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1.
Khirurgiia (Mosk) ; (1): 67-73, 2020.
Artigo em Russo | MEDLINE | ID: mdl-31994502

RESUMO

OBJECTIVE: To compare long-term outcomes in patients after carotid endarterectomy and those who refused surgical correction and received only conservative treatment. MATERIAL AND METHODS: There were 1035 carotid endarterectomies performed at the Kemerovo Regional Clinical Hospital and Kemerovo Regional Clinical Cardiology Dispensary for the period 2014-2017. Surgery was refused by 136 patients for the same time. Thus, two groups of patients were formed: 1 - carotid endarterectomy group; 2 - conservative treatment group. INCLUSION CRITERIA: significant carotid stenosis, absence of severe neurological deficit (over 25 scores by the National Institutes of Health Stroke Scale), absence of concomitant diseases limiting long-term follow-up. RESULTS: Lethal outcome (p=0.0038) and fatal acute cerebrovascular accident (p=0.0005) were significantly more common in the 2nd group in long-term follow-up period. Thus, combined endpoint took the greatest values in patients who refused surgery compared with patients who received surgical treatment (p=0.0001). It should be noted that ischemic stroke de novo occurred in 9 (6.6%) patients of the 2nd group after 10.8 ± 2.5 months. This complication required subsequent hospitalization for carotid endarterectomy. CONCLUSION: Preventive role of carotid endarterectomy was convincingly proved in comparison with drug therapy regarding mortality and fatal ischemic stroke in patients with significant carotid stenoses within 2.5 years of follow-up period.


Assuntos
Estenose das Carótidas/tratamento farmacológico , Estenose das Carótidas/cirurgia , Tratamento Conservador/mortalidade , Endarterectomia das Carótidas/mortalidade , Estenose das Carótidas/complicações , Estenose das Carótidas/mortalidade , Tratamento Conservador/efeitos adversos , Seguimentos , Humanos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Resultado do Tratamento
2.
Vasc Endovascular Surg ; 54(2): 126-134, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31709914

RESUMO

INTRODUCTION: Revascularization is the cornerstone of the treatment of critical limb ischemia (CLI), but the number of elderly frail patients increase. Revascularization is not always possible in these patients and conservative therapy seems to be an option. The goals of this study are to analyze the 1-year quality of life (QoL) results and mortality rates of elderly patients with CLI and to investigate if conservative treatment could be an acceptable treatment option. METHODS: Patients with CLI ≥70 years old were included in a prospective observational cohort study in 2 hospitals in the Netherlands between 2012 and 2016 and were divided over 3 treatment modalities: endovascular therapy, surgical revascularization, and conservative treatment. The World Health Organization Quality of Life (WHOQoL-Bref) instrument, a generic QoL assessment tool that includes components of physical, psychological, social relationships and environment, was used to evaluate QoL at baseline, 6 months, and 1 year. RESULTS: In total, 195 patients (56% male, 33% Rutherford 4, mean age of 80) were included. Physical QoL significantly increased after surgical (10.4 vs 14.9, P < .001), endovascular (10.9 vs 13.7, P < .001), and conservative therapy (11.6 vs 13.2, P = .01) at 1 year. One-year mortality was relatively low after surgery (10%) compared to endovascular (40%) and conservative therapy (37%). CONCLUSION: The results of this study could not be used to designate the superior treatment used in elderly patients with CLI. Conservative treatment could be an acceptable treatment option in selected patients with CLI unfit for revascularization. Treatment of choice in elderly patients with CLI is based on multiple factors and should be individualized in a shared decision-making process.


Assuntos
Tratamento Conservador , Procedimentos Endovasculares , Isquemia/terapia , Doença Arterial Periférica/terapia , Qualidade de Vida , Procedimentos Cirúrgicos Vasculares , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Tratamento Conservador/efeitos adversos , Tratamento Conservador/mortalidade , Estado Terminal , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Isquemia/diagnóstico por imagem , Isquemia/mortalidade , Isquemia/fisiopatologia , Masculino , Países Baixos , Seleção de Pacientes , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Estudos Prospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade
4.
J Stroke Cerebrovasc Dis ; 29(2): 104505, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31786043

RESUMO

BACKGROUND: Whether time of hospital admission-during or outside regular working hours-affects functional outcome in intracerebral hemorrhage (ICH) is unestablished as previous analyses have focused on mortality only. We here investigate whether on- versus off-hour hospital admission in ICH is associated with levels of invasiveness and clinical outcomes. METHODS: Based on the UKER registry (NCT03183167) we grouped ICH-patients according to on- versus off-hour hospital admission. Primary outcome measures was functional outcome after 3 months using the modified Rankin scale (mRS) dichotomized into favorable (mRS = 0-3) and unfavorable (mRS = 4-6). Multivariate regression analyses were used to adjust for baseline imbalances, and subgroup analyses were performed to explore associations of on- versus off-hour admission with invasiveness of therapeutic interventions. RESULTS: A total of 438/1269 (34.5%) of ICH-patients were admitted during regular working hours. Mortality rates were not significantly different among patients with on- versus off-hour admission. On-hour patients showed a significantly larger proportion of patients with favorable outcome (on-hour: mRS = 0-3 after 3 months: 176/416 (42.3%) versus off-hour: 265/784 (33.8%); P = .004). Analysis of invasive therapeutic interventions revealed that likelihood of favorable outcome was significantly increased among on-hour admitted patients who did not require neurosurgical interventions (no external ventricular drain n = 349, OR: 1.67[1.13-2.48], P < .05; no hematoma evacuation surgery n = 423, OR: 1.51[1.07-2.14], P < .05). CONCLUSION: This study verified an "off-hour effect" in ICH that relates to functional outcome, rather than mortality, and which may be linked to different levels of invasive therapeutic interventions in patients admitted during off-hour.


Assuntos
Plantão Médico , Hemorragia Cerebral/terapia , Tratamento Conservador , Procedimentos Endovasculares , Procedimentos Neurocirúrgicos , Admissão do Paciente , Idoso , Idoso de 80 Anos ou mais , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/mortalidade , Hemorragia Cerebral/fisiopatologia , Tratamento Conservador/efeitos adversos , Tratamento Conservador/mortalidade , Avaliação da Deficiência , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/efeitos adversos , Procedimentos Neurocirúrgicos/mortalidade , Recuperação de Função Fisiológica , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
5.
Medicine (Baltimore) ; 98(44): e10281, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31689741

RESUMO

BACKGROUND: It is unclear whether surgery or conservative treatment is more suitable for elderly patients with type II and type III odontoid fractures. We performed this meta-analysis to compare the efficacy of surgical and conservative treatments for type II and type III odontoid fractures. METHODS: A literature search was performed in PubMed, Embase, Web of Science, and Cochrane Library in January 2017. Only articles comparing surgery with conservative treatment in elderly patients with type II and type III odontoid fractures were selected. After 2 authors independently assessed the retrieved studies, 18 articles were included in this meta-analysis, and the primary endpoints were the nonunion rate and mortality rate. The secondary outcomes were patient satisfaction, complications, and the length of the hospital stay. The quality of the included studies was evaluated using the modified Newcastle-Ottawa scale. Sensitivity analyses were performed for high-quality studies, and the publication bias was evaluated using a funnel plot. RESULTS: Lower nonunion (odds ratio [OR]: 0.27, 95% confidence interval [CI]: 0.18-0.40, P < .05) and mortality rates (OR: 0.52, 95% CI: 0.34-0.79, P < .05) confirmed the superiority of surgery in treating type II and type III fractures. The secondary outcomes differed. Patients in the surgery group felt more satisfied with the outcome (OR: 3.44, 95% CI: 1.19-9.95, P < .05), and the complications were similar in the 2 groups (OR: 1.14, 95% CI: 0.78-1.68, P = .5), whereas patients in conservative groups spent less time in the hospital (OR: 5.10, 95% CI: 2.73-7.47, P < .05). The results of the subgroup analyses and sensitivity analysis were similar to the original outcomes, and no obvious publication bias was observed in the funnel plot. CONCLUSION: Most elderly (younger than 70 years) patients with type II or type III odontoid fractures should be considered candidates for surgical treatment, due to the higher union rate and lower mortality rate, while statistically significant differences were not observed in the population with an advanced age (older than 70 years). Therefore, the selection of the therapeutic approach for elderly patients with odontoid fractures requires further exploration. Simultaneously, based on our meta-analysis, a posterior arthrodesis treatment was significantly superior to the anterior odontoid screw treatment.


Assuntos
Tratamento Conservador/mortalidade , Fixação de Fratura/mortalidade , Processo Odontoide/cirurgia , Fraturas da Coluna Vertebral/cirurgia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Tratamento Conservador/efeitos adversos , Tratamento Conservador/métodos , Fixação de Fratura/efeitos adversos , Fixação de Fratura/métodos , Humanos , Tempo de Internação/estatística & dados numéricos , Satisfação do Paciente , Complicações Pós-Operatórias/epidemiologia , Fraturas da Coluna Vertebral/classificação
6.
Am Surg ; 85(10): 1179-1183, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657320

RESUMO

Delayed presentation of acute appendicitis is associated with increased complications. We hypothesized that the outcomes of appendectomy in delayed presentations of acute appendicitis (>72 hours of pain) were dependent on radiologic findings rather than late presentation. We reviewed records from 2009 to 2015 and analyzed delayed presentations of acute appendicitis. We divided patients into three groups based on specific CT findings: uncomplicated appendicitis (UA), phlegmon or abscess (PA), and other perforated appendicitis (PERF, signs of perforation without abscess or phlegmon). One hundred thirty-eight patients were included in this study (58 in the UA, 67 in the PA, and 13 in the PERF groups). Overall, 78 (57%) patients underwent early appendectomy (EA) and 60 (43%) underwent initial conservative management. The incidence of adverse events was lower in EA than that in initial conservative management (17% vs 42%, P = 0.005). EA in the UA group was associated with shorter hospitalization (3.2 vs 5.6 days, P < 0.001) and less adverse events (6% vs 29%, P < 0.05). Severe adverse events (two colectomies and one fecal fistula) were observed in the PA group. In conclusion, in these late presentations of appendicitis, complicated appendicitis was common. EA was safe in selected patients, however, and associated with decreased adverse events.


Assuntos
Apendicectomia , Apendicite/diagnóstico por imagem , Apendicite/cirurgia , Diagnóstico Tardio/efeitos adversos , Perfuração Espontânea/diagnóstico por imagem , Abscesso/diagnóstico por imagem , Abscesso/etiologia , Doença Aguda , Adulto , Apendicectomia/estatística & dados numéricos , Apendicite/complicações , Tratamento Conservador/efeitos adversos , Tratamento Conservador/estatística & dados numéricos , Diagnóstico Tardio/estatística & dados numéricos , Diagnóstico Precoce , Feminino , Humanos , Tempo de Internação , Masculino , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Análise de Regressão , Perfuração Espontânea/complicações , Perfuração Espontânea/cirurgia , Tomografia Computadorizada por Raios X , Resultado do Tratamento
7.
Acta Chir Orthop Traumatol Cech ; 86(4): 294-298, 2019.
Artigo em Tcheco | MEDLINE | ID: mdl-31524593

RESUMO

The team of authors presents a case of the patient who suffered an isolated unstable extra-articular distal ulnar fracture, the surgical treatment of which was affected by a postponed management in consequence of inadequate primary treatment. The primary non-operative treatment resulted in a complex malunion ad latus, ad axim and ad peripheriam. The malunion which led to a painful restricted range of motion of the forearm (59%), decreased hand grip strength and significant limitation of activities of daily living was surgically treated by a triplane corrective osteotomy at 11 months after injury. At 12 months after surgery, a complete ulnar bone union was observed, the patient showed no residual wrist pain, the range of motion of the injured forearm reached 97 % of the range of motion of the unaffected forearm (side), and the hand grip strength was 95% of the hand grip strength in contralateral limb. The treatment outcome can be assessed as very good based on the Quick DASH score. Displaced isolated distal ulnar fractures cause a change in the axial position of the distal end of the bone and can be associated with an injury to the stabilizers of the DRUJ. Thus, they can result in a limited range of motion of the forearm due to the impaired DRUJ biomechanics and development of early post-traumatic osteoarthritis of the DRUJ. The non-operative treatment is recommended only for stable and non-displaced fractures as well as fractures in which surgical treatment is contraindicated. Corrective osteotomy of the distal ulna is the method of choice in managing distal ulna malunion as a result of isolated distal ulnar shaft fractures in symptomatic patients. Good functional outcomes may be achieved if the anatomical position of DRUJ is restored. Key words:corrective osteotomy, distal ulnar fracture.


Assuntos
Fraturas Mal-Unidas/cirurgia , Osteotomia/métodos , Fraturas da Ulna/cirurgia , Tratamento Conservador/efeitos adversos , Fraturas Mal-Unidas/etiologia , Humanos , Amplitude de Movimento Articular , Tempo para o Tratamento , Resultado do Tratamento , Fraturas da Ulna/complicações , Fraturas da Ulna/terapia
8.
Bull Hosp Jt Dis (2013) ; 77(3): 211-215, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31487488

RESUMO

INTRODUCTION: Spinal cord injured patients have an estimated 25% to 34% lifetime incidence of sustaining an extremity fracture. The objective of this study is to describe the outcomes of femur fractures treated in patients with pre-existing spinal cord injury (SCI) and lower extremity paraplegia. MATERIALS AND METHODS: An IRB approved retrospective review of patients 18 years of age and older who sustained a femur fracture a minimum of 2 years following spinal cord injury and received treatment at a regional academic level 1 trauma center over a 10-year period was performed. Patients were divided into two groups based on whether they received operative or nonoperative management of the femoral shaft fracture. The primary outcome assessed was re-operation. Additional outcomes including union, infection, implant failure, and mortality were recorded. RESULTS: Twenty-one patients sustaining a total of 25 femur fractures were identified. The most common mechanism of injury was fall during transfer. Sixteen fractures were treated non-operatively and nine were treated operatively. At a mean of 4.1 years of follow-up (range: 1.1 to 12.1 years) six out of nine (66.7%) patients in the operative group required an unplanned secondary surgery compared to two patients (12.5%) in the non-operative group (p = 0.006). Overall, the rate of fracture union was 48%, and there was no difference seen between treatment groups (56.3% in nonoperative group versus 33.3% in operative group, p = 0.28). Six operative patients (66.7%) developed an infection as compared to one patient (6.3%) in the non-operative group (p = 0.002). Three operative patients (33.3%) had failure of fixation with implant cutout. One patient died within 2 years of fracture in the non-operative group (6.3%) as did one patient in the operative group (11.1%), (p = 1.0). CONCLUSIONS: Surgical treatment of femur fractures in patients with a pre-existing SCI and lower extremity paraplegia had a higher rate of complications than nonoperative management in our series. Based on our experience, we recommend non-operative treatment of femur fractures in patients with pre-existing spinal cord injury and lower extremity paraplegia.


Assuntos
Tratamento Conservador , Fraturas do Fêmur , Fixação de Fratura , Paraplegia , Traumatismos da Medula Espinal , Adulto , Tratamento Conservador/efeitos adversos , Tratamento Conservador/métodos , Tratamento Conservador/estatística & dados numéricos , Feminino , Fraturas do Fêmur/epidemiologia , Fraturas do Fêmur/etiologia , Fraturas do Fêmur/cirurgia , Fixação de Fratura/efeitos adversos , Fixação de Fratura/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Paraplegia/complicações , Paraplegia/epidemiologia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Traumatismos da Medula Espinal/complicações , Traumatismos da Medula Espinal/epidemiologia
9.
Eklem Hastalik Cerrahisi ; 30(2): 143-8, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31291863

RESUMO

OBJECTIVES: This study aims to compare the radiological, clinical and patient-reported outcomes of patients with intra-articular calcaneus fractures treated conservatively or surgically. PATIENTS AND METHODS: Fifty-four patients (30 males, 24 females; mean age 41.0 years; range, 18 to 73 years) treated due to calcaneus fracture were included in the study. Twenty-nine patients underwent conservative treatment (group 1) and 25 patients underwent surgical treatment (group 2). The fractures were classified according to Sanders. At the final follow-up, patients' Bohler's angle, The American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and Foot Function Index (FFI) were used to evaluate their radiological, clinical and patient-reported outcomes. Postoperative complications were also noted. RESULTS: The fracture was at the right foot in 28 patients and the left foot in 26 patients. The mean follow-up duration was 41.1±23.2 months (range, 24 to 126 months). No statistically significant differences were found between the groups in terms of gender, fracture side, mean age, or follow-up duration (p=0.951, p=0.571, p=0.326, and p=0.620, respectively). According to Sanders classification, 18 patients were type 2 and 11 patients were type 3 in group 1, while 11 patients were type 2 and 14 patients were type 3 in group 2. However, there was no statistically significant difference between the groups in terms of the type of the fracture (p=0.184). On the other hand, the outcomes were significantly better for group 2 compared to group 1 in terms of the Bohler's angle, AOFAS and FFI scores (p=0.004, p=0.003 and p=0.006, respectively). In group 1, subtalar arthritis developed in three patients. In group 2, wound healing problems and superficial infection developed in three patients, while subtalar arthritis developed in two patients. CONCLUSION: Surgical treatment is more effective in intra-articular calcaneus fractures compared to conservative treatment according to clinical, radiological and patient-reported outcomes. In addition, wound problems should be considered in surgical management.


Assuntos
Calcâneo/lesões , Tratamento Conservador , Fixação Interna de Fraturas , Fraturas Intra-Articulares/terapia , Adolescente , Adulto , Idoso , Articulação do Tornozelo/diagnóstico por imagem , Articulação do Tornozelo/fisiopatologia , Calcâneo/cirurgia , Tratamento Conservador/efeitos adversos , Feminino , Seguimentos , Fixação Interna de Fraturas/efeitos adversos , Humanos , Fraturas Intra-Articulares/diagnóstico por imagem , Fraturas Intra-Articulares/fisiopatologia , Masculino , Pessoa de Meia-Idade , Osteoartrite/etiologia , Medidas de Resultados Relatados pelo Paciente , Complicações Pós-Operatórias , Resultado do Tratamento , Adulto Jovem
10.
Int J Cardiovasc Imaging ; 35(11): 2049-2056, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31325066

RESUMO

Left atrial (LA) enlargement is a marker of LA cardiopathy and, in patients with patent foramen ovale (PFO), is associated with an increased risk of ischemic stroke. The primary study outcome was the comparison of LA diameter between patients undergoing percutaneous PFO closure versus those treated conservatively. The secondary endpoints were the association of LA diameter with the Risk of Paradoxical Emboli (ROPE) score and the presence of Atrial septal aneurysm (ASA) and Right-To-Left Shunt (RLS). Retrospective analysis of clinical and instrumental data of 1040 subjects referred to a single tertiary center for PFO evaluation and treatment. Seven hundred and nineteen patients were enrolled: 495 patients (closure group, mean RoPE score 7.6 ± 0.8) underwent PFO closure while 224 patients (control group, mean RoPE score 4.1 ± 0.9. p < 0.001) were left to medical therapy. Preoperative LA diameter was significantly larger in closure group and reduced from 44.3 ± 9.1 to 37.3 ± 4.1 mm (p = 0.01) 1 year after the procedure to the size of controls. A larger LA diameter was associated with permanent RLS, RLS curtain pattern, ASA presence and multiple ischemic brain lesions pattern at neuroimaging. A LA diameter ≥ 43 mm was a predictor a RoPEscore > 7. In our patients' cohort, LA diameter was associated with the clinic severity of PFO and RLS. The reversal of LA enlargement after PFO closure suggests a role for RLS to induce LA cardiopathy. LA enlargement has the potential to be considered per se as an indication to transcatheter PFO repair.


Assuntos
Função do Átrio Esquerdo , Remodelamento Atrial , Cateterismo Cardíaco , Tratamento Conservador , Forame Oval Patente/terapia , Adulto , Cateterismo Cardíaco/efeitos adversos , Transtornos Cerebrovasculares/diagnóstico por imagem , Transtornos Cerebrovasculares/etiologia , Tratamento Conservador/efeitos adversos , Embolia Paradoxal/diagnóstico por imagem , Embolia Paradoxal/etiologia , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/fisiopatologia , Aneurisma Cardíaco/diagnóstico por imagem , Aneurisma Cardíaco/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento
11.
Medicine (Baltimore) ; 98(29): e16338, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31335681

RESUMO

BACKGROUND: To systematically review the efficacy of surgical versus nonsurgical treatment for acute patellar dislocation. MATERIALS AND METHODS: PubMed, Cochrane, and Embase were searched up to February 12, 2019. After removing duplicates, preliminary screening, and reading the full texts, we finally selected 16 articles, including 11 randomized controlled trials and 5 cohort studies. The quality of the enrolled studies was evaluated by Jadad score or Newcastle-Ottawa scale. Meta-analyses were performed using odds ratio (OR) and standardized mean difference (SMD) as effect variables. The clinical parameters assessed included mean Kujala score, rate of redislocation, incidence of patellar subluxation, patient satisfaction, and visual analog scale (VAS) for pain. Evidence levels were determined using GRADE profile. RESULTS: The 16 included studies involved 918 cases, 418 in the surgical group and 500 in the nonsurgical group. The results of the meta-analysis showed higher mean Kujala score (SMD = 0.79, 95% confidence interval [CI] [0.3, 1.28], P = .002) and lower rate of redislocation (OR = 0.44, 95% CI [0.3, 0.63], P < .00001) in the surgical group than the nonsurgical group, but showed insignificant differences in the incidence of patellar subluxation (OR = 0.61, 95% CI [0.36, 1.03], P = .06), satisfaction of patients (OR = 1.44, 95% CI [0.64, 3.25], P = .38), and VAS (SMD = 0.84, 95% CI [-0.36, 9.03], P = .84). CONCLUSION: For patients with primary acute patellar dislocation, surgical treatment produces a higher mean Kujala score and a lower rate of redislocation than nonsurgical treatment.


Assuntos
Tratamento Conservador , Procedimentos Ortopédicos , Luxação Patelar/terapia , Tratamento Conservador/efeitos adversos , Tratamento Conservador/métodos , Humanos , Procedimentos Ortopédicos/efeitos adversos , Procedimentos Ortopédicos/métodos , Resultado do Tratamento
12.
Pediatr Surg Int ; 35(8): 861-867, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31161252

RESUMO

BACKGROUND: Peripancreatic fluid collection and pseudocyst development is a common sequela following non-operative management (NOM) of pancreatic injuries in children. Our purpose was to review management strategies and assess outcomes. METHODS: A multicenter, retrospective review was conducted of children treated with NOM following blunt pancreatic injury at 22 pediatric trauma centers between the years 2010 and 2015. Organized fluid collections were called "acute peripancreatic fluid collection" (APFC) if identified < 4 weeks and "pseudocyst" if > 4 weeks following injury. Data analysis included descriptive statistics Wilcoxon rank-sum, Kruskal-Wallis and t tests. RESULTS: One hundred patients with blunt pancreatic injury were identified. Median age was 8.5 years (range 1-16). Forty-two percent of patients (42/100) developed organized fluid collections: APFC 64% (27/42) and pseudocysts 36% (15/42). Median time to identification was 12 days (range 7-42). Most collections (64%, 27/42) were observed and 36% (15/42) underwent drainage: 67% (10/15) percutaneous drain, 7% (1/15) needle aspiration, and 27% (4/15) endoscopic transpapillary stent. A definitive procedure (cystogastrostomy/pancreatectomy) was required in 26% (11/42). Patients with larger collections (≥ 7.1 cm) had longer time to resolution. Comparison of outcomes in patients with observation vs drainage revealed no significant differences in TPN use (79% vs 75%, p = 1.00), hospital length of stay (15 vs 25 median days, p = 0.11), time to tolerate regular diet (12 vs 11 median days, p = 0.47), or need for definitive procedure (failure rate 30% vs 20%, p = 0.75). CONCLUSIONS: Following NOM of blunt pancreatic injuries in children, organized fluid collections commonly develop. If discovered early, most can be observed successfully, and drainage does not appear to improve clinical outcomes. Larger size predicts prolonged recovery. LEVEL OF EVIDENCE: III STUDY TYPE: Case series.


Assuntos
Traumatismos Abdominais/terapia , Tratamento Conservador/efeitos adversos , Drenagem/métodos , Pâncreas/lesões , Pancreatectomia/métodos , Pseudocisto Pancreático/cirurgia , Ferimentos não Penetrantes/terapia , Adolescente , Criança , Pré-Escolar , Endoscopia/métodos , Feminino , Humanos , Lactente , Masculino , Pseudocisto Pancreático/etiologia , Estudos Retrospectivos , Stents
13.
J Stroke Cerebrovasc Dis ; 28(8): 2213-2220, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31151837

RESUMO

OBJECTIVE: Prognostic scores help in predicting mortality and functional outcome post intracerebral hemorrhage (ICH). We aimed to validate the ICH and ICH-GS scores in a cohort of Indian patients with ICH and observe the impact of any surgical intervention on prognostication. METHODS: This was an ambispective observational study of primary ICH cases enrolled between January 2014 and April 2018. Observed mortality on ICH and ICH GS scores for the entire cohort and individually for the medically and surgically managed patients was compared to the published mortality in the original derivation cohorts. RESULTS: 617 patients, (464 retrospective and 153 prospective) of ICH were included. In hospital mortality and 30-day mortality was 28.7% and 28.5% respectively. There was a significant association of increasing mortality with increasing ICH and ICH-GS scores. Area under receiver operating characteristic curve for 30-day mortality was 75.9% and 74.1% for ICH and ICH-GS scores respectively. However, mortality observed at individual scores was significantly less than previously reported. Among the surgically intervened patients (n = 265), both the expected mortality at baseline and discriminative ability of ICH and ICH-GS scores for 30-day mortality was significantly reduced following surgical intervention (ROC in surgically intervened groups: 59.9 (52.6-67.2) and 63(56-70) for ICH and ICH-GS scores respectively). CONCLUSIONS: Although ICH and ICH-GS scores are valid in Indian population, mortality at individual scores is lower than previously reported. Mortality prediction using ICH and ICH GS scores is significantly modified by surgical interventions. Thus, newer prognostic tools which incorporate surgical intervention need to be developed and validated in future.


Assuntos
Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/terapia , Tratamento Conservador , Técnicas de Apoio para a Decisão , Procedimentos Neurocirúrgicos , Adulto , Idoso , Hemorragia Cerebral/mortalidade , Hemorragia Cerebral/fisiopatologia , Tomada de Decisão Clínica , Tratamento Conservador/efeitos adversos , Tratamento Conservador/mortalidade , Avaliação da Deficiência , Feminino , Mortalidade Hospitalar , Humanos , Índia/epidemiologia , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/efeitos adversos , Procedimentos Neurocirúrgicos/mortalidade , Valor Preditivo dos Testes , Estudos Prospectivos , Recuperação de Função Fisiológica , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
14.
J Pediatr Orthop ; 39(Issue 6, Supplement 1 Suppl 1): S47-S49, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31169648

RESUMO

BACKGROUND: Increased participation in youth sports is associated with increased rates of anterior cruciate ligament (ACL) tears in the skeletally immature. Historically, ACL reconstruction was avoided in the skeletally immature, or delayed until skeletal maturity, to avoid physeal injury and growth disturbance. Current practices and meta-analyses support early ACL reconstruction in some groups, to allow for return to activities and to avoid delayed cartilage/meniscus injury. PURPOSE: The purpose of this article was to report on the natural history of ACL injuries in the skeletally immature. METHODS: A review of published literature on pediatric, skeletally immature ACL tears and conservative, nonoperative treatment was conducted via Pubmed articles published from 1970 to 2018. The search criteria included the key terms "anterior cruciate ligament," "pediatric" and/or "adolescent," and "conservative" and/or "nonoperative treatment." A PRISMA workflow was used to narrow down the articles to those relevant to our analysis and available in full text format. RESULTS: Multiple articles on the nonoperative treatment of the ACL showed secondary meniscal and cartilage damage at the time of follow-up. Some articles showed no difference between the rates of secondary injuries between the surgical and nonsurgical treatment groups; however, the nonsurgical treatment groups were often on significant activity modification. Some articles concluded that nonoperative treatment of the ACL tear may be appropriate in low risk, lower level activity patients, and those that will comply with activity restrictions. Even with bracing and PT programs, active athletes treated without surgery appear to have a concerning rate of secondary meniscus injury after the primary ACL injury event. CONCLUSIONS: The natural history of the ACL tear shows nonoperative treatment for the skeletally immature may be a viable treatment pathway for those who are able to comply with the physical activity restrictions. For the general population of young, active adolescents, an ACL injury treated nonoperatively often leads to secondary meniscal and/or cartilage damage, which may lead to knee degeneration and functional instability.


Assuntos
Lesões do Ligamento Cruzado Anterior/terapia , Reconstrução do Ligamento Cruzado Anterior/efeitos adversos , Tratamento Conservador/efeitos adversos , Lesões do Menisco Tibial/etiologia , Adolescente , Lesões do Ligamento Cruzado Anterior/complicações , Criança , Lâmina de Crescimento/crescimento & desenvolvimento , Humanos , Extremidade Inferior/crescimento & desenvolvimento
15.
BMC Musculoskelet Disord ; 20(1): 309, 2019 Jun 29.
Artigo em Inglês | MEDLINE | ID: mdl-31253145

RESUMO

BACKGROUND: Distal radius fractures (DRF) are very common in elderly patients, who present at the Emergency Department. Surgical treatment with open reduction and internal fixation using volar locking plates is widely prevalent despite the lack of evidence proving its superiority to conservative treatment with closed reduction and plaster immobilization. The purpose of this study is to investigate whether conservative treatment is superior to volar plating in terms of number of complications and results in a comparable or superior functional outcome in patients ≥65 years. METHODS: In this single-center, single-blinded randomized-controlled trial, patients ≥65 years with distal radius fractures will be invited to participate. A total of 50 patients per treatment arm is required to provide 80% statistical power at a 5% alpha level assuming a difference of 20% in complication rate between operatively and conservatively treated patients. Primary outcome measures will be complication rate, Quick DASH score (Quick Disabilities of the Arm, Shoulder and Hand), PRWE (Patient rated Wrist evaluation), and range of motion of the wrist. Secondary outcome measures will be grip strength, pinch gauge, pain, use of pain medication EQ5D score (European Quality of life - 5 dimensions), standardized radiographs. One year of follow-up is planned with data collection at the day of injury, after 2 weeks, after 5 weeks, after 6 months, and after 12 months. An intention-totreat and per-protocol analysis will be performed. DISCUSSION: This prospective trial helps to clarify the best treatment strategy for displaced DRF patients ≥65 years. TRIAL REGISTRATION: This trial is approved by the Danish Scientific Ethical Committee (ID: 1-10-72-420-17) and registered at Clinicaltrials.gov (Trial registration number NCT03716661 ).


Assuntos
Tratamento Conservador/métodos , Fixação Interna de Fraturas/instrumentação , Complicações Pós-Operatórias/epidemiologia , Fraturas do Rádio/terapia , Fatores Etários , Idoso , Placas Ósseas , Moldes Cirúrgicos , Tratamento Conservador/efeitos adversos , Avaliação da Deficiência , Feminino , Fixação Interna de Fraturas/efeitos adversos , Fixação Interna de Fraturas/métodos , Humanos , Masculino , Complicações Pós-Operatórias/etiologia , Fraturas do Rádio/diagnóstico , Fraturas do Rádio/fisiopatologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Amplitude de Movimento Articular , Recuperação de Função Fisiológica , Resultado do Tratamento , Articulação do Punho/fisiopatologia
16.
Ann Vasc Surg ; 60: 415-423.e4, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31075482

RESUMO

BACKGROUND: Conservative treatment is feasible in most patients with spontaneous isolated dissection of the superior mesenteric artery (SID-SMA). However, the role of antiplatelet agents and anticoagulants is not well defined in either symptomatic or asymptomatic SID-SMA. This study aimed to conduct a meta-analysis, including a single-arm study, comparing the resolution rate of conservative management with versus without antithrombotics for symptomatic and asymptomatic SID-SMA. METHODS: A systematic search of electronic databases, including PubMed, EMBASE, and Cochrane Library, on August 22nd, 2018, was performed to identify studies concerning SID-SMA. Meta-analyses were conducted to determine the primary resolution rate, long-term aneurysmal change for symptomatic SID-SMA, and any event for asymptomatic SID-SMA. We calculated pooled risk ratios and 95% confidence intervals (CIs) using random-effects model in studies with two arms and in studies with two arms or a single arm. RESULTS: We included data from 35 articles involving 727 patients with SID-SMA (symptomatic 693, asymptomatic 134). No significant differences were observed in the successful resolution rate between conservative management with and without antithrombotics (random-effects model, risk ratio [RR] 0.96; 95% CI, 0.87-1.05]). The pooled resolution rate from combining single-arm studies was 91% (95% CI, 85-95) and 95% (95% CI, 88-100) in conservative management with and without antithrombotic, respectively, which was not statistically significant (RR, 0.97; 95% CI, 0.91-1.02). The pooled morphologic progression rate from combining single-arm studies was 3% (95% CI, 0-8) and 11% (95% CI, 2-26) in conservative management with and without antithrombotics, respectively, which was not statistically significant (RR, 0.44; 95% CI, 0.12-1.64). The adverse event was 0% for both groups for asymptomatic SID-SMA. CONCLUSIONS: Additional antithrombotic therapy for both symptomatic and asymptomatic SID-SMA did not benefit the outcomes. We do not recommend the use of antithrombotics for SID-SMA, unless further evidence shows any beneficial effect.


Assuntos
Aneurisma Dissecante/tratamento farmacológico , Tratamento Conservador/métodos , Fibrinolíticos/uso terapêutico , Artéria Mesentérica Superior/efeitos dos fármacos , Idoso , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/fisiopatologia , Tratamento Conservador/efeitos adversos , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Masculino , Artéria Mesentérica Superior/diagnóstico por imagem , Artéria Mesentérica Superior/fisiopatologia , Pessoa de Meia-Idade , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
18.
Medicine (Baltimore) ; 98(20): e15638, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31096481

RESUMO

BACKGROUNDS: There is no consensus concerning whether surgery or non-surgical treatment is preferred for displaced midshaft clavicle fracture. We performed a meta-analysis of randomized controlled trials (RCTs) to compare healing effects and cosmetic results between surgery and non-surgery. METHODS: We retrieved RCTs regarding open reduction and plate fixation (ORPF) and non-surgical method for the treatment of displaced midshaft clavicle fracture published before June 2018 from PubMed, EMBASE and Cochrane Library. The difference between the two treatments was comparatively discussed in aspects of nonunion, malunion, functional outcome, cosmetic results, and complications. RESULTS: Nine RCTs were included. The results showed that ORPF is advantageous over the non-surgical treatment in terms of nonunion rate (RR, 0.11[95%CI, 0.06-0.23]), malunion rate (RR, 0.16[95%CI, 0.08-0.35]), appearance dissatisfaction rate (RR, 0.35[95%CI 0.23-0.55]), and shoulder appearance defect rate (RR, 0.06[95%CI, 0.02-0.17]). The non-surgical treatment showed lower rate of complication (RR, 1.60[95%CI, 1.02-2.53]) and no significant differences were found between the 2 treatment groups with respect to functional outcome (disabilities of the arm, shoulder and hand (DASH) questionnaire score) (MD, -4.17[95%CI, -9.35 to 1.01]). CONCLUSIONS: This meta-analysis updated previous results. The current findings suggested that ORPF yielded better efficacy than conservation treatment for displaced midshaft clavicle fracture from perspectives of fracture healing and appearance.


Assuntos
Placas Ósseas , Clavícula/cirurgia , Tratamento Conservador/métodos , Fraturas Ósseas/cirurgia , Redução Aberta/métodos , Clavícula/lesões , Tratamento Conservador/efeitos adversos , Fraturas Ósseas/terapia , Fraturas não Consolidadas/cirurgia , Humanos , Redução Aberta/efeitos adversos , Dispositivos de Fixação Ortopédica , Modalidades de Fisioterapia , Ensaios Clínicos Controlados Aleatórios como Assunto , Amplitude de Movimento Articular
19.
Eur J Vasc Endovasc Surg ; 57(5): 676-684, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30982731

RESUMO

OBJECTIVE: Determining the maximum walking time (MWT) using the treadmill test is the gold standard method for evaluating walking capacity and treatment effect in patients with peripheral arterial disease (PAD). However, self reported functional disability is important when assessing quality of life. Changes in the Walking Estimated Limitation Calculated by History (WELCH) questionnaire scores were compared with the MWT. METHODS: A cross sectional study was performed in patients with intermittent claudication. The treadmill test (3.2 km/h; 10% gradient) and WELCH questionnaire were administered to all patients for objective evaluation of walking capacity. Given the log normal distribution of these parameters in patients with PAD, a log transformation was applied to the WELCH score (LnW) and maximum walking time (LnT). The responsiveness of the WELCH score was determined using mean changes and correlation coefficients of LnW and LnT changes. The effect of time on the "estimated minus real" (E - R) changes (LnW - change minus LnT - change) was assessed after categorisation of patients into various test-retest intervals. Patients who underwent lower limb revascularisation between the two tests and those who underwent medical treatment only were analysed. RESULTS: Correlation coefficients between LnW and LnT for tests 1 and 2 were r = 0.514 and r = 0.503, respectively (p < .001, for both). Correlation for LnW change vs. LnT change was 0.384 (p < .001). E - R was positive only early after surgery. E - R was negative for all test-retest intervals >1 year in revascularised and non-revascularised patients. CONCLUSION: Changes in WELCH scores correlated with changes observed on the treadmill in patients with intermittent claudication. For long test-retest intervals, WELCH changes tended to overestimate the worsening of walking impairment as compared with the measured difference observed in both revascularised and non-revascularised patients. A shortlived "honeymoon" (overestimation of the benefit for the shortest test-retest interval) was observed only in revascularised patients.


Assuntos
Tratamento Conservador , Teste de Esforço/métodos , Claudicação Intermitente , Doença Arterial Periférica/diagnóstico , Qualidade de Vida , Inquéritos e Questionários , Procedimentos Cirúrgicos Vasculares , Caminhada , Idoso , Tratamento Conservador/efeitos adversos , Tratamento Conservador/métodos , Correlação de Dados , Avaliação da Deficiência , Tolerância ao Exercício , Feminino , Humanos , Claudicação Intermitente/diagnóstico , Claudicação Intermitente/fisiopatologia , Claudicação Intermitente/psicologia , Claudicação Intermitente/terapia , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/métodos , Caminhada/fisiologia , Caminhada/psicologia
20.
Acta Orthop Traumatol Turc ; 53(4): 278-281, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30982758

RESUMO

OBJECTIVE: The aim of this study was to analyze and compare the results of reverse shoulder arthroplasty (RSA) in proximal humeral fracture sequelae (PHFS) in fractures initially treated conservatively versus those initially treated with open reduction and internal fixation (ORIF). METHODS: It is a retrospective study that includes all PHFS treated with a RSA from September 2006 to December 2013. Twenty-seven patients met the inclusion criteria. There were 9 patients (7 females and 2 males; mean age: 79.11 years) treated with RSA due to a fracture sequelae following conservative treatment and 18 patients (15 females and 3 males; mean age: 76.83 years) treated with a RSA owing to a fracture sequelae after ORIF. The functional outcome was recorded with the aid of the pre-surgery Constant Score and at the latest follow-up (minimum of two years). All the patients included underwent an imaging study that included plain X-Rays and a CT scan prior to surgery and plain X-Rays after surgery. All complications and reoperations during follow-up were also recorded. RESULTS: Both groups had significantly increased Constant Scores after surgery (p < 0.0001), but the patients in the conservative group had significantly better outcomes for the total Constant Score (p = 0.024), for forward elevation (p = 0.026) and for external rotation (p = 0.004). A total of 4 complications (14.8%) were present during the follow-up period. In the conservative group, 1 patient developed an infection and there were 2 dislocations and 1 infection in the ORIF group. CONCLUSION: The use of RSA in the treatment of PHFS results in a limited outcome improvement but with an acceptable complication rate. Patients developing PHFS after conservative treatment may expect better outcomes and fewer complications than those developing PHFS after ORIF. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.


Assuntos
Artroplastia do Ombro , Tratamento Conservador , Fixação Interna de Fraturas , Complicações Pós-Operatórias , Fraturas do Ombro/cirurgia , Idoso , Artroplastia do Ombro/efeitos adversos , Artroplastia do Ombro/métodos , Tratamento Conservador/efeitos adversos , Tratamento Conservador/métodos , Feminino , Fixação Interna de Fraturas/efeitos adversos , Fixação Interna de Fraturas/métodos , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Radiografia/métodos , Reoperação/métodos , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Fraturas do Ombro/diagnóstico , Resultado do Tratamento
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