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1.
Medicine (Baltimore) ; 100(2): e24055, 2021 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-33466161

RESUMO

ABSTRACT: Magnetic foreign bodies ingestion is a special cause for attending emergency department. Here, we aim to analyze the characteristics and treatments of children who ingested magnetic foreign bodies (Buckyballs). Data were collected from children who ingested Buckyballs between February 2017 and October 2019. A retrospective analysis was performed to summarize the experiences of conservative treatment, gastroscopy and surgery when dealing with Buckyballs ingestion.A total of 49 patients with buckyballs ingestion were identified, of whom 11 underwent conservative treatments, 6 underwent gastroscopy, and 32 underwent surgery. Among such individuals, eight patients (72.7%) had a successful conservative treatment (number of Buckyballs [NB]: 3.5[IQR: 2.0-4.0]); four patients (66.7%) had Buckyballs successfully removed by gastroscopy (NB: 3.5[IQR: 3.0-5.5]); 16 asymptomatic (50%) patients (NB: 4.0[IQR: 3.0-8.0]) and 16 symptomatic (50%) patients (NB: 8.5 [IQR: 6.25-11.75]) received emergency surgery. Compared to patients who received conservative treatment, the number of ingested Buckyballs was significantly higher in patients who received surgery or gastroscopy (7.0 [IQR: 3.0-10.75] vs 3.5 [IQR: 2.0-4.0], P < .05). The risk of intestinal perforation was significantly higher in symptomatic patients (P < .05) compared to asymptomatic patients.Gastroscopy is recommended when Buckyballs are in the stomach or esophagus. In asymptomatic patients, conservative treatment can be considered for 4 to 6 days. Patients failing conservative treatment, or those who are symptomatic should undergo emergency surgery.


Assuntos
Abdome , Tratamento Conservador/estatística & dados numéricos , Tratamento de Emergência/estatística & dados numéricos , Corpos Estranhos/terapia , Gastroscopia/estatística & dados numéricos , Imãs , Criança , Pré-Escolar , Serviço Hospitalar de Emergência , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Resultado do Tratamento
2.
Artigo em Inglês | MEDLINE | ID: mdl-33317118

RESUMO

BACKGROUND: To evaluate the effectiveness of conservative treatment with functional appliances for condylar fractures in pediatric age. METHODS: Four electronic databases (PubMed, EBSCO, Scopus, and Web of Science) were consulted with no restriction of publication status or year, up to 31 August 2020. SELECTION CRITERIA: based on the PICOS criteria, the selection criteria were set for observational human studies, with at least 10 patients and six months of follow-up. The study population included pediatric patients (aged 5-16 years), with unilateral or bilateral condylar fracture, treated with functional appliances. Condylar remodeling and mandibular growth were analyzed through sequential radiographic examinations. DATA COLLECTION AND ANALYSIS: Two independent reviewers carried out title-abstract screening, and a senior investigator was involved to solve any disagreement. The quality of the evidence was assessed through the Canada Institute of Health Economics (IHE) quality appraisal checklist, and the National Institutes of Health (NIH) quality assessment tool. RESULTS: A total of 971 articles were retrieved from the electronic search; among them, three studies met the eligibility criteria. A moderate risk of bias was detected in all the studies, due to common limitations (absence of multicenter studies, prospective design, blindness of the investigators, patients' drop-out). At follow-up examinations (between 6 months and 4.9 years), the difference of condylar neck length between the "injured" and "healthy" side was approximately 2 mm, while the anteroposterior condylar width discrepancy was recorded up to 1 mm. CONCLUSIONS: Short- and long-term data revealed that conservative treatment with functional appliances led to partial or full radiological recovery of the joint morphology, along with good to excellent functional results. Patients' age has a crucial role on the treatment choice, and the type of fracture (presence of condylar displacement, or dislocation) is also a major prognostic indicator of the radiologic outcome. LIMITATION: To confirm the effectiveness of functional appliances, more prospective clinical long-term follow-up studies with homogeneous samples of condylar fractures are deemed necessary. Registration: The study protocol was registered on PROSPERO (CRD42020205650).


Assuntos
Tratamento Conservador , Fraturas Mandibulares , Adolescente , Canadá , Criança , Pré-Escolar , Tratamento Conservador/estatística & dados numéricos , Humanos , Fraturas Mandibulares/diagnóstico por imagem , Fraturas Mandibulares/terapia , Aparelhos Ortodônticos Fixos/estatística & dados numéricos , Estudos Prospectivos , Radiografia Panorâmica , Estudos Retrospectivos , Resultado do Tratamento
3.
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
4.
Surgery ; 168(3): 434-439, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32600882

RESUMO

BACKGROUND: Pancreatoduodenectomy with synchronous resection of the portal vein/superior mesenteric vein confluence may result in the development of left-sided portal hypertension. Left-sided portal hypertension presents with splenomegaly and varices and may cause severe gastrointestinal bleeding. The aim of the study is to review the incidence, treatment, and preventive strategies of left-sided portal hypertension. METHODS: A systematic literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement to identify all studies published up to September 30, 2019 reporting data on patients with left-sided portal hypertension after pancreatoduodenectomy with venous resection. RESULTS: Eight articles including 829 patients were retrieved. Left-sided portal hypertension occurred in 7.7% of patients who had splenic vein preservation and 29.4% of those having splenic vein ligation. Fourteen cases of gastrointestinal bleeding owing to left-sided portal hypertension were reported at a mean interval of 28 months from pancreatoduodenectomy. Related mortality at 1 month was 7.1%. Treatment of left-sided portal hypertension consisted of splenectomy in 3 cases (21%) and colectomy in 1 (7%) case, whereas radiologic, endoscopic procedures or conservative treatments were effective in the other cases (71%). CONCLUSION: Left-sided portal hypertension represents a potentially severe complication of pancreatoduodenectomy with venous resection occurring at greater incidence when the splenic vein is ligated and not reimplanted. Left-sided portal hypertension-related gastrointestinal bleeding although rare can be managed depending on the situation by endoscopic, radiologic procedures or operative intervention with low related mortality.


Assuntos
Hipertensão Portal/epidemiologia , Veias Mesentéricas/cirurgia , Pancreaticoduodenectomia/efeitos adversos , Veia Porta/cirurgia , Complicações Pós-Operatórias/epidemiologia , Carcinoma Ductal Pancreático/cirurgia , Colectomia/estatística & dados numéricos , Tratamento Conservador/estatística & dados numéricos , Hemorragia Gastrointestinal/epidemiologia , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/terapia , Humanos , Hipertensão Portal/etiologia , Hipertensão Portal/terapia , Incidência , Ligadura/efeitos adversos , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/métodos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Esplenectomia/estatística & dados numéricos , Esplenomegalia/epidemiologia , Esplenomegalia/etiologia , Esplenomegalia/terapia , Resultado do Tratamento
5.
J Surg Res ; 255: 436-441, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32619858

RESUMO

BACKGROUND: Appendicitis has traditionally been treated surgically. Recently, nonoperative management is emerging as a viable alternative to the traditional operative approach. This raises the question of what are the unintended consequences of nonoperative management of appendicitis with respect to cost and patient burden. METHODS: National Readmissions Database was queried between 2010 and 2014. Patients who were admitted with acute appendicitis between January and June of each year were identified. Patients who underwent appendectomy were compared with those treated nonoperatively. Six-month all-cause readmission rates and aggregate costs between index hospitalization and readmissions were calculated. RESULTS: We identified 438,995 adult admissions for acute appendicitis. Most cases were managed with appendectomy (93.2%). There was a significant increase in the rate of nonoperative management, from 3.6% in 2010 to 6.8% in 2014 (P value for trend <0.01). Discharges receiving nonoperative management tended to be older and have more comorbidities. There was a 59% decreased adjusted odds of readmission within 6 mo among patients receiving appendectomy in comparison to those managed nonoperatively. Despite this, in multivariable linear regression, there was an adjusted $2900 cost increase associated with surgical management (P < 0.01). CONCLUSIONS: This study shows that nonoperative management is increasing. Patients treated nonoperatively may have an increased risk of readmission within 6 mo but incur a decreased average adjusted total cost. Given this, it is important that surgeons critically assess patients who are being considered for nonoperative management of appendicitis.


Assuntos
Apendicite/terapia , Tratamento Conservador/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Adolescente , Adulto , Idoso , Apendicectomia/economia , Apendicite/economia , Apendicite/mortalidade , Tratamento Conservador/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
6.
J Laryngol Otol ; 134(6): 526-532, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32524919

RESUMO

OBJECTIVE: Patulous Eustachian tube appears to be caused by a concave defect in the anterolateral wall of the tubal valve of the Eustachian tube. This study aimed to compare the clinical features of patulous Eustachian tube patients with or without a defect in the anterolateral wall of the tubal valve. METHODS: Sixty-six patients with a patulous Eustachian tube completed a questionnaire, which was evaluated alongside endoscopic findings of the tympanic membrane, nasal cavity and Eustachian tube orifice. RESULTS: Females were more frequently diagnosed with a patulous Eustachian tube, but the valve defect was more common in males (p = 0.007). The ratio of patulous Eustachian tube patients with or without defects in the anterolateral wall of the tubal valve was 1.6:1. Weight loss in the previous six months and being refractory to conservative management were significantly associated with the defect (p = 0.035 and 0.037, respectively). Symptom severity was significantly higher in patients with the defect. CONCLUSION: Patulous Eustachian tube patients without a defect in the anterolateral wall of the tubal valve can be non-surgically treated more often than those with the defect. Identification of the defect could assist in making treatment decisions for patulous Eustachian tube patients.


Assuntos
Tratamento Conservador/métodos , Otopatias/etiologia , Tuba Auditiva/patologia , Otite Média/complicações , Adulto , Tratamento Conservador/estatística & dados numéricos , Otopatias/diagnóstico , Endoscopia/métodos , Tuba Auditiva/diagnóstico por imagem , Tuba Auditiva/fisiopatologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Cavidade Nasal/diagnóstico por imagem , Cavidade Nasal/patologia , Otite Média/diagnóstico por imagem , Otite Média/patologia , Estudos Retrospectivos , Índice de Gravidade de Doença , Inquéritos e Questionários/normas , Membrana Timpânica/diagnóstico por imagem , Perda de Peso
7.
J Surg Res ; 255: 77-85, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32543382

RESUMO

BACKGROUND: Nonoperative management (NOM) of uncomplicated appendicitis has gained recognition as an alternative to surgery. In the largest published randomized trial (Appendicitis Acuta), patients received a 3-d hospital stay for intravenous antibiotics; however, cost implications for health care systems remain unknown. We hypothesized short stay protocols would be cost saving compared with a long stay protocol. MATERIALS AND METHODS: We constructed a Markov model comparing the cost of three protocols for NOM of acute uncomplicated appendicitis: (1) long stay (3-d hospitalization), (2) short stay (1-d hospitalization), and (3) emergency department (ED) discharge. The long stay protocol was modeled on data from the APPAC trial. Model variables were abstracted from national database and literature review. One-way and two-way sensitivity analyses were performed to determine the impact of uncertainty on the model. RESULTS: The long stay treatment protocol had a total 5-y projected cost of $10,735 per patient. The short stay treatment protocol costs $8026 per patient, and the ED discharge protocol costs $6,825, which was $2709 and $3910 less than the long stay protocol, respectively. One-way sensitivity analysis demonstrated that the relative risk of treatment failure with the short stay protocol needed to exceed 6.3 (absolute risk increase of 31%) and with the ED discharge protocol needed to exceed 8.75 (absolute risk increase of 45%) in order for the long stay protocol to become cost saving. CONCLUSIONS: Short duration hospitalization protocols to treat appendicitis nonoperatively with antibiotics are cost saving under almost all model scenarios. Future consideration of patient preferences and health-related quality of life will need to be made to determine if short stay treatment protocols are cost-effective.


Assuntos
Antibacterianos/administração & dosagem , Apendicite/tratamento farmacológico , Apendicite/terapia , Tratamento Conservador/economia , Redução de Custos/estatística & dados numéricos , Administração Intravenosa , Simulação por Computador , Tratamento Conservador/métodos , Tratamento Conservador/estatística & dados numéricos , Análise Custo-Benefício , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Modelos Econômicos , Qualidade de Vida , Fatores de Tempo
8.
Arch Phys Med Rehabil ; 101(8): 1389-1395, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32416147

RESUMO

OBJECTIVE: To quantify and compare utilization of opioids, exercise therapy, and physical therapy in the year before spine surgery. DESIGN: A retrospective cohort of surgical and claims data. SETTING: Beneficiaries of the Military Health System seen at Brooke Army Medical Center PARTICIPANTS: Patients (N=411) undergoing surgery between January 1, 2014, and December 31, 2015, identified retrospectively through the Surgical Scheduling System (S3) based on procedure type (fusion, laminectomy, arthroplasty, vertebroplasty, and diskectomy). INTERVENTIONS: Elective lumbar spine surgery. MAIN OUTCOME MEASURES: Health care utilization variables present during the full 12 months before surgery, which included physical therapy services and visits for exercise therapy or manual therapy procedures and opioid prescriptions. RESULTS: The mean age of participants was 44.8±11.7 years and 32.4% were female. In the year before surgery, 143 (34.8%) patients had a physical therapy plan of care, 140 (34.1%) had at least 1 visit that included exercise therapy, and only 60 (14.6%) had a minimum of 6 exercise therapy visits. However, 347 (84.4%) patients received at least 1 opioid prescription fill (mean of 6.1 unique fills). CONCLUSIONS: Before elective lumbar spine surgery, opioid prescriptions were common but physical therapy services and exercise therapy utilization occurred infrequently.


Assuntos
Analgésicos Opioides/uso terapêutico , Terapia por Exercício/estatística & dados numéricos , Dor Lombar/terapia , Vértebras Lombares/cirurgia , Adolescente , Adulto , Idoso , Tratamento Conservador/métodos , Tratamento Conservador/estatística & dados numéricos , Discotomia , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Humanos , Laminectomia , Masculino , Pessoa de Meia-Idade , Modalidades de Fisioterapia/estatística & dados numéricos , Período Pré-Operatório , Estudos Retrospectivos , Fusão Vertebral , Vertebroplastia , Adulto Jovem
9.
J Surg Res ; 253: 224-231, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32380348

RESUMO

BACKGROUND: Surgical exploration for gunshot wounds to the abdomen has been a surgical standard for the greater part of the past century. Recently, nonoperative management (NOM) has been deemed as a safe option for abdominal gunshot wounds (AGWs). The aim of this analysis was to review the utilization of NOM and mortality after AGWs. METHODS: We performed a 2010-2014 retrospective analysis of the American College of Surgeons Trauma Quality and Improvement Program. We included all adult (aged 18 and older) patients with AGWs. NOM was defined as nonsurgical intervention within the first 6 h. Outcome measures were trends of utilization of NOM and mortality. Cochrane-Armitage trend analysis was performed. RESULTS: A total of 808,272 trauma patients were identified, and 16,866 patients with AGWs were included. During the study period, the incidence of AGWs increased, whereas the proportion of bowel injury (P = 0.75) and solid organ injury (P = 0.44) did not change. The NOM rate of AGW increased (2010: 19.5% versus 2014: 27%, P < 0.001). This was accompanied by a decrease in mortality rate (11% versus 9.4%, P = 0.01). Likewise, there was an increase in the use of angiography (7.5% versus 27%, P < 0.001) and laparoscopy (0.9% versus 2.6%, P < 0.001). Overall, 9.8% of the patients had failed NOM. There was no difference in mortality in patients who were managed successfully or failed NOM (5% versus 4.6%, P = 0.45). CONCLUSIONS: NOM of AGW is more prevalent and is associated with a decrease in mortality rate. Selective NOM may be practiced safely after AGWs.


Assuntos
Traumatismos Abdominais/terapia , Angiografia/tendências , Tratamento Conservador/tendências , Laparoscopia/tendências , Ferimentos por Arma de Fogo/terapia , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/mortalidade , Adulto , Angiografia/normas , Angiografia/estatística & dados numéricos , Tratamento Conservador/normas , Tratamento Conservador/estatística & dados numéricos , Feminino , Humanos , Incidência , Escala de Gravidade do Ferimento , Laparoscopia/normas , Laparoscopia/estatística & dados numéricos , Tempo de Internação , Masculino , Seleção de Pacientes , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Análise de Sobrevida , Falha de Tratamento , Estados Unidos/epidemiologia , Ferimentos por Arma de Fogo/diagnóstico , Ferimentos por Arma de Fogo/mortalidade , Adulto Jovem
10.
J Clin Neurosci ; 76: 107-113, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32327378

RESUMO

Patients with lumbar intervertebral disc herniation classically trial a brief course of conservative management prior to microdiscectomy surgery. Gender differences have previously been identified in the selection and symptomatic response to commonly-utilized nonoperative treatments. However, whether gender differences exist in the degree and cost of nonoperative therapy in this cohort remains unknown. Therefore, the purpose of this study was to assess for gender differences in the utilization and costs of nonoperative therapy in patients diagnosed with symptomatic lumbar intervertebral disc herniation 3-months prior to undergoing microdiscectomy. Medical records from adult patients diagnosed with a lumbar intervertebral disc herniation undergoing index microdiscectomy procedures from 2007 to 2017 were collected retrospectively from a large insurance database. The utilization of nonoperative therapy within 3-months after initial lumbar herniation diagnosis was determined. A total of 13,106 patients (55.4% Males) underwent index microdiscectomy. Male patients were more likely to fail conservative management and opt for surgery (Males: 2.9% vs. Females: 1.8%, p < 0.0001). A greater percentage of female patients utilized muscle relaxants (p = 0.0049), lumbar epidural steroid injections (p = 0.0007), and emergency department services (p = 0.001). The total direct cost of conservative treatment prior to microdiscectomy was $13,205,924, with males accountable for $7,457,023 (56.5%). When normalized by number of patients utilizing the respective therapy, males used fewer units of NSAIDs (males: 84.2 pills/patient; females: 97.3 pills/patient) and muscle relaxants (males: 77.5 pills/patient; females: 89.0 pills/patient). These results suggest that gender differences exist in the utilization of nonoperative therapies for the management of a lumbar intervertebral herniated disc prior to microdiscectomy surgery.


Assuntos
Tratamento Conservador , Discotomia , Deslocamento do Disco Intervertebral/terapia , Fatores Sexuais , Adulto , Estudos de Coortes , Tratamento Conservador/economia , Tratamento Conservador/métodos , Tratamento Conservador/estatística & dados numéricos , Custos e Análise de Custo , Discotomia/economia , Discotomia/métodos , Discotomia/estatística & dados numéricos , Feminino , Humanos , Vértebras Lombares/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
11.
Plast Reconstr Surg ; 145(5): 1147-1154, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32332529

RESUMO

BACKGROUND: Complications from medical tourism can be significant, requiring aggressive treatment at initial presentation. This study evaluates the effect of early surgical versus conservative management on readmission rates and costs. METHODS: A single-center retrospective review was conducted from May of 2013 to May of 2017 of patients presenting with soft-tissue infections after cosmetic surgery performed abroad. Patients were categorized into two groups based on their management at initial presentation as either conservative or surgical. Demographic information, the procedures performed abroad, and the severity of infection were included. The authors' primary outcome was the incidence of readmission in the two groups. International Classification of Diseases, Ninth Revision; International Classification of Diseases, Tenth Revision; and CPT codes were used for direct-billed cost analysis. RESULTS: Fifty-three patients (one man and 52 women) presented with complications after procedures performed abroad, of which 37 were soft-tissue infections. Twenty-four patients with soft-tissue infections at initial presentation were managed conservatively, and 13 patients were treated surgically. The two groups were similar in patient demographics and type of procedure performed abroad. Patients who were managed conservatively at initial presentation had a higher rate of readmission despite having lower severity of infections (OR, 4.7; p = 0.037). A significantly lower total cost of treatment was shown with early surgical management of these complications (p = 0.003). CONCLUSIONS: Conservative management of complications from medical tourism has resulted in a high incidence of failure, leading to readmission and increased costs. This can contribute to poor outcomes in patients that are already having complications from cosmetic surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Assuntos
Tratamento Conservador/estatística & dados numéricos , Técnicas Cosméticas/efeitos adversos , Turismo Médico , Complicações Pós-Operatórias/terapia , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Adulto , Tratamento Conservador/economia , Custos e Análise de Custo/estatística & dados numéricos , Feminino , Humanos , Masculino , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Procedimentos Cirúrgicos Operatórios/economia , Tempo para o Tratamento , Resultado do Tratamento , Adulto Jovem
12.
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
13.
BJOG ; 127(8): 957-965, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32086987

RESUMO

OBJECTIVE: To analyse populational trends and perioperative complications following conservative surgery versus oophorectomy in women <50 years of age with ovarian torsion. DESIGN: Population-based retrospective observational study. SETTING: Nationwide Inpatient Sample in the USA (2001-2015). POPULATION: In all, 89 177 ovarian torsions including 20 597 (23.1%) conservative surgeries and 68 580 (76.9%) oophorectomies. METHODS: (1) Trend analysis to assess utilisation of conservative surgery over time, (2) multivariable binary logistic regression to identify independent factors associated with conservative surgery and (3) inverse probability of treatment weighting with a generalised estimating equation to analyze perioperative complications. MAIN OUTCOME MEASURES: Trends, characteristics and complications related to conservative surgery. RESULTS: Performance of conservative surgery increased from 18.9 to 25.1% between 2001 and 2015 (32.8% relative increase, P = 0.001) but decreased steadily after age 15, and sharply declined after age 35 (P < 0.001). On multivariable analysis, younger age exhibited the largest effect size for conservative surgery among the independent factors (adjusted odds ratios 3.39-7.96, P < 0.001). In the weighted model, conservative surgery was associated with an approximately 30% decreased risk of perioperative complications overall (10.0% versus 13.6%, odds ratio 0.73, 95% confidence interval 0.62-0.85, P < 0.001) and was not associated with venous thromboembolism (0.2 versus 0.3%, P = 0.457) or sepsis (0.4 versus 0.3%, P = 0.638). CONCLUSION: There has been an increasing utilisation of conservative surgery for ovarian torsion in the USA in recent years. Our study suggests that conservative surgery for ovarian torsion may not be associated with increased perioperative complications. TWEETABLE ABSTRACT: Conservative surgery for ovarian torsion may not be associated with increased perioperative complications.


Assuntos
Doenças dos Anexos/cirurgia , Tratamento Conservador , Complicações Intraoperatórias/epidemiologia , Ovariectomia , Padrões de Prática Médica/tendências , Anormalidade Torcional/cirurgia , Doenças dos Anexos/epidemiologia , Adolescente , Adulto , Tratamento Conservador/estatística & dados numéricos , Feminino , Preservação da Fertilidade , Humanos , Pessoa de Meia-Idade , Ovariectomia/estatística & dados numéricos , Pontuação de Propensão , Estudos Retrospectivos , Anormalidade Torcional/epidemiologia , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto Jovem
14.
Urology ; 137: 60-65, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31948677

RESUMO

OBJECTIVE: To characterize the role of clinical and sociodemographic factors in the use of conservative management for localized prostate cancer in the US between 2010 and 2015, and to understand how those factors evolved in light of the recent national increase in conservative management rates. METHODS: Data from the Surveillance, Epidemiology, and End Results Program "Prostate with Watchful Waiting Database," where conservative treatment was delineated by a distinct classifier, was used to evaluate factors associated with electing for conservative management at initial diagnosis (2010-2015). Men aged ≥40 years with cT1-T2a and T2NOS with Gleason score 3 + 3 and 3 + 4 were included (n = 118,415). Multivariable logistic regression was used to determine the association between clinical and sociodemographic factors and electing conservative management. RESULTS: Between 2010 and 15, a total of 22,099 (18.6%) men were managed conservatively. Mean age of men managed conservatively decreased from 66.6 to 64.6 years, and median prostate-specific antigen (PSA) increased from 5.7 to 6.0 ng/mL, P <.0001. Men with lower income experienced a greater increase in conservative management rates compared to those with high income (152% vs 72% for third and fifth [richest] income quintiles, respectively). On multivariable analysis, Gleason score 3 + 3, older age, lower PSA, more recent year, treatment in the West, and higher levels of county income were significantly associated with conservative management. CONCLUSION: Characteristics of men undergoing conservative management are rapidly changing. Younger men, men with higher PSAs, and men of all incomes are increasingly being managed conservatively. Narrowing of income-based disparities with concurrent broadening of patients considered eligible for surveillance is encouraging.


Assuntos
Tratamento Conservador/estatística & dados numéricos , Preferência do Paciente , Neoplasias da Próstata/terapia , Idoso , Tratamento Conservador/tendências , Demografia , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias da Próstata/diagnóstico , Fatores Sociológicos , Fatores de Tempo , Estados Unidos
15.
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
16.
Ann R Coll Surg Engl ; 102(4): 263-270, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31909638

RESUMO

INTRODUCTION: The aim of this study was to study radiological assessment, management and outcome of traumatic splenic injury over 15 years in a UK district general hospital. METHOD: A retrospective database was established including all splenic injury cases from June 2002 to June 2017 by searching the clinical electronic database. We searched the radiological database for computed tomography reported phrases 'spleen injury', 'laceration', 'haematoma', 'trauma'. We interrogated theatre records for operations coded as splenectomy and cross-referenced this with pathology. Records were reviewed for demographics, vital observations, documentation of American Association for the Surgery of Trauma (AAST) grading of splenic injury, subsequent management and outcomes. RESULTS: There were 126 patients identified with traumatic splenic injury, with male to female ratio three to one. Operative management was undertaken in 54/126 (43%) patients and selective non-operative management in the remaining. Splenic artery embolisation was undertaken in 5/126 (4%) and 2/126 underwent splenorrhaphy. Computed tomography was undertaken in 109/126 (87%) patients and AAST grading was reported in 18 (17%) patients. AAST grade reporting did not improve significantly when comparing the first 7.5 years with the latter (2/30, 7%; 16/79, 20%), respectively; p = 0.09). Selective non-operative management increased significantly over the studied period (14/34, 42%; 58/93, 62%; p = 0.04). The overall hospital mortality was 10.3%. DISCUSSION AND CONCLUSION: AAST grade reporting of splenic injury has remained sub-optimal over 15 years. Despite progression towards selective non-operative management, operative intervention remained unacceptably high, with splenectomy being the main therapeutic modality. Standardisation through an integrated multidisciplinary diagnostic and management pathway offers the optimal strategy to reduce trauma-induced splenectomy.


Assuntos
Tratamento Conservador/estatística & dados numéricos , Embolização Terapêutica/estatística & dados numéricos , Baço/lesões , Esplenectomia/estatística & dados numéricos , Esplenopatias/terapia , Técnicas de Sutura/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Feminino , Mortalidade Hospitalar , Hospitais Gerais/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Baço/irrigação sanguínea , Baço/diagnóstico por imagem , Baço/cirurgia , Esplenectomia/normas , Artéria Esplênica , Esplenopatias/diagnóstico , Esplenopatias/etiologia , Esplenopatias/mortalidade , Tomografia Computadorizada por Raios X , Reino Unido , Adulto Jovem
17.
J Shoulder Elbow Surg ; 29(1): e22-e28, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31466891

RESUMO

BACKGROUND: A proximal humeral fracture is well established as a fracture of fragility in elderly patients. However, this injury does not receive the same emphasis on post-injury management as a femoral neck fracture. The objectives of this study were to establish the influence of sustaining a proximal humeral fracture on mortality and to identify the variables predictive of 5-year mortality. METHODS: Between January 2007 and January 2011, 288 consecutive patients who were admitted after sustaining a proximal humeral fracture were identified from the clinical coding department. Data were retrospectively collected and included patient demographic characteristics, comorbidities, anemia, physical and social independence, length of inpatient stay, management, and mortality. RESULTS: Of the patients, 13 (4.5%) had died at 1 month; 28 (9.7%), at 3 months; 46 (16.0%), at 1 year; and 117 (40.6%), at 5 years. A Cox proportional hazards regression identified male sex, comorbidities, unemployment or retirement, and nonoperative management as independent predictors of 5-year mortality. CONCLUSIONS: Elderly patients who require admission after sustaining a proximal humeral fracture are frail and subject to a greater-than-average risk of mortality for their age. The risk of mortality is greater for those of male sex who have comorbidities and a loss of physical and social independence.


Assuntos
Hospitalização , Fraturas do Ombro/mortalidade , Fraturas do Ombro/terapia , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Tratamento Conservador/estatística & dados numéricos , Feminino , Fragilidade/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Aposentadoria/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Fraturas do Ombro/complicações , Desemprego/estatística & dados numéricos
18.
J Shoulder Elbow Surg ; 29(2): 266-272, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31473135

RESUMO

BACKGROUND: The optimal treatment strategy for clavicle fractures remains a topic of debate. We evaluated our step-wise treatment protocol for patients with clavicle fractures to determine our success rate of conservative treatment. In addition, we evaluated the incidence of complications after clavicle plate fixation in patients undergoing acute surgery vs. delayed surgery. METHODS: This was a retrospective analysis in which we registered all patients aged 14 years or older with a clavicle fracture between January 2010 and May 2018 and at least 6 weeks' follow-up. Patients who underwent surgery were included from a prospectively maintained database. Functional outcomes were measured by Disabilities of the Arm, Shoulder and Hand and Constant-Murley scores 6 weeks after surgery. RESULTS: Conservative treatment was successful in 1627 of 1748 patients (93%). Primary fixation was performed in 73 patients (61%) and delayed fixation in 48 (39%). In 8 patients (6.6%), radiologic widening of the acromioclavicular (AC) joint was present after surgery, suggestive of AC injury. The incidence of complications was significantly higher among patients who underwent delayed fixation vs. those who underwent primary fixation: 15 of 48 patients (31.3%) vs. 9 of 73 patients (12.3%). CONCLUSION: Most patients with clavicle fractures have an excellent outcome using conservative management. Acute surgery can be performed in high-demand patients, resulting in high performance scores. Delayed surgery is associated with a higher risk of complications, although the outcome is generally good. Associated AC joint dislocation found on postoperative radiographs does not influence outcomes. Shared decision making is key, and patients should be well aware of the potential risks and benefits of surgery.


Assuntos
Placas Ósseas , Clavícula/cirurgia , Fixação Interna de Fraturas , Fraturas Ósseas/terapia , Tempo para o Tratamento , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Clavícula/lesões , Tratamento Conservador/estatística & dados numéricos , Avaliação da Deficiência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Adulto Jovem
19.
Surg Endosc ; 34(1): 77-87, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-30859489

RESUMO

BACKGROUND: Perforation is a rare but serious adverse event of endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to determine the predictors of morbidity and mortality after surgical management of ERCP-related perforation (EP). METHODS: The records of patients with EP requiring surgical intervention at a tertiary referral center in a 12-year period (2004-2016) were retrospectively analyzed for demography, indications for ERCP, risk factors, timing and type of surgical repair, post-operative course, hospital stay, and outcome. Multiple logistic regression was used to identify the parameters predicting survival. RESULTS: Of 25,300 ERCPs, 380 (1.5%) had EP. Non-operative management was successful in 330 (86.8%) patients. 50 (13.2%) patients were operated for EP. Out of 50, the perforation was detected during ERCP (intra-procedure) in 32 patients (64%). In 30 patients (60%), the surgery was performed within 24 h of ERCP. Twenty patients underwent delayed surgery (after 24 h of ERCP) following the failure of initial non-operative management. The delayed surgery after an unsuccessful medical treatment had a detrimental effect on morbidity, mortality and hospital stay. Post-operative duodenal leak was the only independent predictor of 90-day mortality (p = 0.02, OR = 9.1, 95% CI 1.52-54.64). Addition of T-tube duodenostomy (TTD) to the primary repair for either type I or type II perforations increased post-operative duodenal leak (type I, p = 0.048 and type II; p = 0.001) and mortality (type I, p = 0.009 and type II, p = 0.045). CONCLUSION: Although EP is a rare event, it has a serious impact on morbidity and mortality. Delaying of surgery following failed non-operative management worsens the prognosis. Addition of TTD to the repair is not helpful in these patients.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Tratamento Conservador , Perfuração Intestinal , Reoperação , Colangiopancreatografia Retrógrada Endoscópica/métodos , Tratamento Conservador/métodos , Tratamento Conservador/estatística & dados numéricos , Diagnóstico Tardio/estatística & dados numéricos , Feminino , Humanos , Perfuração Intestinal/etiologia , Perfuração Intestinal/mortalidade , Perfuração Intestinal/cirurgia , Masculino , Pessoa de Meia-Idade , Mortalidade , Reoperação/métodos , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Tempo para o Tratamento/estatística & dados numéricos
20.
J Invest Surg ; 33(2): 159-163, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30212230

RESUMO

Purpose: The aim of this research is to perform a literature review of the treatments available for the anterior iliac spines avulsion fracture on the young subjects. Material and Methods: We performed a systematic literature search for studies on spines avulsion fractures in young subjects from January 1, 2013, to February 2018; abstracts were screened by a single reviewer. For those studies meeting the eligibility criteria, full-text articles were obtained. Results: From 112 studies found only six articles were included in this systematic review. All the studies belonged to level IV of scientific evidence. 64 patients suffered an anterior inferior iliac spine fracture while patients 36% patients suffered an anterior superior iliac spine fracture. 93.2% underwent conservative treatment and 6.8% underwent surgery. Conclusions: The anterior iliac spine avulsions fractures are rare injuries that occur in young male athletes and the conservative option is the most selected treatment modality.


Assuntos
Atletas/estatística & dados numéricos , Tratamento Conservador/métodos , Fixação Interna de Fraturas/métodos , Fratura Avulsão/cirurgia , Ílio/lesões , Fraturas da Coluna Vertebral/terapia , Adolescente , Fatores Etários , Criança , Tratamento Conservador/estatística & dados numéricos , Feminino , Fixação Interna de Fraturas/estatística & dados numéricos , Fratura Avulsão/epidemiologia , Humanos , Ílio/cirurgia , Incidência , Masculino , Fatores de Risco , Fatores Sexuais , Fraturas da Coluna Vertebral/epidemiologia , Resultado do Tratamento , Adulto Jovem
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