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OBJECTIVE: This study analyzed the characteristics and outcomes of veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) due to COVID-19 versus non-COVID causes at US academic centers. BACKGROUND DATA: V-V ECMO support has been utilized for COVID-19 patients with ARDS since the beginning of the pandemic. Mortality for ECMO in COVID-19 has been reported to be high but similar to reported mortality for ECMO support for non-COVID causes of respiratory failure. METHODS: Using ICD-10 codes, data of patients who underwent V-V ECMO for COVID-19 ARDS were compared with patients who underwent V-V ECMO for non-COVID causes between April 2020 and December 2022. The primary outcome was in-hospital mortality. Secondary outcome measures included length of stay and direct cost. Multivariate logistic regression modeling was performed to analyze differences in mortality between COVID and non-COVID groups, adjusting for other important risk factors (age, sex, and race/ethnicity). RESULTS: We identified and compared 6382 patients who underwent V-V ECMO for non-COVID causes to 6040 patients who underwent V-V ECMO for COVID-19. There was a significantly higher proportion of patients aged ≥ 65 years who underwent V-V ECMO in the non-COVID group compared with the COVID group (19.8% vs. 3.7%, respectively, P <0.001). Compared with patients who underwent V-V ECMO for non-COVID causes, patients who underwent V-V ECMO for COVID had increased in-hospital mortality (47.6% vs. 34.5%, P <0.001), length of stay (46.5±41.1 days vs. 40.6±46.1, P <0.001), and direct hospitalization cost ($207,022±$208,842 vs. $198,508±205,510, P =0.02). Compared with the non-COVID group, the adjusted odds ratio (OR) for in-hospital mortality in the COVID group was 2.03 (95% CI: 1.87-2.20, P <0.001). In-hospital mortality for V-V ECMO in COVID-19 improved during the study time period (50.3% in 2020, 48.6% in 2021, and 37.3% in 2022). However, there was a precipitous drop in the ECMO case volume for COVID starting in quarter 2 of 2022. CONCLUSIONS: In this nationwide analysis, COVID-19 patients with ARDS requiring V-V ECMO support had increased mortality compared with patients who underwent V-V ECMO for non-COVID etiologies.
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COVID-19 , Oxigenação por Membrana Extracorpórea , Síndrome do Desconforto Respiratório , Humanos , COVID-19/terapia , COVID-19/complicações , Resultado do Tratamento , Hospitalização , Síndrome do Desconforto Respiratório/etiologia , Síndrome do Desconforto Respiratório/terapia , Estudos RetrospectivosRESUMO
PURPOSE OF REVIEW: Although bariatric surgery is the most effective treatment of severe obesity, a proportion of patients experience clinically significant weight regain (WR) with further out from surgery. The purpose of this review is to summarize the prevalence, predictors, and causes of weight regain. RECENT FINDINGS: Estimating the prevalence of WR is limited by a lack of consensus on its definition. While anatomic failures such as dilated gastric fundus after sleeve gastrectomy and gastro-gastric fistula after Roux-en-Y gastric bypass can lead to WR, the most common causes appear to be dysregulated/maladaptive eating behaviors, lifestyle factors, and physiological compensatory mechanisms. To date, dietary, supportive, behavioral, and exercise interventions have not demonstrated a clinically meaningful impact on WR, and there is limited evidence for pharmacotherapy. Future studies should be aimed at better defining WR to begin to understand the etiologies. Additionally, there is a need for non-surgical interventions with demonstrated efficacy in rigorous randomized controlled trials for the prevention and reversal of WR after bariatric surgery.
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Cirurgia Bariátrica , Derivação Gástrica , Obesidade Mórbida , Humanos , Aumento de Peso/fisiologia , Estudos Retrospectivos , Cirurgia Bariátrica/efeitos adversos , Obesidade/epidemiologia , Obesidade/cirurgia , Obesidade/etiologia , Obesidade Mórbida/cirurgiaRESUMO
BACKGROUND: Revision of a failed laparoscopic fundoplication carries higher risk of complication and lower chance of success compared to the original surgery. Transoral incisionless fundoplication (TIF) may be an endoscopic alternative for select GERD patients without need of a moderate/large hiatal hernia repair. The aim of this study was to assess feasibility, efficacy, and safety of TIF 2.0 after failed laparoscopic Nissen or Toupet fundoplication (TIFFF). METHODS: This is a multicenter retrospective cohort study of patients who underwent TIFFF between September 2017 and December 2020 using TIF 2.0 technique (EsophyX Z/Z+) performed by gastroenterologists and surgeons. Patients were included if they had (1) recurrent GERD symptoms, (2) pathologic reflux based upon pH testing or Grade C/D esophagitis or Barrett's esophagus, and (3) hiatal hernia ≤ 2 cm. The primary outcome was improvement in GERD Health-Related Quality of Life (GERD-HRQL) post-TIFFF. The TIFFF cohort was also compared to a similar surgical re-operative cohort using propensity score matching. RESULTS: Twenty patients underwent TIFFF (median 4.1 years after prior fundoplication) and mean GERD-HRQL score improved from 24.3 ± 22.9 to 14.75 ± 21.6 (p = 0.014); mean Reflux Severity Index (RSI) score improved from 14.1 ± 14.6 to 9.1 ± 8.0 (p = 0.046) with 8/10 (80%) of patients with normal RSI (< 13) post-TIF. Esophagitis healed in 78% of patients. PPI use decreased from 85 to 55% with 8/20 (45%) patients off of PPI. Importantly, mean acid exposure time decreased from 12% ± 17.8 to 0.8% ± 1.1 (p = 0.028) with 9/9 (100%) of patients with normalized pH post-TIF. There were no statistically significant differences in clinical efficacy outcomes between TIFFF and surgical revision, but TIFFF had significantly fewer late adverse events. CONCLUSION: Endoscopic rescue with TIF is a safe and efficacious alternative to redo laparoscopic surgery in symptomatic patients with appropriate anatomy and objective evidence of persistent or recurrent reflux.
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Esofagite , Refluxo Gastroesofágico , Laparoscopia , Humanos , Fundoplicatura/efeitos adversos , Fundoplicatura/métodos , Estudos Retrospectivos , Qualidade de Vida , Refluxo Gastroesofágico/etiologia , Refluxo Gastroesofágico/cirurgia , Refluxo Gastroesofágico/diagnóstico , Resultado do Tratamento , Esofagite/etiologia , Esofagite/cirurgia , Laparoscopia/métodosRESUMO
BACKGROUND: Comparative data on D2-robotic gastrectomy (RG) vs D2-open gastrectomy (OG) are lacking in the Literature. Aim of this paper is to compare RG to OG with a focus on D2-lymphadenectomy. STUDY DESIGN: Data of patients undergoing D2-OG or RG for gastric cancer were retrieved from the international IMIGASTRIC prospective database and compared. RESULTS: A total of 1469 patients were selected for inclusion in the study. After 1:1 propensity score matching, a total of 580 patients were matched and included in the final analysis, 290 in each group, RG vs OG. RG had longer operation time (210 vs 330 min, p < 0.0001), reduced intraoperative blood loss (155 vs 119.7 ml, p < 0.0001), time to liquid diet (4.4 vs 3 days, p < 0.0001) and to peristalsis (2.4 vs 2 days, p < 0.0001), and length of postoperative stay (11 vs 8 days, p < 0.0001). Morbidity rate was higher in OG (24.1% vs 16.2%, p = 0.017). CONCLUSION: RG significantly expedites recovery and reduces the risk of complications compared to OG. However, long-term survival is similar.
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Laparoscopia , Procedimentos Cirúrgicos Robóticos , Neoplasias Gástricas , Humanos , Pontuação de Propensão , Gastrectomia , Excisão de Linfonodo , Neoplasias Gástricas/cirurgia , Resultado do Tratamento , Estudos Retrospectivos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/cirurgiaRESUMO
INTRODUCTION: Reports vary on the impact of obesity on the incidence of lower extremity fractures after a fall. We hypothesized that obese adolescents (OA) presenting after a fall have a higher risk of any and severe lower extremity fractures compared to non-OAs. METHODS: A national database was queried for adolescents (12-17 years old) after a fall. Primary outcome included lower extremity fracture. Adolescents with a body mass index (BMI) ≥ 30 (OA) were compared to adolescents with a BMI < 30 (non-OA). RESULTS: From 20,264 falls, 2523 (12.5%) included OAs. Compared to non-OAs, the rate of any lower extremity fracture was higher for OAs (51.5% vs. 30.7%, p < 0.001). This remained true for lower extremity fractures at all locations (all p < 0.05). After adjusting for sex and age, associated risk for any lower extremity fracture (OR 2.41, CI 2.22-2.63, p < 0.001) and severe lower extremity fracture (OR 1.31, CI 1.15-1.49, p < 0.001) was higher for OAs. This remained true in subset analyses of ground level falls (GLF) and falls from height (FFH) (all p < 0.05). CONCLUSIONS: Obesity significantly impacts adolescents' risk of all types of lower extremity fractures after FFH or GLF. Hence, providers should have heightened awareness for possible lower extremity fractures in OAs. LEVEL OF EVIDENCE: IV.
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Fraturas Ósseas , Obesidade Infantil , Adolescente , Humanos , Criança , Acidentes por Quedas , Obesidade Infantil/complicações , Fraturas Ósseas/epidemiologia , Extremidade Inferior , Índice de Massa Corporal , Fatores de RiscoRESUMO
Effective environmental management higher education programs are essential for achieving the Sustainable Development Goals (SDGs). Yet SDG complexity means many educators focus on environment and avoid critical but challenging social, economic and governance aspects. This undermines the calls for comprehensive environmental management education that effectively integrates all key sustainability dimensions. Various sustainability models, mostly founded on the pillars of sustainability, have consequently evolved. They are generally conceptual and/or involve subjective categorization of the SDGs, which has led to demands for more empirically based models. This study has consequently used a mixed-method approach to model Australian university students' SDG perceptions. The qualitative research identified three items (on average) for each SDG, and a quantitative survey then measured their perceived importance. Factor analysis generated a robust six-dimensional sustainable development model comprised of 37 SDG items, which validates environment and governance aspects of some traditional pillar-based sustainability models. It has also uncovered new social and economic dimensions: social harmony and equality; sustainable consumption and socioeconomic behaviors; sustainable production, industry and infrastructure; and acute poverty reduction. These findings can help educators, organizations and citizens to categorize and integrate SDGs via better understanding of their key dimensions and impacts.
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Conservação dos Recursos Naturais , Desenvolvimento Sustentável , Humanos , Austrália , PobrezaRESUMO
Auditory scene analysis (ASA) is the process through which the auditory system makes sense of complex acoustic environments by organising sound mixtures into meaningful events and streams. Although music psychology has acknowledged the fundamental role of ASA in shaping music perception, no efficient test to quantify listeners' ASA abilities in realistic musical scenarios has yet been published. This study presents a new tool for testing ASA abilities in the context of music, suitable for both normal-hearing (NH) and hearing-impaired (HI) individuals: the adaptive Musical Scene Analysis (MSA) test. The test uses a simple 'yes-no' task paradigm to determine whether the sound from a single target instrument is heard in a mixture of popular music. During the online calibration phase, 525 NH and 131 HI listeners were recruited. The level ratio between the target instrument and the mixture, choice of target instrument, and number of instruments in the mixture were found to be important factors affecting item difficulty, whereas the influence of the stereo width (induced by inter-aural level differences) only had a minor effect. Based on a Bayesian logistic mixed-effects model, an adaptive version of the MSA test was developed. In a subsequent validation experiment with 74 listeners (20 HI), MSA scores showed acceptable test-retest reliability and moderate correlations with other music-related tests, pure-tone-average audiograms, age, musical sophistication, and working memory capacities. The MSA test is a user-friendly and efficient open-source tool for evaluating musical ASA abilities and is suitable for profiling the effects of hearing impairment on music perception.
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Current guidelines recommend neoadjuvant (NAC) and/or adjuvant chemotherapy for locally advanced gastric cancers (LAGCs). However, the choice and duration of NAC regimen is standardized, rather than personalized to biologic response, despite the availability of several different classes of agents for the treatment of gastric cancer (GC). The current trial will use a tumor-informed ctDNA assay (Signatera™) and monitor response to NAC. Based on ctDNA kinetics, the treatment regimen is modified. This is a prospective single center, single-arm, open-label study in clinical stage IB-III GC. ctDNA is measured at baseline and repeated every 8 weeks. Imaging is performed at the same intervals. The primary end point is the feasibility of this approach, defined as percentage of patients completing gastrectomy.
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Terapia Neoadjuvante , Neoplasias Gástricas , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Quimioterapia Adjuvante , Ensaios Clínicos Fase I como Assunto , Estudos de Viabilidade , Gastrectomia/métodos , Humanos , Estadiamento de Neoplasias , Estudos Prospectivos , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/tratamento farmacológicoRESUMO
BACKGROUND: In March 2020, the Surgeon General recommended limiting elective procedures to prepare for the COVID-19 surge. We hypothesize a consequence of COVID-19 is reduced operative volume across the country. We aim to examine changes in volume of common gastrointestinal operations during COVID-19, including elective, urgent/emergent, and cancer operations. We also evaluate if hospitals with more COVID-19 admissions were most impacted. METHODS: The Vizient database was used to determine monthly operative volume from November 2019 to June 2020 for elective operations (hiatal hernia repairs, bariatric surgery), urgent operations (cholecystectomies, appendectomies, inguinal hernia repairs), and cancer operations (colectomies, gastrectomies, esophagectomies). COVID-19 admissions per hospital were also determined. November 2019-January 2020 was defined as "pre-COVID." The monthly reduction in volume from pre-COVID was calculated for each operation. The top quartile (25%) of hospitals with the most COVID admissions were also evaluated separately from hospitals with fewer COVID cases. Data were analyzed using analysis of variance. RESULTS: Data from 559 hospitals were analyzed. The volumes of all operations evaluated were significantly reduced during the pandemic except gastrectomies and esophagectomies for cancer. The greatest reduction in all operations was in April. In April, the volume of bariatric surgery reduced by 98% (P < 0.001), hiatal hernia repairs by 96% (P < 0.001), urgent cholecystectomies by 42% (P < 0.001), urgent inguinal hernia repairs by 40% (P < 0.001), urgent appendectomies by 24% (P < 0.001), and colectomies for cancer by 39% (P < 0.001). Hospitals with the most COVID-19 admissions had greater reductions in all operations than hospitals with fewer COVID cases. CONCLUSIONS: The coronavirus pandemic led to a significant reduction in volume of all gastrointestinal operations evaluated except gastrectomies and esophagectomies. While elective, non-cancer operations were most affected, urgent and some cancer operations also declined significantly. As COVID-19 continues to surge, Americans may suffer continued limited access to surgical care and a significant operative backlog may be forthcoming.
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COVID-19 , Pandemias , Colectomia , Procedimentos Cirúrgicos Eletivos , Humanos , SARS-CoV-2 , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: This study analyzed the outcomes of COVID-19 patients with ARDS who were managed with extracorporeal membrane oxygenation (ECMO) across 155 US academic centers. SUMMARY BACKGROUND DATA: ECMO has been utilized in COVID-19 patients with acute respiratory distress syndrome (ARDS) and refractory hypoxemia. Early case series with the use of ECMO in these patients reported high mortality exceeding 90%. METHODS: Using ICD-10 codes, data of patients with COVID-19 with ARDS, managed with ECMO between April and September 2020, were analyzed using the Vizient clinical database. Outcomes measured included in-hospital mortality, hospital and ICU length of stay, and direct cost. For comparative purposes, the outcome of a subset of COVID-19 patients aged between 18 and 64âyears and managed with versus without ECMO were examined. RESULTS: 1,182 patients with COVID-19 and ARDS received ECMO. In-hospital mortality was 45.9%, mean length of stay was 36.8â±â24.9âdays, and mean ICU stay was 29.1â±â17.3âdays. In-hospital mortality according to age group was 25.2% for 1 to 30âyears; 42.2% for 31 to 50âyears; 53.2% for 51 to 64âyears; and 73.7% for ≥65âyears. A subset analysis of COVID-19 patients, aged 18 to 64âyears with ARDS requiring mechanical ventilation and managed with (n = 1113) vs without (n = 16,343) ECMO, showed relatively high in-hospital mortality for both groups (44.6% with ECMO vs 37.9% without ECMO). CONCLUSIONS: In this large US study of patients with COVID-19 and ARDS managed with ECMO, the in-hospital mortality is high but much lower than initial reports. Future research is needed to evaluate which patients with COVID-19 and ARDS would benefit from ECMO.
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Centros Médicos Acadêmicos , COVID-19/complicações , COVID-19/terapia , Oxigenação por Membrana Extracorpórea , Síndrome do Desconforto Respiratório/terapia , Adolescente , Adulto , Idoso , COVID-19/mortalidade , Criança , Pré-Escolar , Mortalidade Hospitalar , Hospitalização , Humanos , Lactente , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Síndrome do Desconforto Respiratório/mortalidade , Síndrome do Desconforto Respiratório/virologia , Estudos Retrospectivos , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: Gastroesophageal reflux disease (GERD) is a chronic and sometimes disabling disease. An important component in the surgical management of GERD is either laparoscopic or endoscopic restoration of the native gastroesophageal flap valve (GEFV). Recently, a procedure combining laparoscopic hiatal hernia repair with transoral incisionless fundoplication (cTIF) was introduced. This relatively new operation is performed in collaboration between the gastrointestinal (GI) surgeon and the gastroenterologist. METHODS: By working together, both interventionalists gain new insight into the ideal GEFV by observing the same operation being performed from different perspectives. In the cTIF, the gastroenterologist learns from an external perspective, through the laparoscopic view, the importance of the crura in contributing to the antireflux barrier. Similarly, the GI surgeon gains understanding of the elements that define an effective and desirable GEFV through an endoscopic perspective. RESULTS: This collaboration with cTIF and seeing the procedure from different perspectives have led to our improved understanding of 1) factors contributing to an optimal surgically constructed GEFV and 2) the limitations of the GEFV constructed by the conventional laparoscopic total and partial fundoplications. CONCLUSION: The collaboration between GI surgery and gastroenterology with cTIF has led to an improved understanding in characteristics of an optimal antireflux barrier and allowed for a proposed technical modification of the current fundoplication technique to optimize the construct of the surgical GEFV.
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Gastroenterologia , Refluxo Gastroesofágico , Laparoscopia , Fundoplicatura , Refluxo Gastroesofágico/cirurgia , Humanos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Female representation in surgery and surgical subspecialties has increased over the last decade. Studies have shown a discrepancy in compensation in the field of surgery, and several groups have advocated for increasing transparency as a primary solution to decrease this gender salary gap in surgery. The aim of this study was to evaluate differences in compensation between genders in surgical specialties within a large academic healthcare system. METHODS: Using a public compensation database from January 1, 2016 through December 31, 2016, this retrospective observational study analyzed salaries of full-time faculty surgeons within a large multi-institutional academic healthcare system. Surgeons included those who were employed for the entirety of 2016 and were full-time faculty who were then stratified according to surgical specialty and rank. The median base and median total salaries were compared between male and female surgeons with adjustment for rank and surgical specialty. RESULTS: There were 170 surgeons from eight surgical subspecialties included in the study with 29% being female (n = 50). Overall, unadjusted and adjusted median total salaries were significantly lower for female compared to male surgeons by $121,578 and $45,904, respectively. The three subspecialties with the highest compensation had a median total salary of $558,998 and had a high male to female ratio (3.7 male to 1 female), whereas the three subspecialties with the lowest compensation had a median total salary of $376,174 and had a male to female ratio of 1.5 male to 1 female. CONCLUSIONS: In a large academic healthcare system with transparent and publicly accessible salaries, the gender compensation gap in surgery persists. In conjunction with transparency, future academic institutions should consider a value-based, objective compensation plan with personal and systemic introspection of traditional gender biases, in efforts to circumvent the impact of gender on salary.
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Especialidades Cirúrgicas , Cirurgiões , Atenção à Saúde , Docentes de Medicina , Feminino , Humanos , Masculino , Salários e Benefícios , Estados UnidosRESUMO
BACKGROUND: The use of laparoscopic total gastrectomy for gastric cancer remains controversial. Our objective was to compare outcomes of laparoscopic total gastrectomy (LTG) vs. open total gastrectomy (OTG) for gastric adenocarcinoma using a national cancer database. METHODS: The National Cancer Database (2010-2014) was analyzed for total gastrectomy cases performed for gastric adenocarcinoma. Patient demographics and surgical outcomes were stratified by stage and compared based on laparoscopic vs. open surgical approach. Primary outcome measures included 30-day and 90-day mortality and Kaplan-Meier curves to estimate long-term survival. RESULTS: There were 2584 cases analyzed, including 592 (22.9%) stage I, 710 (27.5%) stage II, and 1282 (49.6%) stage III cases. The distribution of LTG vs. OTG cases was 156 (26.4%) vs. 436 (73.6%) for stage I, 163 (23.0%) vs. 547 (77.0%) for stage II, and 241 (18.8%) vs. 1041 (81.2%) for stage III. For all stages analyzed, there was no difference between laparoscopic vs. open approach for adjusted 30-day mortality (stage I: adjusted odds ratio (AOR) 0.52, p = 0.75; stage II: AOR 1.36, p > 0.99; stage III: AOR 0.46, p = 0.29) or 90-day mortality (stage I: AOR 0.46, p = 0.99; stage II: AOR 1.17, p = 0.99; stage III: 0.57, p = 0.29). There was no difference between LTG vs. OTG 5-year Kaplan-Meier estimated survival curves for any stage (stage I: p = 0.20; stage II: p = 0.83; stage III: p = 0.46). When compared to OTG, LTG had a similar hazard ratio (HR) for mortality (HR 0.89 p = 0.20). CONCLUSIONS: Laparoscopic total gastrectomy and OTG have comparable 30-day mortality, 90-day mortality, and long-term survival.
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Adenocarcinoma/cirurgia , Bases de Dados Factuais , Gastrectomia , Laparoscopia , Neoplasias Gástricas/cirurgia , Adenocarcinoma/mortalidade , Idoso , Feminino , Gastrectomia/mortalidade , Humanos , Laparoscopia/mortalidade , Masculino , Pessoa de Meia-Idade , Razão de Chances , Neoplasias Gástricas/mortalidade , Análise de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Hiatal Hernia Repairs (HHR) are performed by both general surgeons (GS) and thoracic surgeons (TS). However, there are limited literature with respect to outcomes of HHR based on specialty training. The objective of this study was to compare the utilization, perioperative outcomes, and cost for HHR performed by GS versus TS. METHODS: The Vizient database was used to identify patients who underwent elective laparoscopic HHR between October 2014 and June 2018. Patients were grouped according to surgeon's specialty (GS vs. TS). Patient demographics and outcomes including in-hospital mortality were compared between groups. RESULTS: During the study period 13,764 patients underwent HHR by either GS or TS. GS performed 9930 (72%) cases while TS performed 3834 (28%) cases. There was no significant difference between GS versus TS with regard to serious morbidity (1.28% vs. 1.30%, p = 0.97) or mortality (0.10% vs. 0.21%, p = 0.19). The mortality index was 0.24 for GS versus 0.45 for TS. Compared to TS, laparoscopic HHR performed by GS was associated with a shorter LOS (2.57 days vs. 2.72 days, p < 0.001) and lower mean hospital costs ($7139 vs. $8032, p < 0.0001). CONCLUSIONS: Within the context of academic centers, laparoscopic HHRs are mostly performed by GS with comparable outcome between general versus thoracic surgeons.
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Hérnia Hiatal/cirurgia , Herniorrafia/métodos , Laparoscopia/métodos , Cirurgiões , Centros Médicos Acadêmicos/economia , Centros Médicos Acadêmicos/estatística & dados numéricos , Adolescente , Adulto , Idoso , Feminino , Hérnia Hiatal/epidemiologia , Hérnia Hiatal/mortalidade , Herniorrafia/economia , Herniorrafia/mortalidade , Custos Hospitalares , Mortalidade Hospitalar , Humanos , Laparoscopia/economia , Laparoscopia/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Postoperative venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), are the leading causes of morbidity and mortality after bariatric surgery. Although several studies have examined VTE, few have examined risk factors separately for DVT and PE after contemporary bariatric surgery, including laparoscopic sleeve gastrectomy (LSG). Our objective was to define risk factors for DVT and PE independently for both LSG and laparoscopic Roux-en-Y gastric bypass (LRYGB) patients using the largest validated bariatric surgery database. METHODS: The metabolic and bariatric surgery accreditation and quality improvement program (MBSAQIP) database was queried to identify patients who underwent LSG or LRYGB between January 2015 and December 2017. Perioperative data were compared using bivariate analysis. Risk of DVT and PE after LSG or LRYGB was determined using multivariable logistic regression analysis. RESULTS: During the study period, 369,032 bariatric cases (72% LSG, 28% LRYGB) were performed. The incidence of DVT was similar between LSG and LRYGB (0.2% vs. 0.2%, p = 0.96), while the incidence of PE was decreased for LSG compared to LRYGB (0.1% vs. 0.2%, p < 0.001). Operative length was associated with increased risk of postoperative DVT (OR 1.1, CI 1.01-1.30, p = 0.04) and postoperative PE (OR 1.4, CI 1.16-1.64, p < 0.001) after surgery. The largest independent risk factors for DVT were history of DVT (OR 6.2, CI 4.44-8.45, p < 0.001) and transfusion (OR 4.2, CI 2.48-6.63, p < 0.001). The largest independent risk factors for PE were transfusion (OR 5.0, CI 2.69-8.36, p < 0.001) and history of DVT (OR 2.8, CI 1.67-4.58, p < 0.001). LSG was associated with a decreased risk of PE compared to LRYGB (OR 0.7 CI 0.55-0.91, p = 0.01). CONCLUSIONS: Prolonged operative length is associated with a higher risk of DVT and PE after either LSG or LRYGB. Transfusion and history of DVT are the largest risk factors for developing DVT and PE. There is a decreased risk of PE after LSG compared to LRYGB.
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Cirurgia Bariátrica/efeitos adversos , Gastrectomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Tromboembolia Venosa/etiologia , Adulto , Cirurgia Bariátrica/métodos , Bases de Dados Factuais , Feminino , Gastrectomia/métodos , Derivação Gástrica/efeitos adversos , Derivação Gástrica/métodos , Humanos , Incidência , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/etiologia , Fatores de Risco , Tromboembolia Venosa/epidemiologia , Trombose Venosa/epidemiologia , Trombose Venosa/etiologiaRESUMO
BACKGROUND: Initial adoption of minimally invasive esophagectomy (MIE) began in the late 1990s but its surgical technique, perioperative management, and outcome continues to evolve. METHODS: The aim of this study was to examine the evolving changes in the technique, outcome, and new strategies in management of postoperative leaks after MIE was performed at a single institution over a two-decade period. A retrospective chart review of 75 MIE operations was performed between November 2011 and September 2018 and this was compared to the initial series of 104 MIE operations performed by the same group between 1998 and 2007. Operative technique, outcomes, and management strategies of leaks were compared. RESULTS: There were 65 males (86.7%) with an average age of 61 years. The laparoscopic/thoracoscopic Ivor Lewis esophagectomy became the preferred MIE approach (49% of cases in the initial vs. 95% in the current series). Compared to the initial case series, there was no significant difference in median length of stay (8 vs. 8 days), major complications (12.5% vs. 14.7%, p = 0.68), incidence of leak (9.6% vs. 10.6%, p = 0.82), anastomotic stricture (26% vs. 32.0%, p = 0.38), or in-hospital mortality (2.9% vs. 2.6%, p = 0.47). Management of esophageal leaks has changed from primarily thoracotomy ± diversion initially (50% of leak cases) to endoscopic stenting ± laparoscopy/thoracoscopy currently (87.5% of leak cases). CONCLUSION: In a single-institutional series of MIE over two decades, there was a shift toward a preference for the laparoscopic/thoracoscopic Ivor Lewis approach with similar outcomes. The management of postoperative leaks drastically changed with predilection toward minimally invasive option with endoscopic drainage and stenting.
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Doenças do Esôfago/cirurgia , Esofagectomia/tendências , Laparoscopia/tendências , Toracoscopia/tendências , Adulto , Idoso , Fístula Anastomótica/etiologia , Esofagectomia/métodos , Feminino , Mortalidade Hospitalar/tendências , Humanos , Laparoscopia/métodos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/tendências , Estudos Retrospectivos , Toracoscopia/métodos , Resultado do TratamentoRESUMO
Climate change adaptation capacity remains low among vulnerable communities in developing countries such as Vietnam. Vector-borne diseases as dengue fever are increasing as a result of changing weather patterns. This study aims to examine the impact of key psychological variables in the Theory of Reasoned Action, the Theory of Planned Behavior, an Extended Parallel Process Model and the Social Cognitive Theory on the intention of schoolchildren to engage in climate change adaptation behavior-in this study, practices which would help reduce the risks of contracting dengue fever. It also seeks to identify the most salient predictors of the behavioral intention across these theories. Data were obtained from 796 Vietnamese schoolchildren who completed questionnaires measuring constructs of the four theories. Multivariate data analysis demonstrated that self-efficacy and severity appeared to be significant and consistent predictors of the individual's intention to reduce dengue fever. The results provide practical suggestions for the use of the theorical constructs tested in climate change communication campaigns in Vietnam and insights generally on pro-environmental behavior change.
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Mudança Climática , Intenção , Povo Asiático , Criança , Humanos , Comunicação Persuasiva , VietnãRESUMO
Highly pathogenic porcine reproductive and respiratory syndrome virus (HP-PRRSV) is characterized by high fever, respiratory distress, and high mortality in pigs of all ages and has severely affected the Vietnam pork industry in recent years. The study was conducted to compare the efficacy, safety, and overall performance of a modified live PRRSV-2 vaccine (Fostera PRRS) to an existing PRRSV modified live vaccine on a farm with a recent history of HP-PRRSV-associated respiratory diseases. A total of 351 pigs were randomly allocated to three treatment groups: (i) vaccinated with Fostera PRRS at 1 day of age (n = 118), (ii) vaccinated with Fostera PRRS (n = 118) at 21 days of age, and (iii) vaccinated with Amervac PRRS (n = 115) at 21 days of age. The Fostera PRRS vaccinated pigs had milder clinical symptoms, lower levels of HP-PRRSV viremia, fewer pathological changes in the lung, and higher body weight gain at the end of the study compared with the Amervac PRRS group. Vaccination of pigs with Fostera PRRS at 1 day of age also significantly reduced viral loads in their blood (P < 0.05) and induced higher anti-PRRSV antibody titers (P < 0.01) compared with pigs vaccinated with Amervac PRRS at 21 days of age. Fostera PRRS vaccination at 1 day of age can be useful in protecting young piglets from early HP-PRRSV infection because the immunized pigs were marketed 20 days earlier than their peers immunized at 21-day old as they reached the target market weight earlier in this study.
Assuntos
Anticorpos Antivirais/sangue , Síndrome Respiratória e Reprodutiva Suína/prevenção & controle , Vacinas Virais/imunologia , Animais , Síndrome Respiratória e Reprodutiva Suína/epidemiologia , Síndrome Respiratória e Reprodutiva Suína/virologia , Vírus da Síndrome Respiratória e Reprodutiva Suína/imunologia , Suínos , Vacinação/veterinária , Vacinas Atenuadas/imunologia , Vietnã , Carga Viral , Viremia/imunologiaRESUMO
BACKGROUND: Abnormally high estimated glomerular filtration rates (eGFRs) are associated with endothelial dysfunction and frailty. Previous studies have shown that low eGFR is associated with increased morbidity, but few reports address high eGFR. The purpose of this study is to evaluate the association of high eGFR with surgical outcomes in patients undergoing surgery for gastrointestinal malignancies. METHODS: We identified patients who underwent elective surgery for gastrointestinal malignancies from 2005 to 2015 in the American College of Surgeons National Surgical Quality Improvement Program database. We evaluated associations of eGFR with surgical outcomes by Cox or logistic models with restricted cubic spline functions, adjusting for case mix variables (i.e. age, gender, race and diabetes). RESULTS: The median eGFR is 83 (interquartile range 67-96) mL/min/1.73 m2. Thirty-day mortality was 1.9% (2555/136 896). There is a U-shaped relationship between eGFR and 30-day mortality. The adjusted hazard ratios (95% confidence intervals) for eGFRs of 30, 60, 105 and 120 mL/min/1.73 m2 (versus 90 mL/min/1.73 m2) are 1.73 (1.52-1.97), 1.00 (0.89-1.11), 1.42 (1.31-1.55) and 2.20 (1.79-2.70), respectively. Similar associations are shown for other surgical outcomes, including return to the operating room and postoperative pneumonia. Subgroup analyses show that eGFRs both higher and lower than the respective medians are consistently associated with a higher risk of adverse outcomes across age, gender and race. CONCLUSIONS: High and low eGFRs are associated with more adverse surgical outcomes in patients undergoing surgery for gastrointestinal malignancies. The eGFR associated with the lowest postoperative risk is approximately at the median eGFR of a given population.
Assuntos
Procedimentos Cirúrgicos do Sistema Digestório , Neoplasias Gastrointestinais/cirurgia , Taxa de Filtração Glomerular/fisiologia , Complicações Pós-Operatórias/epidemiologia , Idoso , Feminino , Neoplasias Gastrointestinais/fisiopatologia , Humanos , Masculino , Morbidade/tendências , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Fatores de Risco , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Studies comparing laparoscopic versus open resection of gastrointestinal stromal tumors (GIST) typically involve small comparative groups and often do not control for tumor size or stage of disease. The objective of this study was to compare adjusted survival outcomes for laparoscopic versus open GIST. METHOD: The National Cancer Database (NCDB) from 2010 to 2014 was evaluated for gastric and small intestinal GIST resections. After stratification by disease stage and adjustment for patient demographics, comorbidity score, tumor size, and tumor location, 90-day mortality rates were compared based on laparoscopic versus open resection. Kaplan-Meier estimates of long-term survival were also compared. A Cox proportional hazards model was used to determine hazard ratios (HR) for survival. RESULTS: There were 5096 cases analyzed, including 2910 (57%) stage I, 954 (19%) stage II, and 1232 (24%) stage III cases. The distribution of laparoscopic versus open cases was 1291 (44%) versus 1619 (56%) for stage I, 318 (33%) versus 636 (67%) for stage II, and 286 (23%) versus 946 (77%) for stage III. There was no significant difference in adjusted 90-day mortality between laparoscopic and open resection. Kaplan-Meier estimates of long-term survival demonstrated improved overall survival curves for laparoscopic resection for stage I and stage II disease, but no significant difference for stage III disease. Factors associated with statistically significant higher adjusted overall mortality included older age (HR 1.06; p < 0.001), black race (HR 1.33; p = 0.04), higher comorbidity score (HR 1.47; p < 0.001), and small intestinal versus gastric tumor location (HR 1.28; p = 0.03). The hazards model suggested improved overall survival for females (HR 0.59; p < 0.001) and laparoscopic approach (HR 0.80; p = 0.06). CONCLUSION: Laparoscopic and open GIST resection have comparable 90-day mortality with possible improved long-term survival with laparoscopy for early-stage disease. These findings support the use of laparoscopy as a viable and potentially more effective approach to GIST resection.