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BACKGROUND: Machine learning (ML) has been successfully implemented for classification tasks (e.g., cancer diagnosis). ML performance for more challenging predictions is largely unexplored. This study's objective was to compare machine learning vs. expert-informed predictions for surgical outcome in patients undergoing major liver surgery. METHODS: Single tertiary center data on preoperative parameters and postoperative complications for elective hepatic surgery patients were included (2008-2021). Expert-informed prediction models were established on 14 parameters identified by two expert liver surgeons to impact on postoperative outcome. ML models used all available preoperative patient variables (n = 62). Model performance was compared for predicting 3-month postoperative overall morbidity. Temporal validation and additional analysis in major liver resection patients were conducted. RESULTS: 889 patients included. Expert-informed models showed low average bias (2-5 CCI points) with high over/underprediction. ML models performed similarly: average prediction 5-10 points higher than observed CCI values with high variability (95% CI -30 to 50). No performance improvement for major liver surgery patients. CONCLUSION: No clinical relevance in the application of ML for predicting postoperative overall morbidity was found. Despite being a novel hype, ML has the potential for application in clinical practice. However, at this stage it does not replace established approaches of prediction modelling.
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Hepatectomia , Aprendizado de Máquina , Complicações Pós-Operatórias , Humanos , Hepatectomia/efeitos adversos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Complicações Pós-Operatórias/etiologia , Resultado do Tratamento , Medição de Risco , Valor Preditivo dos Testes , Estudos RetrospectivosRESUMO
INTRODUCTION: Oral anticancer therapies offer various advantages but also entail risks due to their toxicity and narrow therapeutic ranges. Since these drugs are increasingly prescribed in patients with existing polypharmacy, identifying and assessing potential drug interactions is of great importance for safe and effective therapy. This article provides an overview of the most common pharmacokinetic and pharmacodynamic drug-drug interactions of targeted anticancer therapies, with focus on protein kinase inhibitors.
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Polimedicação , Humanos , Interações MedicamentosasRESUMO
Cancer control by adaptive immunity involves a number of defined death and clearance mechanisms. However, efficient inhibition of exponential cancer growth by T cells and interferon-γ (IFN-γ) requires additional undefined mechanisms that arrest cancer cell proliferation. Here we show that the combined action of the T-helper-1-cell cytokines IFN-γ and tumour necrosis factor (TNF) directly induces permanent growth arrest in cancers. To safely separate senescence induced by tumour immunity from oncogene-induced senescence, we used a mouse model in which the Simian virus 40 large T antigen (Tag) expressed under the control of the rat insulin promoter creates tumours by attenuating p53- and Rb-mediated cell cycle control. When combined, IFN-γ and TNF drive Tag-expressing cancers into senescence by inducing permanent growth arrest in G1/G0, activation of p16INK4a (also known as CDKN2A), and downstream Rb hypophosphorylation at serine 795. This cytokine-induced senescence strictly requires STAT1 and TNFR1 (also known as TNFRSF1A) signalling in addition to p16INK4a. In vivo, Tag-specific T-helper 1 cells permanently arrest Tag-expressing cancers by inducing IFN-γ- and TNFR1-dependent senescence. Conversely, Tnfr1(-/-)Tag-expressing cancers resist cytokine-induced senescence and grow aggressively, even in TNFR1-expressing hosts. Finally, as IFN-γ and TNF induce senescence in numerous murine and human cancers, this may be a general mechanism for arresting cancer progression.
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Senescência Celular/imunologia , Citocinas/imunologia , Neoplasias/imunologia , Neoplasias/patologia , Células Th1/imunologia , Animais , Antígenos Transformantes de Poliomavirus/genética , Antígenos Transformantes de Poliomavirus/metabolismo , Ciclo Celular , Proliferação de Células , Inibidor p16 de Quinase Dependente de Ciclina/deficiência , Inibidor p16 de Quinase Dependente de Ciclina/genética , Inibidor p16 de Quinase Dependente de Ciclina/metabolismo , Modelos Animais de Doenças , Progressão da Doença , Feminino , Humanos , Interferon gama/imunologia , Masculino , Camundongos , Camundongos Endogâmicos NOD , Camundongos SCID , Camundongos Transgênicos , Oncogenes/genética , Fosfosserina/metabolismo , Receptores Tipo I de Fatores de Necrose Tumoral/metabolismo , Proteína do Retinoblastoma/química , Proteína do Retinoblastoma/metabolismo , Fator de Transcrição STAT1/metabolismo , Fatores de Tempo , Células Tumorais Cultivadas , Fator de Necrose Tumoral alfa/imunologia , Proteína Supressora de Tumor p53/metabolismoRESUMO
OBJECTIVE: To explore the added value of the comprehensive complication index (CCI) to standard assessment of postoperative morbidity, and to clarify potential controversies for its application. BACKGROUND: The CCI was introduced about 3 years ago as a novel metric of postoperative morbidity, integrating in a single formula all complications by severity, ranging from 0 (uneventful course) to 100 (death). It remains unclear, how often the CCI adds to standard reporting of complications and how to apply it in complex postoperative courses. METHODS: CCI data were prospectively collected over a 1-year period at our institution. The proportion of patients with more than 1 complication and the severity of those complications were assessed to determine the additional value of the CCI compared to the Clavien-Dindo classification. Complex and controversial cases were presented to 90 surgeons worldwide to achieve consensus in weighing each postoperative event. Descriptive statistics were used to evaluate agreement among surgeons and to suggest solutions for consistent use of the CCI. RESULTS: Complications were identified in 24% (290/1212) of the general surgical population. Of those, 44% (127/290) developed more than 1 complication by the time of discharge, and thereby CCI added information to the standard grading system of complications. Information gained by the CCI increased with the complexity of surgery and observation time. CONCLUSIONS: The CCI adds information on postoperative morbidity in almost half of the patients developing complications, with particular value following extensive surgery and longer postoperative observation up to 3 months. Each single complication, independently of their inter-connection, should be included in the CCI calculation to best mirror the patients' postoperative morbidity.
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Complicações Pós-Operatórias/classificação , Humanos , Estudos Prospectivos , Índice de Gravidade de Doença , Inquéritos e QuestionáriosRESUMO
Background: Cosmetic surgery tourism characterizes a phenomenon of people traveling abroad for aesthetic surgery treatment. Problems arise when patients return with complications or need of follow-up care. Objectives: To investigate the complications of cosmetic surgery tourism treated at our hospital as well as to analyze arising costs for the health system. Methods: Between 2010 and 2014, we retrospectively included all patients presenting with complications arising from cosmetic surgery abroad. We reviewed medical records for patients' characteristics including performed operations, complications, and treatment. Associated cost expenditure and Diagnose Related Groups (DRG)-related reimbursement were analyzed. Results: In total 109 patients were identified. All patients were female with a mean age of 38.5 ± 11.3 years. Most procedures were performed in South America (43%) and Southeast (29.4%) or central Europe (24.8%), respectively. Favored procedures were breast augmentation (39.4%), abdominoplasty (11%), and breast reduction (7.3%). Median time between the initial procedure abroad and presentation was 15 days (interquartile range [IQR], 9) for early, 81.5 days (IQR, 69.5) for midterm, and 4.9 years (IQR, 9.4) for late complications. Main complications were infections (25.7%), wound breakdown (19.3%), and pain/discomfort (14.7%). The majority of patients (63.3%) were treated conservatively; 34.8% became inpatients with a mean hospital stay of 5.2 ± 3.8 days. Overall DRG-related reimbursement premiums approximately covered the total costs. Conclusions: Despite warnings regarding associated risks, cosmetic surgery tourism has become increasingly popular. Efficient patients' referral to secondary/tertiary care centers with standardized evaluation and treatment can limit arising costs without imposing a too large burden on the social healthcare system. Level of Evidence: 4.
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Atenção à Saúde/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Tempo de Internação/economia , Turismo Médico , Procedimentos de Cirurgia Plástica/efeitos adversos , Complicações Pós-Operatórias/economia , Adolescente , Adulto , Feminino , Humanos , Reembolso de Seguro de Saúde/economia , Pessoa de Meia-Idade , Procedimentos de Cirurgia Plástica/economia , Encaminhamento e Consulta/economia , Estudos Retrospectivos , Centros de Cuidados de Saúde Secundários/normas , Suíça , Centros de Atenção Terciária/normas , Adulto JovemRESUMO
OBJECTIVES: Melanomas arising from mucosa are rare and associated with a poor prognosis. This study aims to provide an analysis of metastatic pathways, time intervals, factors influencing metastatic spread and organs for distant metastases. METHODS: A total of 116 patients with mucosal melanomas of different sites were included. The mean follow-up interval was 47 ± 52 months. Patients were assigned to two different metastatic pathways, either presenting loco-regional lymph node metastases as first spread or direct distant metastases. The distribution of distant metastases was assessed. RESULTS: Twenty-six patients presented with a pre-existing metastatic spread and were not assigned to pathways. Of the included patients, 44 developed metastases after treatment of the primary tumour; 25 patients directly developed distant metastases; 16 patients developed regional lymph node metastases prior to distant metastases. Location of the primary tumour in the upper airway or GI tract and advanced T stage were significant risk factors of direct distant metastases. Distant metastases are mainly located in the lung, the liver and non-regional lymph nodes. CONCLUSIONS: Mucosal melanomas show a high rate of direct distant metastases rather than regional lymph node metastases. Thus the follow-up should always include a whole-body cross-sectional imaging in high-risk tumours. KEY POINTS: ⢠Mucosal melanomas show a high rate of direct distant metastases. ⢠T stage and primary location are predictors for direct distant metastases. ⢠Distant metastases were mainly found in lung, liver and lymph nodes. ⢠Follow-up of a high-risk mucosal melanoma should include whole-body imaging.
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Melanoma/diagnóstico por imagem , Melanoma/secundário , Adulto , Idoso , Idoso de 80 Anos ou mais , Progressão da Doença , Feminino , Seguimentos , Humanos , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/secundário , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/secundário , Metástase Linfática , Imageamento por Ressonância Magnética , Masculino , Melanoma/patologia , Pessoa de Meia-Idade , Mucosa , Estadiamento de Neoplasias , Estudos Retrospectivos , Fatores de Risco , Tomografia Computadorizada por Raios X , Adulto JovemRESUMO
Sézary syndrome is a primary cutaneous T-cell lymphoma characterized by pruritic erythroderma, peripheral lymphadenopathy and the presence of malignant T cells in the blood. Unequivocal detection of malignant cells in patients with Sézary syndrome is of important diagnostic, prognostic and therapeutic value. However, no single Sézary syndrome specific cell surface marker has been identified. In a cohort of patients with Sézary syndrome, CD164 expression on total CD4+ lymphocytes was significantly upregulated compared with healthy controls. CD164 expression was in most cases limited to CD4+CD26- malignant T lymphocytes, unequivocally identified using flow-cytometry by the expression of a specific Vß clone for each patient. Increased expression of CD164 may be a promising diagnostic parameter and a potential target for a CD164-linked therapeutic approach in Sézary syndrome.
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Biomarcadores Tumorais/sangue , Linfócitos T CD4-Positivos/imunologia , Síndrome de Sézary/sangue , Neoplasias Cutâneas/sangue , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Células Cultivadas , Dipeptidil Peptidase 4/sangue , Endolina/sangue , Feminino , Citometria de Fluxo , Humanos , Imunofenotipagem/métodos , Masculino , Pessoa de Meia-Idade , Fenótipo , Síndrome de Sézary/diagnóstico , Síndrome de Sézary/imunologia , Síndrome de Sézary/terapia , Neoplasias Cutâneas/diagnóstico , Neoplasias Cutâneas/imunologia , Neoplasias Cutâneas/terapia , Resultado do TratamentoRESUMO
BACKGROUND: Patient blood management (PBM) measures have been shown to be effective in reducing transfusions while maintaining patient outcome. The issuance of transfusion guidelines is seen as being key to the success of PBM programs. As the introduction of guidelines alone did not visibly reduce transfusions in our center, a monitoring and feedback program was established. The aim of our study was to show the effectiveness of such measures in reducing transfusions and cost. STUDY DESIGN AND METHODS: We designed a prospective, interventional cohort study with a 3-year time frame (January 1, 2012 to December 31, 2014). In total, 101,794 patients aged 18 years or older were included. The PBM monitoring and feedback program was introduced on January 1, 2014, with the subsequent issuance of quarterly reporting. RESULTS: Within the first year of introduction, transfusion of all allogeneic blood products per 1000 patients was reduced by 27% (red blood cell units, -24%; platelet units, -25%; and fresh-frozen plasma units, -37%; all p < 0.001) leading to direct allogeneic blood product related savings of more than 2 million USD. The number of blood products transfused per case was significantly reduced from 9 ± 19 to 7 ± 14 (p < 0.001). With an odds ratio of 0.86 (95% confidence interval, 0.82-0.91), the introduction of our PBM monitoring and feedback program was a significant independent factor in the reduction of transfusion probability (p < 0.001). CONCLUSION: Our PBM monitoring and feedback program was highly efficacious in reducing the transfusion of allogeneic blood products and transfusion-related costs.
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Transfusão de Sangue/economia , Transfusão de Sangue/estatística & dados numéricos , Adulto , Idoso , Estudos de Coortes , Retroalimentação , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos ProspectivosRESUMO
BACKGROUND: Since 2012, Swiss inpatient dermatology is funded through a flat rate payment system based on diagnosis-related groups (DRGs). OBJECTIVE: To analyze the reimbursement of nonsurgically treated severe disorders of the skin under the system called SwissDRG. METHODS: Three retrospective, cross-sectional cohort studies were performed. Data sets were received from the Swiss Federal Office of Statistics (1,285,685 retained records), the five Swiss university hospitals (370,964 retained records) and our center (72,211 retained records). RESULTS: Cases accounted for 0.04% of all hospitalizations nationwide, with 43.7% treated at university hospitals. Treatment at university hospitals produced a mean loss of USD 3,711 per case. Lyell syndrome cases were especially underfunded (mean loss USD 31,906). Extra-county admissions and direct referrals were significant predictors of total inpatient costs (p = 0.019 and p < 0.001, respectively). CONCLUSIONS: We suggest grouping Lyell syndrome cases into burn DRGs and evaluating extra-county admissions and direct inpatient referrals as DRG split criteria.
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Efeitos Psicossociais da Doença , Dermatologia/métodos , Pacientes Internados , Mecanismo de Reembolso/economia , Dermatopatias/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Dermatologia/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Dermatopatias/economia , Dermatopatias/epidemiologia , Suíça/epidemiologia , Adulto JovemRESUMO
We describe the case of a 32-year-old woman who presented to the hospital with generalized painful exanthema, blisters and erosions 1 month after giving birth to a healthy girl. The patient's medical history was inconspicuous for comorbidities; however, it included the incidental intake of pain killers and a herbal preparation (fenugreek), which she took regularly over the last 4 weeks to improve lactation. Based on the clinical characteristics, we suspected toxic epidermal necrolysis (TEN), a severe cutaneous adverse drug reaction, which was confirmed by skin biopsy. The patient was treated with high-dose intravenous human immunoglobulins and was discharged 2 weeks after hospital admission in good condition. The allergological workup identified fenugreek as the most likely causative agent. Given the increased self-medication of freely available phytotherapeutics by patients in industrialized countries, herbal mixtures should be taken into consideration in the diagnostic workup of TEN.
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Preparações de Plantas/efeitos adversos , Síndrome de Stevens-Johnson/etiologia , Trigonella/efeitos adversos , Adulto , Feminino , Humanos , Síndrome de Stevens-Johnson/patologiaRESUMO
We report a rare case of rosacea with ocular involvement in a child that remitted with prolonged anti-inflammatory oral tetracycline therapy and provide general expert recommendations. A 14-year-old girl presented with discrete papules and pustules on both cheeks with blepharitis and conjunctivitis. Ophthalmologic examination confirmed bilateral severe blepharitis, as well as a corneal infiltrate in the right eye with additional neovascularization. The diagnosis of rosacea with ocular involvement was made. In addition to the existing antibiotic and anti-inflammatory topical eye therapy, systemic treatment with minocycline 50 mg twice a day was started. After marked improvement, the dose was reduced to 50 mg once a day. After further amelioration, treatment was switched to maintenance therapy with 40 mg of prolonged-release doxycycline. Three years after a 12-month course of anti-inflammatory therapy, the patient remained recurrence free.
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Antibacterianos/uso terapêutico , Doxiciclina/uso terapêutico , Minociclina/uso terapêutico , Rosácea/diagnóstico , Rosácea/tratamento farmacológico , Adolescente , Antibacterianos/administração & dosagem , Diagnóstico Diferencial , Doxiciclina/administração & dosagem , Feminino , Humanos , Minociclina/administração & dosagemRESUMO
BACKGROUND AND OBJECTIVES: The objective was to determine the diagnostic value of direct immunofluorescence (DIF) in ocular mucous membrane pemphigoid (ocular MMP), taking into account immunofluorescence patterns and biopsy sites. PATIENTS AND METHODS: DIF results and medical records of 54 patients with a suspected diagnosis of ocular MMP were reviewed. RESULTS: There was an overall prevalence of ocular MMP in 70.4 % of cases. Linear deposition of IgA, IgG, or C3 showed a high positive predictive value (84-100 %). Sensitivity and negative predictive value of IgG, IgM, IgG, and C3 in DIF were higher in cutaneous samples than in conjunctival biopsies, thus yielding a higher diagnostic accuracy. The sensitivity of DIF in ocular MMP seems to be lower than in bullous pemphigoid. CONCLUSIONS: The diagnostic value of DIF in the workup of ocular MMP was confirmed. However, biopsies taken from non-conjunctival, cutaneous tissue appear to yield more accurate results.
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Citocinas/imunologia , Técnica Direta de Fluorescência para Anticorpo/métodos , Penfigoide Mucomembranoso Benigno/diagnóstico , Penfigoide Mucomembranoso Benigno/imunologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/análise , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Physicians are hesitant to forgo the opportunity of entering unstructured clinical notes for structured data entry in electronic health records. Does free text increase informational value in comparison with structured data? OBJECTIVE: This study aims to compare information from unstructured text-based chief complaints harvested and processed by a natural language processing (NLP) algorithm with clinician-entered structured diagnoses in terms of their potential utility for automated improvement of patient workflows. METHODS: Electronic health records of 293,298 patient visits at the emergency department of a Swiss university hospital from January 2014 to October 2021 were analyzed. Using emergency department overcrowding as a case in point, we compared supervised NLP-based keyword dictionaries of symptom clusters from unstructured clinical notes and clinician-entered chief complaints from a structured drop-down menu with the following 2 outcomes: hospitalization and high Emergency Severity Index (ESI) score. RESULTS: Of 12 symptom clusters, the NLP cluster was substantial in predicting hospitalization in 11 (92%) clusters; 8 (67%) clusters remained significant even after controlling for the cluster of clinician-determined chief complaints in the model. All 12 NLP symptom clusters were significant in predicting a low ESI score, of which 9 (75%) remained significant when controlling for clinician-determined chief complaints. The correlation between NLP clusters and chief complaints was low (r=-0.04 to 0.6), indicating complementarity of information. CONCLUSIONS: The NLP-derived features and clinicians' knowledge were complementary in explaining patient outcome heterogeneity. They can provide an efficient approach to patient flow management, for example, in an emergency medicine setting. We further demonstrated the feasibility of creating extensive and precise keyword dictionaries with NLP by medical experts without requiring programming knowledge. Using the dictionary, we could classify short and unstructured clinical texts into diagnostic categories defined by the clinician.
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OBJECTIVE: To assess the cost-effectiveness and budget impact of olaparib as a maintenance therapy in platinum-responsive, metastatic pancreatic cancer patients harboring a germline BRCA1/2 mutation, using the Swiss context as a model. METHODS: Based on data from the POLO trial, published literature and local cost data, we developed a partitioned survival model of olaparib maintenance including full costs for BRCA1/2 germline testing compared to FOLFIRI maintenance chemotherapy and watch-and-wait. We calculated the incremental cost-effectiveness ratio (ICER) for the base case and several scenario analyses and estimated 5-year budget impact. RESULTS: Comparing olaparib with watch-and wait and maintenance chemotherapy resulted in incremental cost-effectiveness ratios of CHF 2,711,716 and CHF 2,217,083 per QALY gained, respectively. The 5-year costs for the olaparib strategy in Switzerland would be CHF 22.4 million, of which CHF 11.4 million would be accounted for by germline BRCA1/2 screening of the potentially eligible population. This would amount to a budget impact of CHF 15.4 million (USD 16.9 million) versus watch-and-wait. CONCLUSIONS: Olaparib is not a cost-effective maintenance treatment option. Companion diagnostics are an equally important cost driver as the drug itself.
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Neoplasias Ovarianas , Neoplasias Pancreáticas , Piperazinas , Feminino , Humanos , Proteína BRCA1/genética , Neoplasias Ovarianas/genética , Platina/uso terapêutico , Proteína BRCA2/genética , Ftalazinas/uso terapêutico , Neoplasias Pancreáticas/tratamento farmacológico , Neoplasias Pancreáticas/genética , Neoplasias Pancreáticas/patologia , Células Germinativas/patologia , Análise Custo-BenefícioRESUMO
BACKGROUND: The development of immune-related adverse events (irAEs) may be associated with clinical efficacy of checkpoint inhibitors (CPIs) in patients with cancer. We therefore investigated the effect of irAEs and pre-treatment parameters on outcome in a large, real-life patient cohort. METHODS: We performed a single-centre, retrospective, observational study including patients who received CPIs from 2011 to 2018 and followed until 2021. The primary outcome was overall survival, and the secondary outcome was the development of irAEs. RESULTS: In total, 229 patients with different tumour entities (41% non-small cell lung cancer [NSCLC], 29% melanoma) received a total of 282 CPI treatment courses (ipilimumab, nivolumab, pembrolizumab or atezolizumab). Thirty-four percent of patients developed irAEs (of these 17% had CTCAE Grade ≥3). Factors independently associated with mortality were pre-treatment CRP ≥10 mg/L (hazard ratio [HR] 2.064, p = 0.0003), comorbidity measured by Charlson comorbidity index (HR 1.149, p = 0.014) and irAEs (HR 0.644, p = 0.036) (age-adjusted, n = 216). Baseline eosinophil count ≤0.2 × 109 /L was a further independent predictor of mortality (age-, CRP-, CCI- and irAE-adjusted HR = 2.252, p = 0.002, n = 166). Anti-CTLA-4 use (p < 0.001), and pre-treatment CRP <10 mg/L were independently associated with irAE occurrence (p = 0.037). CONCLUSIONS: We found an independent association between irAE occurrence and improved overall survival in a real-life cohort spanning multiple tumour entities and treatment regimens. Pre-treatment comorbidities, CRP and eosinophil count represent potential markers for predicting treatment response.
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Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Humanos , Carcinoma Pulmonar de Células não Pequenas/patologia , Proteína C-Reativa , Neoplasias Pulmonares/patologia , Estudos Retrospectivos , Eosinófilos , ComorbidadeRESUMO
The expansive use of immunosuppressive medications in fields such as transplantational medicine and oncology, the higher frequency of invasive procedures in an ageing population and the HIV/AIDS pandemic have increased the frequency of systemic fungal infections. At the same time, increased resistance of pathogenic fungi to classical antifungal agents has led to sustained research efforts targeting alternative antifungal strategies. In this review, we focus on two promising approaches: cationic peptides and the targeting of fungal virulence factors. Cationic peptides are small, predominantly positively charged protein fragments that exert direct and indirect antifungal activities, one mechanism of action being the permeabilization of the fungal membrane. They include lysozyme, defensins and cathelicidins as well as novel synthetic peptides. Among fungal virulence factors, the targeting of candidal secreted aspartic proteinases seems to be a particularly promising approach.
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Antifúngicos/uso terapêutico , Peptídeos Catiônicos Antimicrobianos/uso terapêutico , Dermatomicoses/tratamento farmacológico , Animais , Candida albicans/efeitos dos fármacos , Candida albicans/patogenicidade , Defensinas/uso terapêutico , Dermatomicoses/microbiologia , Hexosaminidases/uso terapêutico , Histatinas/uso terapêutico , Humanos , Lactoferrina/uso terapêutico , Complexo Antígeno L1 Leucocitário/uso terapêutico , Muramidase/uso terapêutico , Peptídeos/uso terapêutico , Ribonucleases/uso terapêutico , Inibidor Secretado de Peptidases Leucocitárias/uso terapêutico , Fatores de Virulência/antagonistas & inibidores , CatelicidinasRESUMO
BACKGROUND: Reconstruction of osseous and soft tissue defects after surgical resection of oral cavity cancers can be achieved by a single-stage procedure with a microvascular bone flap or by a two-step approach with a soft tissue flap and subsequent bone augmentation. The therapeutic approach should be selected based on the patient’s needs. Economic pressure requires preoperative risk assessment and estimation of the postoperative course. Flat-rate reimbursement systems via diagnosis-related groups with insufficient morbidity adjustments and financial sanction of medical complications might additionally cause false incentives in the choice of treatment. OBJECTIVE: This study aimed to assess the influence of the type of flap chosen for maxillofacial reconstructive surgery on the total costs. Complication rates of different types of flap surgery and their prediction by a preoperative risk assessment tool (American Society of Anesthesiologists [ASA] score) were determined. Overall, the fairness of the current reimbursement system was rated. METHODS: Patient characteristics, clinical data, and data on total costs and reimbursement of patients aged 18 years and older having undergone maxillofacial reconstructive flap surgery at the University Hospital of Zurich (Switzerland) between 2012 and 2014 were analysed. The preoperative risk was classified by the ASA score. Complications were graded according to the Clavien-Dindo classification system and the comprehensive complication index (CCI). Statistical analysis included Spearman and Pearson rank correlation, Kruskal-Wallis and Mann-Whitney nonparametric tests, and linear regression analysis. RESULTS: 129 patients were included in this study. Soft tissue flaps were performed in 82 patients, of which 56 were radial forearm flaps (43.4%), bone flaps in 41 patients, of which 32 were fibula flaps (24.8%), and combined flaps in 6 patients (4.7%). Patients with fibula flaps showed a significantly higher CCI and higher total costs. Higher preoperative ASA scores were significantly associated with increased length of stay, total costs and complications. Both the ASA score and reconstruction with a radial forearm flap were significant predictors of complications and total costs. Total median costs for radial forearm flaps were CHF 50,560 (reimbursement: CHF 60,851; difference: CHF 10,291) and for fibula flaps CHF 66,982 (reimbursement: CHF 58,218; difference: CHF −8,764). CONCLUSION: The ASA score allows a reliable preoperative assessment of patient outcomes and financial burden in maxillofacial reconstructive flap surgery. The type of flap reconstruction significantly influences complications and ultimately total costs. The current reimbursement system via diagnosis-related groups (DRGs) does not take sufficient account of this fact. Adaptations are therefore needed to prevent misplaced incentives to the detriment of patients.
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Procedimentos de Cirurgia Plástica , Custos e Análise de Custo , Hospitais , Humanos , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Retalhos CirúrgicosRESUMO
BACKGROUND: The optimal positioning of anterior cruciate ligament graft is still controversially discussed. We therefore wanted to determine the tunnel-to-joint (TJA), tunnel-to-shaft (TSA), and graft-tunnel divergence angles which would provide the best outcome, determined by the KOOS (Knee Injury and Osteoarthritis Outcome Score). This study evaluated the clinical influence of graft orientation as measured with the KOOS questionnaire in patients with anterior cruciate ligament reconstruction with bone-patellar tendon-bone autografts. METHODS: We designed a prospective cohort study, with a 1 » year recruitment phase from March 2011 to July 2012 and a minimal follow-up period of 1 year. Inclusion criteria were patients ≥ 18 years of age receiving an ACL reconstruction with bone-patellar tendon-bone autografts at our institution after having suffered an acute ACL rupture. The primary outcome was the KOOS. Independent variables were patient age, gender, laterality of rupture, mechanism of trauma, and type of femoral and tibial fixation, as well as sagittal graft-tunnel divergence, TJA, and TSA, the latter two being assessed on coronal slices of magnetic resonance imaging. Equations modeling the relationship between TJA, TSA, and graft-tunnel divergence with the KOOS overall score were fitted, and the optimum angles were mathematically determined. RESULTS: In total, 31 patients were included in our study. Our cohort with a median age of 28 years was predominantly male. The mathematically determined optimal placement of the implant in the coronal plane was a TJA of 74.8°, a TSA of 80.1°, and a graft-tunnel divergence angle of 8.5°. CONCLUSION: With regard to patient-reported outcome, the optimal graft orientation is provided by a coronal tunnel-to-shaft angle of 80° and tunnel-to-joint angle of 75°, respectively. Interestingly, in our series, patients reported best clinical outcomes with a sagittal graft-tunnel divergence. These results should be validated in larger studies.
Assuntos
Reconstrução do Ligamento Cruzado Anterior/métodos , Transplante Ósseo/métodos , Ligamento Patelar/transplante , Medidas de Resultados Relatados pelo Paciente , Procedimentos de Cirurgia Plástica/métodos , Adulto , Estudos de Coortes , Feminino , Fêmur/cirurgia , Seguimentos , Humanos , Masculino , Estudos Prospectivos , Tíbia/cirurgia , Transplante Autólogo , Adulto JovemRESUMO
OBJECTIVE: The purpose of this preliminary retrospective study was to analyse if cone beam CT (CBCT) is able to identify more bleeding sites and corresponding feeding arteries in patients with haemorrhage of uncertain origin. METHODS: In 18 vascular territories (16 patients), pre-interventional CT angiography (CTA) and selective angiograms resulted in discordant information regarding the suspected bleeding site and hence received CBCT. Image data of CTA and selective angiograms in comparison to CBCT were independently reviewed by two interventional radiologists. Image quality, diagnostic confidence, number of bleeding sites and involved vascular territories were investigated. Additionally, the correlation between number of bleeding sites and involved vascular territories with a clinical gold-standard (super-selective angiographic findings and definitive clinical outcomes) was analysed. RESULTS: Overall, subjective image quality did not significantly differ between investigated imaging modalities. However, CBCT significantly improved diagnostic confidence in both readers in detecting bleeding vessel (s) (p = 0.0024/0.0005; Reader 1/Reader2). High correlation coefficients regarding the number of bleeding sites (r = 0.9163/0.7692) in contrast to the number of involved vascular territories (r = 0.2888/0.0105) were observed for CTA in comparison to clinical gold-standard. In this context, CBCT demonstrated a very strong correlation for both parameters, the number of bleeding vessels (r = 0.9720/0.9721) and the number involved vascular territories (r = 0.9441/0.9441). CONCLUSION: In complex cases of suspected haemorrhage, CBCT images can aid the interventionalist in detecting bleeding sites as well as narrowing down the number of involved vascular territories and thereby identifying feeding arteries of the bleeding source. Advances in knowledge: (1) CBCT showed no improvement in image quality. However, in complex bleeding cases CBCT information might aid in treatment planning. (2) CBCT improves visualization of bleeding vessels and involved feeding arteries. (3) Particularly, less experienced interventionalists might benefit from the three-dimensional information gathered by CBCT.