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1.
Actas Urol Esp (Engl Ed) ; 45(3): 207-214, 2021 04.
Artigo em Espanhol | MEDLINE | ID: mdl-34017152

RESUMO

Introduction: The suspension of most elective surgeries during COVID-19 pandemic caused the lengthening of urology surgical waiting lists. The objective of this study is to evaluate the impact of COVID-19 pandemic on urology surgical waiting list in a high-volume hospital. Methods: An observational descriptive study was designed. All patients included in the urology surgical waiting list of our high-volume center on May 1st 2020 (46 days after the suspension of elective surgery) were analyzed. Baseline variables, priority on the waiting list, main urological disease, type of scheduled surgery, and waiting time were recorded. Other variables recorded were the presence of a urinary catheter, number of accesses to the emergency department, evidence of COVID-19 infection, number of deaths and their cause. The waiting time for each disease was compared with the time to surgery in 2019. Results: A total of 350 patients were included. The mean (SD) time on the waiting list was 97.33 (55.47) days. Priority 1 patients, who normally should undergo surgery within 30 days, were on the waiting list for a mean (SD) time of 60.51 (20.14) days. They were mainly patients with ureteral lithiasis (25.6%), high-risk or muscle-invasive bladder cancer (20.9%) and high-risk prostate cancer (13.9%). The mean waiting time had already significantly exceeded the mean time to surgery in 2019 for radical cystectomy (p = 0.04) and URS (p = 0.003). Conclusions: The suspension of most elective surgeries due to COVID-19 had a significant impact on urology surgical waiting list of our high-volume center, especially in priority 1 group.


Assuntos
COVID-19/epidemiologia , Surtos de Doenças , Procedimentos Cirúrgicos Eletivos , Doenças Urológicas/cirurgia , Procedimentos Cirúrgicos Urológicos , Listas de Espera , Idoso , Idoso de 80 Anos ou mais , Feminino , Prioridades em Saúde , Hospitais com Alto Volume de Atendimentos , Humanos , Masculino , Pessoa de Meia-Idade
2.
Bone Joint J ; 103-B(6 Supple A): 131-136, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34053278

RESUMO

AIMS: It has previously been shown that higher-volume hospitals have better outcomes following revision total knee arthroplasty (rTKA). We were unable to identify any studies which investigated the effect of surgeon volume on the outcome of rTKA. We sought to investigate whether patients of high-volume (HV) rTKA surgeons have better outcomes following this procedure compared with those of low-volume (LV) surgeons. METHODS: This retrospective study involved patients who underwent aseptic unilateral rTKA between January 2016 and March 2019, using the database of a large urban academic medical centre. Surgeons who performed ≥ 19 aseptic rTKAs per year during the study period were considered HV and those who performed < 19 per year were considered LV. Demographic characteristics, surgical factors, and postoperative outcomes were compared between the two groups. RESULTS: A total of 308 rTKAs were identified, 132 performed by HV surgeons and 176 by 22 LV surgeons. The LV group had a significantly greater proportion of non-smokers (59.8% vs 49.2%; p = 0.029). For all types of revision, HV surgeons had significantly shorter mean operating times by 17.75 minutes (p = 0.007). For the 169 full revisions (85 HV, 84 LV), HV surgeons had significantly shorter operating times (131.12 (SD 33.78) vs 171.65 (SD 49.88) minutes; p < 0.001), significantly lower re-revision rates (7.1% vs 19.0%; p = 0.023) and significantly fewer re-revisions (0.07 (SD 0.26) vs 0.29 (SD 0.74); p = 0.017). CONCLUSION: Patients of HV rTKA surgeons have better outcomes following full rTKA. These findings support the development of revision teams within arthroplasty centres of excellence to offer patients the best possible outcomes following rTKA. Cite this article: Bone Joint J 2021;103-B(6 Supple A):131-136.


Assuntos
Artroplastia do Joelho , Competência Clínica , Hospitais com Alto Volume de Atendimentos , Reoperação/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Retrospectivos
3.
Artigo em Inglês | MEDLINE | ID: mdl-33917393

RESUMO

This study aimed to identify the association between moving to a high-volume hospital and the mortality of patients with cancer living in the district. The study population comprised participants diagnosed with cancer within the past nine years (2004-2012). The final sample included 8197 patients with cancer, 3939 were males (48.1%), and 4258 were females (51.9%). A Cox proportional hazard model was used to estimate the hazard ratio (HR) for death. Confounding variables including sex, age, type of social security, income level, disability, and utilization volume were incorporated into the model. Among patients with cancer living in the district, 2874 (35.1%) used healthcare services in Seoul. About 10% (n = 834) of patients died during the follow-up period. The HR for death in females (HR: 0.68, 95% CI: 0.58-0.81) was lower than that in males. Additionally, the HR for the death of patients using healthcare services in Seoul (HR: 1.30, 95% CI: 1.11-1.53) was higher than those patients who did not use healthcare services in Seoul. Among patients utilizing services in the province, wealthier patients' survival probability was significantly higher than that of others. The cause of income differences should be identified, and accessibility to medical use of low-income families should be enhanced to prevent mortality of patients from cancer disparities.


Assuntos
Hospitais com Alto Volume de Atendimentos , Neoplasias , Estudos de Coortes , Feminino , Humanos , Renda , Masculino , Modelos de Riscos Proporcionais , Seul
4.
Transplant Proc ; 53(3): 872-880, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33743981

RESUMO

BACKGROUND: Little is known about the outcome of living-donor kidney transplantation (LDKT) performed in low-volume centers lacking the services of full-time transplant surgeons. This retrospective cohort study assessed the outcome of LDKT performed in a low-volume center by visiting transplant surgeons from a high-volume center and managed perioperatively by transplant nephrologists. METHODS: We compared Japanese adult patients who had no donor-specific antibodies and underwent LDKT between 2006 and 2015 either in a low-volume (n = 31) or high-volume (n = 481) center. In the low-volume center, visiting transplant surgeons from the high-volume center conducted LDKT and transplant nephrologists managed the recipients peri- and postoperatively. The primary outcome was the composite of infection, cardiovascular disease, or cancer during 1-year follow-up. The outcomes of the low- and high-volume centers were compared using 1:2 propensity score matching. RESULTS: After matching, 9 of 29 patients in the low-volume center (31.0%) and 16 of 58 patients in the high-volume center (27.6%) experienced the primary composite outcome (risk ratio = 1.13; 95% confidence interval, 0.57-2.23). There were no significant differences between the 2 groups in graft function at 1 year, all-cause graft loss, biopsy-proven rejection, and urological complications. However, the median duration of post-LDKT hospitalization was significantly longer in the low-volume center than in the high-volume center (23 and 16 days, respectively). CONCLUSIONS: Among Japanese patients without preformed donor-specific antibodies, LDKT conducted at a low-volume center by visiting transplant surgeons from a high-volume center and managed clinically by transplant nephrologists was not associated with significantly higher risk of postoperative complications.


Assuntos
Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Transplante de Rim/mortalidade , Nefrologistas/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Adulto , Anticorpos/análise , Feminino , Sobrevivência de Enxerto , Humanos , Japão , Transplante de Rim/métodos , Doadores Vivos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/imunologia , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos
5.
JAMA Netw Open ; 4(2): e2037748, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-33616664

RESUMO

Importance: Mechanical circulatory support (MCS) devices, including intravascular microaxial left ventricular assist devices (LVADs) and intra-aortic balloon pumps (IABPs), are used in patients who undergo percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) complicated by cardiogenic shock despite limited evidence of their clinical benefit. Objective: To examine trends in the use of MCS devices among patients who underwent PCI for AMI with cardiogenic shock, hospital-level use variation, and factors associated with use. Design, Setting, and Participants: This cross-sectional study used the CathPCI and Chest Pain-MI Registries of the American College of Cardiology National Cardiovascular Data Registry. Patients who underwent PCI for AMI complicated by cardiogenic shock between October 1, 2015, and December 31, 2017, were identified from both registries. Data were analyzed from October 2018 to August 2020. Exposures: Therapies to provide hemodynamic support were categorized as intravascular microaxial LVAD, IABP, TandemHeart, extracorporeal membrane oxygenation, LVAD, other devices, combined IABP and intravascular microaxial LVAD, combined IABP and other device (defined as TandemHeart, extracorporeal membrane oxygenation, LVAD, or another MCS device), or medical therapy only. Main Outcomes and Measures: Use of MCS devices overall and specific MCS devices, including intravascular microaxial LVAD, at both patient and hospital levels and variables associated with use. Results: Among the 28 304 patients included in the study, the mean (SD) age was 65.4 (12.6) years and 18 968 were men (67.0%). The overall MCS device use was constant from the fourth quarter of 2015 to the fourth quarter of 2017, although use of intravascular microaxial LVADs significantly increased (from 4.1% to 9.8%; P < .001), whereas use of IABPs significantly decreased (from 34.8% to 30.0%; P < .001). A significant hospital-level variation in MCS device use was found. The median (interquartile range [IQR]) proportion of patients who received MCS devices was 42% (30%-54%), and the median proportion of patients who received intravascular microaxial LVADs was 1% (0%-10%). In multivariable analyses, cardiac arrest at first medical contact or during hospitalization (odds ratio [OR], 1.82; 95% CI, 1.58-2.09) and severe left main and/or proximal left anterior descending coronary artery stenosis (OR, 1.36; 95% CI, 1.20-1.54) were patient characteristics that were associated with higher odds of receiving intravascular microaxial LVADs only compared with IABPs only. Conclusions and Relevance: This study found that, among patients who underwent PCI for AMI complicated by cardiogenic shock, overall use of MCS devices was constant, and a 2.5-fold increase in intravascular microaxial LVAD use was found along with a corresponding decrease in IABP use and a significant hospital-level variation in MCS device use. These trends were observed despite limited clinical trial evidence of improved outcomes associated with device use.


Assuntos
Oxigenação por Membrana Extracorpórea/tendências , Coração Auxiliar/tendências , Balão Intra-Aórtico/tendências , Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea/métodos , Choque Cardiogênico/terapia , Idoso , Circulação Assistida/tendências , Estudos Transversais , Feminino , Parada Cardíaca/epidemiologia , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Hospitais de Ensino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Fatores de Risco , Choque Cardiogênico/etiologia
6.
Anesth Analg ; 132(3): 777-787, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33591093

RESUMO

BACKGROUND: The use of extracorporeal membrane oxygenation (ECMO) as a rescue therapy for cardiopulmonary failure is expanding in critical care medicine. In this case series, we describe the clinical outcomes of 21 consecutive pregnant or postpartum patients that required venovenous (VV) or venoarterial (VA) ECMO. Our objective was to characterize maternal and fetal survival in peripartum ECMO and better understand ECMO-related complications that occur in this unique patient population. METHODS: Between January 2009 and June 2019, all pregnant and postpartum patients treated with ECMO for respiratory or circulatory failure at a single quaternary referral center were identified. For all patients, indications for ECMO, maternal and neonatal outcomes, details of ECMO support, and anticoagulation and bleeding complications were collected. RESULTS: Twenty-one obstetric patients were treated with ECMO over 10 years. Thirteen patients were treated with VV ECMO and 8 patients were treated with VA ECMO. Six patients were pregnant at the time of cannulation and 3 patients delivered while on ECMO; all 6 maternal and infant dyads survived to hospital discharge. The median gestational age at cannulation was 28 weeks (interquartile range [IQR], 24-31). In the postpartum cohort, ECMO initiation ranged from immediately after delivery up to 46 days postpartum. Fifteen women survived (72%). Major bleeding complications requiring surgical intervention were observed in 7 patients (33.3%). Two patients on VV ECMO required bilateral orthotopic lung transplantation and 1 patient on VA ECMO required orthotopic heart transplantation to wean from ECMO. CONCLUSIONS: Survival for mother and neonate are excellent with peripartum ECMO in a high-volume ECMO center. Neonatal and maternal survival was 100% when ECMO was used in the late second or early third trimester. Based on these results, ECMO remains an important treatment option for peripartum patients with cardiopulmonary failure.


Assuntos
Oxigenação por Membrana Extracorpórea , Complicações Cardiovasculares na Gravidez/terapia , Transtornos Puerperais/terapia , Insuficiência Respiratória/terapia , Choque/terapia , Adulto , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Hospitais com Alto Volume de Atendimentos , Humanos , Recém-Nascido , Nascido Vivo , Período Pós-Parto , Gravidez , Complicações Cardiovasculares na Gravidez/mortalidade , Complicações Cardiovasculares na Gravidez/fisiopatologia , Transtornos Puerperais/mortalidade , Transtornos Puerperais/fisiopatologia , Insuficiência Respiratória/mortalidade , Insuficiência Respiratória/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Choque/mortalidade , Choque/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
7.
BMC Cancer ; 21(1): 146, 2021 Feb 09.
Artigo em Inglês | MEDLINE | ID: mdl-33563241

RESUMO

BACKGROUND: Medical centers with varying levels of expertise treat gastroenteropancreatic neuroendocrine tumors (GEP-NETs), which are relatively rare tumors. This study assesses the impact of center volume on GEP-NET treatment outcomes. METHODS: We used the Surveillance, Epidemiology, and End Results (SEER) registry linked to Medicare claims data. The data includes patients diagnosed between 1995 and 2010 who had no health maintenance organization (HMO) coverage, participated in Medicare parts A and B, were older than 65 at diagnosis, had tumor differentiation information, and had no secondary cancer. We identified medical centers at which patients received GEP-NET treatment (surgery, chemotherapy, somatostatin analogues, or radiation therapy) using Medicare claims data. Center volume was divided into 3 tiers - low, medium, and high - based on the number of unique GEP-NET patients treated by a medical center over 2 years. We used Kaplan-Meier curves and Cox regression to assess the association between volume and disease-specific survival. RESULTS: We identified 899 GEP-NET patients, of whom 37, 45, and 18% received treatment at low, medium volume, and high-volume centers, respectively. Median disease-specific survival for patients at low and medium tiers were 1.4 years and 5.3 years, respectively, but was not reached for patients at high volume centers. Results showed that patients treated at high volume centers had better survival than those treated in low volume centers (HR: 0.63, 95% CI: 0.4-0.9), but showed no difference in outcomes between medium and high-volume centers. CONCLUSIONS: Our results suggest that for these increasingly common tumors, referral to a tertiary care center may be indicated. Physicians caring for GEP-NET patients should consider early referral to high volume centers.


Assuntos
Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Neoplasias Intestinais/mortalidade , Tumores Neuroendócrinos/mortalidade , Neoplasias Pancreáticas/mortalidade , Programa de SEER/estatística & dados numéricos , Neoplasias Gástricas/mortalidade , Idoso , Terapia Combinada , Feminino , Seguimentos , Humanos , Neoplasias Intestinais/patologia , Neoplasias Intestinais/terapia , Masculino , Tumores Neuroendócrinos/patologia , Tumores Neuroendócrinos/terapia , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/terapia , Prognóstico , Estudos Retrospectivos , Neoplasias Gástricas/patologia , Neoplasias Gástricas/terapia , Taxa de Sobrevida
8.
J Surg Oncol ; 123(2): 676-686, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33616989

RESUMO

BACKGROUND: The objective of this study is to examine racial differences in receipt of low-value surgical care and time to surgery (TTS) among women receiving treatment at high-volume hospitals. METHODS: Stage I-III non-Hispanic Black (NHB) and Non-Hispanic White (NHW) breast cancer patients were identified in the National Cancer Database. Low-value care included (1) sentinel lymph node biopsy (SLNB) among T1N0 patients age ≥70 with hormone receptor-positive cancers, (2) axillary lymph node dissection (ALND) in patients meeting ACOSOG Z0011 criteria, and (3) contralateral prophylactic mastectomy (CPM) with unilateral cancer. TTS was days from biopsy to surgery. Bivariate and logistic regression analyses were used to compare the groups. RESULTS: Compared to NHWs, NHBs had lower rates of SLNB among women age ≥70 with small hormone-positive cancers (NHB 58.5% vs. NHW 62.2% p < .001) and CPM (NHB 26.3% vs. NHW 36%; p < .001). ALND rates for patients meeting ACOSOG Z0011 criteria were similar between both groups (p = .13). The odds of surgery >60 days were higher among NHBs (odds ratio, 1.77; 95% confidence interval, 1.64-1.91; NHW ref). CONCLUSIONS: NHBs treated at high-volume hospitals have higher rates of surgical delay but are less likely to undergo low-value surgical procedures compared to NHW women.


Assuntos
Neoplasias da Mama/etnologia , Neoplasias da Mama/cirurgia , Grupos Étnicos/estatística & dados numéricos , Disparidades em Assistência à Saúde , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Mastectomia/métodos , Tempo para o Tratamento/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/patologia , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Biópsia de Linfonodo Sentinela , Adulto Jovem
9.
Actas Urol Esp (Engl Ed) ; 45(3): 207-214, 2021 Apr.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-33546905

RESUMO

INTRODUCTION: The suspension of most elective surgeries during COVID-19 pandemic caused the lengthening of urology surgical waiting lists. The objective of this study is to evaluate the impact of COVID-19 pandemic on urology surgical waiting list in a high-volume hospital. METHODS: An observational descriptive study was designed. All patients included in the urology surgical waiting list of our high-volume center on May 1st 2020 (46 days after the suspension of elective surgery) were analyzed. Baseline variables, priority on the waiting list, main urological disease, type of scheduled surgery, and waiting time were recorded. Other variables recorded were the presence of a urinary catheter, number of accesses to the emergency department, evidence of COVID-19 infection, number of deaths and their cause. The waiting time for each disease was compared with the time to surgery in 2019. RESULTS: A total of 350 patients were included. The mean (SD) time on the waiting list was 97.33 (55.47) days. Priority 1 patients, who normally should undergo surgery within 30 days, were on the waiting list for a mean (SD) time of 60.51 (20.14) days. They were mainly patients with ureteral lithiasis (25.6%), high-risk or muscle-invasive bladder cancer (20.9%) and high-risk prostate cancer (13.9%). The mean waiting time had already significantly exceeded the mean time to surgery in 2019 for radical cystectomy (p = 0.04) and URS (p = 0.003). CONCLUSIONS: The suspension of most elective surgeries due to COVID-19 had a significant impact on urology surgical waiting list of our high-volume center, especially in priority 1 group.


Assuntos
COVID-19/epidemiologia , Pandemias , Procedimentos Cirúrgicos Urológicos/estatística & dados numéricos , Listas de Espera , Idoso , Análise de Variância , Cistectomia/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos , Feminino , Prioridades em Saúde , Hospitais com Alto Volume de Atendimentos , Humanos , Neoplasias Renais/epidemiologia , Masculino , Hiperplasia Prostática/epidemiologia , Neoplasias da Próstata/epidemiologia , Espanha/epidemiologia , Estatísticas não Paramétricas , Fatores de Tempo , Cálculos Ureterais/epidemiologia , Neoplasias da Bexiga Urinária/epidemiologia , Suspensão de Tratamento/estatística & dados numéricos
10.
Laryngoscope ; 131(6): E1797-E1804, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33410517

RESUMO

OBJECTIVES/HYPOTHESIS: The COVID-19 pandemic has resulted in a dramatic increase in the number of patients requiring prolonged mechanical ventilation. Few studies have reported COVID-19 specific tracheotomy outcomes, and the optimal timing and patient selection criteria for tracheotomy remains undetermined. We delineate our outcomes for tracheotomies performed on COVID-19 patients during the peak of the pandemic at a major epicenter in the United States. METHODS: This is a retrospective observational cohort study. Mortality, ventilation liberation rate, complication rate, and decannulation rate were analyzed. RESULTS: Sixty-four patients with COVID-19 underwent tracheotomy between April 1, 2020 and May 19, 2020 at two tertiary care hospitals in Bronx, New York. The average duration of intubation prior to tracheotomy was 20 days ((interquartile range [IQR] 16.5-26.0). The mortality rate was 33% (n = 21), the ventilation liberation rate was 47% (n = 30), the decannulation rate was 28% (n = 18), and the complication rate was 19% (n = 12). Tracheotomies performed by Otolaryngology were associated with significantly improved survival (P < .05) with 60% of patients alive at the conclusion of the study compared to 9%, 12%, and 19% of patients undergoing tracheotomy performed by Critical Care, General Surgery, and Pulmonology, respectively. CONCLUSIONS: So far, this is the second largest study describing tracheotomy outcomes in COVID-19 patients in the United States. Our early outcomes demonstrate successful ventilation liberation and decannulation in COVID-19 patients. Further inquiry is necessary to determine the optimal timing and identification of patient risk factors predictive of improved survival in COVID-19 patients undergoing tracheotomy. LEVEL OF EVIDENCE: 4-retrospective cohort study Laryngoscope, 131:E1797-E1804, 2021.


Assuntos
COVID-19/terapia , Intubação Intratraqueal/estatística & dados numéricos , Pandemias/estatística & dados numéricos , Traqueostomia/estatística & dados numéricos , Traqueotomia/estatística & dados numéricos , Idoso , COVID-19/diagnóstico , COVID-19/mortalidade , COVID-19/virologia , Teste de Ácido Nucleico para COVID-19 , Feminino , Mortalidade Hospitalar , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , New York/epidemiologia , Seleção de Pacientes , Estudos Retrospectivos , SARS-CoV-2/genética , SARS-CoV-2/isolamento & purificação , Fatores de Tempo , Tempo para o Tratamento/estatística & dados numéricos , Resultado do Tratamento
11.
Jt Dis Relat Surg ; 32(1): 3-9, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33463411

RESUMO

OBJECTIVES: This study aims to investigate the effectiveness of a screening questionnaire to identify high-risk patients for novel coronavirus-2019 (COVID-19) among those undergoing elective orthopedic surgery. PATIENTS AND METHODS: Between May 4th, 2020 and June 11th, 2020, a total of 1,021 consecutive patients (492 males, 529 females; mean age: 62.3±15.1 years; range, 13 to 91 years) who were scheduled for elective orthopedic surgery were included. A screening questionnaire was applied to all patients. The patients admitted to hospital were also tested for COVID-19 infection through reverse transcription-polymerase chain reaction of the nasopharyngeal swab. RESULTS: Of the patients, 1,003 (98.2%) underwent elective surgery as planned. The screening questionnaire classified 30 patients as high-risk for COVID-19. A total of 18 procedures (n=18, 1.8%) were postponed due to the high risk of possible transmission of COVID-19. None of 991 low-risk patients were tested positive for COVID-19. CONCLUSION: The use of guiding principles for resuming elective orthopedic surgery is safe without a higher risk for complications in selected cases.


Assuntos
Artroplastia/estatística & dados numéricos , Teste para COVID-19 , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Hospitalização , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , COVID-19/epidemiologia , Transmissão de Doença Infecciosa/prevenção & controle , Feminino , Alemanha/epidemiologia , Hospitais com Alto Volume de Atendimentos , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Estudos Retrospectivos , Medição de Risco , Inquéritos e Questionários , Adulto Jovem
12.
Int J Surg ; 86: 7-12, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33429077

RESUMO

BACKGROUND: Few studies have investigated the learning curves of minimally invasive donor nephrectomy (MIDN) using the cumulative sum (CUSUM) analysis. In addition, no study has compared the learning curves of the different surgical MIDN techniques in one cohort study using the CUSUM analysis. This study aims to evaluate and compare learning curves for several MIDN using the CUSUM analysis. METHODS: A retrospective review of consecutive donors, who underwent MIDN between 1997 and 2019, was conducted. Three laparoscopic-assisted techniques were applied in our institution and included for analysis: laparoscopic (LDN), hand-assisted retroperitoneoscopic (HARP), and robot-assisted laparoscopic (RADN) donor nephrectomy. The outcomes were compared based on surgeon volume to develop learning curves for the operative time per surgeon. RESULTS: Out of 1895 MIDN, 1365 (72.0%) were LDN, 427 (22.5%) were HARP, and 103 (5.4%) were RADN. The median operative time and median blood loss were 179 (IQR, 139-230) minutes and 100 (IQR, 40-200) mL, respectively. The incidence of major complication was 1.2% with no mortality, and the median hospital stay was three (IQR, 3-4) days. The CUSUM analysis resulted in learning curves, defined by decreased operative time, of 23 cases in LDN, 45 cases in HARP, and 26 cases in RADN. CONCLUSIONS: Our study shows different learning curves in three MIDN techniques with equal post-operative complications. The LDN and RADN learning curves are shorter than that of the hand-assisted donor nephrectomy. Our observations can be helpful for informing the development of teaching requirements for fellows to be trained in MIDN.


Assuntos
Laparoscopia/métodos , Curva de Aprendizado , Nefrectomia/métodos , Cirurgiões/estatística & dados numéricos , Coleta de Tecidos e Órgãos/métodos , Adulto , Feminino , Laparoscopia Assistida com a Mão/educação , Laparoscopia Assistida com a Mão/métodos , Hospitais com Alto Volume de Atendimentos , Humanos , Rim/cirurgia , Transplante de Rim , Laparoscopia/educação , Tempo de Internação/estatística & dados numéricos , Doadores Vivos , Masculino , Pessoa de Meia-Idade , Nefrectomia/educação , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/educação , Procedimentos Cirúrgicos Robóticos/métodos , Cirurgiões/educação , Coleta de Tecidos e Órgãos/educação
13.
Int J Surg ; 86: 24-31, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33429078

RESUMO

BACKGROUND: In the past, for a number of abdominal surgical interventions a correlation between treatment volume of a hospital and the patient's outcome was shown in national and international studies. METHODS: Based on a systematic literature search we analyzed the absolute and risk-adjusted in-house lethality as well as the rate of complications and the failure to rescue after abdominal surgery in Germany. The hospitals were grouped in quintiles according to the volume of treatment. RESULTS: 11 studies including more than 2 million patients were identified and surgeries for the treatment of 9 disease conditions were studied. The meta-analysis shows a significantly lower absolute and risk-adjusted in-house mortality for surgery in hospitals with high treatment volumes compared to low volume hospitals. In the context of subgroup analysis, this effect is demonstrated especially for complex surgical procedures. The failure to rescue in patients suffering from sepsis is significantly lower in high volume centers compared to low volume centers. CONCLUSION: This systematic review and meta-analysis shows on more than 2 million patients that there is a volume-outcome relationship for the surgical treatment of abdominal diseases in Germany across various organ systems, which is particularly true for complex interventions.


Assuntos
Abdome/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/mortalidade , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Feminino , Alemanha , Mortalidade Hospitalar , Humanos , Masculino
14.
BMC Cardiovasc Disord ; 21(1): 49, 2021 01 25.
Artigo em Inglês | MEDLINE | ID: mdl-33494701

RESUMO

BACKGROUND: Hospital volume is known to be associated with outcomes of patients requiring complicated medical care. However, the relationship between hospital volume and prognosis of hospitalized patients with heart failure (HF) remains not fully understood. We aimed to clarify the impact of hospital volume on clinical outcomes of hospitalized HF patients using a nationwide inpatient database. METHODS AND RESULTS: We studied 447,818 hospitalized HF patients who were admitted from January 2010 and discharged until March 2018 included in the Japanese Diagnosis Procedure Combination database. According to the number of patients, patients were categorized into three groups; those treated in low-, medium-, and high-volume centers. The median age was 81 years and 238,192 patients (53%) were men. Patients who had New York Heart Association class IV symptom and requiring inotropic agent within two days were more common in high volume centers than in low volume centers. Respiratory support, hemodialysis, and intra-aortic balloon pumping were more frequently performed in high volume centers. As a result, length of hospital stay was shorter, and in-hospital mortality was lower in high volume centers. Lower in-hospital mortality was associated with higher hospital volume. Multivariable logistic regression analysis fitted with generalized estimating equation indicated that medium-volume group (Odds ratio 0.91, p = 0.035) and high-volume group (Odds ratio 0.86, p = 0.004) had lower in-hospital mortality compared to the low-volume group. Subgroup analysis showed that this association between hospital volume and in-hospital mortality among overall population was seen in all subgroups according to age, presence of chronic renal failure, and New York Heart Association class. CONCLUSION: Hospital volume was independently associated with ameliorated clinical outcomes of hospitalized patients with HF.


Assuntos
Insuficiência Cardíaca/terapia , Hospitalização , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Mortalidade Hospitalar , Humanos , Japão , Tempo de Internação , Masculino , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo
15.
J Surg Res ; 257: 379-388, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32892134

RESUMO

BACKGROUND: The impact of surgical volume on outcomes in Hirschsprung's disease (HD) remains uninvestigated. We aimed to determine whether higher surgeon and hospital-level HD operative volumes are associated with improved surgical outcomes following primary surgery for neonatal HD. MATERIALS AND METHODS: Neonates who underwent either an ostomy or pull-through (PT) procedure for HD before 60 d of life and a PT procedure by age 1 y were identified in the Pediatric Health Information System (PHIS). Index admissions from January 2000 to September 2012 across 41 tertiary childrens hospitals were included. Surgeon and hospital-level HD operative volume were defined as the average annual number of PT procedures performed for HD in the 2 y preceding each included case. We examined the relationship between operative volumes and all-cause readmission, readmission for Hirschsprung's associated enterocolitis (HAEC), and rates of reoperation within 30 d and 2 y. RESULTS: A total of 1268 infants were included. There were 218 patients (17.2%) readmitted to the hospital within 30 d and 540 (42.6%) within 2 y. A total of 119 patients (9.4%) had HAEC-related readmission within 30 d, and 271 (21.4%) had HAEC-related readmission within 2 y. A total of 57 patients (4.5%) had a reoperation within 30 d and 129 (10.2%) within 2 y. In risk-adjusted analyses, there were no significant associations between either surgeon or hospital HD operative volumes and readmission/reoperation rates within 30 d or 2 y. CONCLUSIONS: Neither surgeon nor hospital PT volumes were significantly associated with readmission or reoperation rates for infants with Hirschsprung's disease. Future work is needed to evaluate whether operative volumes are associated with functional outcomes following PT for HD.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/estatística & dados numéricos , Doença de Hirschsprung/cirurgia , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Feminino , Humanos , Recém-Nascido , Masculino , Estudos Retrospectivos , Resultado do Tratamento
16.
J Plast Reconstr Aesthet Surg ; 74(6): 1180-1192, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33308991

RESUMO

Currently, there are no comprehensive breast sarcoma guidelines in the UK. There is therefore a need for guidelines to clarify surgical management, which we have based on data from our regional audit, current evidence, and consensus between West of Scotland Breast Cancer and Scottish Sarcoma Managed Clinical Networks. Methods and results: From 2007 to 2019, 46 patients were treated with breast sarcoma in the West of Scotland. Sarcoma Centre versus Peripheral Hospitals: Incomplete excision rate was 0% at sarcoma centre and 50% at peripheral hospitals (p = 0.0002, Odds Ratio 43). For angiosarcoma, 0% positive margin at the sarcoma centre versus 62.5% at the peripheral unit (p = 0.0036, odds ratio 39.3). Tumours treated at the sarcoma centre were larger than those treated at peripheral hospitals (92.5 versus 39.7 mm, p = 0.0009). WLE (wide local excision) versus mastectomy: Out of eight WLE patients, seven (87.5%) had positive margins, with 6 of these patients proceeding to mastectomy (i.e. 75% WLE patients ultimately had a mastectomy). The positive margin rate was significantly higher in WLE (87.5%) than in mastectomy (10.3%) (p = 0.0001, odds ratio 60.7). Survival: No difference was noted between the sarcoma centre and peripheral hospitals for overall survival (p = 0.43), stratified for tumours <5 cm (p = 0.16), and disease-free survival (p = 0.45). Conclusions: Our data strongly suggest that specific guidelines are needed for breast sarcoma, and that managing these patients according to breast carcinoma protocols in peripheral hospitals is sub-optimal. We recommend centralisation of breast sarcoma patient care to a specialist sarcoma centre, with WLE not recommended as a firstline surgical option given both the high rates of incomplete excision and subsequent need for completion mastectomy.


Assuntos
Neoplasias da Mama , Protocolos Clínicos/normas , Mastectomia , Guias de Prática Clínica como Assunto , Sarcoma , Idoso , Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Intervalo Livre de Doença , Feminino , Necessidades e Demandas de Serviços de Saúde , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Humanos , Masculino , Margens de Excisão , Mastectomia/efeitos adversos , Mastectomia/métodos , Mastectomia/estatística & dados numéricos , Sistema de Registros , Sarcoma/patologia , Sarcoma/cirurgia , Escócia/epidemiologia
17.
PLoS One ; 15(12): e0244078, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33351841

RESUMO

Regionalization is the integrated organization of a healthcare system, wherein regional structures are responsible for providing and administrating health services in a specific region. This method was adopted by several countries to improve the quality of provided care and to properly utilize available resources. Thus, a systematic review was conducted to verify effective interventions to improve health and management indicators within the health services regionalization. The protocol was registered in PROSPERO (CRD42016042314). We performed a systematic search in databases during February and March 2017 which was updated in October 2020. There was no language or date restriction. We included experimental and observational studies with interventions focused on regionalization-related actions, measures or policies aimed at decentralizing and organizing health offerings, rationalizing scarce capital and human resources, coordinating health services. A methodological assessment of the studies was performed using instruments from the Joanna Briggs Institute and GRADE was also used to assess outcomes. Thirty-nine articles fulfilled the eligibility criteria and sixteen interventions were identified that indicated different degrees of recommendations for improving the management of health system regionalization. The results showed that regionalization was effective under administrative decentralization and for rationalization of resources. The most investigated intervention was the strategy of concentrating procedures in high-volume hospitals, which showed positive outcomes, especially with the reduction of hospitalization days and in-hospital mortality rates. When implementing regionalization, it must be noted that it involves changes in current standards of health practice and in the distribution of health resources, especially for specialized services.


Assuntos
Atenção à Saúde/organização & administração , Mortalidade Hospitalar , Hospitalização , Hospitais com Alto Volume de Atendimentos , Atenção à Saúde/normas , Humanos
18.
Can J Surg ; 63(5): E475-E482, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33107818

RESUMO

BACKGROUND: American studies have shown that higher provider and hospital volumes are associated with reduced risk of mortality following colorectal surgical interventions. Evidence from Canada is limited, and to our knowledge only a single study has considered outcomes other than death. We describe associations between provider surgical volume and all-cause mortality and postoperative complications following colorectal surgical interventions in New Brunswick. METHODS: We used hospital discharge abstracts linked to vital statistics, the provincial cancer registry and patient registry data. We considered all admissions for colorectal surgeries from 2007 through 2013. We used logistic regression to identify odds of dying and odds of complications (from any of anastomosis leak, unplanned colostomy, intra-abdominal sepsis or pneumonia) within 30 days of discharge from hospital according to provider volume (i.e., total interventions performed over the preceding 2 years) adjusted for personal, contextual, provider and hospital characteristics. RESULTS: Overall, 9170 interventions were performed by 125 providers across 18 hospitals. We found decreased odds of experiencing a complication following colorectal surgery per increment of 10 interventions performed per year (odds ratio 0.94, 95% confidence interval 0.91-0.96). We found no associations with mortality. Associations remained consistent across models restricted to cancer patients or to interventions performed by general surgeons and across models that also considered overall hospital volumes. CONCLUSION: Our results suggest that increased caseloads are associated with reduced odds of complications, but not with all-cause mortality, following colorectal surgery in New Brunswick. We also found no evidence of volume having differential effects on outcomes from colon and rectal procedures.


Assuntos
Doenças do Colo/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Doenças Retais/cirurgia , Carga de Trabalho/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Colo/cirurgia , Doenças do Colo/mortalidade , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Feminino , Mortalidade Hospitalar , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Novo Brunswick/epidemiologia , Razão de Chances , Complicações Pós-Operatórias/etiologia , Doenças Retais/mortalidade , Reto/cirurgia , Sistema de Registros/estatística & dados numéricos , Resultado do Tratamento
19.
Pneumologie ; 74(10): 670-677, 2020 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-33059373

RESUMO

Data on surgical lung cancer cases were extracted from the German Federal Statistics on Diagnosis-related groups (DRG) and a possible association between hospital volume and surgical mortality was explored. All treatment cases documented between 2005 and 2015 with the main diagnosis of lung cancer (International Classification of Disease code C34) and the German Operations and Procedure Key (OPS) codes 5-323 to 5-328 for anatomical lung resections were analysed. The treatment cases were assigned to hospital groups, defined according to the number of procedures performed per year. The total number of anatomical lung resections for the diagnosis of lung cancer increased by 24 % from 9376 resections in 2005 to 11,614 resections in 2015. In 2015, 57 % of anatomical lung resections in patients with lung cancer were performed in 47 high volume centres (hospitals with ≥ 75 resections/year); the remaining 43 % of the resections were distributed among 271 hospitals performing fewer than 75 resections per year. In hospitals performing fewer than 25 procedures/year, hospital mortality was almost twice as high as in large centres with ≥ 75 resections per year (5.7 vs. 3.0 %, mean value 2005 to 2015). In summary, our data indicate that a small number of high-volume hospitals perform the major part of lung resections of lung cancer in Germany with better survival as compared to low-volume hospitals. Based on current nationwide data a clear association between hospital volume and surgical mortality could be demonstrated.


Assuntos
Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Neoplasias Pulmonares/cirurgia , Procedimentos Cirúrgicos Operatórios/mortalidade , Alemanha/epidemiologia , Mortalidade Hospitalar , Humanos , Neoplasias Pulmonares/patologia , Avaliação de Resultados em Cuidados de Saúde
20.
J Stroke Cerebrovasc Dis ; 29(11): 105225, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33066917

RESUMO

BACKGROUND: An increased rate of thrombotic events has been associated to Coronavirus Disease 19 (COVID-19) with a variable rate of acute stroke. Our aim is to uncover the rate of acute stroke in COVID-19 patients and identify those cases in which a possible causative relationship could exist. METHODS: We performed a single-center analysis of a prospective mandatory database. We studied all patients with confirmed COVID-19 and stroke diagnoses from March 2nd to April 30th. Demographic, clinical, and imaging data were prospectively collected. Final diagnosis was determined after full diagnostic work-up unless impossible due to death. RESULTS: Of 2050 patients with confirmed SARS-CoV-2 infection, 21 (1.02%) presented an acute ischemic stroke 21 and 4 (0.2%) suffered an intracranial hemorrhage. After the diagnostic work-up, in 60.0% ischemic and all hemorrhagic strokes patients an etiology non-related with COVID-19 was identified. Only in 6 patients the stroke cause was considered possibly related to COVID-19, all of them required mechanical ventilation before stroke onset. Ten patients underwent endovascular treatment; compared with patients who underwent EVT in the same period, COVID-19 was an independent predictor of in-hospital mortality (50% versus 15%; Odds Ratio, 6.67; 95% CI, 1.1-40.4; p 0.04). CONCLUSIONS: The presence of acute stroke in patients with COVID-19 was below 2% and most of them previously presented established stroke risk factors. Without other potential cause, stroke was an uncommon complication and exclusive of patients with a severe pulmonary injury. The presence of COVID-19 in patients who underwent EVT was an independent predictor of in-hospital mortality.


Assuntos
Betacoronavirus/patogenicidade , Infecções por Coronavirus/epidemiologia , Hospitais com Alto Volume de Atendimentos , Pneumonia Viral/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/terapia , Infecções por Coronavirus/virologia , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Interações Hospedeiro-Patógeno , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/mortalidade , Pneumonia Viral/terapia , Pneumonia Viral/virologia , Prognóstico , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Espanha , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/terapia , Acidente Vascular Cerebral/virologia , Fatores de Tempo
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