total 1312 post-operative screening breast MRI matched from 1045 AB-MRI and 677 FDP-MRI, which had histologic confirmation for suspicious MRI findings or 1 year negative follow-up images. This study was approved by the institutional review board and informed patient consent was waved. AB-MRI consists of T2 weighted scanning and dynamic contrast-enhanced imaging including one pre-contrast and two post-contrast scans. We compared the diagnostic performance for recurrent breast cancer in terms of sensitivity, specificity, positive-predictive value, negative-predictive value, and accuracy and area under the curve between the screening AB-MRI and FDP-MRI. RESULTS: Overall, 13 recurrent tumors among 1312 post-operative cases screened with breast MRI (1.0%) were detected including 8 invasive cancer, 2 cases of in situ cancer, and 3 cases of metastatic lymph nodes. The sensitivity and negative predictive value were 70 vs 100 and 99.5% vs 100% in AB-MRI and FDP-MRI. Specificity, positive predictive value, accuracy, and area under the curve of AB-MRI and FDP-MRI were 98.0% vs 96.9%, 35.0% vs 23.1%, 97.6% vs 97.0%, and 0.840 vs 0.985, respectively. CONCLUSION: The performance of AB-MRI was comparable to that of FDP-MRI in detecting recurrent breast cancer and decreased false positive cases. ADVANCES IN KNOWLEDGE: AB-MRI provides a reliable alternative with similar diagnostic performance and shorter MRI acquisition time.


Assuntos
Neoplasias da Mama/diagnóstico , Protocolos Clínicos , Detecção Precoce de Câncer , Feminino , Humanos , Imagem por Ressonância Magnética/métodos , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/diagnóstico , Cuidados Pós-Operatórios , Estudos Retrospectivos , Fatores de Risco
17.
Curr Opin Ophthalmol ; 31(1): 3-9, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31688227

RESUMO

PURPOSE OF REVIEW: This review aims to cover the preoperative planning, intraoperative considerations, and postoperative management that aids in successful outcomes of patients with cataract and uveitis. Disease-specific management and pediatric management will also be addressed. RECENT FINDINGS: Dexamethasone implants appear to be a safe and effective addition to standard steroid treatment in decreasing the incidence of postoperative cystoid macular edema (CME). Intravitreal steroids and topical difluprednate have shown utility in CME treatment. SUMMARY: Cataract surgery in eyes with uveitis is generally safe and effective if inflammation is well controlled; however, complication rates are still higher than in eyes without uveitis. Future investigations should delineate outcomes for eyes with different etiologies of uveitis, and further research is needed to adequately control inflammation and avoid postoperative complications.


Assuntos
Extração de Catarata , Catarata/complicações , Uveíte/complicações , Administração Oftálmica , Dexametasona/administração & dosagem , Implantes de Medicamento , Fluprednisolona/administração & dosagem , Fluprednisolona/análogos & derivados , Glucocorticoides/administração & dosagem , Humanos , Cuidados Intraoperatórios , Injeções Intravítreas , Edema Macular/prevenção & controle , Cuidados Pós-Operatórios , Cuidados Pré-Operatórios , Uveíte/tratamento farmacológico , Acuidade Visual/fisiologia
18.
Rev. Pesqui. (Univ. Fed. Estado Rio J., Online) ; 12: 252-256, jan.-dez. 2020. tab
Artigo em Inglês, Português | LILACS, BDENF - Enfermagem | ID: biblio-1047924

RESUMO

Objetivo: avaliar a influência das orientações em saúde nas complicações no pós-operatório de cirurgias torácicas e abdominais altas. Método: estudo quantitativo transversal realizado com 266 indivíduos. Os dados foram coletados por um questionário sociodemográfico, clínico e assistencial. Foram incluídos sujeitos de ambos os sexos, com faixa etária de 18 a 80 anos, que estivessem na enfermaria em pós-operatório de cirurgias torácicas e ou abdominais altas. Resultados: 82 (30%) dos indivíduos receberam orientações no período de pós-operatório e 184 (70%) não receberam nenhum tipo de orientação. Quatro dos sujeitos que receberam orientações desenvolveram algum tipo de complicação e 16 dos que não receberam tiveram complicações; não apresentando resultados estatisticamente significativos quanto aos pesquisados que tiveram orientação e os que não tiveram orientações (p=0,4). Conclusão: em relação ao número de complicações, ao comparar os indivíduos que receberam orientações com os que não receberam não houve resultado estatisticamente significativo


Objective: to evaluate correlation between health guidelines and complications in the postoperative period after thoracic and upper abdominal surgeries. Method: a cross-sectional quantitative study with 266 individuals. Data were collected by a sociodemographic, clinical and care questionnaire. We included subjects of both sexes, with ages ranging from 18 to 80 years, who were in the postoperative ward after thoracic and/ or upper abdominal surgeries. Results: 82 (30%) of the subjects received guidance in the postoperative period and 184 (70%) received no guidance. Four of the subjects who received guidelines developed some type of complication while 16 of those who did not receive guidance developed complications; therefore, the results were not statistically significant (p=0,4). Conclusion: in relation to the number of complications, when comparing individuals who received guidelines with those who did not receive, there was no statistically significant result


Objetivo: evaluar la influencia de las orientaciones en salud en las complicaciones en el postoperatorio de cirugías torácicas y abdominales altas. Metodo: estudio cuantitativo transversal realizado con 266 individuos. Los datos fueron recolectados por un cuestionario sociodemográfico, clínico y asistencial. Se incluyeron sujetos de ambos sexos, con rango de edad de 18 a 80 años, que estuvieran en la enfermería en postoperatorio de cirugías torácicas y / o abdominales alta. Resultados: 82 (30%) de los individuos recibieron orientaciones en el período de postoperatorio y 184 (70%) no recibieron ningún tipo de orientación. Cuatro de los sujetos que recibieron orientaciones, desarrollaron algún tipo de complicación y 16 de los que no recibieron tuvieron complicaciones; no presentando resultados estadísticamente significativos en cuanto a los encuestados que tuvieron orientación y los que no tuvieron orientaciones (p=0,4). Conclusión: en relación al número de complicaciones, al comparar a los individuos que recibieron orientaciones con los que no recibieron no hubo resultado estadísticamente significativo


Assuntos
Humanos , Animais , Masculino , Adolescente , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Cuidados Pós-Operatórios/educação , Cuidados Pós-Operatórios/estatística & dados numéricos , Cirurgia Torácica/estatística & dados numéricos , Abdome/cirurgia , Cuidados Pós-Operatórios/efeitos adversos , Cuidados Pós-Operatórios/enfermagem , Enfermagem Perioperatória , Estudos Transversais
19.
Orthop Clin North Am ; 51(1): 13-26, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31739876

RESUMO

Open reduction and internal fixation of displaced acetabular fractures has been the gold standard for treatment of these complex injuries. The subset of older patients with dome impaction, femoral head impaction, or a posterior wall component are considered for treatment with concomitant open reduction and internal fixation and total hip arthroplasty. Little has been written on the surgical techniques to perform concomitant open reduction and internal fixation plus total hip arthroplasty safely. This article describes the important intrinsic factors for acetabular component stability, choice of surgical approach for management of these injuries, and surgical technique for anterior and posterior approaches.


Assuntos
Acetábulo/cirurgia , Cabeça do Fêmur/cirurgia , Fixação Interna de Fraturas/métodos , Redução Aberta/métodos , Acetábulo/lesões , Idoso , Artroplastia de Quadril/métodos , Cadáver , Cabeça do Fêmur/lesões , Fixação Interna de Fraturas/normas , Fraturas Ósseas/cirurgia , Fraturas do Quadril/cirurgia , Humanos , Redução Aberta/normas , Cuidados Pós-Operatórios , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Retrospectivos , Resultado do Tratamento
20.
Orthop Clin North Am ; 51(1): 27-36, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31739877

RESUMO

Distal femoral replacement (DFR) is a reasonable treatment option when used for select indications. In the setting of comminuted intra-articular distal femoral fractures, distal femoral arthroplasty should be considered in low-demand patients with poor bone quality. This article summarizes the existing literature plus the authors' personal experience with DFR use for distal femoral fractures of the native knee.


Assuntos
Fraturas do Fêmur/cirurgia , Fêmur/cirurgia , Fraturas Cominutivas/cirurgia , Articulação do Joelho/cirurgia , Idoso , Humanos , Fraturas Intra-Articulares/cirurgia , Pessoa de Meia-Idade , Cuidados Pós-Operatórios , Implantação de Prótese/métodos , Reoperação/métodos , Reoperação/estatística & dados numéricos , Reimplante/métodos , Reimplante/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento
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