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1.
Medicine (Baltimore) ; 100(13): e25334, 2021 Apr 02.
Artigo em Inglês | MEDLINE | ID: mdl-33787631

RESUMO

ABSTRACT: Cervical spine (C-spine) fractures in young children are very rare, and little information on treatment modalities and functional, radiographic, and patient-reported outcome exists. In this 2-center, retrospective case series, we assessed subjective and functional mid-term outcomes in children aged ≤5 years whose C-spine fractures were treated nonoperatively.Between 2000 and 2018, 6 children (median age at injury: 23.5 months; range: 16-31 months) with C1 or C2 injuries were treated with Minerva cast/brace or soft collar brace at 1 of the 2 study centers. Two patients suffered C1 fractures, and 4 patients had lysis of the odontoid synchondrosis. Overall, 3 children had sustained polytrauma. One child died due to the consequences of massive head injury.For the primary outcome parameter, we recorded subjective symptoms such as pain and functional restrictions due to the sequelae of C-spine injuries at follow-up.Based on medical records, we also assessed the causes of injury, diagnostic procedures, treatments and complications, and time to fracture consolidation.Median follow-up of the 5 surviving children was 51 months (range: 36-160 months). At the latest follow-up, 4 of 5 children did not complain of any pain. One child who sustained an open head injury in combination with a subluxation of the odontoid and undisplaced fracture of the massa lateralis reported occasional headache. All patients experienced complete fracture healing and normal range of motion of the cervical spine.Median duration of cast/brace treatment was 8.5 weeks. Fracture healing was confirmed by computed tomography in all patients.All C-spine injuries were managed with either Minerva cast/Halo brace or soft collar brace without complications.In our retrospective case series, nonoperative treatment of atlas fractures and dislocations or subluxations of the odontoid in young children using Minerva casts or prefabricated Halo braces resulted in good subjective and functional outcomes at mid-term. We observed no complications of conservative treatment of C1 and C2 injuries in young children.


Assuntos
Braquetes/efeitos adversos , Atlas Cervical/lesões , Tratamento Conservador/métodos , Processo Odontoide/lesões , Fraturas da Coluna Vertebral/terapia , Atlas Cervical/diagnóstico por imagem , Pré-Escolar , Tratamento Conservador/efeitos adversos , Tratamento Conservador/instrumentação , Feminino , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Incidência , Lactente , Masculino , Processo Odontoide/diagnóstico por imagem , Estudos Retrospectivos , Fraturas da Coluna Vertebral/diagnóstico , Fraturas da Coluna Vertebral/epidemiologia , Tomografia Computadorizada por Raios X , Centros de Traumatologia/estatística & dados numéricos , Resultado do Tratamento
2.
Clin Sports Med ; 40(2): 375-384, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33673893

RESUMO

Pelvic avulsion fractures are common in youth athletes; many of these injuries can be treated conservatively. This article reviews the etiology, presentation, and management of the more common pelvic avulsion fractures, including anterior superior iliac spine, anterior inferior iliac spine, ischial tuberosity, and iliac crest avulsions. Adolescent pelvic avulsion fractures rely on the amount of fracture displacement to guide treatment. Conservative management includes rest and avoiding use of the muscle(s) that attach to the avulsed fragment. Operative treatment is reserved for widely displaced fractures or symptomatic nonunions. With appropriate treatment, young athletes frequently return to their same level of sport.


Assuntos
Traumatismos em Atletas/diagnóstico , Fratura Avulsão/diagnóstico , Pelve/lesões , Adolescente , Atletas , Traumatismos em Atletas/terapia , Tratamento Conservador/efeitos adversos , Fixação Interna de Fraturas/efeitos adversos , Fraturas Ósseas/terapia , Humanos , Ílio/lesões , Ílio/cirurgia , Ísquio/lesões , Ísquio/cirurgia
3.
J Laryngol Otol ; 135(2): 182-184, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33593466

RESUMO

OBJECTIVE: This paper reports a rare case of a 61-year-old man with sialodochitis fibrinosa. METHODS: Clinical case report and review of current literature. RESULTS: Sialodochitis fibrinosa is a diagnosis of exclusion and in many cases can be managed conservatively. Conservative management failed for this patient and he was managed successfully with staged bilateral total parotidectomy. CONCLUSION: Sialodochitis fibrinosa should be considered as a differential diagnosis of painful bilateral facial swelling. While conservative management is successful for many patients, staged bilateral total parotidectomy may be necessary for full remission of symptoms; the timing of this is crucial to reduce the risk of facial nerve palsy.


Assuntos
Tratamento Conservador/efeitos adversos , Paralisia Facial/prevenção & controle , Glândula Parótida/cirurgia , Sialadenite/cirurgia , Tratamento Conservador/estatística & dados numéricos , Diagnóstico Diferencial , Humanos , Hipertrofia , Imagem por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Glândula Parótida/patologia , Infecções Respiratórias/complicações , Infecções Respiratórias/virologia , Sialadenite/diagnóstico por imagem , Sialadenite/patologia , Resultado do Tratamento
4.
Plast Reconstr Surg ; 147(1): 82e-93e, 2021 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-33370060

RESUMO

BACKGROUND: Fractures of the orbital roof require high-energy trauma and have been linked to high rates of neurologic and ocular complications. However, there is a paucity of literature exploring the association between injury, management, and visual prognosis. METHODS: The authors performed a 3-year retrospective review of orbital roof fracture admissions to a Level I trauma center. Fracture displacement, comminution, and frontobasal type were ascertained from computed tomographic images. Pretreatment characteristics of operative orbital roof fractures were compared to those of nonoperative fractures. Risk factors for ophthalmologic complications were assessed using univariable/multivariable regression analyses. RESULTS: In total, 225 patients fulfilled the inclusion criteria. Fractures were most commonly nondisplaced [n = 118 (52.4 percent)] and/or of type II frontobasal pattern (linear vault involving) [n = 100 (48.5 percent)]. Eight patients underwent open reduction and internal fixation of their orbital roof fractures (14.0 percent of displaced fractures). All repairs took place within 10 days from injury. Traumatic optic neuropathy [n = 19 (12.3 percent)] and retrobulbar hematoma [n = 11 (7.1 percent)] were the most common ophthalmologic complications, and led to long-term visual impairment in 51.6 percent of cases. CONCLUSIONS: Most orbital roof fractures can be managed conservatively, with no patients in this cohort incurring long-term fracture-related complications or returning for secondary treatment. Early fracture treatment is safe and may be beneficial in patients with vertical dysmotility, globe malposition, and/or a defect surface area larger than 4 cm2. Ophthalmologic prognosis is generally favorable; however, traumatic optic neuropathy is major cause of worse visual outcome in this population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.


Assuntos
Tratamento Conservador/estatística & dados numéricos , Fixação Interna de Fraturas/estatística & dados numéricos , Redução Aberta/estatística & dados numéricos , Fraturas Orbitárias/terapia , Complicações Pós-Operatórias/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Tratamento Conservador/efeitos adversos , Feminino , Fixação Interna de Fraturas/efeitos adversos , Hematoma/diagnóstico , Hematoma/epidemiologia , Hematoma/etiologia , Hematoma/prevenção & controle , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Redução Aberta/efeitos adversos , Traumatismos do Nervo Óptico/diagnóstico , Traumatismos do Nervo Óptico/epidemiologia , Traumatismos do Nervo Óptico/etiologia , Traumatismos do Nervo Óptico/prevenção & controle , Órbita/irrigação sanguínea , Órbita/diagnóstico por imagem , Órbita/lesões , Órbita/cirurgia , Fraturas Orbitárias/complicações , Fraturas Orbitárias/diagnóstico , Fraturas Orbitárias/epidemiologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Tempo para o Tratamento/estatística & dados numéricos , Tomografia Computadorizada por Raios X , Centros de Traumatologia/estatística & dados numéricos , Resultado do Tratamento , Adulto Jovem
5.
Can J Surg ; 63(5): E431-E434, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33009897

RESUMO

SUMMARY: Hepato-pancreato-biliary (HPB) injuries can be extremely challenging to manage. This scoping review (8438 citations) offers a number of recommendations. If diagnosis and therapy are rapid, patients with major hepatic injuries who present in physiologic extremis have high survival rates despite prolonged hospital stays. Nonoperative management of major liver injuries, as diagnosed using computed tomography, is typically successful. Adjuncts (e.g., angioembolization, laparoscopic washouts, biliary stents) are essential in managing high-grade injuries. Injury to the extrahepatic biliary tree is rare. Cholecystectomy is indicated for all gallbladder trauma. Full-thickness common bile duct injuries require a hepaticojejunostomy, although damage control remains closed suction drainage. Injuries to the pancreatic head often involve concurrent trauma to regional vasculature. Damage control necessitates drainage after stopping hemorrhage. Injury to the left pancreas commonly requires a distal pancreatectomy. Outcomes for high-grade pancreatic and liver injuries are improved by involving an HPB team. Complications are multidisciplinary and should be managed without delay.


Assuntos
Traumatismos Abdominais/terapia , Sistema Biliar/lesões , Fígado/lesões , Pâncreas/lesões , Traumatismos Abdominais/complicações , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/mortalidade , Sistema Biliar/diagnóstico por imagem , Tratamento Conservador/efeitos adversos , Tratamento Conservador/métodos , Tratamento Conservador/normas , Tratamento Conservador/estatística & dados numéricos , Humanos , Fígado/diagnóstico por imagem , Pâncreas/diagnóstico por imagem , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Guias de Prática Clínica como Assunto , Índice de Gravidade de Doença , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/métodos , Procedimentos Cirúrgicos Operatórios/normas , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Fatores de Tempo , Tempo para o Tratamento/normas , Tomografia Computadorizada por Raios X , Resultado do Tratamento
6.
Plast Reconstr Surg ; 146(2): 321-331, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32740582

RESUMO

BACKGROUND: Shoulder release and tendon transfer is frequently performed to address persistent weakness from neonatal brachial plexus palsy. Although postoperative improvements in motion are well described, associated deficits are poorly documented, and functional assessments are lacking. Loss of ability to reach midline can occur with surgery and may result in impairment. The purpose of this study was to comprehensively assess the gains, losses, functional changes, and patient-reported outcome associated with the authors' surgical approach. METHODS: Consecutive patients undergoing surgery with 2-year follow-up were included (n = 30). Prospectively recorded assessments by therapists were reviewed. Changes were assessed by t test and Wilcoxon rank sum (p < 0.05). RESULTS: Active external rotation and abduction improved and internal rotation diminished. Aggregate modified Mallet score increased with improvements in all subscales, except that hand to spine was unchanged and hand to belly decreased. Functional assessment using the Brachial Plexus Outcome Measure revealed an increase of aggregate score, with no decline in any subscales. Improvements were in hand to back of head, forward overhead reach, holds plate with palm up, opening large container, and strings bead. Aggregate patient self-report of appearance and function increased (from 18 to 23). Loss of ability to reach midline occurred in three patients (10 percent) who had extended Erb or total palsy and preoperative limitations of internal rotation. CONCLUSIONS: Secondary reconstruction rebalances shoulder motion by increasing external rotation and abduction and reducing internal rotation. In this study, a conservative surgical approach results in overall improvement in task-based abilities and self-reported outcomes and preservation of internal rotation within a functional range. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.


Assuntos
Tratamento Conservador/métodos , Paralisia do Plexo Braquial Neonatal/cirurgia , Amplitude de Movimento Articular , Articulação do Ombro/fisiopatologia , Transferência Tendinosa/métodos , Moldes Cirúrgicos , Tratamento Conservador/efeitos adversos , Feminino , Seguimentos , Humanos , Masculino , Paralisia do Plexo Braquial Neonatal/fisiopatologia , Paralisia do Plexo Braquial Neonatal/reabilitação , Estudos Retrospectivos , Autorrelato/estatística & dados numéricos , Articulação do Ombro/inervação , Articulação do Ombro/cirurgia , Transferência Tendinosa/efeitos adversos , Resultado do Tratamento
7.
Ann Vasc Surg ; 69: 246-253, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32512111

RESUMO

BACKGROUND: Behcet's disease with arterial involvement shows rapid poor progression compared with Behcet's disease without arterial involvement, such that it may be thought of as a different disease. With arterial involvement, high rates of postoperative recurrence and anastomotic complications are observed. METHODS: The medical records of 1,361 patients diagnosed with Behcet's disease who visited our hospital from January 2007 to December 2019 were reviewed. Overall, 118 patients with blood vessel involvement were considered. Those with only vein involvement, intracerebral arterial involvement, and coronary arterial involvement were excluded. The 8 patients who underwent surgical treatments and the 9 patients who underwent conservative treatments were included and reported in this study. RESULTS: The mean age and mean follow-up duration of the 17 patients with peripheral arterial involvement were 49.82 ± 13.24 years and 89.85 ± 52.70 months, respectively. In all cases where the operations were performed, the first operation was an emergency operation for rupture of the aneurysm, impending sign of rupturing, or acute ischemia. Eight patients received a total of 18 operations. The average number of operations per patient and the reoperation rate were 2.25 ± 0.89 times and 75%, respectively. The 5-year and 10-year survival rates of the patients who underwent surgery were 75.0% and 30.0%, respectively. When arterial involvement occurs in the form of an aneurysm, the hazard ratio for death is 9.644 (P = 0.040, confidence interval 1.11-83.74). CONCLUSIONS: When the artery invades in the form of an aneurysm, the mortality rate is higher regardless of surgery. The main cause of mortality is complications that occur in the anastomosis sites after the operation. Postoperative short-term and regular imaging of the anastomosis area can be beneficial to detect such complications early to decrease the frequency of emergency surgeries, which will help reduce mortality.


Assuntos
Aneurisma/terapia , Síndrome de Behçet/terapia , Tratamento Conservador , Doença Arterial Periférica/terapia , Procedimentos Cirúrgicos Vasculares , Adulto , Aneurisma/diagnóstico por imagem , Aneurisma/mortalidade , Síndrome de Behçet/diagnóstico por imagem , Síndrome de Behçet/mortalidade , Tratamento Conservador/efeitos adversos , Tratamento Conservador/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Recidiva , Reoperação , República da Coreia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade
8.
Tunis Med ; 98(2): 131-137, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32395802

RESUMO

INTRODUCTION: The subdivision into two entities of papillary renal cell carcinoma (PRCC) was established on histological criteria. It's in fact possible to distinguish the two subtypes by the means of radiological and progressive data. The subtype 1 is associated with the favorable profile. The ultrasound and especially CT urography ensure an accurate diagnostic approach with substantial therapeutic and prognostic involvement. The aim of the study is to define the radiological features that distinguish the two subtypes of renal papillary carcinoma, and to study the radiological predictive factors of locoregional recurrence, metastases free survival and specific survival. METHODS: It's about a monocentric, retrospective study led between January 2005 and June 2017, gathering 49 cases of operated PRCC. The study concerned patients over the age of 18, who were diagnosed after anatomopathological examination of the operative specimen (enlarged nephrectomy or conservative surgery). Cases in which diagnosis was made by renal biopsy were excluded. The comparative study concerned ultrasound and CT scan data. Univariate and multivariate analysis were performed to determine factors having a prognostic value in terms of locoregional recurrence, metastases-free and specific survival. RESULTS: On the ultrasound, the subtype 1 tumors were significantly homogenous with regular contours. Tumors were globally spontaneously hypodense and hypo vascular in 97,8% of cases. Enhancement was significantly more heterogonous for subtype 2 (p=0,01). Intratumoral necrosis and adenomegalies were associated with subtype 2 (p=0,0001 and 0,005). The predictive factors of locoregional recurrence, metastases-free survival and specific survival in univariate analysis were the contours' aspect, moderate enhancement and the presence of adenomegalies. On multivariate analysis, only the irregular contours were retained for locoregional recurrence-free survival and specific survival. CONCLUSIONS: Significant differences between the PRCC subtypes were observed when studying the radiological data. Irregular contours, adenomegalies and enhancement degree seemed to predict the progression of PRCC after curative surgery.


Assuntos
Carcinoma de Células Renais/diagnóstico , Diagnóstico por Imagem/métodos , Neoplasias Renais/diagnóstico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Renais/mortalidade , Carcinoma de Células Renais/patologia , Carcinoma de Células Renais/cirurgia , Tratamento Conservador/efeitos adversos , Tratamento Conservador/métodos , Feminino , Humanos , Neoplasias Renais/mortalidade , Neoplasias Renais/patologia , Neoplasias Renais/cirurgia , Masculino , Pessoa de Meia-Idade , Metástase Neoplásica , Recidiva Local de Neoplasia/diagnóstico , Recidiva Local de Neoplasia/etiologia , Estadiamento de Neoplasias , Nefrectomia/efeitos adversos , Nefrectomia/métodos , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Tomografia/métodos , Ultrassonografia/métodos , Adulto Jovem
9.
Vascular ; 28(5): 577-582, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32393107

RESUMO

OBJECTIVE: Primary venous aneurysms are unusual vascular occurrences. Our aim is to document our institution's experience with this pathology; describing frequency, diagnosis, outcomes and medical histories of patients with primary venous aneurysms within a 20-year time frame. METHODS: A retrospective study at our institution using its radiology database was conducted. Results were isolated to primary venous aneurysms diagnosed between 1997 and 2017. Basic demographics and medical history were collected. RESULTS: We identified 32 patients with primary venous aneurysms. Eighteen were male and 14 were female. The average age of presentation was 54 years old, with a range of 17-86. None of these patients reported a family history of aneurysmal disease. The majority were incidental. Of these aneurysms, 3 were of the head and neck, 1 was contained in the thorax, 17 were intra-abdominal and 11 were peripheral. Diagnosis was made by computed tomography, duplex ultrasound, or magnetic resonance imaging. Conservative management was most frequently employed, but four patients underwent surgical repair. Three aneurysms required operation for symptom management (external jugular, subclavian, inferior vena cava), whereas one aneurysm of the popliteal vein was prophylactically managed, given the high risk for pulmonary embolism. CONCLUSIONS: Primary venous aneurysms present infrequently. Despite their rarity, primary venous aneurysms have been reported to occur throughout the venous system. The majority of primary venous aneurysms in this series were found incidentally and can present both symptomatically or asymptomatically. The findings of our 20-year experience were consistent with the existing literature. Because the risk of rupture is negligible, the indications for surgical management remain for cosmesis, symptom management or high risk of thromboembolic events.


Assuntos
Aneurisma/terapia , Tratamento Conservador , Procedimentos Cirúrgicos Vasculares , Veias/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma/diagnóstico por imagem , Tratamento Conservador/efeitos adversos , Bases de Dados Factuais , Feminino , Humanos , Achados Incidentais , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Veias/diagnóstico por imagem , Adulto Jovem
10.
BMC Cardiovasc Disord ; 20(1): 256, 2020 05 29.
Artigo em Inglês | MEDLINE | ID: mdl-32471346

RESUMO

BACKGROUND: Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare vascular disorder, and the treatment strategies remain controversial. This study aimed to compare outcomes of conservative and endovascular treatments in symptomatic patients with SISMAD. METHODS: Forty-two consecutive SISMAD patients who were admitted to a single center between October 2009 and May 2018 were enrolled in this study. Based on their symptoms, 15 had conservative treatment, and 27 had endovascular treatment. The baseline characteristics, treatments, and follow-up results of the conservative group and endovascular group were analysed. RESULTS: The rates of symptom relief were 93.3% in the conservative group and 96.3% in the endovascular group. The procedure-related complications in the endovascular group included one case of pseudoaneurysm formation in the left brachial artery. During the follow-up period (median 28.5 months), a higher proportion of patients in the conservative group had symptom recurrence (42.9% in the conservative group versus 4.8% in the endovascular group, p < 0.001). Four patients in the conservative group and one patient in the endovascular group had additional endovascular intervention during follow-up. Compared with the conservative group, patients in the endovascular group had statistically significantly longer symptom-free survival (p = 0.014) and a higher rate of superior mesenteric artery (SMA) remodeling (p < 0.001). CONCLUSIONS: For symptomatic SISMAD, endovascularly treated patients had a lower rate of symptom recurrence and a higher rate of SMA remodeling in the long term. Prospective, multi-center studies are needed to confirm the long-term outcomes of both treatments.


Assuntos
Aneurisma Dissecante/terapia , Tratamento Conservador , Procedimentos Endovasculares , Artéria Mesentérica Superior/cirurgia , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/fisiopatologia , Tratamento Conservador/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Masculino , Artéria Mesentérica Superior/diagnóstico por imagem , Artéria Mesentérica Superior/fisiopatologia , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Remodelação Vascular
11.
Acta Orthop Traumatol Turc ; 54(2): 213-216, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32254039

RESUMO

Forefoot injuries are commonly caused by sport-related activities and are often around the metatarsophalangeal joints. The hallux interphalangeal (IP) joint is anatomically stable; therefore, injuries to this joint are considered to be rare compared with those to the metatarsophalangeal joint. Instability of the hallux IP joint has rarely been reported in barefoot contact sports, and its treatment has not been sufficiently explored.This study investigated chronic varus instability of the hallux IP joint. We performed a surgical reconstruction owing to conservative treatment failure. A good surgical outcome was achieved by reconstruction of the collateral ligament using the 4th extensor tendon-a promising alternative treatment option for this type of injury. This method indicated no morbidity outside the site of surgery and was more cost-effective than reconstruction using an allograft.


Assuntos
Hallux , Instabilidade Articular/cirurgia , Articulação Metatarsofalângica , Transferência Tendinosa/métodos , Ligamentos Colaterais/cirurgia , Tratamento Conservador/efeitos adversos , Hallux/lesões , Hallux/cirurgia , Humanos , Masculino , Articulação Metatarsofalângica/lesões , Articulação Metatarsofalângica/cirurgia , Resultado do Tratamento , Adulto Jovem
12.
Ann Vasc Surg ; 67: 105-114, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32240729

RESUMO

BACKGROUND: This study was performed to determine the association of frailty and comorbidity status with postoperative morbidity and mortality in patients with acute mesenteric ischemia (AMI). METHODS: Patients diagnosed with AMI between April 2006 and September 2019 were enrolled in this study. Frailty was evaluated by sarcopenia which was diagnosed by third lumbar vertebra psoas muscle area (PMA). Comorbidity status was evaluated by the Charlson Comorbidity Index (CCI) score. Univariate and multivariate analyses evaluating the risk factors for postoperative morbidity and mortality were performed. RESULTS: Of the 174 patients, 86 were managed conservatively and 88 underwent surgery. In surgically managed patients, 39.8% developed complications within 30 days of surgery. Ten patients died within 30 days of the operation. In the univariate analyses, white blood cell >10 g/L, low PMA, CCI score ≥2, and bowel resection were associated with postoperative complications. Multivariate analysis revealed that low PMA, CCI score ≥2, and bowel resection were independent predictors of postoperative complications. CONCLUSIONS: This study demonstrated that low PMA, CCI score ≥2, and bowel resection were independent risk factors for postoperative complications in patients with AMI. Preoperative assessment of frailty using PMA and the evaluation of comorbidity status using CCI may serve as helpful tools in preoperative risk assessment and should be integrated into scoring systems for surgically treated AMI.


Assuntos
Regras de Decisão Clínica , Tratamento Conservador , Idoso Fragilizado , Fragilidade/diagnóstico por imagem , Isquemia Mesentérica/terapia , Oclusão Vascular Mesentérica/terapia , Músculos Psoas/diagnóstico por imagem , Sarcopenia/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Procedimentos Cirúrgicos Vasculares , Doença Aguda , Adulto , Fatores Etários , Idoso , Composição Corporal , Tomada de Decisão Clínica , Comorbidade , Tratamento Conservador/efeitos adversos , Tratamento Conservador/mortalidade , Procedimentos Cirúrgicos Eletivos , Feminino , Fragilidade/mortalidade , Fragilidade/fisiopatologia , Nível de Saúde , Humanos , Masculino , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/mortalidade , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/mortalidade , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Músculos Psoas/fisiopatologia , Medição de Risco , Fatores de Risco , Sarcopenia/mortalidade , Sarcopenia/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade
13.
Ann R Coll Surg Engl ; 102(5): 375-382, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32233854

RESUMO

INTRODUCTION: Selective non-operative management (SNOM) for penetrating abdominal injury (PAI) is accepted in trauma centres in South Africa and the US. Owing to the low incidence of gunshot wounds (GSWs) in Western Europe, few are inclined to practise SNOM for such injuries although it is considered for stab wounds (SWs). This study evaluated the outcome of patients admitted to a Dutch level 1 trauma centre with PAI. METHODS: A retrospective study was undertaken of all PAI patients treated over 15 years. In order to prevent bias, patients admitted six months prior to and six months following implementation of a treatment algorithm were excluded. Data concerning type of injury, injury severity score and treatment were compared. RESULTS: A total of 393 patients were included in the study: 278 (71%) with SWs and 115 (29%) with GSWs. Of the 178 SW patients in the SNOM group, 111 were treated before and 59 after introduction of the protocol. The SNOM success rates were 90% and 88% respectively (p=0.794). There were 43 patients with GSWs in the SNOM cohort. Of these, 32 were treated before and 11 after implementation of the algorithm, with respective success rates of 94% and 100% (p=0.304).The protocol did not bring about any significant change in the rate of non-therapeutic laparotomies for SWs or GSWs. However, the rate of admission for observation for SWs increased from 83% to 100% (p<0.001). There was a decrease in ultrasonography for SWs (from 84% to 32%, p<0.001) as well as for GSWs (from 87% to 43%, p<0.001). X-ray was also used less for GSWs after the protocol was introduced (44% vs 11%, p=0.001). CONCLUSIONS: SNOM for PAI resulting from either SWs or GSWs can be safely practised in Western European trauma centres. Results are comparable with those in trauma centres that treat high volumes of PAI cases.


Assuntos
Traumatismos Abdominais/terapia , Tratamento Conservador/métodos , Ferimentos por Arma de Fogo/terapia , Ferimentos Perfurantes/terapia , Traumatismos Abdominais/diagnóstico , Adulto , Protocolos Clínicos , Tratamento Conservador/efeitos adversos , Tratamento Conservador/estatística & dados numéricos , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Países Baixos , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Centros de Traumatologia/estatística & dados numéricos , Resultado do Tratamento , Ferimentos por Arma de Fogo/diagnóstico , Ferimentos Perfurantes/diagnóstico , Adulto Jovem
14.
Ann Vasc Surg ; 67: 395-402, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32179142

RESUMO

BACKGROUND: Multiple societal guidelines recommend medical optimization and exercise therapy for patients with claudication prior to lower extremity revascularization (LER). However, the application of those guidelines in practice remains unknown. Our hypothesis is that vascular surgeons (VS) are more adherent to guidelines compared to non-VS treating claudication. METHODS: The records of patients undergoing LER for claudication in a single center were reviewed, and adherence to guidelines prior to LER was assessed. Patients received conservative therapy if the impact of claudication on quality of life was documented, ankle-brachial index (ABI) was obtained, and patients were treated with at least 3 months of walking exercise and smoking cessation when indicated. RESULTS: There were 187 patients treated for claudication (VS = 65, non-VS = 122). There were 161 patients who underwent endovascular intervention, 19 patients had an open revascularization, and 7 patients had a hybrid procedure. Patients treated by VS were younger and more likely to be African American. Patients treated by non-VS were more likely to have hyperlipidemia, coronary artery disease, smoke, and be on antiplatelet and statin medications. VS was more likely to assess pattern of symptoms with claudication and obtain ABIs compared to non-VS, although the mean ABIs were no different. VS was more likely to use walking exercises and smoking cessation when indicated before LER. Even though 70.8% and 31.1% of patients treated by VS and non-VS respectively were recommended walking exercises, only 33.8% and 18.0% were given a period of 3 months to benefit from it prior to LER. Conservative therapy was significantly higher among VS compared to non-VS but was overall low (VS = 12.3%, non-VS = 3.3%, P = 0.016). After a mean follow-up of 3.1 ± 1.3 years, there was no difference in mortality or major amputation. CONCLUSIONS: Although adherence to guidelines in the medical management of vascular claudication prior to LER was higher among VS compared with non-VS, overall rates of adherence were low. Stricter institutional protocols and oversight across specialties are needed to reinforce the application of the established standards of care.


Assuntos
Tratamento Conservador/normas , Procedimentos Endovasculares/normas , Claudicação Intermitente/terapia , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/terapia , Padrões de Prática Médica/normas , Comportamento de Redução do Risco , Centros de Atenção Terciária/normas , Procedimentos Cirúrgicos Vasculares/normas , Idoso , Tratamento Conservador/efeitos adversos , Tratamento Conservador/mortalidade , Registros Eletrônicos de Saúde , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Fidelidade a Diretrizes/normas , Disparidades em Assistência à Saúde/normas , Humanos , Claudicação Intermitente/diagnóstico , Claudicação Intermitente/mortalidade , Claudicação Intermitente/fisiopatologia , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Guias de Prática Clínica como Assunto/normas , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade
15.
J Stroke Cerebrovasc Dis ; 29(6): 104795, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32222416

RESUMO

OBJECTIVE: Japan has the largest elderly population in the world. As data on the clinical outcomes in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH), including those older than 80 years, are lacking, we analyzed the characteristics of 54,805 aSAH patients and recorded their treatments and clinical outcomes using a Japanese nationwide inpatient database. METHODS: Using the Japanese Diagnostic Procedure Combination database, we identified aSAH patients aged 18 years or older who were hospitalized between July 1, 2010 and March 31, 2016. They were categorized as less than or equal to 60-, 61-70-, 71-80-, 81-90-, and greater than or equal to 91 years of age. The primary outcome was the modified Rankin Scale (mRS) score at discharge. Multivariable logistic regression analysis was performed to examine factors affecting the mRS score at discharge. RESULTS: Of 54,805 patients, 37.5% were aged less than or equal to 60 years; 24.8% were 61-70-, 21.8% were 71-80-, 13.9% were 81-90-, and 2.0% were greater than or equal to 91 years old at the time of the insult. Among 46,107 patients younger than 81 years, 58.9% underwent surgical clipping (SC), 22.9% endovascular coiling (EC), and 18.2% were treated conservatively. There were 8,698 patients aged 81 years or older, 32.4% underwent SC, 23.2% EC, and 44.4% were treated conservatively. A poor mRS score (3-6) at discharge was recorded in 87.2% of patients older than 80 years. Multivariable logistic regression was used to compare their estimated odds ratio (OR) for a poor mRS score at discharge with that of patients aged less than or equal to 60 years. The OR increased by 87% in patients between 61 and 70 years of age (P < .001; OR, 1.87; 95% confidence interval (CI), 1.77-1.98), by 358% in patients aged from 71 to 80 years (P < .001; OR, 4.58; 95%CI, 4.29-4.89), by 1,035% in patients between 81 and 90 years (P < .001; OR, 11.35; 95%CI, 10.32-12.49), and by 1,710% in patients aged more than or equal to 91 years (P < .001; OR, 18.10; 95%CI, 13.96-23.46). CONCLUSIONS: As the treatment outcomes in elderly aSAH patients, especially those 80 years old or older, were poor, the appropriate therapy decisions must be made on a case-by-case basis.


Assuntos
Tratamento Conservador , Procedimentos Endovasculares , Procedimentos Neurocirúrgicos , Hemorragia Subaracnóidea/terapia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisão Clínica , Tratamento Conservador/efeitos adversos , Tratamento Conservador/mortalidade , Bases de Dados Factuais , Avaliação da Deficiência , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Nível de Saúde , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/efeitos adversos , Procedimentos Neurocirúrgicos/mortalidade , Recuperação de Função Fisiológica , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Hemorragia Subaracnóidea/diagnóstico , Hemorragia Subaracnóidea/mortalidade , Fatores de Tempo , Resultado do Tratamento
16.
J Vasc Surg ; 72(1): 84-91, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32089340

RESUMO

BACKGROUND: The optimum management of isolated penetrating aortic ulceration (PAU), with no associated intramural hematoma or aortic dissection is not clear. We evaluate the short- and long-term outcomes in isolated PAU to better inform management strategies. METHODS: We conducted a retrospective review of 43 consecutive patients (mean age, 72.2 years; 26 men) with isolated PAU (excluding intramural hematoma/aortic dissection) managed at a single tertiary vascular unit between November 2007 and April 2019. Twenty-one percent had PAU of the arch, 62% of the thoracic aorta, and 17% of the abdominal aorta. Conservative and surgical groups were analyzed separately. Primary outcomes included mortality, PAU progression, and interventional complications. RESULTS: Initially, 67% of patients (29/43) were managed conservatively; they had significantly smaller PAU neck widths (P = .04), PAU depths (P = .004), and lower rates of associated aneurysmal change (P = .004) compared with those initially requiring surgery. Four patients (4/29) initially managed conservatively eventually required surgical management at a mean time interval of 49.75 months (range, 9.03-104.33 months) primarily owing to aneurysmal degeneration. Initially, 33% of patients (14/43) underwent surgical management; 7 of the 14 procedures were urgent. Of the 18 patients, 17 eventually managed with surgical intervention had an endovascular repair; 2 of the 17 endovascular cases involved supra-aortic debranching, six used scalloped, fenestrated, or chimney stents. The overall long-term mortality was 30% (mean follow-up, 48 months; range, 0-136 months) with no significant difference between the conservatively and surgically managed groups (P = .98). No aortic-related deaths were documented during follow-up in those managed conservatively. There was no in-hospital mortality after surgical repair. Of these 18 patients, two required reintervention within 30 days for type I or III endoleaks. Among the 18 patients, seven died during follow-up (mean survival, 90.24 months; range, 66.48-113.88) with 1 of the 18 having a confirmed aortic-related death. CONCLUSIONS: Isolated, asymptomatic, small PAUs may be safely managed conservatively with regular surveillance. Those with high-risk features or aneurysmal progression require complex strategies for successful treatment with acceptable long-term survival.


Assuntos
Doenças da Aorta/terapia , Implante de Prótese Vascular , Tratamento Conservador , Procedimentos Endovasculares , Úlcera/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Tratamento Conservador/efeitos adversos , Tratamento Conservador/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Úlcera/diagnóstico por imagem , Úlcera/mortalidade
17.
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
19.
JAMA Netw Open ; 3(1): e1918663, 2020 01 03.
Artigo em Inglês | MEDLINE | ID: mdl-31922556

RESUMO

Importance: Meta-analyses of randomized clinical trials suggest that the advantages and risks of surgery compared with conservative management as the initial treatment for proximal humerus fracture (PHF) vary, or are heterogeneous across patients. Substantial geographic variation in surgery rates for PHF suggests that the optimal rate of surgery across the population of patients with PHF is unknown. Objective: To use geographic variation in treatment rates to assess the outcomes associated with higher rates of surgery for patients with PHF. Design, Setting, and Participants: This comparative effectiveness research study analyzed all fee-for-service Medicare beneficiaries with proximal humerus fracture in 2011 who were continuously enrolled in Medicare Parts A and B for the 365-day period before and immediately after their index fracture. Data analysis was performed January through June 2019. Exposure: Undergoing 1 of the commonly used surgical procedures in the 60 days after an index fracture diagnosis. Main Outcomes and Measures: Risk-adjusted area surgery ratios were created for each hospital referral region as a measure of local area practice styles. Instrumental variable approaches were used to assess the association between higher surgery rates and adverse events, mortality risk, and cost at 1 year from Medicare's perspective for patients with PHF in 2011. Instrumental variable models were stratified by age, comorbidities, and frailty. Instrumental variable estimates were compared with estimates from risk-adjusted regression models. Results: The final cohort included 72 823 patients (mean [SD] age, 80.0 [7.9] years; 13 958 [19.2%] men). The proportion of patients treated surgically ranged from 1.8% to 33.3% across hospital referral regions in the United States. Compared with conservatively managed patients, surgical patients were younger (mean [SD] age, 80.4 [8.1] years vs 78.0 [7.2] years; P < .001) and healthier (Charlson Comorbidity Index score of 0, 14 863 [24.4%] patients vs 3468 [29.1%] patients; Function-Related Indicator score of 0, 20 720 [34.0%] patients vs 4980 [41.8%] patients; P < .001 for both), and a larger proportion were women (49 030 [80.5%] patients vs 9835 [82.5%] patients; P < .001). Instrumental variable analysis showed that higher rates of surgery were associated with increased total costs ($8913) during the treatment period, increased adverse event rates (a 1-percentage point increase in the surgery rate was associated with a 0.19-percentage point increase in the 1-year adverse event rate; ß = 0.19; 95% CI, 0.09-0.27; P < .001), and increased mortality risk (a 1-percentage point increase in the surgery rate was associated with a 0.09-percentage point increase in the 1-year mortality rate; ß = 0.09; 95% CI, 0.04-0.15; P < .01). Instrumental variable mortality results were even more striking for older patients and those with higher comorbidity burdens and greater frailty. Risk-adjusted estimates suggested that surgical patients had higher costs (increase of $17 278) and more adverse events (a 1-percentage point increase in the surgery rate was associated with a 0.12-percentage point increase in the 1-year adverse event rate; ß = 0.12; 95% CI, 0.11 to 0.13; P < .001) but lower risk of mortality after PHF (a 1-percentage point increase in the surgery rate was associated with a 0.01-percentage point decrease in the 1-year mortality rate; ß = -0.01; 95% CI, -0.015 to -0.005; P < .001). Conclusions and Relevance: This study found that higher rates of surgery for treatment of patients with PHF were associated with increased costs, adverse event rates, and risk of mortality. Orthopedic surgeons should be aware of the harms of extending the use of surgery to more clinically vulnerable patient subgroups.


Assuntos
Procedimentos Ortopédicos/efeitos adversos , Procedimentos Ortopédicos/mortalidade , Fraturas do Ombro/cirurgia , Idoso , Idoso de 80 Anos ou mais , Tratamento Conservador/efeitos adversos , Tratamento Conservador/economia , Tratamento Conservador/estatística & dados numéricos , Feminino , Humanos , Masculino , Medicare/estatística & dados numéricos , Procedimentos Ortopédicos/economia , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Estudos Retrospectivos , Risco Ajustado , Fraturas do Ombro/epidemiologia , Estados Unidos/epidemiologia
20.
Ann R Coll Surg Engl ; 102(4): 243-247, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31918554

RESUMO

INTRODUCTION: Since the seminal works by Singh and Blandy in the 1970s, the management of staghorn stones has almost exclusively involved surgical intervention. In contrast, a more recent study found that conservative management was not as unsafe as previously believed. The present review sought to examine the available literature to understand the implications of a conservative strategy. METHODS: A systematic search of the literature was carried out using MEDLINE®, Embase™ and the Cochrane Central Register of Controlled Trials. All papers looking at management of staghorn calculi were reviewed and studies with a conservative management arm were identified. Outcomes of interest were recurrent or severe urinary tract infections, progressive renal deterioration, dialysis requirements, morbidity and disease specific mortality. Owing to the lack of relevant data, a descriptive review was carried out. RESULTS: Our literature search yielded 10 suitable studies involving a total of 304 patients with staghorn stones managed conservatively. Progressive renal deterioration occurred in 0-100% of cases (mean 27.5%) with a higher rate among bilateral staghorn sufferers (44% vs 9%). Dialysis was required in 9% of patients (20% bilateral, 6% unilateral). The mean rate of severe infection was 8.7% and recurrent urinary tract infections occurred in as high as 50% of cases (80% bilateral, 41% unilateral). Disease specific mortality ranged from 0% to 67% (mean 20.5%). CONCLUSIONS: It appears that conservative management of staghorn calculi is not as unsafe as previously thought and selection of patients with unilateral asymptomatic stones with minimal infection should be considered.


Assuntos
Tratamento Conservador/efeitos adversos , Insuficiência Renal/epidemiologia , Cálculos Coraliformes/terapia , Infecções Urinárias/epidemiologia , Tratamento Conservador/métodos , Humanos , Diálise Renal/estatística & dados numéricos , Insuficiência Renal/etiologia , Insuficiência Renal/terapia , Índice de Gravidade de Doença , Cálculos Coraliformes/complicações , Cálculos Coraliformes/mortalidade , Infecções Urinárias/diagnóstico , Infecções Urinárias/etiologia
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