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1.
J Natl Black Nurses Assoc ; 30(1): 40-47, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31465684

RESUMO

The purpose of this article was to help healthcare practitioners understand the dynamics of Alzheimer's care giving and to introduce an evidence-based practice intervention to improve the caregiver's self-efficacy. Over 5 million people in the United States are afflicted with Alzheimer's disease and require a caregiver to assist with all areas of daily activity. Adult care giving is challenging for the caregiver, who is often a family member with little to no knowledge or skill in rendering care. African-American caregivers encounter an even greater challenge by overcoming cultural bias inherent in racial disparity. Evidence-based practice interventions are helpful in successfully rendering care while minimizing stress and burden. Healthcare providers must consider the caregiver, the dynamics of care giving, and cultural norms, in the plan of care to successfully care for the Alzheimer's patient along the trajectory of the disease.


Assuntos
Doença de Alzheimer/terapia , Cuidadores/psicologia , Planejamento de Assistência ao Paciente/organização & administração , Adulto , Afro-Americanos/psicologia , Características Culturais , Prática Clínica Baseada em Evidências , Humanos , Autoeficácia
2.
Am J Orthod Dentofacial Orthop ; 156(2): 210-219, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31375231

RESUMO

INTRODUCTION: More patients are choosing customized orthodontic appliances because of their excellent esthetics. It is essential that clinicians understand the biomechanics of the tooth movement tendency in customized lingual orthodontics. This study aimed to evaluate the tooth movement tendency during space closure in maxillary anterior teeth with the use of miniscrew anchorage in customized lingual orthodontics with various power arm locations. METHODS: Three-dimensional finite element models of the maxilla were created with miniscrews and power arms; the positions were varied to change the force directions. A retraction force (1.5 N) was applied from the top of the miniscrews to the selected points on the power arm, and the initial displacements of the reference nodes of the maxillary teeth were analyzed. RESULTS: After applying force in different directions, power arms located at the distal side of the canines led to larger initial lingual crown tipping and occlusal crown extrusion of the maxillary incisors compared with power arms located at the midpoint between the lateral incisors and canines, and caused a decreasing trend of the intercanine width. CONCLUSIONS: In customized lingual orthodontic treatment, power arms located at the distal side of the canines are unfavorable for anterior teeth torque control and intercanine width control. Power arms located at the midpoint between the lateral incisors and canines can get better torque control, but still cannot achieve excepted torque without extra torque control methods, no matter whether its force application point is higher than, lower than, or equal to the level of the top of the miniscrews.


Assuntos
Parafusos Ósseos , Análise de Elementos Finitos , Procedimentos de Ancoragem Ortodôntica/instrumentação , Procedimentos de Ancoragem Ortodôntica/métodos , Fechamento de Espaço Ortodôntico , Técnicas de Movimentação Dentária/instrumentação , Técnicas de Movimentação Dentária/métodos , Adulto , Fenômenos Biomecânicos , Simulação por Computador , Dente Canino/patologia , Humanos , Imagem Tridimensional/métodos , Incisivo/patologia , Maxila , Modelos Biológicos , Desenho de Aparelho Ortodôntico , Aparelhos Ortodônticos , Braquetes Ortodônticos , Fechamento de Espaço Ortodôntico/instrumentação , Fechamento de Espaço Ortodôntico/métodos , Fios Ortodônticos , Planejamento de Assistência ao Paciente , Estresse Mecânico , Coroa do Dente , Torque , Resultado do Tratamento
3.
Am J Orthod Dentofacial Orthop ; 156(2): 266-274, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31375237

RESUMO

Adult orthodontic treatment involving maxillary transverse deficiency is a challenge for an interdisciplinary team. Surgically assisted rapid palatal expansion to segment the maxilla was once the treatment of choice, but the invasiveness, bone deficiency, and gingival recession hindered its acceptance. Corticotomy-assisted rapid maxillary arch expansion with ridge augmentation has the advantage of augmenting alveolar bony housing to accommodate and facilitate tooth movement. This approach was used to correct a severely constricted maxilla with bilateral posterior crossbite and anterior crowding in a 46-year-old man. Treatment time was 14 months. The accelerated arch expansion overcame the crossbite in 7 months, increasing intercanine distance by 5.2 mm and intermolar distance by 9.8 mm. Subsequent implant prosthesis was able to be restored in a functional normal occlusion. Satisfactory and stable clinical outcome was followed for 7 years. Corticotomy-assisted rapid maxillary arch expansion with alveolar bone augmentation is a novel and effective interdisciplinary approach for correcting adult maxillary transverse deficiency. Well controlled prospective clinical trails are warranted for further investigation.


Assuntos
Aumento do Rebordo Alveolar/métodos , Má Oclusão/terapia , Técnica de Expansão Palatina , Técnicas de Movimentação Dentária/métodos , Cefalometria , Modelos Dentários , Oclusão Dentária , Seguimentos , Humanos , Masculino , Má Oclusão/diagnóstico por imagem , Má Oclusão/patologia , Má Oclusão/cirurgia , Má Oclusão de Angle Classe II/diagnóstico por imagem , Má Oclusão de Angle Classe II/patologia , Má Oclusão de Angle Classe II/cirurgia , Má Oclusão de Angle Classe II/terapia , Má Oclusão de Angle Classe III/diagnóstico por imagem , Má Oclusão de Angle Classe III/patologia , Má Oclusão de Angle Classe III/cirurgia , Má Oclusão de Angle Classe III/terapia , Maxila/anormalidades , Maxila/patologia , Maxila/cirurgia , Pessoa de Meia-Idade , Aparelhos Ortodônticos , Braquetes Ortodônticos , Fios Ortodônticos , Palato/cirurgia , Planejamento de Assistência ao Paciente , Estudos Prospectivos , Resultado do Tratamento
4.
Am J Orthod Dentofacial Orthop ; 156(2): 275-282, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31375238

RESUMO

This case report describes the interdisciplinary treatment of an ectopic horizontally placed maxillary right central incisor with severe root dilaceration. The root was distally angulated and entrapped by the root of the maxillary right lateral incisor. The initial force system was aimed at an occlusal displacement and applied to the crown. During the second phase, a button was cemented onto the apex of the impacted tooth. A force from the apex to a temporary anchorage device in the palate moved the root toward the midline. Finally, a root canal and an apectomy were performed and the central incisor could be moved to its ideal position. The treatment generated a normal height of the alveolar bone and an ideal occlusion with a healthy periodontium.


Assuntos
Incisivo/cirurgia , Técnicas de Movimentação Dentária/métodos , Raiz Dentária/cirurgia , Dente Impactado/cirurgia , Dente Impactado/terapia , Fenômenos Biomecânicos , Criança , Tomografia Computadorizada de Feixe Cônico/métodos , Cavidade Pulpar , Feminino , Humanos , Processamento de Imagem Assistida por Computador/métodos , Imagem Tridimensional , Má Oclusão de Angle Classe I/terapia , Maxila/anatomia & histologia , Maxila/diagnóstico por imagem , Maxila/cirurgia , Aparelhos Ortodônticos Fixos , Extrusão Ortodôntica/métodos , Planejamento de Assistência ao Paciente , Tratamento do Canal Radicular , Coroa do Dente , Dente Impactado/diagnóstico por imagem , Resultado do Tratamento
5.
Am J Orthod Dentofacial Orthop ; 156(1): 113-124, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31256824

RESUMO

Scissor bite often remains unnoticed by patients although it can adversely affect facial symmetry, jaw growth, and mastication. This case report illustrates the efficacy of temporary skeletal anchorage devices (TSADs) and a modified lingual arch in correcting severe scissor bite. A 28-year-old woman presented with severe scissor bite in the mandibular right posterior segment. To treat this condition, TSADs were used for maxillary posterior intrusion and a modified lingual arch for buccally uprighting mandibular posterior teeth. Long-term retention records demonstrate stable treatment results.


Assuntos
Oclusão Dentária , Má Oclusão de Angle Classe II/terapia , Má Oclusão de Angle Classe I/terapia , Ortodontia Corretiva/métodos , Adulto , Cefalometria/métodos , Modelos Dentários , Feminino , Humanos , Má Oclusão de Angle Classe I/diagnóstico por imagem , Má Oclusão de Angle Classe I/cirurgia , Má Oclusão de Angle Classe II/diagnóstico por imagem , Má Oclusão de Angle Classe II/cirurgia , Mandíbula/diagnóstico por imagem , Mandíbula/patologia , Mandíbula/cirurgia , Maxila/diagnóstico por imagem , Maxila/patologia , Maxila/cirurgia , Procedimentos de Ancoragem Ortodôntica/instrumentação , Procedimentos de Ancoragem Ortodôntica/métodos , Desenho de Aparelho Ortodôntico , Aparelhos Ortodônticos , Fios Ortodônticos , Ortodontia Corretiva/instrumentação , Técnica de Expansão Palatina , Planejamento de Assistência ao Paciente , Fatores de Tempo , Resultado do Tratamento
6.
Am J Orthod Dentofacial Orthop ; 156(1): 125-136, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31256825

RESUMO

This case report describes the successful treatment of a 14-year-old girl with severe bilateral idiopathic condylar resorption and resultant mandibular retrusion, increased overjet, and anterior open bite. The nonextraction treatment plan included (1) aligning and leveling the teeth in both arches, (2) performing Le Fort I maxillary osteotomy, bilateral condylectomy, and mandibular joint replacement, and (3) postsurgical correction of the malocclusion. The orthodontic treatment was initiated with the use of custom lingual appliances followed by orthognathic surgery planned with virtual surgical planning. Patient-fitted and customized temporomandibular joint implants were designed and manufactured based on the patient's stereolithic bone anatomic model. Treatment was concluded with detailed orthodontic finishing. Optimum esthetic and functional results were achieved with the cooperation of 2 specialties and the use of state-of-the-art technology.


Assuntos
Braquetes , Prótese Articular , Côndilo Mandibular/cirurgia , Mordida Aberta/cirurgia , Mordida Aberta/terapia , Ortodontia Corretiva/métodos , Procedimentos Cirúrgicos Ortognáticos/métodos , Transtornos da Articulação Temporomandibular/terapia , Adolescente , Pontos de Referência Anatômicos , Reabsorção Óssea/complicações , Reabsorção Óssea/diagnóstico por imagem , Reabsorção Óssea/cirurgia , Reabsorção Óssea/terapia , Cefalometria , Estética Dentária , Feminino , Humanos , Imagem Tridimensional , Mandíbula/cirurgia , Côndilo Mandibular/diagnóstico por imagem , Maxila/cirurgia , Mordida Aberta/diagnóstico por imagem , Aparelhos Ortodônticos , Aparelhos Ortodônticos Fixos , Ortodontia Corretiva/instrumentação , Osteotomia , Planejamento de Assistência ao Paciente , Radiografia Panorâmica , Articulação Temporomandibular/diagnóstico por imagem , Articulação Temporomandibular/cirurgia , Transtornos da Articulação Temporomandibular/complicações , Transtornos da Articulação Temporomandibular/diagnóstico por imagem , Transtornos da Articulação Temporomandibular/cirurgia , Resultado do Tratamento
7.
Am J Orthod Dentofacial Orthop ; 156(1): 148-156, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31256828

RESUMO

This article reports on the technical aspects of using a computer-aided design-computer-aided manufacturing (CAD-CAM) insertion guide for the placement of orthodontic mini-implants used for the purpose of providing anchorage support for maxillary molar distalization. A 10-year-old girl presented with a bilateral full-step Angle Class II molar relationship in the permanent dentition, with anterior arch-length insufficiency and blocked out maxillary canine teeth. The primary treatment objective was to provide an esthetic and functional occlusal outcome, and secondarily to avoid the removal of multiple premolar teeth. The patient was initially treated with an implant-supported distalization device, and the occlusion was subsequently detailed with preadjusted fixed orthodontic appliances. The CAD-CAM procedure facilitates the safe and precise insertion of mini-implants in the anterior palate, potentially broadening the scope of use of palatal mini-implants for less experienced clinicians. The illustrated protocol allows for the insertion of mini-implants and fitting of a prefabricated appliance in a single office appointment.


Assuntos
Parafusos Ósseos , Projeto Auxiliado por Computador , Implantes Dentários , Má Oclusão de Angle Classe II/terapia , Procedimentos de Ancoragem Ortodôntica/métodos , Desenho de Aparelho Ortodôntico/métodos , Técnicas de Movimentação Dentária/métodos , Dente Pré-Molar , Cefalometria/métodos , Criança , Dente Canino , Modelos Dentários , Dentição Permanente , Estética Dentária , Feminino , Humanos , Má Oclusão de Angle Classe II/diagnóstico por imagem , Má Oclusão de Angle Classe II/cirurgia , Maxila/diagnóstico por imagem , Maxila/cirurgia , Dente Molar , Procedimentos de Ancoragem Ortodôntica/instrumentação , Desenho de Aparelho Ortodôntico/instrumentação , Aparelhos Ortodônticos Fixos , Fios Ortodônticos , Palato/diagnóstico por imagem , Palato/cirurgia , Planejamento de Assistência ao Paciente , Técnicas de Movimentação Dentária/instrumentação , Resultado do Tratamento
8.
Lancet ; 394(10193): 160-172, 2019 07 13.
Artigo em Inglês | MEDLINE | ID: mdl-31305254

RESUMO

Adult spinal deformity affects the thoracic or thoracolumbar spine throughout the ageing process. Although adolescent spinal deformities taken into adulthood are not uncommon, the most usual causes of spinal deformity in adults are iatrogenic flatback and degenerative scoliosis. Given its prevalence in the expanding portion of the global population aged older than 65 years, the disorder is of growing interest in health care. Physical examination, with a focus on gait and posture, along with radiographical assessment are primarily used and integrated with risk stratification indices to establish optimal treatment planning. Although non-operative treatment is regarded as the first-line response, surgical outcomes are considerably favourable. Global disparities exist in both the assessment and treatment of adults with spinal deformity across countries of varying incomes, which represents an area requiring further investigation. This Seminar presents evidence and knowledge that represent the evolution of data related to spinal deformity in adults over the past several decades.


Assuntos
Vértebras Lombares/anormalidades , Curvaturas da Coluna Vertebral , Vértebras Torácicas/anormalidades , Adulto , Efeitos Psicossociais da Doença , Humanos , Planejamento de Assistência ao Paciente , Exame Físico , Radiografia , Medição de Risco , Curvaturas da Coluna Vertebral/diagnóstico por imagem , Curvaturas da Coluna Vertebral/epidemiologia , Curvaturas da Coluna Vertebral/psicologia , Curvaturas da Coluna Vertebral/terapia , Resultado do Tratamento
9.
Stud Health Technol Inform ; 262: 388-391, 2019 Jul 04.
Artigo em Inglês | MEDLINE | ID: mdl-31349249

RESUMO

C3-Cloud is a project aiming to provide an ICT infrastructure, which will allow patient centric and integrated care, based on best practice guideline, for patients with multi-morbidity. Clinical Decision Support, by checking the patient's record for known adverse interactions when the medication changes. The drug interaction advisory service provides recommendations in the three languages used in the project's pilot sites, for over 1000 substances, based on the UK's NICE BNF body of knowledge.


Assuntos
Sistemas de Apoio a Decisões Clínicas , Interações de Medicamentos , Consultores , Humanos , Planejamento de Assistência ao Paciente
10.
Medicine (Baltimore) ; 98(29): e16447, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31335699

RESUMO

To evaluate readout-segmented echoplanar (rsEPI) diffusion weighted imaging (DWI) for multiparametric (mp) magnetic resonance imaging (MRI) of the prostate compared to the established single-shot echoplanar imaging (ssEPI) sequence.One hundred ten consecutive patients with clinical suspicion of prostate cancer underwent mp prostate MRI using both, the ssEPI and the rsEPI DWI sequence. For an objective assessment, delineation of the prostate shape on both DWI sequences was compared to T2-weighted images by measuring organ diameters. Apparent diffusion coefficient (ADC) values, image contrast and contrast-to-noise ratio (CNR) were compared between the 2 sequences on a region-of-interest-based analysis. Diagnostic accuracy for quantitative ADC-values was calculated. Histopathology from MRI/ultrasound fusion-guided biopsy was used as reference standard. For a subjective assessment, 2 independent readers visually assessed image quality of both sequences using Likert-scales.Delineation of the prostate shape was more accurate with rsEPI compared to ssEPI. ADC values in target lesions were not significantly different but significantly higher in the surrounding normal prostatic tissue of the transition zone. CNR was comparable between ssEPI and rsEPI. Sensitivity and specificity were good for both sequences with 84/84% and 82/73% with a Youden selected cut-off of ADC = 0.971*10 mm/s for rsEPI and 1.017*10 mm/s for ssEPI. Anatomic artifacts were significantly less and SNR was lower on rsEPI compared to ssEPI in the subjective analysis.Delineation of the prostate shape was more accurate with rsEPI DWI than with ssEPI DWI with less anatomic artifacts and higher subjective SNR and image quality on rsEPI DW images. Diagnostic ability of quantitative ADC-values was not significantly different between the 2 sequences. Thus, rsEPI DWI might be more suitable for prostate MRI with regard to MRI-guided targeted biopsy and therapy planning.


Assuntos
Imagem de Difusão por Ressonância Magnética/métodos , Imagem Ecoplanar/métodos , Próstata , Neoplasias da Próstata , Idoso , Pesquisa Comparativa da Efetividade , Precisão da Medição Dimensional , Humanos , Biópsia Guiada por Imagem/métodos , Masculino , Pessoa de Meia-Idade , Tamanho do Órgão , Planejamento de Assistência ao Paciente , Próstata/diagnóstico por imagem , Próstata/patologia , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/patologia , Reprodutibilidade dos Testes
11.
Tech Vasc Interv Radiol ; 22(2): 58-62, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31079711

RESUMO

Treatment paradigms for primary and metastatic malignancies involving the liver have evolved in recent years to include targeted liver therapies. Transarterial radioembolization is at the forefront of therapy in many treatment algorithms. However, due to significant hepatopulmonary shunting, some patients are excluded from this proven treatment due to the possibility of radiation-induced lung injury. In this article, we review techniques to mitigate hepatopulmonary shunts to improve the likelihood of inclusion and successful treatment in these patients.


Assuntos
Embolização Terapêutica/métodos , Síndrome Hepatopulmonar/prevenção & controle , Neoplasias Hepáticas/radioterapia , Lesões por Radiação/prevenção & controle , Radioisótopos de Ítrio/uso terapêutico , Humanos , Neoplasias Hepáticas/diagnóstico por imagem , Microesferas , Planejamento de Assistência ao Paciente , Seleção de Pacientes , Dosagem Radioterapêutica
12.
Diabetes Res Clin Pract ; 152: 96-102, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31108139

RESUMO

AIMS: Hyperglycemia is the major factor underlying vascular complications of diabetes. Unfortunately, improved glycemia control is frequently accompanied by an increased risk of hypoglycemia. The aim of the study was to assess the relationship between hemoglobin A1c (HbA1c) and 1-week Continuous Glucose Monitoring (CGM) data in long-standing type 1 diabetes (T1DM). METHODS: We recruited 58 subjects with long-standing T1DM consecutively enrolled to the study. Each patient underwent a 1-week CGM and laboratory profile at baseline. Subjects were divided into three subgroups according to baseline HbA1c tertiles: T1 < 7.1%, T2 = 7.1-8.0%, and T3 > 8.0%. RESULTS: T1 patients were characterized by the longest time in range (66% of a week), whereas T3 patients experienced hyperglycemia in >50% time of the week. T1 patients were noted to have 25% of nighttime with glycemia <3.9 mmol/L (8% with glycemia <2.8 mmol/L). Most recent HbA1c closely reflected 10-years mean HbA1c values (R = 0.83; P < 0.0001). CONCLUSIONS: (1) Long-term diabetes control (10 years HbA1c mean) is a strong predictor of the current HbA1c levels. (2) Current and historical HbA1c levels are closely linked to CGM-derived glycemia. (3) Risk of clinically significant hypoglycemia negatively correlates with HbA1c. (4) HbA1c > 8.0% is associated with unsatisfactorily low (44%) time in range.


Assuntos
Glicemia/análise , Diabetes Mellitus Tipo 1/sangue , Hemoglobina A Glicada/metabolismo , Hipoglicemia/sangue , Adulto , Idoso , Glicemia/metabolismo , Automonitorização da Glicemia , Doenças Cardiovasculares/sangue , Doenças Cardiovasculares/etiologia , Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 1/patologia , Angiopatias Diabéticas/sangue , Testes Diagnósticos de Rotina , Progressão da Doença , Feminino , Seguimentos , Hemoglobina A Glicada/análise , Humanos , Hipoglicemia/diagnóstico , Hipoglicemia/etiologia , Masculino , Pessoa de Meia-Idade , Planejamento de Assistência ao Paciente , Fatores de Risco , Fatores de Tempo
13.
Clin Podiatr Med Surg ; 36(3): 483-498, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31079612

RESUMO

Amputations distal to the ankle joint are commonly performed in efforts to preserve a limb. Thorough examination of lower extremity biomechanics, patient functional status, and patient goals must be used to help prevent reulceration and further amputation. Once infection is resolved in the acute setting, musculotendon balancing should be considered at the time of amputation closure to maintain functionality of the limb. Patients should be closely followed postoperatively and monitored for biomechanical deformity that needs to be addressed. Careful attention to detail and adherence to surgical principles can help keep patients active and prevent further amputation.


Assuntos
Amputação , Pé/cirurgia , Amputação/métodos , Órtoses do Pé , Humanos , Salvamento de Membro , Osteomielite/cirurgia , Planejamento de Assistência ao Paciente , Equipe de Assistência ao Paciente , Prognóstico , Infecções dos Tecidos Moles/cirurgia , Sobrevivência de Tecidos
14.
Curr Opin Anaesthesiol ; 32(3): 278-284, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31045634

RESUMO

PURPOSE OF REVIEW: Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality in the United States, and worldwide. Recognition of PPH is challenging, but once hemorrhage is recognized, management needs to focus on achieving adequate uterine tone and maintaining maternal hemodynamic stability. There have been several advances in the management of postpartum hemorrhage, many of which can be implemented at the labor and delivery unit level. RECENT FINDINGS: There have been many advances in the understanding of at-risk parturients, and the use of hemorrhage protocols and safety bundles have been shown to improve patient outcomes. There are many new advances in transfusion management (e.g. fibrinogen concentrate, prothrombin complex concentrate, tranexamic acid) that can compliment traditional component therapy. Consideration should be given to transferring women at high risk for complications (e.g. invasive placentation) to a higher level facility for delivery. SUMMARY: Although postpartum hemorrhage itself may not be preventable, early identification of blood loss, and mobilization of resources may prevent adverse outcomes. Multidisciplinary planning at the system level, ensuring that hemorrhage protocols exist, as well as for management of high-risk patients is important for improving patient outcomes.


Assuntos
Transfusão de Sangue/métodos , Planejamento de Assistência ao Paciente/organização & administração , Hemorragia Pós-Parto/diagnóstico , Gravidez de Alto Risco , Feminino , Humanos , Mortalidade , Equipe de Assistência ao Paciente/organização & administração , Hemorragia Pós-Parto/epidemiologia , Hemorragia Pós-Parto/terapia , Gravidez
15.
Curr Opin Anaesthesiol ; 32(3): 291-297, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31045636

RESUMO

PURPOSE OF REVIEW: The aim of this study was to review the current literature on anesthesia for predelivery procedures and to summarize recent findings on anesthesiological methods used. RECENT FINDINGS: Ex-utero intrapartum treatment (EXIT)-procedures are performed to secure the newborn's oxygenation in case of severe airway obstruction due to multiple conditions. A key feature of EXIT is continued intactness of the maternofetal circulation by uterine relaxation achieved by general anesthesia with high doses of anesthetic gases. A dose reduction may be achieved by combining inhaled anesthesia with propofol. After intrauterine transfusion the anesthesia team needs to be prepared for a potential need of emergency cesarean section. Temporary fetal endoluminal tracheal occlusion and laser coagulation for twin-to-twin transfusion syndrome may be either performed in monitored anesthesia care or neuraxial anesthesia. Neuraxial anesthesia also is a method of choice for fetal valvuloplasty and amniotic band release. Fetal myelomenigocele repair requires general anesthesia with tocolysis. SUMMARY: Predelivery procedures require a differentiated anesthesia approach depending on the invasiveness of the intervention. Anesthesia ranges from monitored care to neuraxial anesthesia and general anesthesia. Depending on the procedure uterine relaxation and fetal immobilization are crucial for technical success. Interdisciplinary consultation optimizes the anesthesia plan for complex procedures.


Assuntos
Anestesia Geral/métodos , Anestésicos Inalatórios/administração & dosagem , Doenças Fetais/terapia , Terapias Fetais/métodos , Bloqueio Nervoso/métodos , Obstrução das Vias Respiratórias/complicações , Anestesia Geral/efeitos adversos , Relação Dose-Resposta a Droga , Feminino , Doenças Fetais/etiologia , Terapias Fetais/efeitos adversos , Humanos , Planejamento de Assistência ao Paciente/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Circulação Placentária , Gravidez
16.
Plast Reconstr Surg ; 143(5): 1027e-1036e, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31033828

RESUMO

BACKGROUND: Three-dimensional surgical planning for orthognathic surgery is becoming prevalent, with improving outcomes. However, conventional dental casts are still used for evaluations, digital image conversion, surgical planning, and occlusal splint production. This study used intraoral scanning for the three-dimensional planning of the final digital occlusion and compared this method with the conventional dental cast approach. METHODS: Thirty consecutive patients who underwent two-jaw orthognathic surgery to treat mandibular prognathism and asymmetry were included. Dental casts (control group) and intraoral scans (study group) were collected simultaneously for designing the final dental occlusion. A step-by-step setup of the final digital occlusion was established for the study group. To validate results, the intraoral scanning-based virtual occlusion was superimposed over the dental model-based final digital occlusion for comparison. Intraobserver and interobserver variability were assessed for setting up the final digital occlusion. The fitness of splints fabricated using the conventional and virtual occlusion methods were compared. RESULTS: The steps for setting up the final digital occlusion were applicable in all cases. The average root-mean-square difference of final occlusion images between the two groups was 0.45 mm, indicating a comparable occlusal relationship. The intraobserver reproducibility and interobserver reliability for setting up the virtual occlusion were satisfactory. Moreover, no significant difference existed in the splint fitness test between the groups. CONCLUSIONS: The proposed intraoral scan and setup process of the final digital occlusion was reliable and accurate. Thus, the method can replace the dental model approach for the three-dimensional planning of orthognathic surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.


Assuntos
Tomografia Computadorizada de Feixe Cônico/métodos , Imagem Tridimensional/métodos , Má Oclusão de Angle Classe III/cirurgia , Procedimentos Cirúrgicos Ortognáticos/métodos , Planejamento de Assistência ao Paciente , Adulto , Cefalometria/métodos , Modelos Dentários , Estudos de Viabilidade , Feminino , Humanos , Masculino , Má Oclusão de Angle Classe III/diagnóstico por imagem , Placas Oclusais , Procedimentos Cirúrgicos Ortognáticos/instrumentação , Impressão Tridimensional , Reprodutibilidade dos Testes , Adulto Jovem
17.
Plast Reconstr Surg ; 143(5): 1053e-1059e, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31033831

RESUMO

BACKGROUND: Complete reoperation is defined as undergoing reoperative/repeated jaw osteotomies, in a patient who previously underwent orthognathic surgery. The purpose of this study is to (1) describe jaw positions at three time-points (before primary and before and after reoperative surgery), (2) investigate factors necessitating reoperation, and (3) outline the technical challenges. METHODS: Repeated orthognathic surgery cases >1-year out were included. Demographic, radiologic, and perioperative data were compiled. Repeated osteotomies (Le-Fort and/or bilateral split sagittal osteotomy, with or without genioplasty), were compared to their respective primary procedures. Statistical analysis was performed using t tests and z-scores. RESULTS: Fifteen patients were included (28.1 years; 71 percent female). Reoperative/repeated surgery was most often needed to address iatrogenic bony malposition and asymmetry. Relapse was a less common indication. Time between reoperative and primary surgery was 14 months. Sagittal discrepancies (p = 0.029) were the most frequent reason for primary orthognathic surgery (e.g., mandibular hypoplasia (p = 0.023). Reoperative/repeated orthognathic was performed for asymmetry (p = 0.014). Repeated procedures used more 3-dimensional planning (p < 0.001), required all three osteotomies (p = 0.034), had longer operative times (p = 0.078), and all required hardware removal (p < 0.001). Anatomical outcomes were good with 100% patient satisfaction at long-term follow-up. CONCLUSIONS: Reoperative/repeated orthognathic surgery is challenging and underreported in the literature. Whereas primary orthognathic typically addressed sagittal discrepancies, reoperative/repeated osteotomies were needed to correct iatrogenic bone malposition and asymmetries. Challenges include: re-planning, scar burden, need to remove integrated hardware, and repeated osteotomy/fixation. Despite these difficulties, outcomes and patient acceptance were good. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.


Assuntos
Mentoplastia/estatística & dados numéricos , Doenças Maxilomandibulares/cirurgia , Osteotomia de Le Fort/estatística & dados numéricos , Reoperação/estatística & dados numéricos , Adulto , Feminino , Seguimentos , Mentoplastia/métodos , Humanos , Imagem Tridimensional , Doenças Maxilomandibulares/diagnóstico por imagem , Masculino , Duração da Cirurgia , Osteotomia de Le Fort/métodos , Planejamento de Assistência ao Paciente , Recidiva , Reoperação/métodos , Estudos Retrospectivos , Resultado do Tratamento
18.
HNO ; 67(5): 326-333, 2019 May.
Artigo em Alemão | MEDLINE | ID: mdl-31001683

RESUMO

At the center of digital ENT surgery are four primary technological developments: in addition to the potential of a digitalized operating room (OR), these are modern navigation approaches, planning software, and robotics-based assistance systems. In the OR of the future, not only will data enrichment and information integration play a role, but so will the incorporation of high-tech medical devices. Their use and the information they generate are simplified, while at the same time, further clinical data are optimized before, during, and after the surgical procedure. Specially designed intuitive user interfaces, automated workflows, and advanced imaging techniques allow the full potential of diagnostic, surgical, and postoperative patient data to be exploited. New surgical planning technology helps ENT surgeons to more easily evaluate complex anatomical structures and more accurately and quickly diagnose conditions. Based on an adaptable anatomical software model, a multitude of anatomical structures can be identified and segmented as objects. The high accuracy and consistency of identification of these objects make segmentation an integral part of precise treatment planning. With modern planning software, in 3D patient images, tumors and structures at risk can be accurately contoured, trajectories planned, and CT and MR images fused and subsequently easily accessed in the OR for further use. This serves as a guide during surgery and ultimately results in improved patient safety and more efficient routine clinical workflows.


Assuntos
Salas Cirúrgicas , Planejamento de Assistência ao Paciente , Cirurgia Assistida por Computador , Comunicação , Humanos , Imagem Tridimensional , Software
19.
J Plast Surg Hand Surg ; 53(4): 189-197, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30977713

RESUMO

The 'Danish Scale' (DS) is a visual rating scale of massive weight loss body contour deformities and excessive skin in female MWL-patients with current BMI < 30 kg/m2 and massive weight loss defined as BMI loss (delta-BMI) > 15 kg/m2, regardless of weight loss method. The scope of the scale is to simplify the reporting of objective findings by a three-step grading of minor, moderate and severe body contour changes in six different body regions: breasts, abdomen, upper back, buttocks, arms and legs. The DS is presented with descriptions of the conceptualization and construct of the scale. It provides a new visual reference tool for indications and preoperative planning in MWL body contouring, that is specific for the post-MWL BMI-range between 21 and 30 kg/m2 and, at the same time, simpler than previous scales. The scale combines evaluations of different and adjacent body regions in a simple manner and presents modern cut-off points for health insurance reimbursement for MWL body contouring as offered in the Danish public health care system. The DS was developed by repeat expert discussions until final nationwide consensus was reached and can act as an adjunct to the written guidelines by the National Board of Health in Denmark.


Assuntos
Contorno Corporal , Tomada de Decisão Clínica , Perda de Peso , Adulto , Cirurgia Bariátrica , Dinamarca , Feminino , Humanos , Pessoa de Meia-Idade , Planejamento de Assistência ao Paciente , Fotografação , Cuidados Pré-Operatórios
20.
Ear Nose Throat J ; 98(3): 158-164, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30938238

RESUMO

The objective of our study is to assess the impact of equivocal or positive positron emission tomography combined with low-dose noncontrast computed tomography (PET/CT) findings in the chest on treatment for head and neck cancer (HNC). We reviewed charts of patients presented at Augusta University's Head and Neck Tumor Board (AUTB) between 2013 and 2016 with the following exclusion criteria: <18 years, Veterans Affairs patients, those with incomplete data, and those without a history of head and neck squamous cell carcinoma. The lung/thorax sections of the radiologists' PET/CT reports were graded as "Positive, Equivocal, or Negative" for chest metastases. Patients who underwent workup for suspected chest metastases were assessed for treatment delays, changes in treatment plans, and complications. In addition, we evaluated the time between AUTB presentation and peri-treatment PET/CT to primary treatment initiation were calculated between groups. There was a total of 363 patients with PET/CT prior to treatment, the read was "Negative" in 71.3% (n = 259), "Equivocal" in 20.9% (n = 76), and "Positive" in 5.8% (n = 21). Of 272 patients with complete treatment data, 22 underwent workup for suspected chest metastases. Mean time from PET/CT to treatment initiation was 27.5 days without workup and 64.9 days with workup ( P < .0001), and from AUTB presentation was 29.1 days without workup and 62.5 days with workup ( P < .0001). Five (19.2%) patients experienced a complication from workup. Twenty (76.9%) patients had no changes in their treatment plan after workup. In conclusion, our results for potential chest metastases on PET/CT in patients with HNC are often not clear-cut. Workup of suspected chest metastasis based on PET/CT findings significantly delays primary treatment initiation and may cause serious complications.


Assuntos
Carcinoma de Células Escamosas , Neoplasias de Cabeça e Pescoço , Planejamento de Assistência ao Paciente/estatística & dados numéricos , Tomografia Computadorizada com Tomografia por Emissão de Pósitrons/métodos , Neoplasias Torácicas , Tórax/diagnóstico por imagem , Tempo para o Tratamento/estatística & dados numéricos , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/terapia , Feminino , Fluordesoxiglucose F18/farmacologia , Neoplasias de Cabeça e Pescoço/patologia , Neoplasias de Cabeça e Pescoço/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Metástase Neoplásica/diagnóstico por imagem , Estadiamento de Neoplasias , Compostos Radiofarmacêuticos/farmacologia , Neoplasias Torácicas/diagnóstico , Neoplasias Torácicas/secundário , Neoplasias Torácicas/terapia , Estados Unidos
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