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Sample records for surgery high-risk patients

  1. Standardizing care for high-risk patients in spine surgery: the Northwestern high-risk spine protocol.

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    Halpin, Ryan J; Sugrue, Patrick A; Gould, Robert W; Kallas, Peter G; Schafer, Michael F; Ondra, Stephen L; Koski, Tyler R

    2010-12-01

    Review article of current literature on the preoperative evaluation and postoperative management of patients undergoing high-risk spine operations and a presentation of a multidisciplinary protocol for patients undergoing high-risk spine operation. To provide evidence-based outline of modifiable risk factors and give an example of a multidisciplinary protocol with the goal of improving outcomes. Protocol-based care has been shown to improve outcomes in many areas of medicine. A protocol to evaluate patients undergoing high-risk procedures may ultimately improve patient outcomes. The English language literature to date was reviewed on modifiable risk factors for spine surgery. A multidisciplinary team including hospitalists, critical care physicians, anesthesiologists, and spine surgeons from neurosurgery and orthopedics established an institutional protocol to provide comprehensive care in the pre-, peri-, and postoperative periods for patients undergoing high-risk spine operations. An example of a comprehensive pre-, peri-, and postoperative high-risk spine protocol is provided, with focus on the preoperative assessment of patients undergoing high-risk spine operations and modifiable risk factors. Standardizing preoperative risk assessment may lead to better outcomes after major spine operations. A high-risk spine protocol may help patients by having dedicated physicians in multiple specialties focusing on all aspects of a patients care in the pre-, intra-, and postoperative phases.

  2. Multidisciplinary perioperative protocol in patients undergoing acute high-risk abdominal surgery

    DEFF Research Database (Denmark)

    Tengberg, L. T.; Bay-Nielsen, M.; Bisgaard, T.

    2017-01-01

    Background: Acute high-risk abdominal (AHA) surgery carries a very high risk of morbidity and mortality and represents a massive healthcare burden. The aim of the present study was to evaluate the effect of a standardized multidisciplinary perioperative protocol in patients undergoing AHA surgery...... = 0·004). Conclusion: The introduction of a multidisciplinary perioperative protocol was associated with a significant reduction in postoperative mortality in patients undergoing AHA surgery. NCT01899885 (http://www.clinicaltrials.gov).......Background: Acute high-risk abdominal (AHA) surgery carries a very high risk of morbidity and mortality and represents a massive healthcare burden. The aim of the present study was to evaluate the effect of a standardized multidisciplinary perioperative protocol in patients undergoing AHA surgery...... after initiation of the AHA protocol as standard care. The intervention cohort was compared with a predefined, consecutive historical cohort of patients from the same department. The protocol involved continuous staff education, consultant-led attention and care, early resuscitation and high...

  3. Feasibility and Safety of Bariatric Surgery in High-Risk Patients: A Single-Center Experience

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    Yusef Moulla

    2018-01-01

    Full Text Available Introduction. Despite the feasibility and safety of bariatric procedures nowadays, high-risk patients with vast obesity and severe comorbidities demonstrate relatively high perioperative morbidity and mortality rates and, therefore, form a distinguished challenge for the bariatric surgeons. Methods. We retrospectively analyzed high-risk patients, who underwent bariatric surgery in University Hospital Leipzig between May 2012 and December 2016. High-risk patients were defined when (Bergeat et al., 2016 at least one of the following risk factors was met: age ≥ 70 years, body mass index (BMI > 70 kg/m2, liver cirrhosis, end-organ failure, or immunosuppression by status after organ transplantation along with (Birkmeyer et al., 2010 at least two comorbidities associated with obesity. Our analysis included early postoperative complications. Results. A total of 25 high-risk obese patients were identified. All patients had a standardized postoperative management with a mean length of hospital stay of 4 ± 1.4 days. One patient required an operative revision due to a stapler line leak after sleeve gastrectomy. No other major postoperative complications occurred. Conclusion. Bariatric surgery for severe high-risk patients can be performed safely in high-volume centers following standardized procedures.

  4. The impact of acute high-risk abdominal surgery on quality of life in elderly patients

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    Tengberg, Line Toft; Foss, Nicolai Bang; Lauritsen, Morten Laksafoss

    2017-01-01

    surgery. METHODS: From 1 November 2014 to 30 April 2015, consecutive patients (≥ 75 years) undergoing AHA surgery were included for follow-up after six months. The patients included answered a health-related quality-of-life questionnaire and a supplemental questionnaire regarding residential status...... and they were willing to undergo surgery again, if necessary. All study participants were admitted from their own home, and 95% had no change in residential status after six months. CONCLUSIONS: The self-reported quality of life in elderly survivors six months after AHA surgery was surprisingly good in a small......INTRODUCTION: Undergoing acute high-risk abdominal (AHA) surgery is associated with reduced survival and a great risk of an adverse outcome, especially in the elderly. The primary aim of this study was to investigate the residential status and quality of life in elderly patients undergoing AHA...

  5. Postoperative acute kidney injury in high-risk patients undergoing major abdominal surgery.

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    Romagnoli, Stefano; Zagli, Giovanni; Tuccinardi, Germana; Tofani, Lorenzo; Chelazzi, Cosimo; Villa, Gianluca; Cianchi, Fabio; Coratti, Andrea; De Gaudio, Angelo Raffaele; Ricci, Zaccaria

    2016-10-01

    Acute kidney injury (AKI) is a frequent complication in high-risk patients undergoing major surgery and is associated with longer hospital stay, increased risk for nosocomial infection and significantly higher costs. A prospective observational study exploring the incidence of AKI (AKIN classification at any stage) in high-risk patients within 48 hours after major abdominal surgery was conducted. Patients' preoperative characteristics, intraoperative management, and outcome were evaluated for associations with AKI using a logistic regression model. Data from 258 patients were analyzed. Thirty-one patients (12%) developed AKI, reaching the AKIN stage 1. No patient reached an AKIN stage higher than 1. AKI patients were older (75.2 vs 70.2 years; P = 0.0113) and had a higher body mass index (26.5 vs 25.1 kg/m(2)). In addition, AKI patients had a significantly longer ICU length of stay (3.4 vs 2.4 days; P= .0017). Creatinine levels of AKI patients increased significantly compared to the preoperative levels at 24 (P= .0486), 48 (P= .0011) and 72 hours (P= .0055), while after 72 hours it showed a downwards trend. At ICU discharge, 28 out of 31 patients (90.3%) recovered preoperative levels. Multivariate analysis identified age (OR 1.088; P= .002) and BMI (OR 1.124; P= .022) as risk factors for AKI development. Moreover, AKI development was an independent risk factor for ICU stays longer than 48 hours (OR 2.561; P= .019). Mild AKI is a not rare complication in high-risk patients undergoing major abdominal surgery. Although in almost the totality of cases, the indicators of renal function recovered to preoperative levels, post-operative AKI represents a primary risk factor for a prolonged ICU stay. Copyright © 2016 Elsevier Inc. All rights reserved.

  6. Percutaneous cholecystostomy to treat acute cholecystitis in patients with high risk for surgery.

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    Cortázar García, R; Sánchez Rodríguez, P; Ramos García, M

    2016-01-01

    To evaluate the results of percutaneous cholecystostomy for urgent treatment of acute cholecystitis, with the aim of identifying factors that predict survival. To analyze the recurrence of cholecystitis after catheter withdrawal in patients considered unsuitable candidates for delayed surgery, with the aim of identifying factors that predict recurrence. We reviewed 40 patients who underwent percutaneous cholecystostomy in a two-year period. We analyzed survival during hospitalization in relation with fever, abdominal pain, leukocytosis, and C-reactive protein before and after the procedure. We analyzed the recurrence of cholecystitis after catheter withdrawal in patients considered unsuitable candidates for delayed surgery, as well as the influence of obstruction seen on cholangiography, age, sex, and comorbidities on the recurrence rate. During the hospital stay, 4 (10%) patients died of septic shock. Cholecystostomy improved fever, leukocytosis, and abdominal pain within five days of the procedure, but these improvements did not have a statistically significant effect on survival and were not therefore considered useful prognostic factors. Among the 15 patients considered unsuitable candidates for delayed surgery, 6 (40%) had recurrences of cholecystitis during a mean follow-up period of 6.7 months after catheter withdrawal. We found no association between recurrence and any of the parameters analyzed. Outcomes in our series of patients with high risk for surgery who underwent cholecystostomy for urgent treatment of acute cholecystitis were similar to those reported in other series. Withdrawing the catheter in patients considered unsuitable candidates for delayed surgery is not recommended due to the high risk of recurrence of cholecystitis in comparison with other series. Copyright © 2015 SERAM. Published by Elsevier España, S.L.U. All rights reserved.

  7. Off-pump coronary surgery: surgical strategy for the high-risk patient.

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    Van Belleghem, Y; Caes, F; Maene, L; Van Overbeke, H; Moerman, A; Van Nooten, G

    2003-02-01

    In a retrospective study, we compared two groups of consecutive patients operated by the same team during the year 2000 for coronary artery disease with the use of extracorporeal circulation (group 1, n=230) or on the beating heart using the Octopus II plus stabiliser (group 2, n=228). High-risk patients were identified by a EuroSCORE plus 6. EuroSCORE definitions and predicted risk models were utilized to compare the variables of the groups. There were no significant differences between the preoperative variables of the groups in age, gender, left ventricular function, diabetes and peripheral vascular and renal disease as is indicated by the Euroscore (resp. 4.7/5.1 p=0.107). Calcification of the ascending aorta and chronic obstructive lung disease were statistically significant more prevalent in the beating heart group. No differences in preoperative variables in the high-risk patients group (Euroscore 8.5/8.1 p=0.356) except for calcification of the ascending aorta. All patients underwent a full revascularisation through a midline sternotomy. Significant more distal anastomoses were performed in group 1 (3.7 per patient (1-6)) with regard to group 2 (2.9 per patient (1-6)). Anesthesia, postoperative treatment and follow up were equal for both groups. A significant lower incidence of atrial fibrillation (p=0.010), shorter ICU stay (p=0.031) and renal insufficiency (p=0.033) was reported in group 2. In the low risk group, we could not diagnose any difference between the two groups, except for atrial fibrillation. The benefits of the beating heart surgery however were more pronounced in the high-risk patient as is indicated by a significant reduction of the ICU stay by 1 day (3.5d/2.5d (p=0.028)), better preservation of the renal function (p=0.017) and a significant reduction of the length of hospital stay by more than two days (p=0.040). A lower incidence of atrial fibrillation, however not significant. In our experience, beating heart surgery is a safe

  8. The myocardial protective effect of dexmedetomidine in high-risk patients undergoing aortic vascular surgery

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    Rabie Soliman

    2016-01-01

    Full Text Available Objective: The aim of the study was to assess the effect of dexmedetomidine in high-risk patients undergoing aortic vascular surgery. Design: A randomized prospective study. Setting: Cairo University, Egypt. Materials and Methods: The study included 150 patients undergoing aortic vascular surgery. Intervention: The patients were classified into two groups (n = 75. Group D: The patients received a loading dose of 1 μg/kg dexmedetomidine over 15 min before induction and maintained as an infusion of 0.3 μg/kg/h to the end of the procedure. Group C: The patients received an equal volume of normal saline. The medication was prepared by the nursing staff and given to anesthetist blindly. Measurements: The monitors included the heart rate, mean arterial blood pressure, central venous pressure, electrocardiogram (ECG, serum troponin I level, end-tidal sevoflurane, and total dose of morphine in addition transthoracic echocardiography to the postoperative in cases with elevated serum troponin I level. Main Results: The dexmedetomidine decreased heart rate and minimized the changes in blood pressure compared to control group (P < 0.05. Furthermore, it decreased the incidence of myocardial ischemia reflected by troponin I level, ECG changes, and the development of new regional wall motion abnormalities (P < 0.05. Dexmedetomidine decreased the requirement for nitroglycerin and norepinephrine compared to control group (P < 0.05. The incidence of hypotension and bradycardia was significantly higher with dexmedetomidine (P < 0.05. Conclusion: The dexmedetomidine is safe and effective in patients undergoing aortic vascular surgery. It decreases the changes in heart rate and blood pressure during the procedures. It provides cardiac protection in high-risk patients reflected by decreasing the incidence of myocardial ischemia and serum level of troponin. The main side effects of dexmedetomidine were hypotension and bradycardia.

  9. Trajectories and Prognosis of Older Patients Who Have Prolonged Mechanical Ventilation After High-Risk Surgery.

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    Nabozny, Michael J; Barnato, Amber E; Rathouz, Paul J; Havlena, Jeffrey A; Kind, Amy J; Ehlenbach, William J; Zhao, Qianqian; Ronk, Katie; Smith, Maureen A; Greenberg, Caprice C; Schwarze, Margaret L

    2016-06-01

    Surgical patients often receive routine postoperative mechanical ventilation with excellent outcomes. However, older patients who receive prolonged mechanical ventilation may have a significantly different long-term trajectory not fully captured in 30-day postoperative metrics. The objective of this study is to describe patterns of mortality and hospitalization for Medicare beneficiaries 66 years old and older who have major surgery with and without prolonged mechanical ventilation. Retrospective cohort study. Hospitals throughout the United States. Five percent random national sample of elderly Medicare beneficiaries (age ≥ 66 yr) who underwent 1 of 227 operations previously defined as high risk during an inpatient stay at an acute care hospital between January 1, 2005, and November 30, 2009. None. We identified 117,917 episodes for older patients who had high-risk surgery; 4% received prolonged mechanical ventilation during the hospitalization. Patients who received prolonged mechanical ventilation had higher 1-year mortality rate than patients who did not have prolonged ventilation (64% [95% CI, 62-65%] vs 17% [95% CI, 16.4-16.9%]). Thirty-day survivors who received prolonged mechanical ventilation had a 1-year mortality rate of 47% (95% CI, 45-48%). Thirty-day survivors who did not receive prolonged ventilation were more likely to be discharged home than patients who received prolonged ventilation 71% versus 10%. Patients who received prolonged ventilation and were not discharged by postoperative day 30 had a substantially increased 1-year mortality (adjusted hazard ratio, 4.39 [95% CI, 3.29-5.85]) compared with patients discharged home by day 30. Hospitalized 30-day survivors who received prolonged mechanical ventilation and died within 6 months of their index procedure spent the majority of their remaining days hospitalized. Older patients who require prolonged mechanical ventilation after high-risk surgery and survive 30 days have a significant 1-year risk

  10. Patients with single ventricle physiology undergoing noncardiac surgery are at high risk for adverse events.

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    Brown, Morgan L; DiNardo, James A; Odegard, Kirsten C

    2015-08-01

    intraoperative adverse events (9.8%) including: arrhythmias requiring treatment (n = 4), conversion from sedation to a general anesthetic (n = 2), difficult airway (n = 1), inadvertent extubation with desaturation and bradycardia (n = 1), hypotension and desaturation (n = 1), and cardiac arrest (n = 1). Postoperative events (surgery in a high-risk subgroup of palliated cardiac patients with single ventricle physiology. However, 11.8% of patients had an adverse event associated with their anesthetic. © 2015 John Wiley & Sons Ltd.

  11. Sevoflurane-Based Inhalation Induction in High-Risk Elderly Patients During Noncardiac Surgery

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    O. A. Grebenchikov

    2011-01-01

    Full Text Available Objective: to study the hemodynamic effects of sevoflurane during the induction of anesthesia in elderly patients at high risk for cardiac events. Subjects and methods. This study enrolled 32 patients who had a left ventricular ejection fraction of <30% during preoperative examination. According to the presumptive type of anesthesia, the patients were randomized to one of the study groups: In the sevoflurane group receiving infusion of fentanyl (1 ig^kg”‘^hr”‘, anesthesia was induced by sevoflurane at the maximum concentration of 8 vol% at first inspiration, without the respiratory circuit being prefilled. After loss of consciousness, further saturation was carried out using Fianesth, 5 vol%. Combination anesthesia (CA was that which was induced by successive administration of dormicum, ketamine, propo-fol, and fentanyl. The trachea was intubated during total myoplegia under the control of TOF (TOF-Watch, Organon, the Netherlands. Results. In all the patients under CA, its induction was made during infusion of dopamine (5 lg^kg”‘^min”‘, the dose of which had to be increased up to 10 ig • kg-1 • min-1 in 6 (75% patients. Nevertheless, there were decreases in mean blood pressure (BPmean to 46±6 mm Hg and in cardiac index (CI to 1.5±0.3 fig • kg-1 • min-1 (by 32% of the outcome value. In the sevoflurane inhalation induction group, only 3 (12.5% patients needed dopamine. Its dose producing a cardiotonic effect was near-minimal; its average maintenance infusion rate was 5.3±0.3 ig^kg”‘^min”‘. The reduction in CI was statistically insignificant; despite a 9% decrease in BPmean, this indicator in the sevoflurane group remained within acceptable ranges. Conclusion. The use of a sevoflurane-based inhalation induction technique permits higher hemodynamic stability in patients at high risk for cardiac events. Key words: inhalation induction, sevoflurane, ketamine, elderly patients.

  12. Personalised Prehabilitation in High-risk Patients Undergoing Elective Major Abdominal Surgery: A Randomized Blinded Controlled Trial.

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    Barberan-Garcia, Anael; Ubré, Marta; Roca, Josep; Lacy, Antonio M; Burgos, Felip; Risco, Raquel; Momblán, Dulce; Balust, Jaume; Blanco, Isabel; Martínez-Pallí, Graciela

    2018-01-01

    The aim of this study was to assess the impact of personalized prehabilitation on postoperative complications in high-risk patients undergoing elective major abdominal surgery. Prehabilitation, including endurance exercise training and promotion of physical activity, in patients undergoing major abdominal surgery has been postulated as an effective preventive intervention to reduce postoperative complications. However, the existing studies provide controversial results and show a clear bias toward low-risk patients. This was a randomized blinded controlled trial. Eligible candidates accepting to participate were blindly randomized (1:1 ratio) to control (standard care) or intervention (standard care + prehabilitation) groups. Inclusion criteria were: i) age >70 years; and/or, ii) American Society of Anesthesiologists score III/IV. Prehabilitation covered 3 actions: i) motivational interview; ii) high-intensity endurance training; and promotion of physical activity. The main study outcome was the proportion of patients suffering postoperative complications. Secondary outcomes included the endurance time (ET) during cycle-ergometer exercise. We randomized 71 patients to the control arm and 73 to intervention. After excluding 19 patients because of changes in the surgical plan, 63 controls and 62 intervention patients were included in the intention-to-treat analysis. The intervention group enhanced aerobic capacity [ΔET 135 (218) %; P high-risk candidates for elective major abdominal surgery, which can be explained by the increased aerobic capacity.

  13. Dopexamine has no additional benefit in high-risk patients receiving goal-directed fluid therapy undergoing major abdominal surgery.

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    Davies, Simon J; Yates, David; Wilson, R Jonathan T

    2011-01-01

    Dopexamine has been shown to reduce both mortality and morbidity in major surgery when it is used as part of a protocol to increase oxygen delivery in the perioperative period. A European multicenter study has examined the use of dopexamine in patients undergoing major abdominal surgery, showing a trend toward improved survival and reduced complications in high-risk patients when receiving low-dose dopexamine (0.5 μg · kg(-1) · min(-1)). A reduced oxygen uptake at the anaerobic threshold (AT) has been shown to confer a significant risk of mortality in patients undergoing major abdominal surgery and allows objective identification of a high-risk operative group. In this study, we assessed the effects of low-dose dopexamine on morbidity after major abdominal surgery in patients who were at increased risk by virtue of a reduced AT. Patients undergoing elective major colorectal or urological surgery who had an AT of surgery, a radial arterial cannula was placed and attached to an Edwards Lifesciences FloTrac/Vigileo system for measuring cardiac output. Patients were given a 250-mL bolus of Voluven (6% hydroxyethyl starch 130/0.4 in 0.9% sodium chloride) until the stroke volume no longer increased by 10%, then received either dopexamine (0.5 μg · kg(-1) · min(-1)) or saline 0.9% for 24 hours. During surgery, fluid boluses of Voluven were given if the stroke volume variation was >10%. No crystalloid was given during surgery. A standardized postoperative fluid regime with Hartmann solution was prescribed at 1.5 mL · kg(-1) · h(-1) for 24 hours. The primary outcome measure was postoperative morbidity measured by the Postoperative Morbidity Survey. One hundred twenty-four patients were recruited over a 23-month period. The incidence of morbidity as measured by the Postoperative Morbidity Survey on day 5 was 55% in the control group versus 47% in the dopexamine group (P = 0.14). There was no significant reduction in morbidity on any measured postoperative day

  14. Early goal-directed therapy in moderate to high-risk cardiac surgery patients

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    Kapoor Poonam

    2008-01-01

    Full Text Available Early goal-directed therapy is a term used to describe the guidance of intravenous fluid and vasopressor/inotropic therapy by using cardiac output or similar parameters in the immediate post-cardiopulmonary bypass in cardiac surgery patients. Early recognition and therapy during this period may result in better outcome. In keeping with this aim in the cardiac surgery patients, we conducted the present study. The study included 30 patients of both sexes, with EuroSCORE ≥3 undergoing coronary artery bypass surgery under cardiopulmonary bypass. The patients were randomly divided into two groups, namely, control and early goal-directed therapy (EGDT groups. All the subjects received standardized care; arterial pressure was monitored through radial artery, central venous pressure through a triple lumen in the right internal jugular vein, electrocardiogram, oxygen saturation, temperature, urine output per hour and frequent arterial blood gas analysis. In addition, cardiac index monitoring using FloTrac™ and continuous central venous oxygen saturation using PreSep™ was used in patients in the EGTD group. Our aim was to maintain the cardiac index at 2.5-4.2 l/min/m 2 , stroke volume index 30-65 ml/beat/m 2 , systemic vascular resistance index 1500-2500 dynes/s/cm 5 /m 2 , oxygen delivery index 450-600 ml/min/m 2 , continuous central venous oximetry more than 70%, stroke volume variation less than 10%; in addition to the control group parameters such as central venous pressure 6-8 mmHg, mean arterial pressure 90-105 mmHg, normal arterial blood gas analysis values, pulse oximetry, hematocrit value above 30% and urine output more than 1 ml/kg/h. The aims were achieved by altering the administration of intravenous fluids and doses of inotropic or vasodilator agents. Three patients were excluded from the study and the data of 27 patients analyzed. The extra volume used (330 ± 160 v/s 80 ± 80 ml, P = 0.043 number of adjustments of inotropic agents (3

  15. Clinical Use of Ultrasensitive Cardiac Troponin I Assay in Intermediate- and High-Risk Surgery Patients

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    Flávia Kessler Borges

    2013-01-01

    Full Text Available Background. Cardiac troponin levels have been reported to add value in the detection of cardiovascular complications in noncardiac surgery. A sensitive cardiac troponin I (cTnI assay could provide more accurate prognostic information. Methods. This study prospectively enrolled 142 patients with at least one Revised Cardiac Risk Index risk factor who underwent noncardiac surgery. cTnI levels were measured postoperatively. Short-term cardiac outcome predictors were evaluated. Results. cTnI elevation was observed in 47 patients, among whom 14 were diagnosed as having myocardial infarction (MI. After 30 days, 16 patients had major adverse cardiac events (MACE. Excluding patients with a final diagnosis of MI, predictors of cTnI elevation included dialysis, history of heart failure, transoperative major bleeding, and elevated levels of pre- and postoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP. Maximal cTnI values showed the highest sensitivity (94%, specificity (75%, and overall accuracy (AUC 0.89; 95% CI 0.80–0.98 for postoperative MACE. Postoperative cTnI peak level (OR 9.4; 95% CI 2.3–39.2 and a preoperative NT-proBNP level ≥917 pg/mL (OR 3.47; 95% CI 1.05–11.6 were independent risk factors for MACE. Conclusions. cTnI was shown to be an independent prognostic factor for cardiac outcomes and should be considered as a component of perioperative risk assessment.

  16. Liberal or restrictive transfusion in high-risk patients after hip surgery.

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    Carson, Jeffrey L; Terrin, Michael L; Noveck, Helaine; Sanders, David W; Chaitman, Bernard R; Rhoads, George G; Nemo, George; Dragert, Karen; Beaupre, Lauren; Hildebrand, Kevin; Macaulay, William; Lewis, Courtland; Cook, Donald Richard; Dobbin, Gwendolyn; Zakriya, Khwaja J; Apple, Fred S; Horney, Rebecca A; Magaziner, Jay

    2011-12-29

    The hemoglobin threshold at which postoperative red-cell transfusion is warranted is controversial. We conducted a randomized trial to determine whether a higher threshold for blood transfusion would improve recovery in patients who had undergone surgery for hip fracture. We enrolled 2016 patients who were 50 years of age or older, who had either a history of or risk factors for cardiovascular disease, and whose hemoglobin level was below 10 g per deciliter after hip-fracture surgery. We randomly assigned patients to a liberal transfusion strategy (a hemoglobin threshold of 10 g per deciliter) or a restrictive transfusion strategy (symptoms of anemia or at physician discretion for a hemoglobin level of liberal-strategy group and none in the restrictive-strategy group. The rates of the primary outcome were 35.2% in the liberal-strategy group and 34.7% in the restrictive-strategy group (odds ratio in the liberal-strategy group, 1.01; 95% confidence interval [CI], 0.84 to 1.22), for an absolute risk difference of 0.5 percentage points (95% CI, -3.7 to 4.7). The rates of in-hospital acute coronary syndrome or death were 4.3% and 5.2%, respectively (absolute risk difference, -0.9%; 99% CI, -3.3 to 1.6), and rates of death on 60-day follow-up were 7.6% and 6.6%, respectively (absolute risk difference, 1.0%; 99% CI, -1.9 to 4.0). The rates of other complications were similar in the two groups. A liberal transfusion strategy, as compared with a restrictive strategy, did not reduce rates of death or inability to walk independently on 60-day follow-up or reduce in-hospital morbidity in elderly patients at high cardiovascular risk. (Funded by the National Heart, Lung, and Blood Institute; FOCUS ClinicalTrials.gov number, NCT00071032.).

  17. Outcome of intraoperative goal-directed therapy using Vigileo/FloTrac in high-risk patients scheduled for major abdominal surgeries: A prospective randomized trial

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    Mohammed A. Elgendy

    2017-07-01

    Conclusion: The applied protocol for intraoperative GDT provided significant reduction of PO morbidities, ICU and hospital LOS but couldn‘t significantly reduce mortality rates in high risk patients scheduled for major abdominal surgeries.

  18. Liberal or Restrictive Transfusion in High-Risk Patients after Hip Surgery

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    Carson, Jeffrey L.; Terrin, Michael L.; Noveck, Helaine; Sanders, David W.; Chaitman, Bernard R.; Rhoads, George G.; Nemo, George; Dragert, Karen; Beaupre, Lauren; Hildebrand, Kevin; Macaulay, William; Lewis, Courtland; Cook, Donald Richard; Dobbin, Gwendolyn; Zakriya, Khwaja J.; Apple, Fred S.; Horney, Rebecca A.; Magaziner, Jay

    2012-01-01

    BACKGROUND The hemoglobin threshold at which postoperative red-cell transfusion is warranted is controversial. We conducted a randomized trial to determine whether a higher threshold for blood transfusion would improve recovery in patients who had undergone surgery for hip fracture. METHODS We enrolled 2016 patients who were 50 years of age or older, who had either a history of or risk factors for cardiovascular disease, and whose hemoglobin level was below 10 g per deciliter after hip-fracture surgery. We randomly assigned patients to a liberal transfusion strategy (a hemoglobin threshold of 10 g per deciliter) or a restrictive transfusion strategy (symptoms of anemia or at physician discretion for a hemoglobin level of <8 g per deciliter). The primary outcome was death or an inability to walk across a room without human assistance on 60-day follow-up. RESULTS A median of 2 units of red cells were transfused in the liberal-strategy group and none in the restrictive-strategy group. The rates of the primary outcome were 35.2% in the liberal-strategy group and 34.7% in the restrictive-strategy group (odds ratio in the liberal-strategy group, 1.01; 95% confidence interval [CI], 0.84 to 1.22), for an absolute risk difference of 0.5 percentage points (95% CI, −3.7 to 4.7). The rates of in-hospital acute coronary syndrome or death were 4.3% and 5.2%, respectively (absolute risk difference, −0.9%; 99% CI, −3.3 to 1.6), and rates of death on 60-day follow-up were 7.6% and 6.6%, respectively (absolute risk difference, 1.0%; 99% CI, −1.9 to 4.0). The rates of other complications were similar in the two groups. CONCLUSIONS A liberal transfusion strategy, as compared with a restrictive strategy, did not reduce rates of death or inability to walk independently on 60-day follow-up or reduce in-hospital morbidity in elderly patients at high cardiovascular risk. (Funded by the National Heart, Lung, and Blood Institute; FOCUS ClinicalTrials.gov number, NCT00071032.) PMID

  19. [Prophylactic surgery in patients mutated BRCA or high risk: retrospective study of 61 patients in the ICO].

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    Oger, A S; Classe, J M; Ingster, O; Morin-Meschin, M E; Sauterey, B; Lorimier, G; Wernert, R; Paillocher, N; Raro, P

    2015-02-01

    Genetic predisposition is involved in only 10% of patients with breast cancer. This study was to evaluate the impact of prophylactic surgery. This is a retrospective study of 61 patients who received prophylactic breast surgery. Data collection was carried out through the computer file of the ICO. The inclusion criteria were: patients who benefited from a bilateral prophylactic mastectomy. There were no exclusion criteria. Patients received a satisfaction questionnaire to complete. Our study included 61 patients, 67% had a history of breast cancer. Bilateral prophylactic surgery was performed in 40 patients. It was made an average of two interventions, 44.3% of them presented postoperative complications, 18% recovery. Forty-three patients were satisfied with the medical information before surgery. The end result matched the expectations of 54.4% and 67.4% of patients would be ready to start. It was found pain associated with breast surgery in 56.5% of patients and almost half reported a change in their sexual life. Prophylactic mastectomy is the most effective technique to prevent the risk of breast cancer. The consequences of such an action are important. It is necessary to better select patients who would benefit most from this type of surgery. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

  20. Transcatheter tricuspid valve-in-valve replacement: one-year results : Alternative to surgery in high-risk patients.

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    Mesquita, João; Teles, Rui Campante; Neves, José Pedro; Abecasis, João; Carmo, Pedro; Brito, João; Abecasis, Miguel; Almeida, Manuel Sousa; Trabulo, Marisa; Ribeiras, Regina; Seabra-Gomes, Ricardo; Mendes, Miguel

    2017-04-01

    Although rheumatic heart disease is becoming uncommon in industrialized countries, its global burden is still significant. We report the case of a 70-year-old male with rheumatic heart disease, who underwent 4 previous heart valve replacement surgeries, and presented to our hospital with refractory heart failure (NYHA functional class IV) due to severe stenosis of a previously implanted tricuspid bioprosthesis. The Heart Team deemed the patient as inoperable/high-risk for surgery. As an alternative, a transcatheter tricuspid valve-in-valve replacement was decided upon and later executed through the right femoral vein, with the insertion of an Edwards SAPIEN XT 29 no. (Edwards Lifesciences, Irvine, CA, USA) through the inferior vena cava, towards the RV, followed by direct implantation in the tricuspid bioprosthesis (valve-in-valve), under rapid pacing, without complications. A substantial clinical and echocardiographic improvement was noted after the procedure and the patient was subsequently discharged in NYHA functional class II. These favourable outcomes persisted through the 1-year follow-up period. This case report adds to the current body of evidence that tricuspid valve implantation stands as a viable and reliable alternative in the treatment of degenerated bioprosthesis in high-surgical-risk patients.

  1. Closed-incision negative-pressure therapy in high-risk general surgery patients following laparotomy: a retrospective study.

    Science.gov (United States)

    Zaidi, A; El-Masry, S

    2017-03-01

    Surgical site infection (SSI) and wound dehiscence are dreaded complications following laparotomy in general surgical patients, and can potentially occur more often in various comorbid states. Negative-pressure wound therapy (NPWT) has a positive effect of on open and complicated wounds and so has been used for at-risk surgical incisions with the aim of redistributing lateral tension and holding incision edges together. The aim of the present study was to compare the rate of wound complications following laparotomy in high-risk general surgical patients with a clean incision treated with closed-incision negative-pressure therapy (ciNPT) with those receiving conventional care. A retrospective review was performed of the hospital medical records of patients who underwent laparotomy between 1 October 2010 and 31 March 2012. Records of 69 patients who received ciNPT and 112 who were managed by adherent gauze dressings were included in the final analysis. Two (2.9%) patients in the ciNPT group and 23 (20.5%) in the non-NPWT group developed a wound complication following laparotomy (P surgery patients considered to have risk of developing wound complications following laparotomy. © 2016 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.

  2. Physical performance following acute high-risk abdominal surgery

    DEFF Research Database (Denmark)

    Jønsson, Line Rokkedal; Ingelsrud, Lina Holm; Tengberg, Line Toft

    2018-01-01

    BACKGROUND: Acute high-risk abdominal (AHA) surgery is associated with high mortality, multiple postoperative complications and prolonged hospital stay. Further development of strategies for enhanced recovery programs following AHA surgery is needed. The aim of this study was to describe physical...... are primarily fatigue and abdominal pain. Further studies investigating strategies for early mobilization and barriers to mobilization in the immediate postoperative period after AHA surgery are needed.......BACKGROUND: Acute high-risk abdominal (AHA) surgery is associated with high mortality, multiple postoperative complications and prolonged hospital stay. Further development of strategies for enhanced recovery programs following AHA surgery is needed. The aim of this study was to describe physical...... performance and barriers to independent mobilization among patients who received AHA surgery (postoperative days [POD] 1-7). METHODS: Patients undergoing AHA surgery were consecutively enrolled from a university hospital in Denmark. In the first postoperative week, all patients were evaluated daily...

  3. Risk factors of postcardiotomy ventricular dysfunction in moderate-to-high risk patients undergoing open-heart surgery

    Directory of Open Access Journals (Sweden)

    Christoph Ellenberger

    2017-01-01

    Full Text Available Introduction: Ventricular dysfunction requiring inotropic support frequently occurs after cardiac surgery, and the associated low cardiac output syndrome largely contributes to postoperative death. We aimed to study the incidence and potential risk factors of postcardiotomy ventricular dysfunction (PCVD in moderate-to-high risk patients scheduled for open-heart surgery. Methods: Over a 5-year period, we prospectively enrolled 295 consecutive patients undergoing valve replacement for severe aortic stenosis or coronary artery bypass surgery who presented with Bernstein-Parsonnet scores >7. The primary outcome was the occurrence of PCVD as defined by the need for sustained inotropic drug support and by transesophageal echography. The secondary outcomes included in-hospital mortality and the incidence of any major adverse events as well as Intensive Care Unit (ICU and hospital length of stay. Results: The incidence of PCVD was 28.4%. Patients with PCVD experienced higher in-hospital mortality (12.6% vs. 0.6% in patients without PCVD with a higher incidence of cardiopulmonary and renal complications as well as a prolonged stay in ICU (median + 2 days. Myocardial infarct occurred more frequently in patients with PCVD than in those without PCVD (19 [30.2%] vs. 12 [7.6%]. By logistic regression analysis, we identified four independent predictors of PCVD: left ventricular ejection fraction <40% (odds ratio [OR] = 6.36; 95% confidence interval [CI], 2.59–15.60, age older than 75 years (OR = 3.35; 95% CI, 1.64–6.81, prolonged aortic clamping time (OR = 3.72; 95% CI, 1.66–8.36, and perioperative bleeding (OR = 2.33; 95% CI, 1.01–5.41. The infusion of glucose-insulin-potassium was associated with lower risk of PCVD (OR = 0.14; 95% CI, 0.06–0.33. Conclusions: This cohort study indicates that age, preoperative ventricular function, myocardial ischemic time, and perioperative bleeding are predictors of PCVD which is associated with poor clinical

  4. A pragmatic multi-centre randomised controlled trial of fluid loading and level of dependency in high-risk surgical patients undergoing major elective surgery: trial protocol.

    Science.gov (United States)

    Cuthbertson, Brian H; Campbell, Marion K; Stott, Stephen A; Vale, Luke; Norrie, John; Kinsella, John; Cook, Jonathan; Brittenden, Julie; Grant, Adrian

    2010-04-16

    Patients undergoing major elective or urgent surgery are at high risk of death or significant morbidity. Measures to reduce this morbidity and mortality include pre-operative optimisation and use of higher levels of dependency care after surgery. We propose a pragmatic multi-centre randomised controlled trial of level of dependency and pre-operative fluid therapy in high-risk surgical patients undergoing major elective surgery. A multi-centre randomised controlled trial with a 2 * 2 factorial design. The first randomisation is to pre-operative fluid therapy or standard regimen and the second randomisation is to routine intensive care versus high dependency care during the early post-operative period. We intend to recruit 204 patients undergoing major elective and urgent abdominal and thoraco-abdominal surgery who fulfil high-risk surgical criteria. The primary outcome for the comparison of level of care is cost-effectiveness at six months and for the comparison of fluid optimisation is the number of hospital days after surgery. We believe that the results of this study will be invaluable in determining the future care and clinical resource utilisation for this group of patients and thus will have a major impact on clinical practice. Trial registration number - ISRCTN32188676.

  5. A pragmatic multi-centre randomised controlled trial of fluid loading and level of dependency in high-risk surgical patients undergoing major elective surgery: trial protocol

    Directory of Open Access Journals (Sweden)

    Norrie John

    2010-04-01

    Full Text Available Abstract Background Patients undergoing major elective or urgent surgery are at high risk of death or significant morbidity. Measures to reduce this morbidity and mortality include pre-operative optimisation and use of higher levels of dependency care after surgery. We propose a pragmatic multi-centre randomised controlled trial of level of dependency and pre-operative fluid therapy in high-risk surgical patients undergoing major elective surgery. Methods/Design A multi-centre randomised controlled trial with a 2 * 2 factorial design. The first randomisation is to pre-operative fluid therapy or standard regimen and the second randomisation is to routine intensive care versus high dependency care during the early post-operative period. We intend to recruit 204 patients undergoing major elective and urgent abdominal and thoraco-abdominal surgery who fulfil high-risk surgical criteria. The primary outcome for the comparison of level of care is cost-effectiveness at six months and for the comparison of fluid optimisation is the number of hospital days after surgery. Discussion We believe that the results of this study will be invaluable in determining the future care and clinical resource utilisation for this group of patients and thus will have a major impact on clinical practice. Trial Registration Trial registration number - ISRCTN32188676

  6. Physical performance following acute high-risk abdominal surgery

    DEFF Research Database (Denmark)

    Jønsson, Line Rokkedal; Ingelsrud, Lina Holm; Tengberg, Line Toft

    2018-01-01

    BACKGROUND: Acute high-risk abdominal (AHA) surgery is associated with high mortality, multiple postoperative complications and prolonged hospital stay. Further development of strategies for enhanced recovery programs following AHA surgery is needed. The aim of this study was to describe physical...... with regards to physical performance, using the Cumulated Ambulation Score (CAS; 0-6 points) to assess basic mobility and the activePAL monitor to assess the 24-hour physical activity level. We recorded barriers to independent mobilization. RESULTS: Fifty patients undergoing AHA surgery (mean age 61.4 ± 17...... for a median of 23.4 hours daily during the first week after AHA surgery, and the main barriers to independent mobilization were fatigue and abdominal pain. CONCLUSION: Patients who receive AHA surgery have very limited physical performance in the first postoperative week. Barriers to independent mobilization...

  7. Transversus abdominis plane block in combination with general anesthesia provides better intraoperative hemodynamic control and quicker recovery than general anesthesia alone in high-risk abdominal surgery patients.

    Science.gov (United States)

    Tsuchiya, M; Takahashi, R; Furukawa, A; Suehiro, K; Mizutani, K; Nishikawa, K

    2012-11-01

    Patients with severe cardiovascular disease are frequently hemodynamically unstable during abdominal surgery. Improving the safety of such patients by stabilizing intraoperative hemodynamics remains a major concern for anesthesiologists. Transversus abdominis plane (TAP) block in combination with general anesthesia may facilitate optimum anesthetic management of these high-risk patients. Patients with cardiovascular disease classified as American Society of Anesthesiologists (ASA) physical status 3 were enrolled. The patients were undergoing elective abdominal surgery and were randomized to a group receiving general anesthesia and TAP block (Group T, N.=33) or a group receiving general anesthesia alone (Group G, N.=35). We compared the groups for intraoperative hemodynamic stability, anesthesia emergence time, amounts of anesthetics and opioids given, and frequency of emergency treatment with cardiovascular agents. A preliminary study demonstrated that systolic blood pressure and heart rate were maintained stable within 70-110% of their preanesthesia values throughout surgery in ASA 1 elderly patients without cardiovascular disease. Thus, the hemodynamically stable time was defined as the time when systolic blood pressure and heart rate were 70-110% of their preanesthesia values. The ratio of hemodynamically stable time to total operative time was used as an index of hemodynamic stability. The median (minimum-maximum) percentage of hemodynamically stable time was longer in Group T (91[50-100]%) than Group G (79[40-91]%, Pabdominal surgery in patients with severe cardiovascular disease, combining TAP block with general anesthesia promotes intraoperative hemodynamic stability and early emergence from anesthesia.

  8. Surgical site infections among high-risk patients in clean-contaminated head and neck reconstructive surgery: concordance with preoperative oral flora.

    Science.gov (United States)

    Yang, Ching-Hsiang; Chew, Khong-Yik; Solomkin, Joseph S; Lin, Pao-Yuan; Chiang, Yuan-Cheng; Kuo, Yur-Ren

    2013-12-01

    Salivary contamination of surgical wounds in clean-contaminated head and neck surgery with free flap reconstruction remains a major cause of infection and leads to significant morbidity. This study investigates the correlation between intraoral flora and surgical site infections (SSIs) among high-risk head and neck cancer patients undergoing resection and free flap reconstruction. One hundred twenty-nine patients were identified as being at high risk for infective complications based on cancer stage, tumor size, comorbid factors, and extent of reconstruction. All patients had intraoral swab cultures before surgery. Patients with culture-confirmed SSI after surgery were chosen for analysis, using the κ index and its 95% confidence interval for concordance analysis. All patients received clindamycin and gentamicin for antibiotic prophylaxis for 5 days. Antibiotic susceptibility testing of all isolates was obtained and analyzed. Thirty-seven patients experienced SSI, or an infection rate of 28.3%, occurring at a mean of 9.3 postoperative days. The overall concordance between oral flora and SSI was fair to moderate (κ index of 0.25), but detailed analysis shows a higher concordance for known and opportunistic pathogens, such as Pseudomonas aeruginosa and Enterococcus faecalis, compared to typical oral commensals. Antibiotic susceptibility tests show rapid and significant increases in resistance to clindamycin, indicating a need for a more effective alternative. Predicting pathogens in SSI using preoperative oral swabs did not demonstrate a good concordance in general for patients undergoing clean-contaminated head and neck surgery, although concordance for certain pathogenic species seem to be higher than for typical intraoral commensals. The rapid development of resistance to clindamycin precludes its use as a prophylactic agent.

  9. Postoperative inspiratory muscle training in addition to breathing exercises and early mobilization improves oxygenation in high-risk patients after lung cancer surgery: a randomized controlled trial.

    Science.gov (United States)

    Brocki, Barbara Cristina; Andreasen, Jan Jesper; Langer, Daniel; Souza, Domingos Savio R; Westerdahl, Elisabeth

    2016-05-01

    The aim was to investigate whether 2 weeks of inspiratory muscle training (IMT) could preserve respiratory muscle strength in high-risk patients referred for pulmonary resection on the suspicion of or confirmed lung cancer. Secondarily, we investigated the effect of the intervention on the incidence of postoperative pulmonary complications. The study was a single-centre, parallel-group, randomized trial with assessor blinding and intention-to-treat analysis. The intervention group (IG, n = 34) underwent 2 weeks of postoperative IMT twice daily with 2 × 30 breaths on a target intensity of 30% of maximal inspiratory pressure, in addition to standard postoperative physiotherapy. Standard physiotherapy in the control group (CG, n = 34) consisted of breathing exercises, coughing techniques and early mobilization. We measured respiratory muscle strength (maximal inspiratory/expiratory pressure, MIP/MEP), functional performance (6-min walk test), spirometry and peripheral oxygen saturation (SpO2), assessed the day before surgery and again 3-5 days and 2 weeks postoperatively. Postoperative pulmonary complications were evaluated 2 weeks after surgery. The mean age was 70 ± 8 years and 57.5% were males. Thoracotomy was performed in 48.5% (n = 33) of cases. No effect of the intervention was found regarding MIP, MEP, lung volumes or functional performance at any time point. The overall incidence of pneumonia was 13% (n = 9), with no significant difference between groups [IG 6% (n = 2), CG 21% (n = 7), P = 0.14]. An improved SpO2 was found in the IG on the third and fourth postoperative days (Day 3: IG 93.8 ± 3.4 vs CG 91.9 ± 4.1%, P = 0.058; Day 4: IG 93.5 ± 3.5 vs CG 91 ± 3.9%, P = 0.02). We found no association between surgical procedure (thoracotomy versus thoracoscopy) and respiratory muscle strength, which was recovered in both groups 2 weeks after surgery. Two weeks of additional postoperative IMT, compared with standard physiotherapy alone, did not preserve

  10. Effect of Individualized vs Standard Blood Pressure Management Strategies on Postoperative Organ Dysfunction Among High-Risk Patients Undergoing Major Surgery: A Randomized Clinical Trial.

    Science.gov (United States)

    Futier, Emmanuel; Lefrant, Jean-Yves; Guinot, Pierre-Gregoire; Godet, Thomas; Lorne, Emmanuel; Cuvillon, Philippe; Bertran, Sebastien; Leone, Marc; Pastene, Bruno; Piriou, Vincent; Molliex, Serge; Albanese, Jacques; Julia, Jean-Michel; Tavernier, Benoit; Imhoff, Etienne; Bazin, Jean-Etienne; Constantin, Jean-Michel; Pereira, Bruno; Jaber, Samir

    2017-10-10

    Perioperative hypotension is associated with an increase in postoperative morbidity and mortality, but the appropriate management strategy remains uncertain. To evaluate whether an individualized blood pressure management strategy tailored to individual patient physiology could reduce postoperative organ dysfunction. The Intraoperative Norepinephrine to Control Arterial Pressure (INPRESS) study was a multicenter, randomized, parallel-group clinical trial conducted in 9 French university and nonuniversity hospitals. Adult patients (n = 298) at increased risk of postoperative complications with a preoperative acute kidney injury risk index of class III or higher (indicating moderate to high risk of postoperative kidney injury) undergoing major surgery lasting 2 hours or longer under general anesthesia were enrolled from December 4, 2012, through August 28, 2016 (last follow-up, September 28, 2016). Individualized management strategy aimed at achieving a systolic blood pressure (SBP) within 10% of the reference value (ie, patient's resting SBP) or standard management strategy of treating SBP less than 80 mm Hg or lower than 40% from the reference value during and for 4 hours following surgery. The primary outcome was a composite of systemic inflammatory response syndrome and dysfunction of at least 1 organ system of the renal, respiratory, cardiovascular, coagulation, and neurologic systems by day 7 after surgery. Secondary outcomes included the individual components of the primary outcome, durations of ICU and hospital stay, adverse events, and all-cause mortality at 30 days after surgery. Among 298 patients who were randomized, 292 patients completed the trial (mean [SD] age, 70 [7] years; 44 [15.1%] women) and were included in the modified intention-to-treat analysis. The primary outcome event occurred in 56 of 147 patients (38.1%) assigned to the individualized treatment strategy vs 75 of 145 patients (51.7%) assigned to the standard treatment strategy

  11. Systematic Second-look Surgery Plus HIPEC in Patients Without Evidence of Recurrence, at High Risk of Carcinomatosis After Colorectal Cancer Resection.

    Science.gov (United States)

    Serrano Del Moral, Ángel; Pérez Viejo, Estibalitz; Manzanedo Romero, Israel; Rodríguez Caravaca, Gil; Pereira Pérez, Fernando

    2018-02-01

    To analyze the impact of systematic second-look surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC) performed 1 year after resection of the primary tumor, in asymptomatic patients at high risk of developing peritoneal carcinomatosis (PC). Between 2012-2016, 33 patients without any sign of peritoneal recurrence on imaging studies were prospectively included in the study and underwent second-look surgery aimed at treating limited PC earlier and were prospectively recorded. They were selected based on 5 primary tumor-associated criteria: resected minimal synchronous macroscopic PC (n = 10), synchronous ovarian metastases (n = 2), positive peritoneal cytology (n = 2), pT4 primary tumors (n = 15) and perforation (n = 4). PC was found and treated by cytoreduction plus HIPEC in 10 of the 33 (30.3%) patients, although it was detected in only 2/15 patients of the pT4 subgroup (13.3%). The patients without PC underwent complete abdominal exploration plus HIPEC. Median follow-up was 14.5 months. One patient died postoperatively at day 55. Severe morbidity rate (Clavien-Dindo III-V) was low (15.2%). The 3-year overall survival rate was 93% and the 3-year disease-free survival rate was 33%. Peritoneal recurrences occurred in 4 patients (12.1%), 2 of whom had macroscopic PC discovered at the second-look (20%), while the other 2 patients had no macroscopic PC (8.7%) (P = .04). The second look + HIPEC strategy in our series of patients at high risk of developing PC, allows its early detection and its treatment in 30.3% of cases, with a very low rate of peritoneal recurrence. It is important to continue evaluating the results to increase the accuracy of the inclusion criteria, especially the pT4 criterion that in this series has a low predictive power for the occurrence of PC. Copyright © 2017 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.

  12. A Prospective Study of the Timing and Accuracy of Neutrophil Gelatinase-Associated Lipocalin Levels in Predicting Acute Kidney Injury in High-Risk Cardiac Surgery Patients.

    Science.gov (United States)

    Fanning, Niall; Galvin, Sinead; Parke, Rachael; Gilroy, James; Bellomo, Rinaldo; McGuinness, Shay

    2016-01-01

    Neutrophil gelatinase-associated lipocalin (NGAL) appears to be a promising biomarker in the effort to predict acute kidney injury (AKI) after cardiac surgery. The authors aimed to identify the specific time point in the perioperative period at which measurement of either urinary or serum concentrations of NGAL would have the highest predictive power for AKI. The authors also investigated whether change in NGAL from baseline was a better predictor of AKI than absolute NGAL values. A prospective, investigator-blinded observational study. The cardiac surgical unit of a university teaching hospital. The study consisted of 50 patients undergoing cardiac surgery who were classified preoperatively as high risk for developing postoperative AKI. No changes to standard practice were required. The authors performed serial measurements of urinary and serum NGAL concentrations at 18 time points throughout the first 48 postoperative hours and assessed the variables required to diagnose AKI with standard criteria. Statistical analysis of predictive ability was performed using the area under receiver operator curves (AUROC) calculated for each time point. It was demonstrated that urinary NGAL performed marginally better than serum NGAL in predicting AKI. Urinary sampling at 4 and 24 hours after initiation of cardiopulmonary bypass provided the greatest diagnostic ability (AUROC, 0.702 and 0.712, respectively). Absolute NGAL values performed better than changes in NGAL values in predicting AKI. Urinary NGAL performed better than serum NGAL in predicting AKI and was most accurate when measured at 24 hours after initiation of cardiopulmonary bypass; however, NGAL appeared to be at best only a fair predictor of cardiac surgery-associated AKI. Copyright © 2016 Elsevier Inc. All rights reserved.

  13. Prevention of Surgical Site Infection After Ankle Surgery Using Vacuum-Assisted Closure Therapy in High-Risk Patients With Diabetes.

    Science.gov (United States)

    Zhou, Zhen-Yu; Liu, Ya-Ke; Chen, Hong-Lin; Liu, Fan

    2016-01-01

    Patients with diabetes have a high risk of surgical site infection (SSI) after ankle surgery. The aim of the present study was to investigate the efficacy of vacuum-assisted closure (VAC) in the prevention of SSI after ankle surgery compared with the efficacy of standard moist wound care (SMWC). A retrospective study was performed of unstable ankle fractures for surgical fixation in patients with diabetes from January 2012 to December 2014. VAC and SMWC were used for surgical incision coverage. The primary outcome was the incidence of SSI, and the secondary outcomes were the length of hospital stay and crude hospital costs. The data from 76 patients were analyzed, with 22 (28.95%) in the VAC group and 54 (71.05%) in the SMWC group. The incidence of SSI was 4.6% in the VAC group compared with 27.8% in the SMWC group (chi-square 5.076; p = .024), and the crude odds ratio for SSI in the VAC group was 0.124 (95% confidence interval 0.002 to 0.938). The length of hospital stay was lower in the VAC group than in the SMWC group (12.6 ± 2.7 days and 15.2 ± 3.5 days, respectively; t = 3.122, p = .003). The crude hospital costs were also lower in the VAC group than in the SMWC group (Chinese yuan 8643.2 ± 1195.3 and 9456.2 ± 1106.3, respectively; t = 2.839, p = .006). After logistic regression analysis, the adjusted odds ratio for the total SSI rate comparing VAC and SMWC was 0.324 (95% confidence interval 0.092 to 0.804; p = .021). Compared with SMWC, VAC can decrease the SSI rate after ankle surgery in patients with diabetes. This finding should be confirmed by prospective, randomized controlled clinical trials. Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.

  14. Does the addition of deep breathing exercises to physiotherapy-directed early mobilisation alter patient outcomes following high-risk open upper abdominal surgery? Cluster randomised controlled trial.

    Science.gov (United States)

    Silva, Y R; Li, S K; Rickard, M J F X

    2013-09-01

    To investigate whether the inclusion of deep breathing exercises in physiotherapy-directed early mobilisation confers any additional benefit in reducing postoperative pulmonary complications (PPCs) when patients are treated once daily after elective open upper abdominal surgery. This study also compared postoperative outcomes following early and delayed mobilisation. Cluster randomised controlled trial. Single-centre study in a teaching hospital. Eighty-six high-risk patients undergoing elective open upper abdominal surgery. Three groups: early mobilisation (Group A), early mobilisation plus breathing exercises (Group B), and delayed mobilisation (mobilised from third postoperative day) plus breathing exercises (Group C). PPCs and postoperative outcomes [number of days until discharge from physiotherapy, physiotherapy input and length of stay (LOS)]. There was no significant difference in PPCs between Groups A and B. The LOS for Group A {mean 10.7 [standard deviation (SD) 5.0] days} was significantly shorter than the LOS for Groups B [mean 16.7 (SD 9.7) days] and C [mean 15.2 (SD 9.8) days; P=0.036]. The greatest difference was between Groups A and B (mean difference -5.93, 95% confidence interval -10.22 to -1.65; P=0.008). Group C had fewer smokers (26%) and patients with chronic obstructive pulmonary disease (0%) compared with Group B (53% and 14%, respectively). This may have led to fewer PPCs in Group C, but the difference was not significant. Despite Group C having fewer PPCs and less physiotherapy input, the number of days until discharge from physiotherapy and LOS were similar to Group B. The addition of deep breathing exercises to physiotherapy-directed early mobilisation did not further reduce PPCs compared with mobility alone. PPCs can be reduced with once-daily physiotherapy if the patients are mobilised to a moderate level of exertion. Delayed mobilisation tended to increase physiotherapy input and the number of days until discharge from physiotherapy

  15. High-risk mitral valve surgery: what is the role of risk calculators?

    Science.gov (United States)

    Tran, Anthony; Ruel, Marc; Chan, Vincent

    2014-03-01

    The purpose of this review is to discuss the role of established risk scores in assessing patient outcomes following high-risk mitral valve surgery. The use of risk calculators has become increasingly popular in cardiac surgery, particularly in assessing risk for sick patients for whom percutaneous therapies may be advantageous. A review of the available literature suggests that validated algorithms, namely, the European System for Cardiac Operative Risk Evaluation II and Society of Thoracic Surgeons models, may have poor discriminatory power in assessing risk for patients undergoing high-risk mitral surgery. Therefore, the limitations of these risk scores in this population must be taken into consideration. Current risk models provide important insight into the perioperative risk to the patient. Further refinement of established risk scores, however, may provide better risk prognostication for patients undergoing high-risk mitral valve surgery.

  16. The MitraClip and survival in patients with mitral regurgitation at high risk for surgery: A propensity-matched comparison.

    Science.gov (United States)

    Velazquez, Eric J; Samad, Zainab; Al-Khalidi, Hussein R; Sangli, Chithra; Grayburn, Paul A; Massaro, Joseph M; Stevens, Susanna R; Feldman, Ted E; Krucoff, Mitchell W

    2015-11-01

    We compared 30-day and 1-year survival among high-risk mitral regurgitation (MR) patients treated with the MitraClip (Abbott Vascular, Abbott Park, IL) with matched non-surgically treated patients from the Duke Echocardiography Laboratory Database (DELD). High-risk patients with 3+/4+ MR managed non-surgically between years 2000 and 2010 in the longitudinal DELD were matched to high-risk MitraClip patients. Patient matching was performed using the method of nearest available Mahalanobis distance metric within calipers defined by the propensity score. Kaplan-Meier estimates and stratified Cox proportional hazards models were used to compare survival at 30 days and 1 year. Among 953 high-risk DELD patients available for matching, 30-day and 1-year mortality were 6.5% and 26.2%. Close matches were obtained for 239 of the 351 MitraClip patients. The 30-day mortality in MitraClip patients was lower (4.2%) when compared with matched DELD patients (7.2%). The 1-year relative risk of mortality of the MitraClip compared with non-surgical treatment was 0.64 (95% CI 0.45-0.91; log-rank P = .013). These results in favor of the MitraClip remained significant upon further adjustment for baseline differences between groups (P = .043). This matched comparison of severe MR patients at high surgical risk supports the safety of the MitraClip relative to medical therapy at 30 days and a survival benefit at 1 year. Copyright © 2015 Elsevier Inc. All rights reserved.

  17. Retrograde type A dissection following hybrid supra-aortic endovascular surgery in high-risk patients unfit for conventional open repair.

    Science.gov (United States)

    Yip, Hon C; Chan, Yiu C; Qing, Kai X; Cheng, Stephen W

    2018-04-01

    Hybrid procedures with combined open extra-anatomical supra-aortic bypasses and endovascular surgery are less invasive for patients with complex aortic arch pathology. The aim of this paper is to report patients who developed retrograde type A aortic dissection following initially successful hybrid endovascular treatment. Retrospective review of prospectively collected computerized departmental database. All patients with supra-aortic hybrid endovascular surgery and post-procedure retrograde type A dissection were identified. Patient demographics, comorbid conditions, perioperative parameters, procedural details and post-operative complications were collected. From May 2005 to July 2014, 163 patients underwent thoracic aortic endovascular procedures at our institution. From the 46 patients who had supra-aortic hybrid endovascular repair, six patients (6/46, 13% of all supra-aortic hybrid cases, 3 males) developed retrograde type A aortic dissection. All were elective cases, with 3 chronic dissecting aneurysms and 3 atherosclerotic aneurysms. All had one-stage hybrid procedures: 2 patients had carotid-carotid bypass grafts, one had carotid-carotid-left subclavian bypass graft, and 3 had bypass grafts from ascending aorta to innominate artery and left carotid artery. Five patients had Cook Zenith thoracic stent-grafts (Cook Medical, Bloomington, IN, USA), and one had Medtronic Valiant stent-grafts (Medtronic Vascular Inc, Santa Rosa, CA, USA). The retrograde type A dissection occurred with sudden symptoms at day 5, 6, 10, 20, 105 and 128, respectively. There were 3 immediate fatalities and 2 patients treated conservatively deemed unfit for reintervention (one died of pneumonia at 9 months, and one remained alive at 7 months post-complication). One patient underwent successful emergency open surgery and survived. Supra-aortic hybrid procedures in treating aortic arch pathology may be at risk of developing retrograde type A dissection. This post-operative complication

  18. Polyurethane film dressings and ceramide 2-containing hydrocolloid dressing reduce the risk of pressure ulcer development in high-risk patients undergoing surgery: a matched case-control study

    Directory of Open Access Journals (Sweden)

    Kohta M

    2015-02-01

    Full Text Available Masushi Kohta,1 Kazumi Sakamoto,2 Tsunao Oh-i31Medical Engineering Laboratory, ALCARE Co, Ltd, Sumida-ku, Tokyo, 2Department of Nursing, 3Department of Dermatology, Tokyo Medical University Ibaraki Medical Center, Ami, Ibaraki, JapanBackground: Numerous clinical challenges regarding adhesive dressings have shown that using an adhesive dressing could minimize or prevent superficial skin loss in patients at risk of developing pressure ulcers. However, evidence that polyurethane film dressings and ceramide 2-containing hydrocolloid dressing can reduce the risk of pressure ulcer development in high-risk patients undergoing surgery is limited. Therefore, we assessed the effects of application of these dressings for reducing the risk of pressure ulcer development in these patients and identified other risk factors.Methods: A matched case-control study was conducted involving 254 patients at high risk for pressure ulcer development at one acute care hospital in Japan. No patients in this study had a pressure ulcer at the start of the study. Thirty-one patients developed a pressure ulcer during surgery, and these patients were defined as cases. Controls were randomly matched for sex and age (±4 years, from which 62 patients were selected. Medical records were obtained for preoperative factors, including age, sex, body mass index, diabetes mellitus, albumin, total protein, C-reactive protein, white cell count, red cell count, and hemoglobin, and for intraoperative factors, including dressing application, operation time, body position, and surgery type. The odds ratio (OR and 95% confidence interval (CI were determined to identify risk factors for pressure ulcer development in patients undergoing surgery.Results: By multiple logistic regression analysis, there was a significantly reduced risk of pressure ulcer development for patients who had dressing applications as compared with those without dressing applications (OR 0.063; 95% CI 0.012–0.343; P=0

  19. Patient Selection and Surgical Management of High-Risk Patients with Morbid Obesity.

    Science.gov (United States)

    Daniel Guerron, A; Portenier, Dana D

    2016-08-01

    Bariatric surgery is the most effective way to improve comorbidities related to obesity. Since the introduction of minimally invasive laparoscopic surgery in the bariatric surgery techniques, the number of procedures has increased substantially; advances in techniques and the transition from open to minimally invasive procedures have decreased morbidity and mortality. Multidisciplinary teams in charge of the operative planning, surgical act, and postoperative recovery are determinant in the success of the management of high-risk bariatric patients; careful identification and preoperative management of these higher-risk patients is crucial in decreasing complications after weight loss surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

  20. Hemopump ventricular support for patients undergoing high risk coronary angioplasty.

    Science.gov (United States)

    Loisance, D; Deleuze, P; Dubois-Rande, J L; Okude, J; Shiiya, N; Wan, F; Geschwind, H

    1990-01-01

    Prophylactic implantation of a Hemopump (Johnson and Johnson, Skillman, NJ) has been evaluated in nine patients selected for high risk coronary angioplasty. They were unstable patients, refractory to maximal pharmacology, with indications for revascularization, but contraindications for surgery such as low ejection fraction and lack of material for bypass. In all, the target lesion was located on the last patent vessel. The pump was inserted under local anesthesia, without any graft. A specially designed occluder permitted avoidance of retrograde bleeding during implantation. The bypass flow ranged from 2.5 to 3.2 L/min, and permitted a rise in cardiac index from 2.05 to 2.55 L/min/m2, with a drop in capillary wedge pressure from 13 (7-18) to 10 (7-13) mmHg. During balloon inflation, no electrocardiographic changes were observed, because only minor ventricular arrhythmias occurred. No significant hemolysis was seen (plasma free hemoglobin less than 10 mg/dl in all) after 2 hr of pumping. The only limitation of the technique appears to be difficulty at the time of implantation from narrow, stenosed, or tortuous iliofemoral arteries (3 patients). This experience strongly supports the benefit of temporary left ventricular Hemopump support in high-risk situations and clearly shows the need for a smaller pump.

  1. Surgery for diverticulitis is associated with high risk of in-hospital mortality and morbidity in older patients with end-stage renal disease.

    Science.gov (United States)

    Moran-Atkin, Erin; Stem, Miloslawa; Lidor, Anne O

    2014-08-01

    End-stage renal disease (ESRD) is associated with poor medical outcomes. This study aimed to compare early outcomes of elective and emergency operation for diverticulitis among older adults with and without a diagnosis of ESRD. Patients 65 years of age and older with a primary diagnosis of diverticulitis who underwent operative intervention were identified in the 100% Medicare Provider Analysis and Review (MEDPAR) inpatient file from 2004 to 2007. Outcomes between the ESRD and non-ESRD patients (elective and emergent) undergoing operation for diverticulitis were compared. A subgroup analysis in patients only undergoing elective or emergent operation was performed. Multivariable analyses were conducted. In addition, a propensity-matched analysis was applied comparing early outcomes between ESRD patients and well-matched controls consisting of non-ESRD patients. A total of 53,560 patients were identified, with 996 (1.86%) ESRD patients. After propensity matching, 962 ESRD and well-matched non-ESRD patients were identified. In the matched cohort, ESRD patients had greater rates of in-hospital mortality (30.9% vs 7.9%, P diverticulitis in the setting of ESRD in patients older than 65 years. Copyright © 2014 Mosby, Inc. All rights reserved.

  2. Trends in hospital volume and operative mortality for high-risk surgery.

    Science.gov (United States)

    Finks, Jonathan F; Osborne, Nicholas H; Birkmeyer, John D

    2011-06-02

    There were numerous efforts in the United States during the previous decade to concentrate selected surgical procedures in high-volume hospitals. It remains unknown whether referral patterns for high-risk surgery have changed as a result and how operative mortality has been affected. We used national Medicare data to study patients undergoing one of eight different cancer and cardiovascular operations from 1999 through 2008. For each procedure, we examined trends in hospital volume and market concentration, defined as the proportion of Medicare patients undergoing surgery in the top decile of hospitals by volume per year. We used regression-based techniques to assess the effects of volume and market concentration on mortality over time, adjusting for case mix. Median hospital volumes of four cancer resections (lung, esophagus, pancreas, and bladder) and of repair of abdominal aortic aneurysm (AAA) rose substantially. Depending on the procedure, higher hospital volumes were attributable to an increasing number of cases nationwide, an increasing market concentration, or both. Hospital volumes rose slightly for aortic-valve replacement but fell for coronary-artery bypass grafting and carotid endarterectomy. Operative mortality declined for all eight procedures, ranging from a relative decline of 8% for carotid endarterectomy (1.3% mortality in 1999 and 1.2% in 2008) to 36% for AAA repair (4.4% in 1999 and 2.8% in 2008). Higher hospital volumes explained a large portion of the decline in mortality for pancreatectomy (67% of the decline), cystectomy (37%), and esophagectomy (32%), but not for the other procedures. Operative mortality with high-risk surgery fell substantially during the previous decade. Although increased market concentration and hospital volume have contributed to declining mortality with some high-risk cancer operations, declines in mortality with other procedures are largely attributable to other factors. (Funded by the National Institute on Aging.).

  3. ANTIDEPRESSANT THERAPY IN HIGH-RISK PATIENTS

    African Journals Online (AJOL)

    Table II pertains to important considerations regarding the moice of antidepressant therapy in patients with hepatic impairment, i.e. the possible risk of hepatotoxicity and the potential need for dosage adjustment. An increased susceptibility to the sedative effects of psychotropic drugs has been described in cirrhotic patients,.

  4. Place of surgery in high-risk tumours of the prostate

    International Nuclear Information System (INIS)

    Soulie, M.; Rozet, F.; Hennequin, C.; Salomon, L.

    2010-01-01

    Among the different options recommended for high-risk prostate cancer, radical prostatectomy is admitted as radiotherapy, but its role is still controversial in mono-therapy and difficult to evaluate in combined treatments. The results of clinical trials combining an external radiotherapy to a long-term androgen deprivation in locally advanced tumours sustain the principle of a multidisciplinary management in high-risk prostate cancer. The impact of surgery on the risk of progression and local recurrence is important in selected patients with low grade and small tumoral volume. Clinical and histological data associated to the MRI assessment remain essential and enhance the preoperative multidisciplinary decision, especially regarding nodal and distant metastases. Radical prostatectomy with an extended pelvic lymphadenectomy can be considered as a viable alternative to radiotherapy and hormonal therapy in these patients with a long life expectancy but presenting a high risk of local progression and a low risk of metastatic disease. Morbidity of the procedure is similar to radical prostatectomy for organ-confined tumours despite more erectile dysfunction due to non-sparing radical prostatectomy in most of cases. Oncological results from recent compiled series show 10- and 15-year specific survival rates around 85 and 75%, respectively, including adjuvant or salvage treatments with radiotherapy, androgen deprivation or chemotherapy. (authors)

  5. Treating Patients with High-Risk Smoldering Myeloma

    Science.gov (United States)

    In this phase III clinical trial, patients with smoldering myeloma classified as high risk for progression will be randomly assigned to undergo standard observation or six 4-week courses of treatment with the drug lenalidomide.

  6. High-risk patients treated with enalapril maleate: safety considerations.

    Science.gov (United States)

    Rucinska, E J; Small, R; Irvin, J

    1989-02-01

    The safety of 738 high-risk patients treated with enalapril under various clinical programs was evaluated. High risk was defined as the presence of a collagen vascular disease; a renal disease, including renovascular hypertension; or either hypertension or refractory cardiac failure with serum creatinine greater than or equal to 1.7 mg/dl at baseline. Essential hypertension was the primary diagnosis in most of these patients. Treatment with enalapril in these patients usually continued without interruption for the length of the particular protocol. The incidence of adverse reactions resulting in discontinuation of treatment was comparable to that observed with other standard antihypertensive therapies in patients with milder forms of disease. No enalapril-related neutropenia, proteinuria, dysgeusia or ageusia were reported in these high-risk patients. The incidence of discontinuation due to rash was less than 0.5%. Resolution and/or improvement of captopril-related adverse effects was observed in many patients crossed over to treatment with enalapril. In patients with collagen vascular diseases and those with severe impairment of renal function (serum creatinine greater than or equal to 3.0 mg/dl), the incidence of discontinuation due to adverse experiences or death as well as the profile of reported adverse experiences was similar to those for the total group of high-risk patients. The data suggest that enalapril is efficacious and well tolerated by the high-risk patients.

  7. HIFU therapy for patients with high risk prostate cancer

    Science.gov (United States)

    Solovov, V. A.; Vozdvizhenskiy, M. O.; Matysh, Y. S.

    2017-03-01

    Objectives. Patients with high-risk prostate cancer undergoing radical prostatectomy, external beam radiation therapy (EBRT) combined with androgen deprivation therapy (ADT) or ADT alone. The widely accepted definition of high-risk prostate was first proposed by D'Amico based on a pretreatment Gleason score of ≥8, clinical stage T3, PSA level ≥20 ng/mL. There is no trial that compares traditional methods of treatment of such patients with HIFU therapy. Here we explored the effectiveness of the HIFU in multimodal treatment for patients with high risk prostate cancer. Materials & Methods. 701 patients with high risk prostate cancer were treated in our center between September 2007 and December 2013. Gleason score were 8-10, stage T3N0M0, age 69 (58-86) years, mean PSA before treatment 43.3 (22.1-92.9) ng/ml, mean prostate volume - 59.3 (38-123) cc. 248 patients were treated by HIFU. We compare this group of patients with patients who undertook EBRT: number 196, and ADT: number 257. Mean follow-up time 58 months (6-72). Results. The 5-year overall survival rates in patients after HIFU were 73.8 %, after EBRT - 63.0 % and after ADT - 18.1%. Conclusions. Our experience showed that HIFU therapy in combined treatment were successful for high risk prostate cancer.

  8. Detection of Patients at High Risk of Medication Errors

    DEFF Research Database (Denmark)

    Sædder, Eva Aggerholm; Lisby, Marianne; Nielsen, Lars Peter

    2016-01-01

    Medication errors (MEs) are preventable and can result in patient harm and increased expenses in the healthcare system in terms of hospitalization, prolonged hospitalizations and even death. We aimed to develop a screening tool to detect acutely admitted patients at low or high risk of MEs...

  9. Association between surgical delay and survival in high-risk emergency abdominal surgery. A population-based Danish cohort study

    DEFF Research Database (Denmark)

    Vester-Andersen, Morten; Lundstrøm, Lars Hyldborg; Buck, David Levarett

    2016-01-01

    OBJECTIVE: In patients with perforated peptic ulcer, surgical delay has recently been shown to be a critical determinant of survival. The aim of the present population-based cohort study was to evaluate the association between surgical delay by hour and mortality in high-risk patients undergoing ...... abdominal surgery, no statistically significant adjusted association between mortality and surgical delay was found. Additional research in diagnosis-specific subgroups of high-risk patients undergoing emergency abdominal surgery is warranted.......OBJECTIVE: In patients with perforated peptic ulcer, surgical delay has recently been shown to be a critical determinant of survival. The aim of the present population-based cohort study was to evaluate the association between surgical delay by hour and mortality in high-risk patients undergoing...... emergency abdominal surgery in general. MATERIAL AND METHODS: All in-patients aged ≥18 years having emergency abdominal laparotomy or laparoscopy performed within 48 h of admission between 1 January 2009 and 31 December 2010 in 13 Danish hospitals were included. Baseline and clinical data, including...

  10. Patients at High-Risk for Surgical Site Infection.

    Science.gov (United States)

    Mueck, Krislynn M; Kao, Lillian S

    Surgical site infections (SSIs) are a significant healthcare quality issue, resulting in increased morbidity, disability, length of stay, resource utilization, and costs. Identification of high-risk patients may improve pre-operative counseling, inform resource utilization, and allow modifications in peri-operative management to optimize outcomes. Review of the pertinent English-language literature. High-risk surgical patients may be identified on the basis of individual risk factors or combinations of factors. In particular, statistical models and risk calculators may be useful in predicting infectious risks, both in general and for SSIs. These models differ in the number of variables; inclusion of pre-operative, intra-operative, or post-operative variables; ease of calculation; and specificity for particular procedures. Furthermore, the models differ in their accuracy in stratifying risk. Biomarkers may be a promising way to identify patients at high risk of infectious complications. Although multiple strategies exist for identifying surgical patients at high risk for SSIs, no one strategy is superior for all patients. Further efforts are necessary to determine if risk stratification in combination with risk modification can reduce SSIs in these patient populations.

  11. [Adverse respiratory events after general anesthesia in patients at high risk of obstructive sleep apnea syndrome].

    Science.gov (United States)

    Xará, Daniela; Mendonça, Júlia; Pereira, Helder; Santos, Alice; Abelha, Fernando José

    2015-01-01

    Patients with STOP-BANG score >3 have a high risk of Obstructive sleep apnea. The aim of this study was to evaluate early postoperative respiratory complications in adults with STOP-BANG score >3 after general anesthesia. This is a prospective double cohort study matching 59 pairs of adult patients with STOP-BANG score >3 (high risk of obstructive sleep apnea) and patients with STOP-BANG score <3 (low risk of obstructive sleep apnea), similar with respect to gender, age and type of surgery, admitted after elective surgery in the Post-Anaesthesia Care Unit in May 2011. Primary outcome was the development of adverse respiratory events. Demographics data, perioperative variables, and postoperative length of stay in the Post-Anesthesia Care Unit and in hospital were recorded. The Mann-Whitney test, the chi-square test and the Fisher exact test were used for comparisons. Subjects in both pairs of study subjects had a median age of 56 years, including 25% males, and 59% were submitted to intra-abdominal surgery. High risk of obstructive sleep apnea patients had a higher median body mass index (31 versus 24kg/m(2), p<0.001) and had more frequently co-morbidities, including hypertension (58% versus 24%, p<0.001), dyslipidemia (46% versus 17%, p<0.001) and insulin-treated diabetes mellitus (17% versus 2%, p=0.004). These patients were submitted more frequently to bariatric surgery (20% versus 2%, p=0.002). Patients with high risk of obstructive sleep apnea had more frequently adverse respiratory events (39% versus 10%, p<0.001), mild to moderate desaturation (15% versus 0%, p=0.001) and inability to breathe deeply (34% versus 9%, p=0.001). After general anesthesia high risk of obstructive sleep apnea patients had an increased incidence of postoperative respiratory complications. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

  12. Adverse respiratory events after general anesthesia in patients at high risk of obstructive sleep apnea syndrome.

    Science.gov (United States)

    Xará, Daniela; Mendonça, Júlia; Pereira, Helder; Santos, Alice; Abelha, Fernando José

    2015-01-01

    Patients with STOP-BANG score >3 have a high risk of Obstructive sleep apnea. The aim of this study was to evaluate early postoperative respiratory complications in adults with STOP-BANG score >3 after general anesthesia. This is a prospective double cohort study matching 59 pairs of adult patients with STOP-BANG score >3 (high risk of obstructive sleep apnea) and patients with STOP-BANG score <3 (low risk of obstructive sleep apnea), similar with respect to gender, age and type of surgery, admitted after elective surgery in the Post-Anaesthesia Care Unit in May 2011. Primary outcome was the development of adverse respiratory events. Demographics data, perioperative variables, and postoperative length of stay in the Post-Anesthesia Care Unit and in hospital were recorded. The Mann-Whitney test, the chi-square test and the Fisher exact test were used for comparisons. Subjects in both pairs of study subjects had a median age of 56 years, including 25% males, and 59% were submitted to intra-abdominal surgery. High risk of obstructive sleep apnea patients had a higher median body mass index (31 versus 24kg/m(2), p<0.001) and had more frequently co-morbidities, including hypertension (58% versus 24%, p<0.001), dyslipidemia (46% versus 17%, p<0.001) and insulin-treated diabetes mellitus (17% versus 2%, p=0.004). These patients were submitted more frequently to bariatric surgery (20% versus 2%, p=0.002). Patients with high risk of obstructive sleep apnea had more frequently adverse respiratory events (39% versus 10%, p<0.001), mild to moderate desaturation (15% versus 0%, p=0.001) and inability to breathe deeply (34% versus 9%, p=0.001). After general anesthesia high risk of obstructive sleep apnea patients had an increased incidence of postoperative respiratory complications. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.

  13. Prediction of Outcome After Emergency High-Risk Intra-abdominal Surgery Using the Surgical Apgar Score.

    Science.gov (United States)

    Cihoric, Mirjana; Toft Tengberg, Line; Bay-Nielsen, Morten; Bang Foss, Nicolai

    2016-12-01

    With current literature quoting mortality rates up to 45%, emergency high-risk abdominal surgery has, compared with elective surgery, a significantly greater risk of death and major complications. The Surgical Apgar Score (SAS) is predictive of outcome in elective surgery, but has never been validated exclusively in an emergency setting. A consecutive prospective single-center cohort study of 355 adults undergoing emergency high-risk abdominal surgery between June 2013 and May 2014 is presented. The primary outcome measure was 30-day mortality. Secondary outcome measures were postoperative major complications, defined according to the Clavien-Dindo scale as well as the American College of Surgeons' National Surgical Quality Improvement Program guidelines, and intensive care unit admission. The SAS was calculated postoperatively. Cochran-Armitage test for trend was used to evaluate the incidence of both outcomes. Area under the curve was used to demonstrate the scores' discriminatory power. One hundred eighty-one (51.0%) patients developed minor or no complications. The overall incidence of major complications was 32.7% and the overall death rate was 16.3%. Risk of major complications, death, and intensive care unit admission increased significantly with decreasing SAS (P high-risk abdominal surgery. Despite its predictive value, the SAS cannot in its current version be recommended as a standalone prognostic tool in an emergency setting.

  14. Management of colorectal cancer patients at high risk of peritoneal metastases.

    Science.gov (United States)

    Shariff, Umar; Seretis, Charalampos; Youssef, Haney

    2015-05-01

    Colorectal cancer (CRC) has potential to spread within the peritoneal cavity, and this transcoelomic dissemination is termed "peritoneal metastases" (PM). Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a radical strategy to treat selected CRC patients with PM. Studies suggest that identification of CRC patients at high risk of PM may lead to earlier treatment strategies and improve survival in this subset of patients. The aim of this article was to summarise the current evidence regarding CRC patients at high risk of PM. A retrospective review of articles on CRC patients with high risk of PM published up to December 2014 in PubMed, Medline, Embase, and Ovid search engines was conducted. The following combination of search terms were used: "intraperitoneal chemotherapy", "HIPEC", "colorectal cancer", "peritoneal carcinomatosis", "peritoneal metastases", "high risk", "peritoneal recurrence". Although opinions differ, CRC patients identified as "high risk" of PM included: limited, synchronous PM completely resected with the primary tumor, ovarian metastases (synchronous or metachronous) and spontaneous or iatrogenic perforation of the bowel by the primary tumor. Aggressive early treatment strategies currently used are: CRS and HIPEC for high-risk primary tumors and second-look CRS and HIPEC often following systematic chemotherapy for the primary resection. Positive results have been shown with both approaches in a number of studies. With CRS/HIPEC for the primary tumor, the overall survival in the two groups (25 patients treated with CRS/HIPEC vs 50 treated with conventional surgery) was significantly improved (p<0.03), as was disease-free survival (p<0.04). For second look surgery, in 29 patients treated with CRS and HIPEC, this resulted in 14% morbidity and 0% mortality and a 2-year disease-free survival rate in excess of 50%. We are progressively moving to an era of individualised treatment strategies. The management of CRC

  15. High risk factors in patient with carcinoma esophagus

    International Nuclear Information System (INIS)

    Afridi, S.P.; Khan, A.; Waheed, I.

    2000-01-01

    This study was conducted to identify the presence of high risk factors in carcinoma esophagus from February, 1992 to August, 1995 at Surgical unit 1, Jinnah Postgraduate Medical Centre (JPMC), Karachi. In all 37 patients, 22 males and 15 females, were included in the study through outpatient department, surgical emergency and those referred from other cities of the country. All patients were cachectic. Diagnosis was made by detailed history, examination and laboratory investigations. Diagnosis was confirmed on barium swallow and endoscopic biopsy. Highest number of patients were in their 6th decade of life. History of snuff inhalation and opium was present in 2.7% cases each. Lower 3rd of the esophagus was affected in 62.16% middle third in 21.62% and upper third in 16.21% cases. Smoking, pan chewing, naswar eating and snuff inhalation were identified as high risk factors among patients of carcinoma esophagus. (author)

  16. The high-risk surgical patient and the role of preoperative management.

    Science.gov (United States)

    Girbes, A R

    2000-09-01

    Reducing the risk in high-risk surgical patients is a common effort of surgeons, anesthesiologists and internists. Several definitions of high-risk surgery exist and one should differentiate the risk for the development of shock and multiple organ dysfunction syndrome from explicitly cardiac risk. Insufficient tissue, especially splanchnic, perfusion can lead to a cascade with the liberation of cytokines and adhesion molecules. Ensuring adequate tissue perfusion is therefore of utmost importance. Assessing tissue perfusion and recognizing hypovolemia is, however, a difficult task using only standard clinical signs as blood pressure and heart rate. Several studies where high-risk surgical patients were treated preoperatively with fluid infusions and/or vasoactive drugs, mainly as determined by invasive monitoring, have shown a positive effect on outcome. On the other hand the value of beta-blockade, started preoperatively, in selected patients at high risk for cardiac complications is accumulating and convincing. The author therefore suggests to aim for targets of therapy based on multiple baseline values for each individual patient. The author also calls for stopping the practice, as is still the case in many hospitals, to leave the patients the night before surgery with an overnight fast, without an intravenous infusion with the appropriate amounts of fluids. However, it is concluded that the definition of 'appropriate' is currently still a matter of opinion and not facts.

  17. Association between surgical delay and survival in high-risk emergency abdominal surgery. A population-based Danish cohort study.

    Science.gov (United States)

    Vester-Andersen, Morten; Lundstrøm, Lars Hyldborg; Buck, David Levarett; Møller, Morten Hylander

    2016-01-01

    In patients with perforated peptic ulcer, surgical delay has recently been shown to be a critical determinant of survival. The aim of the present population-based cohort study was to evaluate the association between surgical delay by hour and mortality in high-risk patients undergoing emergency abdominal surgery in general. All in-patients aged ≥ 18 years having emergency abdominal laparotomy or laparoscopy performed within 48 h of admission between 1 January 2009 and 31 December 2010 in 13 Danish hospitals were included. Baseline and clinical data, including surgical delay and 90-day mortality were collected. The crude and adjusted association between surgical delay by hour and 90-day mortality was assessed by binary logistic regression. A total of 2803 patients were included. Median age (interquartile range [IQR]) was 66 (51-78) years, and 515 patients (18.4%) died within 90 days of surgery. Over the first 24 h after hospital admission, each hour of surgical delay beyond hospital admission was associated with a median (IQR) decrease in 90-day survival of 2.2% (1.9-3.3%). No statistically significant association between surgical delay by hour and 90-day mortality was shown; crude and adjusted odds ratio with 95% confidence interval 1.016 (1.004-1.027) and 1.003 (0.989-1.017), respectively. Sensitivity analyses confirmed the primary finding. In the present population-based cohort study of high-risk patients undergoing emergency abdominal surgery, no statistically significant adjusted association between mortality and surgical delay was found. Additional research in diagnosis-specific subgroups of high-risk patients undergoing emergency abdominal surgery is warranted.

  18. Acute cholecystitis in high-risk patients: percutaneous cholecystostomy vs conservative treatment

    Energy Technology Data Exchange (ETDEWEB)

    Hatzidakis, Adam A.; Prassopoulos, Panos; Petinarakis, Ioannis; Gourtsoyiannis, Nicholas C. [Department of Radiology, University Hospital of Heraklion, Medical School of Crete, Crete (Greece); Sanidas, Elias; Tsiftsis, Dimitrios [Department of Surgical Oncology, University Hospital of Heraklion, Medical School of Crete (Greece); Chrysos, Emmanuel; Chalkiadakis, Georgios [Department of General Surgery, University Hospital of Heraklion, Medical School of Crete (Greece)

    2002-07-01

    Our objective was to compare the effectiveness of percutaneous cholecystostomy (PC) vs conservative treatment (CO) in high-risk patients with acute cholecystitis. The study was randomized and comprised 123 high-risk patients with acute cholecystitis. All patients fulfilled the ultrasonographic criteria of acute inflammation and had an APACHE II score {>=}12. Percutaneous cholecystostomy guided by US or CT was successful in 60 of 63 patients (95.2%) who comprised the PC group. Sixty patients were conservatively treated (CO group). One patient died after unsuccessful PC (1.6%). Resolution of symptoms occurred in 54 of 63 patients (86%). Eleven patients (17.5%) died either of ongoing sepsis (n=6) or severe underlying disease (n=5) within 30 days. Seven patients (11%) were operated on because of persisting symptoms (n=3), catheter dislodgment (n=3), or unsuccessful PC (n=1). Cholecystolithotripsy was performed in 5 patients (8%). Elective surgery was performed in 9 cases (14%). No further treatment was needed in 32 patients (51%). In the CO group, 52 patients (87%) fully recovered and 8 patients (13%) died of ongoing sepsis within 30 days. All successfully treated patients showed clinical improvement during the first 3 days of treatment. Percutaneous cholecystostomy in high-risk patients with acute cholecystitis did not decrease mortality in relation to conservative treatment. Percutaneous cholecystostomy might be suggested to patients not presenting clinical improvement following 3 days of conservative treatment, to critically ill intensive care unit patients, or to candidates for percutaneous cholecystolithotripsy. (orig.)

  19. Raised preoperative international normalised ratio (INR) identifies patients at high risk of perioperative death after simultaneous renal and cardiac surgery for tumours involving the peri-diaphragmatic inferior vena cava and right atrium.

    Science.gov (United States)

    O'Brien, Tim; Fernando, Archie; Thomas, Kay; Van Hemelrijck, Mieke; Bailey, Craig; Austin, Conal

    2017-03-01

    To identify preoperative factors that predict 30-day mortality in patients undergoing simultaneous cardiac and renal surgery for urological tumours involving the peri-diaphragmatic vena cava and right atrium- The ability to predict mortality and therefore avoid surgery in those patients likely to die would be valuable. We retrospectively reviewed perioperative outcomes in patients managed between December 2007 and January 2016 by a single team. The relationships of outcome measurements were analysed using Fisher's exact and Mann-Whitney U-tests. Of the 46 patients identified, 41 (89%) underwent surgery (20 males and 21 females). The median (range) age was 65 (17-95) years. Histology confirmed 37 renal cell cancers, one adrenal cancer, two primitive neuroectodermal tumours, and one leiomyosarcoma. The overall 30-day mortality rate was 7% (three of 41 patients). The international normalised ratio (INR), age, and estimated glomerular filtration rate (eGFR) correlated significantly with 30-day mortality. The mortality rate was high in patients with an INR ≥1.5 and 70 years) and of significant post-operative complications in younger patients (International © 2016 BJU International Published by John Wiley & Sons Ltd.

  20. A Phase 2 Trial of Radiation Therapy With Concurrent Paclitaxel Chemotherapy After Surgery in Patients With High-Risk Endometrial Cancer: A Korean Gynecologic Oncologic Group Study

    International Nuclear Information System (INIS)

    Cho, Hanbyoul; Nam, Byung-Ho; Kim, Seok Mo; Cho, Chi-Heum; Kim, Byoung Gie; Ryu, Hee-Sug; Kang, Soon Beom; Kim, Jae-Hoon

    2014-01-01

    Purpose: A phase 2 study was completed by the Korean Gynecologic Oncologic Group to evaluate the efficacy and toxicity of concurrent chemoradiation with weekly paclitaxel in patients with high-risk endometrial cancer. Methods and Materials: Pathologic requirements included endometrial endometrioid adenocarcinoma stages III and IV. Radiation therapy consisted of a total dose of 4500 to 5040 cGy in 5 fractions per week for 6 weeks. Paclitaxel 60 mg/m 2 was administered once weekly for 5 weeks during radiation therapy. Results: Fifty-seven patients were enrolled between January 2006 and March 2008. The median follow-up time was 60.0 months (95% confidence interval [CI], 51.0-58.2). All grade 3/4 toxicities were hematologic and usually self-limited. There was no life-threatening toxicity. The cumulative incidence of intrapelvic recurrence sites was 1.9% (1/52), and the cumulative incidence of extrapelvic recurrence sites was 34.6% (18/52). The estimated 5-year disease-free and overall survival rates were 63.5% (95% CI, 50.4-76.5) and 82.7% (95% CI, 72.4-92.9), respectively. Conclusions: Concurrent chemoradiation with weekly paclitaxel is well tolerated and seems to be effective for high-risk endometrioid endometrial cancers. This approach appears reasonable to be tested for efficacy in a prospective, randomized controlled study

  1. A Phase 2 Trial of Radiation Therapy With Concurrent Paclitaxel Chemotherapy After Surgery in Patients With High-Risk Endometrial Cancer: A Korean Gynecologic Oncologic Group Study

    Energy Technology Data Exchange (ETDEWEB)

    Cho, Hanbyoul [Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul (Korea, Republic of); Institute of Women' s Life Medical Science, Yonsei University College of Medicine, Seoul (Korea, Republic of); Nam, Byung-Ho [Cancer Biostatistics Branch, Research Institute for National Cancer Control and Evaluation, National Cancer Center, Goyang (Korea, Republic of); Kim, Seok Mo [Department of Obstetrics and Gynecology, Chonnam National University School of Medicine, Gwangju (Korea, Republic of); Cho, Chi-Heum [Department of Obstetrics and Gynecology, Keimyung University School of Medicine, Daegu (Korea, Republic of); Kim, Byoung Gie [Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul (Korea, Republic of); Ryu, Hee-Sug [Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon (Korea, Republic of); Kang, Soon Beom [Department of Obstetrics and Gynecology, Konkuk University School of Medicine, Seoul (Korea, Republic of); Kim, Jae-Hoon, E-mail: jaehoonkim@yuhs.ac [Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul (Korea, Republic of); Institute of Women' s Life Medical Science, Yonsei University College of Medicine, Seoul (Korea, Republic of)

    2014-09-01

    Purpose: A phase 2 study was completed by the Korean Gynecologic Oncologic Group to evaluate the efficacy and toxicity of concurrent chemoradiation with weekly paclitaxel in patients with high-risk endometrial cancer. Methods and Materials: Pathologic requirements included endometrial endometrioid adenocarcinoma stages III and IV. Radiation therapy consisted of a total dose of 4500 to 5040 cGy in 5 fractions per week for 6 weeks. Paclitaxel 60 mg/m{sup 2} was administered once weekly for 5 weeks during radiation therapy. Results: Fifty-seven patients were enrolled between January 2006 and March 2008. The median follow-up time was 60.0 months (95% confidence interval [CI], 51.0-58.2). All grade 3/4 toxicities were hematologic and usually self-limited. There was no life-threatening toxicity. The cumulative incidence of intrapelvic recurrence sites was 1.9% (1/52), and the cumulative incidence of extrapelvic recurrence sites was 34.6% (18/52). The estimated 5-year disease-free and overall survival rates were 63.5% (95% CI, 50.4-76.5) and 82.7% (95% CI, 72.4-92.9), respectively. Conclusions: Concurrent chemoradiation with weekly paclitaxel is well tolerated and seems to be effective for high-risk endometrioid endometrial cancers. This approach appears reasonable to be tested for efficacy in a prospective, randomized controlled study.

  2. Long-Term Outcomes of High-Risk Keratoplasty in Patients Receiving Systemic Immunosuppression.

    Science.gov (United States)

    Chow, Sing-Pey; Cook, Stuart D; Tole, Derek M

    2015-11-01

    Immunological graft rejection after corneal transplantation remains the leading cause of graft failure. Systemic immunosuppression is used for keratoplasty at a high risk of rejection to improve graft survival. We examined the long-term outcomes of high-risk corneal grafts in patients receiving systemic immunosuppression. Thirty-five corneal transplants with a high risk of rejection were identified from 29 patients within a regional immunosuppression service in the United Kingdom. Definition of keratoplasty at "high risk" of rejection included one or more of the following: a history of ipsilateral graft rejection and/or failure, 2 or more quadrants of stromal vascularization, perforation or ocular inflammation at the time of surgery, presence of atopy, and a large-diameter (≥9 mm) graft. Median follow-up duration was 5 years after transplantation. Graft survival at 5 years in patients receiving systemic immunosuppression was 73.5%. Rejection episodes occurred in 14 grafts (40%); these episodes were reversible in 10 grafts (71%). Indications for transplantation were mostly visual (n = 19; 54%) and tectonic (n = 14; 40%). Eighteen grafts (51%) had 2 or more high-risk characteristics. Most patients (n = 20; 69%) received monotherapy, commonly with tacrolimus (n = 15; 52%) or mycophenolate mofetil (n = 8; 28%). Three patients (10%) experienced severe systemic side effects. Median "day-to-day" logMAR visual acuity was 0.5 in grafts for all indications and 0.2 for visual indications. Systemic immunosuppression in patients with high-risk keratoplasty seems to improve graft survival with a median follow-up duration of 5 years and is tolerated by most patients. Despite rejection episodes occurring in 40% of grafts, these were mostly reversible.

  3. Percutaneous transhepatic cholecystostomy for choledocholithiasis with acute cholangitis in high-risk patients.

    Science.gov (United States)

    Ren, Zuhai; Xu, Yong; Zhu, Shaihong

    2012-01-01

    To evaluate the safety and feasibility of percutaneous transhepatic cholecystostomy for choledocholithiasis with acute cholangitis in high-risk patients. Six high-risk patients of choledocholithiasis complicated with moderate to severe acute cholangitis underwent percutaneous transhepatic cholecystostomy and subsequent interval open surgery from January, 2008 to October 2010. These patients, who were not suitable for both endoscopic and transhepatic biliary drainage, were reviewed retrospectively. Percutaneous transhepatic cholecystostomy was performed uneventfully. One patient developed hemoperitoneum which was successfully controlled by conservative treatment. Biliary peritonitits occurred in two patients, one ceased to leak spontaneously, the other developed a biloma which was cured by repuncture. No procedure-related death occurred. Sepsis was relieved completely 3 to 4 days after procedure. Two patients underwent interval open exploration of the common bile duct. One patient who recovered from sepsis succumbed on day 12 post-cholecystostomy because of an acute cardiac infarct. The other 3 patients were cured of sepsis and discharged without further treatment. The results showed that ultrasound-guided percutaneous transhepatic cholecystostomy is a safe and effective procedure for choledocholithiasis with moderate to severe acute cholangitis in highly selected high-risk surgical patients. It may deserve to become a definitive therapy for subsequent surgical management. Larger controlled studies are needed to further confirm our findings.

  4. Is Percutaneous Cholecystostomy a Good Alternative Treatment for Acute Cholecystitis in High-Risk Patients?

    Science.gov (United States)

    Papis, Davide; Khalifa, Eiman; Bhogal, Ricky; Nair, Amit; Khan, Saboor; Hamady, Zaed; Ahmed, Jawad; Marangoni, Gabriele

    2017-06-01

    Cholecystectomy is the treatment of choice for acute cholecystitis but the management of high-risk surgical patients is a difficult dilemma. Percutaneous cholecystostomy (PC) could represent a safer and less invasive option. The aim of the study was to assess the outcomes of PC in high-risk patients. This is a retrospective single-center study; data were collected from our hospital electronic record system. From February 2009 to March 2014, there were 753 patients admitted with acute cholecystitis. Of these 39 were considered high risk for surgery and underwent PC during their hospital stay. The radiological approach was transperitoneal in 29 patients and transhepatic in 10 patients. Median follow-up was 19 months. There were 27 males (69.2%) and 12 females (30.8%) with a mean age of 72 years (range 41-90 years). Twenty-seven patients had PC as definitive treatment (group A) and 12 patients as a bridge to cholecystectomy (group B). There were no postprocedure complications. Five patients in group A were readmitted once with another episode of cholecystitis after PC (18.5%), one patient in group B was readmitted with cholecystitis after two years before proceeding to cholecystectomy, and two patients were readmitted after cholecystectomy (16.6%) for intra-abdominal collections treated with percutaneous radiological drainage. Seven patients died (17.9%) as a result of severe biliary sepsis during their index hospital admission. PC is a safe approach in high-risk patients with acute cholecystitis and can provide satisfactory long-term results when cholecystectomy is not a viable option.

  5. Prediction of Outcome After Emergency High-Risk Intra-abdominal Surgery Using the Surgical Apgar Score

    DEFF Research Database (Denmark)

    Cihoric, Mirjana; Toft Tengberg, Line; Bay-Nielsen, Morten

    2016-01-01

    BACKGROUND: With current literature quoting mortality rates up to 45%, emergency high-risk abdominal surgery has, compared with elective surgery, a significantly greater risk of death and major complications. The Surgical Apgar Score (SAS) is predictive of outcome in elective surgery, but has never...

  6. 2017 Taiwan lipid guidelines for high risk patients

    Directory of Open Access Journals (Sweden)

    Yi-Heng Li

    2017-04-01

    lowering therapies, adjunctive treatment with mipomersen, lomitapide, or PCSK9 inhibitors become necessary to further reduce LDL-C in patients with FH. Overall, these recommendations are to help the health care professionals in Taiwan to treat hyperlipidemia with current scientific evidences. We hope the prescription rate of lipid lowering drugs and control rate of hyperlipidemia in high risk patients could be increased by implementation of the clinical guidelines. The major purpose is to improve clinical outcomes of these high risk patients through the control of hyperlipidemia.

  7. Safe Reentry for False Aneurysm Operations in High-Risk Patients.

    Science.gov (United States)

    Martinelli, Gian Luca; Cotroneo, Attilio; Caimmi, Philippe Primo; Musica, Gabriele; Barillà, David; Stelian, Edmond; Romano, Angelo; Novelli, Eugenio; Renzi, Luca; Diena, Marco

    2017-06-01

    In the absence of a standardized safe surgical reentry strategy for high-risk patients with large or anterior postoperative aortic false aneurysm (PAFA), we aimed to describe an effective and safe approach for such patients. We prospectively analyzed patients treated for PAFA between 2006 and 2015. According to the preoperative computed tomography scan examination, patients were divided into two groups according to the anatomy and extension of PAFA: in group A, high-risk PAFA (diameter ≥3 cm) developed in the anterior mediastinum; in group B, low-risk PAFA (diameter <3 cm) was situated posteriorly. For group A, a safe surgical strategy, including continuous cerebral, visceral, and coronary perfusion was adopted before resternotomy; group B patients underwent conventional surgery. We treated 27 patients (safe reentry, n = 13; standard approach, n = 14). Mean age was 60 years (range, 29 to 80); 17 patients were male. Mean interval between the first operation and the last procedure was 4.3 years. Overall 30-day mortality rate was 7.4% (1 patient in each group). No aorta-related mortality was observed at 1 and 5 years in either group. The Kaplan-Meier overall survival estimates at 1 and 5 years were, respectively, 92.3% ± 7.4% and 73.4% ± 13.4% in group A, and 92.9% ± 6.9% and 72.2% ± 13.9% in group B (log rank test, p = 0.830). Freedom from reoperation for recurrent aortic disease was 100% at 1 year and 88% at 5 years. The safe reentry technique with continuous cerebral, visceral, and coronary perfusion for high-risk patients resulted in early and midterm outcomes similar to those observed for low-risk patients undergoing conventional surgery. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

  8. Rocuronium reversed by sugammadex versus mivacurium during high-risk eye surgery: an institutional anaesthetic practice evaluation.

    Science.gov (United States)

    von Quillfeldt, Susanne; Föhre, Bettina; Andrees, Nicolai; Spies, Claudia D; Galvagni, Daniele; Joussen, Antonia M; Wernecke, Klaus D; Boemke, Willehad

    2013-10-01

    This institutional anaesthetic practice evaluation compared patient safety with respect to residual neuromuscular blockade (NMB) at the time of tracheal extubation in patients undergoing high-risk eye surgery. Two muscle relaxation regimens were compared: rocuronium administered via intravenous (i.v.) bolus dosing combined with reversal through sugammadex at end of surgery (group R/S; 17 patients); mivacurium administered via continuous i.v. infusion without antagonization (group M; 22 patients). Train-of-four (TOF) monitoring determined the depth of NMB. The TOF ratio at the time of tracheal extubation was greater in group R/S (median 1.03) than in group M (median 0.62). Time from end of surgery to tracheal extubation was not significantly different. The surgeons were 100% satisfied with the working conditions provided under both relaxation regimens. Residual postoperative curarization at the time of extubation was frequently observed in group M, whereas there was complete recovery in group R/S. Reversal of NMB by sugammadex provides an additional safety dimension to patient care and should thus be considered especially for those at risk of airway complications or aspiration, in addition to frail patients.

  9. 2017 Taiwan lipid guidelines for high risk patients.

    Science.gov (United States)

    Li, Yi-Heng; Ueng, Kwo-Chang; Jeng, Jiann-Shing; Charng, Min-Ji; Lin, Tsung-Hsien; Chien, Kuo-Liong; Wang, Chih-Yuan; Chao, Ting-Hsing; Liu, Ping-Yen; Su, Cheng-Huang; Chien, Shih-Chieh; Liou, Chia-Wei; Tang, Sung-Chun; Lee, Chun-Chuan; Yu, Tse-Ya; Chen, Jaw-Wen; Wu, Chau-Chung; Yeh, Hung-I

    2017-04-01

    statin to consolidate the CV protection in CKD patients. Mutations in LDL receptor, apolipoprotein B and PCSK9 genes are the common causes of FH. Diagnosis of FH usually depends on family history, clinical history of premature CAD, physical findings of xanthoma or corneal arcus and high levels of LDL-C. In addition to conventional lipid lowering therapies, adjunctive treatment with mipomersen, lomitapide, or PCSK9 inhibitors become necessary to further reduce LDL-C in patients with FH. Overall, these recommendations are to help the health care professionals in Taiwan to treat hyperlipidemia with current scientific evidences. We hope the prescription rate of lipid lowering drugs and control rate of hyperlipidemia in high risk patients could be increased by implementation of the clinical guidelines. The major purpose is to improve clinical outcomes of these high risk patients through the control of hyperlipidemia. Copyright © 2016. Published by Elsevier B.V.

  10. Coronary CT angiography in clinical triage of patients at high risk of coronary artery disease

    DEFF Research Database (Denmark)

    Kühl, J Tobias; Hove, Jens D; Kristensen, Thomas S

    2017-01-01

    OBJECTIVES: To test if cardiac computed tomography angiography (CCTA) can be used in the triage of patients at high risk of coronary artery disease. DESIGN: The diagnostic value of 64-detector CCTA was evaluated in 400 patients presenting with non-ST segment elevation myocardial infarction using......%) coronary artery diameter stenosis with a sensitivity, specificity, and positive and negative predictive value of 99%, 81%, 96% and 95%, respectively. CCTA was used to triage patients into guideline defined treatment groups of "no or medical treatment", "referral to percutaneous coronary intervention......" or to "coronary artery bypass graft surgery" and was compared to the index ICA. CCTA correctly triaged patients in 86% of cases. During a median follow-up of 50 months, the presence of an occluded artery by CCTA was associated with adverse outcome. CONCLUSION: CCTA has high diagnostic and prognostic value...

  11. Low mortality rates after endovascular aortic repair expand use to high-risk patients.

    Science.gov (United States)

    Adkar, Shaunak S; Turner, Megan C; Leraas, Harold J; Gilmore, Brian F; Nag, Uttara; Turley, Ryan S; Shortell, Cynthia K; Mureebe, Leila

    2018-02-01

    presence of each comorbidity increased the odds of 30-day mortality (respiratory odds ratio [OR], 1.62; 95% confidence interval [CI], 1.16-2.26; P = .005; cardiac OR, 1.55; 95% CI, 1.14-2.10; P = .005), the presence of renal criteria disproportionately increased the odds of mortality threefold (OR, 3.42; 95% CI, 2.31-5.09; P < .001). Contemporary 30-day mortality after EVAR in high-risk patients is substantially lower than that reported in the EVAR 2 trial. Whereas low- and high-risk stratification by current comorbidity criteria is appropriate, attention needs to be paid to disproportionate risk contribution from renal disease to mortality compared with cardiac and pulmonary comorbidities. Given the lower mortality risk than previously described, patients stratified as high risk should be thoughtfully considered for definitive EVAR. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

  12. Percutaneous treatment of high-risk patients with intra-articular calcaneus fractures: a case series.

    Science.gov (United States)

    Hammond, Allan William; Crist, Brett D

    2013-11-01

    Diabetics, smokers, patients with open fractures and drug addicts have shown to be at increased risk of having wound complications with traditional calcaneus fixation. The purpose of the study is to examine if high-risk patients with intra-articular calcaneus fractures can be managed safely using percutaneous reduction and fixation by examining a consecutive series of patients treated by the senior author. The treatment group consisted of the senior author's first 17 percutaneously treated calcaneus fractures in high-risk patients. Risk factors included: open fracture, smoking, diabetes and cocaine, alcohol and solvent abuse. Reduction techniques included temporary external fixation, inflatable bone tamps, and arthroscopic assisted reduction manoeuvres. Fixation was accomplished with cannulated 4.5mm screws. Patients were followed up for 3 months minimum to look for wound complications and subsidence. Surgery was performed within 15 days from injury (average 6.7 days). Risk factors included: open fracture 1, smoking 16, diabetes 2, and substance abuse 9. Sanders' classification described: six type 2, nine type 3 and two type 4. Bohlers' angle increased from an average of -1.5° (range -37° to +30) to 25.8° (range 7-36°). There were no wound issues or infections with the calcaneal fixation. Reduction was deemed excellent or good in 14, fair in 2 and poor in 1. Loss of Bohlers' angle of >4° occurred in four cases; in three of these, the patients were non-compliant with weight bearing. High-risk patients with intra-articular calcaneus fractures that meet the criteria for surgical management can be managed with percutaneous surgical techniques with low risk of wound complications. Copyright © 2013 Elsevier Ltd. All rights reserved.

  13. HORMONE AND RADIATION THERAPY IN HIGH- AND VERY HIGH-RISK PATIENTS WITH PROSTATE CANCER

    Directory of Open Access Journals (Sweden)

    A. O. Karyakin

    2012-01-01

    Full Text Available The prevalence of prostate cancer (PC is steadily growing every year. In the Russian Federation, its peak morbidity is in the age group of 70 years. Some patients refuse surgery or have contraindications because of comorbidity. Teleradiotherapy in combination with or without hormone therapy is an alternative treatment. The paper analyzes the authors’ results of treating high- and very high-risk patients with PC who received hormone and radiation therapy. The study retrospectively included the data of 132 patients who had been allocated to 3 groups according to the duration of adjuvant hormone therapy. The treatment results were assessed over a 5-year follow-up period according the following parameters: a lower decreased prostate-specific antigen (PSA score, recurrence rate, and 5-year relapse-free survival determined the by PSA level.

  14. Postoperative radiation therapy after hip replacement in high-risk patients for development of heterotopic bone formation

    International Nuclear Information System (INIS)

    Hashem, R.; Rene, N.; Souhami, L.; Tanzer, M.; Evans, M.

    2011-01-01

    Purpose. - To report the results of postoperative radiation therapy in preventing the development of heterotopic bone formation after hip replacement surgery in high-risk patients. Patients and methods. - Between 1991 and 2007, 44 patients were preventively treated with postoperative RT after total hip replacement. In total, 47 hips were treated. All patients were considered at high risk for developing heterotopic bone formation. Most patients (63.5%) were treated because of a history of severe osteoarthritis or ankylosing spondylitis. All patients were treated with shaped parallel-opposed fields with a single fraction of 7 Gy using 6 or 18 MV photons. Most patients (94%) received radiation therapy within 72 hours postoperative and in only three patients radiation therapy was delivered after 72 hours post-surgery (5-8 days). Results. - Minimum follow-up was 1 year. There were 18 females and 26 males. Median age was 63 years (range: 18-80). Treatments were well tolerated and no acute toxicity was seen post-radiation therapy. Only one of the 47 hips (2%) developed heterotopic bone formation. This patient received postoperative radiation therapy to both hips but only developed heterotopic bone formation in one of them. None of the three patients treated beyond 72 hours failed. To date no late toxicity has been observed. Conclusion. - The use of postoperative radiation therapy was an effective and safe treatment in the prevention of heterotopic bone formation in a high-risk group of patients undergoing total hip replacement. (authors)

  15. Patients with a high risk for obstructive sleep apnea syndrome: postoperative respiratory complications.

    Science.gov (United States)

    Pereira, H; Xará, D; Mendonça, J; Santos, A; Abelha, F J

    2013-01-01

    STOP-BANG score (snore; tired; observed apnea; arterial pressure; body mass index; age; neck circumference and gender) can predict the risk of a patient having Obstructive Syndrome Apnea (OSA). The aim of this study was to evaluate the incidence STOP-BANG score≥3, in surgical patients admitted to the Post-Anesthesia Care Unit (PACU). Observational, prospective study conducted in a post-anesthesia care unit (PACU) during three weeks (2011). The study population consisted of adult patients after noncardiac and non-neurological surgery. Patients were classified as high risk of OSA (HR-OSA) if STOP-BANG score≥3 and Low-risk of OSA (LR-OSA) if STOP-BANG score<3 (LR-OSA). Patient demographics, intraoperative and postoperative data were collected. Patient characteristics were compared using Mann-Whitney U-test, t-test for independent groups, and chi-square or Fisher's exact test. A total of 357 patients were admitted to PACU; 340 met the inclusion criteria. 179 (52%) were considered HR-OSA. These patients were older, more likely to be masculine, had higher BMI, higher ASA physical status, higher incidence of ischemic heart disease, heart failure, hypertension, dyslipidemia and underwent more frequently insulin treatment for diabetes. These patients had more frequently mild/moderated hypoxia in the PACU (9% vs. 3%, p=0.012) and had a higher incidence of residual neuromuscular blockade (NMB) (20% vs. 16%, p=0.035). Patients with HR-OSA had a longer hospital stay. Patients with HR-OSA had an important incidence among patients scheduled for surgery in our hospital. These patients had more co-morbidities and were more prone to post-operative complications. Copyright © 2012 Sociedade Portuguesa de Pneumologia. Published by Elsevier España. All rights reserved.

  16. Utility of sentinel node biopsy in patients with high-risk cutaneous squamous cell carcinoma

    DEFF Research Database (Denmark)

    Allen, J E; Stolle, L B

    2015-01-01

    BACKGROUND: Currently there is no consensual agreement on the standard use of Sentinel Lymph Node Biopsy (SLNB) in staging of high-risk patients. OBJECTIVE: The objective was to define the predictive value and role of SLNB combined with the different high-risk factors to determine which patients ...

  17. Comparison of primary radiation versus robotic surgery plus adjuvant radiation in high-risk prostate cancer: A single center experience

    OpenAIRE

    Prabhsimranjot Singh; Prashant Desai; Shruthi Arora; Anthony H Pham; A Gabriella Wernicke; Michael Smith; Dattatreyudu Nori; K S Clifford Chao; Bhupesh Parashar

    2015-01-01

    Objective: The objective of this study was to compare robotic-prostatectomy plus adjuvant radiation therapy (RPRAT) versus primary RT for high-risk prostate cancer (HRPCa). Materials and Methods: A retrospective chart review was performed for the HRPCa patients treated in our institution between 2000 and 2010. One hundred and twenty-three patients with high-risk disease were identified. The Chi-square test and Fisher′s exact test were used to compare local control and distant failure rate...

  18. Bevacizumab and Combination Chemotherapy in rectal cancer Until Surgery (BACCHUS): a phase II, multicentre, open-label, randomised study of neoadjuvant chemotherapy alone in patients with high-risk cancer of the rectum

    International Nuclear Information System (INIS)

    Glynne-Jones, R.; Hava, N.; Goh, V.; Bosompem, S.; Bridgewater, J.

    2015-01-01

    In locally advanced rectal cancer (LARC) preoperative chemoradiation (CRT) is the standard of care, but the risk of local recurrence is low with good quality total mesorectal excision (TME), although many still develop metastatic disease. Current challenges in treating rectal cancer include the development of effective organ-preserving approaches and the prevention of subsequent metastatic disease. Neoadjuvant systemic chemotherapy (NACT) alone may reduce local and systemic recurrences, and may be more effective than postoperative treatments which often have poor compliance. Investigation of intensified NACT is warranted to improve outcomes for patients with LARC. The objective is to evaluate feasibility and efficacy of a four-drug regimen containing bevacizumab prior to surgical resection. This is a multi-centre, randomized phase II trial. Eligible patients must have histologically confirmed LARC with distal part of the tumour 4–12 cm from anal verge, no metastases, and poor prognostic features on pelvic MRI. Sixty patients will be randomly assigned in a 1:1 ratio to receive folinic acid + flurourcil + oxaliplatin (FOLFOX) + bevacizumab (BVZ) or FOLFOX + irinotecan (FOLFOXIRI) + BVZ, given in 2 weekly cycles for up to 6 cycles prior to TME. Patients stop treatment if they fail to respond after 3 cycles (defined as ≥ 30 % decrease in Standardised Uptake Value (SUV) compared to baseline PET/CT). The primary endpoint is pathological complete response rate. Secondary endpoints include objective response rate, MRI tumour regression grade, involved circumferential resection margin rate, T and N stage downstaging, progression-free survival, disease-free survival, overall survival, local control, 1-year colostomy rate, acute toxicity, compliance to chemotherapy. In LARC, a neoadjuvant chemotherapy regimen - if feasible, effective and tolerable would be suitable for testing as the novel arm against the current standards of short course preoperative radiotherapy (SCPRT

  19. Innovative practice model to optimize resource utilization and improve access to care for high-risk and BRCA+ patients.

    Science.gov (United States)

    Head, Linden; Nessim, Carolyn; Usher Boyd, Kirsty

    2017-02-01

    Bilateral prophylactic mastectomy (BPM) has demonstrated breast cancer risk reduction in high-risk/ BRCA + patients. However, priority of active cancers coupled with inefficient use of operating room (OR) resources presents challenges in offering BPM in a timely manner. To address these challenges, a rapid access prophylactic mastectomy and immediate reconstruction (RAPMIR) program was innovated. The purpose of this study was to evaluate RAPMIR with regards to access to care and efficiency. We retrospectively reviewed the cases of all high-risk/ BRCA + patients having had BPM between September 2012 and August 2014. Patients were divided into 2 groups: those managed through the traditional model and those managed through the RAPMIR model. RAPMIR leverages 2 concurrently running ORs with surgical oncology and plastic surgery moving between rooms to complete 3 combined BPMs with immediate reconstruction in addition to 1-2 independent cases each operative day. RAPMIR eligibility criteria included high-risk/ BRCA + status; BPM with immediate, implant-based reconstruction; and day surgery candidacy. Wait times, case volumes and patient throughput were measured and compared. There were 16 traditional patients and 13 RAPMIR patients. Mean wait time (days from referral to surgery) for RAPMIR was significantly shorter than for the traditional model (165.4 v. 309.2 d, p = 0.027). Daily patient throughput (4.3 v. 2.8), plastic surgery case volume (3.7 v. 1.6) and surgical oncology case volume (3.0 v. 2.2) were significantly greater in the RAPMIR model than the traditional model ( p = 0.003, p < 0.001 and p = 0.015, respectively). A multidisciplinary model with optimized scheduling has the potential to improve access to care and optimize resource utilization.

  20. Pulmonary arteriography in the high-risk patient

    International Nuclear Information System (INIS)

    Perlmutt, L.M.; Braun, S.D.; Newman, G.E.; Dunnick, N.R.

    1986-01-01

    In order to assess the magnitude of risk associated with pulmonary arteriography in patients with pulmonary hypertension and/or right ventricular dysfunction, retrospectively reviewed the incidence of major nonfatal complications and death in patients with these conditions. Of 1,434 examinations, 388 (27%) were performed in patients with pulmonary hypertension and/or elevated right ventricular end-diastolic pressure. Major complications related to contrast agent injection occurred in 30 (2%) of the 1,434 examinations and included chest pain, respiratory distress, arrhythmias, cardiac arrest, and death (two patients). Six (2%) of these complications, including both deaths, occurred in the study group. Both patients who died had severe cardiopulmonary compromise, but most patients with severe cardiopulmonary compromise tolerated angiography well

  1. Incidence of infective endocarditis among patients considered at high risk

    DEFF Research Database (Denmark)

    Østergaard, Lauge; Valeur, Nana; Ihlemann, Nikolaj

    2018-01-01

    and results: Using Danish nationwide registries (1996-2015), we identified all patients with prior IE, a prosthetic heart valve, or a complex CHD (defined as tetralogy of Fallot, truncus arteriosus, and transposition of great arteries) as well as matched control populations. Patients were followed up until...

  2. Original Research Identifying patients at high risk for obstructive ...

    African Journals Online (AJOL)

    This study shows that patients with systemic hypertension, obesity, excessive daytime sleepiness, history of smoking, snoring in a first- degree relative and use of ... alcohol, tobacco, and sedatives and menopause in women.1–4. Screening ..... Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003 ...

  3. Identifying patients at high risk for obstructive sleep apnoea ...

    African Journals Online (AJOL)

    Background: Obstructive sleep apnoea is associated with significant health consequences. A significant proportion of hospitalized patients at risk for obstructive sleep apnoea were never identified and referred for polysomnography for diagnosis. The objective of this study was to determine the factors associated with high ...

  4. Hypertensive patients and diabetes : A high-risk population

    NARCIS (Netherlands)

    Bilo, HJG; Gans, ROB

    1998-01-01

    Rising worldwide rates of diabetes mellitus heighten the need to maintain adequate metabolic control in diabetic patients and to control for other cardiovascular risk factors, such as lipid profile disturbances, high blood pressure, and smoking habits. This is especially the case in diabetic

  5. Endovascular Stenting of Peripheral Infected Aneurysms: A Temporary Measure or a Definitive Solution in High-Risk Patients

    International Nuclear Information System (INIS)

    Riga, Celia; Bicknell, Colin; Jindal, Ravul; Cheshire, Nicholas; Hamady, Mohamad

    2008-01-01

    The purpose of this study was to demonstrate the use of endovascular technology in the management of peripheral infected aneurysms in high-risk patients as a temporary measure or definitive solution. Five cases underwent successful endovascular stenting of infected aneurysms of the subclavian, femoral, and carotid arteries. All these patients were at high risk for open surgery. Covered stents were placed by percutaneous approach under local anesthesia in all patients. Postoperatively, antibiotics were continued for 3 months. A literature review using the Medline database was also undertaken, and all the relevant papers on endovascular management of peripheral infected aneurysms were taken into account. Stent deployment was successful in all patients. One patient died of mediastinal sepsis and another from type A aortic dissection 5 weeks later. Two patients required drainage of the infected hematoma. Three patients did well at a median follow-up of 1 year, with no evidence of sepsis. A review of the literature shows promising early and midterm results. Most early reports were of single cases, reflecting the low incidence of peripheral infected aneurysms. We conclude that further development of endoluminal techniques and long-term follow-up to establish the durability of stenting could potentially lead to a decrease in the high morbidity and mortality rates associated with infected aneurysmal disease in this high-risk group of patients.

  6. Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery.

    Science.gov (United States)

    Vitale, Michael G; Riedel, Matthew D; Glotzbecker, Michael P; Matsumoto, Hiroko; Roye, David P; Akbarnia, Behrooz A; Anderson, Richard C E; Brockmeyer, Douglas L; Emans, John B; Erickson, Mark; Flynn, John M; Lenke, Lawrence G; Lewis, Stephen J; Luhmann, Scott J; McLeod, Lisa M; Newton, Peter O; Nyquist, Ann-Christine; Richards, B Stephens; Shah, Suken A; Skaggs, David L; Smith, John T; Sponseller, Paul D; Sucato, Daniel J; Zeller, Reinhard D; Saiman, Lisa

    2013-01-01

    Perioperative surgical site infection (SSI) after pediatric spine fusion is a recognized complication with rates between 0.5% and 1.6% in adolescent idiopathic scoliosis and up to 22% in "high risk" patients. Significant variation in the approach to infection prophylaxis has been well documented. The purpose of this initiative is to develop a consensus-based "Best Practice" Guideline (BPG), informed by both the available evidence in the literature and expert opinion, for high-risk pediatric patients undergoing spine fusion. For the purpose of this effort, high risk was defined as anything other than a primary fusion in a patient with idiopathic scoliosis without significant comorbidities. The ultimate goal of this initiative is to decrease the wide variability in SSI prevention strategies in this area, ultimately leading to improved patient outcomes and reduced health care costs. An expert panel composed of 20 pediatric spine surgeons and 3 infectious disease specialists from North America, selected for their extensive experience in the field of pediatric spine surgery, was developed. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were as follows: (1) surveyed for current practices; (2) presented with a detailed systematic review of the relevant literature; (3) given the opportunity to voice opinion collectively; and (4) asked to vote regarding preferences privately. Round 1 was conducted using an electronic survey. Initial results were compiled and discussed face-to-face. Round 2 was conducted using the Audience Response System, allowing participants to vote for (strongly support or support) or against inclusion of each intervention. Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible. Repeat voting for consensus was performed. Consensus was reached to support 14 SSI prevention strategies and all participants agreed to implement the BPG in their

  7. HIV-2 diagnosis and quantification in high-risk patients

    Directory of Open Access Journals (Sweden)

    Kojic Erna

    2008-08-01

    Full Text Available Abstract Current diagnostic assays for HIV-1 do not always test for the presence of HIV-2 in the United States. We present the case of a patient from Cape Verde, who was admitted to our hospital with rapidly deteriorating neurological function and multiple white matter lesions on MRI likely secondary to progressive multifocal leukoencephalopathy (PML. Initially, the patient had a positive EIA for HIV, but a negative HIV-1 Western Blot and no viral load detected on a branched-DNA assay. A repeat viral load by reverse transcriptase methodology (RT-DNA detected 121,000 copies and an HIV-2 Western Blot was positive. The case highlights an extremely rare presentation of HIV-2 with severe neurological disease. We discuss the different tests available for the diagnosis and monitoring of HIV-2 in the United States.

  8. Hand-Assisted Robotic Surgery for Staging of Ovarian Cancer and Uterine Cancers With High Risk of Peritoneal Spread: A Retrospective Cohort Study.

    Science.gov (United States)

    Fornalik, Hubert; Brooks, Hannah; Moore, Elizabeth S; Flanders, Nicole L; Callahan, Michael J; Sutton, Gregory P

    2015-10-01

    This study aimed to determine surgical outcomes related to hand-assisted robotic surgery (HARS) for staging of ovarian cancer and uterine cancers with high risk of peritoneal spread and compare them to laparotomy and standard robotic-assisted surgery. A retrospective cohort study of women undergoing staging for uterine and ovarian cancer between January 2011 and July 2013 at a major metropolitan teaching hospital was reviewed. Patients undergoing HARS were matched with patients undergoing staging laparotomy [exploratory laparotomy (XLAP)] for the same indications and with patients undergoing traditional robotic surgery (RS) for staging of endometrioid endometrial cancer. In HARS, a longer incision is used to allow palpation of the peritoneal surfaces, to exteriorize the small bowel, to examine the mesentery, and to perform omentectomy. One hundred five patients were analyzed (15 HARS, 45 RS, 45 XLAP). Compared with XLAP, HARS was associated with decreased blood loss (200 vs 400 mL, P = 0.011) and shorter hospital stay (1 vs 4 days, P < 0.001). Patients who had undergone HARS had fewer major complications, but those results did not reach statistical significance (0% vs 27%, P = 0.063). Hand-assisted robotic surgery was associated with higher blood loss and length of stay as compared to robotic staging of endometrioid endometrial cancer (RS). Minor wound complications were also more common (27% vs 2%, P = 0.012). Hand-assisted robotic surgery allows for thorough visual and tactile assessment of peritoneal surfaces. It represents a safe alternative to laparotomy for staging of ovarian and uterine cancers with high risk of peritoneal spread. Long-term follow-up study is needed to determine oncologic adequacy of HARS.

  9. Hybrid approach for transcatheter paravalvular leak closure of mitral prosthesis in high-risk patients through transapical access.

    Science.gov (United States)

    Davidavicius, Giedrius; Rucinskas, Kestutis; Drasutiene, Agne; Samalavicius, Robertas; Bilkis, Valdas; Zakarkaite, Diana; Aidietis, Audrius

    2014-11-01

    To report "hybrid" procedure feasibility and the clinical success of transcatheter paravalvular leak closure through apical access. Seven patients (73.6±6.1 years; 4 men) with severe mitral prosthesis paravalvular leak were selected. All patients were at high risk for open surgery because of severe comorbidities and heart failure (New York Heart Association class III-IV). The defect size was 25±7.8 mm in the long axis and 9.3±2 mm in the short axis. Two defects were detected in 2 patients. The transapical procedure was performed in a "hybrid" surgery room using minithoracotomy and general anesthesia. Three-dimensional transesophageal echocardiography and fluoroscopy were used for imaging. A total of 19 Amplatzer Vascular Plug III devices (St Jude Medical) were implanted in 7 patients, 2.7/patient and 1 to 3/fistula. The procedure time was 150.7±66.8 minutes. In 6 of 7 patients (85.7%), the paravalvular leak was successfully closed, resulting in no or mild residual regurgitation. One patient had moderate regurgitation despite deployment of 3 Amplatzer Vascular Plug III devices. Two patients required blood transfusion related to procedural blood loss. The patients were discharged at 15.3±6.5 days and followed up at 215.7±138.6 days. All but 1 patient reported symptomatic improvement by ≥1 New York Heart Association class at follow-up. One patient died 216 days postoperatively. A "hybrid approach" for transcatheter paravalvular leak closure of mitral prosthesis from the apical route is effective in reducing the regurgitation grade and improving functional capacity in high-risk patients. Complete closure of the defect was maintained at follow-up in most patients. Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

  10. Identifying patients at high risk of tuberculosis recurrence

    Directory of Open Access Journals (Sweden)

    Ruxana T Sadikot

    2016-01-01

    Full Text Available Several studies have been done in relation to recurrence of tuberculosis (TB following completion of treatment. However, recurrence of TB is still a major problem from a public health perspective in high-burden countries, where no special attention is being given to this issue. Disease recurrence is an important indicator of the efficacy of antituberculosis treatment. The rate of recurrence is highly variable and has been estimated to range from 4.9% to 25%. This variability is not only a reflection of regional epidemiology of recurrence but differences in the definitions used by the TB control programs. In addition to treatment failure related to medication adherence, there are several key host factors that are associated with high rates of recurrence. The widely recognized host factors independent of treatment program that predispose to TB recurrence include: malnutrition; human immunodeficiency virus; substance abuse including tobacco use; comorbidity such as diabetes, renal failure and systemic diseases, especially immunosuppressive states; and environmental exposure such as silicosis. With improved understanding of the human genome, proteome, and metabolome, additional host-specific factors that predispose to recurrence are being discovered. Information on temporal and geographical trends of TB cases as well as genotyping might provide further information to enable us to fully understand TB recurrence and discriminate between reactivation and new infection. The recently launched World Health Organization End TB Strategy emphasizes the importance of integrated, patient-centered TB care. Continued improvement in diagnosis, treatment approaches, and defining host-specific factors are needed to fully understand the clinical epidemiological and social determinants of TB recurrence.

  11. Contemporary management of patients with high-risk non-muscle-invasive bladder cancer who fail intravesical BCG therapy.

    Science.gov (United States)

    Yates, D R; Rouprêt, M

    2011-08-01

    It is advocated that patients with high-risk non-muscle-invasive bladder cancer (NMIBC) receive an adjuvant course of intravesical Bacille Calmette-Guerin (BCG) as first-line treatment. However, a substantial proportion of patients will 'fail' BCG, either early with persistent (refractory) disease or recur late after a long disease-free interval (relapsing). Guideline recommendation in the 'refractory' setting is radical cystectomy, but there are situations when extirpative surgery is not feasible due to competing co-morbidity, a patient's desire for bladder preservation or reluctance to undergo surgery. In this review, we discuss the contemporary management of NMIBC in patients who have failed prior BCG and are not suitable for radical surgery and highlight the potential options available. These options can be categorised as immunotherapy, chemotherapy, device-assisted therapy and combination therapy. However, the current data are still inadequate to formulate definitive recommendations, and data from ongoing trials and maturing studies will give us an insight into whether there is a realistic efficacious second-line treatment for patients who fail intravesical BCG but are not candidates for definitive surgery.

  12. Ultrasound guided percutaneous cholecystostomy in high-risk patients for surgical intervention

    Science.gov (United States)

    Bakkaloglu, Huseyin; Yanar, Hakan; Guloglu, Recep; Taviloglu, Korhan; Tunca, Fatih; Aksoy, Murat; Ertekin, Cemalettin; Poyanli, Arzu

    2006-01-01

    AIM: To assess the efficacy and safety of ultrasound guided percutaneous cholecystostomy (PC) in the treatment of acute cholecystitis in a well-defined high risk patients under general anesthesia. METHODS: The data of 27 consecutive patients who underwent percutaneous transhepatic cholecystostomy for the management of acute cholecystitis from January 1999 to June 2003 was retrospectively evaluated. All of the patients had both clinical and sonographic signs of acute cholecystitis and had comorbid diseases. RESULTS: Ultrasound revealed gallbladder stones in 25 patients and acalculous cholecystitis in two patients. Cholecystostomy catheters were removed 14-32 d (mean 23 d) after the procedure in cases where complete regression of all symptoms was achieved. There were statistically significant reductions in leukocytosis, (13.7 × 103 ± 1.3 × 103 μg/L vs 13 × 103 ± 1 × 103 μg/L, P < 0.05 for 24 h after PC; 13.7 × 103 ± 1.3 × 103 μg/L vs 8.3 × 103 ± 1.2 × 103 μg/L, P < 0.0001 for 72 h after PC), C -reactive protein (51.2 ± 18.5 mg/L vs 27.3 ± 10.4 mg/L, P < 0.05 for 24 h after PC; 51.2 ± 18.5 mg/L vs 5.4 ± 1.5 mg/L, P < 0.0001 for 72 h after PC), and fever (38 ± 0.35°C vs 37.3 ± 0.32°C, P < 0.05 for 24 h after PC; 38 ± 0.35°C vs 36.9 ± 0.15°C, P < 0.0001 for 72 h after PC). Sphincterotomy and stone extraction was performed successfully with endoscopic retrograde cholangio-pancreatography (ERCP) in three patients. After cholecystostomy, 5 (18%) patients underwent delayed cholecystectomy without any complications. Three out of 22 patients were admitted with recurrent acute cholecystitis during the follow-up and recovered with medical treatment. Catheter dislodgement occurred in three patients spontaneously, and two of them were managed by reinsertion of the catheter. CONCLUSION: As an alternative to surgery, percutan-eous cholecystostomy seems to be a safe method in critically ill patients with acute cholecystitis and can be performed with low

  13. Detection of lower limb deep venous thrombosis in asymptomatic high risk patients using a new radiolabelled thrombus specific agent

    Energy Technology Data Exchange (ETDEWEB)

    Butler, S.P.; Rahman, T.; Boyd S.J. [George Hospital, Sydney (Australia)] [and others

    1995-05-01

    Deep venous thrombosis is a serious consequence of major orthopaedic surgery and non invasive screening with either venous ultrasound or impedance plethysmography is unreliable for detecting or excluding DVT in this group. A new method of thrombus detection has been devised using Tc-99m labelled inhibited recombinant tissue plasminogen activator. The accuracy of scanning with this new radiopharmaceutical in asymptomatic high risk patients was evaluated using venography as the gold standard. 36 consecutive asymptomatic high risk patients (17 total hip, 19 total knee replacements) underwent both a contrast venogram on the operated leg and scintigraphic scan 7 days following operation. Scintigraphic imaging was performed at 4 hours post injection. For the purpose of this analysis, each venogram was divided into a proximal and a distal segment. Venograms were interpreted as being positive, negative or uninterpretable in each segment. Similar analysis of the scintigraphic scans was performed except that all segments were considered to be of diagnostic quality. 57 segments were able to be analysed. Of the 13 thrombosed segments (1 proximal, 12 calf), 12 had positive scans; in the 44 non thrombosed segments, 40 had negative scans. Thus in detecting lower limb thrombosis, scanning had a sensitivity of 92% and a specificity of 91%. Scintigraphic scanning with this new radiopharmaceutical permits accurate detection of thrombus in high risk patients.

  14. Breast cancer size estimation with MRI in BRCA mutation carriers and other high risk patients

    NARCIS (Netherlands)

    Mann, R. M.; Bult, P.; van Laarhoven, H. W. M.; Span, P. N.; Schlooz, M.; Veltman, J.; Hoogerbrugge, N.

    2013-01-01

    Objective: To assess the value of breast MRI in size assessment of breast cancers in high risk patients, including those with a BRCA 1 or 2 mutation. Guidelines recommend invariably breast MRI screening for these patients and therapy is thus based on these findings. However, the accuracy of breast

  15. Prescription of antipsychotic medication to patients at ultra high risk of developing psychosis

    NARCIS (Netherlands)

    Nieman, D.H.; Becker, H.E.; Dingemans, P.M.; van Amelsvoort, T.A.; Haan, L.; van der Gaag, M.; Denys, D.A.J.P.; Linszen, D.H.

    2009-01-01

    Little is known about medication prescription in a naturalistic setting to patients at ultra high risk (UHR) of developing psychosis. Antipsychotic medication prescription to UHR patients is not recommended in clinical practice guidelines based on the current evidence. The aim of this study is to

  16. Identification of high risk patients with hypertrophic cardiomyopathy in a northern Greek population

    Directory of Open Access Journals (Sweden)

    Karvounis Charalambos

    2009-07-01

    Full Text Available Abstract Background The percentage of hypertrophic cardiomyopathy (HCM patients who are in high risk for Sudden Death (SD constitutes only a minority of all HCM population but the incidence of SD in this subset is high (at least 5% annually. The identification of this small but important proportion of high risk HCM patients has been the clue in the clinical evaluation of these patients. Methods Our study cohort consisted from 123 patients with HCM who are currently followed up in our Institution. Five clinical risk factors were assessed: a family history of premature SD, unexplained syncope, Non Sustained Ventricular Tachycardia (NSVT on 24-h ECG monitoring, Abnormal Blood Pressure Response (ABPR during upright exercise testing and Maximum left ventricular Wall Thickness (MWT ≥30 mm. The purpose of our study was the identification of high risk HCM patients coming from Northern Greece. Results Fifteen patients (12.2% of the whole cohort had MWT ≥ 30 mm, 30 patients (24.4% had an ABPR to exercise, 17 patients (13.8% had episodes of NSVT in 24-h Holter monitoring, 17 patients (13.8% suffered from syncope, and 8 patients (6.5% had a positive family history of premature SD. Data analysis revealed that 74 patients (60.1% had none risk factor. Twenty four patients (19.5% had 1 risk factor, 17 patients (13.8% had 2 risk factors, 4 patients (3.25% had 3 risk factors, and 4 patients (3.25% had 4 risk factors, while none patient had 5 risk factors. Twenty five patients (20.3% had 2 or more risk factors. Conclusion This study for the first time confirms that, although a 60% of patients with HCM coming from a regional Greek population are in low risk for SD, a substantial proportion (almost 20% carries a high risk for SD justifying prophylactic therapy with amiodaron or ICD implantation.

  17. Prospective, randomized trial comparing fluids and dobutamine optimization of oxygen delivery in high-risk surgical patients [ISRCTN42445141

    Science.gov (United States)

    Lobo, Suzana M; Lobo, Francisco R; Polachini, Carlos A; Patini, Daniela S; Yamamoto, Adriana E; de Oliveira, Neymar E; Serrano, Patricia; Sanches, Helder S; Spegiorin, Marco A; Queiroz, Marcio M; Christiano, Antonio C; Savieiro, Elisangela F; Alvarez, Paula A; Teixeira, Silvia P; Cunrath, Geni S

    2006-01-01

    Introduction Preventing perioperative tissue oxygen debt contributes to a better postoperative recovery. Whether the beneficial effects of fluids and inotropes during optimization of the oxygen delivery index (DO2I) in high-risk patients submitted to major surgeries are due to fluids, to inotropes, or to the combination of the two is not known. We aimed to investigate the effect of DO2I optimization with fluids or with fluids and dobutamine on the 60-day hospital mortality and incidence of complications. Methods A randomized and controlled trial was performed in 50 high-risk patients (elderly with coexistent pathologies) undergoing major elective surgery. Therapy consisted of pulmonary artery catheter-guided hemodynamic optimization during the operation and 24 hours postoperatively using either fluids alone (n = 25) or fluids and dobutamine (n = 25), aiming to achieve supranormal values (DO2I > 600 ml/minute/m2). Results The cardiovascular depression was an important component in the perioperative period in this group of patients. Cardiovascular complications in the postoperative period occurred significantly more frequently in the volume group (13/25, 52%) than in the dobutamine group (4/25, 16%) (relative risk, 3.25; 95% confidence interval, 1.22–8.60; P < 0.05). The 60-day mortality rates were 28% in the volume group and 8% in the dobutamine group (relative risk, 3.00; 95% confidence interval, 0.67–13.46; not significant). Conclusion In patients with high risk of perioperative death, pulmonary artery catheter-guided hemodynamic optimization using dobutamine determines better outcomes, whereas fluids alone increase the incidence of postoperative complications. PMID:16696864

  18. Comparison of ramosetron with ondansetron for the prevention of post-operative nausea and vomiting in high-risk patients

    Directory of Open Access Journals (Sweden)

    Sandip Agarkar

    2015-01-01

    Full Text Available Background and Aims: Post-operative nausea and vomiting (PONV has an 80% incidence in high-risk patients. This is despite the availability of several antiemetic drugs. Selective 5-hydroxytryptamine type 3 (5-HT 3 receptor antagonists are considered first-line for prophylaxis, ondansetron being the most commonly used agent. Ramosetron, another selective 5-HT 3 receptor antagonist, is more potent and longer acting than ondansetron. This study was conducted to evaluate the antiemetic efficacy of ramosetron in comparison with ondansetron in patients at a high risk of PONV. Methods: This was a prospective randomised double-blind study carried out over a 6-month period in which 206 patients with at least two risk factors for PONV were randomised to receive ramosetron 0.3 mg or ondansetron 8 mg, 30 min before the end of surgery. The incidence of PONV, severity of nausea and need for rescue antiemetic were recorded over the next 24 h. Primary outcome was the incidence of PONV. Secondary outcomes included severity of nausea and need for rescue. The data were analysed using the Predictive Analytics Software (PASW, version 18: Chicago, IL, USA. Results: The incidence of PONV was found to be 35% in the ramosetron group as opposed to 43.7% in the ondansetron group (P = 0.199. Need for rescue antiemetic was 23.3% in the ramosetron group and 32% in the ondansetron group (P = 0.156 in the 24 h following surgery. Conclusion: Ramosetron 0.3 mg and ondansetron 8 mg were equally effective in reducing the incidence of PONV in high risk patients.

  19. Influence of early goal-directed therapy using arterial waveform analysis on major complications after high-risk abdominal surgery : study protocol for a multicenter randomized controlled superiority trial

    NARCIS (Netherlands)

    Montenij, Leonard; de Waal, Eric; Frank, Michael; van Beest, Paul; de Wit, Ardine; Kruitwagen, Cas; Buhre, Wolfgang; Scheeren, Thomas

    2014-01-01

    Background:  Early goal-directed therapy refers to the use of predefined hemodynamic goals to optimize tissue oxygen delivery in critically ill patients. Its application in high-risk abdominal surgery is, however, hindered by safety concerns and practical limitations of perioperative hemodynamic

  20. Treatment patterns in patients with osteoporosis at high risk of fracture in Japan: retrospective chart review.

    Science.gov (United States)

    Fujiwara, Saeko; Miyauchi, Akimitsu; Hamaya, Etsuro; Nicholls, Rebecca Jayne; Weston, Adele; Baidya, Santwona; Pinto, Lionel; Barron, Rich; Takada, Junichi

    2018-03-22

    Osteoporosis (OP) causes reduced bone strength and increases risk of fractures. Medical records from specialist clinics in Japan of postmenopausal women with OP and high risk of fracture were analysed. Majority of patients were treated for OP as recommended and were prescribed OP medications soon after high-risk OP diagnosis. The incidence of osteoporosis (OP) in Japan is predicted to increase significantly in coming decades. Resultant osteoporotic fractures are a significant contributor of economic and social burden among elderly osteoporosis patients. This retrospective chart review was conducted as a response to the current evidence gap in the treatment patterns for OP patients with high risk of fracture in Japan. This was a multi-centre retrospective chart review that analysed data extracted from the medical records of postmenopausal OP patients at high risk for fracture who received care at 11 specialist clinics and medical centers in Japan for at least 18 to 24 months. Main outcome was OP treatment patterns. The study included 709 eligible patients of whom 623 (87.9%) were prescribed OP medication during the study period. The most common reason for not taking OP medication was patient unwillingness to take medication. The most common OP medications prescribed initially were minodronic acid (20.1%), alendronate (19.9%), raloxifene (14.1%), weekly teriparatide acetate (12.4%) and eldecalcitol (11.4%). Majority of patients (62.1%) were still taking their initial medication at the end of the 18-24 month follow-up. A high percentage of patients (87.9%) in Japan received OP medications soon after their high-risk diagnosis, with bisphosphonates, selective estrogen receptor modulators and teriparatide being the predominant treatment options.

  1. Medical Assistant-based care management for high risk patients in small primary care practices

    DEFF Research Database (Denmark)

    Freund, Tobias; Peters-Klimm, Frank; Boyd, Cynthia M.

    2016-01-01

    Background: Patients with multiple chronic conditions are at high risk of potentially avoidable hospital admissions, which may be reduced by care coordination and self-management support. Medical assistants are an increasingly available resource for patient care in primary care practices. Objective......: To determine whether protocol-based care management delivered by medical assistants improves patient care in patients at high risk of future hospitalization in primary care. Design: Two-year cluster randomized clinical trial. Setting: 115 primary care practices in Germany. Patients: 2,076 patients with type 2...... diabetes, chronic obstructive pulmonary disease, or chronic heart failure and a likelihood of hospitalization in the upper quartile of the population, as predicted by insurance data analysis. Intervention: We compared protocol-based care management including structured assessment, action planning...

  2. High-Risk Palliative Care Patients' Knowledge and Attitudes about Hereditary Cancer Testing and DNA Banking.

    Science.gov (United States)

    Quillin, John M; Emidio, Oluwabunmi; Ma, Brittany; Bailey, Lauryn; Smith, Thomas J; Kang, In Guk; Yu, Brandon J; Owodunni, Oluwafemi Patrick; Abusamaan, Mohammed; Razzak, Rab; Bodurtha, Joann N

    2017-12-04

    Even at the end of life, testing cancer patients for inherited susceptibility may provide life-saving information to their relatives. Prior research suggests palliative care inpatients have suboptimal understanding of genetic importance, and testing may be underutilized in this clinical setting. These conclusions are based on limited research. This study aimed to estimate genetic testing prevalence among high-risk palliative care patients in a National Cancer Institute-designated comprehensive cancer center. We also aimed to understand these patients' understanding of, and attitudes toward, hereditary cancer testing and DNA banking. Palliative care in-patients with cancer completed structured interviews, and their medical records were reviewed. Among patients at high risk for hereditary cancer, we assessed history of genetic testing/DNA banking; and related knowledge and attitudes. Among 24 high-risk patients, 14 (58.3%) said they/their relatives had genetic testing or they had been referred for a genetics consultation. Of the remaining 10 patients, seven (70%) said they would "probably" or "definitely" get tested. Patients who had not had testing were least concerned about the impact of future testing on their family relationships; two (20%) said they were "extremely concerned" about privacy related to genetic testing. Of patients without prior testing, five (50%) said they had heard or read "a fair amount" about genetic testing. No high-risk patients had banked DNA. Overall, 23 (95.8%) said they had heard or read "almost nothing" or "relatively little" about DNA banking. Written materials and clinician discussion were most preferred ways to learn about genetic testing and DNA banking. Overall, this study demonstrates underutilization of genetics services at the end of life continues to be problematic, despite high patient interest.

  3. Use of a combination of CEA and tumor budding to identify high-risk patients with stage II colon cancer.

    Science.gov (United States)

    Du, Changzheng; Xue, Weicheng; Dou, Fangyuan; Peng, Yifan; Yao, Yunfeng; Zhao, Jun; Gu, Jin

    2017-07-24

    High-risk patients with stage II colon cancer may benefit from adjuvant chemotherapy, but identifying this patient population can be difficult. We assessed the prognosis value for predicting tumor progression in patients with stage II colon cancer, of a panel of 2 biomarkers for colon cancer: tumor budding and preoperative carcinoembryonic antigen (CEA). Consecutive patients (N = 134) with stage II colon cancer who underwent curative surgery from 2000 to 2007 were included. Multivariate analysis was used to evaluate the association of CEA and tumor budding grade with 5-year disease-free survival (DFS). The prognostic accuracy of CEA, tumor budding grade and the combination of both (CEA-budding panel) was determined. The study found that both CEA and tumor budding grade were associated with 5-year DFS. The prognostic accuracy for disease progression was higher for the CEA-budding panel (82.1%) than either CEA (70.9%) or tumor budding grade (72.4%) alone. The findings indicate that the combination of CEA levels and tumor budding grade has greater prognostic value for identifying patients with stage II colon cancer who are at high-risk for disease progression, than either marker alone.

  4. Baseline mutational patterns and sustained MRD negativity in patients with high-risk smoldering myeloma.

    Science.gov (United States)

    Mailankody, Sham; Kazandjian, Dickran; Korde, Neha; Roschewski, Mark; Manasanch, Elisabet; Bhutani, Manisha; Tageja, Nishant; Kwok, Mary; Zhang, Yong; Zingone, Adriana; Lamy, Laurence; Costello, Rene; Morrison, Candis; Hultcrantz, Malin; Christofferson, Austin; Washington, Megan; Boateng, Martin; Steinberg, Seth M; Stetler-Stevenson, Maryalice; Figg, William D; Papaemmanuil, Elli; Wilson, Wyndham H; Keats, Jonathan J; Landgren, Ola

    2017-10-10

    Early results of a prospective phase 2 clinical trial of carfilzomib, lenalidomide, and dexamethasone followed by lenalidomide maintenance in high-risk smoldering myeloma showed promising results that were previously published. Here, we provide novel insights into the genetic landscape of high-risk smoldering myeloma and information on sustained minimal residual disease (MRD) negativity with an expanded cohort of patients. Eighteen patients with high-risk smoldering myeloma were enrolled between 29 May 2012, and 14 January 2014. We included patients with newly diagnosed multiple myeloma enrolled in a parallel trial who received the same therapy (reference group). The overall response rate was 100%. With median potential follow-up of 43.3 months, 10 (63%) remain in MRD negativity, and the estimated 4-year progression-free and overall survival rates are 71% and 100%, respectively. Importantly, we report differences in mutational patterns in patients with high-risk smoldering myeloma and newly diagnosed multiple myeloma, reflected in a lower frequency of mutations in significant myeloma genes (6.6% vs 45%) and NFKB pathway genes (6.6% vs 25%). Treatment with carfilzomib, lenalidomide, and dexamethasone followed by lenalidomide maintenance was associated with a 100% response rate and 63% MRD negativity with a safety profile consistent with previous reports for this regimen. This study had a small numbers of participants, but there seemed to be important differences in the genetic landscape of patients with high-risk smoldering myeloma and those with newly diagnosed multiple myeloma, suggestive of a more treatment-responsive biology in early disease.

  5. Social cognition in patients at ultra-high risk for psychosis

    DEFF Research Database (Denmark)

    Glenthøj, Louise B.; Fagerlund, Birgitte; Hjorthøj, Carsten

    2016-01-01

    Objective: Patients at ultra-high risk (UHR) for psychosis show significant impairments in functioning. It is essential to determine which factors influence functioning, as it may have implications for intervention strategies. This study examined whether social cognitive abilities and clinical...... symptoms are associated with functioning and social skills. Methods: The study included 65 UHR patients and 30 healthy controls. Social cognitive function, social skills, and a broad range of functioning measures were assessed. Results: The UHR patients demonstrated significant decrements on The Awareness...... of Social Inferences Task total score (p = .046, d = .51), and on the CANTAB emotion recognition task total percent correct (p = .023, d = .54) displaying particular difficulties in negative affect recognition. The patients exhibited significant impairments in social skills measured with the High Risk...

  6. High-Dose-Rate Brachytherapy Alone for Localized Prostate Cancer in Patients at Moderate or High Risk of Biochemical Recurrence

    Energy Technology Data Exchange (ETDEWEB)

    Hoskin, Peter [Cancer Centre, Mount Vernon Hospital, Northwood, Middlesex (United Kingdom); Rojas, Ana, E-mail: arc03@btconnect.com [Cancer Centre, Mount Vernon Hospital, Northwood, Middlesex (United Kingdom); Lowe, Gerry; Bryant, Linda; Ostler, Peter; Hughes, Rob; Milner, Jessica; Cladd, Helen [Cancer Centre, Mount Vernon Hospital, Northwood, Middlesex (United Kingdom)

    2012-03-15

    Purpose: To evaluate genitourinary (GU) and gastrointestinal (GI) morbidity and biochemical control of disease in patients with localized prostate adenocarcinoma treated with escalating doses per fraction of high-dose rate brachytherapy alone. Methods and Materials: A total of 197 patients were treated with 34 Gy in four fractions, 36 Gy in four fractions, 31.5 Gy in three fractions, or 26 Gy in two fractions. Median follow-up times were 60, 54, 36, and 6 months, respectively. Results: Incidence of early Grade {>=} 3 GU morbidity was 3% to 7%, and Grade 4 was 0% to 4%. During the first 12 weeks, the highest mean International Prostate Symptom Score (IPSS) value was 14, and between 6 months and 5 years it was 8. Grade 3 or 4 early GI morbidity was not observed. The 3-year actuarial rate of Grade 3 GU was 3% to 16%, and was 3% to 7% for strictures requiring surgery (4-year rate). An incidence of 1% Grade 3 GI events was seen at 3 years. Late Grade 4 GU or GI events were not observed. At 3 years, 99% of patients with intermediate-risk and 91% with high-risk disease were free of biochemical relapse (log-rank p = 0.02). Conclusions: There was no significant difference in urinary and rectal morbidity between schedules. Biochemical control of disease in patients with intermediate and high risk of relapse was good.

  7. Off-pump versus on-pump CABG in high-risk patients

    DEFF Research Database (Denmark)

    Linde, Jesper; Møller, Christian; Hughes, Pia

    2006-01-01

    During recent years Conventional Coronary Artery Bypass Grafting (cCABG) and Off-Pump Coronary Bypass (OPCAB) have been compared in several randomised and non-randomised studies. Focus has been on postoperative outcome with short-term follow-up in low-risk patients and therefore little is known...... of the effectiveness of OPCAB in high-risk patients. Furthermore, it is unknown if a potential beneficial short-term outcome is consistent over time....

  8. The patient perspective: utilizing focus groups to inform care coordination for high-risk medicaid populations.

    Science.gov (United States)

    Sheff, Alex; Park, Elyse R; Neagle, Mary; Oreskovic, Nicolas M

    2017-07-25

    Care coordination programs for high-risk, high-cost patients are a critical component of population health management. These programs aim to improve outcomes and reduce costs and have proliferated over the last decade. Some programs, originally designed for Medicare patients, are now transitioning to also serve Medicaid populations. However, there are still gaps in the understanding of what barriers to care Medicaid patients experience, and what supports will be most effective for providing them care coordination. We conducted two focus groups (n = 13) and thematic analyses to assess the outcomes drivers and programmatic preferences of Medicaid patients enrolled in a high-risk care coordination program at a major academic medical center in Boston, MA. Two focus groups identified areas where care coordination efforts were having a positive impact, as well as areas of unmet needs among the Medicaid population. Six themes emerged from the focus groups that clustered in three groupings: In the first group (1) enrollment in an existing medical care coordination programs, and (2) provider communication largely presented as positive accounts of assistance, and good relationships with providers, though participants also pointed to areas where these efforts fell short. In the second group (3) trauma histories, (4) mental health challenges, and (5) executive function difficulties all presented challenges faced by high-risk Medicaid patients that would likely require redress through additional programmatic supports. Finally, in the third group, (6) peer-to-peer support tendencies among patients suggested an untapped resource for care coordination programs. Programs aimed at high-risk Medicaid patients will want to consider programmatic adjustments to attend to patient needs in five areas: (1) provider connection/care coordination, (2) trauma, (3) mental health, (4) executive function/paperwork and coaching support, and (5) peer-to-peer support.

  9. Radical Prostatectomy is a Valuable Treatment Alternative in Patients with High-Risk Prostate Cancer

    Directory of Open Access Journals (Sweden)

    Naşide Mangır

    2015-09-01

    Full Text Available Objective To review the high-risk prostate cancer (PCa patient database with special emphasis on the role of radical prostatectomy (RP in comparison to external beam radiotherapy (EBRT. Materials and Methods A total of 102 patients with complete and long-term follow-up data were included. High-risk PCa was defined as: a pre-treatment PSA level of ≥20 ng/mL and/or a primary Gleason score of ≥4 and/or clinical stage ≥T3N0M0 disease. A total of 45 (42.5% patients underwent radical RP with extended pelvic lymphadenectomy for-high risk PCa and a total of 57 (53.8% patients received EBRT. Results The mean overall survival (mean survival 95.2 vs. 129.2 months, log rank p=0.73 and cancer-specific survival (mean survival 104 vs. 151.4 months, log rank p=0.35 were not significantly different between RP and EBRT groups. Univariate analysis of variables that may affect overall survival showed no significant effect of pre-treatment PSA, Gleason score, clinical stage or type of therapy. The only factor which reached statistical significance was patient age (p=0.002. Multivariate analysis of variables also showed no significant effect of pre-treatment PSA, Gleason score, clinical stage or type of therapy and, again, the only factor which reached statistical significance was patient age (p=0.012. Conclusion Radical prostatectomy appears to be an effective and a non-inferior treatment option in patients with high-risk localized PCa with acceptable overall and cancer-specific survival compared to RT. Therefore, as the guidelines suggest, it should be provided as an option during patient consultation for a proper informed decision-making.

  10. The effects of intra-aortic balloon pump in coronary stenting for high risk patients

    International Nuclear Information System (INIS)

    Zhang Qi; Shen Weifeng; Zhang Jianshen; Zhang Ruiyan; Hu Jian; Zhang Xian

    2003-01-01

    Objective: To evaluate the therapeutic efficacy of intra-aortic balloon supporting in coronary interventions for high risk patients with coronary artery disease (CAD). Methods: Sixteen high risk CAD patients accepted percutaneous coronary intervention assisted by intra-aortic balloon pumping together with clinical variables, procedural and follow-up informations were recorded and evaluated. Results: All patients presented with severe left ventricular dysfunction, multi-vessel disease and high jeopardy scores. 12 patients acquired complete revascularization. Mean duration of balloon pumping was (31 ± 17) minutes. Aortic diastolic and mean pressures were increased during balloon pumping [diastolic: (69±11) mmHg pre. vs (131±15) mmHg post.; mean: (82±13) mmHg pre. vs (111±7) mmHg post., P<0.001]. With average of 2 years follow-up, one patient died from pump failure but no MACE reaching survival rate of 75%. The ejection fraction and the NYHA grade were significantly improved. Conclusions: Intra-aortic balloon pumping is a safe and effective method in treating high risk CAD patients obtaining rather fare prognosis

  11. Selective screening of 650 high risk Iranian patients for detection of inborn error of metabolism

    Directory of Open Access Journals (Sweden)

    Narges Pishva

    2015-02-01

    Full Text Available Objective: Although metabolic diseases individually are rare ,but overall have an incidence of 1/2000 and can cause devastating and irreversible effect if not diagnosed early and treated promptly. selective screening is an acceptable method for detection of these multi presentation diseases.Method: using panel neonatal screening for detection of metabolic diseases in 650 high risk Iranian patients in Fars province. The following clinical features were used as inclusion criteria for investigation of the patients.Lethargy, poor feeding ,persistent vomiting, cholestasis, intractable seizure ,decreased level of consciousness ,persistent hypoglycemia, unexplained acid base disturbance and unexplained neonatal death.Result: Organic acidemia with 40 cases (42% was the most frequent disorder diagnosed in our high risk populations, followed by disorder of galactose metabolism(30%, 15 patient had classic galactosemia(GALT

  12. Selective screening of 650 high risk Iranian patients for detection of inborn error of metabolism

    Directory of Open Access Journals (Sweden)

    Narges Pishva

    2015-02-01

    Full Text Available Objective: Although metabolic diseases individually are rare ,but overall have an incidence of 1/2000 and can cause devastating and irreversible effect if not diagnosed early and treated promptly. selective screening is an acceptable method for detection of these multi presentation diseases. Method: using panel neonatal screening for detection of metabolic diseases in 650 high risk Iranian patients in Fars province. The following clinical features were used as inclusion criteria for investigation of the patients. Lethargy, poor feeding ,persistent vomiting, cholestasis, intractable seizure ,decreased level of consciousness ,persistent hypoglycemia, unexplained acid base disturbance and unexplained neonatal death. Result: Organic acidemia with 40 cases (42% was the most frequent disorder diagnosed in our high risk populations, followed by disorder of galactose metabolism(30%, 15 patient had classic galactosemia(GALT

  13. Breast cancer size estimation with MRI in BRCA mutation carriers and other high risk patients

    Energy Technology Data Exchange (ETDEWEB)

    Mann, R.M., E-mail: r.mann@rad.umcn.nl [Radboud University Nijmegen Medical Centre, Department of Radiology, Nijmegen (Netherlands); Bult, P., E-mail: p.bult@path.umcn.nl [Radboud University Nijmegen Medical Centre, Department of Pathology, Nijmegen (Netherlands); Laarhoven, H.W.M. van, E-mail: h.vanlaarhoven@amc.uva.nl [Academic Medical Centre, University of Amsterdam, Department of Medical Oncology, Amsterdam (Netherlands); Radboud University Nijmegen Medical Centre, Department of Medical Oncology, Nijmegen (Netherlands); Span, P.N., E-mail: p.span@rther.umcn.nl [Radboud University Nijmegen Medical Centre, Department of Radiation Oncology, Nijmegen (Netherlands); Schlooz, M., E-mail: m.schlooz@chir.umcn.nl [Radboud University Nijmegen Medical Centre, Department of Surgery, Nijmegen (Netherlands); Veltman, J., E-mail: j.veltman@zgt.nl [Hospital group Twente (ZGT), Department of Radiology, Almelo (Netherlands); Hoogerbrugge, N., E-mail: n.hoogerbrugge@gen.umcn.nl [Radboud University Nijmegen Medical Centre, Department of Human Genetics, Nijmegen (Netherlands)

    2013-09-15

    Objective: To assess the value of breast MRI in size assessment of breast cancers in high risk patients, including those with a BRCA 1 or 2 mutation. Guidelines recommend invariably breast MRI screening for these patients and therapy is thus based on these findings. However, the accuracy of breast MRI for staging purposes is only tested in sporadic cancers. Methods: We assessed concordance of radiologic staging using MRI with histopathology in 49 tumors in 46 high risk patients (23 BRCA1, 12 BRCA2 and 11 Non-BRCA patients). The size of the total tumor area (TTA) was compared to pathology. In invasive carcinomas (n = 45) the size of the largest focus (LF) was also addressed. Results: Correlation of MRI measurements with pathology was 0.862 for TTA and 0.793 for LF. TTA was underestimated in 8(16%), overestimated in 5(10%), and correctly measured in 36(73%) cases. LF was underestimated in 4(9%), overestimated in 5(11%), and correctly measured in 36(80%) cases. Impact of BRCA 1 or 2 mutations on the quality of size estimation was not observed. Conclusions: Tumor size estimation using breast MRI in high risk patients is comparable to its performance in sporadic cancers. Therefore, breast MRI can safely be used for treatment planning.

  14. Diagnostic accuracy of high-definition CT coronary angiography in high-risk patients.

    Science.gov (United States)

    Iyengar, S S; Morgan-Hughes, G; Ukoumunne, O; Clayton, B; Davies, E J; Nikolaou, V; Hyde, C J; Shore, A C; Roobottom, C A

    2016-02-01

    To assess the diagnostic accuracy of computed tomography coronary angiography (CTCA) using a combination of high-definition CT (HD-CTCA) and high level of reader experience, with invasive coronary angiography (ICA) as the reference standard, in high-risk patients for the investigation of coronary artery disease (CAD). Three hundred high-risk patients underwent HD-CTCA and ICA. Independent experts evaluated the images for the presence of significant CAD, defined primarily as the presence of moderate (≥ 50%) stenosis and secondarily as the presence of severe (≥ 70%) stenosis in at least one coronary segment, in a blinded fashion. HD-CTCA was compared to ICA as the reference standard. No patients were excluded. Two hundred and six patients (69%) had moderate and 178 (59%) had severe stenosis in at least one vessel at ICA. The sensitivity, specificity, positive predictive value, and negative predictive value were 97.1%, 97.9%, 99% and 93.9% for moderate stenosis, and 98.9%, 93.4%, 95.7% and 98.3%, for severe stenosis, on a per-patient basis. The combination of HD-CTCA and experienced readers applied to a high-risk population, results in high diagnostic accuracy comparable to ICA. Modern generation CT systems in experienced hands might be considered for an expanded role. Copyright © 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

  15. Diagnostic accuracy of high-definition CT coronary angiography in high-risk patients

    International Nuclear Information System (INIS)

    Iyengar, S.S.; Morgan-Hughes, G.; Ukoumunne, O.; Clayton, B.; Davies, E.J.; Nikolaou, V.; Hyde, C.J.; Shore, A.C.; Roobottom, C.A.

    2016-01-01

    Aim: To assess the diagnostic accuracy of computed tomography coronary angiography (CTCA) using a combination of high-definition CT (HD-CTCA) and high level of reader experience, with invasive coronary angiography (ICA) as the reference standard, in high-risk patients for the investigation of coronary artery disease (CAD). Materials and methods: Three hundred high-risk patients underwent HD-CTCA and ICA. Independent experts evaluated the images for the presence of significant CAD, defined primarily as the presence of moderate (≥50%) stenosis and secondarily as the presence of severe (≥70%) stenosis in at least one coronary segment, in a blinded fashion. HD-CTCA was compared to ICA as the reference standard. Results: No patients were excluded. Two hundred and six patients (69%) had moderate and 178 (59%) had severe stenosis in at least one vessel at ICA. The sensitivity, specificity, positive predictive value, and negative predictive value were 97.1%, 97.9%, 99% and 93.9% for moderate stenosis, and 98.9%, 93.4%, 95.7% and 98.3%, for severe stenosis, on a per-patient basis. Conclusion: The combination of HD-CTCA and experienced readers applied to a high-risk population, results in high diagnostic accuracy comparable to ICA. Modern generation CT systems in experienced hands might be considered for an expanded role. - Highlights: • Diagnostic accuracy of High-Definition CT Angiography (HD-CTCA) has been assessed. • Invasive Coronary angiography (ICA) is the reference standard. • Diagnostic accuracy of HD-CTCA is comparable to ICA. • Diagnostic accuracy is not affected by coronary calcium or stents. • HD-CTCA provides a non-invasive alternative in high-risk patients.

  16. Audit of co-management and critical care outreach for high risk postoperative patients (The POST audit).

    Science.gov (United States)

    Story, D A; Shelton, A; Jones, D; Heland, M; Belomo, R

    2013-11-01

    Co-management and critical care outreach for high risk surgical patients have been proposed to decrease postoperative complications and mortality. We proposed that a clinical project with postoperative comanagement and critical care outreach, the Post Operative Surveillance Team: (POST), would be associated with decreased hospital length of stay. We conducted a retrospective before (control group) and after (POST group) audit of this hospital program. POST was staffed for four months in 2010 by two intensive care nurses and two senior registrars who conducted daily ward rounds for the first five postoperative days on high risk patients undergoing inpatient general or urological surgery. The primary endpoint was length of hospital stay and secondary endpoints were Medical Emergency Team (MET) calls, cardiac arrests and in-hospital mortality. There were 194 patients in the POST group and 1,185 in the control group. The length of stay in the POST group, median nine days (Inter-quartile range [IQR]: 5 to 17 days), was longer than the control group, median seven days (IQR: 4 to 13 days): difference two days longer (95.0% confidence interval [95.0% CI]: 1 to 3 days longer, P management, different to POST, or with different performance metrics, could be tested.

  17. Patients with a high risk for obstructive sleep apnea syndrome: Postoperative respiratory complications

    Directory of Open Access Journals (Sweden)

    H. Pereira

    2013-07-01

    Full Text Available Background: STOP-BANG score (snore; tired; observed apnea; arterial pressure; body mass index; age; neck circumference and gender can predict the risk of a patient having Obstructive Syndrome Apnea (OSA. The aim of this study was to evaluate the incidence STOP-BANG score ≥ 3, in surgical patients admitted to the Post-Anesthesia Care Unit (PACU. Methods: Observational, prospective study conducted in a post-anesthesia care unit (PACU during three weeks (2011. The study population consisted of adult patients after noncardiac and non-neurological surgery. Patients were classified as high risk of OSA (HR-OSA if STOP-BANG score ≥ 3 and Low-risk of OSA (LR-OSA if STOP-BANG score  3, em pacientes cirúrgicos internados na Unidade de Cuidados Pós-Anestésica (UCPA. Métodos: Estudo observacional e prospectivo conduzido numa UCPA, durante três semanas (2011. A população de estudo consistiu em doentes adultos após cirurgia não cardíaca e não neurológica. Os doentes foram considerados com alto risco de SAOS (AR-SAOS se tinham um score de STOP-BANG ≥3 e de baixo risco de SAOS (BR-SAOS se tinham score de STOP-BANG <3. Foram avaliados dados demográficos dos doentes e colhidas variáveis intraoperatórias e pós-operatórias. As características dos doentes foram comparadas através do teste de Mann-Whitney, teste t, qui-quadrado ou teste exato de Fisher. Resultados: Um total de 357 doentes foram admitidos de UCPA e 340 preencheram os critérios de inclusão. Cento e setenta e nove (52% tinham AR-SAOS. Estes doentes eram mais velhos, tinham maior probabilidade de serem do sexo masculino, tinham um Índice Massa Corporal superior, tiveram uma classificação maior no estado físico American Society Anesthesiologists, uma maior incidência de doença cardíaca isquémica, insuficiência cardíaca, hipertensão, dislipidemia e eram mais frequentemente doentes

  18. Comparison of primary radiation versus robotic surgery plus adjuvant radiation in high-risk prostate cancer: A single center experience

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    Prabhsimranjot Singh

    2015-01-01

    Full Text Available Objective: The objective of this study was to compare robotic-prostatectomy plus adjuvant radiation therapy (RPRAT versus primary RT for high-risk prostate cancer (HRPCa. Materials and Methods: A retrospective chart review was performed for the HRPCa patients treated in our institution between 2000 and 2010. One hundred and twenty-three patients with high-risk disease were identified. The Chi-square test and Fisher′s exact test were used to compare local control and distant failure rates between the two treatment modalities. For prostate-specific antigen comparisons between groups, Wilcoxon rank-sum test was used. Results: The median follow-up was 49 months (range: 3-138 months. Local control, biochemical recurrence rate, distant metastasis, toxicity, and disease-free survival were similar in the two groups. Conclusions: Primary RT is an excellent treatment option in patients with HRPCa, is equally effective and less expensive treatment compared with RPRAT. A prospective randomized study is required to guide treatment for patients with HRPCa.

  19. Guideline adherence for identification and hydration of high-risk hospital patients for contrast-induced nephropathy.

    NARCIS (Netherlands)

    Schilp, J.; Blok, C. de; Langelaan, M.; Spreeuwenberg, P.; Wagner, C.

    2014-01-01

    Background: Contrast-induced nephropathy (CIN) is a common cause of acute renal failure in hospital patients. To prevent CIN, identification and hydration of high-risk patients is important. Prevention of CIN by hydration of high-risk patients was one of the themes to be implemented in the Dutch

  20. Guideline adherence for identification and hydration of high-risk hospital patients for contrast-induced nephropathy

    NARCIS (Netherlands)

    Schilp, J.; de Blok, C.; Langelaan, M.; Spreeuwenberg, P.; Wagner, C.

    2014-01-01

    Background: Contrast-induced nephropathy (CIN) is a common cause of acute renal failure in hospital patients. To prevent CIN, identification and hydration of high-risk patients is important. Prevention of CIN by hydration of high-risk patients was one of the themes to be implemented in the Dutch

  1. A multidisciplinary team care approach improves outcomes in high-risk pediatric neuroblastoma patients.

    Science.gov (United States)

    Chang, Hsiu-Hao; Liu, Yen-Lin; Lu, Meng-Yao; Jou, Shiann-Tarng; Yang, Yung-Li; Lin, Dong-Tsamn; Lin, Kai-Hsin; Tzen, Kai-Yuan; Yen, Ruoh-Fang; Lu, Ching-Chu; Liu, Chia-Ju; Peng, Steven Shinn-Forng; Jeng, Yung-Ming; Huang, Shiu-Feng; Lee, Hsinyu; Juan, Hsueh-Fen; Huang, Min-Chuan; Liao, Yung-Feng; Lee, Ya-Ling; Hsu, Wen-Ming

    2017-01-17

    We assessed the impact of a multidisciplinary team care program on treatment outcomes in neuroblastoma patients. Newly diagnosed neuroblastoma patients received treatment under the Taiwan Pediatric Oncology Group (TPOG) N2002 protocol at the National Taiwan University Hospital beginning in 2002. A multidisciplinary team care approach that included nurse-led case management for patients treated under this protocol began in January 2010. Fifty-eight neuroblastoma patients, including 29 treated between 2002 and 2009 (Group 1) and 29 treated between 2010 and 2014 (Group 2), were enrolled in the study. The 5-year overall survival (OS) and event-free survival (EFS) rates for all 58 patients were 59% and 54.7%, respectively. Group 2 patients, who were treated after implementation of the multidisciplinary team care program, had better 3-year EFS (P = 0.046), but not OS (P = 0.16), rates than Group 1 patients. In a multivariate analysis, implementation of the multidisciplinary team approach was the only significant independent prognostic factor for neuroblastoma patients. In further subgroup analyses, the multidisciplinary team approach improved EFS, but not OS, in patients with stage 4 disease, those in the high-risk group, and those with non-MYCN amplified tumors. These data indicate a multidisciplinary team care approach improved survival outcomes in high-risk neuroblastoma patients. However, further investigation will be required to evaluate the long-term effects of this approach over longer follow-up periods.

  2. Examining the Association between Vitamin B12 Deficiency and Dementia in High-Risk Hospitalized Patients.

    Science.gov (United States)

    Siswanto, O; Smeall, K; Watson, T; Donnelly-Vanderloo, M; O'Connor, C; Foley, N; Madill, J

    2015-12-01

    To explore the association between vitamin B12 deficiency and dementia in patients at high risk for vitamin B12 deficiency. Chart review. Emergency, critical care/ trauma, neurology, medicine, and rehabilitation units of two hospitals in Southwestern Ontario, Canada. Adult patients (n = 666) admitted from 2010 to 2012. Data collection included: reason for admission, gender, age, clinical signs and symptoms of B12 deficiency, serum B12 concentration, and B12 supplementation. Patients with dementia were identified based on their medication profile and medical history. Vitamin B12 deficiency (pmol/L) was defined as serum B12 concentration 220. Comparisons between B12-deficient patients with and without dementia were examined using parametric and non-parametric tests. Serum B12 values were available for 60% (399/666) of the patients, of whom 4% (16/399) were B12-deficient and 14% (57/399) were marginally deficient. Patients with dementia were not more likely to be B12-deficient or marginally deficient [21% (26/121)] compared to those with no dementia [17% (47/278), p=0.27)]. Based on documentation, 34% (25/73) of the B12-deficient and marginally-deficient patients did not receive B12 supplementation, of whom 40% (10/25) had dementia. In this sample of patients, there was no association between B12 deficiency and dementia. However, appropriate B12 screening protocols are necessary for high risk patient to identify deficiency and then receive B12 supplementation as needed.

  3. High risk for obstructive sleep apnea in patients with acute myocardial infarction

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    Carla Renata Silva Andrechuk

    2015-10-01

    Full Text Available Objectives: to stratify the risk for obstructive sleep apnea in patients with acute myocardial infarction, treated at a public, tertiary, teaching hospital of the state of São Paulo, Brazil, and to identify related sociodemographic and clinical factors.Method: cross-sectional analytical study with 113 patients (mean age 59.57 years, 70.8% male. A specific questionnaire was used for the sociodemographic and clinical characterization and the Berlin Questionnaire for the stratification of the risk of obstructive sleep apnea syndrome.Results: the prevalence of high risk was 60.2% and the outcome of clinical worsening during hospitalization was more frequent among these patients. The factors related to high risk were body mass index over 30 kg/m2, arterial hypertension and waist circumference indicative of cardiovascular risk, while older age (60 years and over constituted a protective factor.Conclusion: considering the high prevalence of obstructive sleep apnea and its relation to clinical worsening, it is suggested that nurses should monitor, in their clinical practice, people at high risk for this syndrome, guiding control measures of modifiable factors and aiming to prevent the associated complications, including worsening of cardiovascular diseases.

  4. Heater probe thermocoagulation for high-risk patients who show rebleeding from peptic ulcers.

    Science.gov (United States)

    Hsieh, Yu-Hsi; Lin, Hwai-Jeng

    2011-08-26

    To investigate whether heater probe therapy is effective for patients showing rebleeding from peptic ulcers. We retrospectively reviewed the case profiles in our previous studies on endoscopic therapy for high-risk patients with peptic ulcer bleeding in the past two decades. We analysed the outcomes of 191 patients who showed rebleeding after initial endoscopic haemostasis and received endoscopic therapy with heater probe thermocoagulation. . A total of 191 patients showing rebleeding received heater probe thermocoagulation. After re-therapy, 158 patients (82.7%) achieved ultimate haemostasis. Twenty-five of the 33 patients who failed to achieve haemostasis received surgical intervention. Ten patients (5.2%) died within 1 month after re-therapy. Heater probe thermocoagulation can be used as the first choice for management of patients showing rebleeding after initial endoscopic therapy.

  5. Mortality, length of hospitalization, and costs associated with invasive fungal infections in high-risk patients.

    Science.gov (United States)

    Menzin, Joseph; Meyers, Juliana L; Friedman, Mark; Perfect, John R; Langston, Amelia A; Danna, Robert P; Papadopoulos, George

    2009-10-01

    The mortality, length of hospitalization, and costs associated with invasive fungal infections (IFIs) in hospitalized patients were studied. This retrospective database study used data from the 2004 Healthcare Cost and Utilization Project Nationwide In-patient Sample. Patients were selected for inclusion based on diagnostic codes corresponding to an IFI. A control group was matched to the IFI group based on high-risk conditions (i.e., cancer, infection with human immunodeficiency virus, chronic obstructive pulmonary disease, diabetes mellitus, and solid-organ, hematopoietic stem cell, or bone marrow transplant), age, sex, and hospital region and teaching status. Excess mortality, length of hospital stay, and costs were estimated as the differences between the IFI and control groups. A total of 11,881 patients were identified with a discharge diagnosis of an IFI who could be matched to a control. Frequent infections included candidiasis (40.2%), other mycoses (36.3%), and aspergillosis (16.4%). Patients with IFIs had a significantly higher mortality rate (15% versus 5%), mean +/- S.E. length of stay (18.7 +/- 0.4 days versus 7.3 +/- 0.1 days), and mean +/- S.E. costs ($44,726 +/- $1,255 versus $15,445 +/- $404) (p < 0.001 for all comparisons) than did patients without IFIs. The burden of IFIs varied by high-risk condition (highest for transplant recipients and patients with cancer) and type of infection (highest for candidiasis, zygomycosis, and aspergillosis). Examination of a large database showed that, compared with high-risk patients without IFIs, those with IFIs had higher mortality, a longer hospital stay, and higher costs associated with their hospitalization.

  6. Prevention and control of proliferative vitreoretinopathy: primary retinal detachment surgery using silicone oil as a planned two-stage procedure in high-risk cases.

    Science.gov (United States)

    Alexander, P; Prasad, R; Ang, A; Poulson, A V; Scott, J D; Snead, M P

    2008-06-01

    For rhegmatogenous retinal detachment, reattachment with a single procedure is associated with better visual outcomes. In the past, silicone oil has been used mostly as a last resort following failed primary surgery. This study evaluates a novel approach to patients at high risk of primary failure, using silicone tamponade as the primary stage of a planned two-stage procedure. We report a series of 140 eyes that underwent primary surgery for rhegmatogenous retinal detachment. Patients at higher risk of surgical failure (eg giant retinal tear, inability to posture, poor view, uncertainty of location of primary break, primary proliferative vitreoretinopathy (PVR), multiple tears with rolled posterior edges, retinoschisis/detachment, staphyloma with macular hole) were managed by a planned staged procedure using primary silicone oil tamponade. This was followed by silicone removal at a later date. Fifty-four eyes underwent scleral buckling alone, with primary success in 52/54 (96%). Fifty-three eyes underwent vitrectomy and gas, achieving primary success in 50/53 (94%). Thirty-three eyes were classified high risk and managed with primary silicone. Silicone was safely removed in 22/25. In eight eyes, silicone was retained without attempt at removal. In total, primary retinal reattachment was achieved in 128 of 140 eyes (91.4%). Of these, 124 (97%) did not require long-term tamponade. Only four eyes (2.9%) developed PVR. A planned two-stage approach to highrisk cases of retinal detachment using primary silicone oil tamponade followed by silicone removal can achieve a high primary reattachment rate with less than 3% incidence of PVR.

  7. The Efficacy of Percutaneous Transhepatic Gallbladder Drainage on Acute Cholecystitis in High-Risk Elderly Patients Based on the Tokyo Guidelines

    Science.gov (United States)

    Ni, Qingqiang; Chen, Dongbo; Xu, Rui; Shang, Dong

    2015-01-01

    Abstract To evaluate the efficacy of percutaneous transhepatic gallbladder drainage (PTGD) for high-risk elderly patients with acute cholecystitis. Retrospective analysis of 159 acute cholecystitis patients who were admitted to General Surgery Division III of the First Affiliated Hospital of Dalian Medical University between January 2005 and November 2012. A total of 123 patients underwent laparoscopic cholecystectomy (LC), and 36 received only PTGD treatment. The LC patients were divided into 3 groups based on their preoperative treatment: group A, emergency patients (33 patients); group B (26 patients), patients who were treated with PTGD prior to LC; and group C (64 patients), patients who received nonsurgical treatment prior to LC. General conditions, LC surgery duration, intraoperative blood loss, rate of conversion to open surgery, incidence of postoperative complications, total fasting time, and total hospitalization time were analyzed and compared among the 3 groups. The remission rates of patients in the PTGD treatment groups (including group B and PTGD treatment only group) were significantly higher within 24 and 48 hours than those of patients who received nonsurgical treatment prior to LC (P cholecystitis patients without surgery contraindications, emergency surgery should be performed as soon as possible after diagnosis. PMID:26313804

  8. Podocyturia as a Diagnostic Marker for Preeclampsia amongst High-Risk Pregnant Patients

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    Belinda Jim

    2012-01-01

    Full Text Available Urinary podocyte (podocyturia has been studied as a diagnostic marker for preeclampsia. We sought to validate its use in preeclampsia and in differentiating it from other high risk pregnancy states. We studied an obstetric population at high risk to develop preeclampsia (study group and uncomplicated pregnancies (control group by analyzing their urine sediment for podocytes within 24 hours of delivery. Podocytes were identified by immunohistochemistry using the podocyte-specific protein synaptopodin. Of the 56 patients who were enrolled, 29 patients were diagnosed with preeclampsia, 9 patients had hypertensive conditions such as chronic and gestational hypertension, 6 patients had Type I/II and gestational diabetes mellitus, 3 patients were classified as others, and 9 patients exhibited uncomplicated pregnancies. Podocyturia was identified in 11 out of 29 (38% of patients with preeclampsia/eclampsia, 3 out of 9 (33% with gestational and chronic hypertension, and 3 out of 6 (50% with Type I/II and gestational diabetes mellitus. None of the 9 patients (0% with uncomplicated pregnancies demonstrated podocyturia. The sensitivity and specificity of podocyturia for preeclampsia were found to be 38% and 70%. Our study showed that podocyturia does not appear to be a sensitive nor a specific marker to diagnose preeclampsia.

  9. Surgical and oncological outcome of laparoscopic surgery, compared to laparotomy, for Japanese patients with endometrial cancer

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    Yasuhisa Terao

    2016-05-01

    Conclusion: Laparoscopic surgery is safe and feasible for patients with early-stage endometrial cancer. However, patients with carcinosarcoma and other histologic types of endometrioid adenocarcinoma require special attention because of the high risk of recurrence and poor prognosis.

  10. Characterization of melanoma susceptibility genes in high-risk patients from Central Italy.

    Science.gov (United States)

    Pellegrini, Cristina; Maturo, Maria Giovanna; Martorelli, Claudia; Suppa, Mariano; Antonini, Ambra; Kostaki, Dimitra; Verna, Lucilla; Landi, Maria Teresa; Peris, Ketty; Fargnoli, Maria Concetta

    2017-06-01

    Genetic susceptibility to cutaneous melanoma has been investigated in Italian high-risk melanoma patients from different geographical regions. CDKN2A, CDK4, and MC1R genes have been screened in most studies, MITF and POT1 were screened in only one study, and none analyzed the TERT promoter. We carried out a mutational analysis of CDKN2A, CDK4 exon 2, POT1 p.S270N, MITF exon 10, MC1R, and the TERT promoter in 106 high-risk patients with familial melanoma (FM) and sporadic multiple primary melanoma (spMPM) from Central Italy and evaluated mutations according to the clinicopathological characteristics of patients and lesions. In FM, CDKN2A mutations were detected in 8.3% of the families, including one undescribed exon 1β mutation (p.T31M), and their prevalence increased with the number of affected relatives within the family. MC1R variants were identified in 65% of the patients and the TERT rs2853669 promoter polymorphism was identified in 58% of the patients. A novel synonymous mutation detected in MITF exon 10 (c.861A>G, p.E287E), although predicted as a splice site mutation by computational tools, could not functionally be confirmed to alter splicing. For spMPM, 3% carried CDKN2A mutations, 79% carried MC1R variants, and 47% carried the TERT rs2853669 promoter polymorphism. MC1R variants were associated with fair skin type and light hair color both in FM and in spMPM, and with a reduction of age at diagnosis in FM patients. Mutations in CDK4 exon 2 and the POT1 p.S270N mutation were not detected. A low frequency of CDKN2A mutations and a high prevalence of MC1R variants characterize high-risk melanoma patients from Central Italy.

  11. Early detection of urothelial premalignant lesions using hexaminolevulinate fluorescence cystoscopy in high risk patients

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    Nespoli Luca

    2010-11-01

    Full Text Available Abstract Background To evaluate fluorescence cystoscopy with hexaminolevulinate (HAL in the early detection of dysplasia (DYS and carcinoma in situ (CIS in select high risk patients. Methods We selected 30 consecutive bladder cancer patients at high risk for progression. After endoscopic resection, all patients received (a induction BCG schedule when needed, and (b white light and fluorescence cystoscopy after 3 months. HAL at doses of 85 mg (GE Healthcare, Buckinghamshire, United Kingdom dissolved in 50 ml of solvent to obtain an 8 mmol/L solution was instilled intravesically with a 12 Fr catheter into an empty bladder and left for 90 minutes. The solution was freshly prepared immediately before instillation. Cystoscopy was performed within 120 minutes of bladder emptying. Standard and fluorescence cystoscopy was performed using a double light system (Combilight PDD light source 5133, Wolf, Germany which allowed an inspection under both white and blue light. Results The overall incidence was 43.3% dysplasia, 23.3% CIS, and 13.3% superficial transitional cell cancer. In 21 patients, HAL cystoscopy was positive with one or more fluorescent flat lesions. Of the positive cases, there were 4 CIS, 10 DYS, 2 association of CIS and DYS, 4 well-differentiated non-infiltrating bladder cancers, and 1 chronic cystitis. In 9 patients with negative HAL results, random biopsies showed 1 CIS and 1 DYS. HAL cystoscopy showed 90.1% sensitivity and 87.5% specificity with 95.2% positive predictive value and 77.8% negative predictive value. Conclusion Photodynamic diagnosis should be considered a very important tool in the diagnosis of potentially evolving flat lesions on the bladder mucosa such as DYS and CIS. Moreover, detection of dysplasic lesions that are considered precursors of CIS may play an important role in preventing disease progression. In our opinion, HAL cystoscopy should be recommended in the early follow-up of high risk patients.

  12. Predictors of Alveolar Process Remodeling Following Ridge Preservation in High-Risk Patients.

    Science.gov (United States)

    Cosyn, Jan; Cleymaet, Roberto; De Bruyn, Hugo

    2016-04-01

    (1) To clinically evaluate horizontal remodeling of the alveolar process (hard and soft tissues) following ridge preservation in high-risk patients and (2) to identify predictors of such remodeling. Periodontally healthy nonsmoking patients with a failing tooth in the anterior maxilla (15-25) were selected for a prospective case series. All were in need of a single implant and demonstrated high risk for aesthetic complications given an incomplete buccal bone wall and/or thin-scalloped gingival biotype. Following flapless tooth extraction, ridge preservation was performed using one or more collagen-enriched, bovine-derived block grafts (Geistlich Bio-Oss® Collagen® 100 mg, Geistlich Pharma AG, Wolhusen, Switzerland) without the additional use of membranes or soft tissue grafts. The change in buccopalatal dimension of the alveolar process between baseline (prior to tooth extraction) and 4 months was assessed on the basis of superimposed occlusal slides. Regression analysis was performed to identify predictors of alveolar process remodeling. Forty-two patients (21 females, 21 males; mean age 38) met the selection criteria and consented to the treatment. Mean alveolar process remodeling was 14% (SD 7, range 4-30) with minimal remodeling (≤ 10%) in 16 patients (38%) and advanced remodeling (>20%) in 10 patients (24%). A single implant could be installed in all subjects without additional guided bone regeneration. Connective tissue grafting was performed later on in the treatment for aesthetic purposes, hereby compensating for tissue loss at the buccal aspect. Predictors of alveolar process remodeling were tooth location (central incisors and cuspids > laterals incisors and premolars), tooth abscess (p = .025), and buccal bone loss (p = .035). Alveolar process remodeling seems inevitable yet acceptable following ridge preservation in high-risk patients. Proper case selection may reduce the incidence of advanced remodeling. © 2014 Wiley Periodicals, Inc.

  13. How to Identify High-Risk APS Patients: Clinical Utility and Predictive Values of Validated Scores.

    Science.gov (United States)

    Oku, Kenji; Amengual, Olga; Yasuda, Shinsuke; Atsumi, Tatsuya

    2017-08-01

    Antiphospholipid syndrome (APS) is a clinical disorder characterised by thrombosis and/or pregnancy morbidity in the persistence of antiphospholipid (aPL) antibodies that are pathogenic and have pro-coagulant activities. Thrombosis in APS tends to recur and require prophylaxis; however, the stereotypical treatment for APS patients is inadequate and stratification of the thrombotic risks is important as aPL are prevalently observed in various diseases or elderly population. It is previously known that the multiple positive aPL or high titre aPL correlate to thrombotic events. To progress the stratification of thrombotic risks in APS patients and to quantitatively analyse those risks, antiphospholipid score (aPL-S) and the Global Anti-phospholipid Syndrome Score (GAPSS) were defined. These scores were raised from the large patient cohort data and either aPL profile classified in detail (aPL-S) or simplified aPL profile with classical thrombotic risk factors (GAPSS) was put into a scoring system. Both the aPL-S and GAPSS have shown a degree of accuracy in identifying high-risk APS patients, especially those at a high risk of thrombosis. However, there are several areas requiring improvement, or at least that clinicians should be aware of, before these instruments are applied in clinical practice. One such issue is standardisation of the aPL tests, including general testing of phosphatidylserine-dependent antiprothrombin antibodies (aPS/PT). Additionally, clinicians may need to be aware of the patient's medical history, particularly with respect to the incidence of SLE, which influences the cutoff value for identifying high-risk patients.

  14. Using clinical parameters to guide fluid therapy in high-risk thoracic surgery. A retrospective, observational study

    DEFF Research Database (Denmark)

    Bjerregaard, Lars Stryhn; Møller-Sørensen, Hasse; Hansen, Kristoffer Lindskov

    2015-01-01

    the use of central venous oxygen saturation and intended low urine output to guide therapy in the early postoperative period. Here we evaluate the consequences of our changes. METHODS: Retrospective, observational study of 30 consecutive patients undergoing EPP; 18 who had surgery before and 12 who had...... surgery after the changes. Data were collected from patient files and from institutional databases. Outcome measures included: Volumes of administered fluids, fluid balances, length of stays and postoperative complications. Dichotomous variables were compared with Fisher's exact test, whereas continuous...... increasing the incidence of postoperative complications. Mean length of stay in the intensive care unit (LOSI) was reduced from three to one day (p = 0.04) after the changes. CONCLUSION: The use of clinical parameters to balance fluid restriction and a sufficient circulation in patients undergoing EPP...

  15. Combined surgical and radiological intervention for complicated cholelithiasis in high-risk patients

    International Nuclear Information System (INIS)

    Gibney, R.G.; Fache, J.S.; Becker, C.D.; Nichols, D.M.; Cooperberg, P.L.; Stoller, J.L.; Burhenne, H.J.

    1987-01-01

    Surgical cholecystostomy under local infiltration anesthesia was combined with radiologic removal of gallstones in 36 high-risk patients with acute calculous gallbladder disease. At cholecystostomy, the fundus of the gallbladder was sutured to the anterior abdominal wall, permitting early percutaneous stone removal through the short surgical tract. All gallstones were removed in 31 of 36 patients, for an overall success rate of 86%. The success rate was 97% for gallbladder stones, 86% for cystic duct stones, and 63% for common bile duct stones which were removed by traversing the cystic duct. There were no deaths or serious complications

  16. [Clinical and laboratory grounds for using solcoseryl in high-risk patients].

    Science.gov (United States)

    Kuznetsova, O Iu; Kolesnichenko, I Iu; Khalikov, A D; Manikhas, G M; Rodionov, G G

    2000-01-01

    In 56 patients aged from 58 to 82 years with the III and IV degrees of risk operated upon for malignant tumors of organs of the thoracic and abdominal organs Solcoseryl was included in the complex of anesthesia measures. It was given intravenously or as inhalation in dosage of 1000 mg. It was found that using Solcoseryl considerably reduced the amount of postoperative complications in high risk patients. It led to lower level of lipid peroxidation and activation of the antioxidant system and thus may be considered as an important component of therapy at the intra- and postoperative periods.

  17. Endovascular Management of Infected Femoral Artery Pseudoaneurysms in High-Risk Patients: A Case Series

    Energy Technology Data Exchange (ETDEWEB)

    D’Oria, Mario, E-mail: mario.doria88@outlook.com; Sgorlon, Giada; Calvagna, Cristiano; Zamolo, Francesca; Chiarandini, Stefano; Adovasio, Roberto; Griselli, Filippo [University Hospital of Cattinara, Vascular and Endovascular Surgery Unit (Italy)

    2017-04-15

    We report our experience with the urgent treatment of two high-risk patients with infected femoral artery pseudoaneurysms (IFAPs) with the placement of a self-expandable covered stent (SECS). In both cases, there was no perioperative mortality and the aneurysm exclusion was successful without early or late stent thrombosis/stent fracture nor acute or chronic limb ischemia or limb loss. There was no recurrence of local or systemic infection during the follow-up period. Endovascular therapy represents a feasible treatment option for IFAPs in those patients for whom the risk of open surgical repair would be prohibitive, especially under urgent circumstances.

  18. Cardiac Autonomic Neuropathy in Patients with Type 2 Diabetes Mellitus at High Risk for Foot Ulcers.

    Science.gov (United States)

    Menon, Anil S; Dixit, Abhinav; Garg, M K; Girish, R

    2017-01-01

    To study the prevalence of cardiac autonomic neuropathy (CAN) in patients with Type 2 diabetes mellitus at high risk for foot ulcers. We screened patients attending diabetic clinic for identifying patients at high risk for foot ulcers. Those with foot risk category 1, 2 and 3 as per criteria of Foot Care Interest Group were subjected to battery of cardiovascular autonomic reflex tests. Those with one abnormal test were termed as probable CAN and those with two abnormal tests as definite CAN. Those with postural fall in blood pressure with one other abnormal test were termed to have advanced CAN. A total of 74 patients were recruited in the study. The prevalence of abnormal cardiovascular autonomic reflex test was sustained hand grip 81%, E/I ratio 66.2%, 30:15 ratio 28.3% and orthostatic hypotension 13.5%. The prevalence of possible CAN was 31.0% (23/74) and definite CAN was 66.2% (49/74). Ten patients had advanced CAN. There was no observable difference in presence of probable or definite CAN in three risk category for foot ulcers. We found a high prevalence of CAN in subgroup of diabetic patients at increased risk for foot ulcer.

  19. Psychosocial differences in high risk versus low risk acute low-back pain patients.

    Science.gov (United States)

    Pulliam, C B; Gatchel, R J; Gardea, M A

    2001-03-01

    The current study built upon previous research that predicted with 90.7% accuracy which patients presenting with acute low-back pain go on to develop chronic disability problems. Fifty-seven patients were classified as high risk (HR) or low risk (LR) according to a predictive algorithm, and were evaluated with a variety of psychosocial measures. Overall, HR patients had more Axis I pathology than LR patients, and used poorer coping styles. Logistic regression analyses identified variables that differentiated, with 80% accuracy, between the HR and LR patients. The results highlight the importance of identifying patients who are at risk for developing chronic pain following acute injury so that prophylactic intervention can be offered before chronic pain disability status becomes entrenched.

  20. Does additional cone beam computed tomography decrease the risk of inferior alveolar nerve injury in high-risk cases undergoing third molar surgery?Does CBCT decrease the risk of IAN injury?

    Science.gov (United States)

    Korkmaz, Y T; Kayıpmaz, S; Senel, F C; Atasoy, K T; Gumrukcu, Z

    2017-05-01

    The objectives of this study were to evaluate the efficacy of additional cone beam computed tomography (CBCT) imaging on decreasing the risk of inferior alveolar nerve (IAN) injury during third molar removal in patients at high risk and to assess the surgical outcomes. The study sample included patients considered at high risk for IAN injury based on panoramic radiography (PAN) evaluation. The primary predictor was the type of imaging method (PAN only or with additional CBCT). The other variables were demographic and anatomical/radiographic factors. The primary outcome variable was IAN injury. The secondary outcome variables were the preoperative surgical plan and surgical results including IAN exposure and duration of surgery. The sample comprised 122 patients (139 teeth) aged 18-48 years. Postoperative temporary IAN injury was present in three (4.2%) cases in the CBCT group and 11 (16.4%) in the PAN group at 7 days after surgery. However, none of the patients had a permanent IAN injury at the 6-month follow-up. Additional CBCT imaging was not superior to PAN in reducing IAN injury after third molar surgery during long-term follow-up. Nonetheless, CBCT may decrease the prevalence of temporary IAN injury and improve the surgical outcomes in high-risk patients. Copyright © 2017 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

  1. Likelihood of Bone Recurrence in Prior Sites of Metastasis in Patients With High-Risk Neuroblastoma

    Energy Technology Data Exchange (ETDEWEB)

    Polishchuk, Alexei L. [Department of Radiation Oncology, University of California at San Francisco School of Medicine and UCSF Benioff Children' s Hospital, San Francisco, California (United States); Li, Richard [Division of Radiation Oncology, Dana Farber/Boston Children' s Cancer and Blood Disorders Center, Brigham and Women' s Hospital, Harvard Medical School, Boston, Massachusetts (United States); Hill-Kayser, Christine [Department of Radiation Oncology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania (United States); Little, Anthony [Division of Oncology, Children' s Hospital of Philadelphia, Philadelphia, Pennsylvania (United States); Hawkins, Randall A. [Department of Radiology, University of California at San Francisco School of Medicine and UCSF Benioff Children' s Hospital, San Francisco, California (United States); Hamilton, Jeffrey; Lau, Michael [Department of Radiation Oncology, University of California at San Francisco School of Medicine and UCSF Benioff Children' s Hospital, San Francisco, California (United States); Tran, Hung Chi [Division of Hematology/Oncology, Children' s Hospital of Los Angeles, Los Angeles, California (United States); Strahlendorf, Caron [Division of Hematology and Oncology, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia (Canada); Lemons, Richard S. [Division of Pediatric Hematology/Oncology, University of Utah School of Medicine, Salt Lake City, Utah (United States); Weinberg, Vivian [Department of Radiation Oncology, University of California at San Francisco School of Medicine and UCSF Benioff Children' s Hospital, San Francisco, California (United States); Matthay, Katherine K.; DuBois, Steven G. [Department of Pediatrics, University of California at San Francisco School of Medicine and UCSF Benioff Children' s Hospital, San Francisco, California (United States); and others

    2014-07-15

    Purpose/Objectives: Despite recent improvements in outcomes, 40% of children with high-risk neuroblastoma will experience relapse, facing a guarded prognosis for long-term cure. Whether recurrences are at new sites or sites of original disease may guide decision making during initial therapy. Methods and Materials: Eligible patients were retrospectively identified from institutional databases at first metastatic relapse of high-risk neuroblastoma. Included patients had disease involving metaiodobenzylguanidine (MIBG)-avid metastatic sites at diagnosis and first relapse, achieved a complete or partial response with no more than one residual MIBG-avid site before first relapse, and received no total body irradiation or therapy with {sup 131}I-MIBG before first relapse. Anatomically defined metastatic sites were tracked from diagnosis through first relapse to determine tendency of disease to recur at previously involved versus uninvolved sites and to assess whether this pattern was influenced by site irradiation. Results: Of 159 MIBG-avid metastatic sites identified among 43 patients at first relapse, 131 (82.4%) overlapped anatomically with the set of 525 sites present at diagnosis. This distribution was similar for bone sites, but patterns of relapse were more varied for the smaller subset of soft tissue metastases. Among all metastatic sites at diagnosis in our subsequently relapsed patient cohort, only 3 of 19 irradiated sites (15.8%) recurred as compared with 128 of 506 (25.3%) unirradiated sites. Conclusions: Metastatic bone relapse in neuroblastoma usually occurs at anatomic sites of previous disease. Metastatic sites identified at diagnosis that did not receive radiation during frontline therapy appeared to have a higher risk of involvement at first relapse relative to previously irradiated metastatic sites. These observations support the current paradigm of irradiating metastases that persist after induction chemotherapy in high-risk patients. Furthermore

  2. A polyvalent vaccine for high-risk prostate patients: "are more antigens better?"

    DEFF Research Database (Denmark)

    Slovin, Susan F; Ragupathi, Govind; Fernandez, Celina

    2007-01-01

    vaccine of synthetic "self" antigens broke immunologic tolerance against two or more antigens in all 30 vaccinated patients, was safe, but antibody titers against several of the antigens were lower than those seen in individual monovalent trials. No impact on PSA slope was detected. We address...... with stimulation by multiple antigens, a hexavalent vaccine was prepared using previously determined doses and administered in a Phase II setting to 30 high-risk patients. The hexavalent vaccine included GM2, Globo H, Lewis(y), glycosylated MUC-1-32mer and Tn and TF in a clustered formation, conjugated to KLH...... and mixed with QS-21. Eight vaccinations were administered over 13 months. All 30 patients had significant elevations in antibody titers to at least two of the six antigens; 22 patients had increased reactivity with FACS. These serologic responses were lower than that seen previously in patients treated...

  3. Results of laparoscopic pelvic lymphadenectomy in patients at high risk for nodal metastases from prostate cancer.

    Science.gov (United States)

    Kava, B R; Dalbagni, G; Conlon, K C; Russo, P

    1998-03-01

    Laparoscopic pelvic lymphadenectomy (LPLND) can be performed safely and with minimal morbidity in the staging of prostate cancer. Its utility in evaluating patients at high risk for metastatic disease before primarily nonsurgical treatment modalities was evaluated. Twenty-four consecutive patients who underwent LPLND between June 1993 and July 1996 were studied. These patients were considered poor surgical candidates based on several risk factors, as follows: elevation of serum PSA >20 in 19 patients (79%); elevation of serum acid phosphatase in 4 patients (17%); digital rectal examination findings indicative of extraprostatic extension or seminal vesical involvement in 14 patients (58%); and poorly differentiated tumors on prostate biopsy in 19 patients (79%). Nineteen patients (79%) had two or more of these risk factors. Median PSA for the entire series of patients was 35.2 ng/mL (range 7.9 to 133 ng/mL), and median Gleason score was 7 (range 5 to 9). Preoperative CT or MRI was negative for pelvic lymph node metastases in 17 of 23 patients (79%), and bone scan was negative in all 24 patients. Unilateral (n = 2) or bilateral (n = 22) LPLND was performed in all patients. Six patients (25%) had lymph node metastases detected laparoscopically. Five of the six patients had palpable extraprostatic extension (T3a/b) or invasion of a seminal vesical (T3c), and in four of these patients the site of the metastatic lymph nodes was ipsilateral to the palpable prostate abnormality. None of the risk factors was independently predictive of lymph node metastases within this series of patients. An average of 10.8 +/- 6.5 lymph nodes was removed at a mean operative time of 174 +/- 10 minutes for patients undergoing bilateral LPLND. Estimated blood loss was minimal for 20 of 22 patients (92%) undergoing LPLND alone, and there were no complications requiring open exploration. Mean postoperative hospital stay was 1.2 +/- 0.5 days for patients undergoing LPLND alone. LPLND can be used

  4. Closed-loop assisted versus manual goal-directed fluid therapy during high-risk abdominal surgery: a case-control study with propensity matching.

    Science.gov (United States)

    Rinehart, Joseph; Lilot, Marc; Lee, Christine; Joosten, Alexandre; Huynh, Trish; Canales, Cecilia; Imagawa, David; Demirjian, Aram; Cannesson, Maxime

    2015-03-19

    Goal-directed fluid therapy strategies have been shown to benefit moderate- to high-risk surgery patients. Despite this, these strategies are often not implemented. The aim of this study was to assess a closed-loop fluid administration system in a surgical cohort and compare the results with those for matched patients who received manual management. Our hypothesis was that the patients receiving closed-loop assistance would spend more time in a preload-independent state, defined as percentage of case time with stroke volume variation less than or equal to 12%. Patients eligible for the study were all those over 18 years of age scheduled for hepatobiliary, pancreatic or splenic surgery and expected to receive intravascular arterial blood pressure monitoring as part of their anesthetic care. The closed-loop resuscitation target was selected by the primary anesthesia team, and the system was responsible for implementation of goal-directed fluid therapy during surgery. Following completion of enrollment, each study patient was matched to a non-closed-loop assisted case performed during the same time period using a propensity match to reduce bias. A total of 40 patients were enrolled, 5 were ultimately excluded and 25 matched pairs were selected from among the remaining 35 patients within the predefined caliper distance. There was no significant difference in fluid administration between groups. The closed-loop group spent a significantly higher portion of case time in a preload-independent state (95 ± 6% of case time versus 87 ± 14%, P =0.008). There was no difference in case mean or final stroke volume index (45 ± 10 versus 43 ± 9 and 45 ± 11 versus 42 ± 11, respectively) or mean arterial pressure (79 ± 8 versus 83 ± 9). Case end heart rate was significantly lower in the closed-loop assisted group (77 ± 10 versus 88 ± 13, P =0.003). In this case-control study with propensity matching, clinician use of closed

  5. Usefulness of an accelerated transoesophageal stress echocardiography in the preoperative evaluation of high risk severely obese subjects awaiting bariatric surgery

    Directory of Open Access Journals (Sweden)

    Tessier Michel

    2010-07-01

    Full Text Available Abstract Background Severe obesity is associated with an increased risk of coronary artery disease (CAD. Bariatric surgery is an effective procedure for long term weight management as well as reduction of comorbidities. Preoperative evaluation of cardiac operative risk may often be necessary but unfortunately standard imaging techniques are often suboptimal in these subjects. The purpose of this study was to demonstrate the feasibility, safety and utility of transesophageal dobutamine stress echocardiography (TE-DSE using an adapted accelerated dobutamine infusion protocol in severely obese subjects with comorbidities being evaluated for bariatric surgery for assessing the presence of myocardial ischemia. Methods Subjects with severe obesity [body mass index (BMI >40 kg/m2] with known or suspected CAD and being evaluated for bariatric surgery were recruited. Results Twenty subjects (9M/11F, aged 50 ± 8 years (mean ± SD, weighing 141 ± 21 kg and with a BMI of 50 ± 5 kg/m2 were enrolled in the study and underwent a TE-DSE. The accelerated dobutamine infusion protocol used was well tolerated. Eighteen (90% subjects reached their target heart rate with a mean intubation time of 13 ± 4 minutes. Mean dobutamine dose was 31.5 ± 9.9 ug/kg/min while mean atropine dose was 0.5 ± 0.3 mg. TE-DSE was well tolerated by all subjects without complications including no significant arrhythmia, hypotension or reduction in blood arterial saturation. Two subjects had abnormal TE-DSE suggestive of myocardial ischemia. All patients underwent bariatric surgery with no documented cardiovascular complications. Conclusions TE-DSE using an accelerated infusion protocol is a safe and well tolerated imaging technique for the evaluation of suspected myocardial ischemia and cardiac operative risk in severely obese patients awaiting bariatric surgery. Moreover, the absence of myocardial ischemia on TE-DSE correlates well with a low operative risk of cardiac event.

  6. Identification of patients with cancer with a high risk to develop delirium.

    Science.gov (United States)

    Neefjes, Elisabeth C W; van der Vorst, Maurice J D L; Verdegaal, Bertha A T T; Beekman, Aartjan T F; Berkhof, Johannes; Verheul, Henk M W

    2017-08-01

    Delirium deteriorates the quality of life in patients with cancer, but is frequently underdiagnosed and not adequately treated. In this study, we evaluated the occurrence of delirium and its risk factors in patients admitted to the hospital for treatment or palliative care in order to develop a prediction model to identify patients at high risk for delirium. In a period of 1.5 years, we evaluated the risk of developing delirium in 574 consecutively admitted patients with cancer to our academic oncology department with the Delirium Observation Screening Scale. Risk factors for delirium were extracted from the patient's chart. A delirium prediction algorithm was constructed using tree analysis, and validated with fivefold cross-validation. A total of 574 patients with cancer were acutely (42%) or electively (58%) admitted 1733 times. The incidence rate of delirium was 3.5 per 100 admittances. Tree analysis revealed that the predisposing factors of an unscheduled admittance and a metabolic imbalance accurately predicted the development of delirium. In this group the incidence rate of delirium was 33 per 100 patients (1:3). The AUC of the model was 0.81, and 0.65 after fivefold cross-validation. We identified that especially patients undergoing an unscheduled admittance with a metabolic imbalance do have a clinically relevant high risk to develop a delirium. Based on these factors, we propose to evaluate preventive treatment of these patients when admitted to the hospital in order to improve their quality of life. © 2017 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.

  7. [Dementia prevention: potential treatments and how to target high risk patients].

    Science.gov (United States)

    Samaras, Nikolaos; Samaras, Dimitrios; Frangos, Emilia; Forster, Alexandre

    2013-05-22

    The burden related to the ever-increasing dementia prevalence in older individuals, imposes the implementation of prevention strategies. It is now known that brain lesions related to Alzheimer's disease precede the onset of the first symptoms. Consequently, prevention strategies should be implemented early, before clinically overt dementia. Blood and spine fluid tests, electroencephalogram, brain magnetic resonance and brain nuclear imaging should help physicians to better target "high-risk" patients prone to benefit from such strategies, already in a preclinical disease stage. Since no efficient pharmacological treatments exist for the time being, lifestyle factors such as nutritionand physical exercise are the cornerstones for dementia prevention.

  8. Multi-targeted and aggressive treatment of patients with type 2 diabetes at high risk

    DEFF Research Database (Denmark)

    Gaede, P; Pedersen, O

    2005-01-01

    addressing additional cardiovascular risk factors including hypertension, dyslipidaemia, sedentary behaviour, smoking and dietary habits causing insulin resistance and pro-inflammation. This type of integrated therapy applied for almost 8 years to high-risk type 2 diabetic patients has cut the relative risk......Results from many single risk factor intervention trials and the multi-targeted Steno-2 trial in the last few years have provided a strong case that management of type 2 diabetes in all age groups requires a structured and intensified approach that is far more than just glucocentric, an approach...

  9. Combined Microwave Ablation and Cementoplasty in Patients with Painful Bone Metastases at High Risk of Fracture

    Energy Technology Data Exchange (ETDEWEB)

    Pusceddu, Claudio, E-mail: clapusceddu@gmail.com [Regional Referral Center for Oncologic Diseases, Division of Interventional Radiology, Department of Oncological Radiology, Ocological Hospital “A. Businco” (Italy); Sotgia, Barbara, E-mail: barbara.sotgia@gmail.com; Fele, Rosa Maria, E-mail: rosellafele@tiscali.it [Regional Referral Center for Oncological Diseases, Department of Oncological Radiology, Oncological Hospital “A. Businco” (Italy); Ballicu, Nicola, E-mail: nicolaballicu77@gmail.com [Regional Referral Center for Oncologic Diseases, Division of Interventional Radiology, Department of Oncological Radiology, Ocological Hospital “A. Businco” (Italy); Melis, Luca, E-mail: doclucamelis@tiscali.it [Regional Referral Center for Oncological Diseases, Department of Oncological Radiology, Oncological Hospital “A. Businco” (Italy)

    2016-01-15

    PurposeTo retrospectively evaluate the effectiveness of computed tomography-guided percutaneous microwave ablation (MWA) and cementoplasty in patients with painful bone metastases at high risk of fracture.Materials and MethodsThirty-five patients with 37 metastatic bone lesions underwent computed tomography-guided MWA combined with cementoplasty (polymethylmethacrylate injection). Vertebrae, femur, and acetabulum were the intervention sites and the primary end point was pain relief. Pain severity was estimated by visual analog scale (VAS) before treatment; 1 week post-treatment; and 1, 6, and 12 months post-treatment. Functional outcome was assessed by improved patient walking ability. Radiological evaluation was performed at baseline and 3 and 12 months post-procedure.ResultsIn all patients, pain reduction occurred from the first week after treatment. The mean reduction in the VAS score was 84, 90, 90 % at week 1, month 1, and month 6, respectively. Improved walking ability occurred in 100 and 98 % of cases at the 1- and 6-month functional outcome evaluations, respectively. At the 1-year evaluation, 25 patients were alive, and 10 patients (28 %) had died because of widespread disease. The mean reduction in the VAS score and improvement in surviving patients’ walking ability were 90 and 100 %, respectively. No patients showed evidence of local tumor recurrence or progression and pathological fracture in the treated sites.ConclusionOur results suggest that MWA combined with osteoplasty is safe and effective when treating painful bone metastases at high risk of fracture. The number of surviving patients at the 1-year evaluation confirms the need for an effective and long-lasting treatment.

  10. Preoperative concurrent chemoradiotherapy against muscle-invasive bladder cancer. Results of partial cystectomy in elderly or high-risk patients

    International Nuclear Information System (INIS)

    Kageyama, Yukio; Okada, Yohei; Arai, Gaku

    2000-01-01

    Good local control has been reported in cases of muscle-invasive bladder cancer treated by chemoradiotherapy and transurethral resection (TUR). However, definitive irradiation or extensive chemotherapy is often intolerable for elderly or poor-risk patients. We report here benefits of partial cystectomy after concurrent low-dose chemoradiotherapy for high-risk patients. Thirty-seven patients with localized muscle-invasive bladder cancer (T2-T4) were treated with concurrent cisplatin (50-100 mg/body x 2 courses) and pelvic irradiation (40 Gy) preoperatively. Among 17 patients (46%) who achieved complete response (CR), 10 were not suitable for radical cystectomy and underwent partial cystectomy. Radical cystectomy was performed in 24 cases [CR=6, partial response (PR)=18]. Two patients (one CR and one PR) rejected open surgery and were treated by TUR of the primary site. One no change (NC) patient received no further treatment because of mental disorder. Median follow-up was 12 months (range 2-37 months). Fifteen of 36 evaluable cases (42%) achieved a pathological T0 response (no residual tumor). Estimated 3-year disease-free survival was 56% for all patients and 100% for T0 responders. Seven of 21 patients with pathological persistent tumor developed local recurrence (three patients) or distant metastasis (four patients). All of the 10 patients (eight with T0 response and two with a small residual tumor nest) who underwent partial cystectomy were recurrence-free for an observation period of up to 3 years. Bladder preservation by partial cystectomy may be a choice for patients who show a good response to preoperative chemoradiotherapy and are not suitable for radical cystectomy. (author)

  11. Preoperative concurrent chemoradiotherapy against muscle-invasive bladder cancer. Results of partial cystectomy in elderly or high-risk patients

    Energy Technology Data Exchange (ETDEWEB)

    Kageyama, Yukio; Okada, Yohei; Arai, Gaku [Tokyo Medical and Dental Univ. (Japan)] [and others

    2000-12-01

    Good local control has been reported in cases of muscle-invasive bladder cancer treated by chemoradiotherapy and transurethral resection (TUR). However, definitive irradiation or extensive chemotherapy is often intolerable for elderly or poor-risk patients. We report here benefits of partial cystectomy after concurrent low-dose chemoradiotherapy for high-risk patients. Thirty-seven patients with localized muscle-invasive bladder cancer (T2-T4) were treated with concurrent cisplatin (50-100 mg/body x 2 courses) and pelvic irradiation (40 Gy) preoperatively. Among 17 patients (46%) who achieved complete response (CR), 10 were not suitable for radical cystectomy and underwent partial cystectomy. Radical cystectomy was performed in 24 cases [CR=6, partial response (PR)=18]. Two patients (one CR and one PR) rejected open surgery and were treated by TUR of the primary site. One no change (NC) patient received no further treatment because of mental disorder. Median follow-up was 12 months (range 2-37 months). Fifteen of 36 evaluable cases (42%) achieved a pathological T0 response (no residual tumor). Estimated 3-year disease-free survival was 56% for all patients and 100% for T0 responders. Seven of 21 patients with pathological persistent tumor developed local recurrence (three patients) or distant metastasis (four patients). All of the 10 patients (eight with T0 response and two with a small residual tumor nest) who underwent partial cystectomy were recurrence-free for an observation period of up to 3 years. Bladder preservation by partial cystectomy may be a choice for patients who show a good response to preoperative chemoradiotherapy and are not suitable for radical cystectomy. (author)

  12. Identification of high-risk patients by human epididymis protein 4 levels during follow-up of ovarian cancer

    DEFF Research Database (Denmark)

    Dahl Steffensen, Karina; Waldstrøm, Marianne; Brandslund, Ivan

    2016-01-01

    -risk patients from those with less aggressive disease. The aim of the present study was to investigate the possible predictive value of human epididymis protein 4 (HE4) and carbohydrate antigen 125 (CA125) in relation to recurrence of epithelial ovarian cancer by measuring the two markers during follow......-up subsequent to surgery and adjuvant first-line carboplatin/paclitaxel chemotherapy. Serum HE4 and CA125 were analyzed in 88 epithelial ovarian cancer patients at the end of treatment and consecutively during follow-up. The patients were divided into a high-risk and a low-risk group based on having an increase...... in HE4 and CA125 levels above or below 50% during follow-up, relative to the baseline (end-of-treatment) level. Disease recurrence was detected in 55 patients during follow-up. Patients with an increase in HE4 of >50% at 3- and 6-month follow-up compared to the end-of-treatment sample had significantly...

  13. Patterns of Relapse in High-Risk Neuroblastoma Patients Treated With and Without Total Body Irradiation

    International Nuclear Information System (INIS)

    Li, Richard; Polishchuk, Alexei; DuBois, Steven; Hawkins, Randall; Lee, Stephanie W.; Bagatell, Rochelle; Shusterman, Suzanne; Hill-Kayser, Christine; Al-Sayegh, Hasan; Diller, Lisa; Haas-Kogan, Daphne A.; Matthay, Katherine K.; London, Wendy B.

    2017-01-01

    Purpose: External beam radiation therapy to initial sites of disease may influence relapse patterns in high-risk neuroblastoma. However, the effect of systemic irradiation by use of total body irradiation (TBI) on anatomic patterns of relapse has not previously been investigated. Methods and Materials: We retrospectively analyzed patients receiving definitive treatment of high-risk neuroblastoma with subsequent relapse in bony metastatic sites, with a date of relapse between January 1, 1997, and December 31, 2012. Anatomic sites of disease, defined by metaiodobenzylguanidine (MIBG) avidity, were compared at diagnosis and at first relapse. The Fisher exact test was performed to compare relapse in initially involved sites between patients treated with and without TBI. Results: Seventy-four patients with a median age at diagnosis of 3.5 years (range, 0.3-15.3 years) had relapse in 227 sites of MIBG-avid metastatic disease, with a median time to relapse of 1.8 years. Of the 227 sites of first relapse, 154 sites (68%) were involved at diagnosis. When we compared relapse patterns in patients treated with and without TBI, 12 of 23 patients (52%) treated with TBI had relapse in ≥1 previously MIBG-avid site of disease whereas 40 of 51 patients (78%) treated without TBI had relapse in ≥1 previously MIBG-avid site of disease (P=.03). Conclusions: Patients treated with systemic irradiation in the form of TBI were significantly less likely to have relapse in prior sites of disease. These findings support further investigation into the role of radiopharmaceutical therapies in curative multimodality therapy.

  14. Patterns of Relapse in High-Risk Neuroblastoma Patients Treated With and Without Total Body Irradiation

    Energy Technology Data Exchange (ETDEWEB)

    Li, Richard [Harvard Medical School, Boston, Massachusetts (United States); Brigham and Women' s Hospital, Boston, Massachusetts (United States); Polishchuk, Alexei [School of Medicine, University of California San Francisco, San Francisco, California (United States); DuBois, Steven [Harvard Medical School, Boston, Massachusetts (United States); Dana-Farber/Boston Children' s Cancer and Blood Disorders Center, Boston, Massachusetts (United States); Hawkins, Randall [School of Medicine, University of California San Francisco, San Francisco, California (United States); Lee, Stephanie W. [Brigham and Women' s Hospital, Boston, Massachusetts (United States); Bagatell, Rochelle [Children' s Hospital of Philadelphia, Philadelphia, Pennsylvania (United States); Shusterman, Suzanne [Harvard Medical School, Boston, Massachusetts (United States); Dana-Farber/Boston Children' s Cancer and Blood Disorders Center, Boston, Massachusetts (United States); Hill-Kayser, Christine [Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (United States); Al-Sayegh, Hasan [Brigham and Women' s Hospital, Boston, Massachusetts (United States); Dana-Farber/Boston Children' s Cancer and Blood Disorders Center, Boston, Massachusetts (United States); Diller, Lisa [Harvard Medical School, Boston, Massachusetts (United States); Dana-Farber/Boston Children' s Cancer and Blood Disorders Center, Boston, Massachusetts (United States); Haas-Kogan, Daphne A. [Harvard Medical School, Boston, Massachusetts (United States); Brigham and Women' s Hospital, Boston, Massachusetts (United States); Dana-Farber/Boston Children' s Cancer and Blood Disorders Center, Boston, Massachusetts (United States); Matthay, Katherine K. [School of Medicine, University of California San Francisco, San Francisco, California (United States); London, Wendy B. [Harvard Medical School, Boston, Massachusetts (United States); Dana-Farber/Boston Children' s Cancer and Blood Disorders Center, Boston, Massachusetts (United States); and others

    2017-02-01

    Purpose: External beam radiation therapy to initial sites of disease may influence relapse patterns in high-risk neuroblastoma. However, the effect of systemic irradiation by use of total body irradiation (TBI) on anatomic patterns of relapse has not previously been investigated. Methods and Materials: We retrospectively analyzed patients receiving definitive treatment of high-risk neuroblastoma with subsequent relapse in bony metastatic sites, with a date of relapse between January 1, 1997, and December 31, 2012. Anatomic sites of disease, defined by metaiodobenzylguanidine (MIBG) avidity, were compared at diagnosis and at first relapse. The Fisher exact test was performed to compare relapse in initially involved sites between patients treated with and without TBI. Results: Seventy-four patients with a median age at diagnosis of 3.5 years (range, 0.3-15.3 years) had relapse in 227 sites of MIBG-avid metastatic disease, with a median time to relapse of 1.8 years. Of the 227 sites of first relapse, 154 sites (68%) were involved at diagnosis. When we compared relapse patterns in patients treated with and without TBI, 12 of 23 patients (52%) treated with TBI had relapse in ≥1 previously MIBG-avid site of disease whereas 40 of 51 patients (78%) treated without TBI had relapse in ≥1 previously MIBG-avid site of disease (P=.03). Conclusions: Patients treated with systemic irradiation in the form of TBI were significantly less likely to have relapse in prior sites of disease. These findings support further investigation into the role of radiopharmaceutical therapies in curative multimodality therapy.

  15. Lung transplantation for high-risk patients with idiopathic pulmonary fibrosis.

    Science.gov (United States)

    De Oliveira, Nilto C; Julliard, Walker; Osaki, Satoru; Maloney, James D; Cornwell, Richard D; Sonetti, David A; Meyer, Keith C

    2016-10-07

    Survival for patients with idiopathic pulmonary fibrosis (IPF) and high lung allocation score (LAS) values may be significantly reduced in comparison to those with lower LAS values. To evaluate outcomes for high-risk IPF patients as defined by LAS values ≥46 (N=42) versus recipients with LAS values pulmonary complications was increased for the higher LAS group versus recipients with LAS <46, 30-day mortality and actuarial survival did not differ between the two cohorts. Although lung transplantation in patients with IPF and high LAS values is associated with increased risk of early post-transplant complications, long-term post-transplant survival for our high-LAS cohort was equivalent to that for the lower LAS recipients.

  16. Value of improved lipid control in patients at high risk for adverse cardiac events.

    Science.gov (United States)

    Jena, Anupam B; Blumenthal, Daniel M; Stevens, Warren; Chou, Jacquelyn W; Ton, Thanh G N; Goldman, Dana P

    2016-06-01

    Lipid-lowering therapy (LLT) is suboptimally used in patients with hyperlipidemia in the 2 highest statin benefit groups (SBGs), as categorized by the American College of Cardiology and the American Heart Association. This study estimated the social value of reducing low-density lipoprotein cholesterol (LDL-C) levels by 50% for patients in SBGs 1 and 2 who have been treated with standard LLT but have not reached LDL-C goal, as well as the potential value of PCSK9 inhibitors for patients in these groups. Simulation model. We used National Health and Nutrition Examination Surveys (NHANES) and US Census data to project the population of SBGs 1 and 2 in the time period 2015 to 2035. We used insurance claims data to estimate incidence rates of major adverse cardiac events (MACEs), and NHANES with National Vital Statistics data to estimate cardiovascular disease mortality rates. Using established associations between LDL-C and MACE risk, we estimated the value of reducing LDL-C levels by 50%. We incorporated results from a meta-analysis to estimate the value of PSCK9 inhibitors. Among those treated with LLT with LDL-C > 70 mg/dL in SBGs 1 and 2, the cumulative value of reducing LDL-C levels by 50% would be $2.9 trillion from 2015 to 2035, resulting primarily from 1.6 million deaths averted. The cumulative value of PCSK9 inhibitors would range from $3.4 trillion to $5.1 trillion (1.9-2.8 million deaths averted), or $12,000 to $17,000 per patient-year of treatment. Lowering LDL-C in high-risk patients with hyperlipidemia has enormous potential social value. For patients in these high-risk groups, PCSK9 inhibitors may have considerable net value depending on the final prices payers ultimately select.

  17. Prospective Biomarker Screening for Diagnosis of Invasive Aspergillosis in High-Risk Pediatric Patients

    Science.gov (United States)

    Hafner, Julia; Mengoli, Carlo; Wirth, Clemens; Heussel, Claus Peter; Löffler, Claudia; White, P. Lewis; Ullmann, Andrew J.; Michel, Denise; Wiegering, Verena; Wölfl, Matthias; Schlegel, Paul Gerhardt; Einsele, Hermann; Springer, Jan; Eyrich, Matthias

    2016-01-01

    ABSTRACT Combined biomarker screening is increasingly used to diagnose invasive aspergillosis (IA) in high-risk patients. In adults, the combination of galactomannan (GM) and fungal DNA detection has proven to be beneficial in the diagnosis of IA. Data in purely pediatric cohorts are scarce. Here, we monitored 39 children shortly before and after allogeneic stem cell transplantation twice weekly by use of a commercial GM enzyme-linked immunosorbent assay (ELISA) and a PCR assay based on amplification of the pan-Aspergillus ITS1/5.8S ribosomal operon. In addition, clinical data were recorded and classification of IA was performed according to the European Organization for the Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria. Among the 39 high-risk children, we identified 4 patients (10.3%) with probable and 2 (5.1%) with possible IA. All patients with probable IA were repeatedly positive for both tests (means of 9.5 and 6.8 positive GM and PCR samples, respectively), whereas both possible IA cases were detected by PCR. The sensitivity and specificity were, respectively, 67% and 89% for GM and 100% and 63% for PCR. Positive and negative predictive values were, respectively, 50% and 100% for GM and 27% and 100% for PCR. For the combined testing approach, both values were 100%. The number of positive samples seemed to be lower in patients undergoing antifungal therapy. Sporadically positive tests occurred in 12% (GM) and 42% (PCR) of unclassified patients. In summary, our data show that combined monitoring for GM and fungal DNA also results in a high diagnostic accuracy in pediatric patients. Future studies have to determine whether combined testing is suitable for early detection of subclinical disease and how antifungal prophylaxis impacts assay performance. PMID:27795339

  18. Colonic resection with early discharge after combined subarachnoid-epidural analgesia, preoperative glucocorticoids, and early postoperative mobilization and feeding in a pulmonary high-risk patient

    DEFF Research Database (Denmark)

    Møiniche, S; Dahl, J B; Rosenberg, J

    1994-01-01

    postoperative day and the patient discharged from the hospital 80 hours after surgery. CONCLUSIONS. The technique of combined neural and humoral mediator block should be evaluated in other high-risk patients undergoing major surgical procedures, where minimal invasive techniques are not possible.......BACKGROUND AND OBJECTIVES. A pulmonary high-risk patient undergoing right hemicolectomy for cancer was treated with a combination of intense afferent neural block with subarachnoid-epidural local anesthetics followed by continuous epidural analgesia, preoperative high-dose glucocorticoids......, and early oral feeding and mobilization. METHODS. Intraoperative subarachnoid anesthesia was followed by epidural analgesia with bupivacaine and morphine for 72 hours and oral acetaminophen 1 g every 6 hours. RESULTS. The technique resulted in a pain-free postoperative course (rest and mobilization...

  19. Factors and Outcomes Associated with MRCP Use prior to ERCP in Patients at High Risk for Choledocholithiasis.

    Science.gov (United States)

    Anand, Gobind; Patel, Yuval A; Yeh, Hsin-Chieh; Khashab, Mouen A; Lennon, Anne Marie; Shin, Eun Ji; Canto, Marcia I; Okolo, Patrick I; Kalloo, Anthony N; Singh, Vikesh K

    2016-01-01

    Background. Consensus guidelines recommend that patients at high risk for choledocholithiasis undergo endoscopic retrograde cholangiopancreatography (ERCP) without additional imaging. This study evaluates factors and outcomes associated with performing magnetic resonance cholangiopancreatography (MRCP) prior to ERCP among patients at high risk for choledocholithiasis. Methods. An institutional administrative database was searched using diagnosis codes for choledocholithiasis, cholangitis, and acute pancreatitis and procedure codes for MRCP and ERCP. Patients categorized as high risk for choledocholithiasis were evaluated. Results. 224 patients classified as high risk, of whom 176 (79%) underwent ERCP only, while 48 (21%) underwent MRCP prior to ERCP. Patients undergoing MRCP experienced longer time to ERCP (72 hours versus 35 hours, p choledocholithiasis is common and associated with greater length of hospital stay, higher radiology charges, and a trend towards higher hospital charges.

  20. Detection of Patients at High Risk of Medication Errors: Development and Validation of an Algorithm.

    Science.gov (United States)

    Saedder, Eva Aggerholm; Lisby, Marianne; Nielsen, Lars Peter; Rungby, Jørgen; Andersen, Ljubica Vukelic; Bonnerup, Dorthe Krogsgaard; Brock, Birgitte

    2016-02-01

    Medication errors (MEs) are preventable and can result in patient harm and increased expenses in the healthcare system in terms of hospitalization, prolonged hospitalizations and even death. We aimed to develop a screening tool to detect acutely admitted patients at low or high risk of MEs comprised by items found by literature search and the use of theoretical weighting. Predictive variables used for the development of the risk score were found by the literature search. Three retrospective patient populations and one prospective pilot population were used for modelling. The final risk score was evaluated for precision by the use of sensitivity, specificity and area under the ROC (receiver operating characteristic) curves. The variables used in the final risk score were reduced renal function, the total number of drugs and the risk of individual drugs to cause harm and drug-drug interactions. We found a risk score in the prospective population with an area under the ROC curve of 0.76. The final risk score was found to be quite robust as it showed an area under the ROC curve of 0.87 in a recent patient population, 0.74 in a population of internal medicine and 0.66 in an orthopaedic population. We developed a simple and robust score, MERIS, with the ability to detect patients and divide them according to low and high risk of MEs in a general population admitted at acute admissions unit. The accuracy of the risk score was at least as good as other models reported using multiple regression analysis. © 2015 Nordic Association for the Publication of BCPT (former Nordic Pharmacological Society).

  1. Patient satisfaction with cataract surgery

    Directory of Open Access Journals (Sweden)

    Wasfi Ehab I

    2008-10-01

    Full Text Available Abstract Introduction Measuring the patient satisfaction is a very important issue that will help very much in improving the service provided to patients and improve the level of satisfaction. Aim To evaluate patient satisfaction with the cataract surgery service and identify any areas for improvement, determination of patient satisfaction with referral, out-patient consultation, pre-assessment clinic, surgery and post-operative care, also to report patients' comments relating to improvement in service provision. Methodology A retrospective study was undertaken for 150 patients underwent cataract surgery at Barrow General Hospital, UK, the survey sample was by postal questionnaires. We collected our data from the theatre lists for a period of 4 month. Results This study included 150 patients; the response rate was (72% 108 patients, Most patients were referred from their general practitioner 86.1%, 93 (86.1% patients were happy with the time interval from seeing their GP to eye clinic. In the eye out patient department many factors significantly affected the level of patient satisfaction, in general the more information provided for the patient the more the satisfaction. Conclusion Patient satisfaction is on important health outcome old understanding both the domains of satisfaction as well as their relative importance to patients is necessary to improve the overall quality of patient care. Meeting the doctor, presenting all relevant information and giving printed information are very important factors in improving the patient's satisfaction with cataract surgery.

  2. The cardiac safety of aripiprazole treatment in patients at high risk for torsade

    DEFF Research Database (Denmark)

    Polcwiartek, Christoffer; Sneider, Benjamin; Graff, Claus

    2015-01-01

    RATIONALE: Certain antipsychotics increase the risk of heart rate-corrected QT (QTc) prolongation and consequently Torsades de Pointes (TdP) and sudden cardiac death (SCD). Drug-induced Brugada syndrome (BrS) is also associated with SCD. Most SCDs occur in patients with additional cardiac risk...... factors. OBJECTIVES: Aripiprazole's cardiac safety has not been assessed in patients at high risk for torsade, where QTc prolongation risk is highly increased. METHODS: MEDLINE, Embase, and The Cochrane Library were searched for preclinical, clinical, and epidemiological studies. Eligible studies were...... reviewed and cardiac safety data were extracted. Continuous and dichotomous QTc data were used in the meta-analysis. RESULTS: Preclinical studies suggested that aripiprazole has limited affinity for the delayed rectifier potassium current. TdP was reported in two case reports and SCD was reported in one...

  3. Risk of Venous Thromboembolism Among Otolaryngology Patients vs General Surgery and Plastic Surgery Patients.

    Science.gov (United States)

    Cramer, John D; Dilger, Amanda E; Schneider, Alex; Smith, Stephanie Shintani; Samant, Sandeep; Patel, Urjeet A

    2017-10-19

    Venous thromboembolism (VTE), which includes deep venous thrombosis or pulmonary embolism, is the number 1 cause of preventable death in surgical patients. Current guidelines from the American College of Chest Physicians provide VTE prevention recommendations that are specific to individual surgical subspecialties; however, no guidelines exist for otolaryngology. To examine the rate of VTE for various otolaryngology procedures compared with an established average-risk field (general surgery) and low-risk field (plastic surgery). This cohort study compared the rate of VTE after different otolaryngology procedures with those of general and plastic surgery in the American College of Surgeons National Surgical Quality Improvement Program from January 1, 2005, through December 31, 2013. We used univariate and multivariable logistic regression analysis of clinical characteristics, cancer status, and Caprini score to compare different risk stratification of patients. Data analysis was performed from May 1, 2016, to April 1, 2017. Surgery. Thirty-day rate of VTE. A total of 1 295 291 patients, including 31 896 otolaryngology patients (mean [SD] age, 53.9 [16.7] years; 14 260 [44.7%] male; 21 603 [67.7%] white), 27 280 plastic surgery patients (mean [SD] age, 50.5 [13.9] years; 4835 [17.7%] male; 17 983 [65.9%] white), and 1 236 115 general surgery patients (mean [SD] age, 54.9 [17.2] years; 484 985 [39.2%] male; 867 913 [70.2%] white) were compared. The overall 30-day rate of VTE was 0.5% for otolaryngology compared with 0.7% for plastic surgery and 1.2% for general surgery. We identified a high-risk group for VTE in otolaryngology (n = 3625) that included free or regional tissue transfer, laryngectomy, composite resection, skull base surgery, and incision and drainage. High-risk otolaryngology patients experienced similar rates of VTE as general surgery patients across all Caprini risk levels. Low-risk otolaryngology patients (n = 28 271) experienced

  4. Neoadjuvant treatment and adjuvant radiotherapy for patients with high risk prostate cancer and radical prostatectomy

    International Nuclear Information System (INIS)

    Scorticati, Carlos; Aguilar, Jorge A.; Gonzalez Granda, Pablo; Mendez, Fernando; Montiel, Raul; Rege, Eduardo; Alvarez, Patricio; Lopez, Miguel A.; Rizzi, Alfredo; Mazza, Osvaldo

    2009-01-01

    Introduction and Objectives: To analyze the results of the treatment in patients with cancer of prostate of high risk. Material and Method: Retrospective and observational analysis of 130 patients operated by CAP of high risk (criteria of D'Amico) average 41,48 months, divided in form nonrandomized in three groups 1: radical prostatectomy, 2: neoadjuvant hormonoterapy (BAC) + PR, 3: BAC + PR + x-ray (RT). Statistical analysis: multivaried, test of curved Chi2 and p statistical and of Kaplan Meier. Results: Biochemical relapse 68 patients (52.3%), average 23,37 months. Without differences according to therapeutic modality (p: 0.043). In the multivaried analysis of the 3 factors of presurgical, single risk we found a statistically significant relation in the coexistence of the 3 factors with the presence of positive margin in the PR piece. (p: 0,002). The analysis to make or not, neoadjuvant BAC without significant difference (p: 0,403) evaluating in such the rate of M+, actuarial global survival according to curves of Kaplan Meier to 5 and 10 years (P: 0,5257) and survival 5 actuarial specific cancer to and 10a (P: 0,2165). Conclusions: Without significant differences in: RB, clinical progression, pathological relapse, global and specific survival, rate of positive surgical margins. The 3 criteria of D'Amico were predictive of positive surgical margins and RB, the patients with RB in group 2 presented/displayed greater risk of clinical progression, the PR demonstrated a global survival and specify actuarial to 10 years greater to 50%, considering it therapeutic an option been worth. (authors) [es

  5. Regression of Some High-risk Features of Age-related Macular Degeneration (AMD in Patients Receiving Intensive Statin Treatment

    Directory of Open Access Journals (Sweden)

    Demetrios G. Vavvas

    2016-03-01

    Conclusions: High-dose statins may result in resolution of drusenoid pigment epithelial detachments (PEDs and improvement in VA, without atrophy or neovascularization in a high-risk subgroup of AMD patients. Confirmation from larger studies is warranted.

  6. Predictors of Early Rebleeding after Endoscopic Therapy in Patients with Nonvariceal Upper Gastrointestinal Bleeding Secondary to High-Risk Lesions

    Directory of Open Access Journals (Sweden)

    Davide Maggio

    2013-01-01

    Full Text Available BACKGROUND: In an era of increasingly shortened admissions, data regarding predictors of early rebleeding among patients with nonvariceal upper gastrointestinal bleeding (NVUGIB exhibiting high-risk stigmata (HRS having undergone endoscopic hemostasis are lacking.

  7. Limited dose warfarin throughout pregnancy in high-risk patients with mechanical valves: A randomized clinical trial

    Directory of Open Access Journals (Sweden)

    Ahmed Hassouna

    2015-06-01

    Conclusions: LDW may be insufficient to achieve the INR target recommended for high-risk pregnant patients with mitral (±aortic MHVP. Phenindione can offer an effective and probably safe alternative (NCT01758640.

  8. Contrast nephropathy in high-risk patients undergoing coronary angiography and intervention

    International Nuclear Information System (INIS)

    Uddin, M.A.; Rabbani, M.A.; Jafary, F.H.; Bhatti, M.A.; Islam, M.

    2005-01-01

    Objective: To determine the incidence of contrast nephropathy in high-risk patients undergoing coronary angiography and percutaneous coronary intervention (PCI), and to define the characteristics of this cohort. Design: Descriptive study. Place and Duration of Study: The Aga Khan University Hospital, Karachi from January to December 2002. Patients and Methods: One hundred and fifteen patients with serum creatinine greater than 1.4mg/dl who underwent coronary angiography or PCI were included. All patients received non-ionic contrast dye. Acute contrast nephropathy was defined as rise in serum creatinine of >0.5mg/dl within 48 hours following the index procedure. Means and standard deviations were calculated for continuous variables and frequencies for categorical variables. Results: Mean age of patients was 62.3 year + 8.83. Mean pre-contrast creatinine was 1.9+0.9mg/dl. Eleven (9.65%) patients developed contrast nephropathy. 4.4% of patients with serum creatinine 4.0(p-value 0.001). 11.9% diabetic patients developed nephropathy compared to 6.3% of non-diabetics (p-value 0.355). 11.4% of hypertensive and 3.7% of non-hypertensive patients developed contrast-nephropathy (p-value 0.454). 12.9% of low dose group ( 100ml) developed nephropathy (p-value 0.188). Mean serum creatinine in low dose group was higher (3.0mg/dl vs. 1.7 mg/dl). Conclusion: The incidence of contrast nephropathy in this study was similar to that reported in literature. Risk of CIN was found to be significantly proportional to the severity of baseline renal disease. Trends towards higher risk of CIN were seen in patients with diabetes and hypertension. Higher incidence of CIN in patients receiving low-dose contrast was confounded by higher baseline serum creatinine in that group. (author)

  9. Adjuvant simultaneous radiochemotherapy following radical hysterectomy for patients with cervical cancers in high-risk situation. Results of a pilot study; Adjuvante simultane Radiochemotherapie nach operiertem Uteruszervixkarzinom in der High-Risk-Situation. Ergebnisse einer Pilotuntersuchung

    Energy Technology Data Exchange (ETDEWEB)

    Haensgen, G.; Kuhnt, T.; Pigorsch, S.; Dunst, J. [Halle-Wittenberg Univ., Halle (Germany). Klinik und Poliklinik fuer Strahlentherapie; Strauss, H. [Klinik fuer Gynaekologie der Martin-Luther-Univ. Halle/Wittenberg (Germany)

    2002-02-01

    Background: The most important factors for prognosis of cervical cancers are age and histological criteria such as the tumor size, the involvement of lymph nodes, lympho-vascular space involvement as well as microvessel involvement and poor tumor differentiation (grading 3). Here we present the results of concomitant chemo-radiation at high-risk situation of patients with cervical cancer after surgery. Patients and Methods: The study comprised 34 patients with median age of 40 years (26-63 years) after Wertheim surgical technique for cervical cancer at the FIGO Stages IB (n = 19) and IIB (n = 15). All patients were treated between November 1995 and June 1999 by a schedule of concomitant chemoradiation. The indication for this treatment was given by the positive histological proof of lymph node metastasis, microvessel or lympho-vascular space involvement as well as a G3 grading. The chemo-therapy was given in week 1 and 5 (day 1-5 and day 29-33). The dosage of cisplatin was 20 mg/m{sup 2}/d on every day and 5-FU was given as a 120-h infusion with 600 mg/m{sup 2}/d. The external beam radiotherapy was applied to the pelvis with 1.8 Gy per fraction up to 50.4-54 Gy. In two patients the paraaortal region was irradiated too because of the involvement of these lymph nodes. Results: The median observation time was 48 months (3-68 months). 30 patients are alive (88%) in complete response. Four patients died. The mean survival was 61 {+-} 3 months. We have seen only slight acute toxicities of grade 1 and 2. Three patients suffered from a grade 3 diarrhea and three patients developed a grade 3 leukopenia. In seven patients we found a secondary lymphedema as a late toxicity. Conclusion: The concomitant chemoradiation containing cisplatin in high-risk situation for cervical cancer after surgery improves the outcome and survival in these patients. (orig.) [German] Hintergrund: Entscheidend fuer die Prognose nach operiertem Uteruszervixkarzinom sind neben dem Alter

  10. Definition and Validation of "Favorable High-Risk Prostate Cancer": Implications for Personalizing Treatment of Radiation-Managed Patients.

    Science.gov (United States)

    Muralidhar, Vinayak; Chen, Ming-Hui; Reznor, Gally; Moran, Brian J; Braccioforte, Michelle H; Beard, Clair J; Feng, Felix Y; Hoffman, Karen E; Choueiri, Toni K; Martin, Neil E; Sweeney, Christopher J; Trinh, Quoc-Dien; Nguyen, Paul L

    2015-11-15

    To define and validate a classification of favorable high-risk prostate cancer that could be used to personalize therapy, given that consensus guidelines recommend similar treatments for all radiation-managed patients with high-risk disease. We studied 3618 patients with cT1-T3aN0M0 high-risk or unfavorable intermediate-risk prostate adenocarcinoma treated with radiation at a single institution between 1997 and 2013. Favorable high-risk was defined as T1c disease with either Gleason 4 + 4 = 8 and prostate-specific antigen 20 ng/mL. Competing risks regression was used to determine differences in the risk of prostate cancer-specific mortality (PCSM) after controlling for baseline factors and treatment. Our results were validated in a cohort of 13,275 patients using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. Patients with favorable high-risk disease had significantly better PCSM than other men with high-risk disease (adjusted hazard ratio [AHR] 0.42, 95% confidence interval [CI] 0.18-0.996, P=.049) and similar PCSM as men with unfavorable intermediate-risk disease (AHR 1.17, 95% CI 0.50-2.75, P=.710). We observed very similar results within the SEER-Medicare cohort (favorable high-risk vs other high-risk: AHR 0.21, 95% CI 0.11-0.41, Prisk vs unfavorable intermediate-risk: AHR 0.67, 95% CI 0.33-1.36, P=.268). Patients with favorable high-risk prostate cancer have significantly better PCSM than other patients with high-risk disease and similar PCSM as those with unfavorable intermediate-risk disease, who are typically treated with shorter-course androgen deprivation therapy. This new classification system may allow for personalization of treatment within high-risk disease, such as consideration of shorter-course androgen deprivation therapy for favorable high-risk disease. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.

  11. Vertebral Body Stapling versus Bracing for Patients with High-Risk Moderate Idiopathic Scoliosis

    Science.gov (United States)

    Cuddihy, Laury; Danielsson, Aina J.; Cahill, Patrick J.; Samdani, Amer F.; Grewal, Harsh; Richmond, John M.; Mulcahey, M. J.; Gaughan, John P.; Antonacci, M. Darryl; Betz, Randal R.

    2015-01-01

    Purpose. We report a comparison study of vertebral body stapling (VBS) versus a matched bracing cohort for immature patients with moderate (25 to 44°) idiopathic scoliosis (IS). Methods. 42 of 49 consecutive patients (86%) with IS were treated with VBS and followed for a minimum of 2 years. They were compared to 121 braced patients meeting identical inclusion criteria. 52 patients (66 curves) were matched according to age at start of treatment (10.6 years versus 11.1 years, resp. [P = 0.07]) and gender. Results. For thoracic curves 25–34°, VBS had a success rate (defined as curve progression <10°) of 81% versus 61% for bracing (P = 0.16). In thoracic curves 35–44°, VBS and bracing both had a poor success rate. For lumbar curves, success rates were similar in both groups for curves measuring 25–34°. Conclusion. In this comparison of two cohorts of patients with high-risk (Risser 0-1) moderate IS (25–44°), in smaller thoracic curves (25–34°) VBS provided better results as a clinical trend as compared to bracing. VBS was found not to be effective for thoracic curves ≥35°. For lumbar curves measuring 25–34°, results appear to be similar for both VBS and bracing, at 80% success. PMID:26618169

  12. Safety and preliminary results of perioperative chemotherapy and hyperthermic intraperitoneal chemotherapy (HIPEC for high-risk gastric cancer patients

    Directory of Open Access Journals (Sweden)

    Costa Wilson L

    2012-09-01

    Full Text Available Abstract Background Gastric cancer relapse occurs in about 30% of the patients treated with gastrectomy and D2-lymphadenectomy, mainly as distant or peritoneal metastases. Hyperthermic intraperitoneal chemotherapy (HIPEC has been associated with an improvement in survival and lower peritoneal recurrence, albeit with increased morbidity. The aim of this study is to report the preliminary results of the association of perioperative chemotherapy, radical surgery and HIPEC in high-risk gastric patients in a single institution. Methods Treatment protocol was started in 2007 and included patients younger than 65 years old, with good performance status and gastric adenocarcinoma with serosa involvement and lymph node metastases, located in the body or antrum. Patients should receive three preoperative cycles of DCF (Docetaxel 75 mg/m2, Cisplatin 75 mg/m2 and continuous intravenous infusion of 5-Fluorouracil 750 mg/m2 for 5 days, followed by gastric resection with D2-lymphadenectomy, hyperthermic intraperitoneal chemotherapy with Mytomicin C 34 mg/m2 and three more postoperative cycles of DCF. Results Ten patients were included between 2007 and 2011. Their median age was 47 years old and six were male. Nine were staged with cT4 cN + tumors and one as cT3 cN+. Nine patients completed all three preoperative chemotherapy cycles. Eight individuals were treated with a total gastrectomy and the other two had a distal gastrectomy, all having HIPEC. Postoperative morbidity was 50%, with no deaths. Regarding postoperative chemotherapy, only 5 patients completed three cycles. With a median follow-up of 25 months, three relapses were identified and 7 patients remain disease-free, two with more than 4 years of follow-up. Conclusion The association of perioperative systemic and intraperitoneal chemotherapy plus radical surgery is a feasible multimodality treatment, with acceptable morbidity. With a longer follow-up and a larger group of

  13. Safety and preliminary results of perioperative chemotherapy and hyperthermic intraperitoneal chemotherapy (HIPEC) for high-risk gastric cancer patients.

    Science.gov (United States)

    Costa, Wilson L; Coimbra, Felipe J F; Ribeiro, Héber S C; Diniz, Alessandro L; de Godoy, André Luís; Begnami, Mariadirleifs; Silva, Milton J B; Fanelli, Marcelo F; Mello, Celso A L

    2012-09-19

    Gastric cancer relapse occurs in about 30% of the patients treated with gastrectomy and D2-lymphadenectomy, mainly as distant or peritoneal metastases. Hyperthermic intraperitoneal chemotherapy (HIPEC) has been associated with an improvement in survival and lower peritoneal recurrence, albeit with increased morbidity. The aim of this study is to report the preliminary results of the association of perioperative chemotherapy, radical surgery and HIPEC in high-risk gastric patients in a single institution. Treatment protocol was started in 2007 and included patients younger than 65 years old, with good performance status and gastric adenocarcinoma with serosa involvement and lymph node metastases, located in the body or antrum. Patients should receive three preoperative cycles of DCF (Docetaxel 75 mg/m2, Cisplatin 75 mg/m2 and continuous intravenous infusion of 5-Fluorouracil 750 mg/m2 for 5 days), followed by gastric resection with D2-lymphadenectomy, hyperthermic intraperitoneal chemotherapy with Mytomicin C 34 mg/m2 and three more postoperative cycles of DCF. Ten patients were included between 2007 and 2011. Their median age was 47 years old and six were male. Nine were staged with cT4 cN + tumors and one as cT3 cN+. Nine patients completed all three preoperative chemotherapy cycles. Eight individuals were treated with a total gastrectomy and the other two had a distal gastrectomy, all having HIPEC. Postoperative morbidity was 50%, with no deaths. Regarding postoperative chemotherapy, only 5 patients completed three cycles. With a median follow-up of 25 months, three relapses were identified and 7 patients remain disease-free, two with more than 4 years of follow-up. The association of perioperative systemic and intraperitoneal chemotherapy plus radical surgery is a feasible multimodality treatment, with acceptable morbidity. With a longer follow-up and a larger group of patients, we hope to be able to determine if it also influences survival

  14. Adjuvant radiochemotherapy in patients with locally advanced high-risk cervical cancer

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    Heinzelmann, F.; Henke, G.; Grafenstein, M. von; Weidner, N.; Paulsen, F.; Bamberg, M.; Weinmann, M. [Tuebingen Univ. (Germany). Dept. of Radiation Oncology; Staebler, A. [Tuebingen Univ. (Germany). Div. of Gynecologic Pathology; Brucker, S. [Tuebingen Univ. (Germany). Dept. of Gynecology

    2012-07-15

    Background and purpose: The aim of this retrospective study was to analyze the outcome of patients with locally advanced cervical carcinoma treated by adjuvant radiochemotherapy and to determine risk factors for local and distant relapse. Furthermore, acute and late effects of treatment were recorded. Patients and methods: A total of 72 patients with FIGO stages I-III cervical carcinoma were treated by radical hysterectomy, pelvic lymphadenectomy, and postoperative radiochemotherapy. Only patients with positive pelvic lymph nodes, parametrial involvement, positive margins, or tumor bulk were eligible. Patients were irradiated with a standard pelvic field (50.4 Gy in 28 fractions). The majority of patients received platinum-based chemotherapy. Results: After a median follow-up of 37 months, estimated 1-, 2-, and 4-year disease-free survival (DFS) and overall survival (OS) rates were 89%, 80%, 68% and 95%, 88%, 76%, respectively. Nine of the 72 patients had pelvic recurrences including only 1 isolated local failure; 23 of the 72 patients presented with distant relapse. The majority of relapses occurred within the first 3 years after adjuvant treatment. The number of positive pelvic lymph nodes (> 1) was the strongest prognostic factor for DFS. Treatment was well tolerated with transient acute hematologic ({proportional_to}30%) and gastrointestinal ({proportional_to}30%) grade 3 toxicity. Small bowel obstruction ({proportional_to}6%) was the only important late sequelae. Conclusion: Adjuvant radiochemotherapy in patients with advanced cervical cancer and several risk factors is highly effective to prevent local relapse. Future efforts to improve outcome should be placed on improvement of systemic control especially in subgroups with high-risk features for distant relapse. Combined treatment was well tolerated with moderate acute and late toxicity. (orig.)

  15. Combination of growth pattern and tumor regression identifies a high-risk group in neoadjuvant treated rectal cancer patients.

    Science.gov (United States)

    Jessberger, Jonas; Erlenbach-Wünsch, Katharina; Posselt, Rebecca; Haderlein, Marlen; Agaimy, Abbas; Fietkau, Rainer; Hartmann, Arndt; Distel, Luitpold

    2017-05-01

    To analyze the prognostic effect of E-cadherin expression, the growth pattern of the tumor and the regression grade in a rectal cancer cohort treated with neoadjuvant radiochemotherapy (RCT). A total of 223 patients with rectal cancer treated with neoadjuvant RCT followed by surgery were included. Altogether 88 biopsies prior to RCT and 213 tumor resections in an average of 55 days post-RCT were investigated. Protein expression of E-cadherin and tumor growth pattern (solid glandular vs single-cell pattern) was assessed by staining tissue microarrays. The regression grade at the invasion front was determined according to the Dworak scale. There was a significant decrease of E-cadherin expression (P = 0.002) and a significant increased single-cell growth (P pattern and the Dworak regression grade was an independent prognostic parameter for tumor-specific survival (P = 0.015). Loss of E-cadherin protein expression in the pretreatment biopsy of rectal cancer is associated with fewer metastases and improved survival. Furthermore, the growth pattern in the post-RCT resection specimen has a prognostic value for survival. A combination of growth pattern and tumor regression score (the RegPat score) showed the highest discriminatory power to identify high-risk patients. © 2017 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd.

  16. Effectiveness of incentive spirometry in patients following thoracotomy and lung resection including those at high risk for developing pulmonary complications.

    Science.gov (United States)

    Agostini, Paula; Naidu, Babu; Cieslik, Hayley; Steyn, Richard; Rajesh, Pala Babu; Bishay, Ehab; Kalkat, Maninder Singh; Singh, Sally

    2013-06-01

    Following thoracotomy, patients frequently receive routine respiratory physiotherapy which may include incentive spirometry, a breathing technique characterised by deep breathing performed through a device offering visual feedback. This type of physiotherapy is recommended and considered important in the care of thoracic surgery patients, but high quality evidence for specific interventions such as incentive spirometry remains lacking. 180 patients undergoing thoracotomy and lung resection participated in a prospective single-blind randomised controlled trial. All patients received postoperative breathing exercises, airway clearance and early mobilisation; the control group performed thoracic expansion exercises and the intervention group performed incentive spirometry. No difference was observed between the intervention and control groups in the mean drop in forced expiratory volume in 1 s on postoperative day 4 (40% vs 41%, 95% CI -5.3% to 4.2%, p=0.817), the frequency of postoperative pulmonary complications (PPC) (12.5% vs 15%, 95% CI -7.9% to 12.9%, p=0.803) or in any other secondary outcome measure. A high-risk subgroup (defined by ≥2 independent risk factors; age ≥75 years, American Society of Anaesthesiologists score ≥3, chronic obstructive pulmonary disease (COPD), smoking status, body mass index ≥30) also demonstrated no difference in outcomes, although a larger difference in the frequency of PPC was observed (14% vs 23%) with 95% CIs indicating possible benefit of intervention (-7.4% to 2.6%). Incentive spirometry did not improve overall recovery of lung function, frequency of PPC or length of stay. For patients at higher risk for the development of PPC, in particular those with COPD or current/recent ex-smokers, there were larger observed actual differences in the frequency of PPC in favour of the intervention, indicating that investigations regarding the physiotherapy management of these patients need to be developed further.

  17. The Finnish Cardiovascular Study (FINCAVAS: characterising patients with high risk of cardiovascular morbidity and mortality

    Directory of Open Access Journals (Sweden)

    Niemi Mari

    2006-03-01

    Full Text Available Abstract Background The purpose of the Finnish Cardiovascular Study (FINCAVAS is to construct a risk profile – using genetic, haemodynamic and electrocardiographic (ECG markers – of individuals at high risk of cardiovascular diseases, events and deaths. Methods and design All patients scheduled for an exercise stress test at Tampere University Hospital and willing to participate have been and will be recruited between October 2001 and December 2007. The final number of participants is estimated to reach 5,000. Technically successful data on exercise tests using a bicycle ergometer have been collected of 2,212 patients (1,400 men and 812 women by the end of 2004. In addition to repeated measurement of heart rate and blood pressure, digital high-resolution ECG at 500 Hz is recorded continuously during the entire exercise test, including the resting and recovery phases. About 20% of the patients are examined with coronary angiography. Genetic variations known or suspected to alter cardiovascular function or pathophysiology are analysed to elucidate the effects and interactions of these candidate genes, exercise and commonly used cardiovascular medications. Discussion FINCAVAS compiles an extensive set of data on patient history, genetic variation, cardiovascular parameters, ECG markers as well as follow-up data on clinical events, hospitalisations and deaths. The data enables the development of new diagnostic and prognostic tools as well as assessments of the importance of existing markers.

  18. The Finnish Cardiovascular Study (FINCAVAS): characterising patients with high risk of cardiovascular morbidity and mortality

    International Nuclear Information System (INIS)

    Nieminen, Tuomo; Turjanmaa, Väinö; Kähönen, Mika; Lehtinen, Rami; Viik, Jari; Lehtimäki, Terho; Niemelä, Kari; Nikus, Kjell; Niemi, Mari; Kallio, Janne; Kööbi, Tiit

    2006-01-01

    The purpose of the Finnish Cardiovascular Study (FINCAVAS) is to construct a risk profile – using genetic, haemodynamic and electrocardiographic (ECG) markers – of individuals at high risk of cardiovascular diseases, events and deaths. All patients scheduled for an exercise stress test at Tampere University Hospital and willing to participate have been and will be recruited between October 2001 and December 2007. The final number of participants is estimated to reach 5,000. Technically successful data on exercise tests using a bicycle ergometer have been collected of 2,212 patients (1,400 men and 812 women) by the end of 2004. In addition to repeated measurement of heart rate and blood pressure, digital high-resolution ECG at 500 Hz is recorded continuously during the entire exercise test, including the resting and recovery phases. About 20% of the patients are examined with coronary angiography. Genetic variations known or suspected to alter cardiovascular function or pathophysiology are analysed to elucidate the effects and interactions of these candidate genes, exercise and commonly used cardiovascular medications. FINCAVAS compiles an extensive set of data on patient history, genetic variation, cardiovascular parameters, ECG markers as well as follow-up data on clinical events, hospitalisations and deaths. The data enables the development of new diagnostic and prognostic tools as well as assessments of the importance of existing markers

  19. The combination of a programmable valve and a subclavicular anti-gravity device in hydrocephalus patients at high risk for hygromas.

    Science.gov (United States)

    Zachenhofer, Iris; Donat, Markus; Roessler, Karl

    2012-04-01

    In order to avoid occurrence of post-operative hygromas in specific hydrocephalus patients being at high risk of overdrainage, a combination of programmable valve and anti-gravity device is widely recommended. We analyzed our series of hydrocephalus patients implanted with such a shunt configuration focusing on complications in relation to over-/underdrainage and neurological outcome. In 28 hydrocephalic patients (14 women and 14 men; mean age 65 years, range from 14 to 82 years; 11 normal pressure, 7 post-traumatic, and 4 post-hemorrhagic hydrocephalus), a Codman Medos programmable valve combined with a Miethke shunt assistant (SA) was implanted at the Department of Neurosurgery of the Academic Teaching Hospital Feldkirch. Implantation was performed simultaneously in 20 patients during the primary procedure: in five patients, SA was placed during revision surgery, and in three patients, the patent system was completed by additional implantation of an SA. Subdural hematoma occurred in one out of 20 patients with SA implantation during primary procedure and in two out of eight patients with SA implantation as secondary procedure, respectively. Shunt occlusion occurred in one patient out of the patients with SA implantation during primary procedure, but was seen in three patients with pre-existing shunt without SA. Shunt infection occurred in one case. Our results suggest the combination of an adjustable valve and SA as an effective treatment for a specific group of hydrocephalus patients being at high risk for overdrainage.

  20. Virtual colonoscopy vs conventional colonoscopy in patients at high risk of colorectal cancer--a prospective trial of 150 patients.

    Science.gov (United States)

    White, T J; Avery, G R; Kennan, N; Syed, A M; Hartley, J E; Monson, J R T

    2009-02-01

    Virtual colonoscopy (VC)/CT colonography has advantages over the well-documented limitations of colonoscopy/barium enema. This prospective blinded investigative comparison trial aimed to evaluate the ability of VC to assess the large bowel, compared to conventional colonoscopy (CC), in patients at high risk of colorectal cancer (CRC). We studied 150 patients (73 males, mean age 60.9 years) at high risk of CRC. Following bowel preparation, VC was undertaken using colonic insufflation and 2D-spiral CT acquisition. Two radiologists reported the images and a consensual agreement reached. Direct comparison was made with CC (performed later the same day). Interobserver agreement was calculated using the Kappa method. Postal questionnaires sought patient preference. Virtual colonoscopy visualized the caecum in all cases. Five (3.33%) VCs were classified as inadequate owing to poor distension/faecal residue. CC completion rate was 86%. Ultimately, 44 patients had normal findings, 44 had diverticular disease, 11 had inflammatory bowel disease, 18 had cancers, and 33 patients had 42 polyps. VC identified 19 cancers--a sensitivity and specificity of 100% and 99.2% respectively. For detecting polyps > 10 mm, VC had a sensitivity and specificity (per patient) of 91% and 99.2% respectively. VC identified four polyps proximal to stenosing carcinomas and extracolonic malignancies in nine patients (6%). No procedural complications occurred with either investigation. A Kappa score achieved for interobserver agreement was 0.777. Virtual colonoscopy is an effective and safe method for evaluating the bowel and was the investigation of choice amongst patients surveyed. VC provided information additional to CC on both proximal and extracolonic pathology. VC may become the diagnostic procedure of choice for symptomatic patients at high risk of CRC, with CC being reserved for therapeutic intervention, or where a tissue diagnosis is required.

  1. HIGH-RISK BEHAVIOURS AND CONCOMITANT MEDICAL ILLNESSES AMONG PATIENTS AT METHADONE MAINTENANCE THERAPY CLINIC, HOSPITAL TENGKU AMPUAN AFZAN, MALAYSIA

    Directory of Open Access Journals (Sweden)

    HAJEE MI

    2009-01-01

    Full Text Available Background: High prevalence of high-risk behaviours and concurrent medical illnesses among opioid drug users would influence the outcome of Methadone Maintenance Programme. It would also require a special medical attention to contain these issues. Objectives: This study explored patients’ characteristics and their high-risk behaviours in order to understand more about opioid dependent users in Malaysia. Methods: A total of 172 patient case notes at Methadone Clinic Hospital Tengku Ampuan Afzan (HTAA were retrieved for relevant data. Results: Many of the patients were engaged in high-risk behaviours such as needle sharing, unsafe sex and criminal activities. A large number of the subjects had contracted blood-borne diseases such as HIV and hepatitis infections. Conclusions: Education on the issue of medical and psychosocial complications related to high risk behaviours is essential. Medical professionals dealing with this group have to pay attention and update their knowledge on the medical issue.

  2. Porocarcinoma scalp with high risk features treated with surgery and adjuvant radiotherapy: A case report and review of literature

    Directory of Open Access Journals (Sweden)

    Wineeta Melgandi

    2016-09-01

    Full Text Available Eccrine porocarcinoma is a rare malignant sweat gland tumor arising from the intra dermal part of the gland and accounts for only 0.005% of all epithelial cutaneous tumors. Commonly involved site includes extremities and face. Scalp is a rare site for porocarcinoma with less than 20 reported cases so far. Wide local excision with clear margins remains the treatment of choice. Review of literature revealed a local recurrence rate of 37.5% and a nodal involvement risk of 20%. Porocarcinoma of the scalp is peculiar in that the primary tumor may be large at presentation, making surgery with adequate margins difficult. Adjuvant radiotherapy must be considered in a case to case basis due to the high local recurrence rates compared to other sites of porocarcinoma and should be given to all patients with close margins and extra capsular extension.

  3. High-Risk Behaviours and Concomitant Medical Illnesses Among Patients at Methadone Maintenance Therapy Clinic, Hospital Tengku Ampuan Afzan, Malaysia

    OpenAIRE

    Ramli, M; Nora, MZ; Zafri, AAB; Junid, MR; Umeed, AK; Hajee, MI

    2009-01-01

    Background: High prevalence of high-risk behaviours and concurrent medical illnesses among opioid drug users would influence the outcome of Methadone Maintenance Programme. It would also require a special medical attention to contain these issues. Objectives: This study explored patients’ characteristics and their high-risk behaviours in order to understand more about opioid dependent users in Malaysia. Methods: A total of 172 patient case notes at Methadone Clinic Hospital Tengku Ampuan Afza...

  4. Efficacy of the Kyoto Classification of Gastritis in Identifying Patients at High Risk for Gastric Cancer.

    Science.gov (United States)

    Sugimoto, Mitsushige; Ban, Hiromitsu; Ichikawa, Hitomi; Sahara, Shu; Otsuka, Taketo; Inatomi, Osamu; Bamba, Shigeki; Furuta, Takahisa; Andoh, Akira

    2017-01-01

    Objective The Kyoto gastritis classification categorizes the endoscopic characteristics of Helicobacter pylori (H. pylori) infection-associated gastritis and identifies patterns associated with a high risk of gastric cancer. We investigated its efficacy, comparing scores in patients with H. pylori-associated gastritis and with gastric cancer. Methods A total of 1,200 patients with H. pylori-positive gastritis alone (n=932), early-stage H. pylori-positive gastric cancer (n=189), and successfully treated H. pylori-negative cancer (n=79) were endoscopically graded according to the Kyoto gastritis classification for atrophy, intestinal metaplasia, fold hypertrophy, nodularity, and diffuse redness. Results The prevalence of O-II/O-III-type atrophy according to the Kimura-Takemoto classification in early-stage H. pylori-positive gastric cancer and successfully treated H. pylori-negative cancer groups was 45.1%, which was significantly higher than in subjects with gastritis alone (12.7%, pgastritis scores of atrophy and intestinal metaplasia in the H. pylori-positive cancer group were significantly higher than in subjects with gastritis alone (all pcancer increased with intestinal metaplasia (odds ratio: 4.453, 95% confidence interval: 3.332-5.950, cancer. The scores of intestinal metaplasia and atrophy of the scoring system in the Kyoto gastritis classification may thus be useful for detecting these patients.

  5. Factors and Outcomes Associated with MRCP Use prior to ERCP in Patients at High Risk for Choledocholithiasis

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    Gobind Anand

    2016-01-01

    Full Text Available Background. Consensus guidelines recommend that patients at high risk for choledocholithiasis undergo endoscopic retrograde cholangiopancreatography (ERCP without additional imaging. This study evaluates factors and outcomes associated with performing magnetic resonance cholangiopancreatography (MRCP prior to ERCP among patients at high risk for choledocholithiasis. Methods. An institutional administrative database was searched using diagnosis codes for choledocholithiasis, cholangitis, and acute pancreatitis and procedure codes for MRCP and ERCP. Patients categorized as high risk for choledocholithiasis were evaluated. Results. 224 patients classified as high risk, of whom 176 (79% underwent ERCP only, while 48 (21% underwent MRCP prior to ERCP. Patients undergoing MRCP experienced longer time to ERCP (72 hours versus 35 hours, p<0.0001, longer length of stay (8 days versus 6 days, p=0.02, higher hospital charges ($23,488 versus $19,260, p=0.08, and higher radiology charges ($3,385 versus $1,711, p<0.0001. The presence of common bile duct stone(s on ultrasound was the only independent factor associated with less use of MRCP (OR 0.09, p<0.0001. Conclusions. MRCP use prior to ERCP in patients at high risk for choledocholithiasis is common and associated with greater length of hospital stay, higher radiology charges, and a trend towards higher hospital charges.

  6. Extended thromboprophylaxis with low-molecular-weight heparins after hospital discharge in high-risk surgical and medical patients: a review.

    Science.gov (United States)

    Huo, Michael H; Muntz, James

    2009-06-01

    Prophylaxis against venous thromboembolism (VTE) is routinely administered during the hospital stay in at-risk surgical and medical patients. However, in high-risk groups, the risk of deep-vein thrombosis or pulmonary embolism may persist for several weeks after discharge. The standard duration of thromboprophylaxis (6-14 days) may not provide adequate protection against such events. This article reviews published data on the efficacy and safety profile of extended-duration thromboprophylaxis in patients at high risk for VTE, the potential cost-effectiveness of such treatment, and practical aspects of ensuring an effective transition from the inpatient to the outpatient setting. MEDLINE and the Cochrane Database of Systematic Reviews were searched through January 2009 for relevant English-language reports of clinical trials, abstracts, and case reports. The search terms included, but were not limited to, venous thromboembolism, pulmonary embolism, anticoagulation, thromboprophylaxis, prolonged duration, and extended duration. The reference lists of the identified articles were reviewed for additional relevant publications. Congress Web sites were also consulted. The principal criteria for inclusion of a study were that it have a prospective, randomized design and include a control group. Case series and retrospective analyses were excluded. Studies have found that extended-duration thromboprophylaxis (28-45 days) with low-molecular-weight heparins (LMWHs) can reduce the risk of VTE in high-risk patients. In separate meta-analyses, extended-duration thromboprophylaxis with LMWH was associated with significant reductions in the likelihood of symptomatic VTE compared with standard-duration thromboprophylaxis in patients undergoing major orthopedic surgery (odds ratio [OR] = 0.38; 95% CI, 0.24-0.61) or major abdominal or pelvic surgery (Peto OR = 0.22; 95% CI, 0.06-0.80). There was large heterogeneity in the reported rates of major and minor bleeding. The occurrence of

  7. Benefits of statin therapy and compliance in high risk cardiovascular patients

    Directory of Open Access Journals (Sweden)

    Joel A Lardizabal

    2010-09-01

    Full Text Available Joel A Lardizabal1, Prakash C Deedwania21Division of Cardiology, Department of Medicine, University of California in San Francisco (Fresno-MEP, Fresno, CA, USA; 2University of California in San Francisco, Chief of Cardiology, Veterans Affairs Central California System, Fresno, CA, USAAbstract: Cardiovascular disease (CVD remains the top cause of global mortality. There is considerable evidence that supports the mortality and morbidity benefit of statin therapy in coronary heart disease (CHD and stroke, both in primary and secondary prevention settings. Data also exist pointing to the advantage of statin treatment in other high-risk CVD conditions, such as diabetes, CKD, CHF, and PVD. National and international clinical guidelines in the management of these CVD conditions all advocate for the utilization of statin therapy in appropriate patients. However, overall compliance to statin therapy remains suboptimal. Patient-, physician-, and economic-related factors all play a role. These factors need to be considered in devising approaches to enhance adherence to guideline-based therapies. To fully reap the benefits of statin therapy, interventions which improve long-term treatment compliance in real-world settings should be encouraged.Keywords: cardiovascular disease, statin therapy, coronary heart disease, long-term treatment compliance

  8. Detection of Inborn Errors of Metabolism using Tandem Mass Spectrometry among High-risk Omani Patients.

    Science.gov (United States)

    Al Riyami, Sulaiman; Al Maney, Matar; Joshi, Surendra Nath; Bayoumi, Riad

    2012-11-01

    This is a report on the types and patterns of inborn errors of metabolism (IEMs) of amino acids, organic acids and fatty acids oxidation detected by Tandem Mass Spectrometry for a period of 10 years (1998-2008) at Sultan Qaboos University Hospital (SQUH), the major centre for diagnosis and management of IEM in Oman. Tandem mass spectrometry (MS/MS) was used in the initial screening and diagnosis of IEMs in high risk neonatal and pediatric populations. Out of 1100 patients investigated, 119 were detected positive for IEM by MS/MS spectrometry. Twenty six different metabolic diseases were detected. Patients were categorized into three major groups: a) 54 with amino acids and urea cycle disorders, b) 35 with organic acid disorders, and c) 30 with fatty acid oxidation disorders. The commonest conditions encountered were maple syrup urine disease (MSUD), phenylketonuria (PKU), propionic and isovaleric acidurias, as well as HMG-CoA lyase deficiency and glutaric aciduria type II (GA-II). Most of these IEMs were over-represented in babies born to consanguineous parents, which is consistent with the recessive autosomal inheritance. This study shows that various types of IEMs, reported elsewhere, were also prevalent in Oman, but the pattern of prevalence and distribution is different. The situation, therefore, warrants the development of a nationwide screening and prevention program.

  9. Detection of Inborn Errors of Metabolism using Tandem Mass Spectrometry among High-risk Omani Patients

    Directory of Open Access Journals (Sweden)

    Sulaiman Al Riyami

    2012-11-01

    Full Text Available Objectives: This is a report on the types and patterns of inborn errors of metabolism (IEMs of amino acids, organic acids and fatty acids oxidation detected by Tandem Mass Spectrometry for a period of 10 years (1998-2008 at Sultan Qaboos University Hospital (SQUH, the major centre for diagnosis and management of IEM in Oman.Methods: Tandem mass spectrometry (MS/MS was used in the initial screening and diagnosis of IEMs in high risk neonatal and pediatric populations.Results: Out of 1100 patients investigated, 119 were detected positive for IEM by MS/MS spectrometry. Twenty six different metabolic diseases were detected. Patients were categorized into three major groups: a 54 with amino acids and urea cycle disorders, b 35 with organic acid disorders, and c 30 with fatty acid oxidation disorders. The commonest conditions encountered were maple syrup urine disease (MSUD, phenylketonuria (PKU, propionic and isovaleric acidurias, as well as HMG-CoA lyase deficiency and glutaric aciduria type II (GA-II. Most of these IEMs were over representedin babies born to consanguineous parents, which is consistent with the recessive autosomal inheritance.Conclusion: This study shows that various types of IEMs, reported elsewhere, were also prevalent in Oman, but the pattern of prevalence and distribution is different. The situation, therefore, warrants the development of a nationwide screening and prevention program.

  10. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients.

    Science.gov (United States)

    Jamerson, Kenneth; Weber, Michael A; Bakris, George L; Dahlöf, Björn; Pitt, Bertram; Shi, Victor; Hester, Allen; Gupte, Jitendra; Gatlin, Marjorie; Velazquez, Eric J

    2008-12-04

    The optimal combination drug therapy for hypertension is not established, although current U.S. guidelines recommend inclusion of a diuretic. We hypothesized that treatment with the combination of an angiotensin-converting-enzyme (ACE) inhibitor and a dihydropyridine calcium-channel blocker would be more effective in reducing the rate of cardiovascular events than treatment with an ACE inhibitor plus a thiazide diuretic. In a randomized, double-blind trial, we assigned 11,506 patients with hypertension who were at high risk for cardiovascular events to receive treatment with either benazepril plus amlodipine or benazepril plus hydrochlorothiazide. The primary end point was the composite of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, hospitalization for angina, resuscitation after sudden cardiac arrest, and coronary revascularization. The baseline characteristics of the two groups were similar. The trial was terminated early after a mean follow-up of 36 months, when the boundary of the prespecified stopping rule was exceeded. Mean blood pressures after dose adjustment were 131.6/73.3 mm Hg in the benazepril-amlodipine group and 132.5/74.4 mm Hg in the benazepril-hydrochlorothiazide group. There were 552 primary-outcome events in the benazepril-amlodipine group (9.6%) and 679 in the benazepril-hydrochlorothiazide group (11.8%), representing an absolute risk reduction with benazepril-amlodipine therapy of 2.2% and a relative risk reduction of 19.6% (hazard ratio, 0.80, 95% confidence interval [CI], 0.72 to 0.90; P<0.001). For the secondary end point of death from cardiovascular causes, nonfatal myocardial infarction, and nonfatal stroke, the hazard ratio was 0.79 (95% CI, 0.67 to 0.92; P=0.002). Rates of adverse events were consistent with those observed from clinical experience with the study drugs. The benazepril-amlodipine combination was superior to the benazepril-hydrochlorothiazide combination in reducing cardiovascular

  11. Effect of probiotics on perinatal outcome in patients at high risk of preterm birth.

    Science.gov (United States)

    Kirihara, Nami; Kamitomo, Masato; Tabira, Tatsunori; Hashimoto, Takashi; Taniguchi, Hiroko; Maeda, Takatsugu

    2018-02-01

    Recent reports have shown lower levels of Clostridium and higher levels of Lactobacillales in the intestinal microbiota in preterm birth patients compared to term birth patients. However, the influence of probiotics on perinatal status has not been elucidated. The aim of our study was to evaluate the effects of probiotics on perinatal outcomes. We retrospectively evaluated the effects of oral probiotics on perinatal outcome in patients at high risk of preterm birth. Probiotics containing Streptococcus faecalis, Clostridium butyricum and Bacillus mesentericus were administered for prophylaxis of bacterial vaginosis or treatment of constipation starting at 12.5 ± 4.1 weeks until delivery. Patients not administered probiotics were defined as the non-probiotics group. Between these two groups, perinatal outcomes including gestational age at birth, birth weight, chorioamnionitis or funisitis and preterm birth before 32 weeks were compared. In addition, multivariate regression analyses were performed to evaluate factors influencing preterm birth before 32 weeks, chorioamnionitis/funisitis and normal vaginal flora. The probiotics group showed longer gestation, higher birth weight, lower rates of chorioamnionitis and higher rates of normal vaginal flora compared to the non-probiotics group. Multivariate regression analysis showed that probiotics significantly suppressed preterm birth before 32 weeks and tended to suppress chorioamnionitis/funisitis. The adjusted odds ratios (95% confidence interval) for preterm birth before 32 weeks and chorioamnionitis/funisitis were 0.05 (0.01-0.71) and 0.07 (0.01-1.03), respectively. Oral probiotics containing Clostridium had a significant effect on the prevention of preterm birth before 32 weeks of gestation. © 2017 Japan Society of Obstetrics and Gynecology.

  12. Tamoxifen for one year versus two years versus 6 months of Tamoxifen and 6 months of megestrol acetate: A randomized comparison in postmenopausal patients with high-risk breast cancer (DBCG 89C)

    DEFF Research Database (Denmark)

    Andersen, Jørn; Kamby, C.; Ejlertsen, B.

    2008-01-01

    From January 1, 1990 to December 31, 1994, DBCG conducted a randomised trial in 1 615 postmenopausal women with operable, high-risk, receptor-positive or -unknown breast cancer. The patients were after surgery randomised to Tamoxifen for 1 year (TAM1), Tamoxifen for 2 years (TAM 2) or Tamoxifen...

  13. Efficacy of US-guided transversus abdominis plane block and rectus sheath block with ropivacaine and dexmedetomidine in elderly high-risk patients.

    Science.gov (United States)

    Xu, Lili; Hu, Zhiyong; Shen, Jianjun; McQuillan, Patrick M

    2018-01-01

    This study was designed to evaluate the effectiveness and safety of ultrasound-guided transversus abdominis plane (TAP) and rectus sheath (RS) blocks with ropivacaine and dexmedetomidine in elderly, high-risk patients undergoing emergency abdominal surgery. Sixty elderly patients undergoing emergency abdominal surgery receiving both bilateral ultrasound-guided TAP and RS blocks were randomly divided into two groups: R+D (10 mL of 0.25% ropivacaine+0.5μg/kg dexmedetomidine) and R (10 mL of 0.25% ropivacaine). Pain scores (at rest and with movement) and overall analgesia satisfaction were assessed. The total amount of sufentanil administered postoperatively during the first 24 h, duration of sensory blockade, first time and total number of patient-controlled intravenous analgesia (PCIA) pump activations on the first postoperative day were recorded. The duration of sensory blockade and the first time to PCIA pump activation in the R+D group were longer than that of the R group (P<0.05). The total number of PCIA pump activations on the first postoperative day as well as the total amount of sufentanil administered during the first 24 h in R+D group were less than in the R group (P<0.05). VAS scores at rest and during activity in the R+D group were lower than those in the R group at 2, 6, and 12 h after surgery (P<0.05). Ultrasound-guided TAP and RS blocks with ropivacaine and dexmedetomidine are more effective in promoting block effect, prolonging the duration of analgesia, reducing postoperative pain in elderly high-risk patients undergoing emergency abdominal surgery.

  14. Medulloblastoma subgroup-specific outcomes in irradiated children: who are the true high-risk patients?

    Science.gov (United States)

    Ramaswamy, Vijay; Remke, Marc; Adamski, Jennifer; Bartels, Ute; Tabori, Uri; Wang, Xin; Huang, Annie; Hawkins, Cynthia; Mabbott, Donald; Laperriere, Normand; Taylor, Michael D; Bouffet, Eric

    2016-02-01

    The advent of integrated genomics has fundamentally changed our understanding of medulloblastoma. Although survival differences exist among the 4 principal subgroups, this has yet to be elucidated in a North American cohort of irradiated patients. Ninety-two consecutive patients between the ages of 3 and 17 treated with surgery, craniospinal irradiation, and chemotherapy were identified at the Hospital for Sick Children. Molecular subgrouping was performed using nanoString. Two treatment periods were identified: prior to 2006 as per the protocols of the Children's Oncology Group, and after 2006 per the St Jude Medulloblastoma 03 protocol. Five-year progression-free survival (PFS) over the entire cohort was 0.801 (95% CI: 0.692-0.875) with no significant difference between treatment protocols. Strikingly, we found that Group 4 patients had excellent 5-year PFS of 0.959 (95% CI: 0.744-0.994) for average risk and 0.887 (95% CI: 0.727-0.956) across all Group 4 patients. Group 3 patients had 5-year PFS of 0.733 (95% CI: 0.436-0.891). Sonic hedgehog patients did poorly across both treatment protocols, with 5-year PFS of 0.613 (95% CI: 0.333-0.804), likely owing to a high proportion of TP53 mutated patients in this age group. In a cohort of irradiated patients over 3 years of age, PFS for Group 4 patients was significantly improved compared with initial reports. The impact of subgroup affiliation in these children needs to be assessed in large prospectively treated cooperative protocols to determine if more than just WNT patients can be safely selected for de-escalation of therapy. © The Author(s) 2015. Published by Oxford University Press on behalf of the Society for Neuro-Oncology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

  15. Cortical thickness and trait empathy in patients and people at high risk for alcohol use disorders.

    Science.gov (United States)

    Schmidt, Tobias; Roser, Patrik; Ze, Oksana; Juckel, Georg; Suchan, Boris; Thoma, Patrizia

    2017-12-01

    Alcoholism not only affects individuals with alcohol use disorder (AUD) but also their biological relatives. This high-risk (HR) group has a higher probability to develop AUD. The aim of our study was to compare cortical thickness (CT) in AUD patients relative to participants with (HR) and without (non-HR) familial predisposition for AUD. We focused on empathy-related brain areas as sociocognitive impairment represents a known risk factor for AUD. We examined 13 individuals with AUD, 14 HR individuals, and 20 non-HR participants using high-resolution T1-weighted magnetic resonance images (3 Tesla) to investigate differences in CT. CT was correlated with self-reported empathy in empathy-related areas. AUD patients showed decreased CT in the left inferior and superior frontal gyri, the right precuneus and bilaterally in the middle frontal gyri/the insula relative to the HR group, and in the left insula, the right middle frontal gyrus and bilaterally in the superior frontal gyrus/the precuneus relative to the non-HR group (all ps < 0.036, all ƞ p 2 between 0.161 and 0.375). Reduced CT in inferior, middle, and superior frontal gyri was related to cognitive (all ps < 0.036) and reduced CT in the inferior frontal gyrus to affective (p = 0.031) empathy. We present preliminary evidence of CT reduction in empathy-associated brain regions in patients with AUD relative to healthy participants with and without familial predisposition for AUD. The results have to be interpreted with caution due to low sample sizes and potential confounding effects of medication, gender, and withdrawal.

  16. Short term outcome of conventional versus off-pump coronary artery bypass grafting for high-risk patients

    Directory of Open Access Journals (Sweden)

    Ahmed F. Elmahrouk

    2018-03-01

    Full Text Available Background: Off-pump coronary artery bypass grafting (OPCAB, avoiding the use of cardiopulmonary bypass, has attracted the interest of an increasing number of surgeons and patients, and has assumed an increasing role in surgical practice. Whether OPCAB have better outcome in high-risk patients as compared to Conventional coronary artery bypass grafting (C-GABG remains to be confirmed. We describe an analysis of early clinical outcomes of high-risk coronary artery disease (CAD patients, subjected to both techniques. Methods: We studied 450 patients with additive EuroSCORE of ≥5 on admission. Patients were divided into 2 groups; Group A was assigned for patients underwent conventional C-CABG, and Group B for patients underwent OPCAB. Data, including gender, age, demographic variables and postoperative complications were extracted from the medical records. Results: Both groups were matched with regard to age, gender, smoking, Diabetes mellitus, dyslipidemia, renal hemodialysis and the mean Euro-Score. We demonstrated a decrease in the incidence of early postoperative atrial fibrillation and renal failure in the Off-pump group. However, we recorded no statistical difference of neurologic complications, acute myocardial infarction or early mortality between the two groups. Conclusions: We recommend OPCAB in high-risk CAD patients, as this technique may carry potential benefits without compromising their clinical outcomes. Keywords: CABG, Off-pump, High-risk, Short term outcome

  17. Vibratory perception threshold in young and middle-aged patients at high risk of knee osteoarthritis compared to controls

    DEFF Research Database (Denmark)

    Thorlund, Jonas Bloch; Shakoor, Najia; Ageberg, Eva

    2012-01-01

    Vibratory perception threshold (VPT) is impaired in patients with knee osteoarthritis (OA). It is, however, not known if sensory deficits precede or follow as a consequence of OA. The aim of this study was to investigate VPT in 2 independent groups of patients with high risk of future OA (young...

  18. Haptoglobin phenotype is not a predictor of recurrence free survival in high-risk primary breast cancer patients

    NARCIS (Netherlands)

    Gast, Marie-Christine W.; van Tinteren, Harm; Bontenbal, Marijke; van Hoesel, Rene Q. G. C. M.; Nooij, Marianne A.; Rodenhuis, Sjoerd; Span, Paul N.; Tjan-Heijnen, Vivianne C. G.; de Vries, Elisabeth G. E.; Harris, Nathan; Twisk, Jos W. R.; Schellens, Jan H. M.; Beijnen, Jos H.

    2008-01-01

    ABSTRACT: BACKGROUND: Better breast cancer prognostication may improve selection of patients for adjuvant therapy. We conducted a retrospective follow-up study in which we investigated sera of high-risk primary breast cancer patients, to search for proteins predictive of recurrence free survival.

  19. Haptoglobin phenotype is not a predictor of recurrence free survival in high-risk primary breast cancer patients

    NARCIS (Netherlands)

    Gast, Marie-Christine W.; van Tinteren, Harm; Bontenbal, Marijke; van Hoesel, Rene Q. G. C. M.; Nooij, Marianne A.; Rodenhuis, Sjoerd; Span, Paul N.; Tjan-Heijnen, Vivianne C. G.; de Vries, Elisabeth G. E.; Harris, Nathan; Twisk, Jos W. R.; Schellens, Jan H. M.; Beijnen, Jos H.

    2008-01-01

    Background: Better breast cancer prognostication may improve selection of patients for adjuvant therapy. We conducted a retrospective follow-up study in which we investigated sera of high-risk primary breast cancer patients, to search for proteins predictive of recurrence free survival. Methods: Two

  20. Haptoglobin phenotype is not a predictor of recurrence free survival in high-risk primary breast cancer patients

    NARCIS (Netherlands)

    M.C.W. Gast; H. van Tinteren (Harm); M. Bontenbal (Marijke); R.Q.G.C.M. van Hoesel (René); M.A. Nooij; S. Rodenhuis (Sjoerd); P.N. Span (Paul); V.C.G. Tjan-Heijnen (Vivianne); E. de Vries (Esther); N. Harris (Nathan); J.W.R. Twisk (Jos); J.H.M. Schellens (Jan); J.H. Beijnen (Jos)

    2008-01-01

    textabstractBackground: Better breast cancer prognostication may improve selection of patients for adjuvant therapy. We conducted a retrospective follow-up study in which we investigated sera of high-risk primary breast cancer patients, to search for proteins predictive of recurrence free survival.

  1. Increased Saccadic Rate during Smooth Pursuit Eye Movements in Patients at Ultra High Risk for Developing a Psychosis

    Science.gov (United States)

    van Tricht, M. J.; Nieman, D. H.; Bour, L. J.; Boeree, T.; Koelman, J. H. T. M.; de Haan, L.; Linszen, D. H.

    2010-01-01

    Abnormalities in eye tracking are consistently observed in schizophrenia patients and their relatives and have been proposed as an endophenotype of the disease. The aim of this study was to investigate the performance of patients at Ultra High Risk (UHR) for developing psychosis on a task of smooth pursuit eye movement (SPEM). Forty-six UHR…

  2. Haptoglobin phenotype is not a predictor of recurrence free survival in high-risk primary breast cancer patients.

    NARCIS (Netherlands)

    Gast, M.C.; Tinteren, H. van; Bontenbal, M.; Hoesel, R.Q. van; Nooij, M.A.; Rodenhuis, S.; Span, P.N.; Tjan-Heijnen, V.C.; Vries, E.G.F. de; Harris, N.; Twisk, J.W.R.; Schellens, J.H.; Beijnen, J.H.

    2008-01-01

    BACKGROUND: Better breast cancer prognostication may improve selection of patients for adjuvant therapy. We conducted a retrospective follow-up study in which we investigated sera of high-risk primary breast cancer patients, to search for proteins predictive of recurrence free survival. METHODS: Two

  3. Varenicline treatment for smoking cessation in high risk patients: a budget impact analysis

    Directory of Open Access Journals (Sweden)

    Federico Spandonaro

    2017-10-01

    CONCLUSIONS: The financial impact on the Italian NHS of the reimbursement of varenicline for the treatment of high risk smoking population would be a sustainable healthcare policy, resulting in cost savings starting from the fourth year.

  4. Non-invasive parameters as predictors of high risk of variceal bleeding in cirrhotic patients

    Directory of Open Access Journals (Sweden)

    María Andrea Peñaloza-Posada

    2014-10-01

    Conclusions: The presence of large esophageal varices is the most important predictive risk factor for the occurrence of VB, independently of the class of Child-Pugh. Additionally, the portal vein diameter ≥ 13 mm is a non-invasive parameter related to high risk of VB. Therefore, these factors could be used as predictors of high risk of VB when the measure of HPVG is not available.

  5. Prosthesis-patient mismatch in high-risk patients with severe aortic stenosis: A randomized trial of a self-expanding prosthesis.

    Science.gov (United States)

    Zorn, George L; Little, Stephen H; Tadros, Peter; Deeb, G Michael; Gleason, Thomas G; Heiser, John; Kleiman, Neal S; Oh, Jae K; Popma, Jeffrey J; Adams, David; Huang, Jian; Reardon, Michael J

    2016-04-01

    We compared the incidence of prosthesis-patient mismatch (PPM) between transcatheter aortic valve replacement (TAVR) using a self-expanding bioprosthesis and surgical aortic valve replacement (SAVR) in the CoreValve US High Risk Pivotal Trial. We sought to determine the influence of PPM on clinical outcomes. Patients with severe aortic stenosis and at increased risk for surgery were randomized 1:1 to TAVR or SAVR. Postoperative PPM was defined by the effective orifice area index (EOAi) as severe PPM (EOAi ≤ 0.65 cm(2)/m(2)) and no severe PPM (EOAi > 0.65 cm(2)/m(2)); clinical outcomes were analyzed in the TAVR arm (n = 389) and SAVR arm (n = 353). Left ventricular mass index and regression were analyzed at baseline and 1 year. The incidence of severe PPM in the SAVR group at 1 year was 25.7% versus 6.2% in the TAVR group (P < .0001). Left ventricular mass index regression at 1 year was 6.8% for TAVR and 15.1% for SAVR in patients with severe PPM. At 1 year the rate of all-cause mortality and acute kidney injury were significantly greater in all patients (TAVR + SAVR) with severe PPM compared with no severe PPM (20.6% vs 12.0% [P = .0145] for death and 19.2% vs 8.5% [P = .0008] for acute kidney injury). In patients with high surgical risk and severe aortic stenosis, severe PPM is more common in patients treated with SAVR than those treated with TAVR. Patients with severe PPM are a greater risk for death and acute kidney injury than patients without severe PPM. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

  6. Lipid Target in Very High-Risk Cardiovascular Patients: Lesson from PCSK9 Monoclonal Antibodies

    Directory of Open Access Journals (Sweden)

    Giovanni Ciccarelli

    2018-03-01

    Full Text Available The role of low-density lipoproteins (LDLs as a major risk factor for cardiovascular disease has been demonstrated by several epidemiological studies. The molecular basis for LDLs in atherosclerotic plaque formation and progression is not completely unraveled yet. Pharmacological modulation of plasma LDL-C concentrations and randomized clinical trials addressing the impact of lipid-lowering interventions on cardiovascular outcome have clearly shown that reducing plasma LDL-C concentrations results in a significant decrease in major cardiovascular events. For many years, statins have represented the most powerful pharmacological agents available to lower plasma LDL-C concentrations. In clinical trials, it has been shown that the greater the reduction in plasma LDL-C concentrations, the lower the rate of major cardiovascular events, especially in high-risk patients, because of multiple risk factors and recurrent events. However, in a substantial number of patients, the recommended LDL target is difficult to achieve because of different factors: genetic background (familial hypercholesterolemia, side effects (statin intolerance, or high baseline plasma LDL-C concentrations. In the last decade, our understanding of the molecular mechanisms involved in LDL metabolism has progressed significantly and the key role of proprotein convertase subtilisin/kexin type 9 (PCSK9 has emerged. This protein is an enzyme able to bind the LDL receptors (LDL-R on hepatocytes, favoring their degradation. Blocking PCSK9 represents an intriguing new therapeutic approach to decrease plasma LDL-C concentrations, which in recent studies has been demonstrated to also result in a significant reduction in major cardiovascular events.

  7. Lipid Target in Very High-Risk Cardiovascular Patients: Lesson from PCSK9 Monoclonal Antibodies.

    Science.gov (United States)

    Ciccarelli, Giovanni; D'Elia, Saverio; De Paulis, Michele; Golino, Paolo; Cimmino, Giovanni

    2018-03-17

    The role of low-density lipoproteins (LDLs) as a major risk factor for cardiovascular disease has been demonstrated by several epidemiological studies. The molecular basis for LDLs in atherosclerotic plaque formation and progression is not completely unraveled yet. Pharmacological modulation of plasma LDL-C concentrations and randomized clinical trials addressing the impact of lipid-lowering interventions on cardiovascular outcome have clearly shown that reducing plasma LDL-C concentrations results in a significant decrease in major cardiovascular events. For many years, statins have represented the most powerful pharmacological agents available to lower plasma LDL-C concentrations. In clinical trials, it has been shown that the greater the reduction in plasma LDL-C concentrations, the lower the rate of major cardiovascular events, especially in high-risk patients, because of multiple risk factors and recurrent events. However, in a substantial number of patients, the recommended LDL target is difficult to achieve because of different factors: genetic background (familial hypercholesterolemia), side effects (statin intolerance), or high baseline plasma LDL-C concentrations. In the last decade, our understanding of the molecular mechanisms involved in LDL metabolism has progressed significantly and the key role of proprotein convertase subtilisin/kexin type 9 (PCSK9) has emerged. This protein is an enzyme able to bind the LDL receptors (LDL-R) on hepatocytes, favoring their degradation. Blocking PCSK9 represents an intriguing new therapeutic approach to decrease plasma LDL-C concentrations, which in recent studies has been demonstrated to also result in a significant reduction in major cardiovascular events.

  8. Just-in-Time Training for High-Risk Low-Volume Therapies: An Approach to Ensure Patient Safety.

    Science.gov (United States)

    Helman, Stephanie; Lisanti, Amy Jo; Adams, Ann; Field, Cynthia; Davis, Katherine Finn

    2016-01-01

    High-risk low-volume therapies are those therapies that are practiced infrequently and yet carry an increased risk to patients because of their complexity. Staff nurses are required to competently manage these therapies to treat patients' unique needs and optimize outcomes; however, maintaining competence is challenging. This article describes implementation of Just-in-Time Training, which requires validation of minimum competency of bedside nurses managing high-risk low-volume therapies through direct observation of a return-demonstration competency checklist.

  9. Chances of Adverse Neonatal Outcome in High-Risk and Low-Risk Obstetrical Patients

    Directory of Open Access Journals (Sweden)

    Y. Krilova

    2008-01-01

    Full Text Available Objective To analyze and compare occurrence of adverse immediate neonatal outcomes in high and low-risk obstetrical population. Methods Retrospective cohort study of 2370 pregnant women. The odds of adverse outcomes (i.e. low Apgar score (1–4 points and intermediate Apgar score (5–8 points at 1 and 5 minutes of life, birth to a small-for-gestational-age neonate (below 90th percentile of birth weight, and requirement for advanced level II-III nursery care as well as odds of primary cesarean delivery–-were analyzed using logistic regression analysis. Results All of the studied outcomes were seen more often among the high-risk patients. When the outcomes were analyzed within a given group some interesting observations were made. The highest odds of abnormal Apgar scores (when compared to the low risk population were seen in patients with preeclampsia–-6.06 (95% CI 3.28; 11.22 and twin pregnancies–-odds ratio of 6.63 (95% CI 2.24; 19.67. Among Small-for-Gestational-Age newborns the most frequently identified maternal condition was preeclampsia (21.57%, out of all fetal conditions twin gestation (26.67% was number one identified scenario. The highest proportion of patients requiring advanced level nursery care (level II and III was observed in those with twin gestation, pregnancies complicated by hypertension with and without diabetes. The highest odds of having primary cesarean delivery in laboring patients (when compared to the low risk population were seen in the patients with IUGR fetus–-odds ratio of 26.78 [95% CI 7.65; 93.75], followed by macrosomia–-odds ratio 5.74 [95% CI 2.14; 15.41], preeclampsia–-odds ratio 5.52 [95% CI 3.14; 9.69]. For additional findings and more information on select conditions, please, refer to the full-text article. Conclusion The studied outcomes are useful markers of fetal/neonatal status and can be used to compare perinatal outcomes between different medical conditions, different locales and to

  10. The alcohol patient and surgery

    DEFF Research Database (Denmark)

    Tønnesen, H

    1999-01-01

    Alcohol abusers have a threefold increased risk of post-operative morbidity after surgery. The most frequent complications are infections, cardiopulmonary insufficiency, and bleeding episodes. Pathogenesis is suppressed immune capacity, subclinical cardiac dysfunction, and haemostatic imbalance....... The economic implications of alcohol abuse in surgical patients are tremendous. Interventional studies are required to reduce future increases in post-operative morbidity....

  11. Tandem autologous-allo-SCT is feasible in patients with high-risk relapsed non-Hodgkin's lymphoma.

    Science.gov (United States)

    Crocchiolo, R; Castagna, L; Fürst, S; El-Cheikh, J; Faucher, C; Oudin, C; Granata, A; Bouabdallah, R; Coso, D; Chabannon, C; Balzarotti, M; Santoro, A; Blaise, D

    2013-02-01

    Allo-SCT is used to exploit GVL effect in high-risk relapsed non-Hodgkin's lymphoma (NHL). Here, we retrospectively analyzed 34 high-risk NHL patients who underwent auto-SCT followed closely by reduced-intensity allo-SCT ('tandem auto-allo') from January 2002 to November 2010. The search for an allogeneic donor was started at the beginning of salvage regimen. Median patients' age was 47 (27-68) years; histotypes were: diffuse large B-cell n=5, follicular n=14, transformed follicular n=4, mantle-cell n=5, plasmocytoid lymphoma n=1, anaplastic large T-cell n=2, peripheral T-cell n=3. Donors were HLA-identical siblings (n=29) or 10/10-matched unrelated individuals (n=5). Median interval between auto-SCT and allo-SCT was 77 days (36-197). At a median follow-up of 46 (8-108) months since allo-SCT, 5-year OS is 77% (61-93) and PFS is 68% (51-85). Disease relapse or progression occurred in six patients, 100-day TRM was 0%, 2-year TRM incidence was 6%. In conclusion, tandem transplantation is feasible in high-risk NHL patients having a HLA-identical donor. This approach could represent a suitable therapeutic option for those patients with high-risk NHL potentially benefitting from further therapy after auto-SCT. Donor searches should be started promptly whenever such an approach is chosen.

  12. Towards safer surgery in patients with sickle cell disease

    International Nuclear Information System (INIS)

    Meshikhes, Abdul-Wahed N.

    2007-01-01

    Surgery in patients with sickle cell disease (SCD) has been associated with high morbidity and mortality. In recent years, a marked improvement in the safety of surgery and anesthesia in this high-risk group of patients has been witnessed; owing to the improvements in surgical and anesthetic care, greater awareness of pathophysiology of disease, proper perioperative preparation and attention to factors predisposing to vasoocclusive crises. However, this is not paralleled by similar improvement in countries where the disease is not prevalent. Greater population mobility in recent years makes recognition of surgical manifestations of the disease and awareness of perioperative management of sickle cell patients undergoing surgical interventions of paramount importance. This article aims to summarize steps towards safer surgery in patients with SCD. (author)

  13. Acetylsalicylic Acid and Eflornithine in Treating Patients at High Risk for Colorectal Cancer | Division of Cancer Prevention

    Science.gov (United States)

    This phase II trial is studying how well giving acetylsalicylic acid together with eflornithine works in treating patients at high risk for colorectal cancer. Chemoprevention is the use of certain drugs to keep cancer from forming. The use of acetylsalicylic acid and eflornithine may prevent colorectal cancer. |

  14. Trends in Vascular Complications in High-Risk Patients Following Transcatheter Aortic Valve Replacement in the United States.

    Science.gov (United States)

    Ando, Tomo; Akintoye, Emmanuel; Telila, Tesfaye; Briasoulis, Alexandros; Takagi, Hisato; Grines, Cindy L; Afonso, Luis

    2017-05-01

    Vascular complications (VC) following transcatheter aortic valve replacement (TAVR) are associated with worse outcomes. The trend of VC incidence in patients considered high risk is unclear. We sought to assess the trend of VC after TAVR in patients at high risk. We investigated the VC trend in female, diabetes mellitus, and peripheral vascular disease (PVD) patients. Patients who underwent TAVR from 2011 to 2014 in the United States were identified using the International Classification of Diseases-Ninth Revision code 35.05 from the Nationwide Inpatient Sample database. Frequency of any VC (per 100 transcatheter aortic valve implantation procedure or hospital discharges) for each year from 2011 to 2014 was assessed for the overall population as well as within each category of high-risk cohorts. The overall VC rate was 6.0% (2,044/33,790). Patients who had VC were more likely to be female and had higher rates of PVD at baseline. The annual rate of VC in the overall population from 2011 to 2014 was 4.6%, 9.4%, 6.8%, and 4.4%, respectively. There was a significant increase in VC rate from 2011 to 2012 (p = 0.03), whereas there was a significant decrease in VC rate from 2012 to 2014 (p trend in VC rate was found among high-risk patients except that the initial increase in rates from 2011 to 2012 did not reach statistical significance. Whether further reduction in VC with improvement in devices and operator/center experience for both overall and high-risk groups in TAVR occurs will require continuous longitudinal monitoring. Copyright © 2017 Elsevier Inc. All rights reserved.

  15. Functional intravascular volume deficit in patients before surgery

    DEFF Research Database (Denmark)

    Bundgaard-Nielsen, M; Jørgensen, C C; Secher, N H

    2010-01-01

    limited data on the volume required to establish a maximal SV before the start of surgery. Therefore, we estimated the occurrence and size of the potential functional intravascular volume deficit in surgical patients. METHODS: Patients scheduled for mastectomy (n=20), open radical prostatectomy (n=20......BACKGROUND: Stroke volume (SV) maximization with a colloid infusion, referred to as individualized goal-directed therapy, improves outcome in high-risk surgery. The fraction of patients who need intravascular volume to establish a maximal SV has, however, not been evaluated, and there are only...... deficit. RESULTS: Forty-two (70%) of the patients needed volume to establish a maximal SV. For the patients needing volume, the required amount was median 200 ml (range 200-600 ml), with no significant difference between the three groups of patients. The required volume was >or=400 ml in nine patients (15...

  16. High Risk Human Papilloma Virus Genotypes in Kurdistan Region in Patients with Vaginal Discharge.

    Science.gov (United States)

    Hussein, Nawfal R; Balatay, Amer A; Assafi, Mahde S; AlMufty, Tamara Abdulezel

    2016-01-01

    The human papilloma virus (HPV) is considered as the major risk factor for the development of cervical cancer. This virus is of different genotypes and generally can be classified into high and low risk types. To determine the rate of high risk HPV genotypes in women with vaginal discharge and lower abdominal pain in Kurdistan region, Iraq. Cervical swabs were taken from 104 women. DNA was extracted and the polymerase chain reaction (PCR) technique was used to determine the presence of high risk genotypes. It was found that 13/104 (12.5%) of the samples were positive for high risk HPV genotypes. Amongst those who were positive, 4/13 (30.7%) were typed as genotype 16 and 7/13 (53.8%) showed mixed genotyping. On the other hand, genotypes 53 and 56 were found in only one sample each. High risk HPV genotypes are not uncommon and further community based study is needed to determine the prevalence of HPV and its genotypes and plan for prevention of infection.

  17. Staircase falls: High-risk groups and injury characteristics in 464 patients

    NARCIS (Netherlands)

    Boele van Hensbroek, P.; Mulder, S.; Luitse, J. S. K.; van Ooijen, M. R.; Goslings, J. C.

    2009-01-01

    Introduction: Few data are available about the epidemiology and injury characteristics in staircase falls. The available literature mainly concerns children and autopsy studies. Objective: To describe the epidemiology and injury characteristics of staircase falls, and to identify high-risk groups

  18. From CURE to MATCH: ADP receptor antagonists as the treatment of choice for high-risk atherothrombotic patients.

    Science.gov (United States)

    Hacke, Werner

    2002-01-01

    Patients with a clinical manifestation of atherothrombosis such as a recent ischaemic cerebrovascular event are at high risk of subsequent events. Atherothrombosis often reflects disseminated disease; thus, further events may occur not only in the same arterial distribution but also in other vascular beds. To achieve adequate secondary prevention in these patients, long-term antiplatelet therapy with consistent benefit across the atherothrombosis spectrum is required. In the CAPRIE (Clopidogrel versus Aspirin in Patients at Risk of Ischaemic Events) Trial, clopidogrel (clopidogrel bisulphate) was superior to acetylsalicylic acid (ASA) in reducing the combined risk of ischaemic stroke (IS), myocardial infarction (MI) or vascular death in patients with symptomatic atherosclerosis. Post hoc analyses demonstrated that the benefit of clopidogrel was amplified in high-risk patients, including patients with a history of previous ischaemic events, diabetic patients and patients with hypercholesterolaemia. The synergistic antiplatelet effect produced by using clopidogrel on top of ASA may be beneficial in high-risk patients. The benefit of dual antiplatelet therapy was recently examined in the CURE (Clopidogrel in Unstable Angina to Prevent Recurrent Events) Study, which demonstrated that long-term treatment with clopidogrel on top of standard therapy including ASA was superior to standard therapy alone in the prevention of major vascular ischaemic events in patients with unstable angina or non-Q-wave MI. The ongoing MATCH (Management of Atherothrombosis with Clopidogrel in High-risk Patients with Recent Transient Ischaemic Attack or Ischaemic Stroke) trial will evaluate the efficacy and safety of clopidogrel plus ASA versus clopidogrel alone in patients with recent transient ischaemic attack (TIA) or IS and with at least one additional risk factor. Approximately 7,600 patients will be enroled, with treatment and follow-up for each patient lasting 18 months. The primary

  19. Utility of a perioperative nutritional intervention on postoperative outcomes in high-risk head & neck cancer patients.

    Science.gov (United States)

    Rowan, Nicholas R; Johnson, Jonas T; Fratangelo, Christina E; Smith, Brenda K; Kemerer, Patricia A; Ferris, Robert L

    2016-03-01

    Investigate both the utility and feasibility of perioperative nutritional supplementation with an arginine-enriched immunonutrition formula to high-risk head and neck cancer surgical patients and examine its effects on acute post-operative clinical outcomes. This prospective, non-randomized, interventional cohort study compared high-risk head and neck cancer surgical patients who consumed a pre- and post-operative arginine-based nutritional supplement to those that did not. Outcome measures included post-operative complications, length of hospitalization, readmission rates and measurement of nutritional biomarkers. 195 high-risk head and neck cancer surgical patients were enrolled. 59% of the patients used the nutritional supplement, 41% did not. Of the 80 patients who did not receive the immunonutrition formula, 38 (47.5%) experienced post-operative complications of all types as compared to 29 of the 115 (25.2%) patients who did consume the product (p=0.0021). Pharyngeal leaks or fistulas were the most common post-operative complications in both groups and more common in patients who did not receive supplementation (p=0.007). Length of stay was on average 2.8 days longer in patients who did not have enhanced nutrition (p=0.02), while readmission rates between the two groups were similar (p=0.91). Measurements of nutritional biomarkers were not reported secondary to low collection rates. Enhanced perioperative nutrition may result in significant reductions of post-operative fistula formations and decreased length of stay in a high-risk head and neck cancer population, even in the setting of poor compliance. The potential quality improvement in both patient care and healthcare cost is both real and significant. Copyright © 2016 Elsevier Ltd. All rights reserved.

  20. Mortality and recurrence rates among systemically untreated high risk breast cancer patients included in the DBCG 77 trials

    DEFF Research Database (Denmark)

    Jensen, Maj Britt; Nielsen, Torsten O.; Knoop, Ann S.

    2018-01-01

    Background: Following loco-regional treatment for early breast cancer accurate prognostication is essential for communicating benefits of systemic treatment. The aim of this study was to determine time to recurrence and long-term mortality rates in high risk patients according to patient characte......Background: Following loco-regional treatment for early breast cancer accurate prognostication is essential for communicating benefits of systemic treatment. The aim of this study was to determine time to recurrence and long-term mortality rates in high risk patients according to patient...... and EGFR positive. Multivariate categorical and fractional polynomials (MFP) models were used to construct prognostic subsets by clinicopathologic characteristics. Results: In a multivariate model, mortality rate was significantly associated with age, tumor size, nodal status, invasion, histological type...

  1. Neoadjuvant FOLFOX 4 versus FOLFOX 4 with Cetuximab versus immediate surgery for high-risk stage II and III colon cancers: a multicentre randomised controlled phase II trial – the PRODIGE 22 - ECKINOXE trial

    International Nuclear Information System (INIS)

    Karoui, Mehdi; Rullier, Anne; Luciani, Alain; Bonnetain, Franck; Auriault, Marie-Luce; Sarran, Antony; Monges, Geneviève; Trillaud, Hervé; Le Malicot, Karine; Leroy, Karen; Sobhani, Iradj; Bardier, Armelle; Moreau, Marie; Brindel, Isabelle; Seitz, Jean François; Taieb, Julien

    2015-01-01

    In patients with high risk stage II and stage III colon cancer (CC), curative surgery followed by adjuvant FOLFOX-4 chemotherapy has become the standard of care. However, for 20 to 30 % of these patients, the current curative treatment strategy of surgical excision followed by adjuvant chemotherapy fails either to clear locoregional spread or to eradicate distant micrometastases, leading to disease recurrence. Preoperative chemotherapy is an attractive concept for these CCs and has the potential to impact upon both of these causes of failure. Optimum systemic therapy at the earliest possible opportunity may be more effective at eradicating distant metastases than the same treatment given after the delay and immunological stress of surgery. Added to this, shrinking the primary tumor before surgery may reduce the risk of incomplete surgical excision, and the risk of tumor cell shedding during surgery. PRODIGE 22 - ECKINOXE is a multicenter randomized phase II trial designed to evaluate efficacy and feasibility of two chemotherapy regimens (FOLFOX-4 alone and FOLFOX-4 + Cetuximab) in a peri-operative strategy in patients with bulky CCs. Patients with CC deemed as high risk T3, T4 and/or N2 on initial abdominopelvic CT scan are randomized to either colectomy and adjuvant chemotherapy (control arm), or 4 cycles of neoadjuvant chemotherapy with FOLFOX-4 (for RAS mutated patients). In RAS wild-type patients a third arm testing FOLFOX+ cetuximab has been added prior to colectomy. Patients in the neoadjuvant chemotherapy arms will receive postoperative treatment for 4 months (8 cycles) to complete their therapeutic schedule. The primary endpoint of the study is the histological Tumor Regression Grade (TRG) as defined by Ryan. The secondary endpoints are: treatment strategy safety (toxicity, primary tumor related complications under chemotherapy, peri-operative morbidity), disease-free and recurrence free survivals at 3 years, quality of life, carcinologic quality and

  2. Mandatory Risk Assessment Reduces Venous Thromboembolism in Bariatric Surgery Patients.

    Science.gov (United States)

    Nimeri, Abdelrahman A; Bautista, Jejomar; Ibrahim, Maha; Philip, Ruby; Al Shaban, Talat; Maasher, Ahmed; Altinoz, Ajda

    2018-02-01

    Bariatric surgery patients are at high risk for venous thromboembolism (VTE), and chemoprophylaxis is recommended. Sheikh Khalifa Medical City (SKMC) is an American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) member since 2009. We report the rates of VTE in bariatric surgery patients from 2010 to 2016 compared to ACS NSQIP bariatric surgery programs before and after switching from heparin to low molecular weight heparin (LMWH), initiating mandatory risk assessment using Caprini scoring for VTE and adopting an aggressive strategy for high-risk patients regarding dosage of LMWH and chemoprophylaxis after discharge. During the study period, there were 1152 cases (laparoscopic Roux-en-Y gastric bypass (LRYGB) 625 and laparoscopic sleeve gastrectomy (LSG) 527) at Bariatric & Metabolic Institute (BMI) Abu Dhabi compared to 65,693 cases (LRYGB 32,130 and LSG 33,563) at ACS NSQIP bariatric surgery programs. VTE rates remained stable at ACS NSQIP bariatric surgery programs from 2010 to 2016 (0.45, 0.45, 0.45, 0.25, 0.35, 0.3, and 0.3%). In contrast, VTE rates at BMI Abu Dhabi decreased from 2.2% in 2011 to 0.35% after we adopted an aggressive strategy to VTE without an increase in bleeding complications. LRYGB patients with VTE had higher OR time, leak, collection, and mortality at ACS NSQIP hospitals compared to those at BMI Abu Dhabi. In contrast, rates were similar in LSG patients with VTE. Changing our approach to VTE management led our VTE rates to decrease and become like those of ACS NSQIP bariatric surgery patients in LSG and LRYGB.

  3. Fluvoxamine may prevent onset of psychosis: a case report of a patient at ultra-high risk of psychotic disorder

    OpenAIRE

    Tadokoro, Shigenori; Kanahara, Nobuhisa; Kikuchi, Shuichi; Hashimoto, Kenji; Masaomi, Iyo

    2011-01-01

    Abstract Background There is emerging evidence that antidepressants may be effective in preventing patients with non-specific and psychotic-like prodromal symptoms, defined as patients at ultra-high risk (UHR) of psychotic disorder, from transitioning to psychosis. However, the mechanism of such an effect is still unknown. Methods We report the case of a 19-year-old Japanese man determined to be at UHR of psychotic disorder in whom fluvoxamine (one of the antidepressants with sigma-1 receptor...

  4. Long-term outcomes of endoscopic gallbladder stenting in high-risk surgical patients with calculous cholecystitis (with videos).

    Science.gov (United States)

    Inoue, Tadahisa; Okumura, Fumihiro; Kachi, Kenta; Fukusada, Shigeki; Iwasaki, Hiroyasu; Ozeki, Takanori; Suzuki, Yuta; Anbe, Kaiki; Nishie, Hirotada; Mizushima, Takashi; Sano, Hitoshi

    2016-05-01

    Recently, endoscopic gallbladder stenting (EGBS) has been performed to prevent recurrences in high-risk surgical patients with cholecystitis. However, evidence regarding the long-term outcomes of EGBS is sparse. We investigated the cholecystitis recurrence rate in high-risk surgical patients with acute calculous cholecystitis and compared the cholecystitis recurrence rates in patients in whom EGBS was performed with those in patients who were observed after percutaneous drainage. We studied 64 consecutive high-risk surgical patients with acute calculous cholecystitis who required gallbladder decompression between 2007 and 2014. We divided the patient cohort into patients who underwent observation after percutaneous drainage between 2007 and 2011 (OAPD group) and those who underwent EGBS between 2012 and 2014 (EGBS group), and we compared the groups. The technical success rate of EGBS was 82.9% based on the intention-to-treat analysis. The cholecystitis recurrence rates were 17.2% in the OAPD group and 0% in the EGBS group, a difference that was significant (P = .043). There was also a significant difference between the groups with respect to the time to recurrent cholecystitis, which was determined by using Kaplan-Meier analysis (P = .015). The overall biliary event rates were 24.1% in the OAPD group and 9.1% in the EGBS group, and no significant difference was noted (P = .207). EGBS reduced the recurrence of cholecystitis in high-risk surgical patients with calculous cholecystitis. However, stent-related adverse events may occur, and modifications are necessary to reduce these. Copyright © 2016 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.

  5. Acetylsalicylic Acid Compared to Placebo in Treating High-Risk Patients With Subsolid Lung Nodules | Division of Cancer Prevention

    Science.gov (United States)

    This randomized phase II trial studies acetylsalicylic acid compared to placebo in treating high-risk patients with subsolid lung nodules. A nodule is a growth or lump that may be malignant (cancer) or benign (not cancer). Chemoprevention is the use of drugs to keep cancer from forming or coming back. The use of acetylsalicylic acid may keep cancer from forming in patients with subsolid lung nodules. |

  6. High-risk human papilloma virus (HPV) and survival in patients with esophageal carcinoma: a pilot study

    International Nuclear Information System (INIS)

    Dreilich, Martin; Bergqvist, Michael; Moberg, Martin; Brattström, Daniel; Gustavsson, Inger; Bergström, Stefan; Wanders, Alkwin; Hesselius, Patrik; Wagenius, Gunnar; Gyllensten, Ulf

    2006-01-01

    Human papilloma virus (HPV) in patients with esophageal carcinoma has previously been studied with an average detection rate of 15%, but the role of HPV in relation to survival is less clear. In cervical cancer, lung cancer and tonsil cancer HPV viral load is a predictive factor for survival and outcome of treatment. The primary aim was to study the spectrum of high-risk HPV types in esophageal tumors. Secondary, as a pilot study we investigated the association between HPV status and the survival rates. We compared both the presence and the viral load of high-risk HPV types 16, 18, 31, 33, 39, 45, 52, 58, and 67 in relation to clinical data from patients with esophageal carcinoma. Survival data and tumor samples were retrieved from 100 patients receiving treatment at the Department of Oncology, Uppsala Hospital, Uppsala, Sweden. The tumor samples were investigated for HPV viral load using real-time PCR. HPV 16 was detected in 16% of the patients; no other HPV type was detected. HPV 16 infection had no significant effect on survival (p = 0.72). Also, HPV 16 did not improve survival after treatment (radiotherapy or chemotherapy). Only HPV 16 was detected among the patients. HPV 16 in esophageal carcinoma patients did not influence survival or improve therapy response. However, given the size of the study there is a need to examine a larger cohort in order to understand in more detail the effect of high risk HPV types in esophageal carcinoma

  7. Transcatheter aortic valve replacement in patients with severe aortic stenosis who are at high risk for surgical complications: summary assessment of the California Technology Assessment Forum.

    Science.gov (United States)

    Tice, Jeffrey A; Sellke, Frank W; Schaff, Hartzell V

    2014-08-01

    The California Technology Assessment Forum is dedicated to assessment and public reporting of syntheses of available data on medical technologies. In this assessment, transcatheter aortic valve replacement (TAVR) was evaluated for patients with severe aortic stenosis (AS) who are at high risk for complications. In this assessment, 5 criteria were used: Regulatory approval, sufficient scientific evidence to allow conclusions on effectiveness, evidence that the technology improves net health outcomes, evidence that the technology is as beneficial as established methods, and availability of the technology outside investigational settings. In this assessment, all 5 criteria were judged to have been met. The primary benefit of TAVR is the ability to treat AS in patients who would otherwise be ineligible for surgical aortic valve replacement. It may also be useful for patients at high surgical risk by potentially reducing periprocedural complications and avoiding the morbidity and recovery from undergoing heart surgery. Potential harms include the need for conversion to an open procedure, perioperative death, myocardial infarction, stroke, bleeding, valve embolization, aortic regurgitation, heart block that requires a permanent pacemaker, renal failure, pulmonary failure, and major vascular complications such as cardiac perforation or arterial dissection. Potential long-term harms include death, stroke, valve failure or clotting, and endocarditis. As highlighted at the February 2012 California Technology Assessment Forum meeting, the dispersion of this technology to new centers across the United States must proceed with careful thought given to training and proctoring multidisciplinary teams to become new centers of excellence. TAVR is a potentially lifesaving procedure that may improve quality of life for patients at high risk for surgical AVR. However, attention needs to be paid to appropriate patient selection, their preoperative evaluation, surgical techniques, and

  8. Ultrasound-guided double-tract percutaneous cholecystostomy combined with a choledochoscope for performing cholecystolithotomies in high-risk surgical patients.

    Science.gov (United States)

    Wang, Tao; Chen, Tao; Zou, Shu; Lin, Ning; Liang, Hong-yin; Yan, Hong-tao; Li, Nan-lin; Liu, Li-ye; Luo, Hao; Chen, Qi; Liu, Wei-hui; Tang, Li-jun

    2014-07-01

    technique for the management of small stones (less than 15 mm) in high-risk surgical patients.

  9. Navigating high-risk surgery: protocol for a multisite, stepped wedge, cluster-randomised trial of a question prompt list intervention to empower older adults to ask questions that inform treatment decisions.

    Science.gov (United States)

    Taylor, Lauren J; Rathouz, Paul J; Berlin, Ana; Brasel, Karen J; Mosenthal, Anne C; Finlayson, Emily; Cooper, Zara; Steffens, Nicole M; Jacobson, Nora; Buffington, Anne; Tucholka, Jennifer L; Zhao, Qianqian; Schwarze, Margaret L

    2017-05-29

    Older patients frequently undergo operations that carry high risk for postoperative complications and death. Poor preoperative communication between patients and surgeons can lead to uninformed decisions and result in unexpected outcomes, conflict between surgeons and patients, and treatment inconsistent with patient preferences. This article describes the protocol for a multisite, cluster-randomised trial that uses a stepped wedge design to test a patient-driven question prompt list (QPL) intervention aimed to improve preoperative decision making and inform postoperative expectations. This Patient-Centered Outcomes Research Institute-funded trial will be conducted at five academic medical centres in the USA. Study participants include surgeons who routinely perform vascular or oncological surgery, their patients and families. We aim to enrol 40 surgeons and 480 patients over 24 months. Patients age 65 or older who see a study-enrolled surgeon to discuss a vascular or oncological problem that could be treated with high-risk surgery will be enrolled at their clinic visit. Together with stakeholders, we developed a QPL intervention addressing preoperative communication needs of patients considering major surgery. Guided by the theories of self-determination and relational autonomy, this intervention is designed to increase patient activation. Patients will receive the QPL brochure and a letter from their surgeon encouraging its use. Using audio recordings of the outpatient surgical consultation, patient and family member questionnaires administered at three time points and retrospective chart review, we will compare the effectiveness of the QPL intervention to usual care with respect to the following primary outcomes: patient engagement in decision making, psychological well-being and post-treatment regret for patients and families, and interpersonal and intrapersonal conflict relating to treatment decisions and treatments received. Approvals have been granted by the

  10. An intervention to improve care and reduce costs for high-risk patients with frequent hospital admissions: a pilot study

    Directory of Open Access Journals (Sweden)

    Kostrowski Shannon

    2011-10-01

    Full Text Available Abstract Background A small percentage of high-risk patients accounts for a large proportion of Medicaid spending in the United States, which has become an urgent policy issue. Our objective was to pilot a novel patient-centered intervention for high-risk patients with frequent hospital admissions to determine its potential to improve care and reduce costs. Methods Community and hospital-based care management and coordination intervention with pre-post analysis of health care utilization. We enrolled Medicaid fee-for-service patients aged 18-64 who were admitted to an urban public hospital and identified as being at high risk for hospital readmission by a validated predictive algorithm. Enrolled patients were evaluated using qualitative and quantitative interview techniques to identify needs such as transportation to/advocacy during medical appointments, mental health/substance use treatment, and home visits. A community housing partner initiated housing applications in-hospital for homeless patients. Care managers facilitated appropriate discharge plans then worked closely with patients in the community using a harm reduction approach. Results Nineteen patients were enrolled; all were male, 18/19 were substance users, and 17/19 were homeless. Patients had a total of 64 inpatient admissions in the 12 months before the intervention, versus 40 in the following 12 months, a 37.5% reduction. Most patients (73.3% had fewer inpatient admissions in the year after the intervention compared to the prior year. Overall ED visits also decreased after study enrollment, while outpatient clinic visits increased. Yearly study hospital Medicaid reimbursements fell an average of $16,383 per patient. Conclusions A pilot intervention for high-cost patients shows promising results for health services usage. We are currently expanding our model to serve more patients at additional hospitals to see if the pilot's success can be replicated. Trial registration

  11. High-risk residual gastric content in fasted patients undergoing gastrointestinal endoscopy: a prospective cohort study of prevalence and predictors.

    Science.gov (United States)

    Phillips, S; Liang, S S; Formaz-Preston, A; Stewart, P A

    2015-11-01

    In this prospective cohort study, we examined the residual gastric contents of 255 fasted patients undergoing gastrointestinal endoscopy. The volume and pH of residual gastric contents collected by suction under direct visualisation during gastroscopy were accurately quantified. All patients completed the minimum two-hour fast for clear fluids and 97.2% of patients completed the minimum six-hour fast for solids. High-risk residual gastric content, defined as volume >25 ml and pH fasting, males presenting for endoscopy are more likely to have high-risk gastric content than females, and that the incidence appears to be reduced with increasing age, and by the use of proton pump inhibitors or histamine type 2 receptor antagonists, we were unable to confirm or exclude an effect of body mass index, peptic pathology, diabetes or other clinical or demographic factors in our study population.

  12. Cost-effectiveness Analysis of Nutritional Support for the Prevention of Pressure Ulcers in High-Risk Hospitalized Patients.

    Science.gov (United States)

    Tuffaha, Haitham W; Roberts, Shelley; Chaboyer, Wendy; Gordon, Louisa G; Scuffham, Paul A

    2016-06-01

    To evaluate the cost-effectiveness of nutritional support compared with standard care in preventing pressure ulcers (PrUs) in high-risk hospitalized patients. An economic model using data from a systematic literature review. A meta-analysis of randomized controlled trials on the efficacy of nutritional support in reducing the incidence of PrUs was conducted. Modeled cohort of hospitalized patients at high risk of developing PrUs and malnutrition simulated during their hospital stay and up to 1 year. Standard care included PrU prevention strategies, such as redistribution surfaces, repositioning, and skin protection strategies, along with standard hospital diet. In addition to the standard care, the intervention group received nutritional support comprising patient education, nutrition goal setting, and the consumption of high-protein supplements. The analysis was from a healthcare payer perspective. Key outcomes of the model included the average costs and quality-adjusted life years. Model results were tested in univariate sensitivity analyses, and decision uncertainty was characterized using a probabilistic sensitivity analysis. Compared with standard care, nutritional support was cost saving at AU $425 per patient and marginally more effective with an average 0.005 quality-adjusted life years gained. The probability of nutritional support being cost-effective was 87%. Nutritional support to prevent PrUs in high-risk hospitalized patients is cost-effective with substantial cost savings predicted. Hospitals should implement the recommendations from the current PrU practice guidelines and offer nutritional support to high-risk patients.

  13. Length of Stay in Ambulatory Surgical Oncology Patients at High Risk for Sleep Apnea as Predicted by STOP-BANG Questionnaire

    Directory of Open Access Journals (Sweden)

    Diwakar D. Balachandran

    2016-01-01

    Full Text Available Background. The STOP-BANG questionnaire has been used to identify surgical patients at risk for undiagnosed obstructive sleep apnea (OSA by classifying patients as low risk (LR if STOP-BANG score < 3 or high risk (HR if STOP-BANG score ≥ 3. Few studies have examined whether postoperative complications are increased in HR patients and none have been described in oncologic patients. Objective. This retrospective study examined if HR patients experience increased complications evidenced by an increased length of stay (LOS in the postanesthesia care unit (PACU. Methods. We retrospectively measured LOS and the frequency of oxygen desaturation (<93% in cancer patients who were given the STOP-BANG questionnaire prior to cystoscopy for urologic disease in an ambulatory surgery center. Results. The majority of patients in our study were men (77.7%, over the age of 50 (90.1%, and had BMI < 30 kg/m2 (88.4%. STOP-BANG results were obtained on 404 patients. Cumulative incidence of the time to discharge between HR and the LR groups was plotted. By 8 hours, LR patients showed a higher cumulative probability of being discharged early (80% versus 74%, P=0.008. Conclusions. Urologic oncology patients at HR for OSA based on the STOP-BANG questionnaire were less likely to be discharged early from the PACU compared to LR patients.

  14. Uso do bloqueio combinado raqui-peridural durante cirurgia de cólon em paciente de alto risco: relato de caso Uso del bloqueo combinado raquiepidural durante cirugía de colon en paciente de alto riesgo: relato de caso Combined spinal epidural anesthesia during colon surgery in a high-risk patient: case report

    Directory of Open Access Journals (Sweden)

    Luiz Eduardo Imbelloni

    2009-12-01

    éter epidural (20G fue introducido cuatro centímetros en dirección cefálica. La sedación se obtuvo con dosis fraccionadas de 1 mg de midazolam (total de 6 mg. La bupivacaína a 0,5% se administró en bolo de 25 mg a través del catéter dos horas después de la anestesia subaracnoidea. No hubo necesidad de aplicar vasopresor ni atropina. CONCLUSIONES: Este caso nos demuestra que la raquianestesia segmentaria puede ser una técnica anestésica para la operación gastrointestinal con respiración espontánea.BACKGROUND AND OBJECTIVES: Combined spinal epidural anesthesia (CSEA has advantages over single injection epidural or subarachnoid blockades. The objective of this report was to present a case in which segmental subarachnoid block can be an effective technique for gastrointestinal surgery with spontaneous respiration. CASE REPORT: Patient with physical status ASA III, with diabetes mellitus type II, hypertension, and chronic obstructive pulmonary disease was scheduled for resection of a right colon tumor. Combined spinal epidural block was performed in the T5-T6 space and 8 mg of 0.5% isobaric bupivacaine with 50 µg of morphine were injected in the subarachnoid space. The epidural catheter (20G was introduced four centimeters in the cephalad direction. Sedation was achieved with fractionated doses of 1 mg of midazolam (total of 6 mg. A bolus of 25 mg of 0.5% bupivacaine was administered through the catheter two hours after the subarachnoid block. Vasopressors and atropine were not used. CONCLUSIONS: This case provides evidence that segmental spinal block can be the anesthetic technique used in gastrointestinal surgeries with spontaneous respiration.

  15. Optimal Duration of Antibiotic Therapy in Patients With Hematogenous Vertebral Osteomyelitis at Low Risk and High Risk of Recurrence.

    Science.gov (United States)

    Park, Ki-Ho; Cho, Oh-Hyun; Lee, Jung Hee; Park, Ji Seon; Ryu, Kyung Nam; Park, Seong Yeon; Lee, Yu-Mi; Chong, Yong Pil; Kim, Sung-Han; Lee, Sang-Oh; Choi, Sang-Ho; Bae, In-Gyu; Kim, Yang Soo; Woo, Jun Hee; Lee, Mi Suk

    2016-05-15

    The optimal duration of antibiotic treatment for hematogenous vertebral osteomyelitis (HVO) should be based on the patient's risk of recurrence, but it is not well established. A retrospective review was conducted to evaluate the optimal duration of antibiotic treatment in patients with HVO at low and high risk of recurrence. Patients with at least 1 independent baseline risk factor for recurrence, determined by multivariable analysis, were considered as high risk and those with no risk factor as low risk. A total of 314 patients with microbiologically diagnosed HVO were evaluable for recurrence. In multivariable analysis, methicillin-resistant Staphylococcus aureus infection (adjusted odds ratio [aOR], 2.61; 95% confidence interval [CI], 1.16-5.87), undrained paravertebral/psoas abscesses (aOR, 4.09; 95% CI, 1.82-9.19), and end-stage renal disease (aOR, 6.58; 95% CI, 1.63-26.54) were independent baseline risk factors for recurrence. Therefore, 191 (60.8%) patients were classified as low risk and 123 (39.2%) as high risk. Among high-risk patients, there was a significant decreasing trend for recurrence according to total duration of antibiotic therapy: 34.8% (4-6 weeks [28-41 days]), 29.6% (6-8 weeks [42-55 days]), and 9.6% (≥8 weeks [≥56 days]) (P = .002). For low-risk patients, this association was still significant but the recurrence rates were much lower: 12.0% (4-6 weeks), 6.3% (6-8 weeks), and 2.2% (≥8 weeks) (P = .02). Antibiotic therapy of prolonged duration (≥8 weeks) should be given to patients with HVO at high risk of recurrence. For low-risk patients, a shorter duration (6-8 weeks) of pathogen-directed antibiotic therapy may be sufficient. © The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.

  16. Amniotic fluid "sludge"; prevalence and clinical significance of it in asymptomatic patients at high risk for spontaneous preterm delivery.

    Science.gov (United States)

    Adanir, Ilknur; Ozyuncu, Ozgur; Gokmen Karasu, Ayse Filiz; Onderoglu, Lutfu S

    2018-01-01

    The aim of our study is to determine prevalence and clinical significance of the presence of amniotic fluid "sludge" among asymptomatic patients at high-risk for spontaneous preterm delivery, prospectively. In our study, 99 patients at high risk for spontaneous preterm delivery were evaluated for the presence of amniotic fluid sludge with transvaginal ultrasonography at 20-22, 26-28, and 32-34 gestational weeks, prospectively; between August 2009 and October 2010 in Hacettepe University Hospital. And, these patients were followed up for their delivery weeks and pregnancy outcomes. We defined the high-risk group as the patients possessing one or more of the followings; a history of spontaneous preterm delivery, recent urinary tract infections, polyhydramnios, uterine leiomyomas, müllerian duct anomalies, and history of cone biyopsy or LEEP. Patients with multiple gestations, placenta previa, fetal anomalies, or symptoms of preterm labor at first examination were excluded. We have obtained ethical board approval from Hacettepe University (16.07.2009-HEK/No:09-141-59). The prevalence of amniotic fluid sludge in the study population was 19,6% (18/92). The rates of spontaneous preterm delivery at preterm delivery (p = 0.002). A higher proportion of neonates born to patients with amniotic fluid sludge had a neonatal morbidity (50% (9/18) vs. 24,3% (18/74), p = 0.044) and died in the perinatal period, (p = 0,013) than those born to patients without sludge. When we combined sludge and cervical lenght (CL) (preterm delivery; it catched more women with preterm delivery, (p = 0.000). While sensitivity of sludge was 37,5%, and sensitivity of CL was 34%, sensitivity of "sludge positive or CL ≤25 mm" was 56% for preterm birth (PTB) in high-risk group. The prevalence of amniotic fluid sludge is 19,6% and "sludge" is an independent risk factor for spontaneous preterm delivery among asymptomatic patients at high-risk for spontaneous preterm delivery. PTB is

  17. Health behavior and health-related quality of life in patients with a high risk of cardiovascular disease

    Directory of Open Access Journals (Sweden)

    Petek Davorina

    2018-01-01

    Full Text Available Health-related quality of life (HRQoL is measuring a patient’s experience of his health status and represents an outcome of medical interventions. Existing data proves that a healthy lifestyle is positively associated with HRQoL in all age groups. Patients with a high risk for cardiovascular disease typically led an unhealthy lifestyle combined with risk diseases. We aimed to analyse these characteristics and their reflection in HRQoL.

  18. Fluoroscopy-Guided Percutaneous Gallstone Removal Using a 12-Fr Sheath in High-Risk Surgical Patients with Acute Cholecystitis

    Energy Technology Data Exchange (ETDEWEB)

    Kim, Young Hwan [Keimyung University, College of Medicine, Daegu (Korea, Republic of); Kim, Yong Joo [Andong General Hospital, Andong (Korea, Republic of); Shin, Tae Beom [Gyeonsang National University, College of Medicine, Jinju (Korea, Republic of)

    2011-04-15

    To evaluate the technical feasibility and clinical efficacy of percutaneous transhepatic cholecystolithotomy under fluoroscopic guidance in high-risk surgical patients with acute cholecystitis. Sixty-three consecutive patients of high surgical risk with acute calculous cholecystitis underwent percutaneous transhepatic gallstone removal under conscious sedation. The stones were extracted through the 12-Fr sheath using a Wittich nitinol stone basket under fluoroscopic guidance on three days after performing a percutaneous cholecystostomy. Large or hard stones were fragmented using either the snare guide wire technique or the metallic cannula technique. Gallstones were successfully removed from 59 of the 63 patients (94%). Reasons for stone removal failure included the inability to grasp a large stone in two patients, and the loss of tract during the procedure in two patients with a contracted gallbladder. The mean hospitalization duration was 7.3 days for acute cholecystitis patients and 9.4 days for gallbladder empyema patients. Bile peritonitis requiring percutaneous drainage developed in two patients. No symptomatic recurrence occurred during follow-up (mean, 608.3 days). Fluoroscopy-guided percutaneous gallstone removal using a 12-Fr sheath is technically feasible and clinically effective in high-risk surgical patients with acute cholecystitis

  19. Bariatric surgery patients: reasons to visit emergency department after surgery.

    Science.gov (United States)

    Gonzalez-Sánchez, Juan A; Corujo-Vázquez, Omar; Sahai-Hernández, Mrisa

    2007-01-01

    Morbid obesity prevalence is reaching epidemic proportions in Western society. Long-term weight loss can be achieved by bariatric surgery. This surgery also has a positive impact in the reduction of obesity related co-morbid conditions. The purpose of this study is to determine the reasons that bariatric surgery patients had to visit the emergency department within a three month period after surgery. A retrospective chart review study was performed at the UPR Hospital in Carolina. Patients with the diagnosis of morbid obesity who had bariatric surgery were identified. Of the 283 patients who met the criteria, the following information was obtained: gender, age, height, weight, pre-operative BMI, obesity-related comorbid conditions, post operative length of stay (LOS), and reasons and length of stay of Emergency Department (ED) visits within a 3 month period after surgery. Statistical analysis was done with Statistical Package for Social Sciences (SPSS) Program. The same profile of gender and BMI was obtained between the population that had the surgery and the sample that visited the ED, the group of patients between 20-29 years old was more likely to visit the ED. No correlation was found between a longer post operative length of stay and an increased probability of visiting the ED. Of the population, 5% had to visit ED within a three month period. The most common post operative complications were: Abdominal Pain (46.2%), Emesis (38.5%), and Dehydration (30.8%). Other less frequent complications were nausea, DVT, pneumonia, dizziness, gastritis, infected wound and upper GI bleeding. The most common reasons that bariatric surgery patients had to visit the emergency department within a three month period after surgery were: abdominal pain, emesis, dehydration and nausea. These complications could most likely be attributed to patient poor compliance with diet, resulting in the classical symptoms of the dumping syndrome which is common in patients that have undergone

  20. The Clinical Value of Intraoperative Mobile Computed Tomography in Managing High-Risk Surgical Patients with Traumatic Brain Injury-A Single Tertiary Trauma Center Experience.

    Science.gov (United States)

    Chen, Ko-Ting; Lee, Shih-Tseng; Wu, Chieh-Tsai

    2017-02-01

    A subset of surgically treated patients with traumatic brain injury (TBI) cannot be stabilized by initial surgery. Mobile computed tomography (CT) provides real-time information for diagnosis in these TBI surgically high-risk (TBI-SHR) patients. The objective of this study was to analyze a 5-year series of TBI-SHR patients to evaluate the impact of intraoperative mobile CT (imCT) on prognosis. Of 1017 surgically treated patients with TBI retrospectively reviewed over a 5-year period (2009-2013), 59 patients required second operations within 72 hours of their initial surgery because of progressive or delayed hematomas (TBI-SHR group). Their clinical, radiographic, and intraoperative findings were compared among 19 patients who received imCT versus 40 patients who received fixed-unit CT. Our TBI-SHR group accounted for 5.8% of all surgically treated patients with TBI. The use of imCT led to a change in surgical plan in 56% of patients with TBI intraoperatively. Younger patients (≤55 years; P 20 mm Hg or acute brain swelling after adequate decompression (P = 0.003 and 0.004, respectively) significantly benefited from imCT in the TBI-SHR group. imCT also provided a quicker diagnosis (P < 0.001), led to a trend toward shorter intensive care unit stays (P = 0.077), and was associated with better neurologic outcomes at discharge days (P = 0.044). The use of imCT is associated with better neurologic outcomes at discharge days compared with the use of fixed-unit CT in TBI-SHR patients. Copyright © 2016 Elsevier Inc. All rights reserved.

  1. Receptivity to Bariatric Surgery in Qualified Patients

    OpenAIRE

    Fung, Michael; Wharton, Sean; Macpherson, Alison; Kuk, Jennifer L.

    2016-01-01

    Objectives. Bariatric surgery has been shown to be an effective intervention for weight loss and diabetes management. Despite this, many patients qualified for bariatric surgery are not interested in undergoing the procedure. The objective of this study is to determine the factors influencing receptivity to bariatric surgery among those who qualify for the procedure. Methods. Patients attending a publicly funded weight management clinic who qualified for bariatric surgery were asked to comple...

  2. Finding the High-Risk Patient in Primary Prevention Is Not as Easy as a Conventional Risk Score!

    Science.gov (United States)

    Ambrose, John A; Acharya, Tushar; Roberts, Micah J

    2016-12-01

    Patients with coronary artery disease or its equivalent are an appropriate target for guideline-directed therapy. However, finding and treating the individuals at risk for myocardial infarction or sudden death in primary prevention has been problematic. Most initial cardiovascular events are acute syndromes, and only a minority of these occurs in those deemed high risk by contemporary algorithms. Even newer noninvasive modalities cannot detect a majority of those at risk. Furthermore, accurate and early detection of high risk/vulnerability does not guarantee event prevention. Until new tools can be identified, one should consider a few simplistic solutions. In addition to a greater emphasis on lifestyle, earlier use of statins than currently recommended and a direct assault on tobacco could go a long way in reducing acute syndromes and cardiovascular mortality. To achieve the tobacco goal, the medical community would have to be directly and communally engaged. Copyright © 2016 Elsevier Inc. All rights reserved.

  3. High-risk human papilloma virus (HPV and survival in patients with esophageal carcinoma: a pilot study

    Directory of Open Access Journals (Sweden)

    Wanders Alkwin

    2006-04-01

    Full Text Available Abstract Background Human papilloma virus (HPV in patients with esophageal carcinoma has previously been studied with an average detection rate of 15%, but the role of HPV in relation to survival is less clear. In cervical cancer, lung cancer and tonsil cancer HPV viral load is a predictive factor for survival and outcome of treatment. The primary aim was to study the spectrum of high-risk HPV types in esophageal tumors. Secondary, as a pilot study we investigated the association between HPV status and the survival rates. Methods We compared both the presence and the viral load of high-risk HPV types 16, 18, 31, 33, 39, 45, 52, 58, and 67 in relation to clinical data from patients with esophageal carcinoma. Survival data and tumor samples were retrieved from 100 patients receiving treatment at the Department of Oncology, Uppsala Hospital, Uppsala, Sweden. The tumor samples were investigated for HPV viral load using real-time PCR. Results HPV 16 was detected in 16% of the patients; no other HPV type was detected. HPV 16 infection had no significant effect on survival (p = 0.72. Also, HPV 16 did not improve survival after treatment (radiotherapy or chemotherapy. Conclusion Only HPV 16 was detected among the patients. HPV 16 in esophageal carcinoma patients did not influence survival or improve therapy response. However, given the size of the study there is a need to examine a larger cohort in order to understand in more detail the effect of high risk HPV types in esophageal carcinoma.

  4. High risk of malnutrition is associated with low muscle mass in older hospitalized patients - a prospective cohort study.

    Science.gov (United States)

    Pierik, Vincent D; Meskers, Carel G M; Van Ancum, Jeanine M; Numans, Siger T; Verlaan, Sjors; Scheerman, Kira; Kruizinga, Roeliene C; Maier, Andrea B

    2017-06-05

    Malnutrition, low muscle strength and muscle mass are highly prevalent in older hospitalized patients and associated with adverse outcomes. Malnutrition may be a risk factor for developing low muscle mass. We aimed to investigate the association between the risk of malnutrition and 1) muscle strength and muscle mass at admission and 2) the change of muscle strength and muscle mass during hospitalization in older patients. The EMPOWER study included 378 patients aged seventy years or older who were acutely or electively admitted to four different wards of an academic teaching hospital in Amsterdam. Patients were grouped into low risk of malnutrition and high risk of malnutrition based on the Short Nutritional Assessment Questionnaire (SNAQ) score and were assessed for hand grip strength and muscle mass using hand held dynamometry respectively bioelectrical impedance analysis (BIA) within 48 h after admission and at day seven, or earlier at the day of discharge. Muscle mass was expressed as skeletal muscle mass, appendicular lean mass, fat free mass and the skeletal muscle index. The mean age of the patients was 79.7 years (SD 6.39), 48.9% were female. At admission, being at high risk of malnutrition was significantly associated with lower muscle mass (Odds Ratio, 95% CI, 0.90, 0.85-0.96), but not with muscle strength. Muscle strength and muscle mass did not change significantly during hospitalization in both groups. In older hospitalized patients, a high risk of malnutrition is associated with lower muscle mass at admission, but not with muscle strength nor with change of either muscle strength or muscle mass during hospitalization.

  5. Mapping Patterns of Ipsilateral Supraclavicular Nodal Metastases in Breast Cancer: Rethinking the Clinical Target Volume for High-risk Patients

    Energy Technology Data Exchange (ETDEWEB)

    Jing, Hao [Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing (China); Wang, Shu-Lian, E-mail: wsl20040118@yahoo.com [Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing (China); Li, Jing; Xue, Mei; Xiong, Zu-Kun [Department of Radiology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing (China); Jin, Jing; Wang, Wei-Hu; Song, Yong-Wen; Liu, Yue-Ping; Ren, Hua; Fang, Hui; Yu, Zi-Hao; Liu, Xin-Fan [Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing (China); Li, Ye-Xiong, E-mail: yexiong12@163.com [Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing (China)

    2015-10-01

    Purpose: To map the location of metastatic supraclavicular (SCV) lymph nodes (LNMs) in breast cancer patients with SCV node involvement and determine whether and where the radiation therapy clinical target volume (CTV) of this region could be modified in high-risk subsets. Methods and Materials: Fifty-five patients with metastatic SCV LNMs were eligible for geographic mapping and atlas coverage analysis. All LNMs and their epicenters were registered proportionally by referencing the surrounding landmarks onto simulation computed tomography images of a standard patient. CTVs based on selected SCV atlases, including the one by the Radiation Therapy Oncology Group (RTOG) were contoured. A modified SCV CTV was tried and shown to have better involved-node coverage and thus theoretically improved prophylaxis in this setting. Results: A total of 50 (91%) and 45 (81.8%) patients had LNMs in the medial and lateral SCV subregions, respectively. Also, 36 patients (65.5%) had LNMs located at the junction of the jugular-subclavian veins. All nodes were covered in only 25.5% to 41.8% of patients by different atlases. The RTOG atlas covered all nodes in 25.5% of patients. Stratified by the nodes in all the patients as a whole, 49.2% to 81.3% were covered, and the RTOG atlas covered 62.6%. The lateral and posterior borders were the most overlooked locations. Modification by extending the borders to natural anatomic barriers allowed the new CTV to cover all the nodes in 81.8% of patients and encompass 96.1% of all the nodes. Conclusions: According to the distribution of SCV LNMs, the extent of existing atlases might not be adequate for potential metastatic sites in certain groups of patients. The extension of the lateral and posterior CTV borders in high-risk or recurrent patients might be a reasonable approach for increasing coverage. However, additional data in more homogeneous populations with localized disease are needed before routine application.

  6. Improved Survival Endpoints With Adjuvant Radiation Treatment in Patients With High-Risk Early-Stage Endometrial Carcinoma

    Energy Technology Data Exchange (ETDEWEB)

    Elshaikh, Mohamed A., E-mail: melshai1@hfhs.org [Department of Radiation Oncology, Henry Ford Hospital, Detroit, Michigan (United States); Vance, Sean; Suri, Jaipreet S. [Department of Radiation Oncology, Henry Ford Hospital, Detroit, Michigan (United States); Mahan, Meredith [Public Health Science, Henry Ford Hospital, Detroit, Michigan (United States); Munkarah, Adnan [Division of Gynecologic Oncology, Department of Women' s Health Services, Henry Ford Hospital, Detroit, Michigan (United States)

    2014-02-01

    Purpose/Objective(s): To determine the impact of adjuvant radiation treatment (RT) on recurrence-free survival (RFS), disease-specific survival (DSS), and overall survival (OS) in patients with high-risk 2009 International Federation of Gynecology and Obstetrics stage I-II endometrial carcinoma. Methods and Materials: We identified 382 patients with high-risk EC who underwent hysterectomy. RFS, DSS, and OS were calculated from the date of hysterectomy by use of the Kaplan-Meier method. Cox regression modeling was used to explore the risks associated with various factors on survival endpoints. Results: The median follow-up time for the study cohort was 5.4 years. The median age was 71 years. All patients underwent hysterectomy and salpingo-oophorectomy, 93% had peritoneal cytology, and 85% underwent lymphadenectomy. Patients with endometrioid histology constituted 72% of the study cohort, serous in 16%, clear cell in 7%, and mixed histology in 4%. Twenty-three percent of patients had stage II disease. Adjuvant management included RT alone in 220 patients (57%), chemotherapy alone in 25 patients (7%), and chemoradiation therapy in 27 patients (7%); 110 patients (29%) were treated with close surveillance. The 5-year RFS, DSS, and OS were 76%, 88%, and 73%, respectively. On multivariate analysis, adjuvant RT was a significant predictor of RFS (P<.001) DSS (P<.001), and OS (P=.017). Lymphovascular space involvement was a significant predictor of RFS and DSS (P<.001). High tumor grade was a significant predictor for RFS (P=.038) and DSS (P=.025). Involvement of the lower uterine segment was also a predictor of RFS (P=.049). Age at diagnosis and lymphovascular space involvement were significant predictors of OS: P<.001 and P=.002, respectively. Conclusion: In the treatment of patients with high-risk features, our study suggests that adjuvant RT significantly improves recurrence-free, disease-specific, and overall survival in patients with early-stage endometrial carcinoma

  7. Laparoscopic surgery compared with open surgery decreases surgical site infection in obese patients

    DEFF Research Database (Denmark)

    Shabanzadeh, Daniel M; Sørensen, Lars T

    2012-01-01

    : To compare surgical site infections rate in obese patients after laparoscopic surgery with open general abdominal surgery.......: To compare surgical site infections rate in obese patients after laparoscopic surgery with open general abdominal surgery....

  8. Reconstructive Surgery in the Thermally Injured Patient

    Science.gov (United States)

    2012-01-01

    the same or Conflicts of interest: The authors disclose no conflicts. a Division of Oral and Maxillofacial Surgery , Dental and Trauma Research...Reconstructive Surgery in the Thermally Injured Patient Davin Mellus, DMDa,* Rodney K. Chan, MDb KEYWORDS • Microvascular free-tissue transfer...Pedicle flaps • Reconstructive Surgery • Thermal injury • Z-plasties • Skin grafting AN INCREASED NEED FOR RECONSTRUCTIVE SURGERY Reconstruction is a

  9. A multi-institutional analysis comparing adjuvant and salvage radiation therapy for high-risk prostate cancer patients with undetectable PSA after prostatectomy

    International Nuclear Information System (INIS)

    Budiharto, Tom; Perneel, Christiaan; Haustermans, Karin; Junius, Sara; Tombal, Bertrand; Scalliet, Pierre; Renard, Laurette; Lerut, Evelyne; Vekemans, Kris; Joniau, Steven; Poppel, Hendrik Van

    2010-01-01

    Background and purpose: In men with adverse pathology at the time of radical prostatectomy (RP), the most appropriate timing to administer radiotherapy (RT) remains a subject for debate. To determine whether salvage radiotherapy (SRT) upon early prostate-specific antigen (PSA) relapse is equivalent to immediate adjuvant radiotherapy (ART) post RP. Material and methods: 130 patients receiving ART and 89 receiving SRT were identified. All had an undetectable PSA after RP. Homogeneous subgroups were built based on the status (±) of lymphatic invasion (LVI) and surgical margins (SM), to allow a comparison of ART and SRT. Biochemical disease-free survival (bDFS) was calculated from the date of surgery and from the end of RT. The multivariate analysis was performed using the Cox Proportional hazard model. Results: In the SM-/LVI- and SM+/LVI- groups, SRT was a significant predictor of a decreased bDFS from the date of surgery, while in the SM+/LVI+ group, there was a trend towards significance. From the end of RT, SRT was also a significant predictor of a decreased bDFS in three patient groups: SM-/LVI-, SM+/LVI- and SM+/LVI+. Gleason score >7 showed to be another factor on multivariate analysis associated with decreased bDFS in the SM-/LVI- group, from the date of surgery and end of RT. Preoperative PSA was a significant predictor in the SM-/LVI- group from the date of RP only. Conclusions: Immediate ART post RP for patients with high risk features in the prostatectomy specimen significantly reduces bDFS after RP compared with early SRT upon PSA relapse.

  10. Patients with eating disorders. A high-risk group for fractures

    DEFF Research Database (Denmark)

    Vestergaard, Peter; Emborg, Charlotte; Støving, René K

    2003-01-01

    PURPOSE: To analyze fracture risk and bone mineral density in patients with eating disorders (anorexia nervosa, bulimia nervosa, and other eating disorders). DESIGN: Clinical overview. FINDINGS: Bone mineral density is decreased and fracture risk increased in patients with anorexia nervosa....... In patients with bulimia nervosa, bone mineral is only marginally decreased and fracture risk marginally increased. In patients with other eating disorders (eating disorders not otherwise specified), bone mineral density is decreased and fracture risk increased. CONCLUSIONS: Fracture risk is increased...... in patients with eating disorders. An eating disorder should be suspected in severely underweight young individuals (primarily girls) presenting with fractures, especially low-energy fractures....

  11. Patients with eating disorders - a high-risk group for fractures

    DEFF Research Database (Denmark)

    Vestergaard, P.; Emborg, C.; Støving, R.K.

    2003-01-01

    PURPOSE: To analyze fracture risk and bone mineral density in patients with eating disorders (anorexia nervosa, bulimia nervosa, and other eating disorders). DESIGN: Clinical overview. FINDINGS: Bone mineral density is decreased and fracture risk increased in patients with anorexia nervosa....... In patients with bulimia nervosa, bone mineral is only marginally decreased and fracture risk marginally increased. In patients with other eating disorders (eating disorders not otherwise specified), bone mineral density is decreased and fracture risk increased. CONCLUSIONS: Fracture risk is increased...... in patients with eating disorders. An eating disorder should be suspected in severely underweight young individuals (primarily girls) presenting with fractures, especially low-energy fractures....

  12. Prognostic Value of Coronary Computed Tomography Imaging in Patients at High Risk Without Symptoms of Coronary Artery Disease.

    Science.gov (United States)

    Dedic, Admir; Ten Kate, Gert-Jan R; Roos, Cornelis J; Neefjes, Lisan A; de Graaf, Michiel A; Spronk, Angela; Delgado, Victoria; van Lennep, Jeanine E Roeters; Moelker, Adriaan; Ouhlous, Mohamed; Scholte, Arthur J H A; Boersma, Eric; Sijbrands, Eric J G; Nieman, Koen; Bax, Jeroen J; de Feijter, Pim J

    2016-03-01

    At present, traditional risk factors are used to guide cardiovascular management of asymptomatic subjects. Intensified surveillance may be warranted in those identified as high risk of developing cardiovascular disease (CVD). This study aims to determine the prognostic value of coronary computed tomography (CT) angiography (CCTA) next to the coronary artery calcium score (CACS) in patients at high CVD risk without symptoms suspect for coronary artery disease (CAD). A total of 665 patients at high risk (mean age 56 ± 9 years, 417 men), having at least one important CVD risk factor (diabetes mellitus, familial hypercholesterolemia, peripheral artery disease, or severe hypertension) or a calculated European systematic coronary risk evaluation of >10% were included from outpatient clinics at 2 academic centers. Follow-up was performed for the occurrence of adverse events including all-cause mortality, nonfatal myocardial infarction, unstable angina, or coronary revascularization. During a median follow-up of 3.0 (interquartile range 1.3 to 4.1) years, adverse events occurred in 40 subjects (6.0%). By multivariate analysis, adjusted for age, gender, and CACS, obstructive CAD on CCTA (≥50% luminal stenosis) was a significant predictor of adverse events (hazard ratio 5.9 [CI 1.3 to 26.1]). Addition of CCTA to age, gender, plus CACS, increased the C statistic from 0.81 to 0.84 and resulted in a total net reclassification index of 0.19 (p value and risk reclassification benefit beyond CACS in patients without CAD symptoms but with high risk of developing CVD. Copyright © 2016 Elsevier Inc. All rights reserved.

  13. Receptivity to Bariatric Surgery in Qualified Patients

    Directory of Open Access Journals (Sweden)

    Michael Fung

    2016-01-01

    Full Text Available Objectives. Bariatric surgery has been shown to be an effective intervention for weight loss and diabetes management. Despite this, many patients qualified for bariatric surgery are not interested in undergoing the procedure. The objective of this study is to determine the factors influencing receptivity to bariatric surgery among those who qualify for the procedure. Methods. Patients attending a publicly funded weight management clinic who qualified for bariatric surgery were asked to complete an elective questionnaire between February 2013 and April 2014. Results. A total of 371 patients (72% female completed the questionnaire. Only 87 of 371 (23% participants were interested in bariatric surgery. Individuals interested in bariatric surgery had a higher BMI (48.0 versus 46.2 kg/m2, P=0.03 and believed that they would lose more weight with surgery (51 versus 44 kg, P=0.0069. Those who scored highly on past weight loss success and financial concerns were less likely to be interested in bariatric surgery, whereas those who scored highly on high receptivity to surgery and positive social support were more likely to be interested in bariatric surgery. Conclusion. Although participants overestimated the effect of bariatric surgery on weight loss, most were still not interested in bariatric surgery.

  14. Receptivity to Bariatric Surgery in Qualified Patients.

    Science.gov (United States)

    Fung, Michael; Wharton, Sean; Macpherson, Alison; Kuk, Jennifer L

    2016-01-01

    Objectives. Bariatric surgery has been shown to be an effective intervention for weight loss and diabetes management. Despite this, many patients qualified for bariatric surgery are not interested in undergoing the procedure. The objective of this study is to determine the factors influencing receptivity to bariatric surgery among those who qualify for the procedure. Methods. Patients attending a publicly funded weight management clinic who qualified for bariatric surgery were asked to complete an elective questionnaire between February 2013 and April 2014. Results. A total of 371 patients (72% female) completed the questionnaire. Only 87 of 371 (23%) participants were interested in bariatric surgery. Individuals interested in bariatric surgery had a higher BMI (48.0 versus 46.2 kg/m(2), P = 0.03) and believed that they would lose more weight with surgery (51 versus 44 kg, P = 0.0069). Those who scored highly on past weight loss success and financial concerns were less likely to be interested in bariatric surgery, whereas those who scored highly on high receptivity to surgery and positive social support were more likely to be interested in bariatric surgery. Conclusion. Although participants overestimated the effect of bariatric surgery on weight loss, most were still not interested in bariatric surgery.

  15. High-Risk Acute Coronary Syndrome in a Patient with Coronary Subclavian Steal Syndrome Secondary to Critical Subclavian Artery Stenosis

    Directory of Open Access Journals (Sweden)

    Zaher Fanari

    2014-01-01

    Full Text Available Patients with multivessel coronary artery disease are more likely to have extensive atherosclerosis that involves other major arteries. Critical subclavian artery (SCA stenosis can result in coronary subclavian steal syndrome that may present as recurrent ischemia and even myocardial infarction in patients with coronary artery bypass graft (CABG. In patients with concomitant severe native coronary disease, occluded saphenous venous grafts (SVG to other arteries, percutaneous intervention on critical subclavian artery (SCA stenosis that will compromise the blood flow to left internal mammary graft (LIMA and left anterior descending (LAD artery will be a high-risk procedure and may be associated with cardiogenic shock, especially in patients with preexisting ischemic cardiomyopathy. The use of percutaneous left ventricular (LV assist device like Impella will offer better hemodynamic support and coronary perfusion and therefore results in decreased myocardial damage, maximized residual cardiac function, and lower incidence of cardiogenic shock.

  16. NSAID-avoidance education in community pharmacies for patients at high risk for acute kidney injury, upstate New York, 2011.

    Science.gov (United States)

    Jang, Soo Min; Cerulli, Jennifer; Grabe, Darren W; Fox, Chester; Vassalotti, Joseph A; Prokopienko, Alexander J; Pai, Amy Barton

    2014-12-18

    Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently associated with community-acquired acute kidney injury (AKI), a strong risk factor for development and progression of chronic kidney disease. Using access to prescription medication profiles, pharmacists can identify patients at high risk for NSAID-induced AKI. The primary objective of this analysis was to evaluate the effectiveness of a community pharmacy-based patient education program on patient knowledge of NSAID-associated renal safety concerns. Patients receiving prescription medications for hypertension or diabetes mellitus were invited to participate in an educational program on the risks of NSAID use. A patient knowledge questionnaire (PKQ) consisting of 5 questions scored from 1 to 5 was completed before and after the intervention. Information was collected on age, race, sex, and frequency of NSAID use. A total of 152 participants (60% women) completed both the pre- and post-intervention questionnaire; average age was 54.6 (standard deviation [SD], 17.5). Mean pre-intervention PKQ score was 3.3 (SD, 1.4), and post-intervention score was 4.6 (SD, 0.9) (P = .002). Participants rated program usefulness (1 = not useful to 5 = extremely useful) as 4.2 (SD, 1.0). In addition, 48% reported current NSAID use and 67% reported that the program encouraged them to limit their use. NSAID use was common among patients at high risk for AKI. A brief educational intervention in a community pharmacy improved patient knowledge on NSAID-associated risks. Pharmacists practicing in the community can partner with primary care providers in the medical home model to educate patients at risk for AKI.

  17. Mortality from nonulcer bleeding is similar to that of ulcer bleeding in high-risk patients with nonvariceal hemorrhage: a prospective database study in Italy.

    Science.gov (United States)

    Marmo, Riccardo; Del Piano, Mario; Rotondano, Gianluca; Koch, Maurizio; Bianco, Maria Antonia; Zambelli, Alessandro; Di Matteo, Giovanni; Grossi, Enzo; Cipolletta, Livio; Prometeo Investigators

    2012-02-01

    Nonulcer causes of bleeding are often regarded as minor, ie, associated with a lower risk of mortality. To assess the risk of death from nonulcer causes of upper GI bleeding (UGIB). Secondary analysis of prospectively collected data from 3 national databases. Community and teaching hospitals. Consecutive patients admitted for acute nonvariceal UGIB. Early endoscopy, medical and endoscopic treatment as appropriate. Thirty-day mortality, recurrent bleeding, and need for surgery. A total of 3207 patients (65.8% male), mean (standard deviation) age 68.3 (16.4) years, were analyzed. Overall mortality was 4.45% (143 patients). According to the source of bleeding, mortality was 9.8% for neoplasia, 4.8% for Mallory-Weiss tears, 4.8% for vascular lesions, 4.4% for gastroduodenal erosions, 4.4% for duodenal ulcer, and 3.1% for gastric ulcer. Frequency of death was not different among benign endoscopic diagnoses (overall P = .567). Risk of death was significantly higher in patients with neoplasia compared with benign conditions (odds ratio 2.50; 95% CI, 1.32-4.46; P Society of Anesthesiologists score (1-2 vs 3-4, P Society of Anesthesiologists class score in the Prometeo study. Nonulcer causes of nonvariceal UGIB have a risk of death, similar to bleeding peptic ulcers in the clinical context of a high-risk patient. Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.

  18. Cardiac safety of systemic therapy in breast cancer patients with high risk of atherosclerosis complications.

    Science.gov (United States)

    Matyszewski, Arthur; Czarnecka, Anna M; Stachowiak, Paweł; Nowakowska, Marta; Kornacewicz-Jach, Zdzisława; Kasprzak, Jarosław D; Szczylik, Cezary

    2017-03-01

    This study was designed to verify the efficacy of breast cancer treatment and its cardiac toxicity in population with significant cardiac comorbidities. Prospective observational study was conducted in 48 patients. The increase and dependence of echocardiographic parameter early/late were observed on hemoglobin level in all patients, and white blood cells and cholesterol in patients with diabetic were reported. Patients undergo left ventricle diameter change on treatment. Use of potentially cardiotoxic chemo regimens in breast cancer patients with cardiac comorbidities, with optimized cardiac therapy accordingly can save patients from development of early myocardial dysfunction induced by chemotherapy - limiting factor to minimize the risk is optimization of lipid level, red blood cell count and platelets count.

  19. Patients at high risk of adverse events from intravenous contrast media after computed tomography examination

    Energy Technology Data Exchange (ETDEWEB)

    Reddan, Donal [University College Galway Hospitals, Unit 7, Merlin Park Hospital, Galway (Ireland)]. E-mail: donal.reddan@mailn.hse.ie

    2007-05-15

    Adverse reactions to iodinated contrast media (CM) may occur and require prompt recognition and treatment. Although adverse reactions to radiocontrast agents cannot be eliminated, an important first step toward reducing their incidence is to identify patients at greatest risk. Prior to examinations using CM, patients should be adequately assessed by obtaining thorough medical histories and using simple screening tests. Studies have demonstrated that patients with a history of asthma, allergy, hyperthyroidism, and previous reaction to CM are at risk for severe reactions to iodinated CM. Renal adverse reactions reportedly occur more frequently in patients with pre-existing chronic kidney disease, especially those with diabetic nephropathy. Patients with congestive heart failure, dehydration, older age, and those who use nephrotoxic medications are also at risk for developing contrast-associated nephropathy. The occurrence of adverse events may be further increased in patients with multiple risk factors. As the number of patients undergoing computed tomography procedures continues to increase, it is essential for physicians to be able to identify patients at risk for adverse events of CM. Patient-related risk factors are discussed and simple tools for risk stratification presented.

  20. Histological evaluation of patients with gastritis at high risk of developing gastric cancer using a conventional index.

    Science.gov (United States)

    Tanaka, Aki; Kamada, Tomoari; Inoue, Kazuhiko; Shiotani, Akiko; Kusunoki, Hiroaki; Manabe, Noriaki; Ito, Masanori; Hata, Jiro; Haruma, Ken

    2011-06-15

    Although gastric cancer (GCa) is strongly associated with Helicobacter pylori infection, only some H. pylori-positive subjects develop gastric cancer. The aim of this study is to identify H. pylori-positive subjects at high risk of developing GCa by assessment of the histopathological findings in the non-cancer-containing mucosa of patients with and without GCa. The subjects were 35 patients with diffuse-type gastric cancer (D-GCa), 55 with intestinal-type gastric cancer (I-GCa), and 99 H. pylori-positive controls without GCa. Two specimens were taken from the greater curvature of the antrum and the middle body. Histopathological gradings were evaluated using the updated Sydney System, and the risk of GCa was evaluated using a modified Meining's gastric cancer risk index (GCRI). Among the H. pylori-positive controls, corpus gastritis was seen in 98.0% (97/99) and corpus atrophic gastritis in 78.8% (78/99). The mean GCRI for the D-GCa (5.514±2.03) and I-GCa (6.836±2.08) groups was significantly greater than that for the H. pylori-positive controls (4.071±2.07; p=0.0005, pcancer. However, H. pylori-positive patients at high risk of developing GCa (not only intestinal-type but also diffuse-type) may be detected using a simple GCRI. Copyright © 2011 Elsevier GmbH. All rights reserved.

  1. Prevention of Subsequent Catheter-Related Bloodstream Infection Using Catheter Locks in High-Risk Patients Receiving Home Parenteral Nutrition.

    Science.gov (United States)

    Davidson, Jacob B; Edakkanambeth Varayil, Jithinraj; Okano, Akiko; Whitaker, Jennifer A; Bonnes, Sara L; Kelly, Darlene G; Mundi, Manpreet S; Hurt, Ryan T

    2017-05-01

    Catheter-related bloodstream infection (CRBSI) is a serious complication in patients receiving home parenteral nutrition (HPN). Antibiotic lock therapy (ALT) and ethanol lock therapy (ELT) can be used to prevent CRBSI episodes in high-risk patients. Following institutional review board approval, all patients enrolled in the Mayo Clinic HPN program from January 1, 2006, to December 31, 2013, with catheter locking were eligible to be included. Patients without research authorization and ELT were estimated in all patients. A total of 63 patients were enrolled during the study period. Of 59 eligible patients, 29 (49%) were female, and 30 (51%) were male. The median duration of HPN was 3.66 (interquartile range, 0.75-8.19) years. The mean age ± SD at initiation of HPN was 49.89 ± 14.07 years. A total of 51 patients were instilled with ALT, and 8 patients were instilled with ELT during their course of HPN. A total of 313 CRBSI episodes occurred in these patients, 264 before locking and 49 after locking ( P ELT can reduce the overall rate of infections per 1000 catheter days. ALT or ELT can be used in appropriate clinical setting for patients receiving HPN.

  2. Venom Immunotherapy in High-Risk Patients: The Advantage of the Rush Build-Up Protocol.

    Science.gov (United States)

    Rosman, Yossi; Confino-Cohen, Ronit; Goldberg, Arnon

    2017-01-01

    Venom immunotherapy (VIT) is considered to be the gold standard treatment for patients with hymenoptera venom allergy. This treatment induces systemic reactions (SR) in a significant number of patients. To evaluate the outcome of VIT in patients with known risk factors for VIT-induced SR and to compare rush VIT (RVIT) and conventional VIT (CVIT). All of the patients who received VIT and had at least one of the following risk factors were included: current cardiovascular disease, uncontrolled asthma, high basal serum tryptase, current treatment with β-blockers or angiotensin-converting enzyme inhibitors, and age >70 or bee venom. Thirty-five (54.7%) patients underwent RVIT and 29 CVIT. The incidence of patients who developed SR during the build-up phase was similar for RVIT and CVIT (25.7 and 27.5%, respectively; p = 1). However, the incidence of SR per injection was significantly higher in CVIT than in RVIT (5.6 and 2.75%, respectively; p = 0.01). Most reactions (79.1%) were mild, limited to the skin. Most of the patients (92.1%) reached the full maintenance dose of 100 μg. This dose was reached by a significantly larger number of patients receiving RVIT compared to CVIT (100 and 82.7%, respectively; p = 0.01). None of the patients experienced exacerbation of their concurrent chronic disease during VIT. VIT can be performed safely and efficiently in patients with risk factors for immunotherapy. In these patients RVIT appears to be safer and more efficient than CVIT. © 2017 S. Karger AG, Basel.

  3. Tailored cognitive-behavioral therapy and exercise training for high-risk patients with fibromyalgia.

    NARCIS (Netherlands)

    Koulil, S. van; Lankveld, W.G.J.M. van; Kraaimaat, F.W.; Helmond, T. van; Vedder, A.; Hoorn, H. van; Donders, R.; Jong, A.J.L. de; Haverman, J.F.; Korff, K.J.; Riel, P.L.C.M. van; Cats, H.A.; Evers, A.W.M.

    2010-01-01

    OBJECTIVE: The treatment of patients with fibromyalgia (FM), a high-prevalence chronic pain condition with a high impact on both patients and society, poses a great challenge to clinicians due to a lack of effective treatments. In view of the large individual variability in outcome, selecting

  4. Percutaneous nephrolithotripsy under assisted local anaesthesia for high risk patients: Is it effective?

    Directory of Open Access Journals (Sweden)

    T.KH. Fathelbab

    2013-12-01

    Conclusion: Our results demonstrated that PNL under local anesthesia with narcotics and sedatives seems to be a satisfying solution for the treatment of a selected group of patients with renal pelvic stones and who have high anesthetic risk. However, additional studies with different groups of patients are required to validate our results.

  5. Case Study: Nutritional management of a patient at high risk of ...

    African Journals Online (AJOL)

    2015-08-14

    Aug 14, 2015 ... Centre of Excellence for Nutrition, North-West University, Potchefstroom Campus ... It is a reflection of the opinion of the dietitians, students and lecturers involved, describes the actions taken during the nutritional management .... recommended to patients with head or neck cancer.12 The patient's.

  6. High risk of ischemic heart disease in patients with lupus nephritis

    DEFF Research Database (Denmark)

    Faurschou, Mikkel; Mellemkjaer, Lene; Starklint, Henrik

    2011-01-01

    To investigate the occurrence of ischemic heart disease (IHD) in a cohort of 104 Danish patients with biopsy-proven lupus nephritis (LN).......To investigate the occurrence of ischemic heart disease (IHD) in a cohort of 104 Danish patients with biopsy-proven lupus nephritis (LN)....

  7. Insulin resistance and adipose tissue in the development of vascular diseases in high-risk patients

    NARCIS (Netherlands)

    Gorter, P.M.

    2008-01-01

    The work in this thesis focused on the relationship between presence of insulin resistance and advanced vascular damage in patients with manifest atherosclerotic vascular disease, and on the occurrence of (new) vascular events in insulin resistant patients with and without evident vascular disease.

  8. Social cognition in patients at ultra-high risk for psychosis: What is the relation to social skills and functioning?

    Science.gov (United States)

    Glenthøj, Louise B; Fagerlund, Birgitte; Hjorthøj, Carsten; Jepsen, Jens R M; Bak, Nikolaj; Kristensen, Tina D; Wenneberg, Christina; Krakauer, Kristine; Roberts, David L; Nordentoft, Merete

    2016-09-01

    Patients at ultra-high risk (UHR) for psychosis show significant impairments in functioning. It is essential to determine which factors influence functioning, as it may have implications for intervention strategies. This study examined whether social cognitive abilities and clinical symptoms are associated with functioning and social skills. The study included 65 UHR patients and 30 healthy controls. Social cognitive function, social skills, and a broad range of functioning measures were assessed. The UHR patients demonstrated significant decrements on The Awareness of Social Inferences Task total score (p = .046, d  = .51), and on the CANTAB emotion recognition task total percent correct (p = .023, d  = .54) displaying particular difficulties in negative affect recognition. The patients exhibited significant impairments in social skills measured with the High Risk Social Challenge (p˂.001, d  = 1.05). Aspects of emotion recognition were associated with role functioning and social skill performance. The level of attributional bias was associated with overall functioning, and theory of mind ability was associated with self-reported functioning. Negative symptoms were associated with all measures of functioning (p ≤ .05). Significant impairments in social cognition and social skills were found in UHR patients. The patients' social cognitive function was associated with overall functioning and social skills. Negative symptoms appear to play an important role for functioning. Research is needed to investigate how the relations between social cognition, social skills and functioning develop from the UHR state to the stage of manifest illness. Research into how deficits in social cognition and social skills can be ameliorated in UHR patients is warranted.

  9. High Risk of Hepatitis B Reactivation among Patients with Acute Myeloid Leukemia.

    Directory of Open Access Journals (Sweden)

    Chien-Yuan Chen

    Full Text Available Hepatitis B virus (HBV infections are common and associated with significant morbidity and mortality in cancer patients. However, the incidence and risk factors of HBV reactivation in patients with acute myeloid leukemia (AML are rarely investigated.AML patients followed-up at the National Taiwan University Hospital between 2006 and 2012 were analyzed. The clinical characteristics and laboratory data were retrospectively reviewed.Four hundred and ninety patients comprising 265 men and 225 women were studied. The median age was 52 years (range, 18 - 94. Chronic HBV carriage was documented at the time of leukemia diagnosis in 57 (11.6% patients. Forty-six (80.7% of the 57 HBV carriers received prophylaxis with anti-HBV agents. Sixteen HBV carriers (28.1% developed hepatitis B reactivation during or after chemotherapy, including 7 patients who had discontinued antiviral therapy. The incidence of hepatitis B reactivation among AML patients with HBV carriage was 9.5 per 100 person-years. Prophylaxis with anti-HBV agents significantly decreased the risk of hepatitis B reactivation among HBV carriers (13% vs. 61%, p<0.001. Four (2.8% of 142 patients with initial positive anti-HBsAb and anti-HBcAb experienced hepatitis B reactivation and lost their protective anti-HBsAb. Multivariate analysis revealed that diabetes mellitus (p=0.008, odds ratio (OR = 2.841, 95% confident interval (CI: 0.985-8.193 and carriage of HBsAg (p<0.001, OR=36.878, 95% CI: 11.770-115.547 were independent risk factors for hepatitis B reactivation in AML patients.Hepatitis B reactivation is not uncommon in the HBsAg positive AML patients. Prophylaxis with anti-HBV agent significantly decreased the risk of hepatitis B reactivation.

  10. Effect of cocoa powder on the modulation of inflammatory biomarkers in patients at high risk of cardiovascular disease.

    Science.gov (United States)

    Monagas, Maria; Khan, Nasiruddin; Andres-Lacueva, Cristina; Casas, Rosa; Urpí-Sardà, Mireia; Llorach, Rafael; Lamuela-Raventós, Rosa Maria; Estruch, Ramón

    2009-11-01

    Epidemiologic studies have suggested that flavonoid intake plays a critical role in the prevention of coronary heart disease. Because atherosclerosis is considered a low-grade inflammatory disease, some feeding trials have analyzed the effects of cocoa (an important source of flavonoids) on inflammatory biomarkers, but the results have been controversial. The objective was to evaluate the effects of chronic cocoa consumption on cellular and serum biomarkers related to atherosclerosis in high-risk patients. Forty-two high-risk volunteers (19 men and 23 women; mean +/- SD age: 69.7 +/- 11.5 y) were included in a randomized crossover feeding trial. All subjects received 40 g cocoa powder with 500 mL skim milk/d (C+M) or only 500 mL skim milk/d (M) for 4 wk. Before and after each intervention period, cellular and serum inflammatory biomarkers related to atherosclerosis were evaluated. Adherence to the dietary protocol was excellent. No significant changes in the expression of adhesion molecules on T lymphocyte surfaces were found between the C+M and M groups. However, in monocytes, the expression of VLA-4, CD40, and CD36 was significantly lower (P = 0.005, 0.028, and 0.001, respectively) after C+M intake than after M intake. In addition, serum concentrations of the soluble endothelium-derived adhesion molecules P-selectin and intercellular adhesion molecule-1 were significantly lower (both P = 0.007) after C+M intake than after M intake. These results suggest that the intake of cocoa polyphenols may modulate inflammatory mediators in patients at high risk of cardiovascular disease. These antiinflammatory effects may contribute to the overall benefits of cocoa consumption against atherosclerosis. This trial was registered in the Current Controlled Trials at London, International Standard Randomized Controlled Trial Number, at controlled-trials.com as ISRCTN75176807.

  11. Lateral lumbar interbody fusion for the correction of spondylolisthesis and adult degenerative scoliosis in high-risk patients: early radiographic results and complications.

    Science.gov (United States)

    Waddell, Brad; Briski, David; Qadir, Rabah; Godoy, Gustavo; Houston, Allison Howard; Rudman, Ernest; Zavatsky, Joseph

    2014-01-01

    Lateral lumbar interbody fusion (LLIF) is not associated with many of the complications seen in other interbody fusion techniques. This study used computed tomography (CT) scans, the radiographic gold standard, to assess interbody fusion rates achieved utilizing the LLIF technique in high-risk patients. We performed a retrospective review of patients who underwent LLIF between January 2008 and July 2013. Forty-nine patients underwent nonstaged or staged LLIF on 119 levels with posterior correction and augmentation. Per protocol, patients received CT scans at their 1-year follow-up. Of the 49 patients, 21 patients with LLIF intervention on 54 levels met inclusion criteria. Two board-certified musculoskeletal radiologists and the senior surgeon (JZ) assessed fusion. Of the 21 patients, 6 patients had had previous lumbar surgery, and the cohort's comorbidities included osteoporosis, diabetes, obesity, and smoking, among others. Postoperative complications occurred in 12 (57.1%) patients and included anterior thigh pain and weakness in 6 patients, all of which resolved by 6 months. Two cases of proximal junctional kyphosis occurred, along with 1 case of hardware pullout. Two cases of abdominal atonia occurred. By CT scan assessment, each radiologist found fusion was achieved in 53 of 54 levels (98%). The radiologists' findings were in agreement with the senior surgeon. Several studies have evaluated LLIF fusion and reported fusion rates between 88%-96%. Our results demonstrate high fusion rates using this technique, despite multiple comorbidities in the patient population. Spanning the ring apophysis with large LLIF cages along with supplemental posterior pedicle screw augmentation can enhance stability of the fusion segment and increase fusion rates.

  12. High Risk of Hepatitis B Reactivation among Patients with Acute Myeloid Leukemia

    Science.gov (United States)

    Chen, Chien-Yuan; Huang, Sheng-Yi; Cheng, Aristine; Chou, Wen-Chien; Yao, Ming; Tang, Jih-Luh; Tsay, Woei; Sheng, Wang-Huei; Tien, Hwei-Fang

    2015-01-01

    Background Hepatitis B virus (HBV) infections are common and associated with significant morbidity and mortality in cancer patients. However, the incidence and risk factors of HBV reactivation in patients with acute myeloid leukemia (AML) are rarely investigated. Methods AML patients followed-up at the National Taiwan University Hospital between 2006 and 2012 were analyzed. The clinical characteristics and laboratory data were retrospectively reviewed. Results Four hundred and ninety patients comprising 265 men and 225 women were studied. The median age was 52 years (range, 18 - 94). Chronic HBV carriage was documented at the time of leukemia diagnosis in 57 (11.6%) patients. Forty-six (80.7%) of the 57 HBV carriers received prophylaxis with anti-HBV agents. Sixteen HBV carriers (28.1%) developed hepatitis B reactivation during or after chemotherapy, including 7 patients who had discontinued antiviral therapy. The incidence of hepatitis B reactivation among AML patients with HBV carriage was 9.5 per 100 person-years. Prophylaxis with anti-HBV agents significantly decreased the risk of hepatitis B reactivation among HBV carriers (13% vs. 61%, pHBcAb experienced hepatitis B reactivation and lost their protective anti-HBsAb. Multivariate analysis revealed that diabetes mellitus (p=0.008, odds ratio (OR) = 2.841, 95% confident interval (CI): 0.985-8.193) and carriage of HBsAg (p<0.001, OR=36.878, 95% CI: 11.770-115.547) were independent risk factors for hepatitis B reactivation in AML patients. Conclusions Hepatitis B reactivation is not uncommon in the HBsAg positive AML patients. Prophylaxis with anti-HBV agent significantly decreased the risk of hepatitis B reactivation. PMID:25973905

  13. The ARTICO study: identification of patients at high risk of vascular recurrence after a first non-cardioembolic stroke.

    Science.gov (United States)

    Serena, Joaquín; Segura, Tomás; Roquer, Jaume; García-Gil, María; Castillo, José

    2015-03-11

    About 20% of patients with a first ischaemic stroke will experience a new vascular event within the first year. The atherosclerotic burden, an indicator of the extension of atherosclerosis in a patient, has been associated with the risk of new cardiovascular events in the general population. However, no predictive models reliably identify groups at a high risk of recurrence. The ARTICO study prospectively analysed the predictive value for the risk of recurrence of specific atherosclerotic markers. The multicentre ARTICO study included 620 consecutive independent patients older than 60 years suffering from a first non-cardioembolic stroke. We analysed classical stroke risk factors; duplex study of supraaortic trunk including intima-media thickness (IMT) measurement; quantification of internal carotid (ICA) stenosis; number, morphology and surface characteristics of carotid plaques; ankle brachial index (ABI); and the presence of microalbuminuria. Patients were followed up at 6 and 12 months after inclusion. The primary end-point was death or major cardiovascular events. Any vascular event or death at 12 months occurred in 78 (13.8%) patients. In 40 (7.1%) of these the vascular event was a stroke recurrence. Weight, history of diabetes mellitus, history of symptomatic PAD, ABI 50%) were associated with a higher risk of vascular events on follow-up in the bivariate analysis. In the final Cox regression analysis, body mass index (BMI), systolic blood pressure, history of diabetes mellitus, symptomatic PAD (HR, 2.76; 95% CI, 1.10-6.95; p=0.03), and particularly patients with both ICA stenosis >50% and PAD (HR 4.52; 95% CI, 2.14-9.53; p50% nor isolated abnormal ABI remained associated with an increased risk of recurrence in comparison with the whole population. Symptomatic PAD identifies a high risk group of vascular recurrence after a first non-cardioembolic stroke. The associated increased risk was particularly high in patients with both ICA stenosis and either

  14. Clinical significance of CD81 expression by clonal plasma cells in high-risk smoldering and symptomatic multiple myeloma patients.

    Science.gov (United States)

    Paiva, B; Gutiérrez, N-C; Chen, X; Vídriales, M-B; Montalbán, M-Á; Rosiñol, L; Oriol, A; Martínez-López, J; Mateos, M-V; López-Corral, L; Díaz-Rodríguez, E; Pérez, J-J; Fernández-Redondo, E; de Arriba, F; Palomera, L; Bengoechea, E; Terol, M-J; de Paz, R; Martin, A; Hernández, J; Orfao, A; Lahuerta, J-J; Bladé, J; Pandiella, A; Miguel, J-F San

    2012-08-01

    The presence of CD19 in myelomatous plasma cells (MM-PCs) correlates with adverse prognosis in multiple myeloma (MM). Although CD19 expression is upregulated by CD81, this marker has been poorly investigated and its prognostic value in MM remains unknown. We have analyzed CD81 expression by multiparameter flow cytometry in MM-PCs from 230 MM patients at diagnosis included in the Grupo Español de Mieloma (GEM)05>65 years trial as well as 56 high-risk smoldering MM (SMM). CD81 expression was detected in 45% (103/230) MM patients, and the detection of CD81(+) MM-PC was an independent prognostic factor for progression-free (hazard ratio=1.9; P=0.003) and overall survival (hazard ratio=2.0; P=0.02); this adverse impact was validated in an additional series of 325 transplant-candidate MM patients included in the GEM05 myeloma.

  15. High-Risk Behaviour among Hepatitis B Virus-Infected Patients in a ...

    African Journals Online (AJOL)

    -risk behaviour for hepatitis B virus (HBV) transmission among HBV-infected Nigerian adults in order to provide clues for intensifying HBV prevention and control. Methodology: 200 hepatitis B surface antigen (HBsAg) positive patients attending ...

  16. High risk of under-grading and -staging in prostate cancer patients eligible for active surveillance.

    Science.gov (United States)

    Heidegger, Isabel; Skradski, Viktor; Steiner, Eberhard; Klocker, Helmut; Pichler, Renate; Pircher, Andreas; Horninger, Wolfgang; Bektic, Jasmin

    2015-01-01

    Active surveillance (AS) is increasingly offered to patients with low risk prostate cancer. The present study was conducted to evaluate the risk of tumor under-grading and -staging for AS eligibility. Moreover, we analyzed possible biomarkers for predicting more unfavorable final tumor histology. 197 patients who underwent radical prostatectomy (RPE) but would have met the EAU (European Association of Urology) criteria for AS (PSA4-10 ng/ml), PSA density (6, extraprostatic extension and positive resection margin (R1) or correlated significantly with up-grading and/or extraprostatic extension in a multivariate model. Only R1 resections were predictable by combining intermediate PSA levels with two positive biopsy cores (p = 0.004). Sub-analyses showed that the number of biopsy cores (10 vs. 15 biopsy cores) had no influence on above mentioned results on predicting biopsy undergrading. Clinical courses of patients showed that 19.9% of patients had a biochemical relapse after RPE, among all of them were undergraded in the initial biopsy. In summary, this study shows that a multitude of patients fulfilling the criteria for AS are under-diagnosed. The use of preoperative PSA levels, PSA density and the number of positive cores were not predictable for undergrading in the present patient collective.

  17. Improved Biochemical Outcomes With Statin Use in Patients With High-Risk Localized Prostate Cancer Treated With Radiotherapy

    International Nuclear Information System (INIS)

    Kollmeier, Marisa A.; Katz, Matthew S.; Mak, Kimberley; Yamada, Yoshiya; Feder, David J.; Zhang Zhigang; Jia Xiaoyu; Shi Weiji; Zelefsky, Michael J.

    2011-01-01

    Purpose: To investigate the association between 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) and biochemical and survival outcomes after high-dose radiotherapy (RT) for prostate cancer. Methods and Materials: A total of 1711 men with clinical stage T1-T3 prostate cancer were treated with conformal RT to a median dose of 81 Gy during 1995-2007. Preradiotherapy medication data were available for 1681 patients. Three hundred eighty-two patients (23%) were taking a statin medication at diagnosis and throughout RT. Nine hundred forty-seven patients received a short-course of neoadjuvant and concurrent androgen-deprivation therapy (ADT) with RT. The median follow-up was 5.9 years. Results: The 5- and 8-year PSA relapse-free survival (PRFS) rates for statin patients were 89% and 80%, compared with 83% and 74% for those not taking statins (p = 0.002). In a multivariate analysis, statin use (hazard ratio [HR] 0.69, p = 0.03), National Comprehensive Cancer Network (NCCN) low-risk group, and ADT use were associated with improved PRFS. Only high-risk patients in the statin group demonstrated improvement in PRFS (HR 0.52, p = 0.02). Across all groups, statin use was not associated with improved distant metastasis-free survival (DMFS) (p = 0.51). On multivariate analysis, lower NCCN risk group (p = 0.01) and ADT use (p = 0.005) predicted improved DMFS. Conclusions: Statin use during high-dose RT for clinically localized prostate cancer was associated with a significant improvement in PRFS in high-risk patients. These data suggest that statins have anticancer activity and possibly provide radiosensitization when used in conjunction with RT in the treatment of prostate cancer.

  18. TandemHeart Insertion via a Femoral Arterial GORE-TEX Graft Conduit in a High-Risk Patient

    Science.gov (United States)

    Busch, Jonas; Torre-Amione, Guillermo; Noon, George P.; Loebe, Matthias

    2008-01-01

    The TandemHeart® percutaneous ventricular assist device (pVAD), which provides temporary circulatory support of the left ventricle, can be used in high-risk and hemodynamically unstable patients. The easily inserted TandemHeart provides cardiac support superior to that from the use of intra-aortic balloon pumps. Herein, we discuss TandemHeart implantation via end-to-side femoral arterial grafting in a cardiac patient whose sepsis and multiorgan failure were complicated by coagulopathy and thromboembolism. A 47-year-old woman, on intra-aortic balloon and intravenous inotropic support after an acute myocardial infarction and emergency coronary artery bypass grafting, was transferred to our institution via helicopter. She developed sepsis and multiorgan failure. Her condition was further complicated by coagulopathy and a left-lower-extremity thromboembolism. After 6 weeks of aggressive pharmacologic and intermittent intra-aortic balloon treatment, the patient developed cardiogenic shock and received a TandemHeart pVAD for short-term circulatory support. A GORE-TEX® access graft, sewn end-to-side to the femoral artery because of the patient's leg ischemia and very small vessels, served as a conduit for the TandemHeart's femoral arterial inflow cannula. Her difficult circulatory, anatomic, and coagulopathic status stabilized after 2 weeks of TandemHeart support, and she was bridged to the long-term MicroMed DeBakey VAD® Child in anticipation of heart transplantation. The case of our patient shows that high-risk patients who have experienced cardiogenic shock with multiorgan failure and coagulopathy can benefit from the TandemHeart pVAD as a bridge to other therapeutic options, even when creative approaches to treatment and to TandemHeart insertion are required. PMID:19156243

  19. Prevention of contrast-induced nephropathy with prostaglandin E1 in high-risk patients undergoing percutaneous coronary intervention.

    Science.gov (United States)

    Li, Wen-Hua; Li, Dong-Ye; Qian, Wen-Hao; Liu, Jia-Li; Xu, Tong-Da; Zhu, Hong; He, Hai-Yan

    2014-04-01

    Contrast-induced nephropathy (CIN) is an important complication in the use of iodinated contrast media. The present study aimed to assess the safety and efficacy of prostaglandin E1 (PGE1) in prevention of CIN in patients with high-risk factors undergoing percutaneous coronary intervention (PCI). The study group consisted of 163 patients who had undergone a coronary intervention procedure between January 1, 2012 and October 31, 2012. Study participants were randomly assigned to either the PGE1 group (82 patients) or the control group (81 patients). Patients in the PGE1 group received PGE1 intravenous infusion of 20 ng/kg/min for 6 h before and after the administration of contrast media. The control group received 0.9 % sodium chloride solution for routine hydration only. A nonionic, low-osmolality contrast agent was used in our laboratory at this time. Serum creatinine (Scr) values and estimated glomerular filtration rate were measured before and within 48 h of the administration of contrast agents. CIN was defined as an increase of ≥0.5 mg/dL or ≥ a 25 % increase in Scr concentrations over baseline within 48 h of angiography. The amount of contrast agent administered was similar for the PGE1 and control groups (156 ± 63 vs. 161 ± 68 mL, P > 0.05). The incidence of CIN was lower in the PGE1 group than in the control group (3.7 vs. 11.1 %, P < 0.05). No serious adverse effects were observed. In patients with high-risk factors undergoing PCI, the use of PGE1 for prevention of CIN is safe and efficacious.

  20. Trial of a "credit card" asthma self-management plan in a high-risk group of patients with asthma.

    Science.gov (United States)

    D'Souza, W; Burgess, C; Ayson, M; Crane, J; Pearce, N; Beasley, R

    1996-05-01

    The "credit card" asthma self-management plan provides the adult asthmatic patient with simple guidelines for the self-management of asthma, which are based on the self-assessment of peak expiratory flow rate recordings and symptoms. The study was a trial of the clinical efficacy of the credit card plan in a high-risk group of asthmatic patients. In this "before-and-after" trial, patients discharged from the emergency department of Wellington Hospital, after treatment for severe asthma were invited to attend a series of hospital outpatient clinics at which the credit card plan was introduced. Questionnaires were used to compare markers of asthma morbidity, requirement for emergency medical care, and medication use during the 6-month period before and after intervention with the credit card plan. Of the 30 patients with asthma who attended the first outpatient clinic, 26 (17 women and 9 men) completed the program. In these 26 participants, there was a reduction in both morbidity and requirement for acute medical services: specifically, the proportion waking with asthma more than once a week decreased from 65% to 23% (p = 0.005) and the proportion visiting the emergency department for treatment of severe asthma decreased from 58% to 15% (p = 0.004). The patients attending the clinics commented favorably on the plan, in particular on its usefulness as an educational tool for monitoring and treating their asthma. Although the interpretation of this study is limited by the lack of a randomized control group, the findings are consistent with other evidence that the credit card asthma self-management plan can be an effective and acceptable system for improving asthma care in a high-risk group of adult patients with asthma.

  1. Expressive writing for high-risk drug dependent patients in a primary care clinic: A pilot study

    Directory of Open Access Journals (Sweden)

    Wedgwood Lucinda

    2006-11-01

    Full Text Available Abstract Background Previous research has shown that expressive writing is beneficial in terms of both physical and emotional health outcomes. This study aimed to investigate the effectiveness and acceptability of a brief expressive writing intervention for high-risk drug dependent patients in a primary care clinic, and to determine the relationship between linguistic features of writing and health outcomes. Methods Participants completed four 15-minute expressive writing tasks over a week, in which they described their thoughts and feelings about a recent stressful event. Self-report measures of physical (SF-12 and psychological health (DASS-21 were administered at baseline and at a two-week follow-up. Fifty-three participants were recruited and 14 (26% completed all measures. Results No statistically significant benefits in physical or psychological health were found, although all outcomes changed in the direction of improvement. The intervention was well-received and was rated as beneficial by participants. The use of more positive emotion words in writing was associated with improvements in depression and stress, and flexibility in first person pronoun use was associated with improvements in anxiety. Increasing use of cognitive process words was associated with worsening depressive mood. Conclusion Although no significant benefits in physical and psychological health were found, improvements in psychological wellbeing were associated with certain writing styles and expressive writing was deemed acceptable by high-risk drug dependent patients. Given the difficulties in implementing psychosocial interventions in this population, further research using a larger sample is warranted.

  2. Increased MACC1 levels in tissues and blood identify colon adenoma patients at high risk.

    Science.gov (United States)

    Ashktorab, Hassan; Hermann, Pia; Nouraie, Mehdi; Shokrani, Babak; Lee, Edward; Haidary, Tahmineh; Brim, Hassan; Stein, Ulrike

    2016-07-20

    Colorectal cancer is a preventable disease if caught at early stages. This disease is highly aggressive and has a higher incidence in African Americans. Several biomarkers and mutations of aggressive tumor behavior have been defined such as metastasis-associated in colon cancer 1 (MACC1) that was associated with metastasis in colorectal cancer patients. Here, we aim to assess colon tissue MACC1 protein and circulating MACC1 transcripts in colon preneoplastic and neoplastic African American patients. Patients' tissue samples (n = 143) have been arranged on three tissue microarrays for normal (n = 26), adenoma (n = 68) and cancer (n = 49) samples. Immunohistochemistry was used to detect MACC1 expression. Blood samples (n = 93) from normal (n = 45), hyperplastic (n = 15) and tubular adenoma (n = 33) patients were used to assess MACC1 transcripts using qRT-PCR. Distribution of continuous variables was tested between different diagnoses with Kruskal-Wallis test. Categorical variables were tested by Chi square test. We assessed the prognostic ability of IHC staining by calculating area under receiver operating characteristics curve (ROC) for adenoma and cancer separately. Differences between groups in terms of MACC1 transcript levels in plasma were calculated by using non-parametric (exact) Wilcoxon-Mann-Whitney tests. We performed all calculations with SPSS, version 21. In patient tissues, there was a statistically significant difference in MACC1 expression in normal vs. adenoma samples (p = 0.004) and normal vs. cancer samples (p tissue in this patient cohort. The plasma transcripts can be used to stratify African American patients at risk for potential malignant colonic lesions.

  3. Anticoagulation dilemma in a high-risk patient with On-X valves

    Directory of Open Access Journals (Sweden)

    Ami M Karkar

    2015-01-01

    Full Text Available Thromboembolism continues to be a major concern in patients with mechanical heart valves, especially in those with unsatisfactory anticoagulation levels. The new On-X valve (On-X Life Technologies, Austin, TX, USA has been reported as having unique structural characteristics that offer lower thrombogenicity to the valve. We report a case where the patient received no or minimal systemic anticoagulation after placement of On-X mitral and aortic valves due to development of severe mucosal arterio-venous malformations yet did not show any evidence of thromboembolism. This case report reinforces the findings of recent studies that lower anticoagulation levels may be acceptable in patients with On-X valves and suggests this valve may be particularly useful in those in whom therapeutic levels of anticoagulation cannot be achieved due to increased risk of bleeding.

  4. Problems and help seeking in high-risk adolescent patients of health clinics.

    Science.gov (United States)

    Stiffman, A R; Earls, F; Robins, L N; Jung, K G

    1988-07-01

    In this study, 2787 adolescents between the ages of 13 and 18 years living in inner-city communities were interviewed about their mental and physical health and their clinic use. The patients used consolidated mental and physical health clinics located in neighborhoods, hospitals, or schools; or traditional neighborhood or hospital health clinics. Analyses of selected patient problems reveal that less than one third of adolescent patients with suicide ideation, conduct disorder, and substance abuse or dependency sought or received care for those problems. Only half of the adolescents with major depression sought or received care for depression, and only two thirds of the sexually active females sought or received help with birth control. A special effort needs to be made to attract troubled youth to clinics and to identify and treat their problems, particularly when those problems involve mental health concerns.

  5. Effect of Additional Treatments Combined with Conventional Therapies in Pregnant Patients with High-Risk Antiphospholipid Syndrome: A Multicentre Study.

    Science.gov (United States)

    Ruffatti, Amelia; Tonello, Marta; Hoxha, Ariela; Sciascia, Savino; Cuadrado, Maria J; Latino, José O; Udry, Sebastian; Reshetnyak, Tatiana; Costedoat-Chalumeau, Nathalie; Morel, Nathalie; Marozio, Luca; Tincani, Angela; Andreoli, Laura; Haladyj, Ewa; Meroni, Pier L; Gerosa, Maria; Alijotas-Reig, Jaume; Tenti, Sara; Mayer-Pickel, Karoline; Simchen, Michal J; Bertero, Maria T; De Carolis, Sara; Ramoni, Véronique; Mekinian, Arsène; Grandone, Elvira; Maina, Aldo; Serrano, Fátima; Pengo, Vittorio; Khamashta, Munther A

    2018-02-28

    The effect of additional treatments combined with conventional therapy on pregnancy outcomes was examined in high-risk primary antiphospholipid syndrome (PAPS) patients to identify the most effective treatment strategy. The study's inclusion criteria were (1) positivity to lupus anticoagulant alone or associated with anticardiolipin and/or anti-β2 glycoprotein I antibodies; (2) a history of severe maternal-foetal complications (Group I) or a history of one or more pregnancies refractory to conventional therapy leading to unexplained foetal deaths not associated with severe maternal-foetal complications (Group II). Two different additional treatments were considered: oral-low-dose steroids (10-20 mg prednisone daily) and/or 200 to 400 mg daily doses of hydroxychloroquine and parenteral-intravenous immunoglobulins at 2 g/kg per month and/or plasma exchange. The study's primary outcomes were live birth rates and pregnancy complications. A total of 194 pregnant PAPS patients attending 20 tertiary centres were retrospectively enrolled. Hydroxychloroquine was found to be linked to a significantly higher live birth rate with respect to the other oral treatments in the Group II patients. The high (400 mg) versus low (200 mg) doses of hydroxychloroquine ( p  = 0.036) and its administration before versus during pregnancy ( p  = 0.021) were associated with a significantly higher live birth rate. Hydroxychloroquine therapy appeared particularly efficacious in the PAPS patients without previous thrombosis. Parenteral treatments were associated with a significantly higher live birth rate with respect to the oral ones ( p  = 0.037), particularly in the Group I patients. In conclusion, some additional treatments were found to be safe and efficacious in high-risk PAPS pregnant women. Schattauer GmbH Stuttgart.

  6. Inpatient Glucose Values: Determining the Nondiabetic Range and Use in Identifying Patients at High Risk for Diabetes.

    Science.gov (United States)

    Rhee, Mary K; Safo, Sandra E; Jackson, Sandra L; Xue, Wenqiong; Olson, Darin E; Long, Qi; Barb, Diana; Haw, J Sonya; Tomolo, Anne M; Phillips, Lawrence S

    2018-04-01

    Many individuals with diabetes remain undiagnosed, leading to delays in treatment and higher risk for subsequent diabetes complications. Despite recommendations for diabetes screening in high-risk groups, the optimal approach is not known. We evaluated the utility of inpatient glucose levels as an opportunistic screening tool for identifying patients at high risk for diabetes. We retrospectively examined 462,421 patients in the US Department of Veterans Affairs healthcare system, hospitalized on medical/surgical services in 2000-2010, for ≥3 days, with ≥2 inpatient random plasma glucose (RPG) measurements. All had continuity of care: ≥1 primary care visit and ≥1 glucose measurement within 2 years before hospitalization and yearly for ≥3 years after discharge. Glucose levels during hospitalization and incidence of diabetes within 3 years after discharge in patients without diabetes were evaluated. Patients had a mean age of 65.0 years, body mass index of 29.9 kg/m 2 , and were 96% male, 71% white, and 18% black. Pre-existing diabetes was present in 39.4%, 1.3% were diagnosed during hospitalization, 8.1% were diagnosed 5 years after discharge, and 51.3% were never diagnosed (NonDM). The NonDM group had the lowest mean hospital RPG value (112 mg/dL [6.2 mmol/L]). Having at least 2 RPG values >140 mg/dL (>7.8 mmol/L), the 95th percentile of NonDM hospital glucose, provided 81% specificity for identifying incident diabetes within 3 years after discharge. Screening for diabetes could be considered in patients with at least 2 hospital glucose values at/above the 95th percentile of the nondiabetic range (141 mg/dL [7.8 mmol/L]). Published by Elsevier Inc.

  7. Percentage prevalence of patient and visitor violence against staff in high-risk UK medical wards.

    Science.gov (United States)

    Lepping, Peter; Lanka, Srinivas Vn; Turner, Jim; Stanaway, Stephen Ers; Krishna, Murali

    2013-12-01

    Patient and visitor violence adversely affects staff and organisations; however, there are few UK data about patient and visitor violence on medical wards. Therefore, we conducted a cross-sectional study using a validated tool (Survey of Violence Experienced by Staff) in six medical wards in three North Wales district general hospitals to assess the prevalence of violence against healthcare staff. A total of 158 staff responded (12 men, 144 women, two not stated). We found that, within the previous 4 weeks, 83% of staff had experienced verbal aggression, 50% had been threatened and 63% had been physically assaulted. Of those assaulted, 56% sustained an injury, with three requiring medical assessment or treatment. Length of experience in the workplace correlated negatively with verbal abuse, but not with threats or assaults. Direct patient contact positively correlated with more overall incidents. There was no correlation between training in aggression management and the experience of incidents. Healthcare support workers and nurses reported a higher prevalence of patient and visitor violence compared with other groups of health worker.

  8. Cardiovascular Efficacy and Safety of Bococizumab in High-Risk Patients

    NARCIS (Netherlands)

    Ridker, Paul M.; Revkin, James; Amarenco, Pierre; Brunell, Robert; Curto, Madelyn; Civeira, Fernando; Flather, Marcus; Glynn, Robert J.; Gregoire, Jean; Jukema, J. Wouter; Karpov, Yuri; Kastelein, John J. P.; Koenig, Wolfgang; Lorenzatti, Alberto; Manga, Pravin; Masiukiewicz, Urszula; Miller, Michael; Mosterd, Arend; Murin, Jan; Nicolau, Jose C.; Nissen, Steven; Ponikowski, Piotr; Santos, Raul D.; Schwartz, Pamela F.; Soran, Handrean; White, Harvey; Wright, R. Scott; Vrablik, Michal; Yunis, Carla; Shear, Charles L.; Tardif, Jean-Claude

    2017-01-01

    BACKGROUND Bococizumab is a humanized monoclonal antibody that inhibits proprotein convertase subtilisin-kexin type 9 (PCSK9) and reduces levels of low-density lipoprotein (LDL) cholesterol. We sought to evaluate the efficacy of bococizumab in patients at high cardiovascular risk. METHODS In two

  9. Lymph node dissection in patients with malignant melanoma is associated with high risk of morbidity

    DEFF Research Database (Denmark)

    Ul-Mulk, Jamshaid; Hölmich, Lisbet Rosenkrantz

    2012-01-01

    Malignant melanoma is one of the most rapidly increasing cancer types globally, and it is by far the most serious skin cancer. Patients with a melanoma ≥ 1 mm in Breslow thickness are offered sentinel node (SN) biopsy and subsequent radical lymph node dissection if the biopsy is positive...

  10. Evaluation of cervical cerclage for sonographically incompetent cervix in at high risk patients

    International Nuclear Information System (INIS)

    Mustajab, Y.; Jehanzaib, M.

    2008-01-01

    To determine the impact of Cervical Cerclage (CC) for prolongation of pregnancy, maternal and foetal outcome. This Descriptive cross-sectional study was conducted over a period of 2 years patients with history of two or more recurrent midtrimester abortions/preterm deliveries were included. Those with abnormal foetus, vaginal bleeding and choreoamneonitis were excluded. All patients were subjected to transvaginal sonography. Those having sonographic evidence of cervical shortening/dilatation/cone formation were subjected to McDonald suture. Age, parity, period of gestation and aetiological factors were determined. Results were evaluated on the basis of pregnancy prolongation, 14-28 weeks (7.5%), 28-36 weeks (18.7%), 35-37 weeks (73.7%), vaginal delivery in (70%), instrumental (1305%), Caesarean section (17.5%),miscarriage (7.5%), prematurity (18.7%), term delivery (73.7%), prenatal death (13.7%), foetal survival rate (85.1%). No intraoperative complication found. During pregnancy premature rupture of membrane (3.7%), abruption (2.5%), severe pre-eclampsia (3.7%). During labour cervical dystocia was found in (2.5%), foetal distress (8.7%), mal-presentations (6.2%), cervical trauma (3.7%). We determined a high success rate of cervical cerclage on properly selected patients with sonographic evidence of cervical changes. Cervical sonography can be a valuable adjunct to clinical evaluation of these patients. (author)

  11. Cardiovascular Efficacy and Safety of Bococizumab in High-Risk Patients

    DEFF Research Database (Denmark)

    Ridker, Paul M; Revkin, James; Amarenco, Pierre

    2017-01-01

    BACKGROUND: Bococizumab is a humanized monoclonal antibody that inhibits proprotein convertase subtilisin-kexin type 9 (PCSK9) and reduces levels of low-density lipoprotein (LDL) cholesterol. We sought to evaluate the efficacy of bococizumab in patients at high cardiovascular risk. METHODS: In tw...

  12. High risk of ischemic heart disease in patients with lupus nephritis

    DEFF Research Database (Denmark)

    Faurschou, Mikkel; Mellemkjaer, Lene; Starklint, Henrik

    2011-01-01

    Abstract OBJECTIVE: To investigate the occurrence of ischemic heart disease (IHD) in a cohort of 104 Danish patients with biopsy-proven lupus nephritis (LN). METHODS: Information on all hospitalizations in Denmark for IHD between 1977 and 2006 was obtained from the Danish National Hospital Register...

  13. Identification of patients at high risk of noncompliance in substance dependence treatment

    NARCIS (Netherlands)

    de Weert-van Oene, G. H.; Burger, H.; Grobbee, D. E.; Schrijvers, A. J. P.

    2007-01-01

    Noncompliance in substance dependence treatment seriously threatens its effectiveness. Pretreatment identification of those at the highest risk allows targeting of specific compliance enhancing interventions to those who may benefit most from it. In a cohort of 292 patients entering a 30-day

  14. Cardiovascular Efficacy and Safety of Bococizumab in High-Risk Patients.

    Science.gov (United States)

    Ridker, Paul M; Revkin, James; Amarenco, Pierre; Brunell, Robert; Curto, Madelyn; Civeira, Fernando; Flather, Marcus; Glynn, Robert J; Gregoire, Jean; Jukema, J Wouter; Karpov, Yuri; Kastelein, John J P; Koenig, Wolfgang; Lorenzatti, Alberto; Manga, Pravin; Masiukiewicz, Urszula; Miller, Michael; Mosterd, Arend; Murin, Jan; Nicolau, Jose C; Nissen, Steven; Ponikowski, Piotr; Santos, Raul D; Schwartz, Pamela F; Soran, Handrean; White, Harvey; Wright, R Scott; Vrablik, Michal; Yunis, Carla; Shear, Charles L; Tardif, Jean-Claude

    2017-04-20

    Bococizumab is a humanized monoclonal antibody that inhibits proprotein convertase subtilisin-kexin type 9 (PCSK9) and reduces levels of low-density lipoprotein (LDL) cholesterol. We sought to evaluate the efficacy of bococizumab in patients at high cardiovascular risk. In two parallel, multinational trials with different entry criteria for LDL cholesterol levels, we randomly assigned the 27,438 patients in the combined trials to receive bococizumab (at a dose of 150 mg) subcutaneously every 2 weeks or placebo. The primary end point was nonfatal myocardial infarction, nonfatal stroke, hospitalization for unstable angina requiring urgent revascularization, or cardiovascular death; 93% of the patients were receiving statin therapy at baseline. The trials were stopped early after the sponsor elected to discontinue the development of bococizumab owing in part to the development of high rates of antidrug antibodies, as seen in data from other studies in the program. The median follow-up was 10 months. At 14 weeks, patients in the combined trials had a mean change from baseline in LDL cholesterol levels of -56.0% in the bococizumab group and +2.9% in the placebo group, for a between-group difference of -59.0 percentage points (P<0.001) and a median reduction from baseline of 64.2% (P<0.001). In the lower-risk, shorter-duration trial (in which the patients had a baseline LDL cholesterol level of ≥70 mg per deciliter [1.8 mmol per liter] and the median follow-up was 7 months), major cardiovascular events occurred in 173 patients each in the bococizumab group and the placebo group (hazard ratio, 0.99; 95% confidence interval [CI], 0.80 to 1.22; P=0.94). In the higher-risk, longer-duration trial (in which the patients had a baseline LDL cholesterol level of ≥100 mg per deciliter [2.6 mmol per liter] and the median follow-up was 12 months), major cardiovascular events occurred in 179 and 224 patients, respectively (hazard ratio, 0.79; 95% CI, 0.65 to 0.97; P=0.02). The

  15. High risk of lower urinary tract symptoms in patients with irritable bowel syndrome.

    Science.gov (United States)

    Zingone, F; Iovino, P; Santonicola, A; Gallotta, S; Ciacci, C

    2017-06-01

    The aim of the present study was to investigate the prevalence of urinary tract infection (UTI) and the risk of lower urinary tract symptoms (LUTS) in women with irritable bowel syndrome (IBS) (including each subtype: constipation, diarrhea, and mixed) compared to women in the general population. Between January 2014 and December 2015, consecutive adult female patients diagnosed with IBS at the outpatient clinic of the University of Salerno and healthy women with regular bowel habits were enrolled in the study. At baseline, we checked for UTI with a dipstick test and questioned patients about the presence of LUTS in the previous 24 h. We enrolled 141 IBS patients and 91 healthy controls in the study. There was no difference in the prevalence of UTI between IBS patients and healthy controls (4.9 vs 3.3%, p = 0.5). When we excluded patients with UTI, we found a 2.79 higher risk of increased urinary frequency [odds ratio (OR) 2.79, 95% confidence interval (CI) 1.37-5.68], a 2.68 higher risk of urinary urgency (OR 2.68, 95% CI 1.04-6.91), and more than three times the risk of having dysuria (OR 3.25, 95% CI 1.06-9.97) in IBS women compared to healthy controls. The risk of having at least one urinary symptom was independent of IBS subtype and IBS severity. Our study shows that IBS women have a similar risk of UTI compared to healthy women even if they complain more of LUTS, independently of IBS subtype and severity.

  16. Surgical Management of a Patient with Anterior Megalophthalmos, Lens Subluxation, and a High Risk of Retinal Detachment

    Directory of Open Access Journals (Sweden)

    María Carmen Guixeres Esteve

    2017-01-01

    Full Text Available The early development of lens opacities and lens subluxation are the most common causes of vision loss in patients with anterior megalophthalmos (AM. Cataract surgery in such patients is challenging, however, because of anatomical abnormalities. Intraocular lens dislocation is the most common postoperative complication. Patients with AM also seem to be affected by a type of vitreoretinopathy that predisposes them to retinal detachment. We here present the case of a 36-year-old man with bilateral AM misdiagnosed as simple megalocornea. He had a history of amaurosis in the right eye due to retinal detachment. He presented with vision loss in the left eye due to lens subluxation. Following the removal of the subluxated lens, it was deemed necessary to perform a vitrectomy in order to prevent retinal detachment. Seven months after surgery, an Artisan® Aphakia iris-claw lens was implanted in the anterior chamber. Fifteen months of follow-up data are provided.

  17. Cyclophosphamide, methotrexate, and fluorouracil; oral cyclophosphamide; levamisole; or no adjuvant therapy for patients with high-risk, premenopausal breast cancer

    DEFF Research Database (Denmark)

    Ejlertsen, Bent; Mouridsen, Henning T; Jensen, Maj-Britt

    2010-01-01

    BACKGROUND: The Danish Breast Cancer Cooperative Group (DBCG) 77B trial examined the relative efficacy of levamisole, single-agent oral cyclophosphamide, and the classic combination of cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) against no adjuvant systemic therapy in high-risk breast...... cancer patients. The authors report the results from that trial after a potential follow-up of 25 years. METHODS: Between 1977 and 1983, 1146 premenopausal patients who had tumors >5 cm or positive axillary lymph nodes were assigned randomly to 1 of 4 options: no systemic therapy, levamisole 5 mg weekly...... for 48 weeks (the levamisole arm), oral cyclophosphamide 130 mg/m(2) on Days 1 through 14 every 4 weeks for 12 cycles (the C arm), or oral cyclophosphamide 80 mg/m(2) on Days 1 through 14 plus methotrexate 30 mg/m(2) and fluorouracil 500 mg/m(2) intravenously on Days 1 and 8 every 4 weeks for 12 cycles...

  18. Hybrid endovascular treatment of an aortic root and thoracoabdominal aneurysm in a high-risk patient with Marfan syndrome.

    Science.gov (United States)

    Gelpi, Guido; Mazzaccaro, Daniela; Romagnoni, Claudia; Contino, Monica; Antona, Carlo

    2013-05-01

    This report describes the hybrid endovascular treatment of an aortic root dilatation and a thoracoabdominal aneurysm in a high-risk patient with Marfan syndrome. A 50-year-old male, in hemodialysis for polycystic kidney and polycystic liver, was referred to our department for aortic root dilatation of 5 cm and a 6.3-cm thoracoabdominal aneurysm . He already underwent surgical repair of abdominal aortic aneurysm 10 years ago, complicated by pseudoaneurysm of the proximal anastomosis that had been treated in another center, with an endoprosthesis. The patient underwent aortic root replacement, aortic valve sparing operation, and rerouting of the superior mesenteric artery and celiac trunk to the ascending aorta. The thoracoabdominal aneurysm was excluded with an endoprosthesis few days after the surgical step. The 12-month computed tomography scan confirmed the complete exclusion of the thoracoabdominal aneurysm.

  19. A case report of cognitive behavioural therapy for social anxiety in an ultra-high risk patient.

    Science.gov (United States)

    Haglund, Margaret; Cabaniss, Deborah; Kimhy, David; Corcoran, Cheryl M

    2014-05-01

    Psychological treatments such as cognitive behavioural therapy (CBT) may have efficacy in young people at ultra-high risk (UHR) for psychosis. Case reports can illuminate the obstacles and challenges, and potential trajectory of symptom changes, observed with this treatment. This is a detailed case report of a young adult at UHR for psychosis who received manualized CBT for accompanying social anxiety. Cognitive deficits and suspiciousness created initial challenges for successful implementation of CBT. Engagement in treatment occurred with slowing of pace and simplification of material, and modelling of social interaction. Treatment of social anxiety was accompanied by decreases in suspiciousness, conceptual disorganization, and social anhedonia, and increase in range of affect. Adaptation of manualized CBT to accommodate cognitive deficits and suspiciousness in UHR patients may improve engagement. CBT focused on social anxiety can lead to improvement across symptom domains in UHR patients. © 2013 Wiley Publishing Asia Pty Ltd.

  20. Magnitude and consequences of undertreatment of high-risk patients with non-ST segment elevation acute coronary syndromes: insights from the DESCARTES Registry.

    Science.gov (United States)

    Heras, M; Bueno, H; Bardají, A; Fernández-Ortiz, A; Martí, H; Marrugat, J

    2006-11-01

    To analyse intensity of treatment of high-risk patients with non-ST elevation acute coronary syndromes (NSTEACS) included in the DESCARTES (Descripción del Estado de los Sindromes Coronarios Agudos en un Registro Temporal Español) registry. Patients with NSTEACS (n = 1877) admitted to 45 randomly selected Spanish hospitals in April and May 2002 were studied. Patients with ST segment depression and troponin rise were considered high risk (n = 478) and were compared with non-high risk patients (n = 1399). 46.9% of high-risk patients versus 39.5% of non-high-risk patients underwent angiography (p = 0.005), 23.2% versus 18.8% (p = 0.038) underwent percutaneous revascularisation, and 24.9% versus 7.4% (p or = 4, 2-3 and or = 4 (OR 2.87, 95% CI 1.27 to 6.52, p = 0.012). Class I recommended treatments were underused in high-risk patients in the DESCARTES registry. This undertreatment was an independent predictor of death of patients with an acute coronary syndrome.

  1. HIGH RISK IN ROOT CANAL NEGOCIATION IN ELDERLY PATIENTS: CLINICAL CASE SERIES

    Directory of Open Access Journals (Sweden)

    Paula PERLEA

    2015-03-01

    Full Text Available Several clinical cases outline the difficulties of root canal treatment, due to the morphological changes of the endodontic space in elderly patients. The changes in the shape of pulp chamber and root canal make the treatment more difficult. It is also shown that the pulp chamber diminishes, due to reparative dentin. Calcification of the pulp space makes more difficult the access to the cavity. The obliterated canals lead to a challenging negotiation of the root canals. To avoid errors in the appreciation of the general health condition of the patient, the specialists should have an accurate preoperative radiograph or cone beam computing tomography (CBCT, use magnification (dental operative microscope, safe-ended burs, consider carefully any morphological changes, and apply the most proper techniques.

  2. Definition and Validation of “Favorable High-Risk Prostate Cancer”: Implications for Personalizing Treatment of Radiation-Managed Patients

    International Nuclear Information System (INIS)

    Muralidhar, Vinayak; Chen, Ming-Hui; Reznor, Gally; Moran, Brian J.; Braccioforte, Michelle H.; Beard, Clair J.; Feng, Felix Y.; Hoffman, Karen E.; Choueiri, Toni K.; Martin, Neil E.; Sweeney, Christopher J.; Trinh, Quoc-Dien; Nguyen, Paul L.

    2015-01-01

    Purpose: To define and validate a classification of favorable high-risk prostate cancer that could be used to personalize therapy, given that consensus guidelines recommend similar treatments for all radiation-managed patients with high-risk disease. Methods and Materials: We studied 3618 patients with cT1-T3aN0M0 high-risk or unfavorable intermediate-risk prostate adenocarcinoma treated with radiation at a single institution between 1997 and 2013. Favorable high-risk was defined as T1c disease with either Gleason 4 + 4 = 8 and prostate-specific antigen <10 ng/mL or Gleason 6 and prostate-specific antigen >20 ng/mL. Competing risks regression was used to determine differences in the risk of prostate cancer–specific mortality (PCSM) after controlling for baseline factors and treatment. Our results were validated in a cohort of 13,275 patients using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. Results: Patients with favorable high-risk disease had significantly better PCSM than other men with high-risk disease (adjusted hazard ratio [AHR] 0.42, 95% confidence interval [CI] 0.18-0.996, P=.049) and similar PCSM as men with unfavorable intermediate-risk disease (AHR 1.17, 95% CI 0.50-2.75, P=.710). We observed very similar results within the SEER-Medicare cohort (favorable high-risk vs other high-risk: AHR 0.21, 95% CI 0.11-0.41, P<.001; favorable high-risk vs unfavorable intermediate-risk: AHR 0.67, 95% CI 0.33-1.36, P=.268). Conclusions: Patients with favorable high-risk prostate cancer have significantly better PCSM than other patients with high-risk disease and similar PCSM as those with unfavorable intermediate-risk disease, who are typically treated with shorter-course androgen deprivation therapy. This new classification system may allow for personalization of treatment within high-risk disease, such as consideration of shorter-course androgen deprivation therapy for favorable high-risk disease.

  3. Definition and Validation of “Favorable High-Risk Prostate Cancer”: Implications for Personalizing Treatment of Radiation-Managed Patients

    Energy Technology Data Exchange (ETDEWEB)

    Muralidhar, Vinayak [Harvard-MIT Division of Health Sciences and Technology, Harvard Medical School, Boston, Massachusetts (United States); Chen, Ming-Hui [Department of Statistics, University of Connecticut, Storrs, Connecticut (United States); Reznor, Gally [Center for Surgery and Public Health, Brigham and Women' s Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts (United States); Moran, Brian J.; Braccioforte, Michelle H. [Prostate Cancer Foundation of Chicago, Westmont, Illinois (United States); Beard, Clair J. [Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women' s Hospital, Boston, Massachusetts (United States); Feng, Felix Y. [Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan (United States); Hoffman, Karen E. [Department of Radiation Oncology, M. D. Anderson Cancer Center, Houston, Texas (United States); Choueiri, Toni K. [Department of Medical Oncology, Dana-Farber Cancer Institute and Brigham and Women' s Hospital, Harvard Medical School, Boston, Massachusetts (United States); Martin, Neil E. [Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women' s Hospital, Boston, Massachusetts (United States); Sweeney, Christopher J. [Department of Medical Oncology, Dana-Farber Cancer Institute and Brigham and Women' s Hospital, Harvard Medical School, Boston, Massachusetts (United States); Trinh, Quoc-Dien [Department of Urology, Brigham and Women' s Hospital, Boston, Massachusetts (United States); Nguyen, Paul L., E-mail: pnguyen@LROC.harvard.edu [Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women' s Hospital, Boston, Massachusetts (United States)

    2015-11-15

    Purpose: To define and validate a classification of favorable high-risk prostate cancer that could be used to personalize therapy, given that consensus guidelines recommend similar treatments for all radiation-managed patients with high-risk disease. Methods and Materials: We studied 3618 patients with cT1-T3aN0M0 high-risk or unfavorable intermediate-risk prostate adenocarcinoma treated with radiation at a single institution between 1997 and 2013. Favorable high-risk was defined as T1c disease with either Gleason 4 + 4 = 8 and prostate-specific antigen <10 ng/mL or Gleason 6 and prostate-specific antigen >20 ng/mL. Competing risks regression was used to determine differences in the risk of prostate cancer–specific mortality (PCSM) after controlling for baseline factors and treatment. Our results were validated in a cohort of 13,275 patients using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. Results: Patients with favorable high-risk disease had significantly better PCSM than other men with high-risk disease (adjusted hazard ratio [AHR] 0.42, 95% confidence interval [CI] 0.18-0.996, P=.049) and similar PCSM as men with unfavorable intermediate-risk disease (AHR 1.17, 95% CI 0.50-2.75, P=.710). We observed very similar results within the SEER-Medicare cohort (favorable high-risk vs other high-risk: AHR 0.21, 95% CI 0.11-0.41, P<.001; favorable high-risk vs unfavorable intermediate-risk: AHR 0.67, 95% CI 0.33-1.36, P=.268). Conclusions: Patients with favorable high-risk prostate cancer have significantly better PCSM than other patients with high-risk disease and similar PCSM as those with unfavorable intermediate-risk disease, who are typically treated with shorter-course androgen deprivation therapy. This new classification system may allow for personalization of treatment within high-risk disease, such as consideration of shorter-course androgen deprivation therapy for favorable high-risk disease.

  4. BRCA1 and BRCA2 genetic test in high risk patients and families: counselling and management.

    Science.gov (United States)

    Marchina, Eleonora; Fontana, Maria Grazia; Speziani, Michela; Salvi, Alessandro; Ricca, Giuseppe; Di Lorenzo, Diego; Gervasi, Maria; Caimi, Luigi; Barlati, Sergio

    2010-12-01

    Hereditary breast cancer accounts for 5-10% of all cases of breast cancer and 10-15% of ovarian cancer and is characterised by dominant inheritance, early onset, the severity of the disease and bilaterality. About 30% of cases with hereditary breast and ovarian cancer have mutations in the BRCA1 and BRCA2 genes. Women with a mutation in the BRCA1 gene have a 80-90% lifetime risk of developing breast cancer, and 40-65% chance of developing ovarian cancer. Most studies carried out throughout the world indicate that the prevalence of BRCA1 and BRCA2 mutation is lower than originally suggested by early studies on large families with several affected members. Studies performed in Italy have reported different prevalence of BRCA1 and BRCA2 mutations, probably due to different selection criteria and to the variability of the techniques used. In this study, we performed a screening of BRCA1 and BRCA2 in families from northern Italy with familial recurrence of breast cancer or ovarian cancer in which the individual risk of patients of being carriers of BRCA1 and BRCA2 mutation was evaluated using BRCAPRO (CAGene) software. We enrolled 27 patients of 101 unrelated families selected when they fulfilled the inclusion criteria of the American Society of Clinical Oncology (ASCO). Specific risk evaluation, genetic test administration if needed, and discussion of the results were offered during multi-disciplinary genetic, surgical and psychological counselling. Seven probands (35%) found BRCA1/2 sequence variation carriers; no BRCA1 and BRCA2 mutations were detected in the remaining 13 probands. Two (15%) patients had BRCA1 mutations and 5 (25%) patients had BRCA2 mutations. In the latter case, BRCA2 delA 9158fs+29stop mutation in exon 22, never previously described and a new sequence variation (T703N) in exon 11 were identified.

  5. A systematic review of basic life support training targeted to family members of high-risk cardiac patients.

    Science.gov (United States)

    Cartledge, Susie; Bray, Janet E; Leary, Marion; Stub, Dion; Finn, Judith

    2016-08-01

    Targeting basic life support (BLS) training to bystanders who are most likely to witness an out of hospital cardiac arrest (OHCA) is an important public health intervention. We performed a systematic review examining the evidence of the effectiveness of providing BLS training to family members of high-risk cardiac patients. A search of Ovid MEDLINE, CINAL, EMBASE, Informit, Cochrane Library, Web of Science, Scopus, ERIC and ProQuest Dissertations and Theses Global was conducted. We included all studies training adult family members of high-risk cardiac patients regardless of methods used for cardiopulmonary resuscitation (CPR) or BLS training. Two reviewers independently extracted data and evaluated the quality of evidence using GRADE (Grades of Recommendation, Assessment, Development and Evaluation). We included 26 of the 1172 studies identified. The majority of studies were non-randomised controlled trials (n=18), of very low to moderate quality. Currently, there is insufficient evidence to indicate a benefit of this intervention for patients; largely because of low numbers of OHCA events and high loss to follow-up. However, the majority of trained individuals were able to competently perform BLS skills, reported a willingness to use these skills and experienced lower anxiety. Whilst there is no current evidence for improvement in patient outcomes from targeted BLS training for family members, this group are willing and capable to learn these skills. Future research may need to examine longer periods of follow-up using alternate methods (e.g. cardiac arrest registries), and examine the effectiveness of training in the modern era. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

  6. Treatment strategies in patients with AML or high-risk myelodysplastic syndrome relapsed after Allo-SCT.

    Science.gov (United States)

    Sauer, T; Silling, G; Groth, C; Rosenow, F; Krug, U; Görlich, D; Evers, G; Albring, J; Besoke, R; Mesters, R M; Müller-Tidow, C; Kessler, T; Büchner, T; Berdel, W E; Stelljes, M

    2015-04-01

    Non-relapse mortality after Allo-SCT has significantly decreased over the last years. Nevertheless, relapse remains a major cause for post SCT mortality in patients with AML and high-risk myelodysplastic syndrome (MDS). In this retrospective single-center analysis, we have analyzed the treatment outcomes of 108 patients with AML or MDS, who relapsed after Allo-SCT. Seventy of these patients (65%) were treated with salvage therapies containing chemotherapy alone, allogeneic cell-based treatment or the combination of both. Thirty-eight patients (35%) received palliative treatment. Median OS after diagnosis of relapse was 130 days. Compared with patients who received chemotherapy alone, response to salvage therapy was significantly improved in patients treated with a combination of chemo- and allogeneic cell-based therapy (CR rate 57% vs 13%, P=0.002). Among risk factors concerning pretreatment characteristics, disease status before first Allo-SCT, and details of transplantation, only the time interval from Allo-SCT to relapse was an independent predictor of response to salvage therapy and OS. These data confirmed that time to relapse after transplantation is an important prognostic factor. Up to now, only patients eligible for treatment regimens containing allogeneic cell-based interventions achieved relevant response rates.

  7. Stents in patients with esophageal cancer before chemoradiotherapy: high risk of complications and no impact on the nutritional status.

    Science.gov (United States)

    Mão-de-Ferro, S; Serrano, M; Ferreira, S; Rosa, I; Lage, P; Alexandre, D P; Freire, J; Mirones, L; Casaca, R; Bettencourt, A; Pereira, A D

    2016-03-01

    Preoperative chemoradiotherapy is the standard of care for locally advanced esophageal cancer, causing persistent deterioration in the nutritional status. We performed a prospective study to evaluate the safety and efficacy of esophageal double-covered self-expandable metal stents in patients with esophageal cancer before chemoradiotherapy. The nutritional status and dysphagia were prospectively recorded. Eleven patients were included: eight were moderate and three were severely malnourished. After stent placement, dysphagia improved in all patients. With regard to complications, one patient developed an esophageal perforation that required urgent esophagectomy. Four patients presented stent migration. Three of these patients required enteral nutrition and none was submitted to surgery because of poor nutritional status. Of the other six patients, only four were operated upon. Stent placement presented a high complication rate and did not prevent weight loss or malnutrition. Other alternatives, including naso-gastric tube placement or endoscopic percutaneous gastrostomy or jejunostomy, should be considered.

  8. Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy (CHOCOLATE trial): Study protocol for a randomized controlled trial

    NARCIS (Netherlands)

    Kortram, Kirsten; van Ramshorst, Bert; Bollen, Thomas L.; Besselink, Marc G. H.; Gouma, Dirk J.; Karsten, Tom; Kruyt, Philip M.; Nieuwenhuijzen, Grard A. P.; Kelder, Johannes C.; Tromp, Ellen; Boerma, Djamila

    2012-01-01

    Background: Laparoscopic cholecystectomy in acute calculous cholecystitis in high risk patients can lead to significant morbidity and mortality. Percutaneous cholecystostomy may be an alternative treatment option but the current literature does not provide the surgical community with evidence based

  9. [Sudden cardiac death in familial hypertrophic cardiomyopathy. Identification of high-risk patients].

    Science.gov (United States)

    Pellnitz, C; Geier, C; Perrot, A; Dietz, R; Osterziel, K J; Haverkamp, W

    2005-05-06

    Hypertrophic cardiomyopathy (HCM) is a relatively frequent, genetically determined primary cardiomyopathy, characterized by most often asymmetric hypertrophy of the ventricular septum with or without systolic obstruction of the left ventricular outflow tract. HCM is a genetically heterogeneous disease, with 12 different disease-causing genes beeing indentified to date. Histologically the disease is characterized by hypertophy and disarray of myofibrils as well as by an increase in myocardial fibrosis. Clinically, these changes may lead to palpitations, dyspnoe on exertion, and/or angina pectoris. However, they also lead to an increased propensity to the development of severe ventricular tachyarrhythmias and sudden cardiac death. The incidence of sudden death is significantly increased in HCM, particularly in affected young subjects. Risk stratification in HCM should include a complete clinical-cardiological evaluation that should also consider new diagnostic features, e. g. MR imaging. Major risk factors for sudden cardiac death include a survived cardiac arrest (ventricular fibrillation), non-sustained and sustained ventricular tachycardia, a history of premature familial sudden death, unexplained syncope, an abnormal blood pressure response on exercise, and left ventricular thickness greater than or equal to 3 cm. Ideally, risk stratification should also include genetic testing, since some gene mutations seem to be associated with a higher risk for sudden cardiac death than others. However, genetic testing in HCM in not yet available on a routine basis. The implantation of a cardioverter/defibrillator is first-line therapy in patients with documented ventricular tachycardia/fibrillation or patients who have survived sudden cardiac death. These devices also play an important role in the primary prevention of sudden cardiac death in HCM. Algorithms and scores are available to estimate the risk of sudden death, however, the decision to implant a cardioverter

  10. Stratified premedication strategy for the prevention of contrast media hypersensitivity in high-risk patients.

    Science.gov (United States)

    Lee, Suh-Young; Yang, Min Suk; Choi, Young-Hoon; Park, Chang Min; Park, Heung-Woo; Cho, Sang Heon; Kang, Hye-Ryun

    2017-03-01

    Although the severity of hypersensitivity reactions to iodinated contrast media varies, it is well correlated with the severity of recurrent reactions; however, prophylaxis protocols are not severity-stratified. To assess the outcomes of tailored prophylaxis according to the severity of hypersensitivity reactions to iodinated contrast media. Our premedication protocols were stratified based on the severity of previous reactions: (1) 4 mg of chlorpheniramine for mild reactions, (2) adding 40 mg of methylprednisolone for moderate reactions, and (3) adding multiple doses of 40 mg of methylprednisolone for severe index reactions. Cases of reexposure in patients with a history of hypersensitivity reactions were routinely monitored and mandatorily recorded. Among a total of 850 patients who underwent enhanced computed tomography after severity-tailored prophylaxis, breakthrough reactions occurred in 17.1%, but most breakthrough reactions (89.0%) were mild and did not require medical treatment. Additional corticosteroid use did not reduce the breakthrough reaction rate in cases with a mild index reaction (16.8% vs 17.2%, P = .70). However, underpremedication with a single dose of corticosteroid revealed significantly higher rates of breakthrough reaction than did double doses of corticosteroid in cases with a severe index reaction (55.6% vs 17.4%, P = .02). Changing the iodinated contrast media resulted in an additional reduction of the breakthrough reaction rate overall (14.9% vs 32.1%, P = .001). In a total severity-based stratified prophylaxis regimens and changing iodinated contrast media can be considered in patients with a history of previous hypersensitivity reaction to iodinated contrast media to reduce the risk of breakthrough reactions. Copyright © 2016 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

  11. Transversus abdominis plane block for an emergency laparotomy in a high-risk, elderly patient

    Directory of Open Access Journals (Sweden)

    Surekha S Patil

    2010-01-01

    Full Text Available A 72-year-old male patient with gall bladder perforation and small intestinal obstruction from impacted gall stone was posted for emergency laparotomy. He had congestive heart failure, severe hypertension at admission and history of multiple other coexisting diseases. On admission, he developed pulmonary oedema from systolic hypertension which was controlled by ventilatory support, nitroglycerine and furosemide. Preoperative international normalized ratio was 2.34 and left ventricular ejection fraction was only 20%. Because of risk of exaggerated fall in blood pressure during induction of anaesthesia (general or neuraxial, a transversus abdominis plane block via combined Petit triangle and subcostal technique was administered and supplemented with Propofol sedation.

  12. Iodinated contrast media and patients with high-risk kidneys. Aiming at rational prevention

    International Nuclear Information System (INIS)

    Fontaine, B.; Frouge, C.; Gagey, N.

    1994-01-01

    Acute renal failure induced by iodinated contrast media (CM) accounts for about 10% of all hospital cases of renal failure, especially in azotemic patients. The specific anatomy and physiology of the inner medulla renalis render it particularly sensitive to even a moderate reduction in blood supply. Renal function will be estimated by measuring serum creatinine levels, before and within 72 hours after administration of the iodinated contrast medium. Hypovolaemia, diabetes mellitus-induced microangiopathy, nephrotoxic drugs and especially dehydratation may provoke renal accidents. Proper hydration, choosing a low osmolality medium and adequately spacing exposures to CM are elementary measures to be adopted to prevent renal failure. (authors)

  13. Effects of extended-release niacin with laropiprant in high-risk patients

    DEFF Research Database (Denmark)

    Landray, Martin J; Haynes, Richard; Hopewell, Jemma C

    2014-01-01

    BACKGROUND: Patients with evidence of vascular disease are at increased risk for subsequent vascular events despite effective use of statins to lower the low-density lipoprotein (LDL) cholesterol level. Niacin lowers the LDL cholesterol level and raises the high-density lipoprotein (HDL) choleste......-release niacin-laropiprant to statin-based LDL cholesterol-lowering therapy did not significantly reduce the risk of major vascular events but did increase the risk of serious adverse events. (Funded by Merck and others; HPS2-THRIVE ClinicalTrials.gov number, NCT00461630.)....

  14. High-Risk Coronary Plaques Complicated with Acute Coronary Syndrome in Young Patients

    Directory of Open Access Journals (Sweden)

    Opincariu Diana

    2017-06-01

    Full Text Available Coronary computed tomography angiography (CCTA has evolved notably over the last decade, gaining an increased amount of temporo-spatial resolution in combination with decreased radiation exposure. The importance of CCTA is emerging especially in vulnerable and young patients who might not have developed a viable collateral vascular network to sustain the circulation to an infarction area during a major adverse coronary event. There are a few well-known markers by which a vulnerable plaque can be assessed and that can predict the subsequent events of sudden myocardial ischemia, such as an increased positive remodeling index (cut-off >1.4, low-attenuation plaque (cut-off 0.7, and napkin-ring sign (NRS. This manuscript presents a series of 3 clinical cases of young patients experiencing symptoms and signs of myocardial ischemia who underwent CCTA in order to assess the composition and functional characteristics of atherosclerotic plaques and their repercussion in developing an acute coronary syndrome.

  15. High Failure Rate of Modular Exchange With a Specific Design of a Constrained Liner in High-Risk Patients Undergoing Revision Total Hip Arthroplasty.

    Science.gov (United States)

    Chalmers, Brian P; Arsoy, Diren; Sierra, Rafael J; Lewallen, David G; Trousdale, Robert T

    2016-09-01

    Addressing recurrent instability in patients with poor bone stock and inadequate abductor tensioning remains a challenge in revision total hip arthroplasty. One treatment method is implantation of a constrained liner. The purpose of this study was to determine clinical outcomes, redislocation rate, and revisions of a focally constrained liner in a high-risk patient cohort. Fifty-eight hips between 2008 and 2011 underwent implantation of a focally constrained liner. Nineteen were placed concurrent with acetabular component revision and 39 were placed into a well-fixed acetabular shell. Mean age was 69 years and mean number of previous ipsilateral hip surgeries was 4.2. At mean follow-up of 3.5 years, we analyzed clinical outcomes, redislocation, and revisions. Mean Harris Hip Scores was 74. Fourteen hips (24%) were revised and 3 hips (5%) required reoperation at final follow-up. Eleven hips (19%) redislocated at a mean time to dislocation of 12.2 months; 31% (11 of 36 patients) that underwent modular exchange specifically for instability redislocated. Risk factors for redislocation included number of previous surgeries (P = .013), implantation of a 28 mm femoral head (hazards ratio 12.8), revision indication of instability (P = .04), and modular exchange with constrained liner implantation without acetabular shell revision (P = .01). Implantation of a focally constrained liner in revision total hip arthroplasty for recurrent instability has a high failure rate, especially with a modular exchange. Although concurrent acetabular revision had a lower redislocation rate, the decision to revise a well-fixed cup should be weighed with potential complications associated with cup revision. Copyright © 2016 Elsevier Inc. All rights reserved.

  16. Bone marrow dendritic cells are reduced in patients with high-risk myelodysplastic syndromes.

    Science.gov (United States)

    Saft, Leonie; Björklund, Elisabet; Berg, Elisabeth; Hellström-Lindberg, Eva; Porwit, Anna

    2013-03-01

    Dendritic cells (DC) are antigen-presenting cells that play a pivotal role in coordinating functions of the immune system. Previous studies suggest that bone marrow (BM) failure in myelodysplastic syndromes (MDS) may be in part immune-mediated, and that the high propensity for relapse may reflect decreased immune surveillance. This study aimed to assess the frequency of DC in BM samples from well-annotated untreated MDS patients by using 4-colour flow cytometry. DC levels were markedly reduced in all subtypes of MDS. The clinical impact of this finding on therapy response and relapse after, e.g. allogeneic stem cell transplantation warrants further investigation. Copyright © 2012 Elsevier Ltd. All rights reserved.

  17. Procalcitonin increase in early identification of critically ill patients at high risk of mortality

    DEFF Research Database (Denmark)

    Jensen, Jens Ulrik; Heslet, L; Jensen, TH

    2006-01-01

    procalcitonin measurements were carried out during the study period as well as measurements of white blood cell count and C-reactive protein and registration of comorbidity. The primary end point was all-cause mortality in a 90-day follow-up period. Secondary end points were mortality during the stay...... in the intensive care unit and in a 30-day follow-up period. A total of 3,642 procalcitonin measurements were evaluated in 472 critically ill patients. We found that a high maximum procalcitonin level and a procalcitonin increase for 1 day were independent predictors of 90-day all-cause mortality...... for 1 day are early independent predictors of all-cause mortality in a 90-day follow-up period after intensive care unit admission. Mortality risk increases for every day that procalcitonin increases. Levels or increases of C-reactive protein and white blood cell count do not seem to predict mortality...

  18. Retinoic acid postconsolidation therapy for high-risk neuroblastoma patients treated with autologous haematopoietic stem cell transplantation.

    Science.gov (United States)

    Peinemann, Frank; van Dalen, Elvira C; Enk, Heike; Berthold, Frank

    2017-08-25

    Neuroblastoma is a rare malignant disease and mainly affects infants and very young children. The tumours mainly develop in the adrenal medullary tissue, with an abdominal mass as the most common presentation. About 50% of patients have metastatic disease at diagnosis. The high-risk group is characterised by metastasis and other features that increase the risk of an adverse outcome. High-risk patients have a five-year event-free survival of less than 50%. Retinoic acid has been shown to inhibit growth of human neuroblastoma cells and has been considered as a potential candidate for improving the outcome of patients with high-risk neuroblastoma. This review is an update of a previously published Cochrane Review. To evaluate the efficacy and safety of additional retinoic acid as part of a postconsolidation therapy after high-dose chemotherapy (HDCT) followed by autologous haematopoietic stem cell transplantation (HSCT), compared to placebo retinoic acid or to no additional retinoic acid in people with high-risk neuroblastoma (as defined by the International Neuroblastoma Risk Group (INRG) classification system). We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (2016, Issue 11), MEDLINE in PubMed (1946 to 24 November 2016), and Embase in Ovid (1947 to 24 November 2016). Further searches included trial registries (on 22 December 2016), conference proceedings (on 23 March 2017) and reference lists of recent reviews and relevant studies. We did not apply limits by publication year or languages. Randomised controlled trials (RCTs) evaluating additional retinoic acid after HDCT followed by HSCT for people with high-risk neuroblastoma compared to placebo retinoic acid or to no additional retinoic acid. Primary outcomes were overall survival and treatment-related mortality. Secondary outcomes were progression-free survival, event-free survival, early toxicity, late toxicity, and health-related quality of life. We used standard

  19. Predictors and prognostic impact of silent coronary artery disease in asymptomatic high-risk patients with diabetes mellitus.

    Science.gov (United States)

    Zellweger, Michael J; Haaf, Philip; Maraun, Michael; Osterhues, Hans H; Keller, Ulrich; Müller-Brand, Jan; Jeger, Raban; Pfister, Otmar; Brinkert, Miriam; Burkard, Thilo; Pfisterer, Matthias

    2017-10-01

    Evaluation of predictors of silent coronary artery disease (SCAD) in high-risk asymptomatic diabetic patients and to evaluate their two-year outcome. Four hundred diabetic patients without prior CAD but at high CAD risk underwent myocardial perfusion scintigraphy (MPS) in this prospective multicentre outcome trial. MPS were abnormal in 22% of patients. Male sex (OR 2.223, 1.152-4.290; p=0.017), diabetes duration (OR 1.049,1.015-1.085; p=0·005), peripheral artery disease (OR 2.134, 1·150-3.961; p=0.016), smoking (OR 2.064, 1.109-3.839; p=0·022), systolic blood pressure (OR 1.014, 1.00-1.03, p=0·056), brain natriuretic peptide (OR 1.002, 1.001-1.004, p=0·005) independently predicted an abnormal MPS: if 3 predictors were present, 3.2% and 47% patients had an abnormal MPS, respectively (p10%, respectively (each pSCAD. In presence of >3 predictors, almost 50% of patients had an abnormal MPS. They may benefit from screening by MPS since the extent of the MPS abnormality discriminated clearly between a favourable compared to a bad 2-year outcome. However, even highest risk patients without objective evidence of CAD had a benign prognosis without need for specific evaluation or therapy. ISRCTN87953632. Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.

  20. Managing high-risk patients: the Mass General care management programme

    Directory of Open Access Journals (Sweden)

    Dennis L Kodner

    2015-09-01

    Full Text Available The Massachusetts General Care Management Program (Mass General CMP or CMP was designed as a federally supported demonstration to test the impact of intensive, practice-based care management on high-cost Medicare fee-for-service (FFS beneficiaries—primarily older persons—with multiple hospitalisations and multiple chronic conditions. The Massachusetts General Care Management Program operated over a 6-year period in two phases (3 years each. It started during the first phase at Massachusetts General Hospital, a major academic medical centre in Boston, Massachusetts in collaboration with Massachusetts General Physicians Organisation. During the second phase, the programme expanded to two more affiliated sites in and around the Boston area, including a community hospital, as well as incorporated several modifications primarily focused on the management of transitions to post-acute care in skilled nursing facilities. At the close of the demonstration in July 2012, Mass General Massachusetts General Care Management Program became a component of a new Pioneer accountable care organisation (ACO. The Massachusetts General Care Management Program is focused on individuals meeting defined eligibility criteria who are offered care that is integrated by a case manager embedded in a primary care practice. The demonstration project showed substantial cost savings compared to fee-for-service patients served in the traditional Medicare system but no impact on hospital readmissions. The Massachusetts General Care Management Program does not rest upon a “whole systems” approach to integrated care. It is an excellent example of how an innovative care co-ordination programme can be implemented in an existing health-care organisation without making fundamental changes in its underlying structure or the way in which direct patient care services are paid for. The accountable care organisation version of the Massachusetts General Care Management Program

  1. Haptoglobin phenotype is not a predictor of recurrence free survival in high-risk primary breast cancer patients

    Directory of Open Access Journals (Sweden)

    Harris Nathan

    2008-12-01

    Full Text Available Abstract Background Better breast cancer prognostication may improve selection of patients for adjuvant therapy. We conducted a retrospective follow-up study in which we investigated sera of high-risk primary breast cancer patients, to search for proteins predictive of recurrence free survival. Methods Two sample sets of high-risk primary breast cancer patients participating in a randomised national trial investigating the effectiveness of high-dose chemotherapy were analysed. Sera in set I (n = 63 were analysed by surface enhanced laser desorption ionisation time-of-flight mass spectrometry (SELDI-TOF MS for biomarker finding. Initial results were validated by analysis of sample set II (n = 371, using one-dimensional gel-electrophoresis. Results In sample set I, the expression of a peak at mass-to-charge ratio 9198 (relative intensity ≤ 20 or > 20, identified as haptoglobin (Hp alpha-1 chain, was strongly associated with recurrence free survival (global Log-rank test; p = 0.0014. Haptoglobin is present in three distinct phenotypes (Hp 1-1, Hp 2-1, and Hp 2-2, of which only individuals with phenotype Hp 1-1 or Hp 2-1 express the haptoglobin alpha-1 chain. As the expression of the haptoglobin alpha-1 chain, determined by SELDI-TOF MS, corresponds to the phenotype, initial results were validated by haptoglobin phenotyping of the independent sample set II by native one-dimensional gel-electrophoresis. With the Hp 1-1 phenotype as the reference category, the univariate hazard ratio for recurrence was 0.87 (95% CI: 0.56 – 1.34, p = 0.5221 and 1.03 (95% CI: 0.65 – 1.64, p = 0.8966 for the Hp 2-1 and Hp 2-2 phenotypes, respectively, in sample set II. Conclusion In contrast to our initial results, the haptoglobin phenotype was not identified as a predictor of recurrence free survival in high-risk primary breast cancer in our validation set. Our initial observation in the discovery set was probably the result of a type I error (i.e. false positive

  2. Prevalence of Mycoplasma genitalium and other sexually transmitted infections causing urethritis among high-risk heterosexual male patients in Estonia.

    Science.gov (United States)

    Tjagur, Stanislav; Mändar, Reet; Punab, Margus

    2018-02-01

    We aimed to evaluate the prevalence of sexually transmitted infections (STI, including Mycoplasma genitalium, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis) among high-risk heterosexual male patients and to clarify their potency to cause complaints and inflammation. The study group included 825 men (18.0-49.5 y) consulting andrologist at Tartu University Hospital (Estonia) due to subjectively perceived risk of STI. Patients completed STI risk behaviour questionnaire. First voided urine was analysed for white blood cells and STIs. In total 193 (23.4%) patients were positive for one or multiple STI. The prevalence of C. trachomatis, M. genitalium, N. gonorrhoeae, T. vaginalis and combined STI was 14.3%, 4.4%, 2.7%, 0.7% and 1.3%, respectively. N. gonorrhoeae had the highest potency to generate inflammatory reaction in first voided urine (100%) followed by C. trachomatis (72.0%), M. genitalium (63.9%) and T. vaginalis (33.3%). N. gonorrhoeae and T. vaginalis caused the highest mean number of complaints while half of T. vaginalis cases and nearly fifth of M. genitalium and C. trachomatis cases were asymptomatic. C. trachomatis has the highest prevalence among Estonian high-risk men but M. genitalium holds an important second place. Prevalence of combined STIs is low. N. gonorrhoeae has the highest potency to generate urethral inflammation followed by C. trachomatis and M. genitalium. The highest number of complaints is also associated with N. gonorrhoeae while half of T. vaginalis cases and nearly a fifth of M. genitalium and C. trachomatis cases are asymptomatic.

  3. Intravenous urography for diagnosing synchronous upper-tract tumours in patients with newly diagnosed bladder carcinoma can be restricted to patients with high-risk superficial disease.

    Science.gov (United States)

    Bajaj, A; Sokhi, H; Rajesh, A

    2007-09-01

    To determine the incidence of synchronous upper-tract transitional cell carcinomas (TCCs) in patients with newly diagnosed bladder cancer and to evaluate the need for performing intravenous urography (IVU) in these patients. Imaging data on 330 consecutive patients who were diagnosed with TCC of the bladder over a 2-year period were retrospectively reviewed. Only 233 out of the 330 patients had IVU at presentation. The IVU results were recorded as normal, abnormal, or equivocal. The follow-up radiological or urological investigations in the patients who had an equivocal IVU were reviewed. Clinical follow-up data on all 330 patients were also recorded. Only 233 out of the 330 patients had an IVU at presentation. Four of these (1.7%) patients were found to have synchronous upper-tract tumours. Twenty-two patients were reported to have equivocal findings on IVU. Nine of these patients had follow-up imaging [computed tomography (CT)=5, IVU=4], which were reported as normal. Retrograde urography was performed in two patients, which was normal. The remaining 11 patients did not have any evaluation of the upper tracts despite the equivocal findings on IVU, but routine clinical follow-up did not reveal any significant disease. Three patients with high-risk superficial disease developed upper-tract tumours that were detected on follow-up. IVU for diagnosing synchronous upper-tract tumours in patients with newly diagnosed bladder carcinoma can be restricted to patients with high-risk superficial disease.

  4. Vacuum-assisted closure downgrades reconstructive demands in high-risk patients with severe lower extremity injuries.

    Science.gov (United States)

    Kakagia, D; Karadimas, E; Drosos, G; Ververidis, A; Kazakos, D; Lazarides, M; Verettas, D

    2009-01-01

    Primary soft tissue reconstruction in complex leg injuries is mandatory in order to protect exposed tissues; however, it may be precluded by the patient's clinical status or by local wound conditions. This retrospective study aims to evaluate the use of negative pressure as an adjunct to delayed soft tissue reconstruction in patients with complex lower limb trauma. Forty-two patients with 49 complex lower limb injuries were treated with Vacuum assisted closure (VAC) 48 hours after bone fixation, vascular repair and surgical debridement. Wound swab cultures were obtained before and after every VAC application. Duration of therapy, wound flora, final reconstructive technique required, outcome and follow-up period were retrieved from medical records. Twenty-four male and eighteen female patients were recruited, with a mean age of 47 years. All were treated with VAC therapy for 15-42 days. Reconstruction was delayed due to the patients' critical condition, advanced age, medical co-morbidities, heavily exuding wounds and questionable viability of soft tissues. Patients were followed up for 90-895 days. Two wounds healed spontaneously, 6 were managed with delayed direct suture, 31 with split thickness skin grafts and 9 required local cutaneous, fasciocutaneous or muscular flaps. One patient died due to fat embolism. Wound bacterial flora progressively decreased in all but one patient. Scar formation was aesthetically acceptable by the patients while function depended on the initial injury. Negative pressure is a safe and effective adjunct to delayed soft tissue reconstruction in high-risk patients with severe lower extremity injuries, minimizing reconstructive requirements and therefore postoperative morbidity.

  5. The alcohol patient and surgery

    DEFF Research Database (Denmark)

    Tønnesen, H

    1999-01-01

    Alcohol abusers have a threefold increased risk of post-operative morbidity after surgery. The most frequent complications are infections, cardiopulmonary insufficiency, and bleeding episodes. Pathogenesis is suppressed immune capacity, subclinical cardiac dysfunction, and haemostatic imbalance...

  6. Noncardiac Surgery in Patients With Aortic Stenosis

    DEFF Research Database (Denmark)

    Andersson, Charlotte; Jørgensen, Mads Emil; Martinsson, Andreas

    2014-01-01

    (MACE) and all-cause mortality were investigated in a contemporary Danish cohort. HYPOTHESIS: AS is not an independent risk factor for adverse outcomes in noncardiac surgery. METHODS: All patients with and without diagnosed AS who underwent noncardiac surgery in 2005 to 2011 were identified through......BACKGROUND: Past research has identified aortic stenosis (AS) as a major risk factor for adverse outcomes in noncardiac surgery; however, more contemporary studies have questioned the grave prognosis. To further our understanding of this, the risks of a 30-day major adverse cardiovascular event...... nationwide administrative registers. AS patients (n = 2823; mean age, 75.5 years, 53% female) were matched with patients without AS (n = 2823) on propensity score for AS and surgery type. RESULTS: In elective surgery, MACE (ie, nonfatal myocardial infarction, ischemic stroke, or cardiovascular death...

  7. EEG indices in patients with high risk of ischemic stroke as predictors of initial disturbed cerebral circulation

    Directory of Open Access Journals (Sweden)

    N. A. Isaeva

    2014-01-01

    Full Text Available Abnormal changes were detected in EEG in patients with high risk of ischemic stroke (higher level than in the population. These changes show the disturbances in forming mechanisms of functional condition of cerebrum during the calm wakeful period. Changes were represented by: the registration of EEG IV- type (the E.A. Zhirmunsky type which was characterized by disorganization of alpha activity and of slow waves; the instability of pattern during the record of background activity; the paroxysmal activity in form of flashes of the bilateral synchronized waves; the strengthening of low-frequency and high-amplitude β-activity. Revealed changes in EEG show the presence of initial disturbed cerebral circulation and can be recommended as predictors of these disturbances.

  8. Mid-term results of zone 0 thoracic endovascular aneurysm repair after ascending aorta wrapping and supra-aortic debranching in high-risk patients.

    Science.gov (United States)

    Pecoraro, Felice; Lachat, Mario; Hofmann, Michael; Cayne, Neal S; Chaykovska, Lyubov; Rancic, Zoran; Puippe, Gilbert; Pfammatter, Thomas; Mangialardi, Nicola; Veith, Frank J; Bettex, Dominique; Maisano, Francesco; Neff, Thomas A

    2017-06-01

    Surgical repair of aneurysmal disease involving the ascending aorta, aortic arch and eventually the descending aorta is generally associated with significant morbidity and mortality. A less invasive approach with the ascending wrapping technique (WT), supra-aortic vessel debranching (SADB) and thoracic endovascular aneurysm repair (TEVAR) in zone 0 was developed to reduce the associated risk in these patients. During a 10-year period, consecutive patients treated by the ascending WT, SADB and TEVAR in zone 0 were included. All patients were considered at high risk for conventional surgery. Measured outcomes included perioperative deaths and morbidity, maximal aortic transverse diameter (TD) and its postoperative evolution, endoleak, survival, freedom from cardiovascular reinterventions, SADB freedom from occlusion and aortic valve function during follow-up. Median follow-up was 37.4 [mean = 34; range, 0-65; standard deviation (SD) = 20] months. Twenty-six cases were included with a mean age of 71.88 ( r  = 56-87; SD = 8) years. A mean of 2.9 supra-aortic vessels (75) per patient was debranched from the ascending aorta. The mean time interval from WT/SADB and TEVAR was 29 ( r  = 0-204; SD = 48) days. TEVAR was associated with chimney and/or periscope grafts in 6 (23%) patients, and extra-anatomical supra-aortic bypasses were performed in 6 (23%) patients. Perioperative mortality was 7.7% (2/26). Neurological events were registered in 3 (11.5%) cases, and a reintervention was required in 3 (11.5%) cases. After the WT, the ascending diameter remained stable during the follow-up period in all cases. At mean follow-up, significant shrinkage of the arch/descending aorta diameter was observed. A type I/III endoleak occurred in 3 cases. At 5 years, the rates of survival, freedom from cardiovascular reinterventions and SADB freedom from occlusion were 71.7, 82.3 and 96%, respectively. The use of the ascending WT, SADB and TEVAR in selected patients

  9. PATIENT SATISFACTION WITH TRICHIASIS SURGERY IN JIGAWA ...

    African Journals Online (AJOL)

    FOBUR

    Purpose: Following the implementation of the SAFE (Surgery, Antibiotics, Facial Cleanliness,. Environmental improvements) strategy for the ... and quality of lid surgeries in endemic areas, to deal with the backlog of the trichiasis cases needing ... Materials and Methods: This was a retrospective cohort study of patients.

  10. CEUS: An essential component in a multimodality approach to small nodules in patients at high-risk for hepatocellular carcinoma

    International Nuclear Information System (INIS)

    Jang, Hyun-Jung; Kim, Tae Kyoung; Burns, Peter N; Wilson, Stephanie R

    2015-01-01

    Highlights: • CEUS resolves hypervascular pseudolesions, frequent on CT and MR, from vascular shunts. • US has the advantage of showing a baseline nodule for characterization. • CEUS shows excellent sensitivity to contrast agents, providing superior arterial phase sensitivity. • Real-time CEUS performance shows optimally perfusion patterns of benign tumor nodules. • CEUS performed at surveillance detection of nodules is efficient and effective. - Abstract: Contrast-enhanced ultrasound (CEUS) plays an essential role in the evaluation of small nodules in livers at high-risk for hepatocellular carcinoma (HCC) and offers unique advantages over CT/MRI. These include the sensitive depiction of arterial hypervascularity of HCC, better demonstration of rapid washout for non-HCC malignancy as well as of very late washout of HCC. Visualization of early vascular filling patterns for benign hypervascular lesions is of indisputable value. A frequently uncounted benefit of CEUS includes the value of its performance following nodule detection at ultrasound surveillance, including one-stop exclusion of typical benignancy, preclusion of arterial pseudolesions shown on CT/MR, and the avoidance of miscorrelation of a nodule on surveillance and subsequent diagnostic imaging. Therefore, CEUS can effectively be used in the diagnostic algorithm for new liver nodules detected during HCC surveillance. Despite the fact that CEUS is actively used as a major diagnostic test for HCC in Asia, Europe, and Canada with increasing demands in clinical practice, CEUS is not included in the diagnostic tests for HCC in some major practice guidelines. In this manuscript, we focus on small nodules in patients at high-risk for HCC, and review some of the unique advantages of CEUS that contribute to lesion characterization and subsequent patient management, showing why CEUS should be an essential component of the diagnostic algorithm for HCC

  11. Outcomes and Cost Analysis in High-Risk Patients Undergoing Simultaneous Free Flap Breast Reconstruction and Gynecologic Procedures.

    Science.gov (United States)

    Del Corral, Gabriel A; Wes, Ari M; Fischer, John P; Serletti, Joseph M; Wu, Liza C

    2015-11-01

    statistically significant difference in the average total cost when comparing the group of patients receiving prophylactic mastectomy/FFR/total abdominal hysterectomy and/or BSO versus the patients who did not have combined gynecologic procedures at the time of reconstruction ($22,994.52 vs $21,029.23, P = 0.0004). For the high-risk breast cancer patient, a combined mastectomy, free flap reconstruction, and gynecologic procedure represents an attractive and safe option.

  12. Coronary calcium score as a predictor for coronary artery disease and cardiac events in Japanese high-risk patients

    International Nuclear Information System (INIS)

    Yamamoto, Hideya; Ohashi, Norihiko; Ishibashi, Ken; Utsunomiya, Hiroto; Kunita, Eiji; Oka, Toshiharu; Kihara, Yasuki; Horiguchi, Jun

    2011-01-01

    Although the coronary artery calcium (CAC) score as measured with computed tomography (CT) is associated with cardiovascular mortality and morbidity in Western countries, little is known in Asian populations. Three hundred and seventeen Japanese patients (205 men and 112 women) were followed in the study and they underwent both coronary angiography and CT for CAC measurements. The frequencies of angiographic coronary artery disease (CAD) were 5%, 36%, 76%, 80%, and 94% (P 1,000 (n=49), respectively. In the average of 6.0 (range, 1-10) years follow-up period, 34 patients died including 13 from reasons of cardiac disease. In a Cox proportional hazard model after adjustment for age and sex, traditional coronary risk factors, previous myocardial infarction, and the need for revascularization, the hazard ratio for cardiac mortality in patients with a CAC score >1,000 was 2.98 (95% confidence interval: 1.15-9.40) compared with those with a CAC score=0-100. The CAC score has a predictive value for angiographical CAD and long-term mortality from cardiac disease in Japanese high-risk patients who undergo coronary angiography. (author)

  13. Fluvoxamine may prevent onset of psychosis: a case report of a patient at ultra-high risk of psychotic disorder

    Directory of Open Access Journals (Sweden)

    Kikuchi Shuichi

    2011-09-01

    Full Text Available Abstract Background There is emerging evidence that antidepressants may be effective in preventing patients with non-specific and psychotic-like prodromal symptoms, defined as patients at ultra-high risk (UHR of psychotic disorder, from transitioning to psychosis. However, the mechanism of such an effect is still unknown. Methods We report the case of a 19-year-old Japanese man determined to be at UHR of psychotic disorder in whom fluvoxamine (one of the antidepressants with sigma-1 receptor agonism showed preventive effects on psychotic-like prodromal symptoms. Results Our patient's depressive symptoms were reduced and maintained below remission as a result of treatment with 100 mg/day of fluvoxamine. In addition, it is likely that an additional dose of fluvoxamine (50 mg/day improved his psychotic-like prodromal symptoms directly, independent of its antidepressive effects. Conclusion Fluvoxamine, a sigma-1 receptor agonist, may be effective in preventing patients at UHR of psychotic disorder from onset of psychosis via its neuroprotective/neurotropic actions, independent of its antidepressive effects.

  14. Fluvoxamine may prevent onset of psychosis: a case report of a patient at ultra-high risk of psychotic disorder.

    Science.gov (United States)

    Tadokoro, Shigenori; Kanahara, Nobuhisa; Kikuchi, Shuichi; Hashimoto, Kenji; Masaomi, Iyo

    2011-09-30

    There is emerging evidence that antidepressants may be effective in preventing patients with non-specific and psychotic-like prodromal symptoms, defined as patients at ultra-high risk (UHR) of psychotic disorder, from transitioning to psychosis. However, the mechanism of such an effect is still unknown. We report the case of a 19-year-old Japanese man determined to be at UHR of psychotic disorder in whom fluvoxamine (one of the antidepressants with sigma-1 receptor agonism) showed preventive effects on psychotic-like prodromal symptoms. Our patient's depressive symptoms were reduced and maintained below remission as a result of treatment with 100 mg/day of fluvoxamine. In addition, it is likely that an additional dose of fluvoxamine (50 mg/day) improved his psychotic-like prodromal symptoms directly, independent of its antidepressive effects. Fluvoxamine, a sigma-1 receptor agonist, may be effective in preventing patients at UHR of psychotic disorder from onset of psychosis via its neuroprotective/neurotropic actions, independent of its antidepressive effects.

  15. Resiquimod as an Immunologic Adjuvant for NY-ESO-1 Protein Vaccination in Patients with High Risk Melanoma

    Science.gov (United States)

    Gnjatic, Sacha; Cruz, Crystal M.; Vengco, Isabelita; Hasan, Farah; Spadaccia, Meredith; Darvishian, Farbod; Chiriboga, Luis; Holman, Rose Marie; Escalon, Juliet; Muren, Caroline; Escano, Crystal; Yepes, Ethel; Sharpe, Dunbar; Vasilakos, John P.; Rolnitzsky, Linda; Goldberg, Judith; Mandeli, John; Adams, Sylvia; Jungbluth, Achim; Pan, Linda; Venhaus, Ralph; Ott, Patrick A.; Bhardwaj, Nina

    2015-01-01

    The TLR7/8 agonist, Resiquimod has been used as an immune adjuvant in cancer vaccines. We evaluated the safety and immunogenicity of the cancer testis antigen NY-ESO-1 given in combination with Montanide with or without Resiquimod in high-risk melanoma patients. In Part I of the study, patients received 100ug full length NY-ESO-1 protein emulsified in 1.25mL Montanide (day 1) followed by topical application of 1000mg of 0.2% Resiquimod gel on days 1 and 3 (Cohort 1) versus days 1, 3, and 5 (Cohort 2) of a 21 day cycle. In Part II, patients were randomized to receive 100ug NY-ESO-1 protein plus Montanide (day 1) followed by topical application of placebo gel (Arm-A; N=8) or 1000mg of 0.2% Resiquimod gel (Arm-B; N=12) using the dosing regimen established in Part I. The vaccine regimens were generally well-tolerated. NY-ESO-1-specific humoral responses were induced or boosted in all patients, many of whom had high titer antibodies. In Part II, 16 of 20 patients in both arms had NY-ESO-1-specific CD4+ T-cell responses. CD8+ T-cell responses were only seen in 3 of 12 patients in Arm B. Patients with TLR7 SNP rs179008 had a greater likelihood of developing NY-ESO-1-specific CD8+ responses. In conclusion, NY-ESO-1 protein in combination with Montanide with or without topical Resiquimod is safe and induces both antibody and CD4+ T-cell responses in the majority of patients; the small proportion of CD8+ T-cell responses suggests that the addition of topical Resiquimod to Montanide is not sufficient to induce consistent NY-ESO-1-specific CD8+ T-cell responses. PMID:25633712

  16. Morbidity after thyroid surgery: patient perspective.

    Science.gov (United States)

    Grover, Gagandeep; Sadler, Gregory P; Mihai, Radu

    2013-09-01

    To evaluate patient perception of morbidity after thyroid surgery. Survey of consecutive patients (case series). A standardized questionnaire was mailed to 312 patients who underwent thyroid surgery during a 3-year period (January 2008 to December 2010). Replies were received from 202 (64%) patients (56 male, 166 female; age, 55 ± 16 years) at 6 to 39 months (median, 23 months) after lobectomy (n = 119) or total thyroidectomy (n = 76) for benign (n = 160) or malignant (n = 42) conditions. Subjective voice assessment using a visual analogue scale was normal in 111 patients, deteriorated in 80 patients, and improved in 21 patients. Voice handicap index scores were normal in 126 (62%) patients and increased in 76 (38%) patients to a median of 17 (range, 11-29). Voice-related quality of life was excellent in 107 (53%) patients, fair to good in 66 patients, and poor to fair in 29 patients. Subjective assessment of swallowing was reported as normal in 84 patients, moderately affected in 56 patients (score, 11-15) and severely affected in 62 patients (score, 16-40; median, 23). Calcium supplements prescribed routinely after bilateral surgery were interrupted within 2 to 4 weeks in 56 patients and within 3 to 6 months in 18 patients. None of the respondents had persistent hypoparathyroidism. Appearance of the scar assessed using the Manchester score ranged from 5 to 16 (median, 7). Asked whether they would consider robotic thyroid surgery to avoid a cervical scar, only 38 patients said they were definitely interested. A large proportion of patients report persistent moderate voice and swallowing problems after thyroid surgery. These findings are similar to a recent international multicenter survey of more than 2,000 patients with thyroid cancer. Hypocalcemia and cosmetic outcome raised no significant concerns. Copyright © 2012 The American Laryngological, Rhinological and Otological Society, Inc.

  17. Clinical outcomes in patients treated with radiotherapy after surgery for cervical cancer

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    Yang, Kyung Mi; Park, Won; Huh, Seung Jae; Bae, Duk Soo; Kim, Byoung Gie; Lee, Jeong Won [Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul (Korea, Republic of)

    2017-03-15

    The purpose of this study was to analyze clinical outcomes from cervical cancer and stratify patients into risk groups for prognostic factors for early-stage disease. We retrospectively reviewed patients with stage IB or IIA cervical cancer treated with adjuvant radiotherapy (RT) or concurrent chemoradiotherapy (CCRT) following primary surgery at Samsung Medical Center from 2001 to 2011. Adjuvant RT was added for patients with intermediate-risk factors, and adjuvant CCRT was performed on high-risk patients after surgery. We reviewed 247 patients—149 in the high-risk group and 98 in intermediate-risk group. The median follow-up was 62 months. Loco-regional failure (LRF) alone occurred in 7 patients (2.8%), distant metastasis alone in 37 patients (15.0%) and LRF with DM in 4 patients (1.6%). The 5-year disease-free survival (DFS) and overall survival (OS) rates for both groups were 79.7% and 87.6%, respectively. In the high-risk group, the 5-year DFS and OS probabilities were 72.5% and 81.9%, respectively. Histologic type, pathologic tumor size, and the number of pelvic lymph node (PLN) metastasis were significant prognostic factors for DFS and OS. We suggest a scoring system (0–3) using these prognostic factors to predict poor prognosis in high-risk patients. Using this system, patients with higher scores have higher recurrence and lower survival rates. In the high-risk cervical-cancer group who received primary surgery and adjuvant CCRT, non-squamous type, large tumor size and the number of PLN metastasis were significant prognostic factors, and the number of these factors was associated with survival rates.

  18. A quality control circle process to improve implementation effect of prevention measures for high-risk patients.

    Science.gov (United States)

    Feng, Haixia; Li, Guohong; Xu, Cuirong; Ju, Changping; Suo, Peiheng

    2017-12-01

    The aim of the study was to analyse the influence of prevention measures on pressure injuries for high-risk patients and to establish the most appropriate methods of implementation. Nurses assessed patients using a checklist and factors influencing the prevention of a pressure injury determined by brain storming. A specific series of measures was drawn up and an estimate of risk of pressure injury determined using the Braden Scale, analysis of nursing documents, implementation of prevention measures for pressure sores and awareness of the system both before and after carrying out a quality control circle (QCC) process. The overall scores of implementation of prevention measures ranged from 74.86 ± 14.24 to 87.06 ± 17.04, a result that was statistically significant (P prevention measure scores ranged from 11.48 ± 4.18 to 13.96 ± 3.92. Differences in all of the above results are statistically significant (P prevention measures for patients who are vulnerable to pressure sores and is of practical importance to their prevention and control. © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd.

  19. Toxoplasma gondii Seropositivity and Co-Infection with TORCH Pathogens in High-Risk Patients from Qatar

    Science.gov (United States)

    Abu-Madi, Marawan A.; Behnke, Jerzy M.; Dabritz, Haydee A.

    2010-01-01

    Testing of patients who are deemed to be at high risk for TORCH pathogens, e.g., pregnant women, their fetuses, neonates, and acquired immunodeficiency syndrome (AIDS) patients, is important so that specific treatment can be initiated. This study included 1,857 such patients between 2005 and 2008. Logistic regression was used to evaluate factors associated with Toxoplasma gondii seropositivity. Among 823 women of childbearing age, 35.1% and 5.2% tested positive for T. gondii IgG and IgM, respectively. Three infants ≤ 6 months of age (0.8% of 353) were congenitally infected. Factors associated with T. gondii IgG seropositivity included older age, East Mediterranean or African nationality, positive cytomegalovirus (CMV) and herpes simplex virus (HSV)-1 serostatus, and negative rubella IgG results. The decreasing prevalence of IgM antibodies between 2005 and 2008 suggested that exposure to T. gondii from food or environmental sources declined over this period in Qatar. Population-based studies of newborns would be helpful to accurately estimate incidence of congenital toxoplasmosis. PMID:20348511

  20. Results of high-risk neutropenia therapy of hematology-oncology patients in a university hospital in Uruguay

    Directory of Open Access Journals (Sweden)

    Matilde Boada Burutaran

    2015-02-01

    Full Text Available Background: Febrile neutropenia is an important cause of mortality and morbidity in hematology-oncology patients undergoing chemotherapy. The management of febrile neutropenia is typically algorithm-driven. The aim of this study was to assess the results of a standardized protocol for the treatment of febrile neutropenia. Methods: A retrospective cohort study (2011-2012 was conducted of patients with high-risk neutropenia in a hematology-oncology service. Results: Forty-four episodes of 17 patients with a median age of 48 years (range: 18-78 years were included. The incidence of febrile neutropenia was 61.4%. The presence of febrile neutropenia was associated with both the duration and severity of neutropenia. Microbiological agents were isolated from different sources in 59.3% of the episodes with bacteremia iso- lated from blood being the most prevalent (81.3%. Multiple drug-resistant gram-negative bacilli were isolated in 62.5% of all microbiologically documented infections. Treatment of 63% of the episodes in which the initial treatment was piperacillin/tazobactam needed to be escalated to meropenem. The mortality rate due to febrile neutropenia episodes was 18.5%. Conclusion: The high rate of gram-negative bacilli resistant to piperacillin/tazobactam (frontline antibiotics in our protocol and the early need to escalate to carbapenems raises the question as to whether it is necessary to change the current protocol.

  1. Assessment of independent risk factors of conversion into psychosis in the ultra-high risk state group of patients

    Directory of Open Access Journals (Sweden)

    Marta Gawłowska

    2010-12-01

    Full Text Available Background: The aim of this study was the independent psychosis risk factors assessment in a group of subjects fulfilling the criteria of at risk mental state, under specialist outpatient psychiatric care. Participants: Seventy-one patients – 33 women and 38 men, were involved into this study, aged on average 17.34, all under psychiatric care. The patients were recruited into the study in the sequence of their outpatient clinic admission. The criterion to be included into the study was the diagnosis of ultra-high risk state (UHRS – defined according to the Australian research group principles. Subsequently, the patients were divided into subgroups according to the clinical features of their mental state. Method: The author’s demographic questionnaire was applied in the study. Information regarding the family history of psychosis was obtained from patients and/or their relatives or carers. The patients’ mental state was assessed monthly – according to the presence of psychotic symptoms, change of their incidence and duration, presence of depressive symptoms or aggressive behaviour (measured by a three-level scale. On the basis of the obtained information, we evaluated: 1 conversion into psychosis time – measured from diagnosing of UHRS to the development of full-symptom psychosis, 2 therapeutic methods used (psychotherapy, pharmacotherapy or both, 3 use of psychoactive substances after being diagnosed with UHRS, 4 presence of serious life stressors (the patients’ subjective estimation – during the six-month period preceding the conversion into psychosis. Results: 1 In the UHRS group of patients, staying under professional outpatient psychiatric care, the use of marijuana was an independent risk factor of conversion into psychosis. 2 In the investigated group of patients with at risk mental state we did not find any correlation between modulating factors (including: therapeutic methods used, depressive symptoms, aggression or

  2. Patients' preferences for information in bariatric surgery.

    Science.gov (United States)

    Coblijn, Usha K; Lagarde, Sjoerd M; de Raaff, Christel A L; van Wagensveld, Bart A; Smets, Ellen M A

    2018-01-31

    The decision to undergo bariatric surgery is multifactorial and made both by patient and doctor. Information is of the utmost importance for this decision. To investigate the bariatric surgery patient's preferences regarding information provision in bariatric surgery. A teaching hospital, bariatric center of excellence in Amsterdam, the Netherlands. All patients who underwent a primary laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy between September 2013 and September 2014 were approached by mail to participate. A questionnaire was used to elicit patient preferences for the content and format of information. Sociodemographic characteristics, clinicopathologic factors, and psychologic factors were explored as predictors for specific preferences. Of the 356 eligible patients, 112 (31.5%) participated. The mean age was 49.2 (±10.7) years, and 91 (81.3%) patients were female. Patients deemed the opportunity to ask questions (96.4%) the most important feature of the consult, followed by a realistic view on expectations-for example, results of the procedure (95.5%) and information concerning the consequences of surgery for daily life (89.1%). Information about the risk of complications on the order of 10% was desired by 93% of patients; 48% desired information about lower risks (.1%). Only 25 patients (22.3%) desired detailed information concerning their weight loss after surgery. Bariatric patients wished for information about the consequences of surgery on daily life, whereas the importance of information concerning complications decreased when their incidence lessened. Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

  3. Why the definition of high risk has been inappropriately used in previous carotid trials.

    Science.gov (United States)

    De Borst, G J; Schermerhorn, M; Moll, F L

    2015-04-01

    Carotid artery revascularization by endarterectomy is an effective means of stroke prevention in selected patients with carotid stenosis. With the development of endovascular techniques, carotid artery stenting (CAS) has been proposed as a viable alternative to carotid endarterectomy (CEA), particularly in patients considered at high risk for CEA. Guidelines have established criteria that outline these patients who are considered at "high risk" for complications after CEA, to whom CAS may provide benefit. The validity of these theoretical high-risk criteria, however, is yet unproven, and, as a consequence, there is no clear evidence suggesting that the risk with CAS is lower in these high-risk patients compared with CEA. This manuscript summarizes the role of "high risk" within recent trials and discusses why the optimal treatment for these patients with deemed high risk for surgery remains a matter of debate.

  4. Gastric cancer surgery in elderly patients.

    Science.gov (United States)

    Gretschel, Stephen; Estevez-Schwarz, Lope; Hünerbein, Michael; Schneider, Ulrike; Schlag, Peter M

    2006-08-01

    To investigate the value of individual risk-adapted therapy in geriatric patients, we performed a consecutive analysis of 363 patients undergoing potentially curative surgery for gastric cancer. All patients underwent extensive preoperative workup to assess surgical risk. The following criteria were evaluated in 3 age groups (75 years): comorbidity, tumor characteristics, type of resection, postoperative morbidity and mortality, recurrence rate, overall survival, and disease-free survival. There was an increased rate of comorbidity in the higher age groups (51% vs 76% vs 83%; PPatient selection and risk-adapted surgery in elderly patients can result in acceptable therapeutic results comparable to younger patients. Limited surgery in elderly gastric cancer patients with high comorbidity does not necessarily compromise oncological outcome.

  5. [Prevalence of HPV high-risk serotypes detected by PCR in patients with normal cervical cytology at the Hospital Regional Adolfo López Mateos, ISSSTE].

    Science.gov (United States)

    Martínez-Portilla, R J; López-Velázquez, J L; Martínez-Rojas, G C; Aguilar-Villagómez, M I; De la Torre-Rendón, F E; Villafán-Bernal, J R

    2016-09-01

    Is fundamental to determine the prevalence of human papiloma virus (HVP) high-risk serotypes in local and regional population in order for health providers to offer patients, vaccines and treatments against specific population-based serotypes. To determine the prevalence of HPV High risk serotypes detected by PCR in patients with normal cytology from the ISSSTE Adolfo Lopez Mateos Regional Hospital. An observational, descriptive, prospective study was conducted from cervical cytologies and high risk HPV test by PCR in patients from the Regional Hospital Adolfo López Mateos, ISSSTE, during the period January 2013-December 2015. Cases of patients with negative cervical cytology were included. Information about age, the result of cervical cytology and high risk HPV test by PCR was obtained. The overall prevalence of HPV infection and the most prevalent serotypes by age groups were calculated. A total of 3258 cervical smears were performed, of which 2557 were negative (78.4%), from this, the global prevalence of HPV infection was 10.2% (n=262). We found that 1.8% (n = 45) of negative reports had HPV16 infection, 0.5% (n=13) had HPV18 and 8.9% (n = 227) were infected by Viral Pool of other high-risk serotypes. The prevalence of infection by viral pool of high risk serotypes was 11.5% in women <20 years, 12.9% in women between 20-29 years and 22.2% in women between 30-39 years. This prevalence was lower in patients older than 40 years (p<0.05). A higher prevalence of viral pool high risk serotypes was found in patients with normal cytology, than the HPV16 and HPV-8 prevalence, which was significantly higher in women younger than 40 years.

  6. The value of perioperative mitomycin C instillation in improving subsequent bacillus calmette-guerin instillation efficacy in intermediate and high-risk patients with non-muscle invasıve bladder cancer: a prospective randomized study

    Directory of Open Access Journals (Sweden)

    Ömer Gülpinar

    2012-08-01

    Full Text Available PURPOSE: We evaluated the efficacy of perioperative mitomycin C (MMC instillation to improve subsequent bacillus Calmette-Guérin (BCG instillation efficacy in intermediate and high risk patients with non-muscle invasive bladder cancer (NMIBC. MATERIALS AND METHODS: From November 2004 to May 2006, 51 patients with intermediate or high risk NMIBC were enrolled in this prospective randomized trial. In group A, patients were treated with perioperative MMC (40 mg MMC in 40 mL saline was administered within 6 hours of surgery followed by delayed (at least 15 days from surgery BCG instillations (once a week for 6 weeks, 5 x 108 colony-forming units in 50 mL saline. Patients in group B were treated with delayed BCG instillations alone. The primary end points were recurrence-free interval and recurrence rate. RESULTS: There were 25 and 26 patients in groups A and B, respectively. Median follow-up was 41.3 months (range 8 to 64 in group A and 40.9 months (range 6 to 68 in group B. Recurrence rate was 36% (9 of 25 and 19.3% (5 of 26 in group A and B, respectively (p = 0.052. Median time to the first recurrence was 8 months in group A and 7 months in group B (p = 0.12. CONCLUSIONS: The present study showed no statistically significant difference in terms of recurrence rate and median time to first recurrence between intermediate or high-risk patients with NMIBC who were treated with early single dose instillation of MMC plus delayed BCG and those who were treated with only BCG.

  7. Recommended nutritional supplements for bariatric surgery patients.

    Science.gov (United States)

    Malone, Margaret

    2008-12-01

    To review nutritional supplements commonly required after bariatric surgery to provide a practical guide and reference source for generalist healthcare providers. A PubMed literature search (1988-July 2008) was conducted, using the search term nutritional deficiency after bariatric surgery, and was limited to English-language literature on adult (aged >19 y) human subjects. Additional references from the selected literature were also included. Data were extracted from large clinical series and practice guidelines whenever possible. Case reports were used only when they were the sole information source. Nutritional deficiencies that occur after bariatric surgery depend significantly on the type of surgery performed. Restrictive procedures such as gastric banding are the least likely to cause nutritional deficits, since none of the intestine is bypassed. Malabsorptive procedures such as biliopancreatic diversion or mixed restrictive/malabsorptive procedures (eg, Roux-en-Y gastric bypass) can result in serious nutritional problems when patients do not take required supplements after surgery. Vitamins and minerals that are commonly deficient in this circumstance include vitamin B(12), calcium, vitamin D, thiamine, folic acid, iron, zinc, and magnesium. Rare ocular complications have been reported with hypovitaminosis A. Healthcare professionals, especially those who practice outside large bariatric centers, must be aware of the supplements required by patients who have had bariatric surgery. Many patients fail to follow up with the surgery centers and are managed by their primary care teams and community pharmacists, especially in the selection of multivitamin and nutritional supplements.

  8. Homoarginine Associates with Zonulin and Tryptophan - Findings in a High-Risk Cohort of Patients Carrying an AICD.

    Science.gov (United States)

    Mann, Elli; Kluesener, Robert; Boschann, Felix; Ruppert, Jana; Armbruster, Franz P; Meinitzer, Andreas; Melzer, Christoph; Dschietzig, Thomas B

    2017-11-01

    Homoarginine (hArg) is known to have an impact on nitric oxide (NO) metabolism. It seems to increase NO generation and/or availability, thereby enhancing endothelial function. In addition, hArg is connected to energy metabolism since the key enzyme, L-arginine-glycine amidinotransferase (AGAT) for hArg synthesis in the kidneys, is also involved in the synthesis of energy metabolites like guanidinoacetate. Former studies indicate that low levels of hArg are linked to cardiovascular disease and increased all-cause mortality. This study investigated the dependence of plasma hArg on various biochemical and clinical factors in 229 patients carrying an automatic, implantable cardioverter/defibrillator (AICD) using multiple linear regression analysis (Generalized Linear Model, GLM). GLM revealed a highly significant, positive association between hArg and zonulin (p zonulin is a novel finding which may indicate a different meaning of circulating versus local (gut) zonulin. Therefore, further experimental and clinical investigation is needed to explore this association, focusing on possible pathophysiological pathways and the role of circulating zonulin levels in cardiovascular disease. The positive correlation of hArg and Trp also deserves further research because both amino acids might have a protective effect on cardiovascular disease by inhibition of the enzyme alkaline phosphatase. Eventually, our study associates low hArg concentrations with chronic low-grade inflammation and parameters of malnutrition in cardiovascular high-risk patients.

  9. Abstinence and teenagers: prevention counseling practices of health care providers serving high-risk patients in the United States.

    Science.gov (United States)

    Harper, Cynthia C; Henderson, Jillian T; Schalet, Amy; Becker, Davida; Stratton, Laura; Raine, Tina R

    2010-06-01

    Abstinence-only education has had little demonstrable impact on teenagers' sexual behaviors, despite significant policy and funding efforts. Given the struggle over resources to improve teenagers' reproductive health outcomes, the views of clinicians serving teenagers at high risk for unintended pregnancy and STDs merit particular attention. In 2005, a qualitative study with 31 clinicians serving low-income, at-risk patients was conducted. A semistructured interview guide was used to ask clinicians about adolescent pregnancy, HIV and STD prevention counseling, and when they include abstinence. Thematic content analysis was used to examine the content of the counseling and the techniques used in different situations. Providers reported offering comprehensive counseling, presenting abstinence as a choice for teenagers, along with information about contraceptives and condoms. Several providers mentioned that with young, sexually inexperienced teenagers, they discuss delaying sexual activity and suggest other ways to be affectionate, while giving information on condoms. Providers explained how they assess whether teenagers feel ready to be sexually active and try to impart skills for healthy relationships. Some described abstinence as giving teenagers a way to opt out of unwanted sexual activity. Many support abstinence if that is the patient's desire, but routinely dispense condoms and contraceptives. Overall, providers did not give abstinence counseling as a rigid categorical concept in their preventive practices, but as a health tool to give agency to teenagers within a harm reduction framework. Their approach may be informative for adolescent policies and programs in the future.

  10. Endovascular Treatment of Infrarenal Abdominal Aortic Aneurysm with Short and Angulated Neck in High-Risk Patient

    Directory of Open Access Journals (Sweden)

    Stylianos Koutsias

    2013-01-01

    Full Text Available Endovascular treatment of abdominal aortic aneurysms (AAA is an established alternative to open repair. However lifelong surveillance is still required to monitor endograft function and signal the need for secondary interventions (Hobo and Buth 2006. Aortic morphology, especially related to the proximal neck, often complicates the procedure or increases the risk for late device-related complications (Hobo et al. 2007 and Chisci et al. 2009. The definition of a short and angulated neck is based on length (60° (Hobo et al. 2007 and Chisci et al. 2009. A challenging neck also offers difficulties during open repairs (OR, necessitating extensive dissection with juxta- or suprarenal aortic cross-clamping. Patients with extensive aneurysmal disease typically have more comorbidities and may not tolerate extensive surgical trauma (Sarac et al. 2002. It is, therefore, unclear whether aneurysms with a challenging proximal neck should be offered EVAR or OR (Cox et al. 2006, Choke et al. 2006, Robbins et al. 2005, Sternbergh III et al. 2002, Dillavou et al. 2003, and Greenberg et al. 2003. In our case the insertion of a thoracic endograft followed by the placement of a bifurcated aortic endograft for the treatment of a very short and severely angulated neck proved to be feasible offering acceptable duration of aneurysm exclusion. This adds up to our armamentarium in the treatment of high-risk patients, and it should be considered in emergency cases when the fenestrated and branched endografts are not available.

  11. Bariatric surgery: nutritional considerations for patients.

    Science.gov (United States)

    Rickers, Lisa; McSherry, Ciara

    Nutritional deficiencies are common in patients who are obese and therefore individuals considering bariatric surgery may require dietary supplementation with multivitamins and minerals before surgery. Nutritional deficiencies following bariatric surgery are often proportional to the degree of malabsorption created by the surgical procedure or the extent of weight loss. Eating habits often contribute to nutritional deficiencies, so appropriate dietary and lifestyle counselling are essential following bariatric procedures to ensure appropriate macronutrient and micronutrient status. Nutritional supplementation following bariatric surgery commonly includes calcium with vitamin D, iron and vitamin B12 in addition to a daily multivitamin and mineral tablet. Although general guidelines exist, individual monitoring and tailoring are frequently required. This article provides an update of guidelines regarding the most common nutritional concerns and myths surrounding bariatric surgery.

  12. Heart rate as a predictor of stroke in high-risk, hypertensive patients with previous stroke or transient ischemic attack.

    Science.gov (United States)

    Sandset, Else Charlotte; Berge, Eivind; Kjeldsen, Sverre E; Julius, Stevo; Holzhauer, Björn; Krarup, Lars-Henrik; Hua, Tsushung A

    2014-01-01

    Risk factors for first stroke are well established, but less is known about risk factors for recurrent stroke. In the present analysis, we aimed to assess the effect of heart rate and other possible predictors of stroke in a hypertensive population with previous stroke or transient ischemic attack (TIA). The Valsartan Antihypertensive Long-Term Use Evaluation trial was a multicentre, double-masked, randomized controlled, parallel group trial comparing the effects of an angiotensin receptor blocker (valsartan) and a calcium channel blocker (amlodipine) in patients with hypertension and high cardiovascular risk. We used Cox proportional hazard models to investigate the effect of baseline variables on the risk of stroke. Quadratic terms of the continuous variables were entered in the models to test for linearity. Of 15,245 patients included in the trial, 3014 had a previous stroke or TIA at baseline and were included in the present analysis. Stroke recurrence occurred in 239 patients (7.9%) during a median of 4.5 years of follow-up. Resting heart rate (per 10 beats per minute; hazard ratio [HR], 2.78; 95% confidence interval [CI], 1.18-6.58) and diabetes mellitus at baseline (HR, 1.47; 95% CI, 1.03-2.10) were significantly associated with an increased risk of stroke recurrence in the multivariable analysis. In high-risk, hypertensive patients with previous stroke or TIA, resting heart rate was the strongest predictor of recurrent stroke. Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.

  13. Are there patients with T1 to T2, lymph node-negative breast cancer who are "high-risk" for locoregional disease recurrence?

    Science.gov (United States)

    Mamtani, Anita; Patil, Sujata; Stempel, Michelle M; Morrow, Monica

    2017-07-15

    Indications for postmastectomy radiotherapy (PMRT) in patients with T1 to T2, lymph node-negative (N0) breast cancer with "high-risk" features are controversial. The European Organization for Research and Treatment of Cancer (EORTC) 22922 and National Cancer Institute of Canada Clinical Trials Group MA20 trials reporting improved 10-year disease-free survival with lymph node irradiation included patients with high-risk N0 disease, but, to the authors' knowledge, benefits in patients receiving modern systemic therapy are uncertain. The authors retrospectively identified patients with T1 to T2N0 disease who were treated with mastectomy from January 2006 through December 2011. High-risk features included age patients, only 15 received PMRT and were excluded. Of the remaining 657 patients, 187 (28%) had 1 high-risk feature and 449 patients (68%) had ≥ 2 high-risk features. A total of 36 patients with unknown tumor grade were excluded from risk analysis. Approximately 98% of patients underwent sentinel lymph node biopsy alone and 86% received adjuvant systemic therapy. At a median of 5.6 years of follow-up, the locoregional disease recurrence (LRR) rate was 4.7% (31 patients). Increasing tumor size was found to be associated with LRR (hazard ratio, 1.70; P = .006), whereas other high-risk features were not (all P > .05). Receipt of systemic therapy decreased the LRR rate (hazard ratio, 0.40; P = .03). Although crude LRR rates increased from 3.8% to 9.4% with 1 versus ≥ 4 high-risk features, the number of risk factors was not found to be significantly associated with LRR (P = .54). In the current study, a low crude LRR rate (4.7%) was observed in a large unselected cohort of patients with T1 to T2N0 breast cancer with high-risk features who were treated with mastectomy and systemic therapy without PMRT. Although increasing tumor size and the omission of systemic therapy were found to be predictive, other features did not confer a higher LRR

  14. Predictive value of pretreatment lymphocyte count in stage II colorectal cancer and in high-risk patients treated with adjuvant chemotherapy.

    Science.gov (United States)

    Liang, Lei; Zhu, Ji; Jia, Huixun; Huang, Liyong; Li, Dawei; Li, Qingguo; Li, Xinxiang

    2016-01-05

    Pretreatment lymphocyte count (LC) has been associated with prognosis and chemotherapy response in several cancers. The predictive value of LC for stage II colorectal cancer (CRC) and for high-risk patients treated with adjuvant chemotherapy (AC) has not been determined. A retrospective review of prospectively collected data from 1332 consecutive stage II CRC patients who underwent curative tumor resection was conducted. A pretreatment LC value risk, 459 (62.2%) of whom received AC. Patients with low LCs had significantly worse 5-year OS (74.6% vs. 90.2%, p risk patients with low LCs had the poorest DFS (p value or combined with high-risk status were both independent prognostic factors(p risk, AC-treated patients with high LCs had significantly longer DFS than untreated patients (HR, 0.594; 95% CI, 0.364-0.970; p = 0.035). There was no difference or trend for DFS or OS in patients with low LCs, regardless of the use of AC (DFS, p = 0.692; OS, p = 0.522). Low LC was also independently associated with poorer DFS in high-risk, AC-treated patients (HR, 1.885; 95% CI, 1.112-3.196; p = 0.019). Pretreatment LC is an independent prognostic factor for survival in stage II CRC. Furthermore, pretreatment LC reliably predicts chemotherapeutic efficacy in high-risk patients with stage II CRC.

  15. Resiquimod as an immunologic adjuvant for NY-ESO-1 protein vaccination in patients with high-risk melanoma.

    Science.gov (United States)

    Sabado, Rachel Lubong; Pavlick, Anna; Gnjatic, Sacha; Cruz, Crystal M; Vengco, Isabelita; Hasan, Farah; Spadaccia, Meredith; Darvishian, Farbod; Chiriboga, Luis; Holman, Rose Marie; Escalon, Juliet; Muren, Caroline; Escano, Crystal; Yepes, Ethel; Sharpe, Dunbar; Vasilakos, John P; Rolnitzsky, Linda; Goldberg, Judith; Mandeli, John; Adams, Sylvia; Jungbluth, Achim; Pan, Linda; Venhaus, Ralph; Ott, Patrick A; Bhardwaj, Nina

    2015-03-01

    The Toll-like receptor (TLR) 7/8 agonist resiquimod has been used as an immune adjuvant in cancer vaccines. We evaluated the safety and immunogenicity of the cancer testis antigen NY-ESO-1 given in combination with Montanide (Seppic) with or without resiquimod in patients with high-risk melanoma. In part I of the study, patients received 100 μg of full-length NY-ESO-1 protein emulsified in 1.25 mL of Montanide (day 1) followed by topical application of 1,000 mg of 0.2% resiquimod gel on days 1 and 3 (cohort 1) versus days 1, 3, and 5 (cohort 2) of a 21-day cycle. In part II, patients were randomized to receive 100-μg NY-ESO-1 protein plus Montanide (day 1) followed by topical application of placebo gel [(arm A; n = 8) or 1,000 mg of 0.2% resiquimod gel (arm B; n = 12)] using the dosing regimen established in part I. The vaccine regimens were generally well tolerated. NY-ESO-1-specific humoral responses were induced or boosted in all patients, many of whom had high titer antibodies. In part II, 16 of 20 patients in both arms had NY-ESO-1-specific CD4⁺ T-cell responses. CD8⁺ T-cell responses were only seen in 3 of 12 patients in arm B. Patients with TLR7 SNP rs179008 had a greater likelihood of developing NY-ESO-1-specific CD8⁺ responses. In conclusion, NY-ESO-1 protein in combination with Montanide with or without topical resiquimod is safe and induces both antibody and CD4⁺ T-cell responses in the majority of patients; the small proportion of CD8⁺ T-cell responses suggests that the addition of topical resiquimod to Montanide is not sufficient to induce consistent NY-ESO-1-specific CD8⁺ T-cell responses. ©2015 American Association for Cancer Research.

  16. How can we identify low- and high-risk patients among unselected patients with possible acute coronary syndrome?

    DEFF Research Database (Denmark)

    Nielsen, Kirsten Melgaard; Færgeman, Ole; Larsen, Mogens Lytken

    2007-01-01

    OBJECTIVE: Prognosis among patients admitted with possible acute coronary syndrome (ACS) may differ from that of patients with definite ACS. The aim of this study was to identify risk factors for mortality among unselected patients and to use the statistical model to identify patients at low or h...

  17. [Quality of life and overall survival in high risk patients after radical cystectomy with a simple urinary derivation].

    Science.gov (United States)

    Mucciardi, Giuseppe; Macchione, Luciano; Galì, Alessandro; di Benedetto, Antonina; Subba, Enrica; Pappalardo, Rosa; Mucciardi, Massimo; Butticè, Salvatore; Inferrera, Antonino; Magno, Carlo

    2015-01-01

    To evaluate quality of life (QoL) and overall survival after radical cystectomy with cutaneous ureterostomies for locally advanced bladder cancer in elderly patients with high surgical risk. Fifty eight patients older than 74 years (mean age 80,6±4,3) with locally advanced bladder cancer (group A), underwent radical cystectomy and ureterocutaneous diversion. Patients completed the EORTC QLQC30 before and six months after surgery to assess functional, clinical and QoL outcomes. The same evaluation was carried out in a control group (group B) of 29 patients (mean age 82,3±3,8 years), who had refused cystectomy. Questionnaires were also administered to patients of both groups who survived at least 20 months and 5 years. All patients presented with an ASA score ≥3. Mean hospital stay was 15.1 days (±4.8) in group A and 23.5 days (±4.1) in Group B. No intraoperative complications occurred in group A. Postoperative overall survival evaluated within 6 months in group A was 97% versus 79% in group B (pbladder cancer and high operative risk. Comparison between two groups showed a statistically significant difference for almost all the Qol related parameters and for short and medium term overall survival. Copyright © 2012 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.

  18. Potential of a Pharmacogenetic-Guided Algorithm to Predict Optimal Warfarin Dosing in a High-Risk Hispanic Patient

    Directory of Open Access Journals (Sweden)

    Dagmar F. Hernandez-Suarez MD

    2016-12-01

    Full Text Available Deep abdominal vein thrombosis is extremely rare among thrombotic events secondary to the use of contraceptives. A case to illustrate the clinical utility of ethno-specific pharmacogenetic testing in warfarin management of a Hispanic patient is reported. A 37-year-old Hispanic Puerto Rican, non-gravid female with past medical history of abnormal uterine bleeding on hormonal contraceptive therapy was evaluated for abdominal pain. Physical exam was remarkable for unspecific diffuse abdominal tenderness, and general initial laboratory results—including coagulation parameters—were unremarkable. A contrast-enhanced computed tomography showed a massive thrombosis of the main portal, splenic, and superior mesenteric veins. On admission the patient was started on oral anticoagulation therapy with warfarin at 5 mg/day and low-molecular-weight heparin. The prediction of an effective warfarin dose of 7.5 mg/day, estimated by using a recently developed pharmacogenetic-guided algorithm for Caribbean Hispanics, coincided with the actual patient’s warfarin dose to reach the international normalized ratio target. We speculate that the slow rise in patient’s international normalized ratio observed on the initiation of warfarin therapy, the resulting high risk for thromboembolic events, and the required warfarin dose of 7.5 mg/day are attributable in some part to the presence of the NQO1*2 (g.559C>T, p.P187S polymorphism, which seems to be significantly associated with resistance to warfarin in Hispanics. By adding genotyping results of this novel variant, the predictive model can inform clinicians better about the optimal warfarin dose in Caribbean Hispanics. The results highlight the potential for pharmacogenetic testing of warfarin to improve patient care.

  19. Potential of a Pharmacogenetic-Guided Algorithm to Predict Optimal Warfarin Dosing in a High-Risk Hispanic Patient

    Directory of Open Access Journals (Sweden)

    Dagmar F. Hernandez-Suarez MD

    2016-12-01

    Full Text Available Deep abdominal vein thrombosis is extremely rare among thrombotic events secondary to the use of contraceptives. A case to illustrate the clinical utility of ethno-specific pharmacogenetic testing in warfarin management of a Hispanic patient is reported. A 37-year-old Hispanic Puerto Rican, non-gravid female with past medical history of abnormal uterine bleeding on hormonal contraceptive therapy was evaluated for abdominal pain. Physical exam was remarkable for unspecific diffuse abdominal tenderness, and general initial laboratory results—including coagulation parameters—were unremarkable. A contrast-enhanced computed tomography showed a massive thrombosis of the main portal, splenic, and superior mesenteric veins. On admission the patient was started on oral anticoagulation therapy with warfarin at 5 mg/day and low-molecular-weight heparin. The prediction of an effective warfarin dose of 7.5 mg/day, estimated by using a recently developed pharmacogenetic-guided algorithm for Caribbean Hispanics, coincided with the actual patient’s warfarin dose to reach the international normalized ratio target. We speculate that the slow rise in patient’s international normalized ratio observed on the initiation of warfarin therapy, the resulting high risk for thromboembolic events, and the required warfarin dose of 7.5 mg/day are attributable in some part to the presence of the NQO1 *2 (g.559C>T, p.P187S polymorphism, which seems to be significantly associated with resistance to warfarin in Hispanics. By adding genotyping results of this novel variant, the predictive model can inform clinicians better about the optimal warfarin dose in Caribbean Hispanics. The results highlight the potential for pharmacogenetic testing of warfarin to improve patient care.

  20. High-risk human papillomavirus (HPV screening and detection in healthy patient saliva samples: a pilot study

    Directory of Open Access Journals (Sweden)

    Wang Robert C

    2011-10-01

    Full Text Available Abstract Background The human papillomaviruses (HPV are a large family of non-enveloped DNA viruses, mainly associated with cervical cancers. Recent epidemiologic evidence has suggested that HPV may be an independent risk factor for oropharyngeal cancers. Evidence now suggests HPV may modulate the malignancy process in some tobacco- and alcohol-induced oropharynx tumors, but might also be the primary oncogenic factor for inducing carcinogenesis among some non-smokers. More evidence, however, is needed regarding oral HPV prevalence among healthy adults to estimate risk. The goal of this study was to perform an HPV screening of normal healthy adults to assess oral HPV prevalence. Methods Healthy adult patients at a US dental school were selected to participate in this pilot study. DNA was isolated from saliva samples and screened for high-risk HPV strains HPV16 and HPV18 and further processed using qPCR for quantification and to confirm analytical sensitivity and specificity. Results Chi-square analysis revealed the patient sample was representative of the general clinic population with respect to gender, race and age (p Conclusions The successful recruitment and screening of healthy adult patients revealed HPV16, but not HPV18, was present in a small subset. These results provide new information about oral HPV status, which may help to contextualize results from other studies that demonstrate oral cancer rates have risen in the US among both females and minorities and in some geographic areas that are not solely explained by rates of tobacco and alcohol use. The results of this study may be of significant value to further our understanding of oral health and disease risk, as well as to help design future studies exploring the role of other factors that influence oral HPV exposure, as well as the short- and long-term consequences of oral HPV infection.

  1. Predictors of 32P β brachytherapy failure in patients with high-risk in-s tent restenosis

    International Nuclear Information System (INIS)

    Ortolani, Paolo; Marzocchi, Antonio; Aquilina, Matteo; Gaiba, William; Bunkheila, Feisal; Neri, Stefano; Lombardo, Enzo; Marrozzini, Cinzia; Pini, Stefania; Taglieri, Nevio; Sbarzaglia, Paolo; Reggiani, Maria Letizia Bacchi; Barbieri, Enza; Branzi, Angelo

    2004-01-01

    Background: The effectiveness of coronary radiation therapy for the treatment of in-stent restenosis (ISR) has been established in several randomized clinical trials. The efficacy of this treatment in the general population is less well established. Methods and materials: We report our experience in 118 consecutive patients with nonselected high-risk ISR who had undergone successful percutaneous coronary intervention and brachytherapy with 32 P β-irradiation and who were prospectively enrolled in a quantitative angiographic and clinical follow-up protocol at 7 months after the index procedure. The aim of this study was to investigate the independent predictor of angiographic restenosis after 32 P brachytherapy treatment. Results: Of the patients, 28.8% were diabetics. The mean lesion and mean radiated lengths were, respectively, 30.1 ± 17.2 and 43.8 ± 16.9 mm. The ISR pattern was diffuse in 96% of the treated lesions; in particular, 22.1% presented an occlusive pattern and 37.1% a proliferative pattern. At follow-up angiographic, restenosis and major adverse cardiac events (MACE) rates were, respectively, 20.8% and 29.6%. The univariate predictors of angiographic restenosis were procedural geographic miss, pattern IV ISR, manual pullback maneuver of the radiation source, preprocedural lesion percentage stenosis and preprocedural lesion MLD. At logistic regression analysis, only geographic miss and pattern IV ISR were independent predictors of post intracoronary radiation therapy (IRT) angiographic restenosis. Conclusion: These data indicate that 7-month angiographic restenosis after 32 P IRT in complex patients with ISR is not a frequent event and is predicted mainly by an occlusive lesion at baseline and by procedural geographical miss

  2. Lack of Apparent Survival Benefit With Use of Androgen Deprivation Therapy in Patients With High-risk Prostate Cancer Receiving Combined External Beam Radiation Therapy and Brachytherapy.

    Science.gov (United States)

    Yang, David D; Muralidhar, Vinayak; Mahal, Brandon A; Nguyen, Paul L; Devlin, Phillip M; King, Martin T; Orio, Peter F

    2018-01-01

    Although level 1 evidence has demonstrated a survival benefit from the addition of androgen deprivation therapy (ADT) to external beam radiation therapy (EBRT) for patients with high-risk prostate cancer, the benefits of ADT with combined EBRT and brachytherapy for high-risk patients are unclear. We examined the association between ADT and overall survival in a national cohort of high-risk patients treated with EBRT with or without brachytherapy. We identified 46,325 men in the National Cancer Database with a diagnosis of high-risk prostate cancer (Gleason score 8-10, clinical stage T3-T4, or prostate-specific antigen >20 ng/mL) who were treated with EBRT with or without brachytherapy and ADT from 2004 through 2011. Multivariable Cox regression analysis adjusting for sociodemographic and clinicopathologic factors was used to identify the association between ADT and overall survival. The median follow-up period was 48.6 and 59.2 months for patients treated with EBRT only and combined modality RT, respectively. ADT was associated with an improvement in overall survival for the 85.0% (39,361) of the study cohort who underwent EBRT alone (adjusted hazard ratio 0.91, P=.001) but not for patients treated with combined modality RT (adjusted hazard ratio 1.05, P=.496), with a significant interaction (P interaction =.036). In contrast to the known survival benefit when ADT is given with EBRT, our results suggest that ADT might not improve survival for high-risk patients who undergo combined EBRT and brachytherapy. Given the significant adverse effects of ADT, in particular, with long-term therapy, a randomized controlled trial of combined EBRT and brachytherapy with or without ADT for select high-risk patients using a noninferiority design should be undertaken. Copyright © 2017 Elsevier Inc. All rights reserved.

  3. Medical Assistant-Based Care Management for High-Risk Patients in Small Primary Care Practices: A Cluster Randomized Clinical Trial

    NARCIS (Netherlands)

    Freund, T.; Peters-Klimm, F.; Boyd, C.M.; Mahler, C.; Gensichen, J.; Erler, A.; Beyer, M.; Gondan, M.; Rochon, J.; Gerlach, F.M.; Szecsenyi, J.

    2016-01-01

    BACKGROUND: Patients with multiple chronic conditions are at high risk for potentially avoidable hospitalizations, which may be reduced by care coordination and self-management support. Medical assistants are an increasingly available resource for patient care in primary care practices. OBJECTIVE:

  4. Utility of multiple rule out CT screening of high-risk atraumatic patients in an emergency department-a feasibility study

    DEFF Research Database (Denmark)

    Pries-Heje, Mia M; Hasselbalch, Rasmus B; Raaschou, Henriette

    2018-01-01

    BACKGROUND: Several large trials have evaluated the effect of CT screening based on specific symptoms, with varying outcomes. Screening of patients with CT based on their prognosis alone has not been examined before. For moderate-to-high risk patients presenting in the emergency department (ED), ...

  5. Dispersal of antibiotic-resistant high-risk clones by hospital networks : changing the patient direction can make all the difference

    NARCIS (Netherlands)

    Donker, T.; Wallinga, J.; Grundmann, H.

    Background: Patients who seek treatment in hospitals can introduce high-risk clones of hospital-acquired, antibiotic-resistant pathogens from previous admissions. In this manner, different healthcare institutions become linked epidemiologically. All links combined form the national patient referral

  6. Prognostic impact of demographic factors and clinical features on the mode of death in high-risk patients after myocardial infarction--a combined analysis from multicenter trials

    DEFF Research Database (Denmark)

    Yap, Yee Guan; Duong, Trinh; Bland, J Martin

    2005-01-01

    of death in high-risk patients post MI in the thrombolytic era. METHODS: In all, 3,431 patients receiving placebo (2,700 men, median age 64 +/- 11 years) from the EMIAT, CAMIAT, SWORD, TRACE, and DIAMOND-MI studies, with LVEF

  7. Meta-analysis of the risk of gastric stump cancer: detection of high risk patient subsets for stomach cancer after remote partial gastrectomy for benign conditions

    NARCIS (Netherlands)

    Tersmette, A. C.; Offerhaus, G. J.; Tersmette, K. W.; Giardiello, F. M.; Moore, G. W.; Tytgat, G. N.; Vandenbroucke, J. P.

    1990-01-01

    Controversy about gastric cancer risk after partial gastrectomy exists, especially in the United States. Therefore, we performed a meta-analysis to determine overall relative risk and weighted mean relative risk for subsets of postgastrectomy patients, define possible high risk patients suitable for

  8. Aspirin in patients undergoing noncardiac surgery

    DEFF Research Database (Denmark)

    Devereaux, P J; Mrkobrada, Marko; Sessler, Daniel I

    2014-01-01

    BACKGROUND: There is substantial variability in the perioperative administration of aspirin in patients undergoing noncardiac surgery, both among patients who are already on an aspirin regimen and among those who are not. METHODS: Using a 2-by-2 factorial trial design, we randomly assigned 10,010...

  9. Revisional bariatric surgery in a transplant patient

    Directory of Open Access Journals (Sweden)

    Salman Al Sabah

    2017-01-01

    Conclusion: Bariatric surgery is a safe and effective procedure to assist renal transplant patients in losing weight. In addition, it has proven to be effective in the management of the co-morbidities that are associated with renal failure. Our study was also able to prove that converting form an SG to a bypass in a transplant patient is a safe and feasible option.

  10. Failure of renal biomarkers to predict worsening renal function in high-risk patients presenting with oliguria.

    Science.gov (United States)

    Legrand, Matthieu; Jacquemod, Aurélien; Gayat, Etienne; Collet, Corinne; Giraudeaux, Veronique; Launay, Jean-Marie; Payen, Didier

    2015-01-01

    Oliguria is a common symptom in critically ill patients and puts patients in a high risk category for further worsening renal function (WRF). We performed this study to explore the predictive value of biomarkers to predict WRF in oliguric intensive care unit (ICU) patients. Single-center prospective observational study. ICU patients were included when they presented a first episode of oliguria. Plasma and urine biomarkers were measured: plasma and urine neutrophil gelatinase-associated lipocalin (pNGAL and uNGAL), urine α1-microglobulin, urine γ-glutamyl transferase, urine indices of tubular function, cystatin C, C terminal fragment of pro-arginine vasopressin (CT-ProAVP), and proadrenomedullin (MR-ProADM). One hundred eleven patients formed the cohort, of whom 41 [corrected] had worsening renal function. Simplified Acute Physiology Score (SAPS) II was 41 (31-51). WRF was associated with increased mortality (hazard ratio 8.65 [95 % confidence interval (CI) 3.0-24.9], p = 0.0002). pNGAL, MR-ProADM, and cystatin C had the best odds ratio and area under the receiver-operating characteristic curve (AUC-ROC: 0.83 [0.75-0.9], 0.82 [0.71-0.91], and 0.83 [0.74-0.90]), but not different from serum creatinine (Screat, 0.80 [0.70-0.88]). A clinical model that included age, sepsis, SAPS II, and Screat had AUC-ROC of 0.79 [0.69-0.87]; inclusion of pNGAL increased the AUC-ROC to 0.86 (p = 0.03). The category-free net reclassification index improved with pNGAL (total net reclassification index for events to higher risk 61 % and nonevents to lower 82 %). All episodes of oliguria do not carry the same risk. No biomarker further improved prediction of WRF compared with Screat in this selected cohort of patients at increased risk defined by oliguria.

  11. Plastic surgery and the teenage patient.

    Science.gov (United States)

    McGrath, M H; Mukerji, S

    2000-08-01

    Over the past year, the media have reported an increase in the number of teenagers undergoing plastic surgery, and with a tone of faint alarm have suggested that this merits some cultural self-scrutiny. This paper presents the statistics on the number and types of plastic surgery operations done in teenagers over the last eight years and discusses these in the context of cultural influences and societal concepts of beauty. The reason to have plastic surgery is psychological and involves body image, which is defined as the subjective perception of the body as it is seen through the mind's eye. To explain why changing the external appearance affects personality and behavior, the complex psychological reactions that occur after an operation that alters the size or shape of a body part are reviewed. Body image development occurs in stages, and puberty stands out as a particularly sensitive time as the teenager undergoes major changes in his or her physical appearance and does this at a time of heightened vulnerability to the opinion of others. Plastic surgery to correct a truly unattractive feature is enormously successful and remarkably free of conflict in this population. Teenagers undergo a rapid reorganization of their self-image after plastic surgery with subsequent positive changes in behavior and interpersonal interactions. The key to achieving success with plastic surgery is patient selection. The core value of the surgery lies not in the objective beauty of the visible result, but in the patient's opinion of and response to the change. Good patient management includes selecting candidates with clear and realistic expectations who are free of psychopathology. There must be true informed consent and attention to psychological issues must continue into the postoperative period. It is the responsibility of the patient's physician and plastic surgeon to recognize a need for psychiatric evaluation and to help the patient get this as needed. The eight operations most

  12. Clinical utility of {sup 18}F-FDG PET/CT in the follow-up of a large cohort of patients with high-risk differentiated thyroid carcinoma

    Energy Technology Data Exchange (ETDEWEB)

    Yang, Ji H.; Maciel, Rui M.B.; Nakabashi, Claudia C.D.; Janovsky, Carolina C.P.S.; Padovani, Rosalia P.; Macellaro, Danielle; Camacho, Cléber P.; Biscolla, Rosa Paula M., E-mail: rui.maciel@unifesp.br [Universidade Federal de São Paulo (EPM/UNIFESP), São Paulo, SP (Brazil). Escola Paulista de Medicina; Osawa, Akemi; Wagner, Jairo [Hospital Israelita Albert Einstein (HIAE), São Paulo, SP (Brazil). Departamento de Imagem

    2017-09-15

    Objective: To evaluate the clinical utility of {sup 18}F-FDG PET/CT in patients with high-risk DTC. Subjects and methods: Single-center retrospective study with 74 patients with high-risk differentiated thyroid cancer (DTC), classified in 4 groups. Group 1: patients with positive sTg or TgAb, subdivided in Group 1A: negative RxWBS and no foci of metastases identified at conventional image (n = 9); Group 1B: RxWBS not compatible with suspicious foci at conventional image or not proportional to sTg level (n = 13); Group 2: patients with histological findings of aggressive DTC variants (n = 21) and Group 3: patients with positive RxWBS (n = 31). Results: {sup 18}F-FDG PET/CT identified undifferentiated lesions and helped restage the disease in groups 1B and 2. The scan helped guide clinical judgment in 9/13 (69%) patients of group 1B, 10/21 (48%) patients of group 2 and 2/31 (6%) patients of group 3. There was no clinical benefit associated with group 1A. {sup 18}F-FDG PET/CT was associated with progressive disease. Conclusion: {sup 18}F-FDG PET/CT is a useful tool in the follow-up of patients with high-risk DTC, mainly in the group of RxWBS not compatible with suspicious foci at conventional image or not proportional to sTg level and in those with aggressive DTC variants. Additionally, this study showed that {sup 18}F-FDG PET/CT was associated with progression and helped display undifferentiated lesions guiding clinical assessments regarding surgeries or expectant treatments. (author)

  13. Medulloblastoma: Conventional Radiation Therapy in Comparison to Chemo Radiation Therapy in The Post-operative Treatment of High-Risk Patients

    International Nuclear Information System (INIS)

    Abd El-Aal, H.H.; Mokhtar, M.M.; Habib, E.E.; El-Kashef, A.T.; Fahmy, E.S.

    2005-01-01

    The aim of this study is to assess treatment results of 48 pediatric high-risk medulloblastoma cases that were treated by surgery, radiotherapy with or without chemotherapy. The impact of adjuvant combination chemotherapy on treatment results will be assessed. Forty-eight cases of pediatric high-risk medulloblastoma treated from July 2001 to July 2004 were randomized into two groups. The first (group I) included 21 patients who received postoperative craniospinal radiation therapy (36 Gy + boost 20 Gy to the posterior fossa). The second (group II) included 27 cases who received postoperative combination cranio-spinal radiation therapy (with the same dose as the first group) and chemotherapy (vincristine, etoposide, cisplatin). Both groups were compared as regards overall survival (OS), disease free survival (DFS), response rate and treatment toxicity. In-group I, complete remission (CR) was achieved in 71.4% of the cases; partial remission (PR) in 14.3% of the patients; stationary disease (SD) in 14.3% and none of the cases suffered from progressive disease. The three year OS was 69.5% and the three-year OFS was 61.3%. In-group II, CR was achieved in 59.3% of the cases; PR in 3.7%; SO in 3.7% and PO in 37.3% of the cases. The three-year OS was 48.4% and the 3-year OFS was 48.9%. Regarding acute treatment toxicity in group I, nine patients (31.5%) developed grade I myelo-suppression and seven cases (24.5%) developed grade II myelo-suppression with three to five days treatment interruption. Whereas in group II, 13 patients (45.5%) developed grade I myelosuppression and seven cases (24.5%) developed grade II myelo-suppression requiring interruption of treatment for a period ranging from five to seven days with spontaneous recovery. In group I no other acute toxicity was recognized, whereas in group II other toxicities related to chemotherapy were noticed. For example, three patients (II %) developed peripheral neuritis during the course of treatment and two patients

  14. Immune status of high-risk smoldering multiple myeloma patients and its therapeutic modulation under LenDex: a longitudinal analysis.

    Science.gov (United States)

    Paiva, Bruno; Mateos, María Victoria; Sanchez-Abarca, Luis Ignacio; Puig, Noemi; Vidriales, María-Belén; López-Corral, Lucía; Corchete, Luis A; Hernandez, Miguel T; Bargay, Joan; de Arriba, Felipe; de la Rubia, Javier; Teruel, Ana-Isabel; Giraldo, Pilar; Rosiñol, Laura; Prosper, Felipe; Oriol, Albert; Hernández, José; Esteves, Graça; Lahuerta, Juan José; Bladé, Joan; Perez-Simon, Jose Antonio; San Miguel, Jesús F

    2016-03-03

    There is significant interest in immunotherapy for the treatment of high-risk smoldering multiple myeloma (SMM), but no available data on the immune status of this particular disease stage. Such information is important to understand the interplay between immunosurveillance and disease transformation, but also to define whether patients with high-risk SMM might benefit from immunotherapy. Here, we have characterized T lymphocytes (including CD4, CD8, T-cell receptor γδ, and regulatory T cells), natural killer (NK) cells, and dendritic cells from 31 high-risk SMM patients included in the treatment arm of the QUIREDEX trial, and with longitudinal peripheral blood samples at baseline and after 3 and 9 cycles of lenalidomide plus low-dose dexamethasone (LenDex). High-risk SMM patients showed at baseline decreased expression of activation-(CD25/CD28/CD54), type 1 T helper-(CD195/interferon-γ/tumor necrosis factor-α/interleukin-2), and proliferation-related markers (CD119/CD120b) as compared with age-matched healthy individuals. However, LenDex was able to restore the normal expression levels for those markers and induced a marked shift in T-lymphocyte and NK-cell phenotype. Accordingly, high-risk SMM patients treated with LenDex showed higher numbers of functionally active T lymphocytes. Together, our results indicate that high-risk SMM patients have an impaired immune system that could be reactivated by the immunomodulatory effects of lenalidomide, even when combined with low-dose dexamethasone, and support the value of therapeutic immunomodulation to delay the progression to multiple myeloma. The QUIREDEX trial was registered to www.clinicaltrials.gov as #NCT00480363. © 2016 by The American Society of Hematology.

  15. Global patient outcomes after elective surgery

    DEFF Research Database (Denmark)

    2016-01-01

    - and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN51817007....... adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration...... of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients...

  16. Impact of Florida's prescription drug monitoring program and pill mill law on high-risk patients: A comparative interrupted time series analysis.

    Science.gov (United States)

    Chang, Hsien-Yen; Murimi, Irene; Faul, Mark; Rutkow, Lainie; Alexander, G Caleb

    2018-04-01

    We quantified the effects of Florida's prescription drug monitoring program and pill mill law on high-risk patients. We used QuintilesIMS LRx Lifelink data to identify patients receiving prescription opioids in Florida (intervention state, N: 1.13 million) and Georgia (control state, N: 0.54 million). The preintervention, intervention, and postintervention periods were July 2010 to June 2011, July 2011 to September 2011, and October 2011 to September 2012. We identified 3 types of high-risk patients: (1) concomitant users: patients with concomitant use of benzodiazepines and opioids; (2) chronic users: long-term, high-dose, opioid users; and (3) opioid shoppers: patients receiving opioids from multiple sources. We compared changes in opioid prescriptions between Florida and Georgia before and after policy implementation among high-risk/low-risk patients. Our monthly measures included (1) average morphine milligram equivalent per transaction, (2) total opioid volume across all prescriptions, (3) average days supplied per transaction, and (4) total number of opioid prescriptions dispensed. Among opioid-receiving individuals in Florida, 6.62% were concomitant users, 1.96% were chronic users, and 0.46% were opioid shoppers. Following policy implementation, Florida's high-risk patients experienced relative reductions in morphine milligram equivalent (opioid shoppers: -1.08 mg/month, 95% confidence interval [CI] -1.62 to -0.54), total opioid volume (chronic users: -4.58 kg/month, CI -5.41 to -3.76), and number of dispensed opioid prescriptions (concomitant users: -640 prescriptions/month, CI -950 to -340). Low-risk patients generally did not experience statistically significantly relative reductions. Compared with Georgia, Florida's prescription drug monitoring program and pill mill law were associated with large relative reductions in prescription opioid utilization among high-risk patients. Copyright © 2018 John Wiley & Sons, Ltd.

  17. Personality traits in aesthetic surgery patients

    Directory of Open Access Journals (Sweden)

    S. Visal Buturak

    2016-09-01

    Full Text Available Purpose: It has been known that psychological factors have an important effect on the decision to undergo aesthetic surgery. In this study, we aimed to test the hypothesis that the personality traits of people admitted for aesthetic surgery differ from those of people who have never planned to undergo aesthetic surgery in their lives. Material and Methods: Forty-seven patients who were referred to the outpatient clinic of the Faculty of Medicine, Department of Plastic, Reconstructive, and Aesthetic Surgery, Kirikkale University to undergo aesthetic surgery were enrolled in the study. Forty-three subjects who neither underwent nor planned to undergo aesthetic surgery at any time in their lives were included in the study as a control group. Psychometric evaluation of the patients and the control group was conducted using the Turkish version of the Minnesota Multiphasic Personality Inventory (MMPI. Results: Taking 65 as a cut-off point, the ratio of patients who scored and #8805;65 on the hysteria subscale of the MMPI was found to be significantly higher in the sugery group than in the control group and the ratio on social introversion subscale was also higher in the patient group than in the control group, very closely approaching significance. Conclusion: It should be kept in mind that people who have personality traits that can be partially improved with psyachiatric treatment, such as social introverted, lonely, timid, shy, and hysterical and feel the need for validation by others, may be more often admitted for aesthetic surgery. [Cukurova Med J 2016; 41(3.000: 554-558

  18. Cannabis use in patients with a first psychotic episode and subjects at ultra high risk of psychosis: impact on psychotic- and pre-psychotic symptoms.

    Science.gov (United States)

    Machielsen, Marise; van der Sluis, Suzanne; de Haan, Lieuwe

    2010-08-01

    Co-morbidity with cannabis use disorder is common in patients with a psychotic disorder and is associated with adverse outcome. This study aimed to determine prevalence of cannabis use disorder among patients with a psychotic disorder and subjects at ultra high risk of psychosis and to study the influence of cannabis use on severity of (pre-)psychotic symptomatology, psychosocial functioning and variables related to the course of the disorder in these patients. In this study 169 consecutively assessed patients with a psychotic disorder were included as well as 59 consecutively assessed subjects at ultra high risk of psychosis. 45% of the patients with a psychotic disorder and 27% of the UHR patients were diagnosed with a co-morbid cannabis use disorder. Patients with cannabis use disorders did not differ from patients without cannabis use disorder in severity of psychotic symptoms. However, excluding patients with substance use disorder other than cannabis use disorder resulted in higher scores on positive symptom levels for patients with cannabis use disorder compared to patients without any substance use disorder. Regarding ultra high risk patients, subjects with cannabis use disorder did not differ from subjects without cannabis use disorder on severity of pre-psychotic symptomatology. However, a negative correlation was found between the amount of cannabis used recently and scores on the pre-psychotic negative subscale. Our results suggest a specific association between cannabis abuse and psychotic symptomatology.

  19. Treatment of primary liver tumors with Yttrium-90 microspheres (TheraSphere) in high risk patients: analysis of survival and toxicities.

    Science.gov (United States)

    Reardon, Kelli A; McIntosh, Alyson F; Shilling, A Tanner; Hagspiel, Klaus D; Al-Osaimi, Abdullah; Berg, Carl; Caldwell, Stephen H; Northup, Patrick G; Angle, Fritz; Mulder, Robert; Rich, Tyvin A

    2009-02-01

    This retrospective study was undertaken to obtain information regarding the survival and toxicities after Yttrium-90 microspheres treatment in patients with primary liver malignancies. Baseline, treatment, and follow-up data were collected and analyzed for 21 patients treated with Yttrium-90 microspheres. Survival analysis was then performed. The results of this study showed that median survival for all the patients was 120 days. Twenty of 21 patients were categorized as high-risk with a median survival of 114 days. It was also found that one high-risk patient has survived 858 days with no recurrence of disease. Acute grade 3-5 toxicities were recorded for nine patients and consisted of elevations in AST and bilirubin, thrombocytopenia, abdominal pain, ascites, nausea, fatigue, and death. This study concluded that Yttrium-90 is a low-toxicity, outpatient alternative for individuals with liver cancer and without many options. The maximal value, however, may lie in the treatment of low-risk patients.

  20. Emergency general surgery in the geriatric patient.

    Science.gov (United States)

    Desserud, K F; Veen, T; Søreide, K

    2016-01-01

    Emergency general surgery in the elderly is a particular challenge to the surgeon in charge of their care. The aim was to review contemporary aspects of managing elderly patients needing emergency general surgery and possible alterations to their pathways of care. This was a narrative review based on a PubMed/MEDLINE literature search up until 15 September 2015 for publications relevant to emergency general surgery in the geriatric patient. The number of patients presenting as an emergency with a general surgical condition increases with age. Up to one-quarter of all emergency admissions to hospital may be for general surgical conditions. Elderly patients are a particular challenge owing to added co-morbidity, use of drugs and risk of poor outcome. Frailty is an important potential risk factor, but difficult to monitor or manage in the emergency setting. Risk scores are not available universally. Outcomes are usually severalfold worse than after elective surgery, in terms of both higher morbidity and increased mortality. A care bundle including early diagnosis, resuscitation and organ system monitoring may benefit the elderly in particular. Communication with the patient and relatives throughout the care pathway is essential, as indications for surgery, level of care and likely outcomes may evolve. Ethical issues should also be addressed at every step on the pathway of care. Emergency general surgery in the geriatric patient needs a tailored approach to improve outcomes and avoid futile care. Although some high-quality studies exist in related fields, the overall evidence base informing perioperative acute care for the elderly remains limited. © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd.

  1. Safety of Cosmetic Surgery in Adolescent Patients.

    Science.gov (United States)

    Yeslev, Max; Gupta, Varun; Winocour, Julian; Shack, R Bruce; Grotting, James C; Higdon, K Kye

    2017-10-01

    Limited surgical literature currently exists that evaluates postoperative complications after cosmetic surgery in adolescents. The purpose of this study was to determine the incidence of major postoperative complications in adolescent patients undergoing cosmetic surgery and compare their complication rates to older patients. A prospective cohort of patients undergoing cosmetic surgical procedures between 2008 and 2013 was identified from the CosmetAssure database. Demographics, clinical characteristics, surgical procedures, and major complications in adolescent patients (age 10-19 years) and older patients (≥20 years old) were compared. Risk factors analyzed included age, gender, body mass index, smoking, diabetes, type of surgical facility, procedure by body region, and combined procedures. Overall, 3519 adolescents and 124,409 older patients underwent cosmetic surgical procedures. The adolescent cohort contained more men (20.0% vs 6.0%, P cosmetic procedures. Adolescent patients had lower complications rates after face, breast, and body procedures compared to the older cohort. The most common postoperative complications in adolescent patients were hematoma (0.34%) and infection (0.28%). Cosmetic surgical procedures in adolescent patients are safe with a lower rate of major postoperative complications compared to older patients. 2. © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com

  2. Optimal hypofractionated conformal radiotherapy for large brain metastases in patients with high risk factors: a single-institutional prospective study

    International Nuclear Information System (INIS)

    Inoue, Hiroshi K; Sato, Hiro; Suzuki, Yoshiyuki; Saitoh, Jun-ichi; Noda, Shin-ei; Seto, Ken-ichi; Torikai, Kota; Sakurai, Hideyuki; Nakano, Takashi

    2014-01-01

    A single-institutional prospective study of optimal hypofractionated conformal radiotherapy for large brain metastases with high risk factors was performed based on the risk prediction of radiation-related complications. Eighty-eight patients with large brain metastases ≥10 cm 3 in critical areas treated from January 2010 to February 2014 using the CyberKnife were evaluated. The optimal dose and number of fractions were determined based on the surrounding brain volume circumscribed with a single dose equivalent (SDE) of 14 Gy (V14) to be less than 7 cm 3 for individual lesions. Univariate and multivariate analyses were conducted. As a result of optimal treatment, 92 tumors ranging from 10 to 74.6 cm 3 (median, 16.2 cm 3 ) in volume were treated with a median prescribed isodose of 57% and a median fraction number of five. In order to compare the results according to the tumor volume, the tumors were divided into the following three groups: 1) 10–19.9 cm 3 , 2) 20–29.9 cm 3 and 3) ≥30 cm 3 . The lesions were treated with a median prescribed isodose of 57%, 56% and 55%, respectively, and the median fraction number was five in all three groups. However, all tumors ≥20 cm 3 were treated with ≥ five fractions. The median SDE of the maximum dose in the three groups was 47.2 Gy, 48.5 Gy and 46.5 Gy, respectively. Local tumor control was obtained in 90.2% of the patients, and the median survival was nine months, with a median follow-up period of seven months (range, 3-41 months). There were no significant differences in the survival rates among the three groups. Six tumors exhibited marginal recurrence 7-36 months after treatment. Ten patients developed symptomatic brain edema or recurrence of pre-existing edema, seven of whom required osmo-steroid therapy. No patients developed radiation necrosis requiring surgical resection. Our findings demonstrate that the administration of optimal hypofractionated conformal radiotherapy based on the dose-volume prediction

  3. Retinoid and carotenoid status in serum and liver among patients at high-risk for liver cancer.

    Science.gov (United States)

    Kataria, Yachana; Deaton, Ryan J; Enk, Erika; Jin, Ming; Petrauskaite, Milita; Dong, Linlin; Goldenberg, Joseph R; Cotler, Scott J; Jensen, Donald M; van Breemen, Richard B; Gann, Peter H

    2016-02-29

    Approximately 2.7 million Americans are chronically infected with hepatitis C virus (HCV). HCV patients with cirrhosis form the largest group of persons at high risk for hepatocellular carcinoma (HCC). Increased oxidative stress is regarded as a major mechanism of HCV-related liver disease progression. Deficiencies in retinoid and carotenoid antioxidants may represent a major modifiable risk factor for disease progression. This study aims to identify key predictors of serum antioxidant levels in patients with HCV, to examine the relationship between retinoid/carotenoid concentrations in serum and hepatic tissue, to quantify the association between systemic measures of oxidative stress and antioxidant status, and to examine the relationship between retinoids and stellate cell activation. Patients undergoing liver biopsy (n = 69) provided fasting blood, fresh tissue, urine and completed a diet history questionnaire. Serum and questionnaire data from healthy volunteers (n = 11), normal liver tissue from public repositories and patients without liver disease (n = 11) were also collected. Urinary isoprostanes, serum and tissue retinoid concentrations were obtained by UHPLC-MS-MS. Immunohistochemistry for αSMA was performed on FFPE sections and subsequently quantified via digital image analysis. Associations between urinary isoprostanes, αSMA levels, and retinoids were assessed using Spearman correlation coefficients and non-parametric tests were utilized to test differences among disease severity groups. There was a significant inverse association between serum retinol, lycopene, and RBP4 concentrations with fibrosis stage. Serum β-carotene and lycopene were strongly associated with their respective tissue concentrations. There was a weak downward trend of tissue retinyl palmitate with increasing fibrosis stage. Tissue retinyl palmitate was inversely and significantly correlated with hepatic αSMA expression, a marker for hepatic stellate cell activation (r = -0

  4. Dose-Escalated Stereotactic Body Radiation Therapy for Patients With Intermediate- and High-Risk Prostate Cancer: Initial Dosimetry Analysis and Patient Outcomes

    Energy Technology Data Exchange (ETDEWEB)

    Kotecha, Rupesh; Djemil, Toufik; Tendulkar, Rahul D.; Reddy, Chandana A.; Thousand, Richard A.; Vassil, Andrew [Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio (United States); Stovsky, Mark; Berglund, Ryan K.; Klein, Eric A. [Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio (United States); Stephans, Kevin L., E-mail: stephak@ccf.org [Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio (United States)

    2016-07-01

    Purpose: To report the short-term clinical outcomes and acute and late treatment-related genitourinary (GU) and gastrointestinal (GI) toxicities in patients with intermediate- and high-risk prostate cancer treated with dose-escalated stereotactic body radiation therapy (SBRT). Methods and Materials: Between 2011 and 2014, 24 patients with prostate cancer were treated with SBRT to the prostate gland and proximal seminal vesicles. A high-dose avoidance zone (HDAZ) was created by a 3-mm expansion around the rectum, urethra, and bladder. Patients were treated to a minimum dose of 36.25 Gy in 5 fractions, with a simultaneous dose escalation to a dose of 50 Gy to the target volume away from the HDAZ. Acute and late GU and GI toxicity outcomes were measured according to the National Cancer Institute Common Terminology Criteria for Adverse Events toxicity scale, version 4. Results: The median follow-up was 25 months (range, 18-45 months). Nine patients (38%) experienced an acute grade 2 GU toxicity, which was medically managed, and no patients experienced an acute grade 2 GI toxicity. Two patients (8%) experienced late grade 2 GU toxicity, and 2 patients (8%) experienced late grade 2 GI toxicity. No acute or late grade ≥3 GU or GI toxicities were observed. The 24-month prostate-specific antigen relapse-free survival outcome for all patients was 95.8% (95% confidence interval 75.6%-99.4%), and both biochemical failures occurred in patients with high-risk disease. All patients are currently alive at the time of this analysis and continue to be followed. Conclusions: A heterogeneous prostate SBRT planning technique with differential treatment volumes (low dose: 36.25 Gy; and high dose: 50 Gy) with an HDAZ provides a safe method of dose escalation. Favorable rates of biochemical control and acceptably low rates of acute and long-term GU and GI toxicity can be achieved in patients with intermediate- and high-risk prostate cancer treated with SBRT.

  5. Dose-Escalated Stereotactic Body Radiation Therapy for Patients With Intermediate- and High-Risk Prostate Cancer: Initial Dosimetry Analysis and Patient Outcomes

    International Nuclear Information System (INIS)

    Kotecha, Rupesh; Djemil, Toufik; Tendulkar, Rahul D.; Reddy, Chandana A.; Thousand, Richard A.; Vassil, Andrew; Stovsky, Mark; Berglund, Ryan K.; Klein, Eric A.; Stephans, Kevin L.

    2016-01-01

    Purpose: To report the short-term clinical outcomes and acute and late treatment-related genitourinary (GU) and gastrointestinal (GI) toxicities in patients with intermediate- and high-risk prostate cancer treated with dose-escalated stereotactic body radiation therapy (SBRT). Methods and Materials: Between 2011 and 2014, 24 patients with prostate cancer were treated with SBRT to the prostate gland and proximal seminal vesicles. A high-dose avoidance zone (HDAZ) was created by a 3-mm expansion around the rectum, urethra, and bladder. Patients were treated to a minimum dose of 36.25 Gy in 5 fractions, with a simultaneous dose escalation to a dose of 50 Gy to the target volume away from the HDAZ. Acute and late GU and GI toxicity outcomes were measured according to the National Cancer Institute Common Terminology Criteria for Adverse Events toxicity scale, version 4. Results: The median follow-up was 25 months (range, 18-45 months). Nine patients (38%) experienced an acute grade 2 GU toxicity, which was medically managed, and no patients experienced an acute grade 2 GI toxicity. Two patients (8%) experienced late grade 2 GU toxicity, and 2 patients (8%) experienced late grade 2 GI toxicity. No acute or late grade ≥3 GU or GI toxicities were observed. The 24-month prostate-specific antigen relapse-free survival outcome for all patients was 95.8% (95% confidence interval 75.6%-99.4%), and both biochemical failures occurred in patients with high-risk disease. All patients are currently alive at the time of this analysis and continue to be followed. Conclusions: A heterogeneous prostate SBRT planning technique with differential treatment volumes (low dose: 36.25 Gy; and high dose: 50 Gy) with an HDAZ provides a safe method of dose escalation. Favorable rates of biochemical control and acceptably low rates of acute and long-term GU and GI toxicity can be achieved in patients with intermediate- and high-risk prostate cancer treated with SBRT.

  6. Prevention of heterotopic bone formation with early post operative irradiation in high risk patients undergoing total hip arthroplasty: comparison of 10.00 Gy vs 20.00 Gy schedules

    International Nuclear Information System (INIS)

    Anthony, P.; Keys, H.; Evarts, C.M.; Rubin, P.; Lush, C.

    1987-01-01

    Prior studies have demonstrated the effectiveness of postoperative radiation therapy (RT) to the hip area following total hip replacement (THR) surgery in preventing the development of heterotopic bone formation in patients considered to be at high risk for development of this complication. Previously, patients received 20.00 Gy in 10 fractions (fx) over 2 weeks, beginning as soon postop as medically feasible (usually post-op day 2). In an effort to reduce hospital stay and risk of secondary malignancy, a prospective treatment program was initiated April 1982 using a reduced dose of 10.00 Gy in 5 fx over 5-7 days. As of February 1984, 46 consecutive hips determined to be at high risk were treated with this reduced dose. Prior studies have demonstrated that heterotopic bone is always radiographically evident by 8 weeks. Of the 46 hips, 41 had been evaluated with the minimum required 8 week follow-up X ray. Twenty-five of these hips, 61%, had a mean long term follow-up of 12 months. It historical control group, consisting of 54 consecutive high risk post-THR's, was shown to have a 68.5% incidence of heterotopic bone. The 20.00 Gy group, when RT was started by post-op day 5, demonstrated a 3.2% incidence, compared to 4.9% in the 10.00 Gy group. Complication rates were also comparable in the two RT groups, 19.4% and 7.3% respectively; 10.00 Gy is apparently as effective as 20.00 Gy in preventing heterotopic bone formation in high risk post-THR patients

  7. Low Rate of Detection of Mucosal High-Risk-Type Human Papillomavirus in Korean Patients with Extragenital Bowen's Disease and Squamous Cell Carcinoma, Especially in Digital Cases

    Directory of Open Access Journals (Sweden)

    Hye-Rim Park

    2013-01-01

    Full Text Available Human papillomavirus (HPV infection has been demonstrated in some of the nonmelanoma skin cancers as well as in precancerous lesions. Multiple infections of mucosal high-risk HPV may contribute to the onset of digital Bowen's disease through, if any, digital-genital transmission. We screened for the presence of the mucosal HPV DNA in patients with extragenital Bowen's disease (, squamous cell carcinoma (, bowenoid papulosis (, verrucous carcinoma (, actinic keratosis (, and basal cell carcinoma (. We used a PANArray HPV Genotyping Chip for high-risk and low-risk mucosal types. Genotyping data was confirmed using a conventional direct DNA sequencing method. Two cases of extragenital Bowen's disease were positive for types 16 and 33 of mucosal HPV, respectively. None of the squamous cell carcinoma cases were positive. Neither patients with digital Bowen's disease ( nor those with squamous cell carcinoma ( showed any mucosal high-risk HPV. Mucosal high-risk HPV DNA was confirmed in 5 (55.6% of the 9 patients with bowenoid papulosis. HPV 16 was most prevalent (, while the DNA of HPVs 35 and 67 was detected in one sample for each of the two types. Our study demonstrated that two (6.7% of the patients with 30 extragenital Bowen's disease were positive for types 16 and 33 of mucosal HPV, respectively. HPVs belonging to the mucosal high-risk group may participate in the development of extragenital Bowen's disease. However, we could not find any relationship between the mucosal high-risk HPV and Bowen's disease or squamous cell carcinoma in the fingers.

  8. Patients' existential situation prior to colorectal surgery.

    Science.gov (United States)

    Moene, Monica; Bergbom, Ingegerd; Skott, Carola

    2006-04-01

    The aim of this paper is to present a hermeneutic phenomenological study illuminating patients' existential situation prior to colorectal surgery. The intention was also to explore the value of the encounter between patient and nurse. Patients waiting for major surgery experience multifarious reactions. Emotions of anxiety, fears of the unknown, anaesthesia, cancer diagnosis and death can arise. Several earlier studies have reported the importance of information, coping strategies and the need to reduce anxiety and stress in relation to surgery. However, there is a lack of studies focusing on patients' existential situation in the preoperative phase. Conversational interviews were conducted with 28 patients 1 week before their surgery during autumn 2002. Analysis of the data was influenced by van Manen's existential themes: lived space/spatiality, lived body/corporeality, lived time/temporality and lived relation/relationality. Participants expressed either hope of increased spatiality or fear of restricted spatiality, according to whether they had a benign or malign diagnosis. Statements about lived time were also related to the diagnosis. Patients waiting for surgery for a benign diagnosis could use the time to relax and gather energy, while malignancy gave them high levels of anxiety and stress. Lived body experiences showed the ambivalence felt in entrusting one's body to professionals. Statements about lived relations drew attention to the need for considerate caregivers to enhance feelings of security and continuity. The existential situation of patients in a preoperative context was shown to be a state of uncertainty with regard to lived space, body, time and relation. The significance of meeting and talking to the nurse did not appear in the statements. The nurse was invisible. If nurses were to employ the existential themes proposed by van Manen in preoperative encounter with patients, their need for care might be more clearly identified and affirmed.

  9. Preclinical pharmacology, efficacy, and safety of varenicline in smoking cessation and clinical utility in high risk patients

    Directory of Open Access Journals (Sweden)

    Zheng-Xiong Xi

    2010-04-01

    Full Text Available Zheng-Xiong XiNational Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, USAAbstract: Smoking is still the most prominent cause of preventable premature death in the United States and an increasing cause of morbidity and mortality throughout the world. Although the current treatments such as nicotine replacement therapy (NRT and bupropion are effective, long-term abstinence rates are low. Mechanism studies suggest that the pleasurable effects of smoking are mediated predominantly by nicotine, which activates the brain reward system by activation of brain α4β2 nicotinic acetylcholine receptors (nAChRs. Varenicline is a novel α4β2 nAChR partial agonist and has been found to be even more effective than NRT or bupropion in attenuating smoking satisfaction and in relieving craving and withdrawal symptoms after abstinence. Thus, varenicline has been recently approved to be a first-line medication for smoking cessation in the United States and European countries. Varenicline is generally well tolerated in healthy adult smokers, with the most commonly reported adverse effects being nausea, insomnia, and headache. However, growing postmarketing data has linked varenicline to an increase in neuropsychiatric symptoms such as seizures, suicidal attempts, depression, and psychosis as well as serious injuries potentially relating to unconsciousness, dizziness, visual disturbances, or movement disorders. Therefore, new safety warnings are issued to certain high risk populations, such as patients with mental illness and operators of commercial vehicles and heavy machinery. In particular, pilots, air traffic controllers, truck and bus drivers have been banned from taking varenicline.Keywords: nicotine, varenicline, α4β2 nicotinic acetylcholine receptor, nAChRs, partial agonist, smoking cessation

  10. Incremental prognostic value of coronary computed tomographic angiography high-risk plaque characteristics in newly symptomatic patients.

    Science.gov (United States)

    Fujimoto, Shinichiro; Kondo, Takeshi; Takamura, Kazuhisa; Baber, Usman; Shinozaki, Tomohiro; Nishizaki, Yuji; Kawaguchi, Yuko; Matsumori, Rie; Hiki, Makoto; Miyauchi, Katsumi; Daida, Hiroyuki; Hecht, Harvey; Stone, Gregg W; Narula, Jagat

    2016-06-01

    The incremental prognostic value of the plaque features in coronary computed tomographic angiography (CTA) has not been well assessed. This study was designed to determine whether CTA high-risk plaques have prognostic value incremental to the Framingham risk score (FRS) and the severity of luminal obstruction. A total of 628 newly symptomatic patients without known coronary artery disease underwent CTA. They were followed for a median of 677 days during which there were 26 cardiac events, including cardiac death, acute myocardial infarction, and hospitalization for unstable angina. Incremental prognostic value of adding plaque characteristics to the number of diseased vessels and the FRS was evaluated using 3 Cox models and net reclassification indexes. The discrimination index was significantly increased by adding the number of diseased vessels to the FRS (change in c-statistic from 65.8% to 78.6%, p=0.028) but not significantly by further adding plaque characteristics (change in c-statistic from 78.6% to 80.0%, p=0.812). However, improved model-fitting by adding plaque characteristics into the linear combination with risk score and the number of diseased vessels (p=0.007 from likelihood ratio test) and the lowest value of Akaike's information criteria of that model indicated that plaque characteristics improved both predictive accuracy and discrimination perspective. More subjects reclassified by plaque characteristics were moved to directions consistent with their subsequent cardiac event status than in an inconsistent direction. Evaluation of CTA plaque characteristics may provide incremental prognostic value to the number of diseased vessels and the FRS. Copyright © 2015 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

  11. Venous thromboembolism prevention in patients undergoing colorectal surgery for cancer.

    Science.gov (United States)

    Holwell, Anna; McKenzie, Jo-Lyn; Holmes, Miranda; Woods, Rodney; Nandurkar, Harshal; Tam, Constantine S; Bazargan, Ali

    2014-04-01

    Patients undergoing surgery for colorectal cancer are at high risk of post-operative venous thromboembolism (VTE). Thromboprophylaxis has been shown to have significant risk reduction, although there remains some controversy surrounding the optimal duration of pharmacological prophylaxis. Our institution does not routinely practise extended prophylaxis. The aim of this study was to retrospectively review the rate of post-operative thromboprophylaxis in colorectal cancer patients, and incidence of symptomatic VTE. We conducted a retrospective audit of 200 consecutive patients who underwent colorectal surgery for cancer. Data to 90 days post-operatively were collected from medical records and imaging and phone calls to patients and family practitioners. Of the patients, 98% received pharmacological prophylaxis, with a median duration of eight days. Eight (4%) symptomatic VTEs were diagnosed within the 90-day follow-up period: two deep vein thrombosis (DVTs), five pulmonary emboli (PE) and one patient with both PE and DVT. A higher proportion of patients developed DVT/PE if they received prophylaxis other than low molecular weight heparin and similarly there was a trend in increased risk of DVT in the presence of metastatic disease. However, using univariate analysis, these results were not statistically significant (P = 0.18 and 0.11, respectively). The use of thromboprophylaxis was high in our centre, and the incidence of VTE was low when patients received a median of 8 days pharmacological prophylaxis combined with mechanical prophylaxis. The VTE incidence of 4% is similar to previous studies using extended prophylaxis. Our study findings do not support changing local protocol to extended prophylaxis. © 2013 Royal Australasian College of Surgeons.

  12. Continued Benefit to Androgen Deprivation Therapy for Prostate Cancer Patients Treated With Dose-Escalated Radiation Therapy Across Multiple Definitions of High-Risk Disease

    International Nuclear Information System (INIS)

    Stenmark, Matthew H.; Blas, Kevin; Halverson, Schuyler; Sandler, Howard M.; Feng, Felix Y.; Hamstra, Daniel A.

    2011-01-01

    Purpose: To analyze prognostic factors in patients with high-risk prostate cancer treated with dose-escalated external-beam radiation therapy (EBRT) and androgen deprivation (ADT). Methods and Materials: Between 1998 and 2008 at University of Michigan Medical Center, 718 men were consecutively treated with EBRT to at least 75 Gy. Seven definitions of high-risk prostate cancer, applying to 11–33% of patients, were evaluated. Biochemical failure (BF), salvage ADT use, metastatic progression, and prostate cancer–specific mortality (PCSM) were estimated by the Kaplan-Meier method and Cox proportional hazards regression. Results: Each high-risk definition was associated with increased BF (hazard ratio [HR] 2.8–3.9, p < 0.0001), salvage ADT use (HR 3.9–6.3, p < 0.0001), metastasis (HR 3.7–6.6, p < 0.0001), and PCSM (HR 3.7–16.2, p < 0.0001). Furthermore, an increasing number of high-risk features predicted worse outcome. Adjuvant ADT yielded significant reductions in both metastases (HR 0.19–0.38, p < 0.001) and PCSM (HR 0.38–0.50, p < 0.05) for all high-risk definitions (with the exception of clinical Stage T3–4 disease) but improved BF only for those with elevated Gleason scores (p < 0.03, HR 0.25–0.48). When treated with ADT and dose-escalated EBRT, patients with Gleason scores 8 to 10, without other high-risk features, had 8-year freedom from BF of 74%, freedom from distant metastases of 93%, and cause-specific survival of 92%, with salvage ADT used in 16% of patients. Conclusion: Adjuvant ADT results in a significant improvement in clinical progression and PCSM across multiple definitions of high-risk disease even with dose-escalated EBRT. There is a subset of patients, characterized by multiple high-risk features or the presence of Gleason Pattern 5, who remain at significant risk for metastasis and PCSM despite current treatment.

  13. Conservation laryngeal surgery in the elderly patient.

    Science.gov (United States)

    Tucker, H M

    1977-12-01

    In the 100 years since Bilroth first undertook a total laryngectomy, general improvements in the prevention and management of childhood and adult disease have led to continuing increase in life expectancy to the point that, in many developed countries, 25% or more of the population is over the age of 65. Although many of these individuals are in otherwise reasonable health, major head and neck procedures are often not performed in favor of radiation therapy for cure, even for lesions that would otherwise be considered amenable to surgery in younger patients, on the grounds that the patient is too old to tolerate the necessary procedure. The same argument has been employed in favoring total laryngectomy over subtotal procedures in the older patient. Review of the author's experience (27 cases) with conservation laryngeal surgery in patients over the age of 65 at the time treatment was undertaken reveals that such procedures are well tolerated in this age group. There were no mortalities and an overall complication rate of 11.1% resulted. These findings compare favorably with complication rates reported for similar patients and surgery in the under 65 age group and strongly suggest that chronologic age alone need not be a contraindication to such surgery.

  14. Effect of Self-monitoring and Medication Self-titration on Systolic Blood Pressure in Hypertensive Patients at High Risk of Cardiovascular Disease

    OpenAIRE

    McManus, Richard J.; Mant, Jonathan; Haque, M. Sayeed; Bray, Emma P.; Bryan, Stirling; Greenfield, Sheila M.; Jones, Miren I.; Jowett, Sue; Little, Paul; Penaloza, Cristina; Schwartz, Claire; Shackleford, Helen; Shovelton, Claire; Varghese, Jinu; Williams, Bryan

    2014-01-01

    IMPORTANCE: Self-monitoring of blood pressure with self-titration of antihypertensives (self-management) results in lower blood pressure in patients with hypertension, but there are no data about patients in high-risk groups.\\ud \\ud OBJECTIVE: To determine the effect of self-monitoring with self-titration of antihypertensive medication compared with usual care on systolic blood pressure among patients with cardiovascular disease, diabetes, or chronic kidney disease.\\ud \\ud DESIGN, SETTING, AN...

  15. Dysfunctional Brain Networking among Autonomic Regulatory Structures in Temporal Lobe Epilepsy Patients at High Risk of Sudden Unexpected Death in Epilepsy.

    Science.gov (United States)

    Allen, Luke A; Harper, Ronald M; Kumar, Rajesh; Guye, Maxime; Ogren, Jennifer A; Lhatoo, Samden D; Lemieux, Louis; Scott, Catherine A; Vos, Sjoerd B; Rani, Sandhya; Diehl, Beate

    2017-01-01

    Sudden unexpected death in epilepsy (SUDEP) is common among young people with epilepsy. Individuals who are at high risk of SUDEP exhibit regional brain structural and functional connectivity (FC) alterations compared with low-risk patients. However, less is known about network-based FC differences among critical cortical and subcortical autonomic regulatory brain structures in temporal lobe epilepsy (TLE) patients at high risk of SUDEP. 32 TLE patients were risk-stratified according to the following clinical criteria: age of epilepsy onset, duration of epilepsy, frequency of generalized tonic-clonic seizures, and presence of nocturnal seizures, resulting in 14 high-risk and 18 low-risk cases. Resting-state functional magnetic resonance imaging (rs-fMRI) signal time courses were extracted from 11 bilateral cortical and subcortical brain regions involved in autonomic and other regulatory processes. After computing all pairwise correlations, FC matrices were analyzed using the network-based statistic. FC strength among the 11 brain regions was compared between the high- and low-risk patients. Increases and decreases in FC were sought, using high-risk > low-risk and low-risk > high-risk contrasts (with covariates age, gender, lateralization of epilepsy, and presence of hippocampal sclerosis). High-risk TLE patients showed a subnetwork with significantly reduced FC ( t  = 2.5, p  = 0.029) involving the thalamus, brain stem, anterior cingulate, putamen and amygdala, and a second subnetwork with significantly elevated FC ( t  = 2.1, p  = 0.031), which extended to medial/orbital frontal cortex, insula, hippocampus, amygdala, subcallosal cortex, brain stem, thalamus, caudate, and putamen. TLE patients at high risk of SUDEP showed widespread FC differences between key autonomic regulatory brain regions compared to those at low risk. The altered FC revealed here may help to shed light on the functional correlates of autonomic disturbances in epilepsy

  16. Four cycles of adriamycin and cyclophosphamide followed by four cycles of docetaxel (NSABP-B27 with concomitant trastuzumab as neoadjuvant therapy for high-risk, early-stage, HER2-positive breast cancer patients

    Directory of Open Access Journals (Sweden)

    Abdel-Razeq H

    2018-04-01

    Full Text Available Hikmat Abdel-Razeq,1,2 Salwa S Saadeh,1 Mahmoud Abu-Nasser,1 Hazem Abdulelah,1 Lina Marie,1 Murad Salam,1 Basel Al-Haj Ali,1 Mohammad Ibrahim,1 Dalia Rimawi3 1Department of Internal Medicine, Section of Hematology and Medical Oncology, King Hussein Cancer Center, Amman, Jordan; 2School of Medicine, University of Jordan, Amman, Jordan; 3Office of Scientific Affairs and Research, King Hussein Cancer Center, Amman, Jordan Background: The majority of breast cancer patients in Jordan are diagnosed at a young age and present with metastatic or locally advanced disease. The National Surgical Adjuvant Breast and Bowel Project Protocol B27 (NSABP-B27 (four cycles of adriamycin and cyclophosphamide [AC] followed by four cycles of docetaxel is a standard neoadjuvant regimen in our institution. In this study, we report the efficacy of adding trastuzumab to docetaxel in this regimen for high-risk human epidermal growth factor receptor 2 (HER2-positive early-stage disease. Patients and methods: Consecutive HER2-positive breast cancer patients treated with this regimen were included. Treatment was given at standard doses and schedules as reported in NSABP-B27. Trastuzumab was given with docetaxel and then continued for 1 year. Results: A total of 121 patients (mean age 45.4 years were included. The majority had high-risk features including large tumor size, positive axillary lymph nodes, and grade III disease. Three patients did not complete the planned cycles of AC due to a lack of response. Eight (6.6% patients missed at least one cycle of docetaxel. Following neoadjuvant therapy, 119 patients underwent surgery, of whom 59 (49.6% patients achieved pathological complete response. The response was higher in node-negative patients (64.0 vs 45.7%; P=0.03 and in hormone receptor-negative disease patients (69.7 vs 41.9%; P=0.018. Breast-conserving surgery was performed in 21.5% of the patients. The median disease-free survival (DFS for the whole group was not

  17. Influence of highly active antiretroviral therapy on the development of CMV disease in HIV positive patients at high risk for CMV disease

    NARCIS (Netherlands)

    Verbraak, F. D.; Boom, R.; Wertheim-van Dillen, P. M.; van den Horn, G. J.; Kijlstra, A.; de Smet, M. D.

    1999-01-01

    In the pre-HAART era, HIV positive patients with CD4+ cell counts below 50 cells x10(6)/l, and those with detectable cytomegalovirus (CMV) DNA in their peripheral blood, were considered to be at high risk for the development of CMV disease. With the start of highly active antiretroviral therapy

  18. Influence of highly active antiretroviral therapy on the development of CMV disease in HIV positive patients at high risk for CMV disease

    NARCIS (Netherlands)

    Verbraak, F.D.; Boom, R.; Wertheim-van Dillen, P.M.E.; Horn, van den G.J.; Kijlstra, A.; Smet, de M.D.

    1999-01-01

    Background/aims. In the pre-HAART era, HIV positive patients with CD4+ cell counts below 50 cells x 106/l, and those with detectable cytomegalovirus (CMV) DNA in their peripheral blood, were considered to be at high risk for the development of CMV disease. With the start of highly active

  19. Maintenance treatment with azacytidine for patients with high-risk myelodysplastic syndromes (MDS) or acute myeloid leukaemia following MDS in complete remission after induction chemotherapy

    DEFF Research Database (Denmark)

    Grövdal, Michael; Karimi, Mohsen; Khan, Rasheed

    2010-01-01

    This prospective Phase II study is the first to assess the feasibility and efficacy of maintenance 5-azacytidine for older patients with high-risk myelodysplastic syndrome (MDS), chronic myelomonocytic leukaemia and MDS-acute myeloid leukaemia syndromes in complete remission (CR) after induction...

  20. Fecal bile acid excretion and messenger RNA expression levels of ileal transporters in high risk gallstone patients

    Directory of Open Access Journals (Sweden)

    Miquel Juan

    2009-12-01

    Full Text Available Abstract Background Cholesterol gallstone disease (GS is highly prevalent among Hispanics and American Indians. In GS, the pool of bile acids (BA is decreased, suggesting that BA absorption is impaired. In Caucasian GS patients, mRNA levels for ileal BA transporters are decreased. We aimed to determine fecal BA excretion rates, mRNA levels for ileal BA transporter genes and of regulatory genes of BA synthesis in Hispanic GS patients. Results Excretion of fecal BA was measured in seven GS females and in ten GS-free individuals, all with a body mass index 2O3 (300 mg/day for 10 days, and fecal specimens were collected on the last 3 days. Chromium was measured by a colorimetric method, and BA was quantitated by gas chromatography/mass spectroscopy. Intake of calories, nutrients, fiber and cholesterol were similar in the GS and GS-free subjects. Mean BA excretion levels were 520 ± 80 mg/day for the GS-free group, and 461 ± 105 mg/day for the GS group. Messenger RNA expression levels were determined by RT-PCR on biopsy samples obtained from ileum during diagnostic colonoscopy (14 GS-free controls and 16 GS patients and from liver during surgery performed at 8 and 10 AM (12 GS and 10 GS-free patients operated on for gastrointestinal malignancies, all with a body mass index Conclusion Hispanics with GS have fecal BA excretion rates and mRNA levels of genes for ileal BA transporters that are similar to GS-free subjects. However, mRNA expression levels of Cyp7A1 are increased in GS, indicating that regulation of BA synthesis is abnormal in Hispanics with GS.

  1. A Clinical Algorithm to Identify HIV Patients at High Risk for Incident Active Tuberculosis: A Prospective 5-Year Cohort Study.

    Directory of Open Access Journals (Sweden)

    Susan Shin-Jung Lee

    Full Text Available Predicting the risk of tuberculosis (TB in people living with HIV (PLHIV using a single test is currently not possible. We aimed to develop and validate a clinical algorithm, using baseline CD4 cell counts, HIV viral load (pVL, and interferon-gamma release assay (IGRA, to identify PLHIV who are at high risk for incident active TB in low-to-moderate TB burden settings where highly active antiretroviral therapy (HAART is routinely provided.A prospective, 5-year, cohort study of adult PLHIV was conducted from 2006 to 2012 in two hospitals in Taiwan. HAART was initiated based on contemporary guidelines (CD4 count < = 350/μL. Cox regression was used to identify the predictors of active TB and to construct the algorithm. The validation cohorts included 1455 HIV-infected individuals from previous published studies. Area under the receiver operating characteristic (ROC curve was calculated.Seventeen of 772 participants developed active TB during a median follow-up period of 5.21 years. Baseline CD4 < 350/μL or pVL ≥ 100,000/mL was a predictor of active TB (adjusted HR 4.87, 95% CI 1.49-15.90, P = 0.009. A positive baseline IGRA predicted TB in patients with baseline CD4 ≥ 350/μL and pVL < 100,000/mL (adjusted HR 6.09, 95% CI 1.52-24.40, P = 0.01. Compared with an IGRA-alone strategy, the algorithm improved the sensitivity from 37.5% to 76.5%, the negative predictive value from 98.5% to 99.2%. Compared with an untargeted strategy, the algorithm spared 468 (60.6% from unnecessary TB preventive treatment. Area under the ROC curve was 0.692 (95% CI: 0.587-0.798 for the study cohort and 0.792 (95% CI: 0.776-0.808 and 0.766 in the 2 validation cohorts.A validated algorithm incorporating the baseline CD4 cell count, HIV viral load, and IGRA status can be used to guide targeted TB preventive treatment in PLHIV in low-to-moderate TB burden settings where HAART is routinely provided to all PLHIV. The implementation of this algorithm will avoid unnecessary

  2. Muscle strength and functional performance in patients at high risk of knee osteoarthritis: a follow-up study

    DEFF Research Database (Denmark)

    Thorlund, Jonas Bloch; Aagaard, Per; Roos, Ewa M.

    2012-01-01

    PURPOSE: To investigate whether changes from 2 to 4 years post arthroscopic partial meniscectomy (APM) in mechanical muscle function and objectively measured function differ between the operated and contra-lateral leg of APM patients or compared with controls. METHODS: Twenty-two patients (age 46.......6 ± 5.0, BMI 24.7 ± 2.9) and 25 controls (age 46.4 ± 5.2, BMI 25.1 ± 4.6) previously examined at ~2 years post APM were examined again at ~4 years post surgery for maximal knee extensor/flexor voluntary contraction (MVC) and rapid force capacity. Functional performance was assessed by the distance achieved...... during a one-leg hop test and the maximum number of knee bends performed in 30 s. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was used to evaluate self-reported outcomes. RESULTS: Overall changes from 2 to 4 years post APM did not differ in maximal muscle strength, rapid force capacity...

  3. Patients undergoing dacryocystorhinostomy surgery in northern Iran ...

    African Journals Online (AJOL)

    The authors suggest regarding high prevalence of sinusitis and allergies in Northern Iran, checking by ENT specialist is beneficial to exact diagnosis and programming for treatment of this kind of patients. Keywords: Dacryocystitis, Dacryocystorhinostomy surgery, Mucopurulent, Nasolacrimal duct obstruction, Tearing ...

  4. PATIENT SATISFACTION WITH TRICHIASIS SURGERY IN JIGAWA ...

    African Journals Online (AJOL)

    FOBUR

    PATIENT SATISFACTION WITH TRICHIASIS SURGERY IN JIGAWA STATE, NIGERIA. 1. 2. 3. 1. 1. Ramyil Alice , Bascaran Covadonga , Bunce Catey , Oyediji Funmilayo , Mpyet Caleb. 1Department of Ophthalmology University of Jos and Jos University Teaching Hospital, Nigeria. 2International Centre for Eye Health, ...

  5. [(18)F]Fluorodeoxyglucose - positron emission tomography/computed tomography improves staging in patients with high-risk muscle-invasive bladder cancer scheduled for radical cystectomy.

    Science.gov (United States)

    Kollberg, Petter; Almquist, Helen; Bläckberg, Mats; Cronberg, Carin; Garpered, Sabine; Gudjonsson, Sigurdur; Kleist, Jakob; Lyttkens, Kerstin; Patschan, Oliver; Liedberg, Fredrik

    2015-01-01

    The aim of this study was to evaluate the clinical use of [(18)F]fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) in addition to conventional preoperative radiological investigations in a defined group of patients with high-risk muscle-invasive bladder cancer. In total, 103 patients with high-risk muscle-invasive bladder cancer defined as stage T3/T4 disease or as stage T2 with hydronephrosis or high-risk histological features, who were provisionally scheduled to undergo cystectomy, were prospectively recruited to the study. The patients were referred to FDG-PET/CT in addition to standard preoperative investigation with computed tomography (CT). The final treatment decision was reached at a multidisciplinary conference based on all available information including the FDG-PET/CT findings. Compared to CT alone, FDG-PET/CT provided more supplemental findings suggesting malignant manifestations in 48 (47%) of the 103 patients. The additional FDG-PET/CT findings led to an altered provisional treatment plan in 28 out of 103 patients (27%), detection of disseminated bladder cancer and subsequent cancellation of the initially intended cystectomy in 16 patients, and identification of disseminated disease and treatment with induction chemotherapy before radical cystectomy in 12 patients. Preoperative FDG-PET/CT changed the treatment plan for a considerable proportion (27%) of the present patients. Accordingly, such examination can potentially improve the preoperative staging of cystectomy patients with high-risk features, and may also reduce the number of futile operations in patients with advanced disease who are beyond cure.

  6. A randomized-clinical trial examining a neoprene abdominal binder in gynecologic surgery patients

    Science.gov (United States)

    Szender, J.B.; Hall, K.L.; Kost, E.R.

    2016-01-01

    Summary Purpose of Investigation Pain control and early ambulation are two important postoperative goals. Strategies that decrease morphine use while increasing ambulation have the potential to decrease postoperative complications. In this study the authors sought to determine the effect of an abdominopelvic binder on postoperative morphine use, pain, and ambulation in the first day after surgery. Materials and Methods The authors randomly assigned 75 patients undergoing abdominal gynecologic surgery to either binder or not after surgery. Demographic data and surgical characteristics were collected. Outcome variables included morphine use, pain score, time to ambulation, and number of ambulations. Results A group at high risk for decreased mobility was identified and the binder increased the number of ambulatory events by 300%, 260%, and 240% in patients with vertical incisions, age over 50 years, and complex surgeries, respectively. Morphine use and pain scores were not significantly different. Conclusion The binder increased ambulations in the subset of patients at the highest risk for postoperative complications: elderly, cancer patients, and vertical incisions. Routine use of the binder may benefit particularly high-risk gynecologic surgical patients. PMID:25864252

  7. Hemostatic function to regulate perioperative bleeding in patients undergoing spinal surgery: A prospective observational study.

    Directory of Open Access Journals (Sweden)

    Atsushi Kimura

    Full Text Available Although bleeding is a common complication of surgery, routine laboratory tests have been demonstrated to have a low ability to predict perioperative bleeding. Better understanding of hemostatic function during surgery would lead to identification of high-risk patients for bleeding. Here, we aimed to elucidate hemostatic mechanisms to determine perioperative bleeding. We prospectively enrolled 104 patients undergoing cervical spinal surgery without bleeding diathesis. Blood sampling was performed just before the operation. Volumes of perioperative blood loss were compared with the results of detailed laboratory tests assessing primary hemostasis, secondary hemostasis, and fibrinolysis. Platelet aggregations induced by several agonists correlated with each other, and only two latent factors determined inter-individual difference. Platelet aggregability independently determined perioperative bleeding. We also identified low levels of plasminogen-activator inhibitor-1 (PAI-1 and α2-plasmin inhibitor to be independent risk factors for intraoperative and postoperative bleeding, respectively. Most important independent factor to determine postoperative bleeding was body weight. Of note, obese patients with low levels of PAI-1 became high-risk patients for bleeding during surgery. Our data suggest that bleeding after surgical procedure may be influenced by inter-individual differences of hemostatic function including platelet function and fibrinolysis, even in the patients without bleeding diathesis.

  8. An invasive management strategy is associated with improved outcomes in high-risk acute coronary syndromes in patients with chronic kidney disease.

    Science.gov (United States)

    Medi, C; Chew, D P B; Amerena, J; Coverdale, S; Soman, A; Astley, C; Rankin, J; Brieger, D

    2011-10-01

    Chronic kidney disease (CKD) is associated with poor outcomes after acute coronary syndromes, yet selection for invasive investigation and management is low. Patients presenting with ST segment elevation myocardial infarction (STEMI) or intermediate- to high-risk non-ST segment elevation acute coronary syndrome (NSTEACS) (n=2597) were stratified into groups based on kidney function, defined as normal (glomerular filtration rate (GFR)≥60mL/min/1.73m(2) ), moderate CKD (GFR 30-59mL/min/1.73m(2) ) and severe CKD (GFR <30mL/min/1.73m(2)). Based on these stratums of kidney function, incidence and outcome measures were obtained for: rates of angiography and revascularization; 6-month mortality; and the incidence and outcome of in-hospital acute kidney impairment (AKI). Patients with CKD were less likely to be offered coronary angiography after STEMI/NSTEACS (P<0.001); however, after selection, revascularization rates were similar (percutaneous coronary intervention (P=0.8); surgery (P=0.4)). Six-month mortality rates increased with CKD (GFR≥60, 2.8%; GFR 30-59, 9.9%; GFR<30, 16.5%, P≤0.001), as well as the combined efficacy/safety end-point (GFR≥60, 9.4%; GFR 30-59, 20.2%; GFR<30, 27.1%, P≤0.001). Six-month mortality was lower in patients who had received prior angiography (GFR≥60, 1.5% vs 3.6%, P=0.001; GFR 30-59, 5.1% vs 12.7%, P<0.001; GFR<30, 7.3% vs 18.5%, P=0.094). Risk of AKI increased with CKD (GFR≥60, 0.7%; GFR 30-59, 3.4%; GFR<30, 6.8%, P≤0.001), and was associated with high 6-month mortality (35.6% vs 4.1%, P<0.001). In patients with CKD after STEMI/NSTEACS, 6-month mortality and morbidity is high, selection for angiography is lower, yet angiography is associated with a reduced long-term mortality, and with comparable revascularization rates to those without CKD. In-hospital AKI is more common in CKD and predicts a high 6-month mortality. © 2011 The Authors. Internal Medicine Journal © 2011 Royal Australasian College of Physicians.

  9. Waiting for surgery from the patient perspective

    Directory of Open Access Journals (Sweden)

    Tracey Carr

    2009-10-01

    Full Text Available Tracey Carr1, Ulrich Teucher2, Jackie Mann4, Alan G Casson31Health Sciences, 2Department of Psychology, 3Department of Surgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; 4Acute Care, Saskatoon Health Region, Saskatoon, Saskatchewan, CanadaAbstract: The aim of this study was to perform a systematic review of the impact of waiting for elective surgery from the patient perspective, with a focus on maximum tolerance, quality of life, and the nature of the waiting experience. Searches were conducted using Medline, PubMed, CINAHL, EMBASE, and HealthSTAR. Twenty-seven original research articles were identified which included each of these three themes. The current literature suggested that first, patients tend to state longer wait times as unacceptable when they experienced severe symptoms or functional impairment. Second, the relationship between length of wait and health-related quality of life depended on the nature and severity of proposed surgical intervention at the time of booking. Third, the waiting experience was consistently described as stressful and anxiety provoking. While many patients expressed anger and frustration at communication within the system, the experience of waiting was not uniformly negative. Some patients experienced waiting as an opportunity to live full lives despite pain and disability. The relatively unexamined relationship between waiting, illness and patient experience of time represents an area for future research.Keywords: wait time, scheduled surgery, patient perspective, literature review

  10. HEART TRANSPLANTATION IN PATIENTS WITH PREVIOUS OPEN HEART SURGERY

    Directory of Open Access Journals (Sweden)

    R. Sh. Saitgareev

    2016-01-01

    Full Text Available Heart Transplantation (HTx to date remains the most effective and radical method of treatment of patients with end-stage heart failure. The defi cit of donor hearts is forcing to resort increasingly to the use of different longterm mechanical circulatory support systems, including as a «bridge» to the follow-up HTx. According to the ISHLT Registry the number of recipients underwent cardiopulmonary bypass surgery increased from 40% in the period from 2004 to 2008 to 49.6% for the period from 2009 to 2015. HTx performed in repeated patients, on the one hand, involves considerable technical diffi culties and high risks; on the other hand, there is often no alternative medical intervention to HTx, and if not dictated by absolute contradictions the denial of the surgery is equivalent to 100% mortality. This review summarizes the results of a number of published studies aimed at understanding the immediate and late results of HTx in patients, previously underwent open heart surgery. The effect of resternotomy during HTx and that of the specifi c features associated with its implementation in recipients previously operated on open heart, and its effects on the immediate and long-term survival were considered in this review. Results of studies analyzing the risk factors for perioperative complications in repeated recipients were also demonstrated. Separately, HTx risks after implantation of prolonged mechanical circulatory support systems were examined. The literature does not allow to clearly defi ning the impact factor of earlier performed open heart surgery on the course of perioperative period and on the prognosis of survival in recipients who underwent HTx. On the other hand, subject to the regular fl ow of HTx and the perioperative period the risks in this clinical situation are justifi ed as a long-term prognosis of recipients previously conducted open heart surgery and are comparable to those of patients who underwent primary HTx. Studies

  11. Body dysmorphic disorder in patients undergoing septorhinoplasty surgery: should we be performing routine screening?

    Science.gov (United States)

    Joseph, J; Randhawa, P; Hannan, S A; Long, J; Goh, S; O'Shea, N; Saleh, H; Hansen, E; Veale, D; Andrews, P

    2017-06-01

    Body dysmorphic disorder (BDD) is defined as having a preoccupation with a perceived flaw in one's appearance, which appears slight to others and significantly interferes with a person's functioning. When undetected in septorhinoplasty patients, it will often lead to poor outcomes. We performed a prospective cohort study to determine the prevalence of BDD in our patients and whether surgical correction could be considered. We recruited 34 patients being considered for septorhinoplasty in a tertiary referral rhinology clinic and a control group of 50 from the otology clinic giving a total of 84. Participants completed the Body Dysmorphic Disorder Questionnaire (BDDQ), the sino-nasal outcome test-23 (SNOT-23) and underwent nasal inspiratory peak flow (NIPF). Those found to be at high risk for BDD were referred to a clinical psychologist. Of the septorhinoplasty patients, 11 (32%) were high risk for BDD. Following psychological assessment, 7 (63%) patients were felt to be unsuitable for surgery and were offered psychological therapy. SNOT-23 scores were significantly higher in the BDD group indicating a negative impact on quality of life. NIPF readings were not significantly different in the BDD group compared to the control group. The BDDQ is a valid tool for identifying patients at risk of BDD. A close working relationship with clinical psychology has been advantageous to help the selection process of candidates for surgery when there is a high risk of BDD. © 2016 John Wiley & Sons Ltd.

  12. Outcome of patients undergoing open heart surgery at the Uganda ...

    African Journals Online (AJOL)

    governments and local charities to support open heart surgeries, more cardiac patients access surgical treatment locally. Keywords: Open heart surgery, ... where surgery is the definitive therapy were operated. The mean age of the patients .... plasma and vitamin K. She remained ventilator depend- ent from initial surgery.

  13. Social Media and the Plastic Surgery Patient.

    Science.gov (United States)

    Sorice, Sarah C; Li, Alexander Y; Gilstrap, Jarom; Canales, Francisco L; Furnas, Heather J

    2017-11-01

    Many plastic surgeons use social media as a marketing tool to attract and retain patients, but information about how patients use social media and their preferred types of plastic surgery posts have been lacking. To investigate patients' preferred social media networks and the type of posts they wished to see, a cross-sectional study was conducted in a single aesthetic practice of two plastic surgeons by surveying 100 consecutive patients. The age of the patients averaged 44.4 years (range, 17 to 78 years). Facebook had the greatest patient use and engagement, with YouTube second in use, and Instagram second in number of engaged users. Over half used Pinterest, but with little daily engagement. Only one-fourth used Snapchat, but the percentage of users who were highly engaged was second only to Facebook. The least popular network was Twitter, with the fewest patient users and least engagement. Social media played a minor role compared with the practice's Web site in both influencing patients to choose the practice and providing information on the day of the appointment. Patients most wanted to see posts on a plastic surgeon's social media platform related to practice information, before-and-after photographs, and contests. Articles about plastic surgery held the least interest. Among five types of Web site content, patients expressed most interest in before-and-after photographs. This study is the first to articulate the plastic surgery patient perspective regarding social media. The findings aim to help plastic surgeons maximize their influence on their target audience.

  14. Importance and inter-relationship of tissue Doppler variables for predicting adverse outcomes in high-risk patients: an analysis of 388 diabetic patients referred for coronary angiography

    DEFF Research Database (Denmark)

    Andersson, Charlotte; Gislason, Gunnar H; Møgelvang, Rasmus

    2012-01-01

    AIMS: To investigate the relative importance of individual tissue Doppler imaging variables to predict adverse events in a high-risk population with diabetes, ischaemic heart disease, and/or systolic dysfunction. METHODS AND RESULTS: Transthoracic echocardiograms were analysed in 388 diabetic...... patients without significant valve disease, bundle branch block, and atrial fibrillation who underwent coronary angiography. Multivariable Cox's regression analyses were used to establish the association between peak systolic (s'), early diastolic (e'), and late diastolic (a') tissue velocities...... and outcomes (hospitalization for heart failure or death). The mean age and left ventricular ejection fraction (LVEF) was 66 ± 10 years and 45 ± 12%, respectively. During 2.3 (±1.0) years of follow-up, 91 patients (24%) met the combined endpoint. After adjustment for LVEF, coronary artery pathology, heart...

  15. Rates and predictors of consideration for adjuvant radiotherapy among high-risk breast cancer patients: a cohort study.

    Science.gov (United States)

    Krotneva, Stanimira; Reidel, Kristen; Nassif, Mohammed; Trabulsi, Nora; Mayo, Nancy; Tamblyn, Robyn; Meguerditchian, Ari N

    2013-07-01

    Radiotherapy (RT) after breast conserving surgery (BCS) represents the standard for local control of breast cancer (BC). However, variations in practice persist. We aimed to characterize the rate of RT consideration (or referral) after BCS and identify predictors in Quebec, Canada, where universal health insurance is in place. A historical prospective cohort study using the provincial hospital discharge and medical services databases was conducted. All women with incident, non-metastatic BC (stages I-III) undergoing BCS (1998-2005) were identified. Odds ratios (ORs) and 95 % confidence intervals (CIs) for RT consideration were estimated with a generalized estimating equations regression model, adjusting for clustering of patients within physicians. Of the 27,483 women selected, 90 % were considered for RT and 84 % subsequently received it. Relative to women 50-69 years old, younger and older women were less likely to be considered: ORs of 0.82 (95 % CI 0.73-0.93) and 0.10 (0.09-0.12), respectively. Emergency room visits and hospitalizations unrelated to BC were associated with decreased odds of RT consideration: 0.85 (0.76-0.94) and 0.83 (0.71-0.97). Women with regional BC considered for chemotherapy were more likely to be considered for RT: 3.41 (2.83-4.11). RT consideration odds increased by 7 % (OR of 1.07, 95 % CI 1.03-1.10) for every ten additional BCSs performed by the surgeon in the prior year. Social isolation, comorbidities, and greater distance to a referral center lowered the odds. Demographic and clinical patient-related risk factors, health service use, gaps in other aspects of BC management, and surgeon's experience predicted RT consideration.

  16. Implications of Public Reporting of Risk-Adjusted Mortality Following Percutaneous Coronary Intervention: Misperceptions and Potential Consequences for High-Risk Patients Including Nonsurgical Patients.

    Science.gov (United States)

    Gupta, Anuj; Yeh, Robert W; Tamis-Holland, Jacqueline E; Patel, Shalin H; Guyton, Robert A; Klein, Lloyd W; Rab, Tanveer; Kirtane, Ajay J

    2016-10-24

    Assessment of clinical outcomes such as 30-day mortality following coronary revascularization procedures has historically been used to spur quality improvement programs. Public reporting of risk-adjusted outcomes is already mandated in several states, and proposals to further expand public reporting have been put forward as a means of increasing transparency and potentially incentivizing high quality care. However, for public reporting of outcomes to be considered a useful surrogate of procedural quality of care, several prerequisites must be met. First, the reporting measure must be truly representative of the quality of the procedure itself, rather than be dominated by other underlying factors, such as the overall level of illness of a patient. Second, to foster comparisons among physicians and institutions, the metric requires accurate ascertainment of and adjustment for differences in patient risk profiles. This is particularly relevant for high-risk clinical patient scenarios. Finally, the potential deleterious consequences of public reporting of a quality metric should be considered prior to expanding the use of public reporting more broadly. In this viewpoint, the authors review in particular the characterization of high-risk patients currently treated by percutaneous coronary interventional procedures, assessing the adequacy of clinical risk models used in this population. They then expand upon the limitations of 30-day mortality as a quality metric for percutaneous coronary intervention, addressing the strengths and limitations of this metric, as well as offering suggestions to enhance its future use in public reporting. Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

  17. Role of P53 and BCL-2 in high-risk breast cancer patients treated with adjuvant anthracycline-based chemotherapy.

    Science.gov (United States)

    Mottolese, M; Benevolo, M; Del Monte, G; Buglioni, S; Papaldo, P; Nisticò, C; Di Filippo, F; Vasselli, S; Vici, P; Botti, C

    2000-12-01

    Adjuvant therapy has become an integral component of the managment of primary high-risk breast cancer patients. However, a considerable fraction of women receive no benefit from this treatment. This study investigates whether a number of biopathological factors can influence the outcome of patients submitted to adjuvant chemotherapy involving the use of high-dose epirubicin and cyclophosphamide. One hundred and fifty-seven primary breast cancer patients, considered at high risk according to the St. Gallen Meeting Consensus Conference, were evaluated immunohistochemically for estrogen, progesterone receptors, p53, bcl-2, HER-2/neu, and Ki-67, of which the results were correlated with patient outcome. Results obtained demonstrated that p53 is a significant predictor of disease-free survival (DFS P < 0.0001) and overall survival (OS P = 0.0002) both in ductal and lobular carcinomas, whereas bcl-2 expression seems to be of prognostic value only in lobular carcinomas (DFS P = 0.01; OS P = 0.02). This data indicates that in high-risk breast cancer patients the immunohistochemical evaluation of p53 and bcl-2 may be of clinical value in distinguishing different responses to adjuvant anthracycline-based chemotherapy.

  18. Dipyridamole thallium imaging may not be a reliable screening test for coronary artery disease in patients undergoing vascular surgery

    International Nuclear Information System (INIS)

    Marwick, T.H.; Underwood, D.A.

    1990-01-01

    Dipyridamole thallium imaging has been proposed for cardiac risk stratification in patients undergoing peripheral vascular surgery. The purpose of this study was to define the benefit of this investigation in routine preoperative evaluation of these patients. The outcome of 86 patients undergoing vascular surgery procedures was examined in light of preoperative clinical assessment and dipyridamole SPECT thallium imaging (DST). Fifty-one patients (59%) were considered at high risk on clinical grounds, and 22 patients (26%) had perfusion defects. Ten patients suffered a perioperative coronary event, including unstable angina, myocardial infarction, or cardiac death. Seven of the patients with such events were among the 51 clinically high-risk subjects (14%). Three perioperative events occurred in the group of 19 patients with positive DST images who underwent surgery (16%), but the DST test failed to identify 7 patients who suffered coronary events. The frequency of abnormal thallium imaging was similar to the prevalence of angiographically significant coronary disease reported previously at this center, but considerably less than the rate of abnormal thallium imaging in past studies of vascular surgery patients. The application of the test to a low to moderate risk population is probably responsible for its lower predictive accuracy for coronary events. DST is not an ideal routine noninvasive technique for risk stratification in patients undergoing vascular surgery

  19. Presence of histopathological premalignant lesions and infection caused by high-risk genotypes of human papillomavirus in patients with suspicious cytological and colposcopy results: A prospective study

    Directory of Open Access Journals (Sweden)

    Golubović Mileta

    2017-01-01

    Full Text Available Background/Aim. In patients with premalignant cervical lesions, human papillomavirus (HPV infection, at any moment, may be spontaneously eliminated, or may persist or transform cervical epithelium from a lower to a higher degree. Due to that, it is necessary to wisely select the patients who are at high risk of cancer development. The aim of the study was to establish the interdependence between a suspicious Papanicolaou (Pap test and colposcopy with the infection caused by high-risk genotypes of human papillomavirus and the presence of premalignant cervical lesions. Methods. This prospective study used cytological, colposcopy, real-time polymerase chain reaction (PCR of high-risk genotypes of human papillomavirus and histopathological analysis of cervical biopsy specimen. Out of 2,578 female patients sent to cytological analyses in Clinical Center of Montenegro, during 2012, 2013 and 2014, the study included 80 women who had to submit their biopsy specimens due to a suspicious Pap test and atypical colposcopy results. Results. In the group of 80 (3.1%; n = 80/2,578 of the selected female patients with suspicious Pap test and colposcopy, 2/3 or 56 (70% of them had cervicitis, and 1/3 or 24 (30% had cervical intraepithelial neoplasia. The most common type in cervical intraepithelial neoplasia was HPV16 in 8 female patients, ie 61.53% out of the number of infected, or 33.33% out of the total number of premalignant lesions. Conclusion. Patients with suspicious Papanicolaou test, colposcopy results and infection which is caused by high-risk HPV infection (HPV 16 in particular often have premalignant cervical lesions. In these cases, histopathological confirmation of lesions is mandatory, since it serves as a definitive diagnostic procedure.

  20. Effect of a dalteparin prophylaxis protocol using anti-factor Xa concentrations on venous thromboembolism in high-risk trauma patients.

    Science.gov (United States)

    Droege, Molly E; Mueller, Eric W; Besl, Kelly M; Lemmink, Jennifer A; Kramer, Elizabeth A; Athota, Krishna P; Droege, Christopher A; Ernst, Neil E; Keegan, Shaun P; Lutomski, Dave M; Hanseman, Dennis J; Robinson, Bryce R H

    2014-02-01

    Low anti-factor Xa (anti-Xa) concentrations with twice-daily enoxaparin are associated with venous thromboembolism (VTE) in high-risk trauma patients. Concerns have been raised with once-daily dalteparin regarding effectiveness and achievable anti-Xa concentrations. The purpose of this before-and-after study was to evaluate the effectiveness of a VTE prophylaxis protocol using anti-Xa concentrations and associated dalteparin dose adjustment in high-risk trauma patients. Adult trauma patients receiving VTE chemoprophylaxis and hospitalized for at least 3 days were prospectively followed during two 6-month epochs before (PRE) and after (POST) implementation of anti-Xa monitoring. In both groups, high-risk patients received dalteparin 5,000 U subcutaneously once daily; low-risk patients received subcutaneous unfractionated heparin. High-risk POST patients with anti-Xa less than 0.1 IU/mL 12 hours after initial dalteparin dose received dalteparin every 12 hours. All patients underwent routine VTE ultrasound surveillance of the lower extremities. The primary outcome was incidence of VTE. A total of 785 patients (PRE, n = 428; POST, n = 357) were included. Demographics, injury patterns, Injury Severity Score (ISS), red blood cell transfusions, intensive care unit and hospital stays, and mortality did not differ between groups. Overall, POST patients had lower VTE (7.0% vs. 13%, p = 0.009) including acute VTE (6.4% vs. 12%, p = 0.01) and proximal deep vein thromboembolism (2.2% vs. 5.7%, p = 0.019). Between high-risk patients, VTE occurred in 53 (16.3%) PRE compared with 24 (9.0%) POST patients (p = 0.01); there was no difference in VTE between low-risk patients (PRE, 2.0% vs. POST, 1.1%; p = 0.86). Among 190 high-risk POST patients with anti-Xa, 97 (51%) were less than 0.1 IU/mL. Patients with low anti-Xa had higher rates of VTE (14.0% vs. 5.4%, p = 0.05) and deep vein thromboembolism (14.4% vs. 3.2%, p = 0.01). Younger age (odds ratio, 0.97; 95% confidence interval, 0

  1. DOC-2/DAB2 Interacting Protein Status in High-Risk Prostate Cancer Correlates With Outcome for Patients Treated With Radiation Therapy

    International Nuclear Information System (INIS)

    Jacobs, Corbin; Tumati, Vasu; Kapur, Payal; Yan, Jingsheng; Hong, David; Bhuiyan, Manzerul; Xie, Xian-Jin; Pistenmaa, David; Yu, Lan; Hsieh, Jer-Tsong; Saha, Debabrata; Kim, D. W. Nathan

    2014-01-01

    Purpose: This pilot study investigates the role of DOC-2/DAB2 Interacting Protein (DAB2IP) and enhancer of zeste homolog 2 (EZH2) as prognostic biomarkers in high-risk prostate cancer patients receiving definitive radiation therapy. Methods and Materials: Immunohistochemistry was performed and scored by an expert genitourinary pathologist. Clinical endpoints evaluated were freedom from biochemical failure (FFBF), castration resistance–free survival (CRFS), and distant metastasis–free survival (DMFS). Log-rank test and Cox regression were used to determine significance of biomarker levels with clinical outcome. Results: Fifty-four patients with high-risk prostate cancer (stage ≥T3a, or Gleason score ≥8, or prostate-specific antigen level ≥20 ng/mL) treated with radiation therapy from 2005 to 2012 at our institution were evaluated. Nearly all patients expressed EZH2 (98%), whereas 28% of patients revealed DAB2IP reduction and 72% retained DAB2IP. Median follow-up was 34.0 months for DAB2IP-reduced patients, 29.9 months for DAB2IP-retained patients, and 32.6 months in the EZH2 study. Reduction in DAB2IP portended worse outcome compared with DAB2IP-retained patients, including FFBF (4-year: 37% vs 89%, P=.04), CRFS (4-year: 50% vs 90%, P=.02), and DMFS (4-year: 36% vs 97%, P=.05). Stratified EZH2 expression trended toward significance for worse FFBF and CRFS (P=.07). Patients with reduced DAB2IP or highest-intensity EZH2 expression exhibited worse FFBF (4-year: 32% vs 95%, P=.02), CRFS (4-year: 28% vs 100%, P<.01), and DMFS (4-year: 39% vs 100%, P=.04) compared with the control group. Conclusion: Loss of DAB2IP is a potent biomarker that portends worse outcome despite definitive radiation therapy for patients with high-risk prostate cancer. Enhancer of zeste homolog 2 is expressed in most high-risk tumors and is a less potent discriminator of outcome in this study. The DAB2IP status in combination with degree of EZH2 expression may be useful for

  2. Mortality in high-risk emergency general surgical admissions.

    Science.gov (United States)

    Symons, N R A; Moorthy, K; Almoudaris, A M; Bottle, A; Aylin, P; Vincent, C A; Faiz, O D

    2013-09-01

    There is increasing evidence of variable standards of care for patients undergoing emergency general surgery in the National Health Service (NHS). The aim of this study was to quantify and explore variability in mortality amongst high-risk emergency general surgery admissions to English NHS hospital Trusts. The Hospital Episode Statistics (HES) database was used to identify high-risk emergency general surgery diagnoses (greater than 5 per cent national 30-day mortality rate). Adults admitted to English NHS Trusts with these diagnoses between 2000 and 2009 were included in the study. Thirty-day in-hospital mortality was adjusted for patient and hospital factors. Trusts were grouped into high- and low-mortality outliers, and resource availability was compared between high- and low-mortality outlier institutions. Some 367 796 patients admitted to 145 hospital Trusts were included in the study; the 30-day mortality rate was 15·6 per cent (institutional range 9·2-18·2 per cent). Fourteen and 24 hospital Trusts were identified as high- and low-mortality outlier institutions respectively. Intensive care and high-dependency bed resources, as well as greater institutional use of computed tomography (CT), were independent predictors of reduced mortality (P emergency general surgery patients. Equitable access to essential hospital resources may reduce variability in outcomes. © 2013 British Journal of Surgery Society Ltd. Published by John Wiley & Sons Ltd.

  3. Prognostic impact of demographic factors and clinical features on the mode of death in high-risk patients after myocardial infarction--a combined analysis from multicenter trials

    DEFF Research Database (Denmark)

    Yap, Yee Guan; Duong, Trinh; Bland, J Martin

    2005-01-01

    patients surviving > or = 45 days after MI up to 2 years were examined using Cox regression. Short-term survival (from onset of MI to Day 44 after MI) was also examined for TRACE and DIAMOND-MI, in which patients were recruited within 2 weeks of MI. RESULTS: After adjustment for treatment and study effects...... mortality, whereas diabetes was only predictive of all-cause mortality. Smoking habit and atrial fibrillation had no prognostic value. Similar parameters were also predictive of short-term mortality, but not identical. CONCLUSIONS: Our study has shown that in high-risk patients post MI, who have been......-risk patients for prophylactic implantable cardiodefibrillator therapy....

  4. Nutritional management of patients after bariatric surgery.

    Science.gov (United States)

    Parkes, Emmy

    2006-04-01

    Bariatric surgery is currently the most effective method of sustainable weight loss among morbidly obese patients. The types of bariatric surgeries can be divided into three categories: restrictive procedures, malabsorptive procedures, and combination (restrictive and malabsorption) procedures. In general, patients undergoing restrictive procedures have the least risk for long-term diet-related complications, whereas patients undergoing malabsorptive procedures have the highest risk. For many patients, the benefits of weight loss, such as decreased blood glucose, lipids, and blood pressure and increased mobility, will outweigh the risks of surgical complications. Most diet-related surgical complications can be prevented by adhering to strict eating behavior guidelines and supplement prescriptions. Eating behavior guidelines include restricting portion sizes, chewing foods slowly and completely, eating and drinking separately, and avoiding foods that are poorly tolerated. Supplement prescriptions vary among practitioners and usually involve at least a multivitamin with minerals. Some practitioners may add other supplements only as needed for diagnosed deficiencies; others may prescribe additional prophylactic supplements. The most common nutrient deficiencies are of iron, folate, and vitamin B12. However, deficiencies of fat-soluble vitamins have been reported in patients with malabsorption procedures, and thiamin deficiency has been reported among patients with very poor intake and/or nausea and vomiting. Frequent monitoring of nutrition status for all patients can aid in preventing severe clinical deficiencies.

  5. Long-Term Outcomes for Patients with Prostate Cancer Having Intermediate and High-Risk Disease, Treated with Combination External Beam Irradiation and Brachytherapy

    Directory of Open Access Journals (Sweden)

    Michael Dattoli

    2010-01-01

    Full Text Available Background. Perception remains that brachytherapy-based regimens are inappropriate for patients having increased risk of extracapsular extension (ECE. Methods. 321 consecutive intermediate and high-risk disease patients were treated between 1/92 and 2/97 by one author (M. Dattoli and stratified by NCCN guidelines. 157 had intermediate-risk; 164 had high-risk disease. All were treated using the combination EBRT/brachytherapy ± hormones. Biochemical failure was defined using PSA >0.2 and nadir +2 at last followup. Nonfailing patients followup was median 10.5 years. Both biochemical data and original biopsy slides were independently rereviewed at an outside institution. Results. Overall actuarial freedom from biochemical progression at 16 years was 82% (89% intermediate, 74% high-risk with failure predictors: Gleason score (=.01 and PSA (=.03. Hormonal therapy did not affect failure rates (=.14. Conclusion. This study helps to strengthen the rationale for brachytherapy-based regimens as being both durable and desirable treatment options for such patients. Prospective studies are justified to confirm these positive results.

  6. Assessing Sexual Abuse/Attack Histories with Bariatric Surgery Patients

    Science.gov (United States)

    Mahony, David

    2010-01-01

    This study assessed sexual abuse/attack histories in 537 bariatric surgery patients using the PsyBari. The prevalence rates found were lower (15.5%, 19.3% of women, 5.2% of men) than other studies that used bariatric surgery patients but consistent with studies that used nonbariatric obese subjects. Furthermore, bariatric surgery patients who…

  7. Postmastectomy radiotherapy improves disease-free survival of high risk of locoregional recurrence breast cancer patients with T1-2 and 1 to 3 positive nodes.

    Directory of Open Access Journals (Sweden)

    Zhen-Yu He

    Full Text Available The indications for post-mastectomy radiotherapy (PMRT with T1-2 breast cancer and 1-3 positive axillary lymph nodes is still controversial. The purpose of this study was to investigate the role of PMRT in T1-2 breast cancer with 1-3 positive axillary lymph node.We retrospectively reviewed the file records of 79 patients receiving PMRT and not receiving PMRT (618 patients.The median follow-up was 65 months. Multivariate analysis showed that PMRT was an independent prognostic factor of locoregional recurrence-free survival (LRFS (P = 0.010. Subgroup analysis of patients who did not undergo PMRT showed that pT stage, number of positive axillary lymph nodes, and molecular subtype were independent prognostic factors of LRFS. PMRT improved LRFS in the entire group (P = 0.005, but did not affect distant metastasis-free survival (DMFS (P = 0.494, disease-free survival (DFS (P = 0.215, and overall survival (OS (P = 0.645. For patients without PMRT, the 5-year LRFS of low-risk patients (0-1 risk factor for locoregional recurrence of 94.5% was significantly higher than that of high-risk patients (2-3 risk factors for locoregional recurrence (80.9%, P < 0.001. PMRT improved LRFS (P = 0.001 and DFS (P = 0.027 in high-risk patients, but did not improve LRFS, DMFS, DFS, and OS in low-risk patients.PMRT is beneficial in patients with high risk of locoregional recurrence breast cancer patients with T1-2 and 1 to 3 positive nodes.

  8. Indications for Elective Tracheostomy in Reconstructive Surgery in Patients With Oral Cancer.

    Science.gov (United States)

    Leiser, Yoav; Barak, Michal; Ghantous, Yasmine; Yehudai, Noam; Abu El-Naaj, Imad

    2017-01-01

    Oral cancer surgery carries a high risk of upper airway obstruction; yet optimal airway management approach remains controversial. The purpose of the present study was to evaluate the use of tracheostomy in oncological patients undergoing oral cancer surgery with intra oral flap reconstruction. The study cohort included 75 patients with oral cancer, who underwent major intraoral resections and reconstruction with vascularized flaps. Thirty-six percent of the patients received elective tracheostomy (27 patients). Mean hospital stay of the patients with tracheostomy was 28.4 ± 12.5 days compared with 9.7 ± 2.1 days in the nontracheostomy patients. A scoring system rendered from this study suggests that patients with a total scoring at or above 8 should be considered for elective tracheostomy. With appropriate postoperative monitoring, selected patients can be managed without routine elective tracheostomy, yet, patients with comorbidities, mostly elderly patients, which undergo surgical resection and reconstruction in high-risk areas that can result in a bulky flap that pose danger to the postoperative airway, should receive elective tracheostomy.

  9. Identification of asymptomatic type 2 diabetes mellitus patients with a low, intermediate and high risk of ischaemic heart disease: is there an algorithm?

    DEFF Research Database (Denmark)

    Poulsen, Mikael Kjær; Henriksen, Jan Erik; Vach, W

    2010-01-01

    index >32 ml/m2, left ventricular ejection fraction algorithm identified low (n=96), intermediate (n=65) and high risk groups (n=115), in which the prevalence of myocardial ischaemia was 15%,23% and 43%, respectively. Overall the algorithm reduced...... the number of patients referred to MPS from 305 to 144.However, the sensitivity and specificity of the algorithm was just 68% and 62%, respectively.CONCLUSIONS/INTERPRETATION: Our algorithm was able to stratify which patients had a low, intermediate or high risk of myocardial ischaemia based on MPS. However......, the algorithm had low sensitivity and specificity, combined with high cost and time requirements.Trial registration: clinicaltrials.gov NCT00298844 Funding: The study was funded by the Danish Cardio vascular Research Academy (DaCRA), The Danish Diabetes Association and The Danish Heart Foundation....

  10. A prospective clinical, economic, and quality-of-life analysis comparing endovascular aneurysm repair (EVAR), open repair, and best medical treatment in high-risk patients with abdominal aortic aneurysms suitable for EVAR: the Irish patient trial.

    LENUS (Irish Health Repository)

    Hynes, Niamh

    2007-12-01

    To report the results of a trial comparing endovascular aneurysm repair (EVAR) to open repair (OR) and best medical therapy (BMT) involving high-risk patients with abdominal aortic aneurysms (AAA) suitable for EVAR.

  11. Psychological, behavioral, and weight-related aspects of patients undergoing reoperative bariatric surgery after gastric band: comparison with primary surgery patients.

    Science.gov (United States)

    Conceição, Eva; Pinto-Bastos, Ana; de Lourdes, Marta; Brandão, Isabel; Teixeira, Cristina; Machado, Paulo P P

    2018-02-15

    Patients experiencing insufficient weight loss or weight regain in their first bariatric surgery may represent a high-risk group with greater problematic eating and general psychopathology levels, which may compromise the success of a reoperative procedure. This study seeks to describe and compare disordered eating-related psychological and behavioral features of primary and reoperative surgery candidates after gastric band. Hospital center and university in Portugal. The baseline (preoperative) data from a longitudinal observational study are presented. Patients were interviewed by trained psychologists to identify binge-eating episodes and grazing and responded to a set of self-report measures: disordered eating, grazing, negative urgency, depression, anxiety, and stress. Two hundred twenty-five patients were undergoing primary surgery, and 166 were undergoing reoperative (REOP group) surgery. The groups did not differ in body mass index preoperatively, but the REOP group had greater weight suppression (t 387 = -5.35, P = .001), higher highest (t 387 = -3.40, P = .001) and lower lowest body mass index (t 381 = 2.22, P = .03). The main reasons for reoperative surgery were weight regain/poor weight loss (42.8%) or medical complications (32.5%). REOP patients with objective binge eating reported a higher frequency of these episodes (t 47 = 2.15, P = .04). No significant difference was found for the self-report measures assessed (only shape concern was higher for REOP group, F 1,216 = 8.30, Psurgeries, the differences in binge eating and weight-related variables may associate with postoperative difficulties. The link between binge eating, weight suppression, and weight gain found in other samples suggests that patients undergoing reoperative surgery may be at increased risk for poor weight outcomes. Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

  12. Potential roles of the wearable cardioverter-defibrillator in acute phase care of patients at high risk of sudden cardiac death: A single-center Japanese experience.

    Science.gov (United States)

    Sasaki, Shingo; Shoji, Yoshihiro; Ishida, Yuji; Kinjo, Takahiko; Tsushima, Yuichi; Seno, Maiko; Nishizaki, Fumie; Itoh, Taihei; Izumiyama, Kei; Yokota, Takashi; Yokoyama, Hiroaki; Yamada, Masahiro; Horiuchi, Daisuke; Kimura, Masaomi; Higuma, Takumi; Tomita, Hirofumi; Okumura, Ken

    2017-01-01

    The wearable cardioverter-defibrillator (WCD) has been expected to play a role as an effective bridge therapy to implantable cardioverter-defibrillator (ICD) implantation in