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

RESUMO

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


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

RESUMO

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


Assuntos
Tratamento Conservador , Procedimentos Endovasculares , Isquemia/terapia , Doença Arterial Periférica/terapia , Qualidade de Vida , Procedimentos Cirúrgicos Vasculares , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Tratamento Conservador/efeitos adversos , Tratamento Conservador/mortalidade , Estado Terminal , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Isquemia/diagnóstico por imagem , Isquemia/mortalidade , Isquemia/fisiopatologia , Masculino , Países Baixos , Seleção de Pacientes , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Estudos Prospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade
3.
J Stroke Cerebrovasc Dis ; 29(2): 104505, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31786043

RESUMO

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


Assuntos
Plantão Médico , Hemorragia Cerebral/terapia , Tratamento Conservador , Procedimentos Endovasculares , Procedimentos Neurocirúrgicos , Admissão do Paciente , Idoso , Idoso de 80 Anos ou mais , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/mortalidade , Hemorragia Cerebral/fisiopatologia , Tratamento Conservador/efeitos adversos , Tratamento Conservador/mortalidade , Avaliação da Deficiência , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/efeitos adversos , Procedimentos Neurocirúrgicos/mortalidade , Recuperação de Função Fisiológica , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
4.
Isr Med Assoc J ; 12(21): 779-784, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31814339

RESUMO

BACKGROUND: Older age is an independent predictor of worse outcome from traumatic brain injury (TBI). No clear guidelines exist for the management of TBI in elderly patients. OBJECTIVES: To describe the outcomes of elderly patients presenting with TBI and intracranial bleeding (ICB), comparing a very elderly population (≥ 80 years of age) to a younger one (70-79). METHODS: Retrospective analysis of the outcomes of elderly patients presenting with TBI with ICB admitted to a level I trauma center. RESULTS: The authors analyzed 100 consecutive patients aged 70-79 and 100 patients aged 80 and older. In-hospital mortality rates were 9% and 21% for groups 70-79 and ≥ 80 years old, respectively (P = 0.017). Patients 70-79 years old showed a 12-month survival rate of 73% and a median survival of 47 months. In patients ≥ 80 years old, 12-month survival was 63% and median survival was 27 months (P = NS). In patients presenting with a Glasgow Coma Scale score of ≥ 8, the in-hospital mortality rates were 41% (n=5/12) and 100% (n=8/8). Among patients ≥ 80 years old undergoing emergent surgical decompression, in-hospital mortality was 66% (n=12/18). Survivors presented with a severe drop in their functional score. Survival was dismal in patients ≥ 80 years old who were treated conservatively despite recommended operative guidelines. CONCLUSIONS: There is a lack of reliable means to evaluate the outcome in patients with poor functional status at baseline. The negative prognostic impact of severe TBI is profound, regardless of treatment choices.


Assuntos
Lesões Encefálicas Traumáticas , Tratamento Conservador , Craniectomia Descompressiva , Hemorragias Intracranianas , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Lesões Encefálicas Traumáticas/diagnóstico , Lesões Encefálicas Traumáticas/mortalidade , Tratamento Conservador/métodos , Tratamento Conservador/mortalidade , Craniectomia Descompressiva/métodos , Craniectomia Descompressiva/estatística & dados numéricos , Feminino , Avaliação Geriátrica/métodos , Escala de Coma de Glasgow , Humanos , Hemorragias Intracranianas/diagnóstico , Hemorragias Intracranianas/mortalidade , Israel/epidemiologia , Masculino , Prognóstico , Recuperação de Função Fisiológica , Taxa de Sobrevida
5.
Medicine (Baltimore) ; 98(50): e18362, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31852141

RESUMO

BACKGROUND: According to the Barcelona Clinic Liver Cancer (BCLC) staging system, the presence of portal vein tumor thrombosis (PVTT) is considered to indicate an advanced stage of hepatocellular carcinoma (HCC) with nearly no cure. Hepatic resection and transarterial chemoembolization (TACE) have recently been recommended for treatment of HCC with PVTT. METHODS: We conducted a systematic review to compare the overall survival between patients with HCC and PVTT undergoing hepatectomy, TACE or conservative treatment including sorafenib chemotherapy. The PubMed, Web of Science, and Cochrane Library databases were searched. All relevant studies were considered. Hazard ratios with 95% confidence intervals were calculated for comparison of the cumulative overall survival. Ten retrospective studies met the inclusion criteria and were included in the review. RESULTS: Overall survival was not higher in the hepatectomy group than TACE group. But survival rate was higher in hepatectomy group than conservative group. The subgroup analysis demonstrated that hepatectomy was superior in patients without PVTT in the main trunk than in patients with main portal vein invasion. In patients without main PVTT, hepatectomy has showed more benefit than TACE. However, there has been no significant difference between the hepatectomy and TACE groups among patients with main PVTT. CONCLUSION: For patients with resectable HCC and PVTT, hepatectomy might be more effective in patients without PVTT in the main trunk than TACE or conservative treatment.


Assuntos
Carcinoma Hepatocelular , Quimioembolização Terapêutica/mortalidade , Hepatectomia/mortalidade , Neoplasias Hepáticas , Veia Porta/cirurgia , Sorafenibe/uso terapêutico , Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/terapia , Tratamento Conservador/mortalidade , Feminino , Humanos , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/terapia , Masculino , Taxa de Sobrevida , Resultado do Tratamento , Trombose Venosa
6.
Medicine (Baltimore) ; 98(44): e10281, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31689741

RESUMO

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


Assuntos
Tratamento Conservador/mortalidade , Fixação de Fratura/mortalidade , Processo Odontoide/cirurgia , Fraturas da Coluna Vertebral/cirurgia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Tratamento Conservador/efeitos adversos , Tratamento Conservador/métodos , Fixação de Fratura/efeitos adversos , Fixação de Fratura/métodos , Humanos , Tempo de Internação/estatística & dados numéricos , Satisfação do Paciente , Complicações Pós-Operatórias/epidemiologia , Fraturas da Coluna Vertebral/classificação
7.
J Stroke Cerebrovasc Dis ; 28(8): 2213-2220, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31151837

RESUMO

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


Assuntos
Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/terapia , Tratamento Conservador , Técnicas de Apoio para a Decisão , Procedimentos Neurocirúrgicos , Adulto , Idoso , Hemorragia Cerebral/mortalidade , Hemorragia Cerebral/fisiopatologia , Tomada de Decisão Clínica , Tratamento Conservador/efeitos adversos , Tratamento Conservador/mortalidade , Avaliação da Deficiência , Feminino , Mortalidade Hospitalar , Humanos , Índia/epidemiologia , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/efeitos adversos , Procedimentos Neurocirúrgicos/mortalidade , Valor Preditivo dos Testes , Estudos Prospectivos , Recuperação de Função Fisiológica , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
8.
Surgery ; 165(6): 1176-1181, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31040040

RESUMO

BACKGROUND: Necrotizing enterocolitis is the leading case of gastrointestinal-related morbidity in premature infants. Necrotizing enterocolitis totalis is an aggressive form of necrotizing enterocolitis, which has traditionally been managed with comfort care. Recent advances in management of short bowel syndrome have resulted in some reported long-term survival. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, studies that reported outcomes in children with necrotizing enterocolitis totalis were identified. The definition of necrotizing enterocolitis totalis was captured along with length of follow-up, patient demographics, and outcomes. RESULTS: A total of 766 articles were screened, of which 166 were selected for full article review. Of these, 32 articles included data on 414 patients with necrotizing enterocolitis totalis. In the majority of studies (52%), necrotizing enterocolitis totalis was not defined. Aggressive surgical therapy (defined as bowel resection or fecal diversion) was undertaken in 32 patients (7.7%), with a mortality rate of 68.8%. In contrast, nonaggressive surgical therapy was undertaken in 382 patients (92.3%), and the mortality in these patients was 95%. Long-term outcomes for necrotizing enterocolitis totalis survivors, such as length of time on parenteral nutrition, progression to liver and/or small bowel transplant, and quality of life, were not reported. CONCLUSION: We found that there is no accepted definition of necrotizing enterocolitis totalis. Aggressive surgical therapy is rarely pursued, which likely drives the overall high mortality rate. This study underscores the importance of standardizing the definition of necrotizing enterocolitis totalis and capturing short and long-term outcomes prospectively. With more aggressive surgical therapy, more infants are likely to survive this abdominal catastrophe, which was once thought to be uniformly fatal.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/métodos , Enterocolite Necrosante/cirurgia , Doenças do Prematuro/cirurgia , Tratamento Conservador/mortalidade , Procedimentos Cirúrgicos do Sistema Digestório/mortalidade , Enterocolite Necrosante/diagnóstico , Enterocolite Necrosante/mortalidade , Enterocolite Necrosante/patologia , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Doenças do Prematuro/diagnóstico , Doenças do Prematuro/mortalidade , Doenças do Prematuro/patologia , Resultado do Tratamento
9.
J BUON ; 24(1): 239-248, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30941976

RESUMO

PURPOSE: To evaluate the effects of radical prostatectomy (RP) and conservative treatment (CT) on the survival of localized prostate cancer by conducting a systematic review and meta-analysis. METHODS: We searched for all studies about RP and CT for localized prostate cancer in PubMed and Web of Science up to December 2017. A systematic review and meta-analysis was performed. RESULTS: There were 4 randomized clinical trials (RCTs) and 12 cohort studies including 69871 patients treated with RP and 65765 patients treated with CT. There was a significantly reduced all-cause mortality (HR:0.575;95%CI:0.487 to 0.678;p<0.001) along with a reduced risk of prostate cancer mortality in patients treated with RP compared to those treated with CT (HR:0.408;95%CI:0.313 to 0.533;p<0.001). RP was effective with a lower all-cause mortality and prostate cancer mortality for patients with intermediate risk disease (HR:0.774;95%CI:0.664 to 0.902,p=0.001; HR:0.428;95%CI:0.286 to 0.641, p=0.001, respectively). However, for low risk (HR:0.774;95%CI:0.505 to 1.187, p=0.241; HR:0.603;95%CI:0.332 to 1.097, p=0.098, respectively) and high risk (HR:0.662;95%CI:0.376 to 1.164, p=0.152; HR:0.584;95%CI:0.315 to 1.084, p=0.089, respectively) prostate cancer patients, there was no significant difference between RP and CT. In the subgroup analysis according to the age and follow-up time, the results favored the RP and there was no specific factor affecting the outcomes. CONCLUSIONS: RP offers a better survival rate than CT in patients with localized prostate cancer. For some patients with localized prostate cancer, treatment should be chosen very carefully.


Assuntos
Tratamento Conservador/mortalidade , Prostatectomia/mortalidade , Neoplasias da Próstata/mortalidade , Estudos de Coortes , Humanos , Masculino , Prognóstico , Neoplasias da Próstata/cirurgia , Neoplasias da Próstata/terapia , Taxa de Sobrevida
10.
Nefrologia ; 39(2): 141-150, 2019.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-30827372

RESUMO

INTRODUCTION: Conservative Management (CM) has become a therapeutic option in Advanced Chronic Kidney Disease in the elderly. However, there is a lack of evidence about prognosis of these patients in terms of survival and health related quality of life (HRQoL). OBJECTIVE: Establish predictive variables associated with mortality and analyse HRQoL in CM patients. PATIENTS AND METHODS: Prospective cohort study. An assessment of renal function parameters and a comprehensive geriatric assessment were made, including: analysis of comorbidity, functional, cognitive, fragility, nutritional, social and HRQoL status. RESULTS: 82 patients with a mean age of 84 years and significant pluripathology were studied: 56% had history of vascular event and Charlson >8. The mortality rate was 23/1,000 patients per month, with a homogeneous mortality rate after 6 months. Survival differed significantly depending on whether they presented with a previous vascular event (36.7 vs. 14.8; p=0.028), Charlson score ≥10 (42 vs. 17; p=0.002), functional status (48.4 vs. 19; p=0.002) and fragility (27 vs. 10; p=0.05). Mortality predictors included eGFR and proteinuria, the presence of previous vascular events, Charlson comorbidity score, malnutrition-inflammation parameters (albumin and MNA score), degree of dependency, physical HRQoL and increase of PTH level. The presence of previous vascular event, comorbidity, decreased albumin and elevated PTH were independent predictors of mortality. HRQoL remained stable over time and no significant worsening occurred during treatment. CONCLUSIONS: Having knowledge of the factors associated with mortality and HRQoL assessment can be a useful tool to helping decision making during CM. Previous vascular events, comorbidity, decreased albumin and increased PTH were independent predictors of mortality.


Assuntos
Tratamento Conservador/mortalidade , Qualidade de Vida , Insuficiência Renal Crônica/mortalidade , Insuficiência Renal Crônica/terapia , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Avaliação Geriátrica , Humanos , Inflamação/epidemiologia , Masculino , Desnutrição/epidemiologia , Hormônio Paratireóideo/sangue , Prognóstico , Estudos Prospectivos , Albumina Sérica/análise , Taxa de Sobrevida
11.
Acta Orthop ; 90(2): 159-164, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30669948

RESUMO

Background and purpose - There are no national guidelines for treatment of hip fractures in Estonia and no studies on management. We assessed treatment methods and mortality rates for hip fracture patients in Estonia. Patients and methods - We studied a population-based retrospective cohort using validated data from the Estonian Health Insurance Fund's database. The cohort included patients aged 50 and over with an index hip fracture diagnosis between January 1, 2009 and September 30, 2017. The study generated descriptive statistics of hip fracture management methods and calculated in-hospital, 1-, 3, 6-, and 12-month unadjusted all-cause mortality rates. [CrossRef] Results - 91% (number of hips: 11,628/12,731) of the original data were included after data validation. Median patient age was 81 years, 83 years for women and 74 years for men. 28% were men. Treatment methods were: total hip arthroplasty 7%; hemiarthroplasty 25%; screws 6%; sliding hip screw 25%; intramedullary nail 27%; and nonoperative management 10%. Unadjusted all-cause mortality rates for in-hospital, 1, 3, 6, and 12 months were: 3%, 9%, 18%, 24%, and 31% respectively. The 12-month mortality rate for nonoperative management was 58%. [CrossRef] Interpretation - High rates of nonoperative management and overall high 1-year mortality rates after an index hip fracture indicate the need to review exclusion criteria for surgery and subacute care in Estonia.


Assuntos
Artroplastia de Quadril , Tratamento Conservador , Fixação Interna de Fraturas , Fraturas do Quadril , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/instrumentação , Artroplastia de Quadril/métodos , Artroplastia de Quadril/estatística & dados numéricos , Pinos Ortopédicos , Parafusos Ósseos , Estudos de Coortes , Tratamento Conservador/efeitos adversos , Tratamento Conservador/métodos , Tratamento Conservador/mortalidade , Estônia/epidemiologia , Feminino , Fixação Interna de Fraturas/efeitos adversos , Fixação Interna de Fraturas/instrumentação , Fixação Interna de Fraturas/métodos , Fixação Interna de Fraturas/estatística & dados numéricos , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/mortalidade , Fraturas do Quadril/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Determinação de Necessidades de Cuidados de Saúde , Estudos Retrospectivos
12.
Asian Cardiovasc Thorac Ann ; 27(3): 192-198, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30665318

RESUMO

OBJECTIVE: Esophageal perforation is a life-threatening condition associated with high mortality and morbidity. Ambiguous clinical presentation is one of the most common causes of delayed and difficult diagnosis of esophageal perforation. In this retrospective single-center study, we reviewed the outcome of primary closure in patients with esophageal perforation between 2009 and 2017. METHODS: The data of 65 patients attending our department of thoracic surgery (from 2009 to 2017) for esophageal perforation were reviewed. Primary repair was attempted in 63 patients irrespective of the site of perforation and time interval between injury and hospital admission. In intrathoracic lesions, continuous mediastinal and pleural irrigation was undertaken, whereas in cervical perforations, gauze packing and local irrigation were performed. Jejunotomy was carried out in patients with inadequate healing. RESULTS: Of the 65 patients, 63 underwent primary closure and 2 were left to heal spontaneously. The majority of patients ( n = 44) had an esophageal perforation at the thoracic level, and only one was admitted early (<24 h after injury). Among the 63 patients managed with primary closure, 55 had satisfactory healing with one surgery. Healing was delayed in the other 10 patients. No mortality was reported. CONCLUSIONS: Esophageal perforation can be well managed by primary closure, irrespective of the time interval between injury and hospital admission and the site of perforation. Conservative management might lead to an increased rate of complications such as empyema or necrotizing mediastinitis, and increased morbidity and mortality.


Assuntos
Tratamento Conservador/métodos , Perfuração Esofágica/cirurgia , Técnicas de Sutura , Irrigação Terapêutica , Tratamento Conservador/efeitos adversos , Tratamento Conservador/mortalidade , Perfuração Esofágica/diagnóstico por imagem , Perfuração Esofágica/etiologia , Perfuração Esofágica/mortalidade , Humanos , Estudos Retrospectivos , Fatores de Risco , Técnicas de Sutura/efeitos adversos , Técnicas de Sutura/mortalidade , Irrigação Terapêutica/efeitos adversos , Irrigação Terapêutica/mortalidade , Fatores de Tempo , Tempo para o Tratamento , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Cicatrização
13.
Eur J Trauma Emerg Surg ; 45(4): 631-644, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30276722

RESUMO

PURPOSE: The aim of this systematic review and meta-analysis was to present current evidence on rib fixation and to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies. METHODS: MEDLINE, Embase, CENTRAL, and CINAHL were searched on June 16th 2017 for both RCTs and observational studies comparing rib fixation versus nonoperative treatment. The MINORS criteria were used to assess study quality. Where possible, data were pooled using random effects meta-analysis. The primary outcome measure was mortality. Secondary outcome measures were hospital length of stay (HLOS), intensive care unit length of stay (ILOS), duration of mechanical ventilation (DMV), pneumonia, and tracheostomy. RESULTS: Thirty-three studies were included resulting in 5874 patients with flail chest or multiple rib fractures: 1255 received rib fixation and 4619 nonoperative treatment. Rib fixation for flail chest reduced mortality compared to nonoperative treatment with a risk ratio of 0.41 (95% CI 0.27, 0.61, p < 0.001, I2 = 0%). Furthermore, rib fixation resulted in a shorter ILOS, DMV, lower pneumonia rate, and need for tracheostomy. Results from recent studies showed lower mortality and shorter DMV after rib fixation, but there were no significant differences for the other outcome measures. There was insufficient data to perform meta-analyses on rib fixation for multiple rib fractures. Pooled results from RCTs and observational studies were similar for all outcome measures, although results from RCTs showed a larger treatment effect for HLOS, ILOS, and DMV compared to observational studies. CONCLUSIONS: Rib fixation for flail chest improves short-term outcome, although the indication and patient subgroup who would benefit most remain unclear. There is insufficient data regarding treatment for multiple rib fractures. Observational studies show similar results compared with RCTs.


Assuntos
Tórax Fundido/terapia , Fixação de Fratura/métodos , Fraturas das Costelas/terapia , Idoso , Tratamento Conservador/métodos , Tratamento Conservador/mortalidade , Tratamento Conservador/estatística & dados numéricos , Cuidados Críticos/estatística & dados numéricos , Feminino , Tórax Fundido/mortalidade , Fixação de Fratura/mortalidade , Fixação de Fratura/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Observacionais como Assunto , Pneumonia/etiologia , Pneumonia/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Respiração Artificial/mortalidade , Respiração Artificial/estatística & dados numéricos , Fraturas das Costelas/mortalidade , Traqueostomia/mortalidade , Traqueostomia/estatística & dados numéricos
14.
Acta Cardiol ; 74(3): 253-261, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30451084

RESUMO

Background and objective: Treatment for patients with hypertrophic obstructive cardiomyopathy (HOCM) can be either conservative or invasive (alcohol septal ablation (ASA) and myectomy). As there is no clear consensus on the long-term effects of these different strategies, the aim was to compare the long-term outcome in a large tertiary referral university hospital. Methods: We retrospectively included 106 HOCM patients. Twenty-nine (27.4%) patients were treated conservatively, 25 (23.6%) underwent ASA and 52 (49.0%) myectomy. Endpoints were all-cause mortality and sudden cardiac death (SCD)-related events (including SCD, aborted SCD and appropriate ICD shocks). Kaplan-Meier survival analysis and Cox proportional hazard regression models were used. Results: The mean follow-up period was 7.7 ± 4.9 years. Overall, there was no significant difference in survival between the three treatment strategies (p = 0.7). Annual rates of SCD-related events at 5 years and the complete follow-up period were significantly higher (p = 0.034) after conservative treatment (4.9%/year and 2.7%/year, respectively) compared to ASA (0.9%/year, 0.5%/year) and myectomy (1.0%/year, 0.6%/year). Independent predictors of SCD-related events were: conservative treatment (HR 10.66; 1.88-60.55), a known mutation (HR 9.36; 1.43-61.20), left ventricular wall thickness (LVWT) > 30 mm (HR 6.48; 1.05-39.92) and non-sustained VT (HR 16.82; 2.29-123.29). Invasive treatment resulted in a significant higher proportion of patients requiring pacing (p = 0.033). Conclusions: Long-term mortality rates for patients with HOCM are similarly low between treatment groups. However, conservative treatment was associated with SCD-related events, as were known mutations, increased LVWT and non-sustained VT. Invasive treatment was associated with a higher need for implantation of a pacemaker.


Assuntos
Técnicas de Ablação , Procedimentos Cirúrgicos Cardíacos , Cardiomiopatia Hipertrófica/terapia , Tratamento Conservador , Morte Súbita Cardíaca/prevenção & controle , Técnicas de Ablação/efeitos adversos , Técnicas de Ablação/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Cardiomiopatia Hipertrófica/diagnóstico , Cardiomiopatia Hipertrófica/mortalidade , Cardiomiopatia Hipertrófica/fisiopatologia , Tratamento Conservador/efeitos adversos , Tratamento Conservador/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
15.
Vasc Endovascular Surg ; 53(2): 132-138, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30466369

RESUMO

PURPOSE:: Endograft infection is an infrequent but one of the most serious and challenging complications after endovascular aortic repair. The aim of this study was to assess the management of this complication in a tertiary center. CASE SERIES:: A retrospective analysis of a prospective database was performed including all patients who underwent elective endovascular abdominal aortic repair (EVAR) from 2003 to 2016 in a tertiary center. Seven cases of endograft infection were identified during the follow-up period from a total of 473 (1.48%) EVAR. Most frequent symptoms at presentation were fever (71.4%) and lumbar pain (57.1%). One case developed an early infection, while 6 cases were diagnosed as late infections. Mean time from endograft placement to symptom presentation was 28.3 months (2-91.5 months). Gram-positive cocci were the microorganisms most commonly isolated in blood cultures (66%). Two cases were managed with endograft removal and aortic reconstruction with a cryopreserved allograft, 2 cases with surgical drainage, and 2 cases exclusively with antibiotic therapy. In 1 case, the diagnosis was performed postoperatively based on intraoperative findings associated with positive graft cultures; and graft explantation was performed with "in situ" reconstruction using a Dacron graft. Perioperative mortality was 42.9%. One-year mortality was 57.1%. Mean follow-up was 21.5 months. CONCLUSION:: Endograft explantation is the gold standard of treatment; however, given the overall high morbi-mortality rates of this pathology, a tailored approach should always be offered depending on the patient's overall condition. Conservative management can be an acceptable option in those patients with short life expectancy and high surgical risk.


Assuntos
Antibacterianos/uso terapêutico , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Prótese Vascular/efeitos adversos , Tratamento Conservador/métodos , Remoção de Dispositivo , Procedimentos Endovasculares/efeitos adversos , Infecções Relacionadas à Prótese/terapia , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/efeitos adversos , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Aortografia/métodos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Tomada de Decisão Clínica , Angiografia por Tomografia Computadorizada , Tratamento Conservador/efeitos adversos , Tratamento Conservador/mortalidade , Bases de Dados Factuais , Remoção de Dispositivo/efeitos adversos , Remoção de Dispositivo/mortalidade , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Humanos , Pessoa de Meia-Idade , Tomografia por Emissão de Pósitrons , Infecções Relacionadas à Prótese/diagnóstico por imagem , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/mortalidade , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Espanha , Fatores de Tempo , Resultado do Tratamento
16.
J Vasc Surg ; 70(1): 181-192, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30583901

RESUMO

OBJECTIVE: We aimed to retrospectively analyze incidence, risk factors, and management of postoperative stent graft (SG) infection after endovascular aneurysm repair (EVAR). METHODS: We evaluated patients who underwent EVAR for infrarenal abdominal aortic aneurysm at our institution between July 2006 and December 2014. The primary end point was SG infection. We compared patients' demographics between the infection (group I) and noninfection (group NI) groups and reviewed management and outcomes in group I. A risk factor for SG infection was assessed by multivariable logistic regression. Patients without aortoenteric fistula (AEF) were treated with conservative therapy for SG infection. RESULTS: A total of 1202 patients underwent EVAR for infrarenal abdominal aortic aneurysm. During a mean follow-up of 43.9 ± 30.4 months, SG infection occurred in 15 cases (incidence, 3.5/1000 person-years). The median time between initial EVAR and detection of infection was 30 months (range, 14 days-86 months). Freedom from SG infection at 1 year, 3 years, and 5 years was 99.5%, 99.2%, and 98.2%, respectively. There were no differences in age, sex, comorbidities, and SG type between the groups. Coil embolization of the hypogastric artery was more frequent in group I (60% vs 31%). During follow-up before infection, type II endoleak (47% vs 24%), sac enlargement (40% vs 16%), and multiple reinterventions (13% vs 2%) were significantly higher in group I; however, after multivariate analysis, only coil embolization of the hypogastric artery (odds ratio, 3.22; 95% confidence interval, 1.12-9.24; P = .029) remained a significant predictor. Among the 15 patients, four had AEF and six bacteriologic species were detected in five patients (33%). Twelve patients (80%) were treated with conservative therapy; three underwent surgical therapy (two patients with SG resection, omentum patching, and extra-anatomic bypass with fistula closure or partial duodenectomy and one patient with graft preservation, irrigation, omentum patching, and aneurysmorrhaphy). In-hospital mortality occurred in three cases; two cases were due to sepsis after conservative therapy, and one case was due to aortic stump rupture after surgical therapy. Excluding in-hospital mortality cases, during a median follow-up of 31 (range, 2-76) months, five patients were lost because of cancer or senility. There was no aneurysm-related death or recurrence of SG infection. CONCLUSIONS: Concomitant coil embolization was a risk factor for SG infection. For patients with AEF, surgical therapy remains the first-line treatment of SG infection after EVAR; however, conservative therapy is a viable option for SG infection in patients without AEF, particularly considering patients' comorbidities and limited life expectancy.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Prótese Vascular/efeitos adversos , Tratamento Conservador , Remoção de Dispositivo , Procedimentos Endovasculares/efeitos adversos , Infecções Relacionadas à Prótese/terapia , Stents/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Comorbidade , Tratamento Conservador/efeitos adversos , Tratamento Conservador/mortalidade , Remoção de Dispositivo/efeitos adversos , Remoção de Dispositivo/mortalidade , Embolização Terapêutica/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Expectativa de Vida , Masculino , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/mortalidade , Reoperação , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Tóquio/epidemiologia , Resultado do Tratamento
19.
Laeknabladid ; 104(79): 391-394, 2018 Sep.
Artigo em Islandês | MEDLINE | ID: mdl-30178752

RESUMO

Backround Sigmoid volvulus is an uncommon cause of bowel obstruction in most western societies. Treatment options include colonoscopy in uncomplicated disease with elective surgery later on. The aim of this study was to assess what treatment sigmoid volvulus patients receive along with long-term outcomes at Landspitali University Hospital. Methods The study was retrospective. Patients diagnosed with sigmoid volvulus at Landspitali University Hospital from 2000-2013 were included. Information regarding age, sex, and duration of hospital stay, treatment, short and long-term outcomes were gathered. Results Forty-nine patients were included in the study, of which 29 men and 20 women. Mean age was 74 (25-93). One patient underwent acute surgery on first arrival due to signs of peritonitis. Others (n=48) were treated conservatively in the first attempt with colonoscopy (n=45), barium enema (n=2) and rectal tube (n=1). Three other patients underwent acute surgery due to failed colonoscopy, 8 patients had planned surgery during the index admission. Thirty-six patients were discharged after conservative treatment with colonoscopy (n=35), barium enema (n=1) or rectal tube (n=1). Two patients came in for elec-tive surgery later on. Twenty-two patients (61%) had recurrence. Median time to recurrence was 101 days (1-803). Disease-free probability in 3, 6 and 24 months was 66%, 55% and 22% respec-tively. Total disease related mortality was 10.2%. Mortality (30 days) after acute surgery was 25% (1/4) and 16,6% (3/18) after planned surgery. Conclusions Sigmoid volvulus has high recurrence rate if not treated operatively. Total mortality due to sigmoid volvulus at Landspitali is low but surgery related mortality high.


Assuntos
Tratamento Conservador , Procedimentos Cirúrgicos do Sistema Digestório , Volvo Intestinal/terapia , Doenças do Colo Sigmoide/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Enema Opaco , Colonoscopia , Tratamento Conservador/efeitos adversos , Tratamento Conservador/mortalidade , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/mortalidade , Feminino , Hospitais Universitários , Humanos , Islândia/epidemiologia , Volvo Intestinal/diagnóstico , Volvo Intestinal/mortalidade , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Intervalo Livre de Progressão , Recidiva , Estudos Retrospectivos , Fatores de Risco , Doenças do Colo Sigmoide/diagnóstico , Doenças do Colo Sigmoide/mortalidade , Fatores de Tempo
20.
J Stroke Cerebrovasc Dis ; 27(11): 3100-3107, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30093202

RESUMO

BACKGROUND AND PURPOSE: The results of the A Randomized Trial of Unruptured Brain Arteriovenous (ARUBA) study, indicating that conservative medical management of unruptured brain arteriovenous malformations (UBAVM) is superior to interventional therapy, have generated debates that have hampered their application into clinical practice. Irrespectively of study conclusions, it seems reasonable to explore how much better interventional therapy would have to be to become competitive with conservative medical management. METHODS: We conducted an exploratory analysis to replicate the original data from ARUBA. The functional form of the replicated ARUBA data, according to their Weibull distribution, allowed estimation of parameters. We carried out Monte Carlo simulations while introducing theoretical reductions of interventional risk, and the results were used to construct theoretical and example Kaplan-Meier curves from simulations. RESULTS: The "ARUBA Replication" analysis showed results nearly identical to those published in the study, with an estimated hazard ratio of 0.27 (95% CI: 0.14-0.55). At 50% interventional risk reduction, the simulations showed an estimated event rate of 14.9%, and the protective effect of conservative medical management was no longer statistically significant. Greater risk reductions hastened the time to benefit for interventional therapy, and an 80% risk reduction demonstrated superiority of interventional therapy at just over 2 years Hazard Ratio (HR: 1.44, 95% CI: 0.55-4.92). CONCLUSIONS: Reduction in risk of interventional therapy by 50%-80% results in more competitive clinical outcomes, equating or surpassing the benefit of conservative medical management of UBAVM. This conjecture should be taken into consideration in the design of future studies of this patient population, particularly because it is supported by recent observational studies.


Assuntos
Tratamento Conservador , Procedimentos Endovasculares , Malformações Arteriovenosas Intracranianas/terapia , Modelos Teóricos , Procedimentos Neurocirúrgicos , Tomada de Decisão Clínica , Simulação por Computador , Tratamento Conservador/efeitos adversos , Tratamento Conservador/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Humanos , Malformações Arteriovenosas Intracranianas/diagnóstico por imagem , Malformações Arteriovenosas Intracranianas/mortalidade , Método de Monte Carlo , Procedimentos Neurocirúrgicos/efeitos adversos , Procedimentos Neurocirúrgicos/mortalidade , Seleção de Pacientes , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
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