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BACKGROUND: This meta-analysis aims to compare morbidity, mortality, oncological safety, and survival outcomes after laparoscopic multi-visceral resection (MVR) of the locally advanced primary colorectal cancer (CRC) compared with open surgery. MATERIALS AND METHODS: A systematic search of multiple electronic data sources was conducted, and all studies comparing laparoscopic and open surgery in patients with locally advanced CRC undergoing MVR were selected. The primary endpoints were peri-operative morbidity and mortality. Secondary endpoints were R0 and R1 resection, local and distant disease recurrence, disease-free survival (DFS), and overall survival (OS) rates. RevMan 5.3 was used for data analysis. RESULTS: Ten comparative observational studies reporting a total of 936 patients undergoing laparoscopic MVR (n = 452) and open surgery (n = 484) were identified. Primary outcome analysis demonstrated a significantly longer operative time in laparoscopic surgery compared with open operations (P = 0.008). However, intra-operative blood loss (P<0.00001) and wound infection (P = 0.05) favoured laparoscopy. Anastomotic leak rate (P = 0.91), intra-abdominal abscess formation (P = 0.40), and mortality rates (P = 0.87) were comparable between the two groups. Moreover the total number of harvested lymph nodes, R0/R1 resections, local/distant disease recurrence, DFS, and OS rates were also comparable between the groups. CONCLUSION: Although inherent limitations exist with observational studies, the available evidence demonstrates that laparoscopic MVR in locally advanced CRC seems to be a feasible and oncologically safe surgical option in carefully selected cohorts.
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Neoplasias Colorretais , Laparoscopia , Humanos , Recidiva Local de Neoplasia/patologia , Intervalo Livre de Doença , Linfonodos/patologia , Neoplasias Colorretais/patologia , Resultado do TratamentoRESUMO
BACKGROUND: Rectal prolapse is a distressing condition for patients and no consensus exists on optimal surgical management. We compared outcomes of two common perineal operations (Delorme's and Altemeier's) used in the treatment of rectal prolapse. METHODS: A systematic search of multiple electronic databases was conducted. Peri- and post-operative outcomes following Delorme's and Altemeier's procedures were extracted. Primary outcomes included recurrence rate, anastomotic dehiscence rate and mortality rate. The secondary outcomes were total operative time, volume of blood loss, length of hospital stay and coloanal anastomotic stricture formation. Revman 5.3 was used to perform all statistical analysis. RESULTS: Ten studies with 605 patients were selected; 286 underwent Altemeier's procedure (standalone), 39 had Altemeier's with plasty (perineoplasty or levatoroplasty), and 280 had Delorme's. Recurrence rate [OR: 0.66; 95% CI [0.44-0.99], P = 0.05] was significantly lower and anastomotic dehiscence [RD: 0.05; 95% CI [0.00-0.09], P = 0.03] was significantly higher in the Altemeier's group. However, sub group analysis of Altemeier's with plasty failed to show significant differences in these outcomes compared with the Delorme's procedure. Length of hospital stay was significantly more following an Altemeier's operation compared with Delorme's [MD: 3.05, 95% CI [0.95 - 5.51], P = 0.004]. No significant difference was found in total operative time, intra-operative blood loss, coloanal anastomotic stricture formation and mortality rates between the two approaches. CONCLUSIONS: A direct comparison of two common perineal procedures used in the treatment of rectal prolapse demonstrated that the Altemeier's approach was associated with better outcomes. Future, well-designed high quality RCTs with long-term follow up are needed to corroborate our findings.
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Procedimentos Cirúrgicos do Sistema Digestório , Prolapso Retal , Humanos , Prolapso Retal/cirurgia , Constrição Patológica , Recidiva Local de Neoplasia , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Perda Sanguínea Cirúrgica , Recidiva , Resultado do TratamentoRESUMO
Introduction: The aim of this systematic review and meta-analysis is to compare the outcomes of single-incision laparoscopic surgery (SILS) versus multi-port laparoscopy for ileocolic resection in patients with Crohn's disease (CD). Patients and Methods: A systematic search of multiple electronic databases was conducted. The peri- and post-operative outcomes were evaluated between Crohn's patients undergoing SILS versus multi-port laparoscopy for ileocolic resection. The primary outcomes included operative time, anastomotic leak rate, post-operative wound infections and length of hospital stay. Analysed secondary outcomes were conversion rates, ileus occurrence, intra-abdominal abscess formation, return to theatre and re-admissions. Revman 5.3 was used to perform the statistical analysis. Results: Five observational studies with 521 patients (SILS: 211; multi-port: 310) were included in the data synthesis. Patients undergoing SILS had a reduced total operative time compared to multi-port laparoscopy (mean difference [MD]: -16.14, 95% confidence interval: [CI] -27.23 - 5.05, P = 0.004). Post-operative hospital stay was also found to be significantly less in the SILS group (MD: -0.57, 95% CI: -0.73--0.42, P < 0.0001). No significant difference was seen in the anastomotic leak rate (MD: -16.14, 95% CI: 0.18-1.71, P = 0.004) or post-operative wound infections (odds ratio: 0.78, 95% CI: 0.24 - 2.47, P = 0.67) between the two groups. Moreover, all the measured secondary outcomes were comparable. Conclusion: SILS seems to be a feasible alternative to multi-port laparoscopic surgery for ileocolic resection in patients with CD. Improved outcomes in terms of total operative time and length of hospital stay were observed in patients undergoing SILS surgery. Adopting this procedure into routine clinical practice constitutes the next step in the development of minimally invasive surgery.
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Aims: This study aims to evaluate comparative outcomes following midline versus off-midline specimen extractions following laparoscopic left-sided colorectal resections. Methods: A systematic search of electronic information sources was conducted. Studies comparing 'midline' versus 'off midline' specimen extraction following laparoscopic left-sided colorectal resections performed for malignancies were included. The rate of incisional hernia formation, surgical site infection (SSI), total operative time and blood loss, anastomotic leak (AL) and length of hospital stay (LOS) was the evaluated outcome parameters. Results: Five comparative observational studies reporting a total of 1187 patients comparing midline (n = 701) and off-midline (n = 486) approaches for specimen extraction were identified. Specimen extraction performed through an off-midline incision was not associated with a significantly reduced rate of SSI (odds ratio [OR]: 0.71; P = 0.68), the occurrence of AL (OR: 0.76; P = 0.66) and future development of incisional hernias (OR: 0.65; P = 0.64) compared to the conventional midline approach. No statistically significant difference was observed in total operative time (mean difference [MD]: 0.13; P = 0.99), intraoperative blood loss (MD: 2.31; P = 0.91) and LOS (MD: 0.78; P = 0.18) between the two groups. Conclusions: Off-midline specimen extraction following minimally invasive left-sided colorectal cancer surgery is associated with similar rates of SSI and incisional hernia formation compared to the vertical midline incision. Furthermore, there were no statistically significant differences observed between the two groups for evaluated outcomes such as total operative time, intra-operative blood loss, AL rate and LOS. As such, we did not find any advantage of one approach over the other. Future high-quality well-designed trials are required to make robust conclusions.
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PURPOSE OF REVIEW: The purpose of the study was to update the recent information pertaining to carotid artery stenosis risk stratification and treatment. RECENT FINDINGS: Current decision-making related to carotid artery stenosis is based on clinical trials that are outdated. Medical therapy has improved considerably in the past two decades, and this has reduced the stroke rate for both symptomatic and asymptomatic carotid stenoses. In recent community-based studies, the stroke risk with asymptomatic stenosis has been < 1% per year. For asymptomatic carotid stenosis, new trials such as CREST 2 and ECST 2 will determine whether revascularization has any benefit beyond aggressive medical management. For symptomatic patients, carotid endarterectomy is associated with a lower periprocedural stroke rate compared to carotid stenting. Age greater than 70 years is also associated with an increased risk for carotid stenting patients. Clinicians should consider a variety of clinical and radiologic variables in reaching treatment decisions for patients with carotid stenosis. Both symptomatic and asymptomatic patients should receive optimal medical therapy.
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Estenose das Carótidas/tratamento farmacológico , Estenose das Carótidas/cirurgia , Inibidores da Agregação Plaquetária/uso terapêutico , Stents , Angioplastia/métodos , Estenose das Carótidas/diagnóstico por imagem , Endarterectomia das Carótidas/métodos , Humanos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: People with acquired immune deficiency syndrome (AIDS) develop ischemic stroke through distinct mechanisms. These include infections such as syphilis, tuberculosis, varicella, and other conditions such as cocaine abuse, endocarditis, and hypercoagulability. The effect of improved awareness, detection, and treatment with highly active antiretroviral therapy (HAART) on the incidence and outcome of AIDS patients with stroke is unknown. METHODS: Data from the Nationwide Inpatient Sample from 1995 to 2010 were analyzed. Patients with ischemic stroke and AIDS were identified using ICD-9 (International Classification of Diseases) codes. Time trends for demographics, survival, and frequency of AIDS-associated conditions were analyzed. RESULTS: Proportion of AIDS among stroke patients increased significantly during the study. Median age of all strokes decreased from 75 years in 1995 to 72 years in 2010. Conversely, median age for men with stroke and AIDS increased from 43 years to 53 years; and for women with stroke and AIDS, from 41 years to 51 years. Death rates from stroke in the AIDS patients declined. In recent years, the death rates from stroke are similar to patients without HIV/AIDS. Stroke patients with AIDS had increased odds of syphilis (odds ratio [OR]: 33.50), varicella (OR: 48.34), tuberculosis (OR: 137.48), endocarditis (OR: 5.19), cocaine abuse (OR: 26.05), and hypercoagulability (OR: 4.82). CONCLUSIONS: In the HAART era, the median age of incident stroke in AIDS has increased and the mortality from stroke has improved. Research should focus on optimal management of dyslipidemia while on HAART. Whether HAART can reduce the incidence and improve survival of stroke needs to be explored.
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Síndrome da Imunodeficiência Adquirida/tratamento farmacológico , Síndrome da Imunodeficiência Adquirida/epidemiologia , Antirretrovirais/uso terapêutico , Isquemia Encefálica/epidemiologia , Sobreviventes de Longo Prazo ao HIV , Acidente Vascular Cerebral/epidemiologia , Síndrome da Imunodeficiência Adquirida/diagnóstico , Síndrome da Imunodeficiência Adquirida/mortalidade , Adulto , Distribuição por Idade , Idoso , Antirretrovirais/efeitos adversos , Terapia Antirretroviral de Alta Atividade , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidade , Causas de Morte , Bases de Dados Factuais , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Razão de Chances , Prognóstico , Medição de Risco , Fatores de Risco , Distribuição por Sexo , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: The aim of this systematic review and meta-analysis is to assess the efficacy and safety of faecal microbiota transplantation [FMT] in the treatment of chronic pouchitis. METHODS: A PRISMA-compliant systematic review and meta-analysis was conducted using the following databases and clinical trial registers: Medline, Embase, Scopus, Cochrane Database of Systematic Reviews [CENTRAL], clinical trials.gov, ScienceDirect, and VHL [virtual health library]. The primary outcome was clinical response/remission in patients treated with FMT. Secondary outcomes included safety profile, quality of life, and changes in the gut microbiome. RESULTS: Seven observational cohort studies/case series and two randomised, controlled trials with a total of 103 patients were included. The route, preparation, and quantity of FMT administered varied among the included studies. Clinical response rate of 42.6% with a remission rate of 29.8% was estimated in our cohort following FMT therapy. Minor, self-limiting, adverse events were reported, and the treatment was well tolerated with good short- and long-term safety profiles. Successful FMT engraftment in recipients varied and, on average, microbial richness and diversity was lower in patients with pouchitis. In some instances, shifts with specific changes towards abundance of species, suggestive of a 'healthier' pouch microbiota, were observed following treatment with FMT. CONCLUSION: The evidence for FMT in the treatment of chronic pouchitis is sparse, which limits any recommendations being made for its use in clinical practice. Current evidence from low-quality studies suggests a variable clinical response and remission rate, but the treatment is well tolerated, with a good safety profile. This review emphasises the need for rationally designed, well-powered, randomised, placebo-controlled trials to understand the efficacy of FMT for the treatment of pouchitis.
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Microbioma Gastrointestinal , Pouchite , Humanos , Transplante de Microbiota Fecal/efeitos adversos , Pouchite/terapia , Pouchite/etiologia , Qualidade de Vida , Indução de Remissão , Resultado do Tratamento , Fezes , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
BACKGROUND: The aim of this systematic review and meta-analysis is to evaluate clinical, functional, and anorectal physiology outcomes of the side-to-end vs colonic J-pouch (CJP) anastomosis following anterior resection for rectal cancer. METHODS: A PRISMA-compliant systematic review and meta-analysis was conducted using multiple electronic databases and clinical trial registers and all studies comparing side-to-end vs CJP anastomosis were included. Peri-operative complications, mortality rate, functional bowel, and anorectal outcomes were evaluated. RESULTS: Eight randomized controlled trials (RCTs) and two observational studies with 1125 patients (side-to-end: n = 557; CJP: n = 568) were included. Of the entire functional bowel outcome parameters analyzed, only the sensation of incomplete bowel evacuation was significant in the CJP group at 6 months [OR: 2.07; 95% CI 1.06 - 4.02, P = .03]. Peri- and post-operative clinical parameters were comparable in both groups (total operative time, intra-operative blood loss, anastomotic leak rate, return to theater, anastomotic stricture formation and mortality). Equally, most of the analyzed anorectal physiology parameters (anorectal volume, anal squeeze pressure, maximum anal volume) were not significantly different between the two groups. However, anal resting pressure (mmHg) 2 years post-operatively was noted to be significantly higher in the side-to-end group than that of the CJP configuration [MD: -8.76; 95% CI - 15.91 - 1.61, P = .02]. DISCUSSION: Clinical and functional outcomes following CJP surgery and side-to-end coloanal anastomosis are comparable. Neither technique appears to proffer solution to low anterior resection syndrome in the short term but future well-designed; high-quality RCTs with long term follow-up are required.
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Anastomose Cirúrgica , Bolsas Cólicas , Proctocolectomia Restauradora , Humanos , Canal Anal/cirurgia , Anastomose Cirúrgica/métodos , Colo/cirurgia , Protectomia , Neoplasias Retais/cirurgia , Reto/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Survival after malignant middle cerebral artery infarcts is dismal. In 2007, a pooled analysis of randomised trials in Europe demonstrated a substantial survival benefit from decompressive hemicraniectomy, with a number needed to treat of 2 for survival. Our objective was to review factors driving the nationwide utilisation of this potentially lifesaving procedure in the USA. METHODS: Data from the Nationwide Inpatient Sample for 2001-2009 were reviewed. Hospitalisations with a discharge diagnosis of an acute ischaemic stroke were included. Hemicraniectomy utilisation was determined within this subset. Nationwide estimates of utilisation were calculated for each year. Trends across the years were estimated for various subgroups. RESULTS: From 2001 to 2009, there were an estimated 4 909 519 acute ischaemic stroke discharges. The estimated frequency of hemicraniectomy increased from 118 (0.02% of stroke discharges in 2001) to 804 (0.15% of stroke discharges in 2009) (trend p<0.001). The increased utilisation was greatest for younger subjects (age<45 years; trend p<0.001) and men (trend p<0.001). Urban teaching hospitals were responsible for the greatest increase in hemicraniectomy utilisation: from 0.05% of stroke discharges in 2001 to 0.28% in 2009. The increase was steady and sustained over the decade. In comparison, rural and urban non-teaching hospitals showed a much smaller improvement in utilisation. CONCLUSION: Utilisation of hemicraniectomy in the USA has increased significantly, in line with compelling results from European clinical trials. Early transfer of patients with malignant infarctions to urban teaching centres could potentially extend the survival benefit to a larger population.
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Isquemia Encefálica/cirurgia , Craniotomia/estatística & dados numéricos , Craniotomia/tendências , Acidente Vascular Cerebral/cirurgia , Idoso , Isquemia Encefálica/complicações , Isquemia Encefálica/epidemiologia , Bases de Dados Factuais , Descompressão Cirúrgica , Difusão de Inovações , Feminino , Humanos , Disseminação de Informação , Pacientes Internados , Classificação Internacional de Doenças , Masculino , Pessoa de Meia-Idade , Fatores Sexuais , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: A recent study found a trend toward increasing hospitalizations for acute ischemic stroke (AIS) among young adults, raising concern for this subgroup. In the present study, we evaluated trends of use of thrombolysis and outcome among young adults (19-44 years of age) with AIS using a nationally representative administrative database. METHODS: Discharge data were obtained from Nationwide Inpatient Sample between 2001 and 2009. Hospitalizations with a discharge diagnosis of AIS for patients 19 to 44 years of age were included. Use of thrombolysis was determined within this subset. The Cochran-Armitage test was used for trend analysis. RESULTS: Thrombolysis in young patients with AIS increased from 354 (1.84%) in 2001 to 1,237 (4.97%) in 2009 (P < .0001). The highest increase was noted at urban teaching hospitals. There was a progressive decrease in mortality in young AIS patients, from 6.81% in 2001 to 5.43% in 2009 (trend P = .027) and significant increase in discharges to rehabilitation (3.42% in 2002 to 12.7% in 2009 [trend P < .0001]). Discharge to other facilities decreased significantly (29.1% in 2001 to 17.8% in 2009 [trend P < .0001]). The rate of intracranial hemorrhage (2.70% in 2001; 2.69% in 2009) did not show any significant change despite the increase in the use of thrombolysis (trend P = .39). CONCLUSIONS: The rate of thrombolysis among young patients with AIS increased significantly between 2001 and 2009. A decrease in deaths with increased rehabilitation placements of young patients with AIS was noted over the last decade, suggesting improving outcomes. The lower rate of use of thrombolysis in rural hospitals may be improved with the widespread use of telestroke.
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Isquemia Encefálica/tratamento farmacológico , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/tendências , Adulto , Idade de Início , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etnologia , Isquemia Encefálica/mortalidade , Feminino , Hospitais Rurais/tendências , Hospitais de Ensino/tendências , Hospitais Urbanos/tendências , Humanos , Hemorragias Intracranianas/etnologia , Masculino , Alta do Paciente/tendências , Melhoria de Qualidade/tendências , Indicadores de Qualidade em Assistência à Saúde/tendências , Centros de Reabilitação/tendências , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etnologia , Acidente Vascular Cerebral/mortalidade , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND: We hypothesized that the presence of an in-house neurologist or a neurology or emergency medicine (EM) residency is associated with a lower rate of missed stroke diagnosis and a greater use of thrombolytic therapy. METHODS: The outpatient Young Stroke registry from our academic medical center was reviewed. Patients 16 to 50 years of age who presented with ischemic stroke were included. Information on presentation, acute therapy, and missed diagnosis was obtained. The presence of an EM or neurology residency at the presenting hospital was recorded. We also assessed whether hospital teaching status in these fields affected missed diagnosis rates, the use of thrombolysis, or stroke intervention. RESULTS: Ninety-three patients were included. Thirteen patients were misdiagnosed. In hospitals with and without a neurology residency, the missed diagnosis rate was 6.3% versus 18.0%, respectively (P=.21). Two patients were misdiagnosed in hospitals with a neurology residency, but neither had neurology consultations in the emergency department. If these cases are removed from our analysis, the rate of missed diagnosis with and without a neurology residency is 0% versus 20.6%, respectively (P=.008). Acute stroke therapy was administered in 17.9% of patients seen with an EM residency, compared to 2.7% without an EM residency (P=.046). With and without a neurology residency, acute stroke therapy was administered in 25% versus 8.2% of cases, respectively (P=.055). CONCLUSIONS: Young adults with ischemic stroke seen at hospitals with a neurology residency had a lower missed diagnosis rate. The presence of an EM resident or a neurology teaching program was associated with a greater use of acute stroke therapies. These results support initiatives to triage young adults with suspected acute stroke to hospitals with access to neurologic expertise in the emergency department.
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Erros de Diagnóstico/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Neurologia , Acidente Vascular Cerebral/diagnóstico , Adolescente , Adulto , Serviços Médicos de Emergência , Feminino , Humanos , Internato e Residência , Masculino , Pessoa de Meia-Idade , Recursos Humanos em Hospital/estatística & dados numéricos , Médicos , Terapia Trombolítica , Adulto JovemRESUMO
Racial differences in stroke risk and risk factor prevalence are well established. The present study explored racial differences in the delivery of care to patients with acute stroke between Joint Commission (JC)-certified hospitals and noncertified hospitals. A retrospective chart review was conducted in patients sustaining ischemic stroke admitted to 5 JC-certified centers and 5 noncertified hospitals. Demographic data, risk factors, utilization of acute stroke therapies, and compliance with core measures were recorded. Racial disparities were investigated in the entire group as well as for JC-certified and noncertified hospitals separately. A total of 574 patients (25.1% African Americans) were included. African Americans were significantly younger and more likely to have previous stroke, whereas Caucasians were more likely to have coronary disease and atrial fibrillation. There were no racial differences in other risk factors or baseline functions. Median National Institutes of Health Stroke Scale scores were similar in African Americans and Caucasians, as were proportions receiving intravenous tissue plasminogen activator (tPA) therapy (2.1% in African Americans, 3.5% in Caucasians; P = .40) and intervention (4.2% in African Americans, 6.8% in Caucasians; P = .26). Caucasians were more likely to arrive by emergency medical services (65.5% vs 51.5%; P = .004), to be evaluated by a stroke team (19.1% vs 7.7%; P = .001), and to have a documented National Institutes of Health Stroke Scale score (40.2% vs 29.9%; P = .03). African Americans often did not receive intravenous tPA because of a delay in arrival. African Americans performed better on virtually all stroke care variables in JC-certified centers. JC certification reduced disparity in certain variables, including tPA and deep venous thrombosis prophylaxis administration. Important racial disparities exist in the delivery of several acute stroke care variables. Efforts must be focused on eliminating disparities in prehospital delays. Guideline-based care tendered at JC-certified centers might help narrow disparities in acute stroke care delivery.
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Negro ou Afro-Americano , Prestação Integrada de Cuidados de Saúde , Acessibilidade aos Serviços de Saúde , Disparidades em Assistência à Saúde/etnologia , Joint Commission on Accreditation of Healthcare Organizations , Qualidade da Assistência à Saúde , Acidente Vascular Cerebral/terapia , População Branca , Idoso , Prestação Integrada de Cuidados de Saúde/normas , Serviços Médicos de Emergência , Procedimentos Endovasculares , Feminino , Fidelidade a Diretrizes , Acessibilidade aos Serviços de Saúde/normas , Disparidades em Assistência à Saúde/normas , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Equipe de Assistência ao Paciente , Guias de Prática Clínica como Assunto , Padrões de Prática Médica , Prevalência , Qualidade da Assistência à Saúde/normas , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etnologia , Terapia Trombolítica , Estados Unidos/epidemiologiaRESUMO
Injury occurs in epilepsy monitoring units (EMUs) to patients with epileptic seizures (ES); however, there are limited data regarding the safety concerns of patients with psychogenic nonepileptic seizures (PNES) being monitored in EMUs. We reviewed EMU records from 116 PNES and compared them to 170 ES. Three falls (2.6%) occurred in PNES without injury compared to 6 falls (3.5%) in ES with 1 injury, a facial hematoma. Of the 9 total falls, 8 patients were ambulatory during their events. Several adverse incidents occurred for both groups. Of the PNES without staff response, 30 of 39 were due to PNES being less than 60s in duration, and 16 of 39 involved lack of push-button activation to alert the staff. For the ES group, 57 of 101 were due to electrographic seizures without seizure detection software or push-button activation. Similar safety protocols should be administered while monitoring these patients regardless of seizure type.
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Acidentes por Quedas , Transtorno Conversivo/complicações , Segurança do Paciente , Transtornos Psicofisiológicos/complicações , Convulsões/complicações , Adulto , Idoso , Transtorno Conversivo/diagnóstico , Transtorno Conversivo/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Transtornos Psicofisiológicos/diagnóstico , Transtornos Psicofisiológicos/psicologia , Convulsões/diagnóstico , Convulsões/psicologiaRESUMO
BACKGROUND: Achieving a clear resection margins for low rectal cancer is technically challenging. Transanal approach to total mesorectal excision (TME) was introduced in order to address the challenges associated with the laparoscopic approach in treating low rectal cancers. However, previous meta-analyses have included mixed population with mid and low rectal tumours when comparing both approaches which has made the interpretation of the real differences between two approaches in treating low rectal cancer difficult. AIM: To investigate the outcomes of transanal TME (TaTME) and laparoscopic TME (LaTME) in patients with low rectal cancer. METHODS: A comprehensive systematic review of comparative studies was performed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards. Intraoperative and postoperative complications, anastomotic leak, R0 resection, completeness of mesorectal excision, circumferential resection margin (CRM), distal resection margin (DRM), harvested lymph nodes, and operation time were the investigated outcome measures. RESULTS: We included twelve comparative studies enrolling 969 patients comparing TaTME (n = 969) and LaTME (n = 476) in patients with low rectal tumours. TaTME was associated with significantly lower risk of postoperative complications (OR: 0.74, P = 0.04), anastomotic leak (OR: 0.59, P = 0.02), and conversion to an open procedure (OR: 0.29, P = 0.002) in comparison with LaTME. Moreover, the rate of R0 resection was significantly higher in the TaTME group (OR: 1.96, P = 0.03). Nevertheless, TaTME and LaTME were comparable in terms of rate of intraoperative complications (OR: 1.87; P = 0.23), completeness of mesoractal excision (OR: 1.57, P = 0.15), harvested lymph nodes (MD: -0.05, P = 0.96), DRM (MD: -0.94; P = 0.17), CRM (MD: 1.08, P = 0.17), positive CRM (OR: 0.64, P = 0.11) and procedure time (MD: -6.99 min, P = 0.45). CONCLUSION: Our findings indicated that for low rectal tumours, TaTME is associated with better clinical and short term oncological outcomes compared to LaTME. More randomised controlled trials are required to confirm these findings and to evaluate long term oncological and functional outcomes.
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We aimed to evaluate comparative outcomes of robotic and laparoscopic splenectomy in patients with non-traumatic splenic pathologies. A systematic search of electronic databases and bibliographic reference lists were conducted, and a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits in electronic databases were applied. Intraoperative and post-operative complications, wound infection, haematoma, conversion to open procedure, return to theatre, volume of blood loss, procedure time and length of hospital stay were the evaluated outcome parameters. We identified 8 comparative studies reporting a total of 560 patients comparing outcomes of robotic (n = 202) and laparoscopic (n = 258) splenectomies. The robotic approach was associated with significantly lower volume of blood loss (MD: -82.53 mls, 95% CI -161.91 to -3.16, P = .04) than the laparoscopic approach. There was no significant difference in intraoperative complications (OR: 0.68, 95% CI .21-2.01, P = .51), post-operative complications (OR: .91, 95% CI .40-2.06, P = .82), wound infection (RD: -.01, 95% CI -.04-.03, P = .78), haematoma (OR: 0.40, 95% CI .04-4.03, P = .44), conversion to open (OR: 0.63; 95% CI, .24-1.70, P = .36), return to theatre (RD: -.04, 95% CI -.09-.02, P = .16), procedure time (MD: 3.63; 95% CI -16.99-24.25, P = .73) and length of hospital stay (MD: -.21; 95% CI -1.17 - .75, P = .67) between 2 groups. In conclusion, robotic and laparoscopic splenectomies seem to have comparable perioperative outcomes with similar rate of conversion to an open procedure, procedure time and length of hospital stay. The former may potentially reduce the volume of intraoperative blood loss. Future higher level research is required to evaluate the cost-effectiveness and clinical outcomes.
Assuntos
Laparoscopia , Procedimentos Cirúrgicos Robóticos , Esplenectomia/métodos , Esplenopatias/cirurgia , Adulto , Viés , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Criança , Conversão para Cirurgia Aberta/estatística & dados numéricos , Hematoma/epidemiologia , Humanos , Complicações Intraoperatórias/epidemiologia , Laparoscopia/efeitos adversos , Laparoscopia/estatística & dados numéricos , Tempo de Internação , Estudos Observacionais como Assunto , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Esplenectomia/efeitos adversos , Infecção da Ferida Cirúrgica/epidemiologiaRESUMO
Aim: To evaluate outcomes of interventions for severe aortic valve stenosis (AS), whether it is done by surgical aortic valvotomy (SAV) or balloon aortic dilatation (BAD). Results: Eleven studies with total number of 1733 patients; 743 patients had SAV, while 990 patients received BAD. There was no significant difference in early mortality (odds ratio [OR]: 0.96, p = 0.86), late mortality (OR: 1.28, p = 0.25), total mortality (OR: 1.10, p = 0.56), and freedom from aortic valve replacement (OR: 1.00, p = 1.00). Reduction of aortic systolic gradient was significantly higher in the SAV group (OR: 2.24, p = 0.00001), and postprocedural AR rate was lower in SAV group (OR: 0.21, p = 0.00001). Conclusion: SAV is associated with better reduction of aortic systolic gradient and lesser post procedural AR which reduce when compared with BAD.
Congenital aortic valve stenosis is disease in which in which babies are born with narrowing of their aortic valve (the valve leading to main body artery). This study aims to evaluate best outcomes for the two main interventions to treat this disease which are; balloon dilatation (keyhole) and open-heart surgery. Our study results showed that there was no significant difference in mortality between the two treatment strategies; however, there is better immediate results in reliving valve narrowing after and less valve leak after open heart surgery than after key hole procedure. These results remain operator dependent and can differ between centers; therefore, more high-quality studies are encouraged to determine best treatment option for aortic stenosis.
Assuntos
Insuficiência da Valva Aórtica , Estenose da Valva Aórtica , Criança , Humanos , Dilatação , Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Cateterismo , Resultado do TratamentoRESUMO
The majority of carotid revascularization procedures are done in patients without recent symptoms of cerebral ischemia (asymptomatic carotid stenosis). In previous studies from the past two decades, the stroke risk associated with asymptomatic carotid stenosis has been estimated to be 2-2.5% per year. Given the relatively benign nature of asymptomatic carotid stenosis, it has been proposed that confining revascularization to a limited, higher-risk subgroup is a sensible strategy. Evidence is accumulating that improved medical therapy has led to a lower risk of stroke in medically treated patients and that ultrasound methods can identify higher-risk patients. These developments are highlighted in this article.
Assuntos
Artérias Carótidas/patologia , Estenose das Carótidas/tratamento farmacológico , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Estenose das Carótidas/complicações , Estenose das Carótidas/patologia , Humanos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler TranscranianaRESUMO
Misdiagnosis or delayed diagnosis of acute ischemic stroke can result in neurologic worsening or a missed opportunity for thrombolysis. Because stroke in young adults is less common than stroke in the elderly, we sought to determine clinical characteristics associated with misdiagnosis of stroke in young adults. Patients from the prospectively maintained Young Stroke Registry in our comprehensive stroke center were reviewed. Demographic information, past medical history, presentation within the 3-hour time window, and outcomes were assessed. We compared patients misdiagnosed and those correctly diagnosed to identify factors associated with misdiagnosis of acute stroke. A total of 57 patients aged 16-50 were enrolled in the registry during 2001-2006. Eight patients (14%; 4 men and 4 women; mean age, 38 years) were misdiagnosed. Seven of these 8 patients were discharged from the emergency department initially. Patients age <35 years (P = .05) and patients with posterior circulation stroke (P = .006) were more likely to be misdiagnosed. All 8 misdiagnosed patients were initially evaluated at hospitals that were not certified primary stroke centers. Patients presenting with vertebrobasilar territory ischemia have a greater rate of misdiagnosis. Our study demonstrates the increasing need for "young stroke awareness" among emergency department personnel. Initial misdiagnosis can potentially lead to a lost opportunity for thrombolysis in otherwise good candidates.
Assuntos
Erros de Diagnóstico , Acidente Vascular Cerebral/diagnóstico , Adolescente , Adulto , Fatores Etários , Atitude do Pessoal de Saúde , Distribuição de Qui-Quadrado , Competência Clínica , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Michigan , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Sistema de Registros , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/complicações , Adulto JovemRESUMO
Cocaine use is associated with ischemic stroke through unique mechanisms, including reversible vasospasm, drug-induced arteritis, enhanced platelet aggregation, cardioembolism, and hypertensive surges. To date, no study has described disability in patients with cocaine-related ischemic stroke. The present study compared risk factors, comorbidities, complications, laboratory findings, medications, and outcomes in patients with cocaine-related (n = 41) and non-cocaine-related (n = 221) ischemic stroke (n = 147) and transient ischemic attack (n = 115) in 3 academic hospitals. The patients with cocaine-related stroke were younger (mean age, 51.9 years vs 59.1 years; P = .0008) and more likely to be smokers (95% vs 62.9%; P < .004). The prevalence of arrhythmias was significantly higher in the patients with cocaine-related stroke, and that of diabetes was significantly higher in those with non-cocaine-related strokes. The prevalence of hypertension and lipid profiles were similar in the 2 groups; however, those with cocaine-related stroke were less likely to receive statins. Antiplatelet use was similar in the 2 groups. Survivors of both groups had similar modified Rankin scores and lengths of hospital stay. In the older urban population, smoking and cocaine use may coexist with other cerebrovascular risk factors, and cocaine-related strokes have similar morbidities and mortality as non-cocaine-related strokes. Moreover, because the patients with cocaine-related stroke is younger, they have an earlier morbidity. New strategies for effective stroke prevention interventions are needed in this subgroup.
Assuntos
Isquemia Encefálica/diagnóstico , Transtornos Relacionados ao Uso de Cocaína/complicações , Avaliação da Deficiência , Ataque Isquêmico Transitório/diagnóstico , Acidente Vascular Cerebral/diagnóstico , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Arritmias Cardíacas/epidemiologia , Isquemia Encefálica/etiologia , Isquemia Encefálica/mortalidade , Distribuição de Qui-Quadrado , Transtornos Relacionados ao Uso de Cocaína/mortalidade , Diabetes Mellitus/epidemiologia , Dislipidemias/epidemiologia , Feminino , Hospitais Comunitários , Hospitais Universitários , Humanos , Hipertensão/epidemiologia , Ataque Isquêmico Transitório/etiologia , Ataque Isquêmico Transitório/mortalidade , Tempo de Internação , Modelos Logísticos , Masculino , Michigan/epidemiologia , Pessoa de Meia-Idade , Prevalência , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fumar/efeitos adversos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Fatores de TempoRESUMO
BACKGROUND: The authors report the effects of patient risk factors and physician specialty on the clinical outcomes of patients with spontaneous intracerebral hemorrhage (ICH), who were treated nonsurgically at 3 academic medical centers. To our knowledge, there is no reported literature on the effect of physician specialty and outcomes (modified Rankin scale [mRS] score, in-hospital death, and hospital length of stay [LOS]). METHODS: A new patent pending data-mining method, Healthcare Smart Grid, retrospectively analyzed hospital data for 129 patients with spontaneous ICH admitted to 3 (two university and one community) hospitals in a single metropolitan region and treated nonsurgically. Patients with traumatic hemorrhages and subarachnoid hemorrhages were excluded from the study. Demographic data, clinical presentation, medical risk factors, and hematoma characteristics were tested for associations with 3 outcomes: in-hospital death, mRS score at discharge, and LOS. RESULTS: A total of 129 cases were identified in the university (77 cases) and community (52 cases) hospitals during a 20-month period (December 2005-July 2007). The mean age was 64.1 years with 48% being men and 83% being black. The median LOS among survivors was 6 days. LOS was significantly associated with physician specialty (P=.002 for both comparisons: neurologists and neurosurgeons with internists) and hemorrhage volume. Mortality in these patients was 23%. In an adjusted analysis, hemorrhage volume (P < .001) and Glasgow Coma Scale score at admission (P=.001) were significant predictors of in-hospital mortality, whereas physician specialty, number of comorbidities, and other risk factors were not. The median mRS score at discharge was 3. Larger hemorrhage volume tends to predict greater disability (P=.06). CONCLUSIONS: LOS for spontaneous nonsurgically treated ICH tends to be the least with admission to specialist services such as neurologists and neurosurgeons. Physician specialties do not seem to influence mRS score or mortality in medically managed spontaneous ICH. Hemorrhage volume has a statistically significant association with death and LOS.