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1.
Clin Gastroenterol Hepatol ; 21(3): 704-712.e3, 2023 03.
Artigo em Inglês | MEDLINE | ID: mdl-35337982

RESUMO

BACKGROUND & AIMS: Although liver transplantation (LT) has been demonstrated to provide survival benefit for patients with acute-on-chronic liver failure (ACLF), data are lacking regarding resource utilization for this population after LT. METHODS: We retrospectively reviewed data from 10 centers in North America of patients transplanted between 2018 and 2019. ACLF was identified by using the European Association for the Study of the Liver-Chronic Liver Failure criteria. RESULTS: We studied 318 patients of whom 106 patients (33.3%) had no ACLF, 61 (19.1%) had ACLF-1, 74 (23.2%) had ACLF-2, and 77 (24.2%) had ACLF-3 at transplantation. Healthcare resource utilization after LT was greater among recipients with ACLF compared with patients without ACLF regarding median post-LT length of hospital stay (LOS) (P < .001), length of post-LT dialysis (P < .001), discharge to a rehabilitation center (P < .001), and 30-day readmission rates (P = .042). Multivariable negative binomial regression analysis demonstrated a significantly longer LOS for patients with ACLF-1 (1.9 days; 95% confidence interval [CI], 0.82-7.51), ACLF-2 (6.7 days; 95% CI, 2.5-24.3), and ACLF-3 (19.3 days; 95% CI, 1.2-39.7), compared with recipients without ACLF. Presence of ACLF-3 at LT was also associated with longer length of dialysis after LT (9.7 days; 95% CI, 4.6-48.8) relative to lower grades. Multivariable logistic regression analysis revealed greater likelihood of discharge to a rehabilitation center among recipients with ACLF-1 (odds ratio [OR], 1.79; 95% CI, 1.09-4.54), ACLF-2 (OR, 2.23; 95% CI, 1.12-5.01), and ACLF-3 (OR, 2.23; 95% CI, 1.40-5.73). Development of bacterial infection after LT also predicted LOS (20.9 days; 95% CI, 6.1-38.5) and 30-day readmissions (OR, 1.39; 95% CI, 1.17-2.25). CONCLUSIONS: Patients with ACLF at LT, particularly ACLF-3, have greater post-transplant healthcare resource utilization.


Assuntos
Insuficiência Hepática Crônica Agudizada , Transplante de Fígado , Humanos , Insuficiência Hepática Crônica Agudizada/complicações , Cirrose Hepática/complicações , Estudos Retrospectivos , Aceitação pelo Paciente de Cuidados de Saúde , Prognóstico
2.
Liver Transpl ; 28(6): 1078-1089, 2022 06.
Artigo em Inglês | MEDLINE | ID: mdl-35020260

RESUMO

Although liver transplantation (LT) yields survival benefit for patients with acute-on-chronic liver failure grade 3 (ACLF-3), knowledge gaps remain regarding risk factors for post-LT mortality. We retrospectively reviewed data from 10 centers in the United States and Canada for patients transplanted between 2018 and 2019 and who required care in the intensive care unit prior to LT. ACLF was identified using the European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) criteria. A total of 318 patients were studied, of whom 106 (33.3%) had no ACLF, 61 (19.1%) had ACLF-1, 74 (23.2%) had ACLF-2, and 77 (24.2%) had ACLF-3 at transplantation. Survival probability 1 year after LT was significantly higher in patients without ACLF (94.3%) compared with patients with ACLF (87.3%; P = 0.02), but similar between ACLF-1 (88.5%), ACLF-2 (87.8%), and ACLF-3 (85.7%; P = 0.26). Recipients with ACLF-3 and circulatory failure (n = 29) had similar 1-year post-LT survival (82.3%) compared with patients with ACLF-3 without circulatory failure (89.6%; P = 0.32), including those requiring multiple vasopressors. For patients transplanted with ACLF-3 including respiratory failure (n = 20), there was a trend toward significantly lower post-LT survival (P =  0.07) among those with respiratory failure (74.1%) compared with those without (91.0%). The presence of portal vein thrombosis (PVT) at LT for patients with ACLF-3 (n = 15), however, yielded significantly lower survival (91.9% versus 57.1%; P < 0.001). Multivariable logistic regression analysis revealed that PVT was significantly associated with post-LT mortality within 1 year (odds ratio, 7.3; 95% confidence interval, 1.9-28.3). No correlation was found between survival after LT and the location or extent of PVT, presence of transjugular intrahepatic portosystemic shunt, or anticoagulation. LT in patients with ACLF-3 requiring vasopressors yields excellent 1-year survival. LT should be approached cautiously among candidates with ACLF-3 and PVT.


Assuntos
Insuficiência Hepática Crônica Agudizada , Transplante de Fígado , Insuficiência Respiratória , Insuficiência Hepática Crônica Agudizada/complicações , Insuficiência Hepática Crônica Agudizada/diagnóstico , Insuficiência Hepática Crônica Agudizada/cirurgia , Humanos , Cirrose Hepática/complicações , Transplante de Fígado/efeitos adversos , América do Norte , Prognóstico , Insuficiência Respiratória/complicações , Estudos Retrospectivos , Fatores de Risco
3.
J Clin Gastroenterol ; 54(6): 558-560, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32011402

RESUMO

GOALS: The aim of this study was to evaluate the efficacy of tilt-down (TD) versus left lateral (LL) positioning in speed and ease of colonoscope insertion in women with risk factors for difficult colonoscopy. BACKGROUND: Risk factors for difficult colonoscopy in women include pelvic surgery, diverticulosis, and thin body habitus. STUDY: Female patients with body mass index (BMI) under 25, diverticulosis and history of pelvic surgery were randomized to TD or LL positioning. Five colonoscopists performed all studies at a single center. Time to splenic flexure and cecum, type and amount of medication administered, Boston Bowel Prep Score (BBPS), adverse events, and findings were recorded. The Mann-Whitney U test was used to evaluate the primary endpoint. RESULTS: A total of 150 women were enrolled (81 TD, 69 LL). The mean age was 60.1 (SD 10.5) and the mean BMI was 23.9 (SD 3.5). In total 98 (65.3%) women had prior pelvic surgery, 94 (62.7%) had BMI <25 and 60 (40.0%) had diverticulosis. There was no statistically significant difference in time to the splenic flexure overall but insertion to the splenic flexure was significantly faster in the TD position as compared with the LL position in patients with diverticulosis (124 s for TD, 160 s for LL, P=0.022). In a linear regression analysis, lower BMI, diverticulosis and lower BBPS were significantly associated with a longer insertion time to the splenic flexure. There were no adverse events. CONCLUSION: TD positioning represents a straightforward maneuver to facilitate advancement through the sigmoid colon and may be beneficial in women with diverticular disease.


Assuntos
Colonoscópios , Colonoscopia , Boston , Ceco , Feminino , Humanos , Pessoa de Meia-Idade , Posicionamento do Paciente
5.
J Vasc Interv Radiol ; 27(12): 1788-1796, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27745968

RESUMO

PURPOSE: To evaluate the safety and effectiveness of cryoablation of musculoskeletal metastases in terms of achieving pain palliation and local tumor control. MATERIALS AND METHODS: A retrospective review was performed of 92 musculoskeletal metastases in 56 patients treated with percutaneous image-guided cryoablation. Mean age of the cohort was 53.9 y ± 15.1, and cohort included 48% (27/56) men. Median tumor volume was 13.0 cm3 (range, 0.5-577.2 cm3). Indications for treatment included pain palliation (41%; 38/92), local tumor control (15%; 14/92), or both (43%; 40/92). Concurrent cementoplasty was performed after 28% (26/92) of treatments. RESULTS: In 78 tumors treated for pain palliation, median pain score before treatment was 8.0. Decreased median pain scores were reported 1 day (6.0; P < .001, n = 62), 1 week (5.0; P < .001, n = 70), 1 month (5.0; P < .001, n = 63), and 3 months (4.5; P = .01, n = 28) after treatment. The median pain score at 6-month follow-up was 7.5 (P = .33, n = 11). Radiographic local tumor control rates were 90% (37/41) at 3 months, 86% (32/37) at 6 months, and 79% (26/33) at 12 months after treatment. The procedural complication rate was 4.3% (4/92). The 3 major complications included 2 cases of hemothorax and 1 transient foot drop. CONCLUSIONS: Cryoablation is an effective treatment for palliating painful musculoskeletal metastases and achieving local tumor control.


Assuntos
Neoplasias Ósseas/secundário , Neoplasias Ósseas/cirurgia , Criocirurgia/métodos , Neoplasias Musculares/secundário , Neoplasias Musculares/cirurgia , Dor Musculoesquelética/prevenção & controle , Cuidados Paliativos/métodos , Adulto , Idoso , Neoplasias Ósseas/complicações , Neoplasias Ósseas/diagnóstico por imagem , Cementoplastia , Criocirurgia/efeitos adversos , Feminino , Transtornos Neurológicos da Marcha/etiologia , Hemotórax/etiologia , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Missouri , Neoplasias Musculares/complicações , Neoplasias Musculares/diagnóstico por imagem , Dor Musculoesquelética/diagnóstico , Dor Musculoesquelética/etiologia , Medição da Dor , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Estudos Retrospectivos , Resultado do Tratamento , Carga Tumoral
6.
Skeletal Radiol ; 45(2): 273-8, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26572628

RESUMO

OBJECTIVES: Percutaneous biopsy of discitis-osteomyelitis is performed to isolate the causative microorganism and exclude alternative diagnoses. We compared drill-assisted and manual fluoroscopy-guided intervertebral disc biopsies with respect to conscious sedation requirements and histologic quality of obtained specimens. MATERIALS AND METHODS: Medical records of all single-level, fluoroscopy-guided intervertebral disc biopsies supervised by one of two musculoskeletal radiologists between January 2010 and March 2015 were reviewed. Duration and cumulative medication doses required for each biopsy were recorded. Pathology reports were reviewed to determine whether the obtained specimens were adequate for histopathologic evaluation. Microbiology reports were reviewed to determine whether the causative organism was isolated from the biopsy specimen. RESULTS: During the study period, 21 drill-assisted and 20 manual biopsies were performed. The median duration of conscious sedation for drill-assisted biopsies was 30 min (range, 17-40 min) compared with 39 min (range, 20-90 min) for manual biopsies (p < 0.01). Drill-assisted biopsies also required lower median cumulative doses of intravenous midazolam [2 mg (range, 0-5 mg) vs. 3 mg (range, 0-9 mg); p = 0.02]. All drill-assisted biopsy specimens were adequate for histopathologic evaluation. One manual biopsy specimen (5 %; 1/20) was inadequate for histopathologic evaluation owing to crush artifact. The microbiology yields of drill-assisted and manual biopsies were comparable [14 % (3/21) vs. 20 % (4/20); p = 0.62]. CONCLUSIONS: Fluoroscopically-guided intervertebral disc biopsies performed with drill assistance require less conscious sedation compared with manual biopsies and yield specimens that are adequate for histopathologic evaluation.


Assuntos
Discite/patologia , Disco Intervertebral/patologia , Osteomielite/patologia , Radiografia Intervencionista/métodos , Adulto , Idoso , Biópsia/instrumentação , Feminino , Fluoroscopia/métodos , Humanos , Masculino , Pessoa de Meia-Idade
7.
Neuroradiology ; 57(6): 639-44, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25779098

RESUMO

INTRODUCTION: Cerebrospinal fluid shunts are primarily used for the treatment of hydrocephalus. Shunt complications may necessitate multiple non-contrast head CT scans resulting in potentially high levels of radiation dose starting at an early age. A new head CT protocol using automatic exposure control and automated tube potential selection has been implemented at our institution to reduce radiation exposure. The purpose of this study was to evaluate the reduction in radiation dose achieved by this protocol compared with a protocol with fixed parameters. METHODS: A retrospective sample of 60 non-contrast head CT scans assessing for cerebrospinal fluid shunt malfunction was identified, 30 of which were performed with each protocol. The radiation doses of the two protocols were compared using the volume CT dose index and dose length product. The diagnostic acceptability and quality of each scan were evaluated by three independent readers. RESULTS: The new protocol lowered the average volume CT dose index from 15.2 to 9.2 mGy representing a 39 % reduction (P < 0.01; 95 % CI 35-44 %) and lowered the dose length product from 259.5 to 151.2 mGy/cm representing a 42 % reduction (P < 0.01; 95 % CI 34-50 %). The new protocol produced diagnostically acceptable scans with comparable image quality to the fixed parameter protocol. CONCLUSION: A pediatric shunt non-contrast head CT protocol using automatic exposure control and automated tube potential selection reduced patient radiation dose compared with a fixed parameter protocol while producing diagnostic images of comparable quality.


Assuntos
Derivações do Líquido Cefalorraquidiano , Hidrocefalia/diagnóstico por imagem , Hidrocefalia/terapia , Doses de Radiação , Exposição à Radiação/prevenção & controle , Tomografia Computadorizada por Raios X/métodos , Adolescente , Adulto , Criança , Pré-Escolar , Protocolos Clínicos , Falha de Equipamento , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Adulto Jovem
8.
J Clin Ultrasound ; 43(8): 516-9, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25502778

RESUMO

Hemangiomas of the submandibular space are very rare. Only 11 cases have been reported in the English literature, all of which were cavernous hemangiomas. In this report, we describe the case of a venous hemangioma in a 70-year-old woman. Ultrasound examination revealed a lobulated, homogeneous, hypoechoic mass, and minimal flow was detected on power Doppler evaluation. The mass and the submandibular gland were surgically excised, and the endothelium was found to be positive for CD31 and D2-40 markers, consistent with venous hemangioma. To our knowledge, this is the first reported case of a venous hemangioma in the submandibular space.


Assuntos
Hemangioma/diagnóstico por imagem , Glândula Submandibular/irrigação sanguínea , Glândula Submandibular/diagnóstico por imagem , Idoso , Biópsia por Agulha Fina , Diagnóstico Diferencial , Feminino , Hemangioma/cirurgia , Humanos , Biópsia Guiada por Imagem , Glândula Submandibular/cirurgia , Tomografia Computadorizada por Raios X , Ultrassonografia
9.
Clin Liver Dis ; 25(1): 137-155, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33978575

RESUMO

Hepatitis C virus has historically been the leading indication for liver transplant, followed by nonalcoholic steatohepatitis (NASH) and alcoholic liver disease. Severe alcoholic hepatitis has become a growing indication for liver transplant, and overall alcohol use rates continue to increase in the United States. Rates of obesity and NASH in the United States continue to increase and are expected to place increasing demand on liver transplant infrastructure. In the current absence of robust pharmacologic therapy for NASH, the use of bariatric procedures and surgeries is being explored, as are other innovative approaches to curtail this upward trend.


Assuntos
Hepatite C , Hepatopatias Alcoólicas , Transplante de Fígado , Hepatopatia Gordurosa não Alcoólica , Hepacivirus , Hepatite C/complicações , Hepatite C/tratamento farmacológico , Hepatite C/epidemiologia , Humanos , Hepatopatias Alcoólicas/epidemiologia , Hepatopatias Alcoólicas/cirurgia , Hepatopatia Gordurosa não Alcoólica/epidemiologia , Estados Unidos/epidemiologia
10.
World J Pediatr Congenit Heart Surg ; 7(3): 334-43, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-27142401

RESUMO

BACKGROUND: Adults with congenital heart disease are hospitalized at increasing rates in the Western world. Identification of rates of and risk factors for hospitalization is essential for research and improving patient outcomes. METHODS: We conducted a single-center retrospective analysis of patients with a primary diagnosis of tetralogy of Fallot (TOF), transposition of the great arteries (both d- and l-transposition of the great arteries [TGAs]), or single ventricle (SV). We investigated the rates of mortality, annual hospitalization, and patient-specific risk factors for unplanned cardiac hospitalization. RESULTS: Adult patients with complex congenital heart disease are hospitalized at a rate four to eight times greater than the general US population (P < .001). In addition, there are significant differences between the rates of hospitalization in TOF and TGA (0.39 and 0.41 hospitalizations per patient-year, respectively) and SV (0.72 hospitalizations per patient-year). The majority of excess hospitalizations in the study group were due to cardiac disease (P < .001 for all three groups). Risk factors for unplanned cardiac hospitalization in TOF included pulmonary atresia, depressed left ventricular and right ventricular ejection fraction, and smoking; in TGA, they included Ebstein malformation, surgeries other than primary repair, noncardiac diagnoses, atrial arrhythmias, atrioventricular nodal block, left ventricular ejection fraction, and smoking; and in SV, they included atrial arrhythmias and cyanosis. CONCLUSIONS: Patients born with complex congenital heart disease are hospitalized far more frequently than the general US population, primarily for cardiac-related illness. Future research should focus on confirming the present findings and on identification of strategies to improve outcomes in this growing group of patients.


Assuntos
Tetralogia de Fallot/terapia , Transposição dos Grandes Vasos/terapia , Adulto , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Tetralogia de Fallot/mortalidade , Transposição dos Grandes Vasos/mortalidade
11.
J Neurointerv Surg ; 8(4): 378-85, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25801775

RESUMO

BACKGROUND AND PURPOSE: Perimesencephalic subarachnoid hemorrhage (PSAH) is not consistently defined in the existing literature. The purpose of this study was to test the inter-observer variability and specificity for non-aneurysmal subarachnoid hemorrhage (SAH) of an anatomic definition of PSAH. METHODS: Medical records of all patients who underwent catheter angiography for evaluation of non-traumatic SAH between July 2002 and April 2012 were reviewed. Patients with anterior circulation aneurysms were excluded. Three blinded reviewers assessed whether each admission CT scan met the following anatomic criteria for PSAH: (1) center of bleeding located immediately anterior and in contact with the brainstem in the prepontine, interpeduncular, or posterior suprasellar cistern; (2) blood limited to the prepontine, interpeduncular, suprasellar, crural, ambient, and/or quadrigeminal cisterns and/or cisterna magna; (3) no extension of blood into the Sylvian or interhemispheric fissures; (4) intraventricular blood limited to incomplete filling of the fourth ventricle and occipital horns of the lateral ventricles (ie, consistent with reflux); (5) no intraparenchymal blood. RESULTS: 56 patients with non-aneurysmal SAH and 50 patients with posterior circulation or posterior communicating artery aneurysms were identified. Seventeen (16%) of the 106 admission CT scans met the anatomic criteria for PSAH. No aneurysm was identified in this subgroup. Inter-observer agreement was excellent with κ scores of 0.89-0.96 and disagreement in 2.8% (3/106) of cases. CONCLUSIONS: Our anatomic definition of PSAH correlated with a low risk of brain aneurysm and was applied with excellent inter-observer agreement.


Assuntos
Mesencéfalo/diagnóstico por imagem , Hemorragia Subaracnóidea/diagnóstico por imagem , Tomografia Computadorizada por Raios X/normas , Adulto , Idoso , Humanos , Pessoa de Meia-Idade , Método Simples-Cego
12.
Interv Neuroradiol ; 21(6): 742-9, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26500233

RESUMO

Stereotactic radiosurgery and percutaneous radiofrequency ablation are emerging therapies for pain palliation and local control of spinal metastases. However, the post-treatment imaging findings are not well characterized and the risk of long-term complications is unknown. We present the case of a 46-year-old woman with delayed vertebral body collapse after stereotactic radiosurgery and radiofrequency ablation of a painful lumbar metastasis. Histopathologic-MRI correlation confirmed osteonecrosis as the underlying etiology and demonstrated that treatment-induced vascular fibrosis and tumor progression can have identical imaging appearances.


Assuntos
Ablação por Cateter , Fraturas por Compressão/etiologia , Leiomiossarcoma/cirurgia , Complicações Pós-Operatórias/etiologia , Radiocirurgia , Fraturas da Coluna Vertebral/etiologia , Neoplasias da Coluna Vertebral/cirurgia , Evolução Fatal , Feminino , Fluordesoxiglucose F18 , Fraturas por Compressão/diagnóstico por imagem , Fraturas por Compressão/cirurgia , Humanos , Biópsia Guiada por Imagem , Leiomiossarcoma/diagnóstico por imagem , Leiomiossarcoma/secundário , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/cirurgia , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Medição da Dor , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/cirurgia , Compostos Radiofarmacêuticos , Fraturas da Coluna Vertebral/diagnóstico por imagem , Fraturas da Coluna Vertebral/cirurgia , Neoplasias da Coluna Vertebral/diagnóstico por imagem , Neoplasias da Coluna Vertebral/secundário
13.
Clin Neurol Neurosurg ; 137: 67-71, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26151343

RESUMO

OBJECTIVE: A variant of perimesencephalic subarachnoid hemorrhage (PSAH) has been described characterized by blood centered in the quadrigeminal cistern and limited to the superior vermian and perimesencephalic cisterns. Herein, three cases of quadrigeminal PSAH are presented. MATERIALS AND METHODS: Medical records of all patients who underwent digital subtraction angiography for evaluation of non-traumatic SAH between July 2002 and April 2012 were reviewed. Patients with anterior circulation aneurysms were excluded. Two blinded reviewers identified admission noncontrast CT scans with pretruncal and quadrigeminal patterns of PSAH. RESULTS: The total cohort included 106 patients: 53% (56/106) with one or more negative digital subtraction angiograms and 47% (50/106) with posterior circulation or posterior communicating artery aneurysms. Three patients with quadrigeminal PSAH were identified, two with nonaneurysmal SAH and one with a posterior circulation aneurysm. Seventeen patients (16%; 17/106) with pretruncal PSAH were identified, none of whom were found to have an aneurysm. The quadrigeminal pattern comprised 11% (2/19) of cases of pretruncal or quadrigeminal nonaneurysmal PSAH. CONCLUSION: A small subset of patients with nonaneurysmal PSAH present with blood centered in the quadrigeminal cistern, and the etiology of this pattern may be similar to that of the classic pretruncal variant. However, patients with quadrigeminal PSAH must still undergo thorough vascular imaging, including at least two digital subtraction angiograms, to exclude a ruptured aneurysm.


Assuntos
Aneurisma Roto/diagnóstico por imagem , Aneurisma Roto/cirurgia , Aneurisma Intracraniano/cirurgia , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/cirurgia , Adulto , Aneurisma Roto/diagnóstico , Angiografia Digital/métodos , Encéfalo/diagnóstico por imagem , Angiografia Cerebral/métodos , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico , Masculino , Pessoa de Meia-Idade , Hemorragia Subaracnóidea/diagnóstico , Espaço Subaracnóideo/diagnóstico por imagem
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