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1.
Med Clin North Am ; 104(2): 279-292, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32035569

RESUMO

Neck pain is the fourth leading cause of disability. Acute neck pain largely resolves within 2 months. History and physical examination play a key role in ruling out some of the more serious causes for neck pain. The evidence for pharmacologic interventions for acute and chronic musculoskeletal neck pain is limited. Lower back pain is the leading cause of disability and productivity loss. Consultation with a physical medicine and rehabilitation spine specialist within 48 hours for acute pain and within 10 days for all patients with lower back pain may significantly decrease rate of surgical interventions and increase patient satisfaction.


Assuntos
Dor Lombar , Cervicalgia , Administração dos Cuidados ao Paciente/métodos , Humanos , Dor Lombar/diagnóstico , Dor Lombar/terapia , Cervicalgia/diagnóstico , Cervicalgia/terapia , Prognóstico , Tempo para o Tratamento
2.
Isr Med Assoc J ; 22(2): 83-88, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32043324

RESUMO

BACKGROUND: Rapid and selective bromelain-based enzymatic debridement provides a non-surgical alternative for the eschar removal in deep burns, which allows for early debridement of large surface areas, accurate evaluation of burn and wound depth, and the need for skin grafting. OBJECTIVES: To evaluate the efficacy of application of a bromelain-based selective enzymatic debridement (Nexobrid®) beyond the manufacturer's guidelines for use in burns > 48 hours as well as chemical, electrical, and pediatric burns, and chronic wounds. METHODS: This retrospective review included records collected between January 2017 and April 2019, from male and female patients aged 8 months to 99 years with deep burns or wounds treated with bromelain-based selective enzymatic debridement. RESULTS: Of the 33 patients who received the bromelain-based selective enzymatic debridement agent beyond the manufacturer's guidelines, 25 (76%) were observed to have successful debridement of the eschar, 8 (24%) were observed to have little effect on the burn eschar. Sixteen required further surgery after debridement. Clinical data on the use of bromelain-based selective enzymatic debridement agents are limited, but these results suggest the capacity to effectively debride burns > 48 hours (late presentation burns), use for pediatrics and for chemical and electrical burns, and apply to hard to heal full thickness chronic wounds. CONCLUSIONS: Bromelain-based selective enzymatic debridement was found to be an effective treatment modality beyond the recommended guidelines including late presentation burns and chronic wounds. This debridement method warrants further consideration when making clinical decisions concerning burn and wound care.


Assuntos
Bromelaínas/administração & dosagem , Queimaduras , Terapia Enzimática/métodos , Cicatrização/efeitos dos fármacos , Ferimentos e Lesões , Administração Tópica , Adulto , Queimaduras/diagnóstico , Queimaduras/terapia , Monitoramento de Medicamentos/métodos , Feminino , Humanos , Masculino , Estudos Retrospectivos , Tempo para o Tratamento , Índices de Gravidade do Trauma , Resultado do Tratamento , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/terapia
3.
Emergencias (Sant Vicenç dels Horts) ; 32(1): 33-39, feb. 2020. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-185851

RESUMO

Objetivo. Identificar los factores asociados con una respuesta inicial inmediata a los síntomas en los pacientes que han padecido un ictus isquémico. Método. Estudio observacional transversal en el que se incluyeron a todos los pacientes con ictus isquémico ingresados de forma consecutiva en el Hospital Universitario de Burgos (España) durante 1 año. Se recogieron parámetros sociodemográficos, clínicos, conductuales, cognitivos y contextuales, y se estudió su posible relación con el tiempo de reacción del paciente (TR) mediante análisis univariante y multivariante. Resultados. Se incluyeron 425 pacientes (mediana del TR de 140 minutos). El TR supuso un 72,6% del tiempo prehospitalario total (TPH), con una respuesta inmediata si el paciente se encontraba acompañado (OR 9,57; IC95% 3,89-23,52), si los síntomas se iniciaban durante el día (OR 8,77; 3,40-22,63), si el paciente sabía cómo actuar ante un posible ictus (OR 3,84; 2,77-7,09), si el primer contacto médico era con el servicio de emergencias médicas (SEM) (OR 3,03; 1,62-5,68), si el paciente percibía la situación como grave o muy grave (OR 2,38; 1,17-4,83) o si el ictus ocurría en el ámbito urbano (OR 2,17; 1,16-4,06). Conclusión. El intervalo de tiempo entre el inicio de los síntomas y la respuesta inicial del paciente se relaciona con factores conductuales, cognitivos y contextuales, los cuales deberían ser considerados en la planificación de futuras campañas educacionales


Objective. To identify factors related to a rapid response to the onset of symptoms and a call for help for patients with ischemic stroke. Methods. Observational cross-sectional study of all patients with ischemic stroke admitted consecutively to Hospital Universitario de Burgos in Spain during 1 year. We collected sociodemographic, clinical, behavioral, cognitive, and contextual data for all patients and applied uni- and multivariate analysis to explore possible associations with the patient's response time. Results. A total of 425 patients were included. The mean patient response time was 140.00 minutes. Patient delay accounted for 72.6% of the total prehospital response time. Factors associated with a rapid call for help were the presence of an accompanying person (OR, 9.57; 95% CI, 3.89-23.52), daytime onset of symptoms (OR, 8.77; 3.40-22.63), patient knowledge of how to act in case of stroke symptoms (OR, 3.84; 2.77-7.09), first medical contact through the public health system's emergency medical service (OR, 3.03; 1.62-5.68), patient perception of symptoms as severe or very severe (OR, 2.38; 1.17-4.83), and stroke onset in an urban area (OR, 2.17; 1.16-4.06). Conclusions. The patient's response time between onset of symptoms is related to behavioral, cognitive and contextual factors that should be taken into account when planning future patient education campaigns


Assuntos
Humanos , Masculino , Feminino , Idoso , Acidente Vascular Cerebral/epidemiologia , Isquemia Encefálica/complicações , Fatores de Tempo , Tempo para o Tratamento , Estudos Transversais , Análise Multivariada , Assistência Pré-Hospitalar/estatística & dados numéricos , Comportamento de Busca de Ajuda
4.
Bone Joint J ; 102-B(1): 72-81, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31888363

RESUMO

AIMS: The early mortality in patients with hip fractures from bony metastases is unknown. The objectives of this study were to quantify 30- and 90-day mortality in patients with proximal femoral metastases, and to create a mortality prediction tool based on biomarkers associated with early death. METHODS: This was a retrospective cohort study of consecutive patients referred to the orthopaedic department at a UK trauma centre with a proximal femoral metastasis (PFM) over a seven-year period (2010 to 2016). The study group were compared to a matched control group of non-metastatic hip fractures. Minimum follow-up was one year. RESULTS: There was a 90-day mortality of 46% in patients with metastatic hip fractures versus 12% in controls (89/195 and 24/192, respectively; p < 0.001). Mean time to surgery was longer in symptomatic metastases versus complete fractures (9.5 days (SD 19.8) and 3.4 days (SD 11.4), respectively; p < 0.05). Albumin, urea, and corrected calcium were all independent predictors of early mortality and were used to generate a simple tool for predicting 90-day mortality, titled the Metastatic Early Prognostic (MEP) score. An MEP score of 0 was associated with the lowest risk of death at 30 days (14%, 3/21), 90 days (19%, 4/21), and one year (62%, 13/21). MEP scores of 3/4 were associated with the highest risk of death at 30 days (56%, 5/9), 90 days (100%, 9/9), and one year (100%, 9/9). Neither age nor primary cancer diagnosis was an independent predictor of mortality at 30 and 90 days. CONCLUSION: This score could be used to predict early mortality and guide perioperative counselling. The delay to surgery identifies a potential window to intervene and correct these abnormalities with the aim of improving survival. Cite this article: Bone Joint J. 2020;102-B(1):72-81.


Assuntos
Neoplasias Femorais/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores Tumorais/metabolismo , Estudos de Casos e Controles , Feminino , Neoplasias Femorais/secundário , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Escócia/epidemiologia , Índice de Gravidade de Doença , Análise de Sobrevida , Tempo para o Tratamento
5.
Zhonghua Yu Fang Yi Xue Za Zhi ; 54(1): 69-75, 2020 Jan 06.
Artigo em Chinês | MEDLINE | ID: mdl-31914572

RESUMO

Objective: To understand the consciousness of the cancer early treatment and its demographic and socioeconomic factors. Methods: A cross-sectional survey was conducted in 16 provinces covered by the Cancer Screening Program in Urban China (CanSPUC) from 2015 to 2017. A total of 32 257 local residents aged ≥18 years old who could understand the investigation procedure were included in the study by using the cluster sampling method and convenient sampling method. All local residents were categorized into four groups, which contained 15 524 community residents, 8 016 cancer risk assessment/screening population, 2 289 cancer patients and 6 428 occupational population, respectively. The questionnaire collected personal information, the consciousness of the cancer early treatment and relevant factors. The Chi square test was used to compare the difference between the consciousness of the cancer early treatment and relevant factors among the four groups. The logistic regression model was used to analyze the influencing factors related to the consciousness of the cancer early treatment. Results: With the assumption of being diagnosed as precancer or cancer, 89.97% of community residents, 91.84% of cancer risk assessment/screening population, 93.00% of cancer patients and 91.52% of occupational population would accept active treatments (P<0.001). If the immediate family members were diagnosed as precancer or cancer, people who would encourage their family members to receive early treatment in the four groups accounted for 91.96%, 91.94%, 92.44% and 91.55%, respectively (P<0.001). The company employees, annual household income with 40 000 yuan and more and other three groups had a relatively better consciousness of the cancer early treatment (P<0.05). Male, widowed, unemployed and from the central and western regions had a relatively worse consciousness of the cancer early treatment (P<0.05). Conclusion: Residents in urban China participants had a good consciousness of the cancer early treatment. The marital status, occupation, annual household income and residential regions were major factors related to the consciousness of the cancer early treatment.


Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Neoplasias/terapia , Tempo para o Tratamento/estatística & dados numéricos , População Urbana , Adolescente , Adulto , China , Estudos Transversais , Feminino , Humanos , Masculino , Fatores Socioeconômicos , População Urbana/estatística & dados numéricos
6.
J Surg Oncol ; 121(3): 486-493, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31919862

RESUMO

BACKGROUND: Chemotherapy improves outcomes in patients with resectable gastric cancer. Minimally invasive gastrectomy (MIS) rates are increasing, though the impact of MIS on postoperative chemotherapy remains uncertain. This study examines the impact of MIS vs open gastrectomy (OG) on utilization of adjuvant chemotherapy for high-risk gastric cancer. METHODS: Patients in the National Cancer Database who underwent resection for high-risk gastric adenocarcinoma between 2010 and 2015 were included. Patients were stratified by surgical approach (MIS vs OG) and analyzed using multivariable regression modeling. Primary endpoints were utilization of and time to initiation of adjuvant chemotherapy. RESULTS: Overall, 23 071 patients were included; 16 595 (71.9%) underwent OG and 6476 (28.1%) underwent MIS. After adjusting for patient and tumor characteristics, MIS was not associated with increased use of adjuvant chemotherapy (odds ratio [OR]: 1.027, 95% confidence interval [CI]: 0.95 to 1.11, P = .50), and time to initiation of chemotherapy was similar (-2% change, 95% CI: -5% to +1%, P = .27). MIS was associated with shorter hospital stays (-1 day). Thirty-day readmission rates, 90-day mortality, and overall survival were similar between groups. CONCLUSIONS: In this study, while MIS for gastric adenocarcinoma was associated with shorter hospital stays and comparable survival, it was not associated with improved utilization or time to initiation of adjuvant chemotherapy.


Assuntos
Adenocarcinoma/mortalidade , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Quimioterapia Adjuvante/mortalidade , Gastrectomia/mortalidade , Procedimentos Cirúrgicos Minimamente Invasivos/mortalidade , Neoplasias Gástricas/mortalidade , Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/patologia , Adenocarcinoma/cirurgia , Idoso , Feminino , Seguimentos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Neoplasias Gástricas/tratamento farmacológico , Neoplasias Gástricas/patologia , Neoplasias Gástricas/cirurgia , Taxa de Sobrevida , Fatores de Tempo , Tempo para o Tratamento
8.
Bone Joint J ; 102-B(1): 33-41, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31888365

RESUMO

AIMS: The aim of this study was to explore whether time to surgery affects functional outcome in displaced proximal humeral fractures. METHODS: A total of 250 patients presenting within three weeks of sustaining a displaced proximal humeral fracture involving the surgical neck were recruited at 32 acute NHS hospitals in the United Kingdom between September 2008 and April 2011. Of the 125 participants, 109 received surgery (fracture fixation or humeral head replacement) as per randomization. Data were included for 101 and 67 participants at six-month and five-year follow-up, respectively. Oxford Shoulder Scores (OSS) collected at six, 12, and 24 months and at three, four, and five years following randomization was plotted against time to surgery. Long-term recovery was explored by plotting six-month scores against five-year scores and agreement was illustrated with a Bland-Altman plot. RESULTS: The mean time from initial trauma to surgery was 10.5 days (1 to 33). Earlier surgical intervention did not improve OSS throughout follow-up, nor when stratified by participant age (< 65 years vs ≥ 65 years) and fracture severity (one- and two-part vs three- and four-part fractures). Participants managed later than reported international averages (three days in the United States and Germany, eight days in the United Kingdom) did not have worse outcomes. At five-year follow-up, 50 participants (76%) had the same or improved OSS compared with six months (six-month mean OSS 35.8 (SD 10.0); five-year mean OSS 40.1 (SD 9.1); r = 0.613). A Bland-Altman plot demonstrated a positive mean difference (3.3 OSS points (SD 7.92)) with wide 95% limits of agreement (-12.2 and 18.8 points). CONCLUSION: Timing of surgery did not affect OSS at any stage of follow-up, irrespective of age or fracture type. Most participants had maximum functional outcome at six months that was maintained at five years. These findings may help guide providers of trauma services on surgical prioritization. Cite this article: Bone Joint J 2020;102-B(1):33-41.


Assuntos
Fraturas do Ombro/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/estatística & dados numéricos , Feminino , Seguimentos , Fixação de Fratura/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente , Tempo para o Tratamento
9.
Int J Radiat Biol ; 96(1): 4-11, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-30403905

RESUMO

Purpose: In the wake of a nuclear detonation, individuals with acute radiation syndrome will be a significant source of morbidity and mortality. Mathematical modeling can compare response strategies developed for real-world chaotic conditions after a nuclear blast in order to identify optimal strategies for administering effective treatment to these individuals. To maximize responders' abilities to save lives it is critical to understand how treatment efficacy is impacted by real-world conditions and levels of supportive care. To illustrate the importance of these factors, we developed a mathematical model of cytokine administration 24 h after the blast with varying levels of supportive care described in the primary literature.Conclusion: The results highlight the proportionally higher life-saving benefit of administering cytokines to individuals with a moderate to high dose of radiation exposure, compared to those with a lower dose. However, the fidelity of mathematical models is dependent on the primary data informing them. We describe the data needed to fully explore the impact of timing, dosage, and fractional benefit of cytokines and supportive care treatment in non-optimal situations that could be seen after a nuclear detonation. Studies addressing these types of knowledge gaps are essential to evaluating the relative efficacy of countermeasures to refine existing plans and help develop new strategies and priorities.


Assuntos
Contramedidas Médicas , Armas Nucleares , Exposição à Radiação/efeitos adversos , Tempo para o Tratamento , Síndrome Aguda da Radiação/etiologia , Síndrome Aguda da Radiação/metabolismo , Síndrome Aguda da Radiação/prevenção & controle , Síndrome Aguda da Radiação/terapia , Citocinas/metabolismo , Humanos
10.
BJOG ; 127(3): 405-413, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31762140

RESUMO

OBJECTIVE: To determine variations in cord blood gas (CBG) parameters after 3-minute delayed cord clamping (DCC) in vaginal deliveries (VDs) and caesarean deliveries (CDs) at term without fetal distress. DESIGN: Prospective observational study. SETTING: University hospital. SAMPLE: CBG from 97 VDs and 124 CDs without fetal distress. METHODS: Comparison of paired arterial-venous CBG parameters drawn at birth from the unclamped cord and after 3-minutes DCC for VDs and CDs. MAIN OUTCOME MEASURES: Base excess, bicarbonate, haematocrit and haemoglobin from both arterial and venous cord blood, lactate, neonatal outcomes, partial pressure of oxygen (pO2 ), partial pressure of carbon dioxide (pCO2 ), pH, and postpartum haemorrhage. RESULTS: Arterial cord blood pH, bicarbonate ( HCO 3 - , mmol/l), and base excess (BE, mmol/l) decreased significantly after 3-minute DCC both in VDs (pH = 7.23 versus 7.27; P < 0.001; HCO 3 -  = 23.3 versus 24.3; P = 0.004; BE = -5.1 versus -2.9; P < 0.001) and CDs (pH = 7.28 versus 7.34; P < 0.001; HCO 3 -  = 26.2 versus 27.2; P < 0.001; BE = -1.5 versus 0.7; P < 0.001). After 3-minute DCC, pCO2 increased in CDs only (57 versus 51; P < 0.001), whereas lactate increased more in CDs compared with VDs (lactate, +1.1 [0.9, 1.45] versus +0.5 [-0.65, 2.35]; P = 0.01). Postpartum maternal haemorrhage, neonatal maximum bilirubin concentration, and need for phototherapy were similar between the two groups. Newborns born by CD more frequently required postnatal clinical monitoring or admission to a neonatal intensive care unit. CONCLUSIONS: After 3-minute DCC, the acid-base status shifted towards mixed acidosis in CDs and prevalent metabolic acidosis in VDs. CDs were associated with a more pronounced increase in arterial lactate, compared with VDs. TWEETABLE ABSTRACT: By 3-minute DCC, acid-base status shifts towards mixed and metabolic acidosis in caesarean and vaginal delivery, respectively.


Assuntos
Acidose , Cesárea , Parto Obstétrico , Sangue Fetal/metabolismo , Complicações do Trabalho de Parto , Cordão Umbilical/cirurgia , Acidose/sangue , Acidose/diagnóstico , Acidose/etiologia , Gasometria/métodos , Cesárea/efeitos adversos , Cesárea/métodos , Cesárea/estatística & dados numéricos , Constrição , Parto Obstétrico/efeitos adversos , Parto Obstétrico/métodos , Parto Obstétrico/estatística & dados numéricos , Feminino , Humanos , Recém-Nascido , Itália/epidemiologia , Masculino , Complicações do Trabalho de Parto/diagnóstico , Complicações do Trabalho de Parto/epidemiologia , Complicações do Trabalho de Parto/etiologia , Gravidez , Resultado da Gravidez/epidemiologia , Tempo para o Tratamento
11.
J Surg Res ; 245: 619-628, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31522035

RESUMO

BACKGROUND: Gastric adenocarcinoma is a leading cause of cancer death worldwide and, in the United States, can present emergently with upper GI hemorrhage, obstruction, or perforation. No large studies have examined how urgent surgery affects patient outcomes. This study examines the outcomes of urgent versus elective surgery for gastric cancer. MATERIALS AND METHODS: Patients with gastric adenocarcinoma from the National Cancer Database from 2004 to 2015 were examined retrospectively. Patients with metastatic disease or incomplete data were excluded. Urgent surgery was defined as definitive surgery within 3 d of diagnosis. Univariate and multivariate analysis of patient factors, surgical outcomes, and oncologic data was performed. P-values <0.05 were statistically significant. RESULTS: Of 26,116 total patients, 2964 had urgent surgery and 23,468 had elective surgery. Urgent surgery patients were significantly older, were female, were nonwhite, had higher pathologic stage, and were treated at a low-volume center. Urgent surgery was associated with decreased quality lymph node harvest (odds ratio [OR] 0.68 95% confidence interval {CI} [0.62, 0.74]), increased positive surgical margin (OR 1.48, 95% CI [1.32, 1.65]), increased 30-d mortality (OR 1.38, 95% CI [1.16, 1.65]), increased 90-d mortality (OR 1.30, 95% CI [1.14, 1.49]), and decreased overall survival (hazard ratio 1.21, 95% CI [1.15, 1.27]). CONCLUSIONS: Urgent surgery for gastric cancer is associated with significantly worse outcomes than elective surgery. Stable patients requiring urgent surgical resection for gastric cancer may benefit from referral to a high-volume center for resection by an experienced surgeon. Patients undergoing urgent resection for gastric cancer should be referred to surgical and medical oncologists to ensure they receive appropriate adjuvant therapy and surveillance.


Assuntos
Adenocarcinoma/cirurgia , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Gastrectomia/efeitos adversos , Complicações Pós-Operatórias/mortalidade , Neoplasias Gástricas/cirurgia , Adenocarcinoma/mortalidade , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Gastrectomia/métodos , Mortalidade Hospitalar , Humanos , Excisão de Linfonodo , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Neoplasias Gástricas/mortalidade , Análise de Sobrevida , Fatores de Tempo , Tempo para o Tratamento , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto Jovem
12.
Gastroenterology ; 158(1): 168-175.e6, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31563627

RESUMO

BACKGROUND & AIMS: We performed a large, multicenter, randomized controlled trial to determine the efficacy and safety of early colonoscopy on outcomes of patients with acute lower gastrointestinal bleeding (ALGIB). METHODS: We performed an open-label study at 15 hospitals in Japan of 170 patients with ALGIB randomly assigned (1:1) to groups that underwent early colonoscopy (within 24 hours of initial visit to the hospital) or elective colonoscopy (24-96 hours after hospital admission). The primary outcome was identification of stigmata of recent hemorrhage (SRH). Secondary outcomes were rebleeding within 30 days, endoscopic treatment success, need for transfusion, length of stay, thrombotic events within 30 days, death within 30 days, and adverse events. RESULTS: SRH were identified in 17 of 79 patients (21.5%) in the early colonoscopy group vs 17 of 80 patients (21.3%) in the elective colonoscopy group (difference, 0.3; 95% confidence interval, -12.5 to 13.0; P = .967). Rebleeding within 30 days of hospital admission occurred in 15.3% of patients in the early colonoscopy group and 6.7% of patients in the elective colonoscopy group (difference, 8.6; 95% confidence interval, -1.4 to 18.7); there were no significant differences between groups in successful endoscopic treatment rate, transfusion rate, length of stay, thrombotic events, or death within 30 days. The adverse event of hemorrhagic shock occurred during bowel preparation in no patient in the early group vs 2 patients (2.5%) in the elective colonoscopy group. CONCLUSIONS: In a randomized controlled study, we found that colonoscopy within 24 hours after hospital admission did not increase SRH or reduce rebleeding compared with colonoscopy at 24-96 hours in patients with ALGIB. ClinicalTrials.gov, Numbers: UMIN000021129 and NCT03098173.


Assuntos
Doenças do Colo/cirurgia , Colonoscopia/efeitos adversos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Hemorragia Gastrointestinal/cirurgia , Tempo para o Tratamento , Doença Aguda/mortalidade , Doença Aguda/terapia , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue/estatística & dados numéricos , Doenças do Colo/mortalidade , Feminino , Hemorragia Gastrointestinal/mortalidade , Mortalidade Hospitalar , Humanos , Japão , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Recidiva , Resultado do Tratamento
13.
Angiology ; 71(1): 48-55, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31315429

RESUMO

We searched PubMed, EMBASE, Cochrane Library, and Web of Science for studies using fractional flow reserve (FFR) to determine whether revascularization should be performed or deferred for patients with coronary stenosis and grey zone FFR. Meta-analysis was performed using the generic inverse variance method, and hazard ratios (HR) were synthesized with a random-effects model. Of 2766 records, 7 nonrandomized studies including 2683 patients were selected. The pooled results demonstrated, during a median follow-up of 32 months, that revascularization significantly reduced the risk of major adverse cardiac events (MACE; 7 studies: HR [95% confidence interval, CI]: 0.65 [0.45-0.93], P = .02) and target vessel revascularization (TVR; 4 studies: HR [95% CI]: 0.52 [0.36-0.76], P < .01). Whereas revascularization was not significantly superior in terms of all-cause death (3 studies: HR [95% CI]: 0.56 [0.26-1.22], P = .14), cardiac death (2 studies: HR [95% CI]: 0.57 [0.16-2.01], P = .38), myocardial infarction (MI; 4 studies: HR [95% CI]: 1.03 [0.26-4.03]), and all-cause death or MI (3 studies: HR [95% CI]: 0.66 [0.20-2.19], P = .50). Therefore, revascularization appeared to be superior to deferral for patients with grey zone FFR in MACE and TVR, while hard end points did not show such significance. This work was registered in PROSPERO (CRD42019118432).


Assuntos
Estenose Coronária/terapia , Reserva Fracionada de Fluxo Miocárdico , Revascularização Miocárdica , Tempo para o Tratamento , Idoso , Tomada de Decisão Clínica , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Estenose Coronária/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/efeitos adversos , Revascularização Miocárdica/mortalidade , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
14.
Ann Otol Rhinol Laryngol ; 129(1): 32-38, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31409113

RESUMO

OBJECTIVES: Injury to the recurrent laryngeal nerve (RLN), if severe enough, can result in vocal fold paralysis. Reinnervation surgery can improve patient outcomes, but previous studies have reported a negative correlation between time since onset of paralysis and surgical outcomes. The ability of the paralyzed nerve to serve as a conduit for donor nerve fibers may be a factor in the success of reinnervation; however, changes in RLN composition after paralysis have not been well studied. Therefore, we investigated the morphometric composition of explanted RLN sections from patients who had experienced vocal fold paralysis for varying length of times. METHODS: Nine nerve sections from unilateral vocal fold paralysis (UVP) patients and seven control nerve sections were analyzed for morphometric parameters including fascicular area, fiber count, fiber density, fiber packing, mean g-ratio, and fiber diameter distribution. Nerves from UVP patients were also compared as a function of time since UVP onset. RESULTS: In comparison to control nerves, paralyzed nerves were found to have significantly lower fiber densities and fiber packing, higher mean g-ratio values, and a shift in diameter distributions toward smaller diameter fibers. With respect to paralysis duration, no significant differences were observed except in fiber diameter distributions, where those with paralysis for >2 years had distributions that were significantly shifted toward smaller diameter fibers. CONCLUSIONS: The morphometric data presented here suggest that correlations between the time since onset of vocal fold paralysis and reinnervation outcomes may be due to fiber size changes in the paralyzed nerve over time.


Assuntos
Fibras Nervosas/patologia , Traumatismos do Nervo Laríngeo Recorrente/patologia , Nervo Laríngeo Recorrente/patologia , Paralisia das Pregas Vocais/cirurgia , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transferência de Nervo , Tamanho do Órgão , Nervo Laríngeo Recorrente/cirurgia , Traumatismos do Nervo Laríngeo Recorrente/complicações , Traumatismos do Nervo Laríngeo Recorrente/cirurgia , Fatores de Tempo , Tempo para o Tratamento , Paralisia das Pregas Vocais/etiologia , Adulto Jovem
15.
J Surg Res ; 245: 72-80, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31401250

RESUMO

BACKGROUND: Patients with blunt chest trauma with multiple rib fractures (RF) may require tracheostomy. The goal was to compare early (≤7 d) versus late (>7 d) tracheostomy patients and to analyze clinical outcomes, to determine which timing is more beneficial. METHODS: This retrospective review included 124 patients with RF admitted to trauma ICU at two level 1 trauma centers who underwent tracheostomy. Analyzed variables included age, gender, injury severity score, Glasgow Coma Scale, number of ribs fractured, total fractures of the ribs, prevalence of bilateral RF, flail chest, maxillofacial injuries, cervical vertebrae trauma, traumatic brain injuries (TBI), coinjuries, epidural analgesia, surgical stabilization of RF, failure to extubate, hospital LOS, intensive care unit LOS (ICULOS), duration of mechanical ventilation, mortality, and timing and type of tracheostomy. RESULTS: Mean number of RF in all tracheostomized patients with blunt chest trauma was 5.2 and 85% of patients had pulmonary co-injuries. Mean tracheostomy timing was 9.9 d. Early tracheostomy (ET) was correlated with statistically significant reduction in ICULOS and duration of mechanical ventilation. The dominant cause of mortality in all groups was TBI and it was more pronounced in the ET patients. Most deaths were encountered between 3 and 5 wk after admission. ET was more often performed in the operating room with an open technique, whereas late tracheostomy was more often implemented with percutaneous technique at bedside. CONCLUSIONS: ET could be beneficial in chest trauma patients with multiple RF as it reduces ICULOS and ventilation requirements. Mortality benefits are not correlated with tracheostomy timing.


Assuntos
Fraturas das Costelas/terapia , Traumatismos Torácicos/complicações , Tempo para o Tratamento , Traqueostomia/métodos , Adulto , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Fraturas das Costelas/diagnóstico , Fraturas das Costelas/etiologia , Fraturas das Costelas/mortalidade , Análise de Sobrevida , Taxa de Sobrevida , Traumatismos Torácicos/diagnóstico , Traumatismos Torácicos/mortalidade , Traumatismos Torácicos/terapia , Adulto Jovem
16.
Lakartidningen ; 1162019 Dec 02.
Artigo em Sueco | MEDLINE | ID: mdl-31794045

RESUMO

Atrial fibrillation is one of the most common arrhythmias. As the symptoms can be abrupt in onset it is associated with a substantial burden on the medical emergency system. By routine practice patients with symptomatic atrial fibrillation of a duration less than 48 hours are commonly offered cardioversion therapy. Data from a recent study shows that more than two thirds of patients convert to sinus rhythm spontaneously within 48 hours. A watch-and-wait approach in rhythm control management may be suggested for clinical praxis, considering the high chance of spontaneous cardioversion. Long-term results for a group with early and delayed cardioversion were similar with regards to maintenance of sinus rhythm at 4 weeks.


Assuntos
Fibrilação Atrial/terapia , Cardioversão Elétrica , Tempo para o Tratamento , Humanos , Conduta Expectante
17.
Lakartidningen ; 1162019 Dec 02.
Artigo em Sueco | MEDLINE | ID: mdl-31794048

RESUMO

This study reviewed 102 decisions on error reports in ophthalmic health care in Sweden between March 2017 and October 2018. The study included children, adults, women and men. We found that there was a clear association between long waiting times for ophthalmic health care and negative visual outcomes. As a result of care delay, 71 percent of the patients had moderate vision loss and 17 percent of the patients experienced severe vision loss. Patients with glaucoma and wet macular degeneration accounted for the majority of the patients with negative outcomes. Timely follow-up and prompt treatment are critical to patients' visual outcomes.


Assuntos
Erros Médicos/estatística & dados numéricos , Oftalmologia/normas , Tempo para o Tratamento , Adulto , Idoso , Criança , Feminino , Glaucoma/epidemiologia , Humanos , Degeneração Macular/epidemiologia , Masculino , Pessoa de Meia-Idade , Qualidade da Assistência à Saúde/normas , Suécia/epidemiologia , Resultado do Tratamento , Transtornos da Visão/epidemiologia , Listas de Espera
19.
Am Surg ; 85(11): 1205-1208, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31775959

RESUMO

Our department has a database of thoracic gunshot wounds (GSWs), which has cataloged these injury patterns over the past five decades. Prevailing wisdom on the management of these injuries suggested operative treatment beyond tube thoracostomy is not commonly required. It was our clinical impression that the operative treatment required beyond chest tube placement has greatly increased over the past several decades, whereas the operative management of cardiac GSWs seemed to be increasingly infrequent events. To test these observations, we analyzed the treatment of GSWs to the chest and heart in four distinct time periods, categorized as "historical" (1973-1975 and 1988-1990) and "modern" (2005-2007 and 2015-2017). There was a significant increase in emergent thoracotomy, delayed thoracic operations, overall operative interventions, and pulmonary resections from the historical period to the modern era. There was a decline in cardiac injuries treated, whereas the number of injuries remained constant. Mortality was unchanged between the early and later periods. Operative treatment beyond tube thoracostomy was much more prevalent for noncardiac thoracic GSWs in the past two decades than in the prior decades, whereas the number of cardiac wounds treated decreased by half.


Assuntos
Traumatismos Torácicos/cirurgia , Ferimentos por Arma de Fogo/cirurgia , Emergências , Traumatismos Cardíacos/epidemiologia , Traumatismos Cardíacos/mortalidade , Traumatismos Cardíacos/cirurgia , Humanos , Kentucky/epidemiologia , Pulmão/cirurgia , Traumatismos Torácicos/epidemiologia , Traumatismos Torácicos/mortalidade , Toracostomia/métodos , Toracotomia/estatística & dados numéricos , Toracotomia/tendências , Fatores de Tempo , Tempo para o Tratamento , Ferimentos por Arma de Fogo/epidemiologia , Ferimentos por Arma de Fogo/mortalidade
20.
Am Surg ; 85(11): 1209-1212, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31775960

RESUMO

Prompt appendectomy has long been the standard of care for acute appendicitis because of the risk of progression to perforation. Recently, studies have suggested nonemergent management of acute appendicitis. Our study aimed to determine changes in risk of rupture and complications in patients with appendicitis, with increasing time from symptom onset to treatment. Retrospective study of patients aged ≥18 years presenting to the University of North Carolina Hospitals with signs and symptoms of acute appendicitis who subsequently underwent appendectomy from 2011 to 2015 was performed. Demographic, clinical, laboratory, and pathologic data were reviewed. Bivariate analysis was performed to assess variables associated with increased risk of perforation. Poisson regression modeling was completed to evaluate the risk of perforation and postoperative abscess based on time from symptoms to treatment. Within our database of 1007 patients, the mean time from onset of symptoms to operative intervention was 3.24 ± 2.2 days. Modified Poisson regression modeling demonstrated the relative risk for perforation increases by 9% (RR 1.09, P < 0.001) for each day delay. Age (RR 1.03), male gender (RR 1.50), temperature on admission (RR 1.32), and the presence of fecalith (RR 1.89) statistically significantly increased the risk of perforation. Furthermore, for each day delay, there is an 8% increased risk of postoperative abscess (RR 1.08, P = 0.027). The relative risk for appendiceal perforation is 9 per cent per day delay with a resultant 8 per cent increased risk of postoperative abscess. Thus, appendectomy for acute appendicitis should remain an emergent procedure, given that delays in operative management lead to complications and increases in cost of care.


Assuntos
Abscesso/etiologia , Apendicite/complicações , Apendicite/cirurgia , Perfuração Intestinal/etiologia , Doença Aguda , Adulto , Fatores Etários , Temperatura Corporal , Estudos de Casos e Controles , Emergências , Impacção Fecal/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Distribuição de Poisson , Estudos Retrospectivos , Fatores de Risco , Ruptura Espontânea/etiologia , Fatores Sexuais , Tempo para o Tratamento
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