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1.
Cochrane Database Syst Rev ; 5: CD012830, 2021 05 27.
Artigo em Inglês | MEDLINE | ID: mdl-34043237

RESUMO

BACKGROUND: Cataract surgery is one of the most common surgical procedures performed worldwide. Achieving appropriate intraoperative mydriasis is one of the critical factors associated with the safety and performance of the surgery. Inadequate pupillary dilation or constriction of the pupil during cataract surgery can impair the surgeon's field of view and make it difficult to maneuver instruments. OBJECTIVES: To evaluate the relative effectiveness of achieving pupillary dilation during phacoemulsification for cataract extraction using three methods of pupillary dilation: topical mydriatics, intracameral mydriatics, or depot delivery systems. We also planned to document and compare the risk of intraoperative and postoperative complications following phacoemulsification for cataract extraction, as well as the cost-effectiveness of these methods for pupillary dilation. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register) (2021, Issue 1); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 22 January 2021. SELECTION CRITERIA: We included only randomized controlled trial (RCTs) in which participants underwent phacoemulsification for cataract extraction. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methodology. MAIN RESULTS: We included a total of 14 RCTs (1670 eyes of 1652 participants) in this review. Of the 14 trials, 7 compared topical versus intracameral mydriatics, 6 compared topical mydriatics versus depot delivery systems, and 1 compared all three methods. We were unable to calculate overall estimates of comparative effectiveness for most outcomes due to statistical heterogeneity among the estimates from individual studies or because outcome data were available from only a single study. Furthermore, the certainty of evidence for most outcomes was low or very low, due primarily to imprecision and risk of bias. Comparison 1: topical mydriatics versus intracameral mydriatics Four RCTs (739 participants, 757 eyes) of the 8 RCTs that had compared these two methods reported mean pupillary diameters at the time surgeons had performed capsulorhexis; all favored topical mydriatics, but heterogeneity was high (I2 = 95%). After omitting 1 RCT that used a paired-eyes design, evidence from three RCTs (721 participants and eyes) suggests that mean pupil diameter at the time of capsulorhexis may be greater with topical mydriatics than with intracameral mydriatics, but the evidence is of low certainty (mean difference 1.06 mm, 95% confidence interval (CI) 0.81 mm to 1.31 mm; I2 = 49%). Four RCTs (224 participants, 242 eyes) reported mean pupillary diameter at the beginning of cataract surgery; the effect estimates from all trials favored topical mydriatics, with very low-certainty evidence. Five RCTs (799 participants, 817 eyes) reported mean pupillary diameter at the end of cataract surgery. Data for this outcome from the largest RCT (549 participants and eyes) provided evidence of a small difference in favor of intracameral mydriasis. On the other hand, 2 small RCTs (78 participants, 96 eyes) favored topical mydriatics, and the remaining 2 RCTs (172 participants) found no meaningful difference between the two methods, with very low-certainty evidence. Five RCTs (799 participants, 817 eyes) reported total intraoperative surgical time. The largest RCT (549 participants and eyes) reported decreased total intraoperative time with intracameral mydriatics, whereas 1 RCT (18 participants, 36 eyes) favored topical mydriatics, and the remaining 3 RCTs (232 participants) found no difference between the two methods, with very low-certainty evidence. Comparison 2: topical mydriatics versus depot delivery systems Of the 7 RCTs that compared these two methods, none reported mean pupillary diameter at the time surgeons performed capsulorhexis. Six RCTs (434 participants) reported mean pupillary diameter at the beginning of cataract surgery. After omitting 1 RCT suspected to be responsible for high heterogeneity (I2 = 80%), meta-analysis of the other 5 RCTs (324 participants and eyes) found no evidence of a meaningful difference between the two methods, with very low-certainty evidence. Three RCTs (210 participants) reported mean pupillary diameter at the end of cataract surgery, with high heterogeneity among effect estimates for this outcome. Estimates of mean differences and confidence intervals from these three RCTs were consistent with no difference between the two methods. A fourth RCT reported only means for this outcome, with low-certainty evidence. Two small RCTs (118 participants) reported total intraoperative time. Surgical times were lower when depot delivery was used, but the confidence interval estimated from one trial was consistent with no difference, and only mean times were reported from the other trial, with very low-certainty evidence. Comparison 3: Intracameral mydriatics versus depot delivery systems Only one RCT (60 participants) compared intracameral mydriatics versus depot delivery system. Mean pupillary diameter at the time the surgeon performed capsulorhexis, phacoemulsification time, and cost outcomes were not reported. Mean pupil diameter at the beginning and end of cataract surgery favored the depot delivery system, with very low-certainty evidence. Adverse events Evidence from one RCT (555 participants and eyes) comparing topical mydriatics versus intracameral mydriatics suggests that ocular discomfort may be greater with topical mydriatics than with intracameral mydriatics at one week (risk ratio (RR) 10.57, 95% CI 1.37 to 81.34) and one month (RR 2.51, 95% CI 1.36 to 4.65) after cataract surgery, with moderate-certainty evidence at both time points. Another RCT (30 participants) reported iris-related complications in 11 participants in the intracameral mydriatics group versus no complications in the depot delivery system group, with very low-certainty evidence. Cardiovascular related adverse events were rarely mentioned. AUTHORS' CONCLUSIONS: Data from 14 completed RCTs were inadequate to establish the superiority of any of three methods to achieve mydriasis for cataract surgery, based on pupillary dilation at different times during the surgery or on time required for surgery. Only one trial had a sample size adequate to yield a robust effect estimate. Larger, well-designed trials are needed to provide robust estimates for the comparison of mydriasis approaches for beneficial and adverse effects.


Assuntos
Midriáticos/administração & dosagem , Facoemulsificação/métodos , Pupila/efeitos dos fármacos , Idoso , Viés , Extração de Catarata , Preparações de Ação Retardada , Humanos , Complicações Intraoperatórias , Período Intraoperatório , Pessoa de Meia-Idade , Pupila/fisiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo
2.
Am J Gastroenterol ; 116(4): 666-668, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33982932

RESUMO

Nearly 25 years after its initial description, endoscopic therapy of walled-off pancreatic necrosis has become widely accepted. Endoscopic therapy is composed of transmural placement of stents, now most commonly lumen-apposing metal stents and removal of solid debris, if needed. Removal of solid debris can be achieved with irrigation provided by percutaneously or endoscopically placed (nasocystic) tubes or by mechanically through direct necrosectomy. This editorial provides commentary on the use of hydrogen peroxide instilled at the time of direct necrosectomy for treatment of walled-off pancreatic necrosis.


Assuntos
Drenagem/métodos , Endoscopia do Sistema Digestório/métodos , Peróxido de Hidrogênio/uso terapêutico , Pancreatectomia/métodos , Pancreatite Necrosante Aguda/terapia , Anti-Infecciosos Locais/uso terapêutico , Endossonografia , Humanos , Período Intraoperatório , Pancreatite Necrosante Aguda/diagnóstico
3.
Int J Comput Assist Radiol Surg ; 16(5): 767-777, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33877526

RESUMO

PURPOSE: Reduction and osteosynthesis of ankle fractures is a challenging surgical procedure when it comes to the verification of the reduction result. Evaluation is conducted using intra-operative imaging of the injured ankle and depends on the expertise of the surgeon. Studies suggest that intra-individual variance of the ankle bone shape and pose is considerably lower than the inter-individual variance. It stands to reason that the information gain from the healthy contralateral side can help to improve the evaluation. METHOD: In this paper, an assistance system is proposed that provides a side-to-side view of the two ankle joints for visual comparison and instant evaluation using only one 3D C-arm image. Two convolutional neural networks (CNN) are employed to extract the relevant image regions and pose information of each ankle so that they can be aligned with each other. A first U-Net uses a sliding window to predict the location of each ankle. The standard plane estimation is formulated as segmentation problem so that a second U-Net predicts the three viewing planes for alignment. RESULTS: Experiments were conducted to assess the accuracy of the individual steps on 218 unilateral ankle datasets as well as the overall performance on 7 bilateral ankle datasets. The experiments on unilateral ankles yield a median position-to-plane error of [Formula: see text] mm and a median angular error between 2.98[Formula: see text] and 3.71[Formula: see text] for the plane normals. CONCLUSION: Standard plane estimation via segmentation outperforms direct pose regression. Furthermore, the complete pipeline was evaluated including ankle detection and subsequent plane estimation on bilateral datasets. The proposed pipeline enables a direct contralateral side comparison without additional radiation. This has the potential to ease and improve the intra-operative evaluation for the surgeons in the future and reduce the need for revision surgery.


Assuntos
Fraturas do Tornozelo/diagnóstico por imagem , Articulação do Tornozelo/diagnóstico por imagem , Fixação Interna de Fraturas/métodos , Processamento de Imagem Assistida por Computador/métodos , Imageamento Tridimensional/métodos , Algoritmos , Humanos , Período Intraoperatório , Redes Neurais de Computação , Reoperação , Reprodutibilidade dos Testes
4.
Thorac Surg Clin ; 31(2): 161-169, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33926669

RESUMO

Postoperative air leak is one of the most common complications after pulmonary resection and contributes to postoperative pain, complications, and increased hospital length of stay. Several risk factors, including both patient and surgical characteristics, increase the frequency of air leaks. Appropriate intraoperative tissue handling is the most important surgical technique to reduce air leaks. Digital drainage systems have improved the management of postoperative air leak via objective data, portability, and ease of use in the outpatient setting. Several treatment strategies have been used to address prolonged air leak, including pleurodesis, blood patch, placement of endobronchial valves, and reoperative surgery.


Assuntos
Pulmão/cirurgia , Pleurodese/efeitos adversos , Pleurodese/métodos , Pneumonectomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Próteses e Implantes , Idoso , Tubos Torácicos , Drenagem , Feminino , Volume Expiratório Forçado , Humanos , Período Intraoperatório , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pneumonectomia/métodos , Período Pós-Operatório , Fatores de Risco , Esteroides/uso terapêutico , Resultado do Tratamento
5.
BMC Cancer ; 21(1): 445, 2021 Apr 22.
Artigo em Inglês | MEDLINE | ID: mdl-33888088

RESUMO

BACKGROUND: Whether patients with non-small cell lung cancer (NSCLC) with unexpected pleural dissemination (UPD) could get survival benefit from tumor resection remained controversial. METHODS: Totally, 169 patients with NSCLC with UPD were included between 2012 and 2016. Patients were divided into the tumor resection and open-close group. Progression-free survival (PFS) and overall survival (OS) were compared with a log-rank test. The multivariable Cox analysis was applied to identify prognostic factors. RESULTS: Sixty-five patients received open-close surgery and 104 patients underwent main tumor and visible pleural nodule resection. Tumor resection significantly prolonged OS (hazard ratio [HR]: 0.408, P < 0.001), local PFS (HR: 0.283, P < 0.001), regional PFS (HR: 0.506, P = 0.005), and distant metastasis (HR: 0.595, P = 0.032). Multivariable Cox analysis confirmed that surgical method was an independent prognostic factor for OS, local PFS and regional PFS, except distant metastasis. Subgroup analyses indicated that tumor resection could not improve OS in the patients who received targeted therapy (HR: 0.649, P = 0.382), however, tumor resection was beneficial for the patients who received adjuvant chemotherapy alone (HR: 0.322, P < 0.001). In the tumor resection group, lobectomy (HR: 0.960, P = 0.917) and systematic lymphadenectomy (HR: 1.512, P = 0.259) did not show survival benefit for OS. CONCLUSIONS: Main tumor and visible pleural nodule resection could improve prognosis in patients with UPD who could not receive adjuvant targeted therapy. Sublobar resection without systematic lymphadenectomy may be the optimal procedure.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/patologia , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/cirurgia , Neoplasias Pleurais/secundário , Neoplasias Pleurais/cirurgia , Idoso , Carcinoma Pulmonar de Células não Pequenas/etiologia , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Tomada de Decisão Clínica , Terapia Combinada , Comorbidade , Gerenciamento Clínico , Feminino , Humanos , Achados Incidentais , Período Intraoperatório , Estimativa de Kaplan-Meier , Neoplasias Pulmonares/etiologia , Neoplasias Pulmonares/mortalidade , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias Pleurais/mortalidade , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Resultado do Tratamento
6.
Yakugaku Zasshi ; 141(3): 403-413, 2021.
Artigo em Japonês | MEDLINE | ID: mdl-33642511

RESUMO

Pharmacists began preparing drug solutions intraoperatively for postoperative analgesia in the Department of Surgery at Chiba University Hospital from May 2014. To verify the usefulness of pharmacists preparing these drug solutions, we conducted a questionnaire survey among 51 anesthesiologists and received 44 responses (recovery rate 86.3%). Burden on the anesthesiologists was significantly reduced both temporally and mentally when the pharmacists prepared the drug solutions compared with when the anesthesiologists did (p<0.01). The anesthesiologists' degree of anxiety about sometimes having to prepare drug solutions alone without any confirmation was also significantly reduced when pharmacists prepared them (p<0.01), which implies the need for a double-check system. In addition, 88.6% of anesthesiologists said that they were reassured with preparations done by the pharmacists under a sterile environment using a clean bench. Overall, 88.6% of anesthesiologists responded that they were satisfied with the preparation of drug solutions by pharmacists. Based on the results of this survey, pharmacists' preparation of drug solutions for postoperative analgesia is considered to be useful in ensuring the quality and safety of medical care because it reduced anesthesiologists' work to prepare the drug solutions, allowing them to concentrate on anesthesia and related work, it established a double-check system between the two staff teams, and it was done under a sterile environment.


Assuntos
Analgésicos , Anestesiologistas/psicologia , Composição de Medicamentos/métodos , Dor Pós-Operatória/prevenção & controle , Farmacêuticos , Centro Cirúrgico Hospitalar , Ansiedade , Atitude do Pessoal de Saúde , Ambiente Controlado , Humanos , Período Intraoperatório , Japão , Equipe de Assistência ao Paciente , Satisfação Pessoal , Preparações Farmacêuticas , Qualidade da Assistência à Saúde , Segurança , Soluções , Inquéritos e Questionários
7.
J Cardiothorac Surg ; 16(1): 58, 2021 Mar 26.
Artigo em Inglês | MEDLINE | ID: mdl-33771192

RESUMO

BACKGROUND: Acute Kidney Injury (AKI) adversely affects outcomes after cardiac surgery. A major mediator of AKI is the activation of leukocytes through exposure to the cardiopulmonary bypass circuit. We evaluate the use of leukodepletion filters throughout bypass to protect against post-operative AKI by removing activated leukocytes during cardiac surgery. METHODS: This is a single-centre, double-blind, randomized controlled trial comparing the use of leukodepletion versus a standard arterial filter throughout bypass. Elective adult patients undergoing heart valve surgery with or without concomitant procedures were investigated. The primary clinical outcome measured was the development of AKI according to the KDIGO criteria. Secondary measures included biomarkers of renal tubular damage (urinary Retinol Binding Protein and Kidney Injury Molecule-1), glomerular kidney injury (urinary Micro Albumin and serum Cystatin C) and urinary Neutrophil Gelatinase Associated Lipocalin, as well as the length of hospital stay and quality of life measures through EQ-5D-5L questionnaires. RESULTS: The ROLO trial randomized 64 participants with a rate of recruitment higher than anticipated (57% achieved, 40% anticipated). The incidence of AKI was greater in the leukodepletion filter group (44% versus 23%, risk difference 21, 95% CI - 2 to 44%). This clinical finding was supported by biomarker levels especially by a tendency toward glomerular insult at 48 h, demonstrated by a raised serum Cystatin C (mean difference 0.11, 95% CI 0.00 to 0.23, p = 0.068) in the leukodepleted group. There was however no clear association between the incidence or severity of AKI and length of hospital stay. On average, health related quality of life returned to pre-operative levels in both groups within 3 months of surgery. CONCLUSIONS: Leukocyte depletion during cardiopulmonary bypass does not significantly reduce the incidence of AKI after valvular heart surgery. Other methods to ameliorate renal dysfunction after cardiac surgery need to be investigated. TRIAL REGISTRATION: The trial was registered by the International Standard Randomized Controlled Trial Number Registry ISRCTN42121335 . Registered on the 18 February 2014. The trial was run by the Bristol Clinical Trials and Evaluation Unit. This trial was financially supported by the National Institute of Health Research (Research for Patient Benefit), award ID: PB-PG-0711-25,090.


Assuntos
Injúria Renal Aguda/prevenção & controle , Procedimentos Cirúrgicos Cardíacos/métodos , Doenças das Valvas Cardíacas/cirurgia , Valvas Cardíacas/cirurgia , Procedimentos de Redução de Leucócitos/métodos , Qualidade de Vida , Injúria Renal Aguda/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Método Duplo-Cego , Feminino , Humanos , Período Intraoperatório , Testes de Função Renal , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Adulto Jovem
8.
Int J Comput Assist Radiol Surg ; 16(4): 619-627, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33704665

RESUMO

PURPOSE: Planning a safe path for flexible catheters is one of the major challenges of endovascular catheterization. State-of-the-art methods rarely consider the catheter curvature constraint and reduced computational time of path planning which guarantees the possibility to re-plan the path during the actual operation. METHODS: In this manuscript, we propose a fast two-phase path planning approach under the robot curvature constraint. Firstly, the vascular structure is extracted and represented by vascular centerlines and corresponding vascular radii. Then, the path is searched along the vascular centerline using breadth first search (BFS) strategy and locally optimized via the genetic algorithm (GA) to satisfy the robot curvature constraint. This approach (BFS-GA) is able to respect the robot curvature constraint while keeping it close to the centerlines as much as possible. We can also reduce the optimization search space and perform parallel optimization to shorten the computational time. RESULTS: We demonstrate the method's high efficiency in two-dimensional and three-dimensional space scenarios. The results showed the planner's ability to satisfy the robot curvature constraint while keeping low computational time cost compared with sampling-based methods. Path replanning in femoral arteries can reach an updating frequency at [Formula: see text]Hz. CONCLUSION: The presented work is suited for surgical procedures demanding satisfying curvature constraints while optimizing specified criteria. It is also applicable for curvature constrained robots in narrow passages.


Assuntos
Cateterismo , Cateteres , Intervenção Coronária Percutânea/métodos , Algoritmos , Simulação por Computador , Artéria Femoral/diagnóstico por imagem , Humanos , Período Intraoperatório , Procedimentos Cirúrgicos Robóticos , Robótica , Cirurgia Assistida por Computador
9.
Int J Comput Assist Radiol Surg ; 16(6): 1027-1035, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33779936

RESUMO

PURPOSE: Low-dose-rate permanent-seed (LDR-PS) brachytherapy has shown a great potential for treating breast cancer. An implantation scheme indicating the template pose and needle trajectories is determined before the operation. However, when performing the pre-planned scheme intraoperatively, a change of the patient's posture will cause seed placements away from the desired locations. Hence, the implantation scheme should update based on the current patient's posture. METHODS: A numerical method of optimizing the implantation scheme for the LDR-PS breast brachytherapy is presented here. The proposed algorithm determines the fewest needle trajectories and template poses for delivering the seeds to the intraoperative desired locations. The clinical demand, such as the minimum distance between the chest wall and the needle, is considered in the optimization process. RESULTS: The method was simulated for a given LDR-PS brachytherapy procedure to evaluate the optimal scheme as the number of the template poses changing. The optimization parameters of the needles' number and the implantation errors are used to adjust the algorithm outcome. The results show that the implantation schemes obtained by our method have a satisfactory accuracy in the cases of 2 or 3 template poses. The computation time is about 76s to 150s according to the number of the template poses from 1 to 3. CONCLUSION: The proposed method can find the optimal implantation scheme corresponding to the current desired seed locations immediately once there is a change of patient's posture. This work can be applied to the robot-assisted LDR-PS breast brachytherapy for improving the operation accuracy and efficiency.


Assuntos
Algoritmos , Braquiterapia/métodos , Neoplasias da Mama/radioterapia , Mama/diagnóstico por imagem , Mastectomia/métodos , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/cirurgia , Feminino , Humanos , Período Intraoperatório , Dosagem Radioterapêutica
10.
Knee ; 29: 291-297, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33677153

RESUMO

BACKGROUND: It is unknown whether intraoperative kinematics of bicruciate-stabilized total knee arthroplasty (BCS-TKA) are different for different activities. It has also not been established whether intraoperative high-flexion motions correlate with postoperative patient-reported outcome measures (PROMs). We aimed to clarify the intraoperative kinematics of BCS-TKA during high-flexion activities and describe the relationship between intraoperative and postoperative patient-reported outcomes. METHODS: We examined 33 knees from 31 patients who underwent BCS-TKA and measured intraoperative knee kinematics, passive knee flexion, and cross-legged flexion using a navigation system. We also calculated knee flexion, varus-valgus, and rotation angles. As a secondary evaluation, we divided the patients into two clusters based on the PROMs and compared the kinematics between them. RESULTS: The valgus moved by 1.3 ± 1.3° beyond 90° knee flexion during passive flexion. In contrast, during cross-legged flexion, the varus moved by 4.6 ± 5.1° beyond 30° flexion. This indicated significantly increased varus alignment in the cross-legged flexion as compared with passive flexion. Beyond 60° of flexion, the femur displayed 8.8 ± 4.8° of external rotation relative to the tibia. In cross-legged flexion, the femur displayed 9.2 ± 6.5° of external rotation relative to the tibia beyond 45° of flexion. At 90° of flexion, the cross-legged knees rotated more externally. There were no significant postoperative differences between the high- and low-score clusters. CONCLUSION: The intraoperative knee kinematics after BCS-TKA during high-flexion motions differed depending on the performance of an individual. This will be useful for physicians who might recommend BCS-TKA to new patients.


Assuntos
Artroplastia do Joelho/métodos , Articulação do Joelho/fisiopatologia , Articulação do Joelho/cirurgia , Amplitude de Movimento Articular/fisiologia , Idoso , Fenômenos Biomecânicos , Feminino , Humanos , Período Intraoperatório , Masculino , Osteoartrite do Joelho/fisiopatologia , Osteoartrite do Joelho/cirurgia , Medidas de Resultados Relatados pelo Paciente , Cirurgia Assistida por Computador
11.
Knee ; 29: 323-331, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33684863

RESUMO

BACKGROUND: We evaluated the effectiveness of our new technique "Range of motion-anatomical (ROM-A) technique" which is the combination of the self-positioning technique "Range of motion (ROM) technique" and the anatomical landmarks technique in determining the tibial component (TC) rotation alignment in total knee arthroplasty (TKA) using a navigation system. METHODS: This retrospective study included 103 knees who underwent TKA. The ROM-A technique was consisted of two steps. First, the TC was set and marked by the ROM technique in knee extension. Second, the TC was set according to the marking in the knee flexion and the component rotational angle relative to the anatomical tibial anteroposterior (AP) axis was adjusted between 0° and 10° external rotation using the navigation system. The rotational angle of TC relative to the anatomical AP axis was measured using postoperative computed tomography. Moreover, the hypothetical rotational angle of the TC in the ROM technique was calculated only from the intraoperative difference between the two techniques. RESULTS: The actual rotational angle by the ROM-A technique was externally rotated 3.0°, and the rotational outlier occurred in 3.0%. A significant difference in outlier rate was observed between the two techniques (p = 0.03). The hypothetical rotational angle of TC determined by the ROM technique (the first step only in the ROM-A technique) was externally rotated 4.6° and the TC rotational outlier (difference to AP axis: >10°) occurred in 11.7%. CONCLUSION: Using the ROM-A technique, the TC was finally fixed in almost all targeted rotational positions, and this technique could reduce the anatomical rotational outlier compared with the ROM technique.


Assuntos
Artroplastia do Joelho/métodos , Prótese do Joelho , Ajuste de Prótese/métodos , Cirurgia Assistida por Computador , Idoso , Feminino , Humanos , Período Intraoperatório , Masculino , Osteoartrite do Joelho/cirurgia , Estudos Retrospectivos
12.
JAMA Netw Open ; 4(3): e212240, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33783520

RESUMO

Importance: Postoperative complications can significantly impact perioperative care management and planning. Objectives: To assess machine learning (ML) models for predicting postoperative complications using independent and combined preoperative and intraoperative data and their clinically meaningful model-agnostic interpretations. Design, Setting, and Participants: This retrospective cohort study assessed 111 888 operations performed on adults at a single academic medical center from June 1, 2012, to August 31, 2016, with a mean duration of follow-up based on the length of postoperative hospital stay less than 7 days. Data analysis was performed from February 1 to September 31, 2020. Main Outcomes and Measures: Outcomes included 5 postoperative complications: acute kidney injury (AKI), delirium, deep vein thrombosis (DVT), pulmonary embolism (PE), and pneumonia. Patient and clinical characteristics available preoperatively, intraoperatively, and a combination of both were used as inputs for 5 candidate ML models: logistic regression, support vector machine, random forest, gradient boosting tree (GBT), and deep neural network (DNN). Model performance was compared using the area under the receiver operating characteristic curve (AUROC). Model interpretations were generated using Shapley Additive Explanations by transforming model features into clinical variables and representing them as patient-specific visualizations. Results: A total of 111 888 patients (mean [SD] age, 54.4 [16.8] years; 56 915 [50.9%] female; 82 533 [73.8%] White) were included in this study. The best-performing model for each complication combined the preoperative and intraoperative data with the following AUROCs: pneumonia (GBT), 0.905 (95% CI, 0.903-0.907); AKI (GBT), 0.848 (95% CI, 0.846-0.851); DVT (GBT), 0.881 (95% CI, 0.878-0.884); PE (DNN), 0.831 (95% CI, 0.824-0.839); and delirium (GBT), 0.762 (95% CI, 0.759-0.765). Performance of models that used only preoperative data or only intraoperative data was marginally lower than that of models that used combined data. When adding variables with missing data as input, AUROCs increased from 0.588 to 0.905 for pneumonia, 0.579 to 0.848 for AKI, 0.574 to 0.881 for DVT, 0.5 to 0.831 for PE, and 0.6 to 0.762 for delirium. The Shapley Additive Explanations analysis generated model-agnostic interpretation that illustrated significant clinical contributors associated with risks of postoperative complications. Conclusions and Relevance: The ML models for predicting postoperative complications with model-agnostic interpretation offer opportunities for integrating risk predictions for clinical decision support. Such real-time clinical decision support can mitigate patient risks and help in anticipatory management for perioperative contingency planning.


Assuntos
Sistemas de Apoio a Decisões Clínicas , Aprendizado de Máquina , Complicações Pós-Operatórias/diagnóstico , Medição de Risco/métodos , Feminino , Seguimentos , Humanos , Incidência , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Período Pré-Operatório , Curva ROC , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia
13.
Rev. SOBECC ; 26(1): 50-59, 31-03-2021.
Artigo em Inglês | LILACS | ID: biblio-1177911

RESUMO

Objetivo: Conhecer as publicações científicas relacionadas aos diagnósticos de enfermagem (DEs) no período perioperatório do paciente cirúrgico. Método: Revisão integrativa nas bases de dados Web of Science, Scopus, Wiley Online Library e na plataforma da Revista SOBECC Nacional. Descritores utilizados na busca: "nursing diagnosis" e "surgery". Critérios de inclusão: estudos publicados entre 2014 e 2019, disponíveis em português, inglês ou espanhol, e responder à questão norteadora. Resultados: Selecionados 15 artigos, sendo oito publicados em periódicos internacionais, entretanto todos produzidos por pesquisadores brasileiros. Seis publicações identificaram os principais DEs no perioperatório, os demais pesquisaram um DE específico. Evidenciou-se o pós-operatório como o período mais pesquisado. Os estudos foram classificados conforme níveis de evidência (NE): seis com NE 4, seis com NE 5 e três com NE 6. Conclusão: O pós-operatório foi o período mais relacionado aos DEs. Apenas um estudo abordou o DE especificamente no intraoperatório. Constatou-se que a população mais estudada foi a de pacientes submetidos à cirurgia cardíaca.


Objective: To assess scientific publications related to nursing diagnoses (NDs) for surgical patients in the perioperative period. Method: This is an integrative review conducted in the Web of Science, Scopus, and Wiley Online Library databases and in the platform of the National SOBECC Journal. The keywords used in the search were: "nursing diagnosis" and "surgery". The inclusion criteria were: studies published between 2014 and 2019, available in Portuguese, English, or Spanish, and that answered the guiding question. Results: We selected 15 articles, of which 8 were published in international journals, even though all studies were produced by Brazilian researchers. Six publications identified the main NDs in the perioperative period, while the others investigated a specific ND. The postoperative period was the most studied. Studies were classified according to their level of evidence (LE): six with LE 4, six with LE 5, and three with LE 6. Conclusion: The postoperative period was the one most associated with NDs. Only one study addressed NDs specifically in the intraoperative period. The most studied population was that of patients submitted to cardiac surgery.


Objetivo: Conocer las publicaciones científicas relacionadas con los Diagnósticos de Enfermería (DEs) en el período perioperatorio del paciente quirúrgico. Método: Revisión integrativa en las bases de datos de Web of Science, SCOPUS, Wiley Online Library y la plataforma de Revista SOBECC Nacional. Descriptores utilizados en la búsqueda: "diagnóstico de enfermería" y "cirugía". Criterios de inclusión: estudios publicados entre 2014 y 2019, disponibles en portugués, inglés o español y que respondan a la pregunta orientadora. Resultados: Se seleccionaron 15 artículos, ocho de los cuales fueron publicados en revistas internacionales, sin embargo, todos producidos por investigadores brasileños. Seis publicaciones identificaron los principales DEs en el período perioperatorio, las otras investigaron un DE específico. El postoperatorio se convirtió en el período más investigado. Los estudios se clasificaron según niveles de evidencia (NE): seis con NE 4, seis con NE 5 y tres con NE 6. Conclusión: El postoperatorio fue el período más relacionado con la DE. Solo un estudio abordó la DE específicamente durante la operación. Se encontró que la población más estudiada fueron los pacientes sometidos a cirugía cardíaca.


Assuntos
Humanos , Período Pós-Operatório , Período Perioperatório , Período Intraoperatório , Cirurgia Torácica , Diagnóstico de Enfermagem
14.
Vet Surg ; 50(4): 833-842, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33754391

RESUMO

OBJECTIVE: To report the relative sensitivity of different diagnostic imaging (DI) techniques to detect migrating foreign bodies (FB) in subcutaneous and underlying soft tissue structures of dogs and evaluate the value of intraoperative ultrasonography (intraop-US). STUDY DESIGN: Retrospective study. SAMPLE POPULATION: Forty-one dogs. METHODS: Medical records (2007-2019) of dogs that underwent surgery for a chronic abscess or draining tract were included when preoperative US (preop-US), computed tomography (preop-CT), or preop-MRI, and at least 6 months of follow-up information were available. Collected data included the DI techniques used, DI findings, and surgical findings. The relative sensitivity of each preoperative DI (preop-DI) technique was calculated. Dogs were divided into two groups, dogs that underwent only a preop-DI examination (group A) and dogs that underwent an additional intraop-US (group B). The success rates for FB surgical removal were compared between groups. RESULTS: The relative sensitivity of preop-US and preop-CT/MRI was 88% (95% CI, 70%-95.8%) and 57.1% (95% CI, 32.6%-78.6%), respectively. The success rate for FB removal was higher in group B (89.5%) than in group A (59.1%; P = .038). Clinical resolution occurred in 90.2% of dogs for a median duration of follow-up of 4.2 years (6 months to 9.3 years). CONCLUSION: Preoperative US seems more suitable than preop-CT/MRI for detection of migrating FB in subcutaneous and underlying soft tissue structures. The use of intraop-US increases the success rate for FB surgical removal. CLINICAL SIGNIFICANCE: Intraoperative US should be used in combination with preop-US to increase the likelihood of migrating FB surgical removal in dogs.


Assuntos
Cães/lesões , Migração de Corpo Estranho/veterinária , Cuidados Pré-Operatórios/veterinária , Ultrassonografia/veterinária , Animais , Cães/cirurgia , Feminino , Migração de Corpo Estranho/diagnóstico , Migração de Corpo Estranho/cirurgia , Período Intraoperatório , Masculino , Período Pré-Operatório
15.
Lancet Oncol ; 22(5): e186-e195, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33765422

RESUMO

Fluorescence-guided surgery is an intraoperative optical imaging method that provides surgeons with real-time guidance for the delineation of tumours. Currently, in phase 1 and 2 clinical trials, evaluation of fluorescence-guided surgery is primarily focused on its diagnostic performance, although the corresponding outcome variables do not inform about the added clinical benefit of fluorescence-guided surgery and are challenging to assess objectively. Nonetheless, the effect of fluorescence-guided surgery on intraoperative decision making is the most objective outcome measurement to assess the clinical value of this imaging method. In this Review, we explore the study designs of existing trials of fluorescence-guided surgery that allow us to extract information on potential changes in intraoperative decision making, such as additional or more conservative resections. On the basis of this analysis, we offer recommendations on how to report changes in intraoperative decision making that result from fluorescence imaging, which is of utmost importance for the widespread clinical implementation of fluorescence-guided surgery.


Assuntos
Tomada de Decisões , Neoplasias/cirurgia , Imagem Óptica/métodos , Cirurgia Assistida por Computador/métodos , Ensaios Clínicos como Assunto , Fluorescência , Humanos , Período Intraoperatório , Projetos de Pesquisa
16.
N Z Med J ; 134(1531): 55-62, 2021 03 12.
Artigo em Inglês | MEDLINE | ID: mdl-33767487

RESUMO

AIMS: The management of a macroscopically normal appendix during diagnostic laparoscopy depends on the accuracy of surgeons' intra-operative assessments. This study aims to determine the accuracy of this assessment and identify factors affecting it. METHODS: We reviewed appendicectomies on adult patients at Waikato District Health Board in 2017. The primary outcome was the agreement between the operative assessment and the gold standard histopathologic assessment. Secondary outcomes were predictors of this agreement. RESULTS: 420 patients were included. Among 74 appendixes assessed as normal by surgeons, 16 (21.6%) had appendicitis on histology. Surgeons assessed 346 appendixes as inflamed; however, 22 (6.3%) were revealed to be histologically normal. Only 2 of the 14 appendiceal neoplasms on histology were identified at the time of laparoscopy. Overall, there was disagreement in 9.1% of cases. This yielded a kappa of 0.69, indicating moderate inter-rater reliability. An inflamed appendix was significantly more likely to be falsely assessed as normal by non-trainee registrars, in female patients and in patients with a pre-operative ultrasound. A pre-operative computerised tomography scan (CT) decreased the odds of false negative operative diagnoses, but it increased the odds of false positives. CONCLUSIONS: Macroscopic assessment of the appendix lacks accuracy and may be challenging in certain groups of operators and patients.


Assuntos
Apendicite/diagnóstico , Erros de Diagnóstico/estatística & dados numéricos , Período Intraoperatório , Adolescente , Adulto , Apendicectomia , Apendicite/cirurgia , Auditoria Clínica , Competência Clínica , Feminino , Humanos , Laparoscopia , Masculino , Pessoa de Meia-Idade , Nova Zelândia , Estudos Retrospectivos , Adulto Jovem
17.
Mayo Clin Proc ; 96(3): 619-635, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33673914

RESUMO

OBJECTIVE: To assess the association between the preoperative model for end-stage liver disease (MELD) and MELD-XI (exclude international normalized ratio) score and outcomes in patients undergoing pericardiectomy for constrictive pericarditis. PATIENTS AND METHODS: Patients >18 years of age undergoing pericardiectomy for constrictive pericarditis between January 1, 2007, and October 12, 2017, were analyzed with data for MELD and MELD-XI score calculation within 30 days preoperatively. The association between the MELD and MELD-XI scoring systems and risk of postoperative outcomes was assessed in regression models adjusting for relevant covariates. The primary outcome was operative mortality (death within 90 days or in hospital). Secondary outcomes included various measures of postoperative morbidity. RESULTS: A total of 175 and 226 patients had data for MELD/MELD-XI, respectively. Ninety-day mortality was 8.7%. When stratified into tertiles of MELD-XI, the unadjusted risk of 90-day mortality was 2.7%, 8.2%, and 16.0%, respectively. In Cox regression models fitted for MELD-XI and MELD, higher scores associated with increased risk of mortality (P<.001 for both). In secondary multivariable analyses, both MELD-XI and MELD were associated with increased incidence of renal failure and greater levels of chest-tube output and transfusion, whereas MELD-XI was additionally associated with prolonged intubation and extended intensive care unit and hospital stays. CONCLUSION: Among patients undergoing pericardiectomy for constrictive pericarditis, MELD-XI and MELD were associated with increased postoperative morbidity and mortality. Although the simpler MELD-XI score generally performed as well or better than MELD as a correlate of various outcomes, both scores can serve as a simple yet robust risk stratification tool for patients undergoing pericardiectomy for constrictive pericarditis.


Assuntos
Doença Hepática Terminal/mortalidade , Pericardiectomia/mortalidade , Pericardite Constritiva/mortalidade , Pericardite Constritiva/cirurgia , Índice de Gravidade de Doença , Adulto , Idoso , Doença Hepática Terminal/complicações , Feminino , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Pericardite Constritiva/complicações , Período Pós-Operatório , Medição de Risco , Fatores de Risco , Resultado do Tratamento
19.
Br J Anaesth ; 126(3): 599-607, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33549321

RESUMO

BACKGROUND: Increased intravascular volume has been associated with protection from acute kidney injury (AKI), but in patients with congestive heart failure, venous congestion is associated with increased AKI. We tested the hypothesis that intraoperative venous congestion is associated with AKI after cardiac surgery. METHODS: In patients enrolled in the Statin AKI Cardiac Surgery trial, venous congestion was quantified as the area under the curve (AUC) of central venous pressure (CVP) >12, 16, or 20 mm Hg during surgery (mm Hg min). AKI was defined using Kidney Disease Improving Global Outcomes (KDIGO) criteria and urine concentrations of tissue inhibitor of metalloproteinase-2 and insulin-like growth factor binding protein 7 ([TIMP-2]⋅[IGFBP7]), a marker of renal stress. We measured associations between venous congestion, AKI and [TIMP-2]⋅[IGFBP7], adjusted for potential confounders. Values are reported as median (25th-75th percentile). RESULTS: Based on KDIGO criteria, 104 of 425 (24.5%) patients developed AKI. The venous congestion AUCs were 273 mm Hg min (81-567) for CVP >12 mm Hg, 66 mm Hg min (12-221) for CVP >16 mm Hg, and 11 mm Hg min (1-54) for CVP >20 mm Hg. A 60 mm Hg min increase above the median venous congestion AUC above each threshold was independently associated with increased AKI (odds ratio=1.06; 95% confidence interval [CI], 1.02-1.10; P=0.008; odds ratio=1.12; 95% CI, 1.02-1.23; P=0.013; and odds ratio=1.30; 95% CI, 1.06-1.59; P=0.012 for CVP>12, >16, and >20 mm Hg, respectively). Venous congestion before cardiopulmonary bypass was also associated with increased [TIMP-2]⋅[IGFBP7] measured during cardiopulmonary bypass and after surgery, but neither venous congestion after cardiopulmonary bypass nor venous congestion throughout surgery was associated with postoperative [TIMP-2]⋅[IGFBP7]. CONCLUSION: Intraoperative venous congestion was independently associated with increased AKI after cardiac surgery.


Assuntos
Injúria Renal Aguda/etiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Pressão Venosa Central , Hiperemia/etiologia , Injúria Renal Aguda/epidemiologia , Idoso , Estudos de Coortes , Feminino , Humanos , Hiperemia/epidemiologia , Período Intraoperatório , Masculino , Estudos Prospectivos , Fatores de Risco , Resultado do Tratamento
20.
J Orthop Surg Res ; 16(1): 101, 2021 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-33526054

RESUMO

BACKGROUND: Traditionally, the technique of modified tension band wires (MTBW) has been the most commonly used surgical procedure. The purpose of this study is to design a precise navigation device that can obtain a standard position of K-wires for (MTBW) and to compare the precise MTBW (P-MTBW) by a navigation device with the conventional MTBW (C-MTBW) by hands in a retrospective study. METHODS: The device was designed by solidworks2012 software (USA), which could provide a precise guidance for obtaining parallel K-wires. Besides, it could set the distance between two K-wires and the level of K-wires below patellar anterior surface. From June 2014 to August 2018, a total of 112 patients were employed in this retrospective study. The patients were divided into P-MTBW group and C-MTBW group according to the surgical technique with or without the precise navigation device. We needed to record and analyze the operation time and the number of fluoroscopy, postoperative internal fixation imaging, knee function and complications. RESULTS: There were 54 patients in P-MTBW group and 58 patients in C-MTBW group. There were statistically significant differences (P < 0.001) in the operation time between P-MTBW group (39.5 ± 4.7; range, 32-49 min) and C-MTBW group (53.7 ± 6.8; range, 42-71 min). The number of intraoperative fluoroscopy was significantly less (P < 0.001) in P-MTBW group (4.2 ± 1.4) versus that of C-MTBW group (8.3 ± 2.7). According to Iowa knee score, there was no significant difference (P = 0.268 at 1 year) in function between the two groups. According to our own evaluation criteria for MTBW, anyone in the P-MTBW group was excellent and 26 patients were excellent, 20 patients were good, and 2 patients were fair in the C-MTBW group. CONCLUSION: The navigation device can reduce operation time and intraoperative fluoroscopy frequency. P-MTBW fixation is an accurate and effective surgical procedure for patella fractures.


Assuntos
Fios Ortopédicos , Fixação Interna de Fraturas/métodos , Fraturas Ósseas/cirurgia , Patela/cirurgia , Sistemas de Navegação Cirúrgica , Desenho de Equipamento , Feminino , Fluoroscopia/estatística & dados numéricos , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Retrospectivos , Resultado do Tratamento
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