RESUMO
OBJECTIVES: Enhanced Recovery After Surgery (ERAS) programs are mechanisms for achieving value-based improvements in surgery. This report provides a detailed analysis of the impact of an ERAS program on patient outcomes as well as quality and safety measures during implementation on a gynecologic oncology service at a major academic medical center. METHODS: A retrospective review of gynecologic oncology patients undergoing elective laparotomy during the implementation phase of an ERAS program (January 2016 through December 2016) was performed. Patient demographics, surgical variables, postoperative outcomes, and adherence to core safety measures, including antimicrobial and venous thromboembolism (VTE) prophylaxis, were compared to a historical patient cohort (January 2015 through December 2015). Statistical analyses were performed using t-tests, Wilcoxon rank sum tests, and Chi squared tests. RESULTS: The inaugural 109 ERAS program participants were compared to a historical patient cohort (n=158). There was no difference in BMI, race, malignancy, or complexity of procedure between cohorts. ERAS patients required less narcotics (70.7 vs 127.4, p=0.007, oral morphine equivalents) and PCA use (32.1% vs. 50.6%, p=0.002). Despite this substantial reduction in narcotics, ERAS patients did not report more pain and in fact reported significantly less pain by postoperative day 3. There were no differences in length of stay (5days), complication rates (13.8% vs. 20.3%, p=0.17) or 30-day readmission rates (9.5 vs 11.9%, p=0.54) between ERAS and historical patients, respectively. Compliance with antimicrobial prophylaxis was 97.2%. However, 33.9% of ERAS patients received substandard preoperative VTE prophylaxis. CONCLUSIONS: ERAS program implementation resulted in reductions in narcotic requirements and PCA use without changes in length of stay or readmission rates. Compliance should be diligently audited during the implementation phase of ERAS programs, with special attention to adherence to pre-existing core safety measures.
Assuntos
Neoplasias dos Genitais Femininos/cirurgia , Procedimentos Cirúrgicos em Ginecologia/métodos , Entorpecentes/administração & dosagem , Dor Pós-Operatória/prevenção & controle , Feminino , Fidelidade a Diretrizes , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Procedimentos Cirúrgicos em Ginecologia/reabilitação , Procedimentos Cirúrgicos em Ginecologia/normas , Humanos , Pessoa de Meia-Idade , Dor Pós-Operatória/tratamento farmacológico , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/normas , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/normas , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Melhoria de Qualidade , Estudos Retrospectivos , Padrão de CuidadoRESUMO
OBJECTIVES: Minimally invasive surgery (MIS) is a quality measure for endometrial cancer (EC) established by the Society of Gynecologic Oncology and the American College of Surgeons. Our study objective was to assess the proportion of EC cases performed by MIS at National Comprehensive Cancer Network (NCCN) centers and evaluate perioperative outcomes. METHODS: A retrospective cohort study of women who underwent surgical treatment for EC from 2013 to 2014 was conducted at four NCCN centers. Multivariable mixed logistic regression models analyzed factors associated with failure to perform MIS and perioperative complications. RESULTS: In total 1621 patients were evaluated; 86.5% underwent MIS (robotic-assisted 72.5%, laparoscopic 20.9%, vaginal 6.6%). On multivariable analysis, factors associated with failure to undergo MIS were uterine size >12cm (Odds Ratio [OR]: 0.17, 95% CI 0.03-0.9), stage III (OR: 0.16, 95% CI 0.05-0.49) and IV disease (OR: 0.07, 95% CI 0.02-0.22). For stage I/II disease, complications occurred in 5.1% of MIS and 21.7% of laparotomy cases (p<0.01). Laparotomy was associated with increases in any complication (OR: 6.0, 95% CI 3.3-10.8), gastrointestinal (OR: 7.2, 95% CI 2.6-19.5), wound (OR: 3.7, 95% CI 1.5-9.2), respiratory (OR 37.5, 95% CI 3.9-358.0), VTE (OR 10.5, 95% CI 1.3-82.8) and 30-day readmission (OR: 2.6, 95% CI 1.4-4.9) compared to MIS. CONCLUSIONS: At NCCN-designated centers, the MIS hysterectomy rate in EC is higher than the published national average, with low perioperative complications. Previously identified disparities of age, race, and BMI were not observed. A proposed MIS hysterectomy benchmark of >80% in EC care is feasible when performed at high volume centers.
Assuntos
Adenocarcinoma de Células Claras/cirurgia , Carcinoma Endometrioide/cirurgia , Neoplasias do Endométrio/cirurgia , Histerectomia/métodos , Laparoscopia/estatística & dados numéricos , Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Neoplasias Císticas, Mucinosas e Serosas/cirurgia , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Adenocarcinoma de Células Claras/patologia , Idoso , Institutos de Câncer , Carcinoma Endometrioide/patologia , Estudos de Coortes , Feminino , Gastroenteropatias/epidemiologia , Humanos , Histerectomia Vaginal/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Modelos Logísticos , Excisão de Linfonodo , Pessoa de Meia-Idade , Análise Multivariada , Estadiamento de Neoplasias , Neoplasias Císticas, Mucinosas e Serosas/patologia , Razão de Chances , Omento/cirurgia , Tamanho do Órgão , Ovariectomia/métodos , Readmissão do Paciente , Pelve , Doenças Respiratórias/epidemiologia , Estudos Retrospectivos , Salpingectomia/métodos , Infecção da Ferida Cirúrgica/epidemiologia , Útero/patologiaRESUMO
It is widely accepted that central and effector memory CD4+ T cells originate from naïve T cells after they have encountered their cognate antigen in the setting of appropriate co-stimulation. However, if this were true the diversity of T cell receptor (TCR) sequences within the naïve T cell compartment should be far greater than that of the memory T cell compartment, which is not supported by TCR sequencing data. Here we demonstrate that aged mice with far fewer naïve T cells, respond to the model antigen, hen eggwhite lysozyme (HEL), by utilizing the same TCR sequence as their younger counterparts. CD4+ T cell repertoire analysis of highly purified T cell populations from naive animals revealed that the HEL-specific clones displayed effector and central "memory" cell surface phenotypes even prior to having encountered their cognate antigen. Furthermore, HEL-inexperienced CD4+ T cells were found to reside within the naïve, regulatory, central memory, and effector memory T cell populations at similar frequencies and the majority of the CD4+ T cells within the regulatory and memory populations were unexpanded. These findings support a new paradigm for CD4+ T cell maturation in which a specific clone can undergo a differentiation process to exhibit a "memory" or regulatory phenotype without having undergone a clonal expansion event. It also demonstrates that a foreign-specific T cell is just as likely to reside within the regulatory T cell compartment as it would the naïve compartment, arguing against the specificity of the regulatory T cell compartment being skewed towards self-reactive T cell clones. Finally, we demonstrate that the same set of foreign and autoreactive CD4+ T cell clones are repetitively generated throughout adulthood. The latter observation argues against T cell-depleting strategies or autologous stem cell transplantation as therapies for autoimmunity-as the immune system has the ability to regenerate pathogenic clones.
Assuntos
Linfócitos T CD4-Positivos/imunologia , Memória Imunológica , Subpopulações de Linfócitos T/imunologia , Fatores Etários , Animais , Antígenos/imunologia , Autoimunidade , Linfócitos T CD4-Positivos/metabolismo , Galinhas , Células Dendríticas/imunologia , Células Dendríticas/metabolismo , Proteínas do Ovo/imunologia , Encefalomielite Autoimune Experimental/imunologia , Encefalomielite Autoimune Experimental/metabolismo , Encefalomielite Autoimune Experimental/terapia , Feminino , Transplante de Células-Tronco Hematopoéticas , Imunofenotipagem , Contagem de Linfócitos , Depleção Linfocítica , Camundongos , Fenótipo , Especificidade do Receptor de Antígeno de Linfócitos T/genética , Especificidade do Receptor de Antígeno de Linfócitos T/imunologia , Subpopulações de Linfócitos T/metabolismo , Linfócitos T Reguladores/imunologia , Linfócitos T Reguladores/metabolismoRESUMO
OBJECTIVES: Women with advanced-stage, low-grade serous ovarian carcinoma (LGSC) have low chemotherapy response rates and poor overall survival. Most LGSC tumors overexpress hormone receptors, which represent a potential treatment target. Our study objective was to determine the outcomes of patients with advanced-stage LGSC treated with primary cytoreductive surgery (CRS) and hormone therapy (HT). METHODS: A retrospective study was performed at two academic cancer centers. Patients with Stage II-IV LGSC underwent either primary or interval CRS followed by adjuvant HT between 2004 and 2016. Gynecologic pathologists reviewed all cases. Two-year progression-free (PFS) and overall survival (OS) were calculated. RESULTS: Twenty-seven patients were studied; primary CRS followed by HT were administered in 26, while 1 patient had neoadjuvant chemotherapy followed by CRS and HT. The median patient age was 47.5, and patients had Stage II (n=2), Stage IIIA (n=6), Stage IIIC (n=18), and Stage IV (n=1) disease. Optimal cytoreduction to no gross residual was achieved in 85.2%. Ninety six percent of tumors expressed estrogen receptors, while only 32% expressed progesterone receptors. Letrozole was administered post operatively in 55.5% cases, anastrozole in 37.1% and tamoxifen in 7.4%. After a median follow up of 41months, only 6 patients (22.2%) have developed a tumor recurrence and two patients have died of disease. Median PFS and OS have not yet been reached, but 2-year PFS and OS were 82.8% and 96.3%, respectively, and 3-year PFS and OS were 79.0% and 92.6%, respectively. CONCLUSIONS: Our series describes the initial experience with cytoreductive surgery and hormonal monotherapy for women with Stage II-IV primary ovarian LGSC. While surgery remains the mainstay of treatment, chemotherapy may not be necessary in patients with advanced-stage disease who receive adjuvant hormonal therapy. A cooperative group, Phase III trial is planned to define the optimal therapy for women with this ovarian carcinoma subtype.
Assuntos
Antineoplásicos/uso terapêutico , Cistadenocarcinoma Seroso/terapia , Procedimentos Cirúrgicos de Citorredução , Uso Excessivo dos Serviços de Saúde/prevenção & controle , Neoplasias Ovarianas/terapia , Adulto , Idoso , Anastrozol , Quimioterapia Adjuvante , Terapia Combinada/métodos , Feminino , Humanos , Letrozol , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Nitrilas/uso terapêutico , Estudos Retrospectivos , Análise de Sobrevida , Tamoxifeno/uso terapêutico , Triazóis/uso terapêuticoRESUMO
Ovarian carcinoma is the most lethal malignancy of the female genital tract. Population-based trials in the general population have not demonstrated that screening improves early detection or survival. Therefore, application of prevention strategies is vital to improving outcomes from this disease. Surgical prevention reduces risk and prophylactic risk-reducing salpingo-oophorectomy is the most effective means to prevent ovarian carcinoma in the high-risk patient although the risks do not outweigh the benefits in average risk patients. Other surgical and medical options have unknown or limited efficacy in the high-risk patient. In this review, we define the patient at high risk for ovarian cancer, discuss how to identify these women and weigh their available ovarian cancer prevention strategies.
Assuntos
Carcinoma/prevenção & controle , Detecção Precoce de Câncer/métodos , Testes Genéticos/métodos , Neoplasias Ovarianas/prevenção & controle , Procedimentos Cirúrgicos Profiláticos/métodos , Adulto , Carcinoma/genética , Feminino , Genes BRCA1 , Genes BRCA2 , Mutação em Linhagem Germinativa , Humanos , Pessoa de Meia-Idade , Neoplasias Ovarianas/genética , Medição de Risco , Fatores de RiscoRESUMO
Little research has focused on what precedes the processing of health messages to predict recall of information and whether age matters in this regard. To address this gap, this study investigates the relationship between attention and recall among younger (<65 years) and older (≥65 years) adults. Using eye tracking, we exposed participants to a webpage consisting of text-only information, text with cognitive illustrations, or text with affective illustrations. When attention to text increased, older adults recalled more information, whereas younger adults did not. However, younger adults paid more attention to cognitive illustrations than older adults and recalled more information. These results reveal conditions under which health messages are effectively recalled by younger and older adults.
Assuntos
Informação de Saúde ao Consumidor , Internet , Rememoração Mental/fisiologia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Atenção/fisiologia , Movimentos Oculares , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
BACKGROUND/AIMS: To examine the relationship of the amniotic fluid index (AFI) and single deepest pocket (SDP) with an AFV as modelled by Brace or Magann. METHODS: AFI and SDP were evaluated for their correlation with an actual AFV using the Spearman correlation coefficient. RESULTS: 482 AFI and 468 SDP pregnancies were evaluated. There was a significant association between the AFI and SDP and an actual AFV (p < 0.0001). The AFI range of 5.1-20 was better correlated than 5.1-24 for normal AFVs Brace (κ = 0.175) and Magann (κ = 0.356) versus 5.1-24 (κ = 0.150 and κ = 0.319), respectively. The agreement level t for the AFI (κ = 0.175) and SDP (κ = 0.126) using Brace was slight and for the AFI (κ = 0.356) and SDP (κ = 0.295) using Magann was fair. CONCLUSIONS: Both the AFI and SDP were correlated with actual AFV using both models. AFI of 5.1-20 better categorizes normal volumes. Although the Magann model correlates AFI/SDP and AFV better, the superiority is minimal.
Assuntos
Líquido Amniótico/diagnóstico por imagem , Técnica de Diluição de Corante , Ultrassonografia Pré-Natal , Adulto , Fenômenos Biofísicos , Feminino , Idade Gestacional , Humanos , Oligo-Hidrâmnio/diagnóstico por imagem , Poli-Hidrâmnios/diagnóstico por imagem , Gravidez , Estudos RetrospectivosRESUMO
The objectives of this systematic review were to examine the reproducibility of sonographic estimates of amniotic fluid volume (AFV) in twin pregnancies, compare the association of sonographic estimates of AFV with dye-determined AFV, and correlate AFV with antepartum, intrapartum, and perinatal outcomes in twin pregnancies. Studies were included if they were adequately powered and investigated antepartum, intrapartum, and/or perinatal adverse outcome parameters in twin gestations. Studies with comparable populations and exclusion criteria were merged into forest plots. Data comparing the accuracy of AFV assessment, correlation of AFV with gestational age, and adverse outcomes were tabulated. Five of the 6 studies investigating AFV by the amniotic fluid index as a function of gestational age reported data fitting a quadratic equation, with fluid volumes peaking at mid gestation and then declining. This trend was less pronounced when AFV was assessed by the single deepest pocket (2 of 4 studies reporting a quadratic fit). Polyhydramnios was associated with prematurity in 2 of 4 studies (1 amniotic fluid index and 1 single deepest pocket), and oligohydramnios was associated with prematurity in 1 single deepest pocket study. Stillbirth was the only intrapartum outcome reported in more than 1 study. Perinatal outcomes associated with polyhydramnios included neonatal death (P < .05 in 1 of 2 studies), low Apgar scores (1 of 2 studies), neonatal intensive care unit admission (1 of 2 studies), and low birth weight (2 of 3 studies).
Assuntos
Líquido Amniótico/diagnóstico por imagem , Resultado da Gravidez , Gravidez de Gêmeos , Gêmeos , Ultrassonografia Pré-Natal/métodos , Feminino , Humanos , Oligo-Hidrâmnio/diagnóstico por imagem , Poli-Hidrâmnios/diagnóstico por imagem , Gravidez , Reprodutibilidade dos TestesRESUMO
OBJECTIVE: To identify risk factors for surgical site infection and to define rates associated with cytoreductive surgery before and after implementation of an infection prevention bundle. METHODS: We conducted a prospective quality improvement study. Patients who underwent ovarian, fallopian tube, or peritoneal cancer cytoreductive surgery at an academic tertiary care center from April 2014 to April 2016 were prospectively enrolled. Patient demographics, surgical variables, and surgical site infection rates were compared with a historical cohort after introduction of a 5-point infection prevention bundle, including: 1) preoperative and intraoperative skin preparation with 4% chlorhexidine and intraoperative vaginal preparation with 4% chlorhexidine; 2) preoperative use of oral antibiotics and mechanical bowel preparation; 3) appropriate timing of intraoperative antibiotics; 4) adoption of enhanced sterile surgical techniques for colon procedures and incisional closure; and 5) perioperative incision management. RESULTS: During the study period, 219 women underwent surgery: 91 prebundle and 128 treated in the postbundle period. Stage, body mass index, proportion of patients undergoing colon or upper abdominal surgery, and estimated blood loss were not different between the cohorts. Overall, the surgical site infection rate prebundle was 18 (20%); this was reduced to four (3%) postbundle (odds ratio [OR] 0.13, 95% CI 0.037-0.53; P<.001). Patients who underwent a colon resection prebundle had an infection rate of 14 (33%) compared with three (7%) in the postbundle group (OR 0.14, 95% CI 0.037-0.53; P<.001). Additionally, rates of surgical site infection-related hospital readmission were also lower in the postbundle (4/128 [3%]) compared with the prebundle group (12/91 [13%]; P=.005). CONCLUSION: Infection is common after ovarian cancer cytoreductive surgery. Implementation of a 5-point surgical site infection prevention bundle in women undergoing ovarian cancer operations was associated with dramatically decreased infection rates and lower hospital readmission rates.
Assuntos
Procedimentos Cirúrgicos de Citorredução/métodos , Neoplasias Ovarianas/cirurgia , Pacotes de Assistência ao Paciente/métodos , Infecção da Ferida Cirúrgica/prevenção & controle , Abdome/cirurgia , Antibacterianos/administração & dosagem , Anti-Infecciosos Locais/administração & dosagem , Antibioticoprofilaxia/métodos , Antibioticoprofilaxia/normas , Clorexidina/administração & dosagem , Colo/cirurgia , Procedimentos Cirúrgicos de Citorredução/efeitos adversos , Procedimentos Cirúrgicos de Citorredução/normas , Neoplasias das Tubas Uterinas/cirurgia , Feminino , Humanos , Pessoa de Meia-Idade , Razão de Chances , Pacotes de Assistência ao Paciente/normas , Readmissão do Paciente , Neoplasias Peritoneais/cirurgia , Estudos Prospectivos , Melhoria de Qualidade , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia , Resultado do TratamentoRESUMO
Escherichia coli is one of the main causes of urinary tract infections (UTIs). E. coli is commonly detected from urine using standard culture method. However, the urine sampling and analysis required for these methods can be costly, time consuming (requires 24 to 48 hours) and labor-intensive. This work proposes a capacitive touch screen sensor concept as possible alternative device for rapid detection of E. coli in urine samples. E. coli solutions prepared at different concentrations and urine samples (with spiked and nor spike E. coli) obtained from healthy women participants, have been analyzed using a capacitance evaluation kit. It has been demonstrated in this study that the use of this evaluation kit provides a low-cost and simple alternative system for detecting E. coli present in urine. Several experimental tests were performed to determine the optimal testing volume, the sensitivity of the sensor, limit of detection and repeatability. The optimal testing volume was 80 microliters and the analytical sensitivity was 17 counts per picofarad (pF). The lowest detectable concentration is around 3.98 × 10(5) CFU/ml. The repeatability (r) was found to be 7.2 or 6.2 % (in r%). The capacitive touch sensor gave promising results that could be used to design and realize a portable diagnostic device for early-stage detection of UTIs.
Assuntos
Escherichia coli/isolamento & purificação , Infecções Urinárias/urina , Contagem de Células , Capacitância Elétrica , Feminino , HumanosRESUMO
Vulvar cancer is a rare carcinoma constituting only 4% of gynecologic malignancies and 0.6% of female cancers. Most chemotherapy regimens have been created from extrapolation from anal and cervical cancer research. Advanced stages have the worst prognosis and oftentimes invasive surgical procedures are needed to cure disease with high recurrence rates. Case. A 50 yo G2P2 presented for a 2 cm mass in her right labia. The patient underwent a partial radical vulvectomy and bilateral superficial and deep inguinal lymph node dissection. Bilateral inguinal lymph nodes were positive for residual disease. The patient underwent whole pelvic radiation with cisplatin as a radiosensitizer. The primary tumor was epidermal growth factor receptor (EGFR) positive and cetuximab, a monoclonal antibody to EGFR, was added. The patient underwent seven cycles of chemotherapy including cisplatin and cetuximab with adjuvant radiation therapy to the pelvis. She currently is without evidence of disease recurrence since completing treatment 4 years ago. Conclusion. One previous case report showed short-term palliative success of five months for recurrent, metastatic vulvar cancer. This case suggests that cetuximab could possibly be used in initial management of patients with advanced stages of vulvar cancer to improve prognosis.