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Sample records for surgically high-risk patients

  1. Using bispectral index and cerebral oximetry to guide hemodynamic therapy in high-risk surgical patients.

    PubMed

    Bidd, Heena; Tan, Audrey; Green, David

    2013-05-19

    High-risk surgery represents 12.5% of cases but contributes 80% of deaths in the elderly population. Reduction in morbidity and mortality by the use of intervention strategies could result in thousands of lives being saved and savings of up to £400m per annum in the UK. This has resulted in the drive towards goal-directed therapy and intraoperative flow optimization of high-risk surgical patients being advocated by authorities such as the National Institute of Health and Care Excellence and the Association of Anaesthetists of Great Britain and Ireland.Conventional intraoperative monitoring gives little insight into the profound physiological changes occurring as a result of anesthesia and surgery. The build-up of an oxygen debt is associated with a poor outcome and strategies have been developed in the postoperative period to improve outcomes by repayment of this debt. New monitoring technologies such as minimally invasive cardiac output, depth of anesthesia and cerebral oximetry can minimize oxygen debt build-up. This has the potential to reduce complications and lessen the need for postoperative optimization in high-dependency areas.Flow monitoring has thus emerged as essential during intraoperative monitoring in high-risk surgery. However, evidence suggests that current optimization strategies of deliberately increasing flow to meet predefined targets may not reduce mortality.Could the addition of depth of anesthesia and cerebral and tissue oximetry monitoring produce a further improvement in outcomes?Retrospective studies indicate a combination of excessive depth of anesthesia hypotension and low anesthesia requirement results in increased mortality and length of hospital stay.Near infrared technology allows assessment and maintenance of cerebral and tissue oxygenation, a strategy, which has been associated with improved outcomes. The suggestion that the brain is an index organ for tissue oxygenation, especially in the elderly, indicates a role for this

  2. Risk factors for gallbladder contractility after cholecystolithotomy in elderly high-risk surgical patients

    PubMed Central

    Wang, Tao; Luo, Hao; Yan, Hong-tao; Zhang, Guo-hu; Liu, Wei-hui; Tang, Li-jun

    2017-01-01

    Objective Cholecystolithiasis is a common disease in the elderly patient. The routine therapy is open or laparoscopic cholecystectomy. In the previous study, we designed a minimally invasive cholecystolithotomy based on percutaneous cholecystostomy combined with a choledochoscope (PCCLC) under local anesthesia. Methods To investigate the effect of PCCLC on the gallbladder contractility function, PCCLC and laparoscope combined with a choledochoscope were compared in this study. Results The preoperational age and American Society of Anesthesiologists (ASA) scores, as well as postoperational lithotrity rate and common biliary duct stone rate in the PCCLC group, were significantly higher than the choledochoscope group. However, the pre- and postoperational gallbladder ejection fraction was not significantly different. Univariable and multivariable logistic regression analyses indicated that the preoperational thickness of gallbladder wall (odds ratio [OR]: 0.540; 95% confidence interval [CI]: 0.317–0.920; P=0.023) and lithotrity (OR: 0.150; 95% CI: 0.023–0.965; P=0.046) were risk factors for postoperational gallbladder ejection fraction. The area under receiver operating characteristics curve was 0.714 (P=0.016; 95% CI: 0.553–0.854). Conclusion PCCLC strategy should be carried out cautiously. First, restricted by the diameter of the drainage tube, the PCCLC should be used only for small gallstones in high-risk surgical patients. Second, the usage of lithotrity should be strictly limited to avoid undermining the gallbladder contractility and increasing the risk of secondary common bile duct stones. PMID:28138229

  3. Patient-prosthesis mismatch: surgical aortic valve replacement versus transcatheter aortic valve replacement in high risk patients with aortic stenosis

    PubMed Central

    Kron, Irving L.

    2016-01-01

    Patient prosthesis mismatch (PPM) can occur when a prosthetic aortic valve has an effective orifice area (EOA) less than that of a native valve. A recent study by Zorn and colleagues evaluated the incidence and significance of PPM in high risk patients with severe aortic stenosis who were randomized to transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). TAVR is associated with decreased incidence of severe PPM compared to traditional SAVR valves. Severe PPM increases risk for death at 1 year postoperatively in high risk patients. The increased incidence of PPM is largely due to differences in valve design and should encourage development of newer SAVR valves to reduce risk for PPM. In addition more vigorous approaches to root enlargement in small annulus should be performed with SAVR to prevent PPM. PMID:27867654

  4. Patient-prosthesis mismatch: surgical aortic valve replacement versus transcatheter aortic valve replacement in high risk patients with aortic stenosis.

    PubMed

    Ghanta, Ravi K; Kron, Irving L

    2016-10-01

    Patient prosthesis mismatch (PPM) can occur when a prosthetic aortic valve has an effective orifice area (EOA) less than that of a native valve. A recent study by Zorn and colleagues evaluated the incidence and significance of PPM in high risk patients with severe aortic stenosis who were randomized to transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). TAVR is associated with decreased incidence of severe PPM compared to traditional SAVR valves. Severe PPM increases risk for death at 1 year postoperatively in high risk patients. The increased incidence of PPM is largely due to differences in valve design and should encourage development of newer SAVR valves to reduce risk for PPM. In addition more vigorous approaches to root enlargement in small annulus should be performed with SAVR to prevent PPM.

  5. Incidence of bisphosphonate-related osteonecrosis of the jaw in high-risk patients undergoing surgical tooth extraction.

    PubMed

    Bodem, Jens Philipp; Kargus, Steffen; Eckstein, Stefanie; Saure, Daniel; Engel, Michael; Hoffmann, Jürgen; Freudlsperger, Christian

    2015-05-01

    As the most suitable approach for preventing bisphosphonate-related osteonecrosis of the jaw (BRONJ) in patients undergoing surgical tooth extraction is still under discussion, the present study evaluates the incidence of BRONJ after surgical tooth extraction using a standardized surgical protocol in combination with an adjuvant perioperative treatment setting in patients who are at high-risk for developing BRONJ. High-risk patients were defined as patients who received intravenous bisphosphonate (BP) due to a malignant disease. All teeth were removed using a standardized surgical protocol. The perioperative adjuvant treatment included intravenous antibiotic prophylaxis starting at least 24 h before surgery, a gastric feeding tube and mouth rinses with chlorhexidine (0.12%) three times a day. In the follow-up period patients were examined every 4 weeks for the development of BRONJ. Minimum follow-up was 12 weeks. In 61 patients a total number of 184 teeth were removed from 102 separate extraction sites. In eight patients (13.1%) BRONJ developed during the follow-up. A higher risk for developing BRONJ was found in patients where an additional osteotomy was necessary (21.4% vs. 8.0%; p = 0.0577), especially for an osteotomy of the mandible (33.3% vs. 7.3%; p = 0.0268). Parameters including duration of intravenous antibiotic prophylaxis, the use of a gastric feeding tube and the duration of intravenous BP therapy showed no statistical impact on the development of BRONJ. Furthermore, patients currently undergoing intravenous BP therapy showed no higher risk for BRONJ compared with patients who have paused or completed their intravenous BP therapy (p = 0.4232). This study presents a protocol for surgical tooth extraction in high-risk BP patients in combination with a perioperative adjuvant treatment setting, which reduced the risk for postoperative BRONJ to a minimum. However, the risk for BRONJ increases significantly if an additional osteotomy is necessary

  6. CyberKnife with Tumor Tracking: An Effective Treatment for High-Risk Surgical Patients with Single Peripheral Lung Metastases.

    PubMed

    Snider, James W; Oermann, Eric K; Chen, Viola; Rabin, Jennifer; Suy, Simeng; Yu, Xia; Vahdat, Saloomeh; Collins, Sean P; Banovac, Filip; Anderson, Eric; Collins, Brian T

    2012-01-01

    Standard treatment for operable patients with single peripheral lung metastases is metastasectomy. We report mature CyberKnife outcomes for high-risk surgical patients with biopsy proven single peripheral lung metastases. Twenty-four patients (median age 73 years) with a mean maximum tumor diameter of 2.5 cm (range, 0.8-4.5 cm) were treated over a 6-year period extending from September 2004 to September 2010 and followed for a minimum of 1 year or until death. A mean dose of 52 Gy (range, 45-60 Gy) was delivered to the prescription isodose line in three fractions over a 3-11 day period (mean, 7 days). At a median follow-up of 20 months, the 2-year Kaplan-Meier local control and overall survival rates were 87 and 50%, respectively. CyberKnife with fiducial tracking is an effective treatment for high-risk surgical patients with single small peripheral lung metastases. Trials comparing CyberKnife with metastasectomy for operable patients are necessary to confirm equivalence.

  7. Identification of the high risk emergency surgical patient: Which risk prediction model should be used?

    PubMed Central

    Stonelake, Stephen; Thomson, Peter; Suggett, Nigel

    2015-01-01

    Introduction National guidance states that all patients having emergency surgery should have a mortality risk assessment calculated on admission so that the ‘high risk’ patient can receive the appropriate seniority and level of care. We aimed to assess if peri-operative risk scoring tools could accurately calculate mortality and morbidity risk. Methods Mortality risk scores for 86 consecutive emergency laparotomies, were calculated using pre-operative (ASA, Lee index) and post-operative (POSSUM, P-POSSUM and CR-POSSUM) risk calculation tools. Morbidity risk scores were calculated using the POSSUM predicted morbidity and compared against actual morbidity according to the Clavien–Dindo classification. Results The actual mortality was 10.5%. The average predicted risk scores for all laparotomies were: ASA 26.5%, Lee Index 2.5%, POSSUM 29.5%, P-POSSUM 18.5%, CR-POSSUM 10.5%. Complications occurred following 67 laparotomies (78%). The majority (51%) of complications were classified as Clavien–Dindo grade 2–3 (non-life-threatening). Patients having a POSSUM morbidity risk of greater than 50% developed significantly more life-threatening complications (CD 4–5) compared with those who predicted less than or equal to 50% morbidity risk (P = 0.01). Discussion Pre-operative risk stratification remains a challenge because the Lee Index under-predicts and ASA over-predicts mortality risk. Post-operative risk scoring using the CR-POSSUM is more accurate and we suggest can be used to identify patients who require intensive care post-operatively. Conclusions In the absence of accurate risk scoring tools that can be used on admission to hospital it is not possible to reliably audit the achievement of national standards of care for the ‘high-risk’ patient. PMID:26468369

  8. PTEN Protein Loss by Immunostaining: Analytic Validation and Prognostic Indicator for a High Risk Surgical Cohort of Prostate Cancer Patients

    PubMed Central

    Lotan, Tamara L.; Gurel, Bora; Sutcliffe, Siobhan; Esopi, David; Liu, Wennuan; Xu, Jianfeng; Hicks, Jessica L.; Park, Ben H.; Humphreys, Elizabeth; Partin, Alan W.; Han, Misop; Netto, George J.; Isaacs, William B.; De Marzo, Angelo M.

    2011-01-01

    Purpose Analytically validated assays to interrogate biomarker status in clinical samples are crucial for personalized medicine. PTEN is a tumor suppressor commonly inactivated in prostate cancer that has been mechanistically linked to disease aggressiveness. Though deletion of PTEN, as detected by cumbersome fluorescence in situ hybridization (FISH) spot counting assays, is associated with poor prognosis, few studies have validated immunohistochemical (IHC) assays to determine whether loss of PTEN protein is associated with unfavorable disease. Experimental Design PTEN IHC was validated by employing formalin fixed and paraffin embedded isogenic human cell lines containing or lacking intact PTEN alleles. PTEN IHC was 100% sensitive and 97.8% specific for detecting genomic alterations in 58 additional cell lines. PTEN protein loss was then assessed on 376 prostate tumor samples, and PTEN FISH or high resolution SNP microarray analysis was performed on a subset of these cases. Results PTEN protein loss, as assessed as a dichotomous IHC variable, was highly reproducible, correlated strongly with adverse pathologic features (e.g. Gleason score and pathological stage), detected between 75% and 86% of cases with PTEN genomic loss, and was found at times in the absence of apparent genomic loss. In a cohort of 217 high risk surgically treated patients, PTEN protein loss was associated with decreased time to metastasis. Conclusions These studies validate a simple method to interrogate PTEN status in clinical specimens and support the utility of this test in future multi-center studies, clinical trials and ultimately perhaps for routine clinical care. PMID:21878536

  9. TIMP2•IGFBP7 biomarker panel accurately predicts acute kidney injury in high-risk surgical patients

    PubMed Central

    Gunnerson, Kyle J.; Shaw, Andrew D.; Chawla, Lakhmir S.; Bihorac, Azra; Al-Khafaji, Ali; Kashani, Kianoush; Lissauer, Matthew; Shi, Jing; Walker, Michael G.; Kellum, John A.

    2016-01-01

    BACKGROUND Acute kidney injury (AKI) is an important complication in surgical patients. Existing biomarkers and clinical prediction models underestimate the risk for developing AKI. We recently reported data from two trials of 728 and 408 critically ill adult patients in whom urinary TIMP2•IGFBP7 (NephroCheck, Astute Medical) was used to identify patients at risk of developing AKI. Here we report a preplanned analysis of surgical patients from both trials to assess whether urinary tissue inhibitor of metalloproteinase 2 (TIMP-2) and insulin-like growth factor–binding protein 7 (IGFBP7) accurately identify surgical patients at risk of developing AKI. STUDY DESIGN We enrolled adult surgical patients at risk for AKI who were admitted to one of 39 intensive care units across Europe and North America. The primary end point was moderate-severe AKI (equivalent to KDIGO [Kidney Disease Improving Global Outcomes] stages 2–3) within 12 hours of enrollment. Biomarker performance was assessed using the area under the receiver operating characteristic curve, integrated discrimination improvement, and category-free net reclassification improvement. RESULTS A total of 375 patients were included in the final analysis of whom 35 (9%) developed moderate-severe AKI within 12 hours. The area under the receiver operating characteristic curve for [TIMP-2]•[IGFBP7] alone was 0.84 (95% confidence interval, 0.76–0.90; p < 0.0001). Biomarker performance was robust in sensitivity analysis across predefined subgroups (urgency and type of surgery). CONCLUSION For postoperative surgical intensive care unit patients, a single urinary TIMP2•IGFBP7 test accurately identified patients at risk for developing AKI within the ensuing 12 hours and its inclusion in clinical risk prediction models significantly enhances their performance. LEVEL OF EVIDENCE Prognostic study, level I. PMID:26816218

  10. Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy (CHOCOLATE trial): Study protocol for a randomized controlled trial

    PubMed Central

    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 advice. Methods/Design The CHOCOLATE trial is a randomised controlled, parallel-group, superiority multicenter trial. High risk patients, defined as APACHE-II score 7-14, with acute calculous cholecystitis will be randomised to laparoscopic cholecystectomy or percutaneous cholecystostomy. During a two year period 284 patients will be enrolled from 30 high volume teaching hospitals. The primary endpoint is a composite endpoint of major complications within three months following randomization and need for re-intervention and mortality during the follow-up period of one year. Secondary endpoints include all other complications, duration of hospital admission, difficulty of procedures and total costs. Discussion The CHOCOLATE trial is designed to provide the surgical community with an evidence based guideline in the treatment of acute calculous cholecystitis in high risk patients. Trial Registration Netherlands Trial Register (NTR): NTR2666 PMID:22236534

  11. Extracranial Carotid Artery Stenting in Surgically High-Risk Patients Using the Carotid Wallstent Endoprosthesis:Midterm Clinical and Ultrasound Follow-Up Results

    SciTech Connect

    Maleux, Geert Bernaerts, Pauwel; Thijs, Vincent; Daenens, Kim; Vaninbroukx, Johan; Fourneau, Inge; Nevelsteen, Andre

    2003-08-15

    The purpose of this study was to evaluate the feasibility, safety and midterm outcome of elective implantation of the Carotid Wallstent (registered) in patients considered to be at high surgical risk. In a prospective study, 54 carotid artery stenoses in 51 patients were stented over a 24-month period. Three patients underwent bilateral carotid artery stenting. Institutional inclusion criteria for invasive treatment of carotid occlusive disease (carotid endarterectomy or carotid artery stenting) are patients presenting with a 70% or more symptomatic stenosis and those with an 80% or more asymptomatic stenosis having a life-expectancy of more than 1 year. All patients treated by carotid artery stenting were considered at high risk for carotid endarterectomy because of a hostile neck (17 patients-31.5%) or because of severe comorbidities (37 patients-68.5%). No cerebral protection device was used. Of the 54 lesions, 33 (61.1%) were symptomatic and 21 (38.8%) were asymptomatic. Follow-up was performed by physical examination and by duplex ultrasonography at 1 month, 6 months, 1 year and 2 years after the procedure. All 54 lesions could be stented successfully without periprocedural stroke. Advert events during follow-up (mean 13.9 {+-} 5.7 months) were non-stroke-related death in 6 patients (11.1%), minor stroke in 4 stented hemispheres(7.4%), transient ipsilateral facial pain in 1 patient (1.8%),infection of the stented surgical patch in 1 patient (1.8%) and asymptomatic in stent restenosis in 4 patients (7.4%). The percutaneous implantation of the Carotid Wallstent (registered) , even without cerebral protection device, appears to be a safe procedure with acceptable clinical and ultrasonographic follow-up results in patients at high surgical risk. But some late adverse events such as ipsilateral recurrence of non-disabling (minor) stroke or in stent restenosis still remain real challenging problems.

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

    PubMed Central

    Faiz, Saadia A.; Hernandez, Mike; Bashoura, Lara; Cherian, Sujith V.; French, Katy E.

    2016-01-01

    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. PMID:27610133

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

    PubMed

    Balachandran, Diwakar D; Faiz, Saadia A; Hernandez, Mike; Kowalski, Alicia M; Bashoura, Lara; Goravanchi, Farzin; Cherian, Sujith V; Rebello, Elizabeth; Kee, Spencer S; French, Katy E

    2016-01-01

    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/m(2) (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. Surgical Management of a Patient with Anterior Megalophthalmos, Lens Subluxation, and a High Risk of Retinal Detachment

    PubMed Central

    Guixeres Esteve, María Carmen; Pardo Saiz, Augusto Octavio; Martínez-Costa, Lucía; González-Ocampo Dorta, Samuel; Sanz Solana, Pedro

    2017-01-01

    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. PMID:28203198

  15. Transcatheter Mitral Valve Repair in Surgical High-Risk Patients: Gender-Specific Acute and Long-Term Outcomes

    PubMed Central

    Tigges, Eike; Kalbacher, Daniel; Thomas, Christina; Appelbaum, Sebastian; Deuschl, Florian; Schofer, Niklas; Schlüter, Michael; Conradi, Lenard; Schirmer, Johannes; Treede, Hendrik; Reichenspurner, Hermann; Blankenberg, Stefan; Schäfer, Ulrich; Lubos, Edith

    2016-01-01

    Background. Analyses emphasizing gender-related differences in acute and long-term outcomes following MitraClip therapy for significant mitral regurgitation (MR) are rare. Methods. 592 consecutive patients (75 ± 8.7 years, 362 men, 230 women) underwent clinical and echocardiographic follow-up for a median of 2.13 (0.99–4.02) years. Results. Significantly higher prevalence of cardiovascular comorbidities, renal failure, and adverse echocardiographic parameters in men resulted in longer device time (p = 0.007) and higher numbers of implanted clips (p = 0.0075), with equal procedural success (p = 1.0). Rehospitalization for heart failure did not differ (p[logrank] = 0.288) while survival was higher in women (p[logrank] = 0.0317). Logarithmic increase of NT-proBNP was a common independent predictor of death. Hypercholesterolemia and peripheral artery disease were predictors of death only in men while ischemic and dilative cardiomyopathy (CM) and age were predictors in women. Independent predictors of rehospitalization for heart failure were severely reduced ejection fraction and success in men while both ischemic and dilative CM, logistic EuroSCORE, and MR severity were predictive in women. Conclusions. Higher numbers of implanted clips and longer device time are likely related to more comorbidities in men. Procedural success and acute and mid-term clinical outcomes were equal. Superior survival for women in long-term analysis is presumably attributable to a comparatively better preprocedural health. PMID:27042662

  16. Lack of extended venous thromboembolism prophylaxis in high-risk patients undergoing major orthopaedic or major cancer surgery. Electronic Assessment of VTE Prophylaxis in High-Risk Surgical Patients at Discharge from Swiss Hospitals (ESSENTIAL).

    PubMed

    Kalka, Christoph; Spirk, David; Siebenrock, Klaus-Arno; Metzger, Urs; Tuor, Philipp; Sterzing, Daniel; Oehy, Kurt; Wondberg, Daniela; Mouhsine, El Yazid; Gautier, Emanuel; Kucher, Nils

    2009-07-01

    Extended pharmacological venous thromboembolism (VTE) prophylaxis beyond discharge is recommended for patients undergoing high-risk surgery. We prospectively investigated prophylaxis in 1,046 consecutive patients undergoing major orthopaedic (70%) or major cancer surgery (30%) in 14 Swiss hospitals. Appropriate in-hospital prophylaxis was used in 1,003 (96%) patients. At discharge, 638 (61%) patients received prescription for extended pharmacological prophylaxis: 564 (77%) after orthopaedic surgery, and 74 (23%) after cancer surgery (p < 0.001). Patients with knee replacement (94%), hip replacement (81%), major trauma (80%), and curative arthroscopy (73%) had the highest prescription rates for extended VTE prophylaxis; the lowest rates were found in patients undergoing major surgery for thoracic (7%), gastrointestinal (19%), and hepatobiliary (33%) cancer. The median duration of prescribed extended prophylaxis was longer in patients with orthopaedic surgery (32 days, interquartile range 14-40 days) than in patients with cancer surgery (23 days, interquartile range 11-30 days; p<0.001). Among the 278 patients with an extended prophylaxis order after hip replacement, knee replacement, or hip fracture surgery, 120 (43%) received a prescription for at least 35 days, and among the 74 patients with an extended prophylaxis order after major cancer surgery, 20 (27%) received a prescription for at least 28 days. In conclusion, approximately one quarter of the patients with major orthopaedic surgery and more than three quarters of the patients with major cancer surgery did not receive prescription for extended VTE prophylaxis. Future effort should focus on the improvement of extended VTE prophylaxis, particularly in patients undergoing major cancer surgery.

  17. Development of an intervention model for the prevention of aspiration pneumonia in high-risk patients on a medical-surgical unit.

    PubMed

    Echevarria, Ilia M; Schwoebel, Ann

    2012-01-01

    Aspiration pneumonia is associated with significantly high morbidity and mortality rates, accompanied by high health care costs. As a result, aspiration pneumonia preventive efforts are a national priority. The development of an intervention model for the prevention of aspiration pneumonia in high-risk medical-surgical inpatients at an urban teaching hospital is described. The intervention model consists of the implementation and evaluation of a risk assessment tool and development of an aspiration pneumonia prevention protocol.

  18. CyberKnife with Tumor Tracking: An Effective Treatment for High-Risk Surgical Patients with Stage I Non-Small Cell Lung Cancer.

    PubMed

    Chen, Viola J; Oermann, Eric; Vahdat, Saloomeh; Rabin, Jennifer; Suy, Simeng; Yu, Xia; Collins, Sean P; Subramaniam, Deepa; Banovac, Filip; Anderson, Eric; Collins, Brian T

    2012-01-01

    Published data suggests that wedge resection for stage I non-small cell lung cancer (NSCLC) is associated with improved overall survival compared to stereotactic body radiation therapy. We report CyberKnife outcomes for high-risk surgical patients with biopsy-proven stage I NSCLC. PET/CT imaging was completed for staging. Three-to-five gold fiducial markers were implanted in or near tumors to serve as targeting references. Gross tumor volumes (GTVs) were contoured using lung windows; the margins were expanded by 5 mm to establish the planning treatment volume (PTV). Treatment plans were designed using a mean of 156 pencil beams. Doses delivered to the PTV ranged from 42 to 60 Gy in three fractions. The 30 Gy isodose contour extended at least 1 cm from the GTV to eradicate microscopic disease. Treatments were delivered using the CyberKnife system with tumor tracking. Examination and PET/CT imaging occurred at 3 month follow-up intervals. Forty patients (median age 76) with a median maximum tumor diameter of 2.6 cm (range, 1.4-5.0 cm) and a mean post-bronchodilator percent predicted forced expiratory volume in 1 s (FEV1) of 57% (range, 21-111%) were treated. A median dose of 48 Gy was delivered to the PTV over 3-13 days (median, 7 days). The 30 Gy isodose contour extended a mean 1.9 cm from the GTV. At a median 44 months (range, 12-72 months) follow-up, the 3 year Kaplan-Meier locoregional control and overall survival estimates compare favorably with contemporary wedge resection outcomes at 91 and 75%, respectively. CyberKnife is an effective treatment approach for stage I NSCLC that is similar to wedge resection, eradicating tumors with 1-2 cm margins in order to preserve lung function. Prospective randomized trials comparing CyberKnife with wedge resection are necessary to confirm equivalence.

  19. Preoperative patient assessment: Identifying patients at high risk.

    PubMed

    Boehm, O; Baumgarten, G; Hoeft, A

    2016-06-01

    Postoperative mortality remains alarmingly high with a mortality rate ranging between 0.4% and 4%. A small subgroup of multimorbid and/or elderly patients undergoing different surgical procedures naturally confers the highest risk of complications and perioperative death. Therefore, preoperative assessment should identify these high-risk patients and stratify them to individualized monitoring and treatment throughout all phases of perioperative care. A "tailored" perioperative approach might help further reduce perioperative morbidity and mortality. This article aims to elucidate individual morbidity-specific risks. It further suggests approaches to detect patients at the risk of perioperative complications.

  20. Incisional Reinforcement in High-Risk Patients

    PubMed Central

    Feldmann, Timothy F.; Young, Monica T.; Pigazzi, Alessio

    2014-01-01

    Hernia formation after surgical procedures continues to be an important cause of surgical morbidity. Incisional reinforcement at the time of the initial operation has been used in some patient populations to reduce the risk of subsequent hernia formation. In this article, reinforcement techniques in different surgical wounds are examined to identify situations in which hernia formation may be prevented. Mesh use for midline closure, pelvic floor reconstruction, and stoma site reinforcement is discussed. Additionally, the use of retention sutures, closure of the open abdomen, and reinforcement after component separation are examined using current literature. Although existing studies do not support the routine use of mesh reinforcement for all surgical incisions, certain patient populations appear to benefit from reinforcement with lower rates of subsequent hernia formation. The identification and characterization of these groups will guide the future use of mesh reinforcement in surgical incisions. PMID:25435823

  1. [Cardiovascular polypill in high risk patients].

    PubMed

    Lafeber, Melvin; Spiering, Wilko; Bots, Michiel L; de Valk, Vincent; Visseren, Frank L J; Grobbee, Diederick E

    2011-01-01

    The initial theoretical concept of a polypill was a fixed-dosed combination pill containing an antiplatelet agent, a cholesterol-lowering agent and multiple blood pressure-lowering agents aimed at the prevention of atherosclerotic vascular disease in the population aged 55 years and up. The reduction in the risk of cardiovascular disease does not depend on the cholesterol level and blood pressure at the start of treatment. The pharmacological reduction in risk factors in individuals with a high risk of atherosclerotic vascular disease is often suboptimal, partly due to the complexity of the guidelines and low adherence to the therapy. A polypill may offer opportunities for improvement. Research has shown that the use of combination products leads to a greater reduction in risk factors than the use of separate substances, possibly through improved adherence to the therapy. The use of a polypill in the prevention of vascular disease in high-risk patients may lead to a more effective reduction in risk, a decrease in costs and a reduction in pharmacological expenditure.

  2. Preoperative IABP in high risk patients undergoing CABG.

    PubMed

    Theologou, T; Field, M L

    2011-01-01

    A recent international consensus conference on the reduction in mortality in cardiac anesthesia and intensive care included intraoperative aortic balloon pump among the ancillary (i.e. non-surgical) drugs/techniques/strategies that might influence survival rates in patients undergoing cardiac surgery. The consensus conferences state that "Pre-operative intraoperative aortic balloon pump might reduce 30-day mortality in elective high risk patients undergoing coronary artery bypass surgery unless specifically contraindicated". The authors of this "expert opinion" presents their insights into the use of the preoperative intraoperative aortic balloon pump and conclude that based on available limited randomized controlled trials and clinical experience preoperative intraoperative aortic balloon pump saves lives in unstable patients.

  3. Incidence and Sequelae of Prosthesis-Patient Mismatch in Transcatheter Vs Surgical Valve Replacement in High-Risk Patients with Severe Aortic Stenosis – A PARTNER Trial Cohort A Analysis

    PubMed Central

    Pibarot, Philippe; Weissman, Neil J.; Stewart, William J.; Hahn, Rebecca T.; Lindman, Brian R.; McAndrew, Thomas; Kodali, Susheel K.; Mack, Michael J.; Thourani, Vinod H.; Miller, D. Craig; Svensson, Lars G.; Herrmann, Howard C.; Smith, Craig R.; Rodés-Cabau, Josep; Webb, John; Lim, Scott; Xu, Ke; Hueter, Irene; Douglas, Pamela S.; Leon, Martin B.

    2014-01-01

    BACKGROUND Little is known about the incidence of prosthesis-patient mismatch (PPM) and its impact on outcomes after transcatheter aortic valve replacement (TAVR). OBJECTIVES The objectives of this study were: 1) to compare the incidence of PPM in the transcatheter and surgical aortic valve replacement (SAVR) randomized (RCT) arms of the PARTNER-I trial Cohort A; and 2) to assess the impact of PPM on regression of left ventricular (LV) hypertrophy and mortality in these 2 arms and in the TAVR nonrandomized continued access (NRCA) Registry cohort. METHODS The PARTNER trial Cohort A randomized patients 1:1 to TAVR or bioprosthetic SAVR. Postoperative PPM was defined as absent if indexed effective orifice area >0.85, moderate ≥0.65 but ≤0.85, or severe <0.65 cm2/m2. LV mass regression and mortality were analyzed using the SAVR-RCT (n = 270), TAVR-RCT (n = 304) and TAVR-NRCA (n = 1637) cohorts. RESULTS Incidence of PPM was 60.0% (severe: 28.1%) in SAVR-RCT versus 46.4% (severe: 19.7%) in TAVR-RCT (p < 0.001) and 43.8% (severe: 13.6%) in TAVR-NRCA. In patients with aortic annulus diameter < 20 mm, severe PPM developed in 33.7% undergoing SAVR compared to 19.0% undergoing TAVR (p = 0.002). PPM was an independent predictor of less LV mass regression at 1 year in SAVR-RCT (p = 0.017) and TAVR-NRCA (p = 0.012) but not in TAVRRCT (p = 0.35). Severe PPM was an independent predictor of 2-year mortality in SAVR-RCT (hazard ratio [HR]: 1.78; p = 0.041) but not in TAVR-RCT (HR: 0.58; p = 0.11). In the TAVRNRCA, severe PPM was not a predictor of 1-year mortality in the whole cohort (HR: 1.05; p = 0.60) but did independently predict mortality in the subset of patients with no post-procedural aortic regurgitation (HR: 1.88; p = 0.02). CONCLUSIONS In patients with severe aortic stenosis and high surgical risk, PPM is more frequent and more often severe following SAVR than TAVR. Patients with PPM after SAVR have worse survival and less LV mass regression than those without PPM

  4. Treating Patients with High-Risk Smoldering Myeloma

    Cancer.gov

    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.

  5. Robot-assisted radical prostatectomy in low- and high-risk prostate cancer patients

    PubMed Central

    Boylu, Uğur; Bindayi, Ahmet; Küçük, Eyüp Veli; Önol, Fikret Fatih; Gümüş, Eyüp

    2017-01-01

    Objective To evaluate the benefit of robot-assisted radical prostatectomy (RARP) in the low-risk prostate cancer (PCa) patients suitable for active surveillance and in the high-risk PCa patients who would be considered for alternative treatments such as radiotherapy (RT) and androgen deprivation therapy (ADT) instead of radical prostatectomy. Material and methods Of 548 patients, who underwent RARP, 298 PCa patients (258 low-risk and 40 high-risk) with a mean of 3.6 years follow-up, were included into this study. Oncological outcomes were compared separately in low- and high-risk PCa patients. Results The pathologic Gleason scores were ≥7 in 73 (28%), and 68 (26%) patients had a pathologic stage of T3, 29 (11%) patients had a positive surgical margin (PSM), and 20 (7%) patients had biochemical recurrence (BCR) in the first year follow-up in the low-risk group. Of 258 low-risk PCa patients, a total of 93 (36%) patients had not either BCR, pathologic Gleason score ≥7, or ≥pT3 disease with PSM. In the high-risk group, the pathologic stage was pT2 in 14 (35%) patients and 29 (72%) patients had no biochemical recurrence in the follow-up of these high-risk PCa patients. Of 40 high-risk PCa patients, in a total of 25 (62.5%) patients ≥pT3b disease, BCR, pT3a disease with PSM were not detected. Conclusion Approximately two thirds of high-risk PCa patients benefit from RARP without additional RT or ADT. Besides, more than one third of low-risk PCa patients who fit active surveillance criteria would have unfavorable results. PMID:28270949

  6. HIFU therapy for patients with high risk prostate cancer

    NASA Astrophysics Data System (ADS)

    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.

  7. Results of Open-Heart Surgery in High-Risk Patients

    PubMed Central

    Chafizadeh, G.N.

    1982-01-01

    Of 732 patients undergoing open heart surgery in Pars Hospital Tehran, 127 were classified in a high risk surgical category. Of these, there were 19 mortalities. Three main groups of patients were studied; Group I consisted of those with congenital disorders, such as Ebstein's anomaly and the medical-necrosis type of ascending aneurysms; Group II consisted of reoperaton cases; and Group III was composed of patients with cardiomegaly who required double or triple-valve surgery. PMID:15226817

  8. Embedded CMs work with high-risk patients.

    PubMed

    2014-01-01

    Care managers embedded in primary care clinics work with patients with high-risk diagnoses and multiple visits to the emergency department or hospital. Patients are identified though risk assessments, suggestions from inpatient case management, and requests from primary care clinicians. Care managers call patients before their clinic visits, look for gaps in care and find out patients' questions and concerns, sharing the information with the treating clinicians. Care managers follow patients for four weeks after their visit, helping them meet their health care goals and follow their treatment plan.

  9. Resuscitation and perioperative management of the high-risk single ventricle patient: first-stage palliation.

    PubMed

    Lowry, Adam W

    2012-01-01

    Infants born with hypoplastic left heart syndrome or other lesions resulting in a single right ventricle face the highest risk of mortality among all forms of congenital heart disease. Before the modern era of surgical palliation, these conditions were universally lethal; recent refinements in surgical technique and perioperative management have translated into dramatic improvements in survival. Nonetheless, these infants remain at a high risk of morbidity and mortality, and an appreciation of single ventricle physiology is fundamental to the care of these high-risk patients. Herein, resuscitation and perioperative management of infants with hypoplastic left heart syndrome are reviewed. Basic neonatal and pediatric life support recommendations are summarized, and perioperative first-stage clinical management strategies are reviewed.

  10. The cardiovascular polypill in high-risk patients.

    PubMed

    Lafeber, Melvin; Spiering, Wilko; Singh, Kavita; Guggilla, Rama K; Patil, Vinodvenkatesh; Webster, Ruth

    2012-12-01

    Atherosclerotic cardiovascular diseases remain the leading cause of morbidity and mortality in both developed and developing countries. Adequate treatment of vascular risk factors, such as low-density lipoprotein cholesterol and systolic blood pressure are known to reduce the future risk of cardiovascular disease in these patients. However currently, large treatment gaps exist among high-risk individuals, in whom the guidelines recommend concomitant treatment with aspirin, statin, and blood-pressure lowering agents. Combining aspirin, cholesterol, and blood-pressure lowering agents into a single pill called the cardiovascular polypill has been proposed as complementary care in the prevention of cardiovascular diseases in both intermediate- and high-risk patient populations. It is now a decade since the first recommendations to develop and trial cardiovascular polypills. The major scientific debate has been about the appropriate initial target population. This review article focuses on the potential role of fixed-dose combination therapy in different patient populations, outlines the pros and cons of combination therapy, and emphasizes the rationale for trialing their use. Current and planned future cardiovascular polypill trials are summarized and the pre-requisites for implementation of the polypill strategy in both primary and secondary prevention are described. The recent development of combination pills containing off-patent medications holds promise for highly affordable and effective treatment and evidence is emerging on the use of this strategy in high-risk populations.

  11. Lymphadenectomy in elderly/high risk patients: should it be different?

    PubMed Central

    Galli, Federica; Pappalardo, Vincenzo; Inversini, Davide; Martignoni, Francesco; Boni, Luigi; Dionigi, Gianlorenzo; Rausei, Stefano

    2017-01-01

    The global aging of population will lead a greater number of elderly patients to undergo surgical procedure in a near future. Concerning gastric cancer, the impact of lymphadenectomy on survival has been demonstrated in RCTs, and extended lymphadenectomy is now considered as gold standard of treatment in non-early tumors. However, the role of age as a prognostic factor and the benefit of extended surgery in elderly/high-risk patients are not clearly defined yet. From our revision of literature, it seems that surgery for gastric cancer may have a further tailorization, considering not only the stage of disease, but also patients’ age and comorbidities. PMID:28217755

  12. Brachytherapy boost to the tumour bed in high risk patients after limited surgery for breast cancer.

    PubMed

    Ulutin, H C; Ash, D; Dodwell, D

    2003-05-01

    The results of treatment for 174 patients at high risk of local recurrence, referred for radiotherapy after conservative surgery for early breast cancer, are evaluated. Microscopic margin involvement, extensive carcinoma in situ, and vascular/lymphatic invasion were the main risk factors for local recurrence. Whole-breast irradiation (40 Gy in 15 fractions over 3 weeks) followed with a brachytherapy boost (Ir192 wire implant or PDR Ir192) of 25 Gy was applied. Median follow-up was 80 months. The actuarial 6-year overall survival rate was 91% and the within breast recurrence-free survival was 88%. The most common risk factor among those recurring within the breast was involved surgical margins (13 out of 17). Cosmesis was reported to be good or excellent in 79% of cases. In patients at high risk for local recurrence, tumour-bed boost with brachytherapy can provide satisfactory local control after limited surgery and external radiotherapy.

  13. Perceptions of high-risk patients and their providers on the patient-centered medical home.

    PubMed

    Kangovi, Shreya; Kellom, Katherine; Sha, Christopher; Johnson, Sarah; Chanton, Casey; Carter, Tamala; Long, Judith A; Grande, David

    2015-01-01

    To explore perceptions of high-risk patients and their practice staff on the patient-centered medical home, we conducted a multisite qualitative study with chronically ill, low-income patients and their primary care practice staff (N = 51). There were 3 key findings. Both patients and staff described a trade-off: timely care from an unfamiliar provider versus delayed access to their personal physician. Staff were enthusiastic about enhancing access through strategies such as online communication, yet high-risk patients viewed these as access barriers. Practices lacked capacity to manage high-risk patients and therefore frequently referred them to the emergency room.

  14. 2017 Taiwan lipid guidelines for high risk patients.

    PubMed

    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

    -C should be lowered to < 100 mg/dL. Statin is necessary for DM patients with CV disease and the LDL-C target is < 70 mg/dL. For diabetic patients who are ≥ 40 years of age, or who are < 40 years of age but have additional CV risk factors, the LDL-C target should be < 100 mg/dL. After achieving LDL-C target, combination of other lipid-lowering agents with statin is reasonable to attain TG < 150 mg/dL and HDL-C >40 in men and >50 mg/dL in women in DM. LDL-C increased CV risk in patients with CKD. In adults with glomerular filtration rate (GFR) < 60 mL/min/1.73m(2) without chronic dialysis (CKD stage 3-5), statin therapy should be initiated if LDL-C ≥ 100 mg/dL. Ezetimibe can be added to 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.

  15. Mid-Term Results After Endovascular Stent-Grafting of Descending Aortic Aneurysms in High-Risk Patients

    SciTech Connect

    Brandt, Michael Walluscheck, Knut P.; Jahnke, Thomas; Attmann, Tim; Heller, Martin; Cremer, Jochen; Mueller-Huelsbeck, Stefan

    2006-10-15

    Purpose. To analyze our experience with endovascular stent-grafting of descending aortic aneurysms in high-risk patients. Methods. Nineteen patients underwent endovascular stent-graft repair of descending aortic aneurysms using the Talent Stent Graft System (Medtronic). All patients were considered high-risk for open surgical repair due to their age, requirement for emergency surgery, and comorbidities. Computed tomography and/or MR tomography were performed at 3, 6 and 12 months postoperatively and thereafter every 12 months. Results. Secondary technical success was 100%. Thirty-day mortality was 5%. Incidence of postoperative stroke and paraplegia were 5% each. One patient required a second stent-graft due to a type I endoleak during the same hospital stay (primary technical success 95%). All patients have been followed for a median of 20 months. No migration, wire fractures or endoleak appeared during follow-up. Conclusion. Endovascular stent-grafting had a low 30-day mortality and morbidity in high-risk patients. One patient developed an aortoesophageal fistula 40 days after stent implantation. Stent-graft repair is a valuable supplement to surgical therapy in high-risk patients.

  16. Biochemical Recurrence Prediction in High-Risk Prostate Cancer Patients, Following Robot-Assisted Radical Prostatectomy

    PubMed Central

    Yamaguchi, Noriya; Yumioka, Tetsuya; Iwamoto, Hideto; Masago, Toshihiko; Morizane, Shuichi; Honda, Masashi; Sejima, Takehiro; Takenaka, Atsushi

    2016-01-01

    Background High-risk prostate cancer treatment has been controversial. Some high-risk prostate cancer patients fail to respond to radical prostatectomy only. Thus, we aimed to investigate the predictive factors for biochemical recurrence (BCR) and identify patients who could achieve sufficient therapeutic effect by radical prostatectomy only. Methods Of 264 medical records reviewed, 141 low-intermediate-risk and 100 high-risk prostate cancer patients, excluding those who had received neoadjuvant hormone therapy, were analyzed. BCR was defined as the first increase in prostate-specific antigen levels (≥ 0.2 ng/mL), with levels not decreasing to undetectable limits, after radical prostatectomy. Log-rank test and Cox proportional hazards regression analyses were performed to determine the prognostic factors. We investigated the perioperative predictive factors for BCR and BCR-free survival rates, with the number of National Comprehensive Cancer Network (NCCN) high-risk factors for high-risk prostate cancer patients who underwent robot-assisted radical prostatectomy. Results Multivariate analyses showed that clinical T3 was significantly associated with BCR [hazard ratio (HR) = 4.052; 95% confidence interval (CI), 1.26–12.99; P = 0.019]. Of the 100 patients, 77 had 1 high-risk factor and 23 had ≥ 2 high-risk factors; the 1-year BCR-free survival rate of patients with 1 high-risk factor and those with ≥ 2 high-risk factors was 94.8% and 69.6%, respectively. Patients with ≥ 2 high-risk factors were significantly associated with BCR (P = 0.002). No difference in BCR rate between patients with 1 high-risk factor and those with low- and intermediate-risk was found. Conclusion High-risk prostate cancer patients with 1 NCCN high-risk factor can be considered for robot-assisted radical prostatectomy treatment only. PMID:28070166

  17. Improving Early Identification of the High-Risk Elderly Trauma Patient By Emergency Medical Services

    PubMed Central

    Newgard, Craig D.; Holmes, James F.; Haukoos, Jason S.; Bulger, Eileen M.; Staudenmayer, Kristan; Wittwer, Lynn; Stecker, Eric; Dai, Mengtao; Hsia, Renee Y.

    2015-01-01

    Study Objective We sought to (1) define the high-risk elderly trauma patient based on prognostic differences associated with different injury patterns and (2) derive alternative field trauma triage guidelines that mesh with national field triage guidelines to improve identification of high-risk elderly patients. Methods This was a retrospective cohort study of injured adults ≥ 65 years transported by 94 EMS agencies to 122 hospitals in 7 regions from 1/1/2006 through 12/31/2008. We tracked current field triage practices by EMS, patient demographics, out-of-hospital physiology, procedures and mechanism of injury. Outcomes included Injury Severity Score ≥ 16 and specific anatomic patterns of serious injury using Abbreviated Injury Scale score ≥ 3 and surgical interventions. In-hospital mortality was used as a measure of prognosis for different injury patterns. Results 33,298 injured elderly patients were transported by EMS, including 4.5% with ISS ≥ 16, 4.8% with serious brain injury, 3.4% with serious chest injury, 1.6% with serious abdominal-pelvic injury and 29.2% with serious extremity injury. In-hospital mortality ranged from 18.7% (95% CI 16.7–20.7) for ISS ≥ 16 to 2.9% (95% CI 2.6–3.3) for serious extremity injury. The alternative triage guidelines (any positive criterion from the current guidelines, GCS ≤ 14 or abnormal vital signs) outperformed current field triage practices for identifying patients with ISS ≥ 16: sensitivity (92.1% [95% CI 89.6–94.1%] vs. 75.9% [95% CI 72.3–79.2%]), specificity (41.5% [95% CI 40.6–42.4%] vs. 77.8% [95% CI 77.1–78.5%]). Sensitivity decreased for individual injury patterns, but was higher than current triage practices. Conclusions High-risk elderly trauma patients can be defined by ISS ≥ 16 or specific non-extremity injury patterns. The field triage guidelines could be improved to better identify high-risk elderly trauma patients by EMS, with a reduction in triage specificity. PMID:26477345

  18. Antithrombin alfa in hereditary antithrombin deficient patients: A phase 3 study of prophylactic intravenous administration in high risk situations.

    PubMed

    Tiede, Andreas; Tait, R Campbell; Shaffer, Don W; Baudo, Francesco; Boneu, Bernard; Dempfle, Carl Erik; Horellou, Marie Helene; Klamroth, Robert; Lazarchick, John; Mumford, Andrew D; Schulman, Sam; Shiach, Caroline; Bonfiglio, Laura J; Frieling, Johan T M; Conard, Jacqueline; von Depka, Mario

    2008-03-01

    During surgery and childbirth, patients with hereditary antithrombin (AT) deficiency are at high risk for thrombosis, and heparin prophylaxis may not be sufficiently efficacious. In these patients, exogenous AT may be used in association with heparin. A recombinant human AT (generic name: antithrombin alfa) has been developed. This multi-center study assessed the efficacy and safety of prophylactic intravenous administration of antithrombin alfa to hereditary AT deficient patients in high risk situations, including elective surgery, childbirth, or cesarean section. Antithrombin alfa was administered prior to and during the high risk period for restoration and maintenance of AT activity at 100% of normal. Heparin, low-molecular-weight heparin, and/or vitamin K antagonists were used according to standard of care. The primary efficacy endpoint was the incidence of acute deep vein thrombosis (DVT) from baseline up to day 30 post dosing as assessed by independent central review of duplex ultrasonograms and/or venograms. Safety was assessed based on adverse events (AEs) and laboratory evaluations. Five surgical and nine obstetrical hereditary AT deficiency patients received antithrombin alfa for a mean period of seven days. No clinically overt DVT occurred. Central review of ultrasonograms identified signs of acute DVT in two out of 13 evaluable patients. No antithrombin alfa-related AEs were reported. No patient developed anti-antithrombin alfa antibodies. In conclusion, this study suggests that antithrombin alfa is a safe and effective alternative to human plasma-derived AT for treating hereditary AT deficiency patients at high risk for thromboembolic events.

  19. The enhanced healing of a high-risk, clean, sutured surgical incision by prophylactic negative pressure wound therapy as delivered by Prevena™ Customizable™: cosmetic and therapeutic results.

    PubMed

    Scalise, Alessandro; Tartaglione, Caterina; Bolletta, Elisa; Calamita, Roberto; Nicoletti, Giovanni; Pierangeli, Marina; Grassetti, Luca; Di Benedetto, Giovanni

    2015-04-01

    According to the literature, incisional closure complications may range from postoperative surgical site infections, representing 17-22% of health care-associated infections, surgical wound dehiscence and formation of haematomas or seromas, and can lead to delayed or impaired incision healing. These kinds of situations are more common when wounds are closed under tension or in specific patient morbidities. Obesity, in particular, is associated with an impaired blood flow to tissues, predisposing the patient to increased risk of wound complications by various mechanisms. Incisional complications can become relevant economic burdens for health care systems because of an increase in the average length of hospital stay and readmissions, and additional medical and surgical procedures. Thus, a preventive therapy may have a critical role in the management of healing. Negative pressure wound therapy (NPWT) technology as delivered by Prevena™ Customizable™ (Kinetic Concepts Inc., San Antonio, TX) has recently been the focus of a new investigation, as a prophylactic measure to prevent complications via immediate postoperative application in high-risk, clean, closed surgical incisions. The authors present a 62-year-old class II obese female, who underwent bilateral inguinal dermolipectomy. Prophylactic NPWT as delivered by Prevena™ was performed successfully over surgical incisions. Cosmetic and therapeutic results are shown.

  20. Nutritional screening in surgical patients.

    PubMed

    Thompson, J S; Burrough, C A; Green, J L; Brown, G L

    1984-03-01

    Routine nutritional screening of patients admitted to the surgical services confirms a substantial prevalence of malnutrition. Identification of the malnourished patient and the patient who is likely to become malnourished should be done as early as possible in the hospital stay and usually requires only simple, readily available parameters. Nutritional screening is only the first step in the optimal nutritional management of surgical patients. This information should be used to determine the need for further nutritional assessment, the appropriate consultation, and nutritional therapy.

  1. Identifying patients at high risk of breast cancer recurrence: strategies to improve patient outcomes

    PubMed Central

    Martei, Yehoda M; Matro, Jennifer M

    2015-01-01

    Identifying patients at high risk of breast cancer recurrence has important implications not only for enabling the ability to provide accurate information to patients but also the potential to improve patient outcomes. Patients at high recurrence risk can be offered appropriate treatment to improve the overall survival. However, the major challenge is identifying patients with early-stage breast cancer at lower risk who may be spared potentially toxic therapy. The successful integration of molecular assays into clinical practice may address the problem of overtreatment and improve overall patient outcomes. PMID:26504408

  2. Asymptomatic pulmonary embolism. A common event in high risk patients.

    PubMed Central

    Williams, J W; Eikman, E A; Greenberg, S

    1982-01-01

    Ventilation and perfusion lung scans were obtained before and at weekly intervals following hip surgery or major amputation in 158 patients. Pulmonary arteriograms were obtained in 21 of 33 patients developing perfusion patterns strongly suggesting embolism; 19 of the 21 arteriograms demonstrated pulmonary embolism. From autopsy and clinical data, 36 patients were diagnosed as having an embolus while under study, and 12 patients were suspected of having had an embolus during their illness but prior to entry into the study. Only four of these 48 patients experienced symptoms suggestive of pulmonary embolism. We conclude that asymptomatic pulmonary embolism is a common event in the populations studied. PMID:7059242

  3. Asymptomatic pulmonary embolism: a common event in high risk patients

    SciTech Connect

    Williams, J.W.; Eikman, E.A.; Greenberg, S.

    1982-03-01

    Ventilation and perfusion lung scans were obtained before and at weekly intervals following hip surgery or major amputation in 158 patients. Pulmonary arteriograms were obtained in 21 of 33 patients developing perfusion patterns strongly suggesting embolism; 19 of the 21 arteriograms demonstrated pulmonary embolism. From autopsy and clinical data, 36 patients were diagnosed as having an embolus while under study, and 12 patients were suspected of having had an embolus during their illness but prior to entry into the study. Only four of these 48 patients experienced symptoms suggestive of pulmonary embolism. We conclude that asymptomatic pulmonary embolism is a common event in the populations studied.

  4. [High risk infective endocarditis embolism during pregnancy: Medical or surgical management?].

    PubMed

    Echeverría, Luis Eduardo; Figueredo, Antonio; Gómez, Juan Carlos; Salazar, Leonardo Alberto; Rodriguez, Jaime Alberto; Pizarro, Camilo Ernesto; Riaño, Carlos Eduardo; Perroni, Addy; Cuadros, Alba Lucía; Villamizar, María Cristina; Suárez, Edwin Uriel

    2013-01-01

    A 22-year-old pregnant woman was seen at 14 weeks of pregnancy for infective endocarditis with a vegetation of 15 mm and wide mobility, which affected the native mitral valve accompanied by severe valvular insufficiency. Antibiotic treatment was given for 4 weeks despite the embolism risk. Due to persistence of vegetation size and after considering the fetal and maternal risk, the surgical procedure was favored. We decided to perform valvuloplasty and removal of lesion at 18 weeks of pregnancy. Fetal protection techniques were used and a bioprosthesis was placed before attempting a repair. The postoperative follow-up was satisfactory, achieving a successful birth by cesarean section at 30 weeks.

  5. Kidney transplantation in immunologically high-risk patients.

    PubMed

    Keven, K; Sengul, S; Celebi, Z K; Tuzuner, A; Yalcin, F; Duman, T; Tutkak, H

    2013-04-01

    An increased number of sensitized patients await kidney transplantation (KTx). Sensitization has a major impact on patient mortality and morbidity due to prolonged waiting time and may preclude live donor transplantation. However, recent reports have shown that KTx can be performed successfully using novel immunosuppressive protocols. This study presents our experience with patients displaying donor-specific antibody (DSA) (+). We enrolled 5 lymphocyte cross-match (LCM) negative (complement-dependent cytotoxicity) and panel-reactive antibody (PRA) plus DSA-positive patients mean fluorescein intensity [MFI] > 1000) who underwent living kidney donor procedures. All subjects were females and their mean age was 36.7 years. In our protocol, we started mycophenolate mofetil (2 g/d), tacrolimus (0.01 mg/kg) and prednisolone (0.5 mg/kg) on day -6. We performed 2 sessions of total plasma exchange (TPE) with albumin replacement and administered 2 doses of IVIG (5 g/d). On day -1, we added rituximab (200 mg). On the operation day and on day +4, the patients received doses of basiliximab. Serum samples were taken on days -6, 0, and 30 as well as at 1 year after transplantation. All patients displayed immediate graft function. Mean basal DSA titer was 5624 MFI. After desensitization, the MFI titers decreased at the time of transplantation to 2753 MFI, and were 2564 MFI at the 1st month and 802 MFI at 1st year. Three patients experienced acute rejection episodes (60%). After treatment for rejection, the average follow-up was 17 months and last creatinine levels were 0.6-0.8 mg/dL (minimum-maximum). In conclusion, KTx can be succesfully performed in sensitized patients displaying DSA. However, there seems to be a greater acute rejection risk. There is no consensus regarding adequate doses of IVIG or plasmapheresis treatments; furthermore, more studies are needed to clarify the safe MFI titer of the DSA.

  6. High Risk of Depressive Disorders in Patients With Gout

    PubMed Central

    Changchien, Te-Chang; Yen, Yung-Chieh; Lin, Cheng-Li; Lin, Ming-Chia; Liang, Ji-An; Kao, Chia-Hung

    2015-01-01

    Abstract Metabolic abnormalities are common in patients with depressive disorders. However, the relationship between gout and depression is unclear. We explored the causal relationship among gout, antigout medication, and the associated risk of incidental depressive disorders. In this nationwide cohort study, we sampled data from the National Health Insurance Research Database to recruit 34,050 patients with gout as the gout cohort and 68,100 controls (without gout) as the nongout cohort. Our primary endpoint was the diagnosis of depressive disorders during follow-up. The overall study population was followed up until depression diagnosis, withdrawal from the NHI program, or the end of the study. The differences in demographic and clinical characteristics between both cohorts were determined using the Chi-square test for categorical variables and the t-test for continuous variables. Cox proportional hazard regression models were used to examine the effect of gout on the risk of depression, represented using the hazard ratio with the 95% confidence interval. Patients with gout exhibited a higher risk of depressive disorders than controls did. The risk of depressive disorders increased with age and was higher in female patients and those with hypertension, stroke, and coronary artery disease. Nonsteroidal antiinflammatory drug and prednisolone use was associated with a reduced risk of depression. Patients with gout who had received antigout medication exhibited a reduced risk of depressive disorders compared with nongout patients. Our findings support that gout increases the risk of depressive disorders, and that antigout medication use reduces the risk. PMID:26717394

  7. Usefulness of postoperative hip irradiation in the prevention of heterotopic bone formation in a high risk group of patients

    SciTech Connect

    MacLennan, I.; Keys, H.M.; Evarts, C.M.; Rubin, P.

    1984-01-01

    Heterotopic ossification is a complication of total hip arthroplasty in 14 to 30% of patients. Significant functional impairment will occur in up to 28% of patients with ectopic bone. The high risk group includes those with preexisting heterotopic bone in either hip, those suffering from hypertrophic osteoarthritis or ankylosing spondylitis and patients who have had multiple procedures on the hip. Fifty-eight patients (67 hips) were irradiated after surgical removal of ectopic bone (53 hips) or received radiation prophylaxis of heterotopic ossification (14 hips). Ninety-five percent of patients had either no bone visible or insignificant amounts of ectopic bone visible on postoperative hip X-rays. Only 5% of patients showed significant persistence of ectopic bone. Postoperative hip function was dramatically improved compared to preoperative function in all patients treated. The importance of early commencement of irradiation is emphasized.

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

    PubMed Central

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

    2017-01-01

    Background Bilateral prophylactic mastectomy (BPM) has shown 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. Methods 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. Results 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). Conclusion A multidisciplinary model with optimized scheduling has the potential to improve access to care and optimize resource utilization. PMID:28234588

  9. [Combined Antihypertensive Therapy in Patients at High Risk].

    PubMed

    Lyamina, N P; Kotelnikova, E V; Nalivaeva, A V

    2015-10-01

    Presents opportunities to increase the effectiveness of combination antihypertensive therapy (AHT) in patients with arterial hypertension (AH) and high cardiovascular risk. Displaying increase in the proportion of patients with target blood pressure up to 82.4%; high commitment combined AHT (96%) and medical recommendations for lifestyle changes (54%) using the power of information computer technology (ICT) in order to carry out continuous monitoring of blood pressure and other risk factors (RF), commitment to the patients drug and non-drug assignments. Thus, ICT can be seen as a tool that can give a real idea of the scale and nature of the deviation from the medical recommendations that can serve as a basis for personalized AHT.

  10. Survival of high-risk pediatric neuroblastoma patients in a developing country.

    PubMed

    Easton, Joseph C; Gomez, Sergio; Asdahl, Peter H; Conner, J Michael; Fynn, Alcira B; Ruiz, Claudia; Ojha, Rohit P

    2016-09-01

    Little information is available about survival of high-risk pediatric neuroblastoma patients in developing countries. We aimed to assess survival among high-risk pediatric neuroblastoma patients in La Plata, Argentina. Individuals eligible for our cohort were aged <20 yr when diagnosed with high-risk neuroblastoma and received cancer-directed therapy including stem cell transplantation at Hospital de Niños Sor Maria Ludovica between February 1999 and February 2015. We estimated overall survival probabilities using an extended Kaplan-Meier approach. Our study population comprised 39 high-risk neuroblastoma patients, of whom 39% were aged >4 yr at diagnosis, 54% were male, and 62% had adrenal neuroblastoma. We observed 18 deaths, and the median survival time of our study population was 1.7 yr. The five-yr overall survival probability was 24% (95% CL: 10%, 41%). In contrast, five-yr survival of high-risk neuroblastoma patients ranges between 23% and 76% in developed countries. Survival among high-risk neuroblastoma patients is generally poor regardless of geographic location, but our results illustrate dramatically worse survival for patients in a developing country. We speculate that the observed survival differences could be attenuated or eliminated with improvements in treatment and supportive care, but addressing these issues will require creative solutions because of resource limitations.

  11. Pain Among High-Risk Patients on Methadone Maintenance Treatment.

    PubMed

    Voon, Pauline; Hayashi, Kanna; Milloy, M-J; Nguyen, Paul; Wood, Evan; Montaner, Julio; Kerr, Thomas

    2015-09-01

    The complexity of treating concurrent pain and opioid dependence among many methadone-maintained individuals presents a major challenge in many clinical settings. Furthermore, recent expert guidelines have called for increased research on the safety of methadone in the context of chronic pain. This study explores the prevalence and correlates of pain among a prospective cohort of people who use illicit drugs in Vancouver, British Columbia, Canada, who reported enrollment in methadone maintenance treatment (MMT) between 2011 and 2014. Among the 823 participants eligible for this analysis, 338 (40.9%) reported moderate pain and 91 (11.1%) reported extreme pain at the first study visit. In multivariable, generalized, linear mixed model analyses, higher pain severity was positively and independently associated with self-managing pain (adjusted odds ratio [AOR] 2.15, 95% confidence interval [CI] 1.77-2.60), patient perception of methadone dose being too low (AOR 1.82, 95% CI 1.41-2.34), older age (AOR 1.31, 95% CI 1.13-1.51), having a physical disability (AOR 4.59, 95% CI 3.73-5.64), having ever been diagnosed with a mental illness (AOR 1.44, 95% CI 1.13-1.84), white ethnicity (AOR 1.42, 95% CI 1.10-1.83), and marijuana use (AOR 1.25, 95% CI 1.02-1.52). These findings suggest several areas for clinical intervention, particularly related to patient education and alternative analgesic approaches for MMT patients experiencing pain. Perspective: To better understand the complexity of concurrent pain and opioid dependency among individuals on methadone maintenance treatment, this article describes the prevalence and correlates of higher pain severity among methadone-maintained people who use illicit drugs. Patients on methadone with comorbid pain may benefit from education and alternative analgesic approaches.

  12. Long-Term Outcomes of Conventional Aortic Valve Replacement in High-Risk Patients: Where Do We Stand?

    PubMed Central

    Fortuna, Daniela; Contini, Giovanni Andrea; Pacini, Davide; Gabbieri, Davide; De Palma, Rossana; Gherli, Tiziano

    2016-01-01

    Purpose: The introduction of transcatheter aortic valves has focused attention on the results of conventional aortic valve surgery in high-risk patients. The aim of the study was to evaluate 5-years outcomes in this category of patients in the current surgical era. Methods: This is an observational retrospective study of 581 high-risk patients undergoing aortic valve replacement from 2008 to 2013, with a mean logistic EuroSCORE of 26.6% ± 14.6%. Data were prospectively collected in a database of Emilia-Romagna region (Italy). Results: Overall 30-day mortality was 9.3%. Stroke rate was 1.5%. At 1-, 3-, and 5-years overall mortality was 18.2%, 30.4%, and 42.2%, cardiac death rate was 3.9%, 9.2%, and 12.9%, stroke rate 2.5%, 7.7%, and 10.2%, re-operation occurrence 0.2%, 0.9% and 1.3%, and new pacemaker implantation was 2.3%, 5.1% and 7.8%. At multivariate analysis, urgency, hemodynamic instability, LVEF ≤30%, NYHA III-IV, severe chronic obstructive pulmonary disease (COPD), extra-cardiac arteriopathy, cerebrovascular disease, and creatinine >2.0 mg/dL remained independent predictors of 5-year mortality. Conclusion: The results of the current study add weight to the evidence that traditional aortic valve replacement can be performed in high-risk patients with satisfactory 5-year mortality and morbidity. Our study may help to improve decision-making in this category of high-risk patients with aortic valve disease. PMID:27645551

  13. Reduced systemic toxicity from superselective chemoembolization compared with systemic chemotherapy in patients with high-risk metastatic gestational trophoblastic disease

    SciTech Connect

    Lang, Erich K.

    1997-07-15

    Purpose. The efficacy of chemoembolization of primary and metastatic gestational trophoblastic neoplasms was studied. Methods. Six female patients, 19-33 years old, with high-risk trophoblastic disease were subjected to one to five chemoembolizations in 3-week intervals. Three of the patients had metastases to the liver, 2 had local tumor extension to the pelvic wall, and all 5 had failed initial systemic chemotherapy. The sixth patient was treated for a trophoblastic remnant following surgical expression of a tubal pregnancy. For follow-up, beta hCG levels in urine and serum and dynamic or angiocomputed tomograms were obtained in biweekly to 6-month intervals. Results. Two of 3 patients with liver metastases are alive and free of disease 6 and 7 years after initial chemoembolization. The third is alive at 3 years but with evidence of recurrent disease. Two patients treated for locally invasive trophoblastic disease died 3 months and 4 years, respectively, after initial chemoembolization. One had a 21/2-year remission. The patient treated for a trophoblastic remnant in the tube is alive and free of disease at 6-year follow-up. Hematologic toxicity occurred in only one. Conclusion. Selective chemoembolization in our small series of patients with high-risk trophoblastic disease was equally effective as results reported for multi-drug systemic chemotherapy but had markedly lower renal, liver, and hematologic toxicity.

  14. Bioengineered Corneas Grafted as Alternatives to Human Donor Corneas in Three High-Risk Patients

    PubMed Central

    Buznyk, Oleksiy; Pasyechnikova, Nataliya; Islam, M Mirazul; Iakymenko, Stanislav; Fagerholm, Per; Griffith, May

    2015-01-01

    Corneas with severe pathologies have a high risk of rejection when conventionally grafted with human donor tissues. In this early observational study, we grafted bioengineered corneal implants made from recombinant human collagen and synthetic phosphorylcholine polymer into three patients for whom donor cornea transplantation carried a high risk of transplant failure. These patients suffered from corneal ulcers and recurrent erosions preoperatively. The implants provided relief from pain and discomfort, restored corneal integrity by promoting endogenous regeneration of corneal tissues, and improved vision in two of three patients. Such implants could in the future be alternatives to donor corneas for high-risk patients, and therefore, merits further testing in a clinical trial. PMID:25996570

  15. Nutritional assessment of surgical patients.

    PubMed

    Brown, C S; Stegman, M R

    1988-10-01

    In order to test the sensitivity and specificity of the East Orange Nutritional Screening Form (EONSF), nutritional assessments were performed on a random sample of 10% of general medical/surgical admissions at a large midwestern veteran's administration hospital. Patients were followed until discharge to determine if they met the standard criteria of additional nutritional support. The tool correctly identified patients at nutritional risk (sensitivity) 95% of the time and patients not at nutritional risk (specificity) 89% of the time. It proved to be an effective, low-cost tool for identifying patients at risk and for planning appropriate nutritional strategies.

  16. Fast-track rapid warfarin reversal for elective surgery: extending the efficacy profile to high-risk patients with cancer.

    PubMed

    Byrne, T J; Riedel, B; Ismail, H M; Heriot, A; Dauer, R; Westerman, D; Seymour, J F; Kenchington, K; Burbury, K

    2015-11-01

    Periprocedural management of patients on long-term warfarin therapy remains a common and important clinical issue, with little high-quality data to guide this complex process. The current accepted practice is cessation of warfarin five days preoperatively, but this is not without risk and can be complicated, particularly if bridging is required. An alternative method utilising low-dose intravenous vitamin K the day before surgery has been shown previously to be efficacious, safe and convenient in an elective surgical population receiving chronic warfarin therapy. The efficacy and utility of this 'fast-track' warfarin reversal protocol in surgical patients with cancer, who were at high risk of both thromboembolism and bleeding was investigated in a prospective, single-arm study at a dedicated cancer centre. Seventy-one patients underwent 82 episodes of fast-track warfarin reversal (3 mg intravenous vitamin K 18 to 24 hours before surgery). No patient suffered an adverse reaction to intravenous vitamin K, all but one achieved an International Normalized Ratio =1.5 on the day of surgery, and no surgery was deferred. Assays of vitamin K-dependent factor levels pre- and post-vitamin K demonstrated restoration of functional activity to within an acceptable range for surgical haemostasis. While this alternative method requires further validation in a larger prospective randomised study, we have now extended our use of fast-track warfarin reversal using vitamin K to patients with cancer, on the basis of our experience of its safety, convenience, reliability and efficacy.

  17. Off-pump coronary artery bypass grafting in high-risk patients: a review

    PubMed Central

    Chivasso, Pierpaolo; Fudulu, Daniel; Rapetto, Filippo; Sedmakov, Christo; Marsico, Roberto; Zakkar, Mustafa; Bryan, Alan J.; Angelini, Gianni D.

    2016-01-01

    The role of off-pump coronary artery bypass (OPCAB) grafting in high risk patients remains controversial. While there have been studies showing the potential benefits of it, there is still a lot to be learned from the application of this technique in this sub-group of patients. The results of the different trials and papers that we reviewed seem to indicate a benefit in the OPCAB group. Despite of the fact that trials were significantly different in methodology, especially when choosing the risk score stratification tool or the cut-off to define high risk the literature seems to suggest a benefit from the use of OPCAB surgery. Here, we present a review which focussed on early and late outcome in high risk patients undergoing on- and off-pump coronary revascularization. PMID:27942397

  18. Vaccination of high-risk patients for influenza. A comparison of telephone and mail reminder methods.

    PubMed

    Brimberry, R

    1988-04-01

    During the 1984-1985 influenza season two study groups were used to compare telephone and letter reminder methods with a control group that received no reminder to determine which was the most effective strategy to increase influenza vaccination rates among the high-risk patient population of a university-based family practice. Seven hundred eighty-seven high-risk patients were randomly assigned to one of the three study groups: a mailed-reminder group, a telephone-reminder group, and a control group. Vaccination rates for both reminder methods were significantly higher than for the control group (P less than .02), and if successfully contacted, the telephone-reminder group had a significantly better vaccination rate than the mailed-reminder group (P less than .05). If successful telephone contact can be made, this reminder method is more effective than a letter reminder to increase influenza vaccination rates among high-risk patients.

  19. Prospective randomized controlled study of prophylaxis with cefamandole in high risk patients undergoing operations upon the biliary tract.

    PubMed

    Cáinzos, M; Potel, J; Puente, J L

    1985-01-01

    In this study, 52 high risk patients who underwent operations upon the biliary tract were assigned to receive either antibiotic prophylaxis or no treatment with antibiotics. Twenty-seven patients were given 2 grams of cefamandole intramuscularly 30 minutes before operation and 2 grams every eight hours for two days postoperatively. The remaining patients were in the control group and did not receive antibiotics. Surgical wounds were inspected daily by a surgeon while the patients were in the hospital and a follow-up revision was done four weeks after discharge from the hospital. Samples of exudate or pus were taken when the wound appeared infected and cultures of aerobic and anaerobic organism done. Chi-square affinity test with Yate's correction was used for statistical results; only p values more than or equal to 0.5 were considered significant. Seven patients (28 per cent) in the control group had complications develop postoperatively; seven surgical wound infections, one of which included a subphrenic abscess. Postoperatively, there were no septic complications in the group who received cefamandole as a prophylaxis. The incidence of infection was higher for females than males. The organisms most frequently isolated were Escherichia coli and Klebsiella; only in one instance was Clostridum sporogenes found. Polymicrobial infections accounted for 42.8 per cent of the infections. No incidences were reported with the use of cefamandole in those patients who were treated prophylactically. In view of these results, we believe that cefamandole is an ideal antibiotic to be used in the prophylactic treatment of infections of high risk patients who undergo operations upon the biliary tract.

  20. Carfilzomib significantly improves the progression-free survival of high-risk patients in multiple myeloma

    PubMed Central

    Fonseca, Rafael; Siegel, David; Dimopoulos, Meletios A.; Špička, Ivan; Masszi, Tamás; Hájek, Roman; Rosiñol, Laura; Goranova-Marinova, Vesselina; Mihaylov, Georgi; Maisnar, Vladimír; Mateos, Maria-Victoria; Wang, Michael; Niesvizky, Ruben; Oriol, Albert; Jakubowiak, Andrzej; Minarik, Jiri; Palumbo, Antonio; Bensinger, William; Kukreti, Vishal; Ben-Yehuda, Dina; Stewart, A. Keith; Obreja, Mihaela; Moreau, Philippe

    2016-01-01

    The presence of certain high-risk cytogenetic abnormalities, such as translocations (4;14) and (14;16) and deletion (17p), are known to have a negative impact on survival in multiple myeloma (MM). The phase 3 study ASPIRE (N = 792) demonstrated that progression-free survival (PFS) was significantly improved with carfilzomib, lenalidomide, and dexamethasone (KRd), compared with lenalidomide and dexamethasone (Rd) in relapsed MM. This preplanned subgroup analysis of ASPIRE was conducted to evaluate KRd vs Rd by baseline cytogenetics according to fluorescence in situ hybridization. Of 417 patients with known cytogenetic risk status, 100 patients (24%) were categorized with high-risk cytogenetics (KRd, n = 48; Rd, n = 52) and 317 (76%) were categorized with standard-risk cytogenetics (KRd, n = 147; Rd, n = 170). For patients with high-risk cytogenetics, treatment with KRd resulted in a median PFS of 23.1 months, a 9-month improvement relative to treatment with Rd. For patients with standard-risk cytogenetics, treatment with KRd led to a 10-month improvement in median PFS vs Rd. The overall response rates for KRd vs Rd were 79.2% vs 59.6% (high-risk cytogenetics) and 91.2% vs 73.5% (standard-risk cytogenetics); approximately fivefold as many patients with high- or standard-risk cytogenetics achieved a complete response or better with KRd vs Rd (29.2% vs 5.8% and 38.1% vs 6.5%, respectively). KRd improved but did not abrogate the poor prognosis associated with high-risk cytogenetics. This regimen had a favorable benefit-risk profile in patients with relapsed MM, irrespective of cytogenetic risk status, and should be considered a standard of care in these patients. This trial was registered at www.clinicaltrials.gov as #NCT01080391. PMID:27439911

  1. Pancreatic Stenting Reduces Post-ERCP Pancreatitis and Biliary Sepsis in High-Risk Patients: A Randomized, Controlled Study

    PubMed Central

    Wu, Hai-En; Li, Qi-Xiang; Wang, Wei; Ou, Wei-Lin; Xia, Harry Hua-Xiang

    2016-01-01

    Background. Endoscopic retrograde cholangiopancreatography (ERCP) is an established treatment modality for bile duct disorders, but patients have a risk of post-ERCP pancreatitis (PEP) and biliary sepsis. Aim. To evaluate the effectiveness and safety of pancreatic stent for prophylaxis of PEP and biliary sepsis in high-risk patients with complicating common bile duct (CBD) disorders. Methods. Two hundred and six patients with complicating confirmed or suspected CBD disorders were randomly assigned to receive ERCP with pancreatic stenting (experimental group) or without stenting (control group). Primary outcome measure was frequency of PEP, and secondary outcome measures included operative time, blood loss, postoperative recovery times, and other ERCP-associated morbidities. Results. Baseline age, sex, CBD etiology, concomitant medical/surgical conditions, cannulation difficulty, and ERCP success were comparable between the two groups (all P > 0.05). Compared to the control group, the experimental group had a significantly lower frequency of PEP (7.7% versus 17.7%, P < 0.05) and positive bile microbial culture (40.4% versus 62.7%, P < 0.05). However, the two groups were similar in operative time, blood loss, postoperative recovery times, and other ERCP-associated morbidities (all P > 0.05). Conclusions. Pancreatic stenting can reduce the occurrence of PEP and biliary sepsis in high-risk patients with complicating CBD disorders but does not increase other ERCP-associated morbidities. This trial is registered with the Chinese Clinical Trial Registry (registration identifier ChiCTR-OCH-14005134). PMID:27057161

  2. Goal-directed Therapy Improves the Outcome of High-risk Cardiac Patients Undergoing Off-pump Coronary Artery Bypass

    PubMed Central

    Kapoor, Poonam Malhotra; Magoon, Rohan; Rawat, Rajinder Singh; Mehta, Yatin; Taneja, Sameer; Ravi, R; Hote, Milind P

    2017-01-01

    Background: There has been a constant emphasis on developing management strategies to improve the outcome of high-risk cardiac patients undergoing surgical revascularization. The performance of coronary artery bypass surgery on an off-pump coronary artery bypass (OPCAB) avoids the risks associated with extra-corporeal circulation. The preliminary results of goal-directed therapy (GDT) for hemodynamic management of high-risk cardiac surgical patients are encouraging. The present study was conducted to study the outcome benefits with the combined use of GDT with OPCAB as compared to the conventional hemodynamic management. Material and Method: Patients with the European System for Cardiac Operative Risk Evaluation ≥3 scheduled for OPCAB were randomly divided into two groups; the control and GDT groups. The GDT group included the monitoring and optimization of advanced parameters, including cardiac index (CI), systemic vascular resistance index, oxygen delivery index, stroke volume variation; continuous central venous oxygen saturation (ScVO2), global end-diastolic volume, and extravascular lung water (EVLW), using FloTrac™, PreSep™, and EV-1000® monitoring panels, in addition to the conventional hemodynamic management in the control group. The hemodynamic parameters were continuously monitored for 48 h in Intensive Care Unit (ICU) and corrected according to GDT protocol. A total of 163 patients consented for the study. Result: Seventy-five patients were assigned to the GDT group and 88 patients were in the control group. In view of 9 exclusions from the GDT group and 12 exclusions from control group, 66 patients in the GDT group and 76 patients in control group completed the study. Conclusion: The length of stay in hospital (LOS-H) (7.42 ± 1.48 vs. 5.61 ± 1.11 days, P < 0.001) and ICU stay (4.2 ± 0.82 vs. 2.53 ± 0.56 days, P < 0.001) were significantly lower in the GDT group as compared to control group. The duration of inotropes (3.24 ± 0.73 vs. 2.89

  3. Albumin synthesis in surgical patients.

    PubMed

    Hülshoff, Ansgar; Schricker, Thomas; Elgendy, Hamed; Hatzakorzian, Roupen; Lattermann, Ralph

    2013-05-01

    Albumin plasma concentrations are being used as indicators of nutritional status and hepatic function based on the assumption that plasma levels reflect the rate of albumin synthesis. However, it has been shown that albumin levels are not reliable markers of albumin synthesis under a variety of clinical conditions including inflammation, malnutrition, diabetes mellitus, liver disease, and surgical tissue trauma. To date, only a few studies have measured albumin synthesis in surgical and critically ill patients. This review summarizes the findings from these studies, which used different tracer methodology in various surgical or critically ill patient populations. The results indicate that the fractional synthesis rate of albumin appears to decrease during surgery, followed by an increase during the postoperative phase. In the early postoperative phase, albumin fractional synthesis rate can be stimulated by perioperative nutrition, if enough amino acids are being provided and if nutrition is being initiated before the operation. The physiologic meaning of albumin synthesis after surgery, however, still needs to be further clarified.

  4. Optimal Blood Pressure Goals in Patients With Hypertension at High Risk for Cardiovascular Events.

    PubMed

    Aronow, Wilbert S

    2016-01-01

    Existing epidemiologic and clinical trial data suggest that the blood pressure in patients with hypertension at high risk for cardiovascular events because of coronary artery disease, diabetes mellitus, chronic kidney disease, stroke, or heart failure should be reduced to <140/90 mm Hg in patients younger than 80 years and the systolic blood pressure be reduced to 140-145 mm Hg if tolerated in patients aged 80 years and older. Studies from patients with coronary artery disease, diabetes mellitus, chronic kidney disease, stroke, and heart failure will be discussed that support a blood pressure goal of <140/90 mm Hg in patients younger than 80 years at high risk for cardiovascular events.

  5. Predicting Negative Events: Using Post-discharge Data to Detect High-Risk Patients

    PubMed Central

    Sulieman, Lina; Fabbri, Daniel; Wang, Fei; Hu, Jianying; Malin, Bradley A

    2016-01-01

    Predicting negative outcomes, such as readmission or death, and detecting high-risk patients are important yet challenging problems in medical informatics. Various models have been proposed to detect high-risk patients; however, the state of the art relies on patient information collected before or at the time of discharge to predict future outcomes. In this paper, we investigate the effect of including data generated post discharge to predict negative outcomes. Specifically, we focus on two types of patients admitted to the Vanderbilt University Medical Center between 2010-2013: i) those with an acute event - 704 hip fractures and ii) those with chronic problems — 5250 congestive heart failure (CHF) patients. We show that the post-discharge model improved the AUC of the LACE index, a standard readmission scoring function, by 20 - 30%. Moreover, the new model resulted in higher AUCs by 15 - 27% for hip fracture and 10 - 12% for CHF compared to standard models. PMID:28269914

  6. Considering psychoeducation on structural dissociation for dialectical behavior therapy patients experiencing high-risk dissociative behaviors.

    PubMed

    Shabb, Olivia

    2016-01-01

    Dialectical behavioral therapy (DBT) programs, particularly for low-functioning individuals at the safety and stabilization phase of therapy, work with a variety of high-risk and often complex cases, with a curriculum consisting primarily of concrete skill acquisition and application. A significant subset of individuals in DBT programs, however, may suffer high-risk dissociative episodes in which skill application may be less available to them, contributing to further destabilization, demoralization, and thoughts of self-inefficacy in treatment. This article evaluates the potential benefits of complementing traditional DBT with psychoeducation on structural dissociation for such patients, acknowledging and addressing some of the concerns that might accompany such a consideration.

  7. Transcatheter aortic valve implantation: a revolution in the therapy of elderly and high-risk patients with severe aortic stenosis

    PubMed Central

    Kilic, Teoman; Yilmaz, Irem

    2017-01-01

    Transcatheter aortic valve implantation (TAVI) represents a real revolution in the field of interventional cardiology for the treatment of elderly or high-risk surgical patients with severe symptomatic aortic valve stenosis. Today, TAVI seems to play a key and a reliable role in the treatment of intermediate and maybe low-risk patients with severe aortic stenosis. TAVI has also evolved from a complex and hazardous procedure into an effective and safe therapy by the development of new generation devices. This article aims to review the background and future of TAVI, clinical trials and registries with old and new generation TAVI devices and to focus on some open issues related to post-procedural outcomes.

  8. Is extended preoperative antibiotic prophylaxis for high-risk patients necessary before percutaneous nephrolithotomy?

    PubMed Central

    Park, Alyssa M.; Bauman, Tyler M.; Larson, Jeffrey A.; Vetter, Joel M.; Benway, Brian M.; Desai, Alana C.

    2016-01-01

    Purpose The goal of this study was to compare the rate of systemic inflammatory response syndrome (SIRS) in high-risk patients undergoing percutaneous nephrolithotomy (PCNL) between patients who received 7, 2, or 0 days of preoperative antibiotics. Materials and Methods We retrospectively reviewed a series of consecutive PCNLs performed at our institution. Patients with infected preoperative urine cultures were excluded. High-risk patients were defined as those with a history of previous urinary tract infection (UTI), hydronephrosis, or stone size ≥2 cm. Patients were treated with 7, 2, or 0 days of preoperative antibiotic prophylaxis prior to PCNL. All patients received a single preoperative dose of antibiotics within 60 minutes of the start of surgery. Fisher exact test was used to compare the rate of SIRS by preoperative antibiotic length. Results Of the 292 patients identified, 138 (47.3%) had sterile urine and met high-risk criteria, of which 27 (19.6%), 39 (28.3%), and 72 (52.2%) received 7, 2, and 0 days of preoperative antibiotics, respectively. The 3 groups were similar in age, sex, and duration of surgery (p>0.05). There was no difference in the rate of SIRS between the groups, with 1 of 27 (3.7%), 2 of 39 (5.1%) and 3 of 72 patients (4.2%) meeting criteria in the 7, 2, and 0 days antibiotic groups (p=~1). Conclusions Extended preoperative antibiotic prophylaxis was not found to reduce the risk of SIRS after PCNL in our institutional experience of high-risk patients. For these patients, a single preoperative dose of antibiotics is sufficient. PMID:27847915

  9. Nonoperative options for management of residual stones after cholecystostomy in high-risk patients

    NASA Astrophysics Data System (ADS)

    Reed, David M.; Daye, S. S.; Lincer, R. M.

    1993-05-01

    Cholecystostomy is frequently performed to obtain control of sepsis in high risk patients with acute cholecystitis. Retained stones in the gallbladder may cause future clinical problems. We present two patients with cholecystostomy tubes managed non-operatively. A review of other reported methods for stone extraction or destruction is also presented. Knowledge of safe and effective techniques for removal of these stones, using minimally invasive techniques is useful to the general surgeon.

  10. Improving outcomes from high-risk surgery: a multimethod evaluation of a patient-centred advanced care planning intervention

    PubMed Central

    Senthuran, Siva; Blakely, Brette; Lane, Paul; North, John; Clay-Williams, Robyn

    2017-01-01

    Introduction Patients who are frail, have multiple comorbidities or have a terminal illness often have poor outcomes from surgery. However, sole specialists may recommend surgery in these patients without consultation with other treating clinicians or allowing for patient goals. The Patient-Centred Advanced Care Planning (PC-ACP) model of care provides a framework in which a multidisciplinary advanced care plan is devised to incorporate high-risk patients' values and goals. Decision-making is performed collaboratively by patients, their family, surgeons, anaesthetists, intensivists and surgical case managers. This study aims to evaluate the feasibility of this new model of care, and to determine potential benefits to patients and clinicians. Methods and analysis After being assessed for frailty, patients will complete a patient–clinician information engagement survey pretreatment and at 6 months follow-up. Patients (and/or family members) will be interviewed about their experience of care pretreatment and at 3 and 6 months follow-ups. Clinicians will complete a survey on workplace attitudes and engagement both preimplementation and postimplementation of PC-ACP and be interviewed, following each survey, on the implementation of PC-ACP. We will use process mapping to map the patient journey through the surgical care pathway to determine areas of improvement and to identify variations in patient experience. Ethics and dissemination This study has received ethical approval from Townsville Hospital and Health Service HREC (HREC/16/QTHS/100). Results will be communicated to the participating hospital, presented at conferences and submitted for publication in a peer-reviewed MEDLINE-indexed journal. PMID:28242771

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

    PubMed

    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.

  12. High-risk plaque in patients with near normal coronary angiograms.

    PubMed

    Turner, Michael C

    2016-11-01

    The increased use of cardiac computed tomography angiography in the emergency room to triage patients who present with chest pain syndrome has led to the identification of individuals with coronary plaques with high-risk characteristics in the absence of significant stenoses. Anecdotal observations have suggested that the presence of coronary high-risk plaque results in an increased risk of acute coronary syndrome over time. This case presentation represents an example of this subgroup of patients. Intuitively, it would seem that high-dose statin therapy would be the treatment of choice, with percutaneous intervention reserved for the development of flow-limiting lesions; however, a prospective trial to determine outcomes to our knowledge has not been performed.

  13. Telomere stability is frequently impaired in high-risk groups of patients with myelodysplastic syndromes.

    PubMed

    Ohyashiki, J H; Iwama, H; Yahata, N; Ando, K; Hayashi, S; Shay, J W; Ohyashiki, K

    1999-05-01

    Genomic instability induces an accumulation of genetic changes and may play a role in the pathogenesis of myelodysplastic syndromes (MDS). To clarify the possible association between genomic instability and clinical outcome in MDS patients, we compared telomere dynamics to the recently established International Prognostic Scoring System (IPSS) risk groups for MDS. We measured the terminal restriction fragments (TRFs) of 93 patients with MDS at the time of diagnosis, and telomerase activity was analyzed in 62 patients with MDS using the PCR-based telomeric repeat amplification protocol (TRAP) assay. A total of 53 of 93 MDS patients had TRFs within the age-matched normal range, and the remaining patients showed shortened TRFs (35 patients) or elongated TRFs (5 patients). MDS patients with shortened TRFs had a significantly low hemoglobin concentration (P = 0.04), a high percentage of marrow blasts (P = 0.02), and a high incidence of cytogenetic abnormalities (P < 0.05). The incidence of leukemic transformation was significantly high in patients with shortened TRF length (P < 0.05). In addition, patients with shortened TRF length were frequently seen in the IPSS high-risk group (P < 0.01). Most of the MDS patients had normal-to-low levels of telomerase activity, suggesting that changes in TRF length rather than telomerase activity may more accurately reflect the pathophysiology of MDS. MDS patients with shortened TRF length had a very poor prognosis (P < 0.01), suggesting that telomere dynamics may be linked to clinical outcome in MDS patients. Thus, an abnormal mechanism of telomere maintenance in subgroups of MDS patients may be an early indication of genomic instability. This study demonstrates that telomere stability is frequently impaired in a high-risk group of MDS patients and suggests that, in combination with the IPSS classification system, measurement of TRFs may be useful in the future to stratify MDS patients according to risk and manage the care of MDS

  14. Evidence Base for Restrictive Transfusion Triggers in High-Risk Patients

    PubMed Central

    Spahn, Donat R.; Spahn, Gabriela H.; Stein, Philipp

    2015-01-01

    Liberal versus restrictive red blood cell (RBC) transfusion triggers have been debated for years. This review illustrates the human body's physiologic response to acute anemia and summarizes the evidence from prospective randomized trials (RCTs) for restrictive use of RBC transfusions in high-risk patients. During progressive anemia, the human body maintains the oxygen delivery to the tissues by an increase in cardiac output and peripheral oxygen extraction. Seven RCTs with a total of 5,566 high-risk patients compared a restrictive hemoglobin (Hb) transfusion trigger (Hb < 70 or < 80 g/l) with a liberal Hb transfusion trigger (Hb < 90 or < 100 g/l). Unanimously these studies show non-inferiority, safety, and a significant reduction in RBC transfusions in the restrictive groups. In one RCT mortality was higher in the liberal Hb transfusion group, and in two additional RCTs mortality of subgroups or after risk adjustment was significantly higher in the liberal Hb transfusion trigger groups. Conclusion Strong RCT evidence suggests the safety of restrictive transfusion triggers. As a consequence, an Hb transfusion trigger of <70 g/l is recommended for high risk patients. PMID:26019706

  15. High risk for obstructive sleep apnea in patients with acute myocardial infarction1

    PubMed Central

    Andrechuk, Carla Renata Silva; Ceolim, Maria Filomena

    2015-01-01

    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. PMID:26487128

  16. Central venous oxygen saturation during high-risk general surgical procedures-relationship to complications and clinical outcomes.

    PubMed

    Boyle, M S; Bennett, M; Keogh, G W; O'Brien, M; Flynn, G; Collins, D W; Bihari, D

    2014-01-01

    Major non-cardiac surgery is associated with postoperative morbidity, and perioperative central venous oxygen saturation (ScvO2) may be a predictor of morbidity. This pilot study aimed to define intraoperative ScvO2 and to identify factors associated with postoperative complications. ScvO2 (reflection spectrophotometry) was recorded continuously in a convenience sample of adults undergoing high-risk general surgery. Demographics, intraoperative management, surgery duration, postoperative complications and deaths within 28 days were recorded. Data from 51 patients were analysed. Two (4%) died and 24 (47%) had at least one complication (range 1 to 5). The hospital length-of-stay and duration of surgery were longer in those with complications (22.1±6.1 versus 9.6±3.6 days, P >0.0001, and 328±162 minutes versus 241±94 minutes, P=0.02, respectively). Overall, the ScvO2 was 82±8% and ranged from 40% to 97% with 17 (33%) patients having at least one episode of ScvO2 >70%. Hospital length-of-stay (P >0.0001), time ScvO2 >90% (P=0.003), surgery duration (P=0.005) and blood loss (P=0.02) were correlated with the number of complications. Using multivariate analysis, surgery duration (odds ratio 1.008 [95% confidence interval 1.002 to 1.013]; P=0.006) and change in oxygen extraction ratio (O2ER) at the end of surgery compared to the beginning (odds ratio 1.13 [95% confidence interval 1.001 to 1.28]; P=0.04) were independently associated with complications. The surgery duration and an increased O2ER are factors related to the development of postoperative complications.

  17. Intensive combined modality therapy including low-dose TBI in high-risk Ewing's sarcoma patients

    SciTech Connect

    Kinsella, T.J.; Glaubiger, D.; Diesseroth, A.; Makuch, R.; Waller, B.; Pizzo, P.; Glatstein, E.

    1983-12-01

    Twenty-four high-risk Ewing's sarcoma patients were treated on an intensive combined modality protocol including low-dose fractionated total body irradiaiton (TBI) and autologous bone marrow infusion (ABMI). Twenty patients (83%) achieved a complete clinical response to the primary and/or metastatic sites following induction therapy. The median disease-free interval was 18 months, and nine patients remain disease-free with a follow-up of 22 to 72 months. Local failure as a manifestation of initial relapse occurred in only three patients (15%), each having synchronous distant failure. Eight patients failed initially with only distant metastases, usually within 1-2 years following a complete clinical response. Two patterns of granulocyte recovery following consolidative therapy (including TBI and ABMI) were recognized. The time to platelet recovery was different for the groups with early and late granulocyte recovery. Patients with late recovery did not tolerate maintenance chemotherapy. However, there was no difference in disease-free and overall survival, when comparing the groups with early and late granulocyte recovery. It is concluded that these high-risk Ewing's sarcoma patients remain a poor-prognosis group in spite of intensive combined modality therapy including low-dose TBI. The control of microscopic systemic disease remains the major challenge to improving the cure rate. A new combined modality protocol with high-dose 'therapeutic' TBI (800 rad/2 fractions) is being used and the protocol design is outlined.

  18. Does the Application of Incisional Negative Pressure Therapy to High-Risk Wounds Prevent Surgical Site Complications? A Systematic Review

    PubMed Central

    Ingargiola, Michael J.; Daniali, Lily N.; Lee, Edward S.

    2013-01-01

    Purpose: The application of incisional negative pressure wound therapy (INPWT) to clean, closed surgical incisions is a growing clinical practice. A systematic review was conducted to evaluate the effect of INPWT on surgical sites healing by primary intention. The primary outcomes of interest are incidence of complications (infection, dehiscence, seroma, hematoma, skin necrosis, or blistering). Methods: Two independent reviewers performed a search of the Ovid MEDLINE and EMBASE databases from 2006 to 2012 for published articles. Supplemental searches were performed using reference lists and conference proceedings. Studies were selected for inclusion based on predetermined inclusion and exclusion criteria. Data extraction regarding study quality, demographic and clinical characteristics, and outcomes was performed independently, and data on the incidence of infection was combined using a fixed-effects meta-analysis model. Results: Ten (5 randomized controlled trials and 5 observational) studies were included, which investigated the outcomes of 626 incisions on 610 patients. Six studies compared INPWT with sterile dry dressings (SDDs). The literature shows a significant decrease in rates of infection when using INPWT. Results on dehiscence do show a decrease in some studies, but results are inconsistent to make a conclusion. Because of limited studies, it is difficult to make any assertions on seroma, hematoma, and skin necrosis. Conclusions: This systematic review shows possible evidence of a decrease in the incidence of infection with application of INPWT. Looking at other variables such as dehiscence, seroma, hematoma, and skin necrosis show no consistent data and suggest further studies in order for proper recommendations for INPWT. PMID:24106562

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

    PubMed

    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 <0.001). There were no important differences in the proportion of patients having MET calls (16.0% POST versus. 13% control (P=0.25)) or mortality (2.1% POST versus 2.8% Control (P=0.82)). Our audit found that the POST service was not associated with reduced length of stay. Models of co-management, different to POST, or with different performance metrics, could be tested.

  20. Stem Cell Transplant-Associated Wernicke Encephalopathy in a Patient with High-Risk Neuroblastoma.

    PubMed

    Darlington, Wendy S; Pinto, Navin; Hecktman, Hillary M; Cohn, Susan L; LaBelle, James L

    2015-12-01

    Children undergoing intense cancer treatment frequently require total parenteral nutrition (TPN). Rarely, vitamins are removed due to hypersensitivity to the carrier vehicle in the formulation. We present the case of a 5-year-old patient with stage 4, high-risk neuroblastoma who developed altered mental status, ataxia, and tachycardia during consolidative autologous stem cell transplantation. Skin findings and brain MRI were consistent with thiamine (vitamin B1) deficiency and Wernicke encephalopathy. Vitamin B1 administration rapidly reversed all skin and neurologic symptoms. This case highlights the importance of close monitoring of micronutrients in pediatric patients receiving prolonged courses of chemotherapy and stem cell transplantation.

  1. Shorter leukocyte telomere length in patients at ultra high risk for psychosis.

    PubMed

    Maurya, Pawan Kumar; Rizzo, Lucas Bortolotto; Xavier, Gabriela; Tempaku, Priscila Farias; Zeni-Graiff, Maiara; Santoro, Marcos L; Mazzotti, Diego Robles; Zugman, André; Pan, Pedro; Noto, Cristiano; Maes, Michael; Asevedo, Elson; Mansur, Rodrigo B; Cunha, Graccielle R; Gadelha, Ary; Bressan, Rodrigo A; Belangero, Sintia Iole; Brietzke, Elisa

    2017-03-05

    Telomere length attrition has been demonstrated in schizophrenia but not in individuals in ultra high risk (UHR) for psychosis. The present study aimed to compare the leukocyte telomere length (TL) between patients at UHR for psychosis and healthy controls (HC). Twenty-two participants with UHR and 88 HC were enrolled in this study. Telomere lengths were determined using a multiplex qPCR assay. After adjustment for age, sex, ethnicity, and education, patients in UHR, compared with HC groups, had shorter telomere length (RR: 0.929, p=0.031). Shorter leukocyte telomere length in UHR could represent early signs of accelerated aging in this population.

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

    PubMed

    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.

  3. Percutaneous cholecystostomy for acute cholecystitis in high-risk elderly patients.

    PubMed

    Lin, Wei-Chen; Chang, Chen-Wang; Chu, Cheng-Hsin

    2016-10-01

    Emergency cholecystectomy for acute cholecystitis (AC) is associated with high morbidity and mortality rates in elderly patients with significant comorbidities. The aim of this study was to evaluate percutaneous cholecystostomy for AC in elderly patients with various coexisting diseases. We retrospectively reviewed the records of 4311 patients with AC treated in Mackay Memorial Hospital between the years 2000 and 2015. The clinical course of AC was compared between nonelderly (age ≤70 years) and elderly patients (age>70 years). In total, 67 elderly patients and 32 nonelderly patients received percutaneous cholecystostomy. The rate of percutaneous cholecystostomy increased between the years 2011 and 2015 (from 2.5% to 12.2%) and this procedure was more common in the elderly group (p=0.009). In addition, the comorbidities of ischemic heart disease and chronic kidney disease were higher in elderly than in nonelderly patients (p=0.014 and p=0.015, respectively). The American Society of Anesthesiologists' classification was higher in the elderly patients (p=0.001). The overall survival-free rate of recurrent cholecystitis in patients who did not receive cholecystectomy was not significantly different in the two groups. When compared with emergent cholecystectomy in high-risk elderly patients, percutaneous cholecystostomy resulted in reduced hospital stay and morbidity (p=0.002 and p=0.013, respectively). Our results demonstrate that percutaneous cholecystostomy has become a common and early treatment for AC in high-risk elderly patients with ischemic heart disease or chronic kidney disease. Identifying such patients will possibly improve clinical outcomes, reduce hospital stay and morbidity, and facilitate delayed laparoscopic cholecystectomy.

  4. Prophylactic isopropyl alcohol inhalation and intravenous ondansetron versus ondansetron alone in the prevention of postoperative nausea and vomiting in high-risk patients.

    PubMed

    Radford, Kennett D; Fuller, Thomas N; Bushey, Brent; Daniel, Carole; Pellegrini, Joseph E

    2011-08-01

    Patients identified as high risk for postoperative nausea and vomiting (PONV) are often treated prophylactically with intravenous (IV) ondansetron and an additional agent. Limited options exist for a second agent with no adverse effects. The purpose of this investigation was to determine if combining the prophylactic inhalation of isopropyl alcohol (IPA) vapors, an agent with no adverse effects, with IV ondansetron would be more effective than IV ondansetron alone in the prevention of PONV in high-risk patients. A total of 76 patients at high risk for PONV were randomized into control (n = 38) and experimental (n = 38) groups. All patients received IV ondansetron before emergence from general anesthesia. In addition, the experimental group inhaled IPA vapors before induction. Severity of PONV was measured using a 0 to 10 verbal numeric rating scale. Other measured variables included time to onset and incidence of PONV, 24-hour composite nausea score, and satisfaction with nausea control. No significant differences in demographics, surgical or anesthesia time, number of risk factors, severity or incidence of PONV, or satisfaction scores were noted. Prophylactic inhalation of IPA vapors in combination with IV ondansetron was no more efficacious than IV ondansetron alone in the prevention of PONV in a high-risk population.

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

    SciTech Connect

    Polishchuk, Alexei L.; Li, Richard; Little, Anthony; Hawkins, Randall A.; Hamilton, Jeffrey; Lau, Michael; Tran, Hung Chi; Lemons, Richard S.; Matthay, Katherine K.; DuBois, Steven G.; 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

  6. Management of a high risk epileptic patient under conscious sedation: A multidisciplinary approach

    PubMed Central

    Chellathurai, Burnice Nalina Kumari; Thiagarajan, Ramakrishnan; Jayakumaran, SelvaKumar; Devadoss, Pradeep; Elavazhagan

    2016-01-01

    Epilepsy, characterized by the risk of recurrent seizures, is a chronic disease that afflicts about 5% of the world's population. The main dental problems associated with epileptic patients include gingival hyperplasia, minor oral injuries, tooth trauma, and prosthodontic problems, which require the dental treatment. Stress and fear are the most common triggering factors for the epilepsy in dental chair. Therefore, a more appropriate method of treating such epileptic patients may be warranted. Conscious sedation is a technique of providing good anesthesia and analgesia to patients, the main advantage of which is the patient's rapid return to presentation levels. Midazolam used as a sedative agent has anticonvulsant properties. This case report highlights a case requiring multiple dental procedures carried out in a high risk epileptic patient under conscious sedation. PMID:27041847

  7. Management of a high risk epileptic patient under conscious sedation: A multidisciplinary approach.

    PubMed

    Chellathurai, Burnice Nalina Kumari; Thiagarajan, Ramakrishnan; Jayakumaran, SelvaKumar; Devadoss, Pradeep; Elavazhagan

    2016-01-01

    Epilepsy, characterized by the risk of recurrent seizures, is a chronic disease that afflicts about 5% of the world's population. The main dental problems associated with epileptic patients include gingival hyperplasia, minor oral injuries, tooth trauma, and prosthodontic problems, which require the dental treatment. Stress and fear are the most common triggering factors for the epilepsy in dental chair. Therefore, a more appropriate method of treating such epileptic patients may be warranted. Conscious sedation is a technique of providing good anesthesia and analgesia to patients, the main advantage of which is the patient's rapid return to presentation levels. Midazolam used as a sedative agent has anticonvulsant properties. This case report highlights a case requiring multiple dental procedures carried out in a high risk epileptic patient under conscious sedation.

  8. Obligations and frustrations with high-risk patients: ethics of physicians' evaluations.

    PubMed

    Jones, James W; McCullough, Laurence B

    2015-02-01

    A surgeon, Dr A. Droit, has been following a 97-year-old male with a type IV thoracoabdominal aneurysm, which became symptomatic this morning and is leaking. The patient is frail but active with no important comorbidities. The anatomy demands an open procedure. The patient is a former renowned physician who has been a longtime family friend of Dr Droit-like a grandfather. He presented incoherent with sagging blood pressure. A complicating factor is that Dr D. Rag, the chief anesthesiologist, decided that neither he nor any of his staff would provide anesthesia. Dr Droit knows an anesthesiologist who handles high-risk patients at another hospital in the medical center. The patient has worsened over the last hour, is becoming more unstable, and is unable to respond but his wife wishes to consent for surgery. What should Dr Droit do?

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

    SciTech Connect

    Pusceddu, Claudio; Sotgia, Barbara Fele, Rosa Maria; Ballicu, Nicola; Melis, Luca

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

    PubMed

    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.

  11. Toxicity of combined treatment of adjuvant irradiation and interferon alpha2b in high-risk melanoma patients.

    PubMed

    Conill, Carlos; Jorcano, Sandra; Domingo-Domènech, Josep; Marruecos, Jordi; Vilella, Ramón; Malvehy, Josep; Puig, Susana; Sánchez, Marcelo; Gallego, Rosa; Castel, Teresa

    2007-10-01

    Surgically resected stage III melanoma patients commonly receive adjuvant therapy with interferon (IFN) alpha2b. For those patients with high-risk features of draining node recurrence, radiation therapy can also be considered as a treatment option. The purpose of this retrospective study was to assess the efficacy and radiation-related toxicity of this combined therapy. Eighteen patients receiving adjuvant IFNalpha2b therapy during radiation therapy, or within 1 month of its completion, were reviewed retrospectively and analysed for outcome. Radiation was delivered at 600 cGy dose per fraction, in 16 out of 18 patients, twice a week, and at 200 cGy dose per fraction in two patients five times a week. Total radiation dose and number of fractions were as follows: 30 Gy/5 fr (n=8), 36 Gy/6 fr (n=8) and 50 Gy/25 fr (n=2). The percentage of disease-free patients, with no local recurrence, at 3 years was 88%. In 10 patients, IFNalpha2b was administered concurrently with radiotherapy; in three, within 30 days before or after radiation; and in five, more than 30 days after radiation. All the patients experienced acute skin reactions, grade I on the Radiation Therapy Oncology Group (RTOG) scale. Late radiation-related toxicity was seen in one patient with grade III (RTOG) skin reaction and two with grade IV (RTOG) radiation-induced myelitis. Concurrent use of adjuvant radiotherapy and IFNalpha2b might enhance radiation-induced toxicity, and special care should be taken when the spinal cord is included in the radiation field.

  12. Home Monitoring Program Reduces Mortality in High-Risk Sociodemographic Single-Ventricle Patients.

    PubMed

    Castellanos, Daniel Alexander; Herrington, Cynthia; Adler, Stacey; Haas, Karen; Ram Kumar, S; Kung, Grace C

    2016-12-01

    A clinician-driven home monitoring program can improve interstage outcomes in single-ventricle patients. Sociodemographic factors have been independently associated with mortality in interstage patients. We hypothesized that even in a population with high-risk sociodemographic characteristics, a home monitoring program is effective in reducing interstage mortality. We defined interstage period as the time period between discharge following Norwood palliation and second-stage surgery. We reviewed the charts of patients for the three-year period before (group 1) and after (group 2) implementation of the home monitoring program. Clinical variables around Norwood palliation, during the interstage period, and at the time of second-stage surgery were analyzed. There were 74 patients in group 1 and 52 in group 2. 59 % patients were Hispanic, and 84 % lived in neighborhoods where over 5 % families lived below poverty line. There was no significant difference in pre-Norwood variables, Norwood discharge variables, age at second surgery, or outcomes at second surgery. There were more Sano shunts performed at the Norwood procedure as the source of pulmonary blood flow in group 2 (p value <0.05). There were more unplanned hospital admissions and percutaneous re-interventions in group 2. Patients in group 2 whose admission criteria included desaturation had a 45 % likelihood of having an unplanned re-intervention. Group 2 noted an 80 % relative reduction in interstage mortality (p < 0.01). In a multiple regression analysis, after accounting for ethnicity, socio-economic status, and source of pulmonary blood flow, enrollment in a home monitoring program independently predicted improved interstage survival (p < 0.01). A clinician-driven home monitoring program reduces interstage mortality even when the majority of patients has high-risk sociodemographic characteristics.

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

    PubMed Central

    Soliman, Rabie; Zohry, Gomaa

    2016-01-01

    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. PMID:27716690

  14. Retroperitoneal Sarcoma (RPS) High Risk Gross Tumor Volume Boost (HR GTV Boost) Contour Delineation Agreement Among NRG Sarcoma Radiation and Surgical Oncologists

    PubMed Central

    Baldini, Elizabeth H.; Bosch, Walter; Kane, John M.; Abrams, Ross A.; Salerno, Kilian E.; Deville, Curtiland; Raut, Chandrajit P.; Petersen, Ivy A.; Chen, Yen-Lin; Mullen, John T.; Millikan, Keith W.; Karakousis, Giorgos; Kendrick, Michael L.; DeLaney, Thomas F.; Wang, Dian

    2015-01-01

    Purpose Curative intent management of retroperitoneal sarcoma (RPS) requires gross total resection. Preoperative radiotherapy (RT) often is used as an adjuvant to surgery, but recurrence rates remain high. To enhance RT efficacy with acceptable tolerance, there is interest in delivering “boost doses” of RT to high-risk areas of gross tumor volume (HR GTV) judged to be at risk for positive resection margins. We sought to evaluate variability in HR GTV boost target volume delineation among collaborating sarcoma radiation and surgical oncologist teams. Methods Radiation planning CT scans for three cases of RPS were distributed to seven paired radiation and surgical oncologist teams at six institutions. Teams contoured HR GTV boost volumes for each case. Analysis of contour agreement was performed using the simultaneous truth and performance level estimation (STAPLE) algorithm and kappa statistics. Results HRGTV boost volume contour agreement between the seven teams was “substantial” or “moderate” for all cases. Agreement was best on the torso wall posteriorly (abutting posterior chest abdominal wall) and medially (abutting ipsilateral para-vertebral space and great vessels). Contours varied more significantly abutting visceral organs due to differing surgical opinions regarding planned partial organ resection. Conclusions Agreement of RPS HRGTV boost volumes between sarcoma radiation and surgical oncologist teams was substantial to moderate. Differences were most striking in regions abutting visceral organs, highlighting the importance of collaboration between the radiation and surgical oncologist for “individualized” target delineation on the basis of areas deemed at risk and planned resection. PMID:26018727

  15. Selective use of post-mastectomy flap irradiation in high-risk breast cancer patients.

    PubMed

    Asgeirsson, Kristjan S; Holroyd, Ben; Morgan, David A L; Robertson, John F R; Blamey, Roger W; Pinder, Sarah E; Macmillan, R Douglas

    2005-08-01

    The incidence of local recurrence after mastectomy can be reduced by chest wall radiotherapy. However, only a minority of patients are at substantial risk. No UK national guidelines exist for the use of mastectomy flap radiotherapy. This study evaluated a protocol, whereby only high-risk patients were treated with post-mastectomy flap radiotherapy; identified histologically by grade, vascular invasion and nodal status. All women treated by simple mastectomy for invasive breast cancer at the Nottingham Breast Unit from January 1993 to December 1995 were studied (n=292). Postoperative flap radiotherapy was given to 147 high-risk women (50.3%). Median follow-up was 76 months. Overall, 12 women (4.1%) developed a chest wall recurrence; six were single spot recurrences and the remaining six were either multiple spot (n=3) or field change (field change dermal invasion, n=3). The chest wall recurrence rate was 2.7% in those treated with radiotherapy. A low rate of local recurrence has been achieved with selective use of mastectomy flap radiotherapy.

  16. Vulnerable Blood in High Risk Vascular Patients: Study Design and Methods

    PubMed Central

    McDermott, Mary M.; Greenland, Philip; Liu, Kiang; Tian, Lu; Green, David; Shah, Sanjiv J.; Huffman, Mark; Wilkins, John; Kibbe, Melina; Liao, Yihua; Huang, Chiang-Ching; Skelly, Christopher; Jacobs, Chad; McCarthy, Walter; Auerbach, Amanda; Lloyd-Jones, Donald

    2014-01-01

    BACKGROUND Basic research suggests that rapid increases in circulating inflammatory and hemostatic blood markers may trigger or indicate impending plaque rupture and coronary thrombosis, resulting in acute ischemic heart disease (IHD) events. However, these associations are not established in humans. METHODS AND RESULTS The Biomarker Risk Assessment in Vulnerable Outpatients (BRAVO) Study will determine whether levels of inflammatory and hemostatic biomarkers rapidly increase during the weeks prior to an acute IHD event in people with lower extremity peripheral artery disease (PAD). The BRAVO Study will determine whether biomarker levels measured immediately prior to an IHD event are higher than levels not preceding an IHD event; whether participants who experience an IHD event (cases) have higher biomarker levels immediately prior to the event and higher biomarker levels at each time point leading up to the IHD event than participants without an IHD event (controls); and whether case participants have greater increases in biomarkers during the months leading up to the event than controls. BRAVO enrolled 595 patients with PAD, a population at high risk for acute IHD events. After a baseline visit, participants returned every two months for blood collection, underwent an electrocardiogram to identify new silent myocardial infarctions, and were queried about new hospitalizations since their prior study visit. Mortality data were also collected. Participants were followed prospectively for up to three years. CONCLUSIONS BRAVO results will provide important information about the pathophysiology of IHD events and may lead to improved therapies for preventing IHD events in high-risk patients. PMID:24721480

  17. Next-generation personalised medicine for high-risk paediatric cancer patients - The INFORM pilot study.

    PubMed

    Worst, Barbara C; van Tilburg, Cornelis M; Balasubramanian, Gnana Prakash; Fiesel, Petra; Witt, Ruth; Freitag, Angelika; Boudalil, Miream; Previti, Christopher; Wolf, Stephan; Schmidt, Sabine; Chotewutmontri, Sasithorn; Bewerunge-Hudler, Melanie; Schick, Matthias; Schlesner, Matthias; Hutter, Barbara; Taylor, Lenka; Borst, Tobias; Sutter, Christian; Bartram, Claus R; Milde, Till; Pfaff, Elke; Kulozik, Andreas E; von Stackelberg, Arend; Meisel, Roland; Borkhardt, Arndt; Reinhardt, Dirk; Klusmann, Jan-Henning; Fleischhack, Gudrun; Tippelt, Stephan; Dirksen, Uta; Jürgens, Heribert; Kramm, Christof M; von Bueren, Andre O; Westermann, Frank; Fischer, Matthias; Burkhardt, Birgit; Wößmann, Wilhelm; Nathrath, Michaela; Bielack, Stefan S; Frühwald, Michael C; Fulda, Simone; Klingebiel, Thomas; Koscielniak, Ewa; Schwab, Matthias; Tremmel, Roman; Driever, Pablo Hernáiz; Schulte, Johannes H; Brors, Benedikt; von Deimling, Andreas; Lichter, Peter; Eggert, Angelika; Capper, David; Pfister, Stefan M; Jones, David T W; Witt, Olaf

    2016-09-01

    The 'Individualized Therapy for Relapsed Malignancies in Childhood' (INFORM) precision medicine study is a nationwide German program for children with high-risk relapsed/refractory malignancies, which aims to identify therapeutic targets on an individualised basis. In a pilot phase, reported here, we developed the logistical and analytical pipelines necessary for rapid and comprehensive molecular profiling in a clinical setting. Fifty-seven patients from 20 centers were prospectively recruited. Malignancies investigated included sarcomas (n = 25), brain tumours (n = 23), and others (n = 9). Whole-exome, low-coverage whole-genome, and RNA sequencing were complemented with methylation and expression microarray analyses. Alterations were assessed for potential targetability according to a customised prioritisation algorithm and subsequently discussed in an interdisciplinary molecular tumour board. Next-generation sequencing data were generated for 52 patients, with the full analysis possible in 46 of 52. Turnaround time from sample receipt until first report averaged 28 d. Twenty-six patients (50%) harbored a potentially druggable alteration with a prioritisation score of 'intermediate' or higher (level 4 of 7). Common targets included receptor tyrosine kinases, phosphoinositide 3-kinase-mammalian target of rapamycin pathway, mitogen-activated protein kinase pathway, and cell cycle control. Ten patients received a targeted therapy based on these findings, with responses observed in some previously treatment-refractory tumours. Comparative primary relapse analysis revealed substantial tumour evolution as well as one case of unsuspected secondary malignancy, highlighting the importance of re-biopsy at relapse. This study demonstrates the feasibility of comprehensive, real-time molecular profiling for high-risk paediatric cancer patients. This extended proof-of-concept, with examples of treatment consequences, expands upon previous personalised oncology endeavors

  18. Risk Factors for Urinary Tract Infections in Cardiac Surgical Patients

    PubMed Central

    Gillen, Jacob R.; Isbell, James M.; Michaels, Alex D.; Lau, Christine L.

    2015-01-01

    Abstract Background: Risk factors for catheter-associated urinary tract infections (CAUTIs) in patients undergoing non-cardiac surgical procedures have been well documented. However, the variables associated with CAUTIs in the cardiac surgical population have not been clearly defined. Therefore, the purpose of this study was to investigate risk factors associated with CAUTIs in patients undergoing cardiac procedures. Methods: All patients undergoing cardiac surgery at a single institution from 2006 through 2012 (4,883 patients) were reviewed. Patients with U.S. Centers for Disease Control (CDC) criteria for CAUTI were identified from the hospital's Quality Assessment database. Pre-operative, operative, and post-operative patient factors were evaluated. Univariate and multivariable analyses were used to identify significant correlations between perioperative characteristics and CAUTIs. Results: There were 55 (1.1%) documented CAUTIs in the study population. On univariate analysis, older age, female gender, diabetes mellitus, cardiogenic shock, urgent or emergent operation, packed red blood cell (PRBC) units transfused, and intensive care unit length of stay (ICU LOS) were all significantly associated with CAUTI [p<0.05]. On multivariable logistic regression, older age, female gender, diabetes mellitus, and ICU LOS remained significantly associated with CAUTI. Additionally, there was a significant association between CAUTI and 30-d mortality on univariate analysis. However, when controlling for common predictors of operative mortality on multivariable analysis, CAUTI was no longer associated with mortality. Conclusions: There are several identifiable risk factors for CAUTI in patients undergoing cardiac procedures. CAUTI is not independently associated with increased mortality, but it does serve as a marker of sicker patients more likely to die from other comorbidities or complications. Therefore, awareness of the high-risk nature of these patients should lead to

  19. Comparison of two adjuvant hormone therapy regimens in patients with high-risk localized prostate cancer after radical prostatectomy: primary results of study CU1005.

    PubMed

    Chang, Kun; Qin, Xiao-Jian; Zhang, Hai-Liang; Dai, Bo; Zhu, Yao; Shi, Guo-Hai; Shen, Yi-Jun; Zhu, Yi-Ying; Ye, Ding-Wei

    2016-01-01

    The role of adjuvant hormonal therapy and optimized regimens for high-risk localized prostate cancer after radical prostatectomy remains controversial. Herein, the clinical trial CU1005 prospectively evaluated two regimens of maximum androgen blockage  or bicalutamide 150 mg daily as immediate adjuvant therapy for high-risk localized prostate cancer. Overall, 209 consecutive patients were recruited in this study, 107 of whom received 9 months of adjuvant maximum androgen blockage, whereas 102 received 9 months of adjuvant bicalutamide 150 mg. The median postoperative follow-up time was 27.0 months. The primary endpoint was biochemical recurrence. Of the 209 patients, 59 patients developed biochemical recurrence. There was no difference between the two groups with respect to clinical characteristics, including age, pretreatment prostate-specific antigen, Gleason score, surgical margin status, or pathological stages. The maximum androgen blockage group experienced longer biochemical recurrence-free survival (P = 0.004) compared with the bicalutamide 150 mg group. Side-effects in the two groups were similar and could be moderately tolerated in all patients. In conclusion, immediate, 9-month maximum androgen blockage should be considered as an alternative to bicalutamide 150 mg as adjuvant treatment for high-risk localized prostate cancer patients after radical prostatectomy.

  20. Beneficial effect of preventative intra-aortic balloon pumping in high-risk patients undergoing first-time coronary artery bypass grafting-a single center experience.

    PubMed

    Gong, Qingcheng; Xing, Jialin; Miao, Na; Zhao, Yanyan; Jia, Zaishen; Li, Jiawei; Chen, Yu; Gao, Quanxin; Liu, Anxin; Sun, Zhiquan; Liu, Xiaojun; Ji, Bingyang

    2009-08-01

    than in Group 2, respectively (22.0 +/- 1.6 h vs. 39.6 +/- 2.1 h, P < 0.01 and 58.0 +/- 1.5 h vs. 98.5 +/- 1.9 h, P < 0.005). There were no differences in mortality between the two groups (n = 1 in Group 1 and n = 3 in Group 2). Preoperative and preventative insertion of IABP can be performed safely in selected high-risk patients undergoing CABG, with results comparable to those in patients who received obligatory IABP intraoperatively and postoperatively. Therefore, earlier IABP support as part of surgical strategy may help to improve the outcome in high-risk first-time CABG patients.

  1. Preoperative intra-aortic balloon pumping in high-risk cardiac surgery patients.

    PubMed

    Moon, Chooza

    2012-01-01

    Intra-aortic balloon pumping increases myocardial oxygen supply and decreases myocardial oxygen demand by inflation and deflation of the balloon. This leads to increased perfusion of the coronary arteries during diastole. This technology has been used for critically ill cardiac patients for more than 30 years. The literature suggests that preoperative use of an intra-aortic balloon pump can be effective in high-risk coronary artery bypass grafting patients. Preoperative benefits of this technology may yield positive outcomes in terms of hemodynamic effect, decreased length of stay in both the intensive care unit and the hospital, and the reduction of complications. However, the intra-aortic balloon pump must be used with a profound understanding of proper mechanism and function, monitoring, and observation for potential complications. This requires excellent critical care nursing management.

  2. Off-Pump Myocardial Revascularization in a High-Risk Patient with Essential Thrombocythemia

    PubMed Central

    Darwazah, Ahmad K.; Madi, Hamad; Zagha, Rami; Hawash, Yahia

    2014-01-01

    Essential thrombocythemia is a rare type of myeloproliferative disorder. Cerebral, myocardial, and peripheral thrombosis are all frequent complications of the disease. A 71-year-old man presented with severe coronary artery disease, associated with cerebral vascular ischemic changes and erythromelalgia. His platelet count was 1,486 ×103/μL. The patient underwent successful myocardial revascularization by means of an off-pump technique after his platelet count had been reduced by hydroxycarbamide administration. We conclude that the use of off-pump cardiopulmonary bypass in high-risk patients with essential thrombocythemia is safe. Reducing platelet count via the administration of hydroxycarbamide and the careful balancing of antiplatelets and anticoagulants is crucial in determining the outcome of surgery. PMID:25425991

  3. Barotrauma-induced pneumocephalus experienced by a high risk patient after commercial air travel.

    PubMed

    Huh, Jisoon

    2013-08-01

    A 49-year-old female with a history of several neurosurgical and otolaryngologic procedures for occipital meningioma and cerebrospinal fluid leaks was diagnosed with pneumocephalus after a one hour flight on a domestic jet airliner. Despite multiple operations, the air appeared to enter the cranium through a weak portion of the skull base due to the low atmospheric pressure in the cabin. The intracranial air was absorbed with conservative management. The patient was recommended not to fly before a definite diagnostic work up and a sealing procedure for the cerebrospinal fluid leak site had been performed. Recent advances in aviation technology have enabled many people to travel by air, including individuals with medical conditions. Low cabin pressure is not dangerous to healthy individuals; however, practicing consultant neurosurgeons should understand the cabin environment and prepare high risk patients for safe air travel.

  4. Perfecting patient flow in the surgical setting.

    PubMed

    Amato-Vealey, Elaine J; Fountain, Patricia; Coppola, Deborah

    2012-07-01

    Reduced surgical efficiency and productivity, delayed patient discharges, and prolonged use of hospital resources are the results of an OR that is unable to move patients to the postanesthesia care unit or other patient units. A primary reason for perioperative patient flow delay is the lack of hospital beds to accommodate surgical patients, which consequently causes backups of patients currently in the surgical suite. In one facility, implementing Six Sigma methodology helped to improve OR patient flow by identifying ways that frontline staff members could work more intelligently and more efficiently, and with less stress to streamline workflow and eliminate redundancy and waste in ways that did not necessitate reducing the number of employees. The results were improved employee morale, job satisfaction and safety, and an enhanced patient experience.

  5. Oral candidiasis in high-risk patients as the initial manifestation of the acquired immunodeficiency syndrome.

    PubMed

    Klein, R S; Harris, C A; Small, C B; Moll, B; Lesser, M; Friedland, G H

    1984-08-09

    We studied the frequency with which unexplained oral candidiasis led to unequivocal acquired immunodeficiency syndrome (AIDS) in patients at risk. Twenty-two previously healthy adults with unexplained oral candidiasis, of whom the 19 tested had a reversed T4/T8 ratio and 20 had generalized lymphadenopathy, were compared with 20 similar patients with a reversed T4/T8 ratio and generalized lymphadenopathy who did not have oral candidiasis. All were intravenous-drug abusers, homosexual or bisexual men, or both. Thirteen of the 22 patients with oral candidiasis (59 per cent) acquired a major opportunistic infection or Kaposi's sarcoma at a median of three months (range, 1 to 23) as compared with none of 20 patients with generalized lymphadenopathy and immunodeficiency but without candidiasis who were followed for a median of 12 months (range, 5 to 21) (P less than 0.001). AIDS developed in 12 of 15 patients with candidiasis and T4/T8 ratios less than or equal to 0.51, as compared with none of four with ratios equal to or greater than 0.60 (P less than 0.01). We conclude that in patients at high risk for AIDS, the presence of unexplained oral candidiasis predicts the development of serious opportunistic infections more than 50 per cent of the time. Whether the remainder will have AIDS is not yet known.

  6. Initial results of a thoracic aortic endovascular program: safer in high-risk patients.

    PubMed

    Stouffer, Chadwick W; Mansour, M Ashraf; Ott, Mickey M; Hooker, Robert L; Gorsuch, Jill M; Cuff, Robert F; Davis, Alan T

    2009-01-01

    Results are presented from our single-institutional experience with thoracic endovascular aortic repair to confirm that it is safe in patients with significant comorbidities. A retrospective review of all patients undergoing endovascular or open thoracic aortic repair at our institution since 2002 was performed. Main outcome measures included clinical presentation, demographics, preoperative risk factors, operative details, and clinical outcomes. The endovascular group included 37 patients (22 males), whereas the open group included 19 patients (eight males). Eight patients per group were treated emergently for trauma or rupture (22% and 42%, respectively; p=0.11). Endovascular patients were significantly older with more comorbid conditions (p<0.05). However, the overall perioperative complication rate was similar in the two groups (32.4% and 31.6%, respectively). Postoperative renal failure occurred only in four open patients (21.1% vs. 0%, p < 0.05). Operative time, ventilator days, and total length of stay were also greater for open patients (p<0.05). There was one death in the endovascular group and three in the open group (2.7% and 15.8%, respectively; p=0.07). Endovascular patients had shorter operative time and length of stay, fewer ventilator days and intensive care unit days, and fewer transfusions. Although the endovascular patients were significantly older with more comorbidities, the complication rate was similar to the open group. Also, there was a trend toward lower mortality in the endovascular group (p=0.07). Endovascular repair is the procedure of choice for treating the descending thoracic aorta in high-risk patients even in the emergent setting.

  7. Hydrogel-coated ventricular catheters for high-risk patients receiving ventricular peritoneum shunt.

    PubMed

    Xu, Hao; Huang, Yimin; Jiao, Wei; Sun, Wei; Li, Ran; Li, Jiaqing; Lei, Ting

    2016-07-01

    Shunt infection is a morbid complication of cerebrospinal fluid (CSF) shunting. The catheters with a hydrophilic surface may impede bacterial adherence and thereby reduce catheter-related CSF infection.A retrospective study compared the occurrence of CSF infection related to use of either standard silastic catheters or hydrogel-coated ventricular catheters (Bioglide, Medtronic). The enrolment was available to neurosurgery patients undergoing shunt surgery from October 2012 to 2015 in two centers. The follow-up period was more than months.A total of 78 patients were included in the study. In 33 patients 35-cm hydrogel-coated ventricular peritoneum shunts (VPS) were used, and in remaining 45 patients 35-cm standard silastic VPS catheters were used. Infection occurred in 14 (17.9%) patients, including definite VPS-related CSF infection in 6 patients (7.7%) and probable infection in remaining 8 patients (10.3%). There was a significant difference found in patients with total infection between the two groups [RR (95% CI); 0.200 (0.050-0.803), P = 0.014]. Analysis of Kaplan-Meier curve estimates indicated significant statistical difference between the two catheter types in duration (log rank = 4.204, P < 0.05). Significant statistical differences were also found in the subgroups including previous CSF infection within 1 month (log rank = 4.391, P = 0.04), conversion of external ventricular drains to shunt (Log Rank = 4.520, P = 0.03), and hospital stay >1 month (log rank = 5.252, P = 0.02). There was no difference found between the two groups of the patients with other infections within 1 month. The follow-up period was of 36 months.The hydrogel-coated catheter is a safe and related to lower infection rates for high-risk patients who underwent shunt surgery.

  8. Hydrogel-coated ventricular catheters for high-risk patients receiving ventricular peritoneum shunt

    PubMed Central

    Xu, Hao; Huang, Yimin; Jiao, Wei; Sun, Wei; Li, Ran; Li, Jiaqing; Lei, Ting

    2016-01-01

    Abstract Shunt infection is a morbid complication of cerebrospinal fluid (CSF) shunting. The catheters with a hydrophilic surface may impede bacterial adherence and thereby reduce catheter-related CSF infection. A retrospective study compared the occurrence of CSF infection related to use of either standard silastic catheters or hydrogel-coated ventricular catheters (Bioglide, Medtronic). The enrolment was available to neurosurgery patients undergoing shunt surgery from October 2012 to 2015 in two centers. The follow-up period was more than months. A total of 78 patients were included in the study. In 33 patients 35-cm hydrogel-coated ventricular peritoneum shunts (VPS) were used, and in remaining 45 patients 35-cm standard silastic VPS catheters were used. Infection occurred in 14 (17.9%) patients, including definite VPS-related CSF infection in 6 patients (7.7%) and probable infection in remaining 8 patients (10.3%). There was a significant difference found in patients with total infection between the two groups [RR (95% CI); 0.200 (0.050–0.803), P = 0.014]. Analysis of Kaplan–Meier curve estimates indicated significant statistical difference between the two catheter types in duration (log rank = 4.204, P < 0.05). Significant statistical differences were also found in the subgroups including previous CSF infection within 1 month (log rank = 4.391, P = 0.04), conversion of external ventricular drains to shunt (Log Rank = 4.520, P = 0.03), and hospital stay >1 month (log rank = 5.252, P = 0.02). There was no difference found between the two groups of the patients with other infections within 1 month. The follow-up period was of 36 months. The hydrogel-coated catheter is a safe and related to lower infection rates for high-risk patients who underwent shunt surgery. PMID:27442653

  9. Long-Term Follow-Up of Patients at High Risk for Nephropathy After Contrast Exposure.

    PubMed

    Abaci, Okay; Harmankaya, Ozlem; Kocas, Betul; Kocas, Cuneyt; Bostan, Cem; Coskun, Ugur; Yildiz, Ahmet; Ersanli, Murat

    2015-07-01

    Contrast medium-induced acute kidney injury (CI-AKI) is associated with morbidity and mortality, but the long-term outcomes of patients who do not develop CI-AKI remain unknown. We assessed clinical end points during long-term follow-up in patients at high risk for nephropathy who did not develop CI-AKI. Patients (n = 135) with impaired renal function (estimated glomerular filtration rate: 30-60 mL/min/1.73 m(2)) were divided into 2 groups according to contrast media (CM) exposure. The primary end point of this study was a composite outcome measure of death or renal failure requiring dialysis. Multivariate analyses identified CM exposure to be independently associated with major adverse long-term outcomes (hazard ratio: 2.3; 95% confidence interval, 1.34-6.52; P = .018). Even when CM exposure does not cause CI-AKI in patients with impaired renal function, in the long term, primary end points occur more frequently in patients exposed to CM than in those with no CM exposure.

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

    PubMed Central

    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

  11. The Current National Criteria for Carotid Artery Stenting Overestimates Its Efficacy in Patients Who Are Symptomatic and High Risk

    PubMed Central

    Yoshida, Shunsuke; Bensley, Rodney P.; Glaser, Julia D.; Nabzdyk, Christoph S.; Hamdan, Allen D.; Wyers, Mark C.; Chaikof, Elliot L.; Schermerhorn, Marc L.; Boston

    2013-01-01

    Background The Centers for Medicare and Medicaid Services (CMS) have established guidelines that outline patients who are considered “high risk” for complications following CEA for which CAS may provide benefit. The validity of these high risk criteria are yet unproven. In this study, we stratified patients who underwent either CAS or CEA by CMS high risk criteria and symptom status, and examined their 30-day outcomes. Methods A non-randomized, retrospective cohort study was performed by chart review of all patients undergoing CEA or CAS from January 1, 2005 to December 31, 2010 at our institution. Demographic data, as well as data pertaining to the presence or absence of high risk factors were collected. Patients were stratified using symptom status and high risk status as variables and 30-day adverse events (stroke, death, and/or myocardial infarction (MI)) were compared. Results 271 patients underwent CAS with 30-day complication rates of stroke (3.0%), death (1.1%), MI (1.5%), stroke/death (3.7%), and stroke/death/MI (5.2%). 830 patients underwent CEA with 30-day complication rates of stroke (2.0%), death (0.1%), MI (0.6%), stroke/death (1.9%), and stroke/death/MI (2.7%). Among symptomatic patients, physiologic high risk status was associated with increased stroke/death (6/42, 14.3% vs. 2/74, 2.7%, P<0.01), and anatomic high risk status was associated with a trend towards increased stroke/death (5/31, 16.1% vs. 0/20, 0.0%, P=0.14) in patients who underwent CAS compared to CEA. Analysis of asymptomatic patients showed no differences among the two groups overall, except for a trend towards higher rate of MI following CAS compared to CEA (3/71, 4.2% vs. 0/108, 0.0%, P=.06) in those who were physiologically high risk. Among symptomatic patients who underwent CAS, patients with physiologic and anatomic high risk factors had a higher rate of stroke/death compared to non-high risk patients (6/42, 14.3% vs. 0/24, 0.0% and 5/31, 16.1% vs. 0/24, 0.0%, respectively

  12. Analyzing treatment aggressiveness and identifying high-risk patients in diabetic foot ulcer return to care.

    PubMed

    Remington, Austin C; Hernandez-Boussard, Tina; Warstadt, Nicholus M; Finnegan, Micaela A; Shaffer, Robyn; Kwong, Jereen Z; Curtin, Catherine

    2016-07-01

    Rates of diabetes and its associated comorbidities have been increasing in the United States, with diabetic foot ulcer treatment representing a large cost to the patient and healthcare system. These ulcers often result in multiple hospital admissions. This study examined readmissions following inpatient care for a diabetic foot ulcer and identified modifiable factors associated with all-cause 30-day readmissions to the inpatient or emergency department (ED) setting. We hypothesized that patients undergoing aggressive treatment would have lower 30-day readmission rates. We identified patient discharge records containing International Classification of Disease ninth revision codes for both diabetes mellitus and distal foot ulcer in the State Inpatient and Emergency Department databases from the Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project in Florida and New York, 2011-2012. All-cause 30-day return to care visits (ED or inpatient) were analyzed. Patient demographics and treatment characteristics were evaluated using univariate and multivariable regression models. The cohort included 25,911 discharges, having a mean age of 63 and an average of 3.8 comorbidities. The overall rate of return to care was 30%, and 21% of subjects underwent a toe or midfoot amputation during their index stay. The most common diagnosis codes upon readmission were diabetes mellitus (19%) and infection (13%). Patients with a toe or midfoot amputation procedure were less likely to be readmitted within 30 days (odds ratio: 0.78; 95% confidence interval: 0.73, 0.84). Presence of comorbidities, black and Hispanic ethnicities, and Medicare and Medicaid payer status were also associated with higher odds of readmission following initial hospitalization (p < 0.05). The study suggests that there are many factors that affect readmission rates for diabetic foot ulcer patients. Understanding patients at high-risk for readmission can improve counseling and

  13. Lower Extremity Function following Partial Calcanectomy in High-Risk Limb Salvage Patients

    PubMed Central

    Oliver, Noah G.; Steinberg, John S.; Powers, Kelly; Evans, Karen K.; Kim, Paul J.; Attinger, Christopher E.

    2015-01-01

    Partial calcanectomy (PC) is an established limb salvage procedure for treatment of deep heel ulceration with concomitant calcaneal osteomyelitis. The purpose of this study is to determine if a relationship exists between the amount of calcaneus removed during PC and the resulting lower extremity function and limb salvage outcomes. Consecutive PC patients were retrospectively divided into two cohorts defined by the amount of calcaneus resected before wound closure: patients in cohort 1 retained = 50% of calcaneus, while patients in cohort 2 underwent resection of >50% of the calcaneus. The Lower Extremity Function Scale (LEFS) was used to assess postoperative lower extremity function. The average amount of calcaneus resected was 13% ± 9.2 (1–39%) and 74% ± 19.5 (51–100) in cohorts 1 and 2, respectively (P < 0.0001). Below knee amputation was performed in 7 (28%) and 5 (29%) of subjects in cohorts 1 and 2, respectively (P = 1.0). The average LEFS score was 33.9 ± 15.0 for subjects in cohort 1 and 36.2 ± 19.9 for the subjects cohort 2 (P = 0.8257) which correlates to “moderate to quite a bit of difficulty.” Our study suggests that regardless of the amount of calcaneus resected, PC provides a viable treatment option for high-risk patients with calcaneal osteomyelitis. PMID:25692151

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

    PubMed Central

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

    2006-01-01

    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. PMID:16515696

  15. High risk of developing subsequent epilepsy in patients with sleep-disordered breathing

    PubMed Central

    Harnod, Tomor; Wang, Yu-Chiao; Lin, Cheng-Li; Tseng, Chun-Hung

    2017-01-01

    Purpose Sleep-disordered breathing (SDB) is often associated with other medical disorders. Whether SDB interacts with other factors for developing subsequent epilepsy remains unclear. Methods This population-based cohort study was conducted using the National Health Insurance Research Database of Taiwan. Patients aged >20 years and diagnosed with SDB between 2000 and 2010 comprised the SDB cohort (n = 138,507), and their data were compared with those of the comparison cohort (n = 138,507). The adjusted hazard ratio (aHR) for epilepsy was calculated using a multivariate Cox proportional hazards model. Results The SDB cohort had an increased risk of epilepsy (aHR = 1.50, 95% confidence interval [CI] = 1.36–1.66). The sex-stratified analysis revealed a significant adjusted hazard ratio (aHR) for epilepsy with a 1.51-fold higher risk for female patients, and also a significantly 1.49-fold higher risk for male patients in the SDB cohort. Although epilepsy incidence increased with age in both cohorts, different age groups in the SDB cohort all had a significantly higher risk of developing epilepsy than comparison cohort. Conclusion This population-based cohort study indicates that patients with SDB are at a high risk of developing subsequent epilepsy, in both sexes and all age groups. PMID:28291799

  16. Balloon aortic valvuloplasty as a bridge-to-decision in high risk patients with aortic stenosis: a new paradigm for the heart team decision making

    PubMed Central

    Saia, Francesco; Moretti, Carolina; Dall'Ara, Gianni; Ciuca, Cristina; Taglieri, Nevio; Berardini, Alessandra; Gallo, Pamela; Cannizzo, Marina; Chiarabelli, Matteo; Ramponi, Niccolò; Taffani, Linda; Bacchi-Reggiani, Maria Letizia; Marrozzini, Cinzia; Rapezzi, Claudio; Marzocchi, Antonio

    2016-01-01

    Background Whilst the majority of the patients with severe aortic stenosis can be directly addressed to surgical aortic valve replacement (AVR) or transcatheter aortic valve implantation (TAVI), in some instances additional information may be needed to complete the diagnostic workout. We evaluated the role of balloon aortic valvuloplasty (BAV) as a bridge-to-decision (BTD) in selected high-risk patients. Methods Between 2007 and 2012, the heart team in our Institution required BTD BAV in 202 patients. Very low left ventricular ejection fraction, mitral regurgitation grade ≥ 3, frailty, hemodynamic instability, serious comorbidity, or a combination of these factors were the main drivers for this strategy. We evaluated how BAV influenced the final treatment strategy in the whole patient group and in each specific subgroup. Results Mean logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 23.5% ± 15.3%, age 81 ± 7 years. In-hospital mortality was 4.5%, cerebrovascular accident 1% and overall vascular complications 4% (0.5% major; 3.5% minor). Of the 193 patients with BTD BAV who survived and received a second heart team evaluation, 72.6% were finally deemed eligible for definitive treatment (25.4% for AVR; 47.2% for TAVI): 96.7% of patients with left ventricular ejection fraction recovery; 70.5% of patients with mitral regurgitation reduction; 75.7% of patients who underwent BAV in clinical hemodynamic instability; 69.2% of frail patients and 68% of patients who presented serious comorbidities. Conclusions Balloon aortic valvuloplasty can be considered as bridge-to-decision in high-risk patients with severe aortic stenosis who cannot be immediate candidates for definitive transcatheter or surgical treatment. PMID:27582761

  17. Awake palliative thoracic surgery in a high-risk patient: one-lung, non-invasive ventilation combined with epidural blockade.

    PubMed

    Guarracino, F; Gemignani, R; Pratesi, G; Melfi, F; Ambrosino, N

    2008-07-01

    We report the case of a terminally ill cancer patient with recurrent pericardial and bilateral pleural effusions who was scheduled for video-assisted thoracoscopic surgery. The operation was performed with the patient awake under epidural anaesthesia. The patient's cough reflex in response to lung manipulation was successfully minimised by the inhalation of aerosolised lidocaine. Video-assisted thoracic surgery requires the exclusion of a lung from ventilation. In order to support one-lung spontaneous ventilation in this high-risk patient, we successfully used non-invasive bilevel positive airway pressure ventilation via a facemask. Based on this preliminary experience, we think that critically ill patients scheduled for palliative surgery can be successfully managed with the combination of minimally invasive surgical techniques and neuraxial block with non-invasive lung ventilation.

  18. Rhabdomyolysis in Critically Ill Surgical Patients

    PubMed Central

    Kuzmanovska, Biljana; Cvetkovska, Emilija; Kuzmanovski, Igor; Jankulovski, Nikola; Shosholcheva, Mirjana; Kartalov, Andrijan; Spirovska, Tatjana

    2016-01-01

    Introduction: Rhabdomyolysis is a syndrome of injury of skeletal muscles associated with myoglobinuria, muscle weakness, electrolyte imbalance and often, acute kidney injury as severe complication. The aim: of this study is to detect the incidence of rhabdomyolysis in critically ill patients in the surgical intensive care unit (ICU), and to raise awareness of this medical condition and its treatment among the clinicians. Material and methods: A retrospective review of all surgical and trauma patients admitted to surgical ICU of the University Surgical Clinic “Mother Teresa” in Skopje, Macedonia, from January 1st till December 31st 2015 was performed. Patients medical records were screened for available serum creatine kinase (CK) with levels > 200 U/l, presence of myoglobin in the serum in levels > 80 ng/ml, or if they had a clinical diagnosis of rhabdomyolysis by an attending doctor. Descriptive statistical methods were used to analyze the collected data. Results: Out of totally 1084 patients hospitalized in the ICU, 93 were diagnosed with rhabdomyolysis during the course of one year. 82(88%) patients were trauma patients, while 11(12%) were surgical non trauma patients. 7(7.5%) patients diagnosed with rhabdomyolysis developed acute kidney injury (AKI) that required dialysis. Average values of serum myoglobin levels were 230 ng/ml, with highest values of > 5000 ng/ml. Patients who developed AKI had serum myoglobin levels above 2000 ng/ml. Average values of serum CK levels were 400 U/l, with highest value of 21600 U/l. Patients who developed AKI had serum CK levels above 3000 U/l. Conclusion: Regular monitoring and early detection of elevated serum CK and myoglobin levels in critically ill surgical and trauma patients is recommended in order to recognize and treat rhabdomyolysis in timely manner and thus prevent development of AKI. PMID:27703296

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

    PubMed Central

    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 < 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. PMID:27446845

  20. Monitoring high-risk patients: minimally invasive and non-invasive possibilities.

    PubMed

    Renner, Jochen; Grünewald, Matthias; Bein, Berthold

    2016-06-01

    Over the past decades, there has been considerable progress in the field of less invasive haemodynamic monitoring technologies. Substantial evidence has accumulated, which supports the continuous measurement and optimization of flow-based variables such as stroke volume, that is, cardiac output, in order to prevent occult hypoperfusion and consequently to improve patients' outcome in the perioperative setting. However, there is a striking gap between the developments in haemodynamic monitoring and the increasing evidence to implement defined treatment protocols based on the measured variables, and daily clinical routine. Recent trials have shown that perioperative morbidity and mortality is higher than anticipated. This emphasizes the need for the anaesthesia community to address this issue and promotes the implementation of proven concepts into clinical practice in order to improve patients' outcome, especially in high-risk patients. The advances in minimally invasive and non-invasive monitoring techniques can be seen as a driving force in this respect, as the degree of invasiveness of any monitoring tool determines the frequency of its application, especially in the operating room (OR). From this point of view, we are very confident that some of these minimally invasive and non-invasive haemodynamic monitoring technologies will become an inherent part of our monitoring armamentarium in the OR and in the intensive care unit (ICU).

  1. Postoperative extended-volume external-beam radiation therapy in high-risk esophageal cancer patients: a prospective experience

    PubMed Central

    Yu, E.; Tai, P.; Younus, J.; Malthaner, R.; Truong, P.; Stitt, L.; Rodrigues, G.; Ash, R.; Dar, R.; Yaremko, B.; Tomiak, A.; Dingle, B.; Sanatani, M.; Vincent, M.; Kocha, W.; Fortin, D.; Inculet, R.

    2009-01-01

    Background and Purpose Extended-volume external-beam radiation therapy (rt) following esophagectomy is controversial. The present prospective study evaluates the feasibility of extended-volume rt treatment in high-risk esophagectomy patients with a cervical anastomosis receiving postoperative combined chemoradiation therapy. Patients and Methods From 2001 to 2006, 15 patients with resected esophageal cancer were prospectively accrued to this pilot study to evaluate the adverse effects of extended-volume rt. Postoperative management was carried out at London Regional Cancer Program. Eligibility criteria were pathology-proven esophageal malignancy (T3–4, N0–1), disease amenable to surgical resection, and esophagectomy with or without resection margin involvement. Patients with distant metastases (M1) and patients treated with previous rt were excluded. All 15 study patients received 4 cycles of 5-fluorouracil–based chemotherapy. External-beam rt was conducted using conformal computed tomography planning, with multi-field arrangement tailored to the pathology findings, with coverage of a clinical target volume encompassing the primary tumour bed and the anastomotic site in the neck. The radiation therapy dose was 50.40 Gy at 1.8 Gy per fraction. The rt was delivered concurrently with the third cycle of chemotherapy. The study outcomes—disease-free survival (dfs) and overall survival (os)—were calculated by the Kaplan–Meier method. Treatment-related toxicities were assessed using the U.S. National Cancer Institute’s Common Toxicity Criteria. Results The study accrued 10 men and 5 women of median age 64 years (range: 48–80 years) and TNM stages T3N0 (n = 1), T2N1 (n = 2), T3N1 (n = 11), and T4N1 (n = 1). Histopathology included 5 adenocarcinomas and 10 squamous-cell carcinomas. Resection margins were clear in 10 patients. The median follow-up time was 19 months (range: 3.5–53.4 months). Before radiation therapy commenced, delay in chemotherapy occurred

  2. Should elective surgery for chronic pancreatitis be performed in high-risk patients?

    PubMed

    Schnelldorfer, Thomas; Adams, David B

    2006-07-01

    As morbidity and mortality rates for pancreatic surgery have improved over the past decades, patients with major medical comorbidities have been considered for operative treatment. The influence of poor health status on operative morbidity in patients with chronic pancreatitis is evaluated in this study. The records of 313 consecutive patients who underwent pancreaticoduodenectomy (n = 78), distal pancreatectomy (n = 83), or lateral pancreaticojejunostomy (n = 152) for chronic pancreatitis were retrospectively reviewed and analyzed. Patients' risk for adverse outcome resulting from overall health status was audited using age, comorbidities, and Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) physiological score. Univariate analysis showed that patient's age did not contribute to change in morbidity (odds ratio [OR] = 1.01, P = 0.59). The presence of cardiac disease but not other comorbidities increased adverse outcome affected the need for intensive care unit stay and length of hospital stay (morbidity: 29% vs. 51%, OR = 2.6, P = 0.003). POSSUM physiological score was associated with an increase in morbidity and mortality (morbidity: OR = 1.16, P = 0.001; mortality: OR = 1.49, P = 0.001), in particular intraabdominal abscesses. Multivariate analysis showed that the only variable independently correlating with perioperative complications was POSSUM physiological score. Single comorbidities do not independently influence outcome after operations for chronic pancreatitis. A combination of several comorbidities is associated with an increase in postoperative infectious morbidity and mortality. High-risk patients should not be excluded from operative treatment, but need to be closely selected on a case-by-case basis.

  3. [Surgical infections as patient safety problems].

    PubMed

    Baranyai, Zsolt; Kulin, László; Jósa, Valéria; Mayer, Akos

    2011-06-01

    Surgical infections are severe complications of surgical interventions and one of the most important patient safety issues. These are associated with increased morbidity, mortality, costs and decreased quality of life. Prevention of infections is essential, while one has to consider pre-, intra- and postoperative factors and procedures in the clinical practice. In this article we summarize the latest recommendations for clinicians based on the relevant published literature.

  4. Work-up and management of a high-risk patient with primary central nervous system lymphoma

    PubMed Central

    Zeynalova, Pervin A.; Tumyan, Gayane S.; Dolgushin, Mikhail B.; Akhmedov, Mobil I.

    2016-01-01

    Primary central nervous system lymphoma (PCNSL) is a rare disorder that, in 95% of cases, represents diffuse large B-cell lymphoma. As such, making an accurate diagnosis is important. At present, stereotactic-guided biopsy is a recognized method of choice for tissue analysis. However, the diagnostic work-up for high-risk patients is determined by their performance status. Here, we report a case of PCNSL in a high-risk patient, for whom diagnosis was established by cerebrospinal fluid cytology and flow cytometry, which significantly shortened a diagnostic work-up period and allowed for the immediate treatment of the patient. PMID:28154784

  5. Nutritional supplements in the surgical patient.

    PubMed

    Stohs, Sidney J; Dudrick, Stanley J

    2011-08-01

    This article presents an overview of the current knowledge, status, and use of supplements by patients before surgical operations, together with the benefits expected of the supplements by the patients. The indications, potential advantages and disadvantages, and the relationships with various aspects of the preoperative preparation and postoperative management of surgical patients are discussed, with emphasis on the significant percentage of this population that is deficient in fundamental nutrients. Recent revisions and recommendations for some of the macronutrients are presented, together with a summary of federal regulations and an oversight of supplements.

  6. [Informed consent of the surgical patient].

    PubMed

    Kovács, József

    2014-02-01

    The article analyses the consequences of the paradigm shift in the surgical practice in the last fifty years. The earlier, paternalistic physician-patient relationship has been replaced by an equal one, which is based on informing the patient and involving him or her in the treatment decisions. This shift did not happen uniformly in various medical subspecialties. In this respect, surgery is more conservative than general medicine. The article analyses the most frequent problems of informing patients, and examines the major elements of information, together with their technical conditions in surgery. It reflects on specifics of surgical information disclosure and conditions of refusing medical interventions.

  7. Prominent Pulmonary Metastases Without Concurrent Osseous Involvement in Patients With High-Risk Neuroblastoma.

    PubMed

    Bai, Xia; Zhuang, Hongming

    2017-02-13

    Metastases from high-risk neuroblastomas generally are to the bone or bone marrow. Multiple lung metastases are rare, especially when there was no concurrent osseous metastasis. We report 2 cases of high-risk neuroblastomas having prominent lung metastases without concurrent osseous lesion observed.

  8. Improved detection of circulating tumor cells in non-metastatic high-risk prostate cancer patients

    PubMed Central

    Kuske, Andra; Gorges, Tobias M.; Tennstedt, Pierre; Tiebel, Anne-Kathrin; Pompe, Raisa; Preißer, Felix; Prues, Sandra; Mazel, Martine; Markou, Athina; Lianidou, Evi; Peine, Sven; Alix-Panabières, Catherine; Riethdorf, Sabine; Beyer, Burkhard; Schlomm, Thorsten; Pantel, Klaus

    2016-01-01

    The relevance of blood-based assays to monitor minimal residual disease (MRD) in non-metastatic prostate cancer (PCa) remains unclear. Proving that clinically relevant circulating tumor cells (CTCs) can be detected with available technologies could address this. This study aimed to improve CTC detection in non-metastatic PCa patients by combining three independent CTC assays: the CellSearch system, an in vivo CellCollector and the EPISPOT. Peripheral blood samples from high-risk PCa patients were screened for CTCs before and three months after radical prostatectomy (RP). Combining the results of both time points, CTCs were detected in 37%, 54.9% and 58.7% of patients using CellSearch, CellCollector and EPISPOT, respectively. The cumulative positivity rate of the three CTC assays was 81.3% (87/107) with 21.5% (23/107) of patients harboring ≥5 CTCs/7.5 ml blood. Matched pair analysis of 30 blood samples taken before and after surgery indicated a significant decrease in CTCs captured by the CellCollector from 66% before RP to 34% after therapy (p = 0.031). CTC detection by EPISPOT before RP significantly correlated with PSA serum values (p < 0.0001) and clinical tumor stage (p = 0.04), while the other assays showed no significant correlations. In conclusion, CTC-based liquid biopsies have the potential to monitor MRD in patients with non-metastatic prostate cancer. PMID:28000772

  9. Molecular evidence of high-risk human papillomavirus infection in colorectal tumours from Cuban patients

    PubMed Central

    Soto, Yudira; Limia, Celia Maria; González, Licet; Grá, Bienvenido; Hano, Olga Marina; Martínez, Pedro Ariel; Kourí, Vivian

    2016-01-01

    The association between colorectal cancer and human papillomavirus (HPV) infection is still unproven. The aim of this study was to investigate the presence of high-risk HPV (HR-HPV) DNA in colorectal tissues from Cuban patients. A total of 63 colorectal formalin-fixed paraffin-embedded tissues were studied (24 adenocarcinoma, 18 adenoma, and 21 colorectal tissues classified as benign colitis). DNA from colorectal samples was analysed by quantitative real-time polymerase chain reaction to detect the most clinically relevant high HR-HPV types (HPV-16, -18, -31, -33, -45, -52, and -58). Associations between histologic findings and other risk factors were also analysed. Overall, HPV DNA was detected in 23.8% (15/63) of the samples studied. Viral infections were detected in 41.7% of adenocarcinoma (10/24) and 27.7% of adenoma cases (5/18). HPV DNA was not found in any of the negative cases. An association between histological diagnosis of adenocarcinoma and HPV infection was observed (odd ratio = 4.85, 95% confidence interval = 1.40-16.80, p = 0.009). The only genotypes identified were HPV 16 and 33. Viral loads were higher in adenocarcinoma, and these cases were associated with HPV 16. This study provides molecular evidence of HR-HPV infection in colorectal adenocarcinoma tissues from Cuban patients. PMID:27812599

  10. Coronary blood flow during percutaneous hemopump in patients at high risk for angioplasty

    NASA Astrophysics Data System (ADS)

    Geschwind, Herbert J.; Dubois-Rande, Jean Luc; Dupouy, Patrick J.; Larrazet, Fabrice S.; Kvasnicka, Jan; El-Ghalid, Ahmed; Deleuze, Philippe; Loisance, Daniel

    1995-05-01

    Hemopump is a ventricular assist device which is aimed at improving the management of high- risk patients for PTCA. The aim of the study was to access coronary blood flow velocity during hemopump. The hemopump was inserted percutaneously into the femoral artery. Coronary blood flow was measured with a 12 MHz Doppler-tipped guidewire proximal and distal to the stenosis before, during and after PTCA. Coronary vascular reserve was assessed by intracoronary 12 mg bolus injection of Papaverine. Collateral flow was assessed during balloon occlusion by inverted velocity signals below baseline. Eight patients aged 59 +/- 11 yrs, with unstable angina, a last patent vessel and/or major left ventricular dysfunction (EF < 0.20) had hemopump during PTCA of stenosis (86 +/- 14%) of the LAD (n equals 4) or the LCX (n equals 4). Collateral flow was slightly increased (+25 +/- 18%) by the Hemopump. Hemopump did not strongly affect coronary flow velocity, did not significantly increase collateral flow and increased slightly coronary vascular reserve.

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

    ERIC Educational Resources Information Center

    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…

  12. Psychiatric Symptoms and Community Violence among High-Risk Patients: A Test of the Relationship at the Weekly Level

    ERIC Educational Resources Information Center

    Skeem, Jennifer L.; Schubert, Carol; Odgers, Candice; Mulvey, Edward P.; Gardner, William; Lidz, Charles

    2006-01-01

    Given the availability of violence risk assessment tools, clinicians are now better able to identify high-risk patients. Once these patients have been identified, clinicians must monitor risk state and intervene when necessary to prevent harm. Clinical practice is dominated by the assumption that increases in psychiatric symptoms elevate risk of…

  13. Thromboprophylaxis and Incidence of Venous Thromboembolism in Patients With Hemophilia A or B Who Underwent High-Risk Orthopedic Surgeries.

    PubMed

    Raza, Shahzad; Kale, Gautam; Kim, Daniel; Akbar, Syed A; Holm, Lisa; Naidzionak, Ulad; Hossain, Akm M; Dong, Xiang; Doll, Donald C; Freter, Carl E; Hopkins, Tamara

    2016-03-01

    Total hip replacement (THR) and total knee arthroplasty (TKA) carry a high risk of postoperative venous thromboembolism (VTE); therefore, anticoagulation prophylaxis is recommended in these patients. Unfortunately, there are no guidelines about VTE prophylaxis in patients with hemophilia who underwent these high-risk surgeries. To determine whether these patients have high risk of VTE, we conducted a retrospective study on patients with hemophilia who underwent elective THR/TKA at our institute from 2004 to 2012. Postoperatively, we collected information on duration and method of factor VIII/IX infusion, VTE-prophylaxis, and complications. There were 23 patients with hemophilia, 18 (78%) with hemophilia A and 5 (22%) with hemophilia B, who underwent high-risk surgeries (39% THR and 61% TKA). The VTE prophylaxis included sequential compression device, 12 (52%), and prophylactic enoxaparin, 1 (4%). Ten (43%) patients did not receive VTE prophylaxis. At 1-year follow-up, we did not find any evidence of clinical VTE in our patients. Better risk stratification is needed to identify patients who would benefit from pharmacological prophylaxis.

  14. Argon plasma coagulation for superficial esophageal squamous-cell carcinoma in high-risk patients

    PubMed Central

    Tahara, Kumiko; Tanabe, Satoshi; Ishido, Kenji; Higuchi, Katsuhiko; Sasaki, Tohru; Katada, Chikatoshi; Azuma, Mizutomo; Nakatani, Kento; Naruke, Akira; Kim, Myungchul; Koizumi, Wasaburo

    2012-01-01

    AIM: To evaluate the usefulness and safety of argon plasma coagulation (APC) for superficial esophageal squamous-cell carcinoma (SESC) in high-risk patients. METHODS: We studied 17 patients (15 men and 2 women, 21 lesions) with SESC in whom endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and open surgery were contraindicated from March 1999 through February 2009. None of the patients could tolerate prolonged EMR/ESD or open surgery because of severe concomitant disease (e.g., liver cirrhosis, cerebral infarction, or ischemic heart disease) or scar formation after EMR/ESD and chemoradiotherapy. After conventional endoscopy, an iodine stain was sprayed on the esophageal mucosa to determine the lesion margins. The lesion was then ablated by APC. We retrospectively studied the treatment time, number of APC sessions per site, complications, presence or absence of recurrence, and time to recurrence. RESULTS: The median duration of follow-up was 36 mo (range: 6-120 mo). All of the tumors were macroscopically classified as superficial and slightly depressed type (0-IIc). The preoperative depth of invasion was clinical T1a (mucosal cancer) for 19 lesions and clinical T1b (submucosal cancer) for 2. The median treatment time was 15 min (range: 10-36 min). The median number of treatment sessions per site was 2 (range: 1-4). The median hospital stay was 14 d (range: 5-68 d). Among the 17 patients (21 lesions), 2 (9.5%) had recurrence and underwent additional APC with no subsequent evidence of recurrence. There were no treatment-related complications, such as bleeding or perforation. CONCLUSION: APC is considered to be safe and effective for the management of SESC that cannot be resected endoscopically because of underlying disease, as well as for the control of recurrence after EMR and local recurrence after chemoradiotherapy. PMID:23082058

  15. Patient-Reported Offers of Alcohol Treatment for Primary Care Patients at High-Risk for an Alcohol Use Disorder

    PubMed Central

    Grant, Sean; Watkins, Katherine E.; Bogart, Andy; Paddock, Susan M.; Hepner, Kimberly A.

    2016-01-01

    Background This study assessed patient-reported alcohol treatment offers by healthcare providers following routine annual screening for alcohol use in primary care. Methods A telephone interview within 30 days of the annual screen assessed demographics, alcohol and other drug use, mental health symptoms, and offers of formal treatment for alcohol by a VA healthcare provider. We included male patients (n = 349) at high-risk for an alcohol use disorder (AUD) who had not received alcohol treatment in the past three months. We assessed self-reported receipt of any offers of formal treatment for alcohol, and associations of offer of formal treatment for alcohol with demographic and clinical variables. Results 145 (41.5%) patients reported an offer of at least one type of formal treatment for alcohol. More severe alcohol misuse (OR 1.07, 95% CI 1.03 to 1.11) and younger age (OR 0.97, 95% CI 0.95 to 0.99) were associated with reporting an offer of formal treatment. Discussion Most primary care patients at high-risk for an AUD were not offered treatment following an annual screening. Our results highlight the importance of training primary care providers in what constitutes appropriate medical treatment for this population and the most effective ways of making a treatment offer. PMID:28076250

  16. [Strategies for screening for pancreatic adenocarcinoma in high-risk patients: the place of endoscopic ultrasound].

    PubMed

    Béchade, Dominique

    2011-03-01

    Screening high-risk individuals with imaging tests, such endoscopic ultrasound and computed tomography, can lead to the detection and treatment of predominantly asymptomatic premalignant lesions. These pancreatic lesions consist of resectable, mostly branch-type non invasive intraductal papillary mucinous neoplasms. Endoscopic ultrasound features of chronic pancreatitis are highly prevalent in high-risk individuals and these directly correlate with multifocal lobulocentric parenchymal atrophy due to pancreatic intraepithelial neoplasia. Long-term, multi-prospective studies are needed to determine if screening for early pancreatic adenocarcinoma and timely intervention results in decreased pancreatic cancer incidence and mortality in high-risk individuals.

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

    PubMed

    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.

  18. Specificity of Incident Diagnostic Outcomes in Patients at Clinical High Risk for Psychosis

    PubMed Central

    Webb, Jadon R.; Addington, Jean; Perkins, Diana O.; Bearden, Carrie E.; Cadenhead, Kristin S.; Cannon, Tyrone D.; Cornblatt, Barbara A.; Heinssen, Robert K.; Seidman, Larry J.; Tarbox, Sarah I.; Tsuang, Ming T.; Walker, Elaine F.; McGlashan, Thomas H.; Woods, Scott W.

    2015-01-01

    It is not well established whether the incident outcomes of the clinical high-risk (CHR) syndrome for psychosis are diagnostically specific for psychosis or whether CHR patients also are at elevated risk for a variety of nonpsychotic disorders. We collected 2 samples (NAPLS-1, PREDICT) that contained CHR patients and a control group who responded to CHR recruitment efforts but did not meet CHR criteria on interview (help-seeking comparison patients [HSC]). Incident diagnostic outcomes were defined as the occurrence of a SIPS-defined psychosis or a structured interview diagnosis from 1 of 3 nonpsychotic Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) groups (anxiety, bipolar, or nonbipolar mood disorder), when no diagnosis in that group was present at baseline. Logistic regression revealed that the CHR vs HSC effect did not vary significantly across study for any emergent diagnostic outcome; data from the 2 studies were therefore combined. CHR (n = 271) vs HSC (n = 171) emergent outcomes were: psychosis 19.6% vs 1.8%, bipolar disorders 1.1% vs 1.2%, nonbipolar mood disorders 4.4% vs 5.3%, and anxiety disorders 5.2% vs 5.3%. The main effect of CHR vs HSC was statistically significant (OR = 13.8, 95% CI 4.2–45.0, df = 1, P < .001) for emergent psychosis but not for any emergent nonpsychotic disorder. Sensitivity analyses confirmed these findings. Within the CHR group emergent psychosis was significantly more likely than each nonpsychotic DSM-IV emergent disorder, and within the HSC group emergent psychosis was significantly less likely than most emergent nonpsychotic disorders. The CHR syndrome is specific as a marker for research on predictors and mechanisms of developing psychosis. PMID:26272875

  19. Immunomodulation by imiquimod in patients with high-risk primary melanoma

    PubMed Central

    Narayan, Rupa; Nguyen, Hong; Bentow, Jason J.; Moy, Lauren; Lee, Diana K.; Greger, Stephanie; Haskell, Jacquelyn; Vanchinathan, Veena; Chang, Pei-Lin; Tsui, Shanli; Konishi, Tamiko; Comin-Anduix, Begonya; Dauphine, Christine; Vargas, Hernan I.; Economou, James S.; Ribas, Antoni; Bruhn, Kevin W.; Craft, Noah

    2011-01-01

    Imiquimod is a synthetic Toll-like receptor 7 (TLR7) agonist approved for the topical treatment of actinic keratoses, superficial basal cell carcinoma, and genital warts. Imiquimod leads to an 80–100% cure rate of lentigo maligna, but studies of invasive melanoma are lacking. We conducted a pilot study to characterize the local, regional, and systemic immune responses induced by imiquimod in patients with high-risk melanoma. After treatment of the primary melanoma biopsy site with placebo or imiquimod cream, we measured immune responses in the treated skin, sentinel lymph nodes (SLN), and peripheral blood. Treatment of primary melanomas with 5% imiquimod cream was associated with an increase in both CD4+ and CD8+ T cells in the skin, and CD4+ T cells in the SLN. Most of the CD8+ T cells in the skin were CD25 negative. We could not detect any increases in CD8+ T cells specifically recognizing HLA-A*0201-restricted melanoma epitopes in the peripheral blood. The findings from this small pilot study demonstrate that topical imiquimod treatment results in enhanced local and regional T cell numbers in both the skin and SLN. Further research into TLR7 immunomodulating pathways as a basis for effective immunotherapy against melanoma in conjunction with surgery is warranted. PMID:21850019

  20. EMA-CO chemotherapy for high-risk gestational trophoblastic neoplasia: a clinical analysis of 54 patients.

    PubMed

    Lu, W-G; Ye, F; Shen, Y-M; Fu, Y-F; Chen, H-Z; Wan, X-Y; Xie, X

    2008-01-01

    This study was designed to analyze the outcomes of chemotherapy for high-risk gestational trophoblastic neoplasia (GTN) with EMA-CO regimen as primary and secondary protocol in China. Fifty-four patients with high-risk GTN received 292 EMA/CO treatment cycles between 1996 and 2005. Forty-five patients were primarily treated with EMA-CO, and nine were secondarily treated after failure to other combination chemotherapy. Adjuvant surgery and radiotherapy were used in the selected patients. Response, survival and related risk factors, as well as chemotherapy complications, were retrospectively analyzed. Thirty-five of forty-five patients (77.8%) receiving EMA-CO as first-line treatment achieved complete remission, and 77.8% (7/9) as secondary treatment. The overall survival rate was 87.0% in all high-risk GTN patients, with 93.3% (42/45) as primary therapy and 55.6% (5/9) as secondary therapy. The survival rates were significantly different between two groups (chi(2)= 6.434, P =0.011). Univariate analysis showed that the metastatic site and the number of metastatic organs were significant risk factors, but binomial distribution logistic regression analysis revealed that only the number of metastatic organs was an independent risk factor for the survival rate. No life-threatening toxicity and secondary malignancy were found. EMA-EP regimen was used for ten patients who were resistant to EMA-CO and three who relapsed after EMA-CO. Of those, 11 patients (84.6%) achieved complete remission. We conclude that EMA-CO regimen is an effective and safe primary therapy for high-risk GTN, but not an appropriate second-line protocol. The number of metastatic organs is an independent prognostic factor for the patient with high-risk GTN. EMA-EP regimen is a highly effective salvage therapy for those failing to EMA-CO.

  1. Cognitive impairment and structural brain changes in patients with clinically isolated syndrome at high risk for multiple sclerosis.

    PubMed

    Hynčicová, Eva; Vyhnálek, Martin; Kalina, Adam; Martinkovič, Lukáš; Nikolai, Tomáš; Lisý, Jiří; Hort, Jakub; Meluzínová, Eva; Laczó, Jan

    2017-03-01

    Patients with clinically isolated syndrome (CIS), unlike those with multiple sclerosis (MS), have a selective cognitive impairment which is not consistently related to structural brain changes. Our objective was to characterize a profile of cognitive impairment and its association with structural brain changes in patients with CIS who are at high risk of developing MS. Patients with CIS at high risk for MS on interferon-beta (n = 51) and age-, gender-, and education-matched controls (n = 44) underwent comprehensive neuropsychological testing and MRI brain scan with voxel-based morphometry. The CIS group had lower cognitive performance in verbal and nonverbal memory, information processing speed/attention/working memory, and executive and visuo-spatial functions compared to controls (p ≤ 0.040). Lower cognitive performance was present in 18-37 and 14-26% of patients with CIS at high risk for MS depending on the criteria used. Brain volume was reduced predominantly in fronto-temporal regions and the thalamus in the CIS group (p ≤ 0.019). Cognitive performance was not associated with structural brain changes except for the association between worse visuo-spatial performance and lower white matter volume in the CIS group (β = 0.29; p = 0.042). Our results indicated that patients with CIS at high risk for MS may have a pattern of lower cognitive performance and regional brain atrophy similar to that found in patients with MS. Lower cognitive performance may be present in up to one-third of patients with CIS at high risk for MS, but, unlike patients with MS, variability in their cognitive performance may lead to a lack of consistent associations with structural brain changes.

  2. Control of endemic nosocomial legionnaires' disease by using sterile potable water for high risk patients.

    PubMed Central

    Marrie, T. J.; Haldane, D.; MacDonald, S.; Clarke, K.; Fanning, C.; Le Fort-Jost, S.; Bezanson, G.; Joly, J.

    1991-01-01

    In a setting where potable water is contaminated with Legionella pneumophila serogroup 1, we performed two case control studies. The first case control study consisted of 17 cases of nosocomial Legionnaires' disease (LD) and 33 control (the patients who were admitted to the ward where the case was admitted immediately before and after the case) subjects. Cases had a higher mortality rate 65% vs 12% (P less than 0.004); were more likely to have received assisted ventilation (P less than 0.00001); to have nasogastric tubes (P less than 0.0004) and to be receiving corticosteroids or other immunosuppressive therapy (P less than 0.0001). Based on the results of this study, sterile water was used to flush nasogastric tubes and to dilute nasogastric feeds. Only 3 cases of nosocomial LD occurred during the next year compared with 12 the previous year (P less than 0.0001). Nine cases subsequently occurred and formed the basis for the second case-control study. Eighteen control subjects were those patients admitted to the same unit where the case developed LD, immediately before and after the case. The mortality rate for the cases was 89% vs 6% for controls (P less than 0.00003). The only other significant difference was that cases were more likely to be receiving corticosteroids or other immunosuppressive therapy 89% vs 39% (less than 0.01). We hypothesized that microaspiration of contaminated potable water by immunocompromised patients was a risk factor for nosocomial Legionnaires' disease. From 17 March 1989 onwards such patients were given only sterile potable water. Only two cases of nosocomial LD occurred from June 1989 to September 1990 and both occurred on units where the sterile water policy was not in effect. We conclude that aspiration of contaminated potable water is a possible route for acquisition of nosocomial LD in our hospital and that provision of sterile potable water to high risk patients (those who are receiving corticosteroids or other immunosuppressive

  3. Occult adrenal insufficiency in surgical patients.

    PubMed Central

    Hubay, C A; Weckesser, E C; Levy, R P

    1975-01-01

    Eight patients admitted to a University hospital with acute surgical problems and related adrenal insufficiency were reviewed and three are presented in detail. Surgical stress and continued sepsis played major roles in the lack of responsiveness to usual modes of therapy until the adrenal insufficiency was corrected. The patients fell into three major clinical categories of adrenal insufficiency. Chronic illness and sepsis are shown to affect steroid production and metabolism, as well as adrenal responsiveness to ACTH. Pharmacologic amounts of steroids are often needed in patients with shock, gram negative sepsis and prolonged illnesses, even if normal or elevated serum cortisols are present. Therapeutic trials of cortisol administration are shown to be confusing when not accompanied by easily performed diagnostic tests of adrenal function. It is emphasized that a pretreatment serum cortisol should be obtained whenever possible. The evaluation of adrenal function is of lifelong importance to the patient. PMID:165792

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

    Cancer.gov

    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. |

  5. Urinary tract infections in surgical patients.

    PubMed

    Ramanathan, Rajesh; Duane, Therese M

    2014-12-01

    Catheter-associated urinary tract infections (CAUTI) are common in surgical patients. CAUTI are associated with adverse patient outcomes, and negatively affects public safety reporting and reimbursement. Inappropriate catheter use and prolonged catheter duration are major risk factors for CAUTI. CAUTI pathogenesis and treatment are complicated by the presence of biofilms. Prevention strategies include accurate identification and tracking of CAUTIs, and the development of institutional guidelines for the appropriate use, duration, alternatives, and removal of indwelling urinary catheters.

  6. [Patients' Rights Act - Relevance for surgical disciplines].

    PubMed

    Haier, J

    2014-01-01

    The new Patients' Rights Act does not reflect rights of patients as professional obligations of physicians for the first time. It adopted common longtime jurisdiction, but in some respects it is going beyond. This law clearly extends the documentation requirements of physicians, especially concerning the extent of documentation. In surgical fields the requirements for enlightening physicians were more strongly worded than in previous jurisdiction. In medical facilities it is now mandatory to establish an internal quality management system.

  7. “Impactibility Models”: Identifying the Subgroup of High-Risk Patients Most Amenable to Hospital-Avoidance Programs

    PubMed Central

    Lewis, Geraint H

    2010-01-01

    Context: Predictive models can be used to identify people at high risk of unplanned hospitalization, although some of the high-risk patients they identify may not be amenable to preventive care. This study describes the development of “impactibility models,” which aim to identify the subset of at-risk patients for whom preventive care is expected to be successful. Methods: This research used semistructured interviews with representatives of thirty American organizations that build, use, or appraise predictive models for health care. Findings: Impactibility models may refine the output of predictive models by (1) giving priority to patients with diseases that are particularly amenable to preventive care; (2) excluding patients who are least likely to respond to preventive care; or (3) identifying the form of preventive care best matched to each patient's characteristics. Conclusions: Impactibility models could improve the efficiency of hospital-avoidance programs, but they have important implications for equity and access. PMID:20579284

  8. Strategies for screening for pancreatic adenocarcinoma in high-risk patients.

    PubMed

    Canto, Marcia Irene

    2007-08-01

    Identification of high-risk individuals, genetic counseling, and informed consent are important components of a screening program for familial pancreatic cancer. Screening high-risk individuals with imaging tests, such endoscopic ultrasound (EUS) and computed tomography (CT), can lead to the detection and treatment of predominantly asymptomatic early pancreatic neoplasms, as well as extra-pancreatic tumors. These pancreatic neoplasms consist of resectable, mostly branch-type non-invasive intraductal papillary mucinous neoplasms (IPMNs). EUS can visualize these very early IPMNs as focal duct ectasias or cysts. EUS features of chronic pancreatitis are highly prevalent in high-risk individuals and these directly correlate with multifocal lobulocentric parenchymal atrophy due to multifocal pancreatic intraepithelial neoplasia (PanIN). No one molecular marker is ready for "prime time" screening of high-risk individuals. Translational studies are underway to discover novel biomarkers for IPMNs, PanIN-3 lesions, or microinvasive adenocarcinoma, which are likely to be cured by timely intervention. Long-term, multi-prospective studies are needed to determine if screening for early pancreatic neoplasia and timely intervention results in decreased pancreatic cancer incidence and mortality in high-risk individuals.

  9. Rates of violence in patients classified as high risk by structured risk assessment instruments

    PubMed Central

    Singh, Jay P.; Fazel, Seena; Gueorguieva, Ralitza; Buchanan, Alec

    2014-01-01

    Background Rates of violence in persons identified as high risk by structured risk assessment instruments (SRAIs) are uncertain and frequently unreported by validation studies. Aims To analyse the variation in rates of violence in individuals identified as high risk by SRAIs. Method A systematic search of databases (1995-2011) was conducted for studies on nine widely used assessment tools. Where violence rates in high-risk groups were not published, these were requested from study authors. Rate information was extracted, and binomial logistic regression was used to study heterogeneity. Results Information was collected on 13 045 participants in 57 samples from 47 independent studies. Annualised rates of violence in individuals classified as high risk varied both across and within instruments. Rates were elevated when population rates of violence were higher, when a structured professional judgement instrument was used and when there was a lower proportion of men in a study. Conclusions After controlling for time at risk, the rate of violence in individuals classified as high risk by SRAIs shows substantial variation. In the absence of information on local base rates, assigning predetermined probabilities to future violence risk on the basis of a structured risk assessment is not supported by the current evidence base. This underscores the need for caution when such risk estimates are used to influence decisions related to individual liberty and public safety. PMID:24590974

  10. High-risk patients following hospitalisation for an acute exacerbation of COPD.

    PubMed

    Piquet, Jacques; Chavaillon, Jean-Michel; David, Philippe; Martin, Francis; Blanchon, François; Roche, Nicolas

    2013-10-01

    The aim of this study was to assess long-term mortality and predictive factors of death after hospital admission for acute exacerbation of chronic obstructive pulmonary disease (COPD). 1824 patients (23.2% female; mean age 70.3±11.3 years) consecutively admitted for acute exacerbation of COPD in the respiratory medicine departments of 68 general hospitals between October 2006 and June 2007 were prospectively enrolled in a follow-up cohort. Their vital status was documented between October 2010 and April 2011. Vital status was available for 1750 patients (95.9%), among whom 787 (45%) died during follow-up. Multivariate analysis found that age (60-80 years and ≥80 years versus <60 years, relative risk 2.99, 95% CI 2.31-3.89), lower body mass index (25-30 kg·m(-2) versus ≤20 kg·m(-2), relative risk 0.80, 95% CI 0.66-0.97), lung cancer (relative risk 2.08, 95% CI 1.43-3.01), cardiovascular comorbidity (relative risk 1.35, 95% CI 1.16-1.58), previous hospital admissions for acute exacerbation of COPD (four or more versus none, relative risk 1.91, 95% CI 1.44-2.53), use of accessory respiratory muscles (relative risk 1.19, 95% CI 1.01-1.40) or lower-limb oedema (relative risk 1.74, 95% CI (1.44-2.12)) at admission and treatment by long-term oxygen therapy at discharge (relative risk 2.09, 95% CI 1.79-2.45) were independent risk factors of death. Mortality rate during the 4 years following hospital admission for acute exacerbation of COPD was high (45%). Simple clinical information relating to respiratory and general status can help in identifying high-risk patients and targeting more intensive follow-up and care. Interestingly, cardiovascular comorbidities and past hospitalisations for acute exacerbation of COPD, but not forced expiratory volume in 1 s, independently predicted the risk of death.

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

    PubMed

    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.

  12. The Role of Potentially Retrievable Inferior Vena Cava Filters in High-Risk Patients Undergoing Joint Arthroplasty

    PubMed Central

    Stulberg, S. David; Puri, Lalit; Karp, Jennifer; Ryu, Robert K; Lewandowski, Robert J

    2015-01-01

    Introduction Some patients undergoing total joint arthroplasty are at increased risk for venous thromboembolism (VTE). The aim of the present study was to evaluate the safety and efficacy of prIVCF in preventing PE in patients undergoing joint replacement surgery who are at high-risk for VTE. Materials and Methods In this prospective, IRB-approved study, prIVCF were placed in consecutive patients who met specific high-risk criteria (history of VTE or hypercoaguable state) prior to total joint arthroplasty. Patients were followed until the IVC filter was removed. Outcomes and complications were recorded per Society of Interventional Radiology guidelines. Results One hundred and nine potentially retrievable IVC filters were placed in 105 patients, who all subsequently underwent joint arthroplasty. One hundred eight IVC filters (98.9%) were retrieved successfully in a mean time of 44.1 days (range 13-183 days). There was 1 failed IVC filter retrieval attempt (0.9%) at 46 days post implantation. Two patients (1.9%) presented with recurrent PE and were successfully treated with anticoagulation prior to IVC filter retrieval. There were no fatalities from perioperative PE. In 1 patient (0.9%), a fractured filter leg had embolized during retrieval. Conclusion Potentially retrievable IVC filters are safe and effective for prophylaxis against PE in patients at high-risk for VTE undergoing joint arthroplasty. PMID:26816965

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

    SciTech Connect

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

    2008-11-15

    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.

  14. Rationale for and review of neoadjuvant therapy prior to radical prostatectomy for patients with high-risk prostate cancer.

    PubMed

    McKay, Rana R; Choueiri, Toni K; Taplin, Mary-Ellen

    2013-09-01

    Despite state of the art local therapy, a significant portion of men with high-risk prostate cancer develop progressive disease. Neoadjuvant systemic therapy prior to radical prostatectomy (RP) is an approach that can potentially maximize survival outcomes in patients with localized disease. This approach is under investigation with a wide array of agents and provides an opportunity to assess pathologic and biologic activity of novel treatments. The aim of this review is to explore the past and present role of neoadjuvant therapy prior to definitive therapy with RP in patients with high-risk localized or locally advanced disease. The results of neoadjuvant androgen-deprivation therapy (ADT), including use of newer agents such as abiraterone, are promising. Neoadjuvant chemotherapy, primarily with docetaxel, with or without ADT has also demonstrated efficacy in men with high-risk disease. Other novel agents targeting the vascular endothelial growth factor receptor (VEGFR), epidermal growth factor receptor (EGFR), platelet-derived growth factor receptor (PDGFR), clusterin, and the immune system are currently under investigation and have led to variable results in early clinical trials. Despite optimistic data, approval of neoadjuvant therapy prior to RP in patients with high-risk prostate cancer will depend on positive results from well designed phase III trials.

  15. CD34-selected allogeneic hematopoietic stem cell transplantation for patients with relapsed, high-risk multiple myeloma

    PubMed Central

    Smith, Eric; Devlin, Sean M.; Orlando, Evelyn; Landau, Heather; Lesokhin, Alex M.; Chung, David J.; Hassoun, Hani; Lendvai, Nikoletta; Landgren, Ola; Giralt, Sergio; Chari, Ajai; Jagannath, Sundar; Koehne, Guenther

    2016-01-01

    We report results of a retrospective analysis of 44 patients with relapsed and high-risk multiple myeloma (MM) undergoing allogeneic CD34-selected hematopoietic stem-cell transplantation (CD34-selected HSCT) from human leukocyte antigen (HLA)-compatible donors. Patients had multiply relapsed disease including relapse at <15 months after autologous transplant and most patients (28/44; 65%) also had high-risk cytogenetics. Before transplant, patients received busulfan (0.8 mg/kg X 10 doses), melphalan (70 mg/m2 X 2 days), fludarabine (25 mg/m2 X 5 days), and rabbit anti-thymocyte globulin (2.5 mg/kg X 2 days). Patients with 10/10 HLA-matched donors were treated prophylactically with low doses of donor lymphocyte infusions (0.5 to 1 X 106 CD3+/kg) starting at 4–6 months post CD34-selected HSCT. Acute (grade II–IV) graph-versus-host disease (GVHD) and transplant-related mortality at 12 months were 2% and 18%, respectively. Chronic GVHD was not observed in any patient. Overall and progression-free survival at 2 years was 54% and 31%, respectively. By multivariate analyses, the outcomes of CD34-selected HSCT were influenced by presence of extramedullary disease, disease status prior to CD34-selected HSCT and age. This study demonstrates notable safety and efficacy of CD34-selected HSCT in patients with multiply relapsed MM including those with high-risk cytogenetics. PMID:26325439

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

    Cancer.gov

    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. |

  17. Early detection of tumor relapse/regrowth by consecutive minimal residual disease monitoring in high-risk neuroblastoma patients

    PubMed Central

    Hirase, Satoshi; Saitoh, Atsuro; Hartomo, Tri Budi; Kozaki, Aiko; Yanai, Tomoko; Hasegawa, Daiichiro; Kawasaki, Keiichiro; Kosaka, Yoshiyuki; Matsuo, Masafumi; Yamamoto, Nobuyuki; Mori, Takeshi; Hayakawa, Akira; Iijima, Kazumoto; Nishio, Hisahide; Nishimura, Noriyuki

    2016-01-01

    Neuroblastoma is an aggressive pediatric tumor accounting for ~15% of cancer-associated mortalities in children. Despite the current intensive therapy, >50% of high-risk patients experience tumor relapse or regrowth caused by the activation of minimal residual disease (MRD). Although several MRD detection protocols using various reverse transcription-quantitative polymerase chain reaction (RT-qPCR) markers have been reported to evaluate the therapeutic response and disease status of neuroblastoma patients, their clinical significance remains elusive. The present study reports two high-risk neuroblastoma patients, whose MRD was consecutively monitored using 11 RT-qPCR markers (CHRNA3, CRMP1, DBH, DCX, DDC, GABRB3, GAP43, ISL1, KIF1A, PHOX2B and TH) during their course of treatment. The two patients initially responded to the induction therapy and reached MRD-negative status. The patients' MRD subsequently became positive with no elevation of their urinary homovanillic acid, urinary vanillylmandelic acid and serum neuron-specific enolase levels at 13 or 19 weeks prior to the clinical diagnosis of tumor relapse or regrowth. The present cases highlight the possibility of consecutive MRD monitoring using 11 markers to enable an early detection of tumor relapse or regrowth in high-risk neuroblastoma patients. PMID:27446404

  18. Phase II Study of Vinorelbine and Estramustine in Combination With Conformational Radiotherapy for Patients With High-Risk Prostate Cancer

    SciTech Connect

    Carles, Joan; Nogue, Miguel; Sole, Josep M.; Foro, Palmira; Domenech, Montserrat; Suarez, Marta; Gallardo, Enrique; Garcia, Dario; Ferrer, Ferran; Gelabert-Mas, Antoni; Gayo, Javier; Fabregat, Xavier

    2010-03-15

    Purpose: To evaluate the efficacy and safety profile of vinorelbine and estramustine in combination with three-dimensional conformational radiotherapy (3D-CRT) in patients with localized high-risk prostate cancer. Methods and Materials: Fifty patients received estramustine, 600 mg/m{sup 2} daily, and vinorelbine, 25 mg/m{sup 2}, on days 1 and 8 of a 21-day cycle for three cycles in combination with 8 weeks of 3D-CRT (total dose of 70.2 gray [Gy] at 1.8-Gy fractions or 70 Gy at 2.0-Gy fractions). Additionally, patients received luteinizing hormone-releasing hormone analogs for 3 years. Results: All patients were evaluated for response and toxicity. Progression-free survival at 5 years was 72% (95% confidence interval [CI]: 52-86). All patients who relapsed had only biochemical relapse. The most frequent severe toxicities were cystitis (16% of patients), leucopenia (10% of patients), diarrhea (10% of patients), neutropenia (8% of patients), and proctitis (8% of patients). Six patients (12%) did not complete study treatment due to the patient's decision (n = 1) and to adverse events such as hepatotoxicity, proctitis, paralytic ileus, and acute myocardial infarction. Conclusions: Vinorelbine and estramustine in combination with 3D-CRT is a safe and effective regimen for patients with localized high-risk prostate cancer. A randomized trial is needed to determine whether the results of this regimen are an improvement over the results obtained with radiotherapy and androgen ablation.

  19. Intravenous lipids in adult surgical patients.

    PubMed

    Klek, Stanislaw; Waitzberg, Dan L

    2015-01-01

    Parenteral nutrition is considered an essential element of the perioperative management of surgical patients. It is recommended in patients who require nutritional therapy but in whom the enteral route is contraindicated, not recommended or non-feasible. The new generation of lipid emulsions (LEs) based on olive and fish oils are safe and may improve clinical outcome in surgical patients. The increased provision of n-3 polyunsaturated fatty acids in fish oil-containing LEs seems to be associated with fewer infectious complications and shorter ICU and hospital stays following major abdominal surgery. Increased provision of olive oil in the absence of fish oil may also exert beneficial effects, but a clear conclusion on this is limited due to the low number of available studies. Hence, at the moment, the evidence supports the use of n-3-polyunsaturated fatty acid-enriched LEs as a part of the parenteral nutrition regimen for selected groups of patients, such as those with major surgical trauma or those undergoing extended resections or liver transplantation.

  20. Sorafenib therapy following resection prolongs disease-free survival in patients with advanced hepatocellular carcinoma at a high risk of recurrence

    PubMed Central

    Liao, Yadi; Zheng, Yun; He, Wei; Li, Qijiong; Shen, Jingxian; Hong, Jian; Zou, Ruhai; Qiu, Jiliang; Li, Binkui; Yuan, Yunfei

    2017-01-01

    Sorafenib is the standard systemic treatment for patients with advanced hepatocellular carcinoma (HCC); however, its therapeutic value in patients with HCC following resection remains controversial. The current retrospective study was undertaken to assess the effects of sorafenib treatment following surgical resection in patients with advanced HCC disease who were at a high risk for recurrence. Between July 2010 and July 2013, a consecutive cohort of 42 patients with advanced HCC and at a high risk of recurrence (i.e., those with portal vein tumor thrombosis, adjacent organ involvement or tumor rupture) who underwent resection were analyzed. The patients were categorized into the sorafenib group (n=14) or the best supportive care (BSC) group (n=28). Although the histological grade, Barcelona Clinic Liver Cancer Stage, tumor size, nodule number and proportion of patients with high serum α-fetoprotein levels were comparable between the sorafenib and BSC groups, those receiving sorafenib following resection had significantly longer disease-free survival (DFS) of 5.2 months [95% confidence interval (CI), 1.2–9.2 months] compared with the BSC group [1.8 months (95% CI, 0.6–3.0 months)]. No differences in overall survival were noted between the groups. Furthermore, no drug-related adverse events resulted in discontinuation of sorafenib therapy. Univariate log-rank analysis revealed that sorafenib treatment (P=0.002) and treatment prior to resection (P=0.012) were significantly associated with longer DFS; however, sorafenib therapy (P=0.027) and tumor size (P=0.028) were associated with longer DFS by multivariate analysis. Furthermore, sorafenib was well-tolerated and improved DFS in patients with advanced HCC who underwent hepatic resection. Thus, tumor resection followed by sorafenib therapy may represent an effective therapeutic strategy for patients with advanced HCC. This possibility should be confirmed in larger, multicenter studies. PMID:28356989

  1. Predicting biochemical recurrence in patients with high-risk prostate cancer using the apparent diffusion coefficient of magnetic resonance imaging

    PubMed Central

    Yoon, Min Young; Park, Juhyun; Cho, Jeong Yeon; Jeong, Chang Wook; Ku, Ja Hyeon; Kim, Hyeon Hoe

    2017-01-01

    Purpose We aimed to investigate whether the apparent diffusion coefficient (ADC) value in diffusion-weighted magnetic resonance imaging predicts the prognoses of patients with high-risk prostate cancer. Materials and Methods A total of 157 patients with high-risk prostate cancer (based on D'Amico's criteria) were included in the analysis. Patients underwent preoperative 3.0 Tesla magnetic resonance imaging within 2 months before radical prostatectomy. Those who received neoadjuvant hormone therapy (33 persons) or radiation therapy (18 persons) were excluded. The ADC of the tumor calculated from 2 b-values (0 and 1,000 s/mm2) was measured. Areas under receiver operating characteristics curves were calculated to maximize the accuracy of the ADC value. Based on the obtained cutoff value, the patients were stratified into 2 groups: Group A consisted of patients with ADC values <746×10−6 mm2/s and group B comprised those with ADC values ≥746×10−6 mm2/s. Results Group A showed higher rate of lymph positive and biochemical recurrence (BCR) rates than group B. Kaplan-Meier analysis showed that the BCR-free survival rate of group A was much lower than that of group B (p<0.001). On Cox proportional regression analyses, ADC group A (hazard ratio [HR], 3.238, p=0.002) and pathologic lymph node positive (HR, 2.242; p=0.009) were independent predictors of BCR. Conclusions In patients with high-risk prostate cancer, ADC value is significantly associated with BCR-free survival. Therefore, the ADC value is a useful tool for predicting the prognoses of these high-risk patients. PMID:28097263

  2. Outcomes of BCG Induction in High-Risk Non-Muscle-Invasive Bladder Cancer Patients (NMIBC): A Retrospective Cohort Study

    PubMed Central

    Ghauri, Rashid; Ahmed, Monis J; Shah, Muhammad F; Nasir, Irfan ul Islam; Siddiqui, Jasim; Ahmed, Irfan; Mir, Khurram

    2017-01-01

    Non-muscle-invasive bladder cancer (NMIBC) is categorized into high-risk and low-risk groups. Although, bacillus Calmette-Guerin (BCG) is the recommended adjuvant therapy of high-risk bladder tumor, optimal schedule (induction versus maintenance) of this therapy is a subject of debate. The objective was to evaluate outcomes of induction BCG in high-risk NMIBC patients at Shaukat Khanum Memorial Cancer Hospital & Research Centre, Pakistan and retrospective cohort study conducted in the department of urology, Shaukat Khanum Memorial Cancer Hospital & Research Centre, Pakistan. Three-year disease-free survival and progression-free survival was the main outcome measure. Data of 68 high-risk (Ta and T1 with G3 or high-grade subtype) bladder cancer patients who underwent transurethral resection followed by six-weekly intravesical BCG instillation was included in the study. Recurrence was described as biopsy-proven bladder cancer; whereas the presence of muscle invasion was considered as progression. Disease-free survival and progression-free survival were defined as time intervals elapsed between the starting date of BCG instillation and recurrence or progression, respectively. Kaplan-Meier curve was employed to estimate the three-year study end-points. Disease-free survival at three years was observed to be 66.2% and progression-free survival at 86.8%. The use of induction BCG alone for high-risk patients of NMIBC is a viable option both in terms of effective disease-free and progression-free survival rates. PMID:28168135

  3. Coronectomy versus surgical removal of the lower third molars with a high risk of injury to the inferior alveolar nerve. A bibliographical review

    PubMed Central

    Moreno-Vicente, Javier; Schiavone-Mussano, Rocío; Clemente-Salas, Enrique; Marí-Roig, Antoni; Jané-Salas, Enric

    2015-01-01

    Background Coronectomy is the surgical removal of the crown of the tooth deliberately leaving part of its roots. This is done with the hope of eliminating the pathology caused, and since the roots are still intact, the integrity of the inferior alveolar nerve is preserved. Objectives The aim is to carry out a systematic review in order to be able to provide results and conclusions with the greatest scientific evidence possible. Material and Methods A literature review is carried out through the following search engines: Pubmed MEDLINE, Scielo, Cochrane library and EMI. The level of evidence criteria from the Agency for Healthcare Research and Quality was applied, and the clinical trials’ level of quality was analyzed by means of the JADAD criteria. Results The following articles were obtained which represents a total of 17: 1 systematic review, 2 randomized clinical trials and 2 non-randomized clinical trials, 3 cohort studies, 2 retrospective studies, 3 case studies and 4 literature reviews. Conclusions Coronectomy is an adequate preventative technique in protecting the inferior alveolar nerve, which is an alternative to the conventional extraction of third molars, which unlike the former technique, presents a high risk of injury to the inferior alveolar nerve. However, there is a need for new clinical studies, with a greater number of samples and with a longer follow-up period in order to detect potential adverse effects of the retained roots. Key words: Coronectomy, inferior alveolar nerve, nerve injury, wisdom tooth removal, paresthesia, and systematic review. PMID:25858081

  4. Cost-Effectiveness of Skin Surveillance Through a Specialized Clinic for Patients at High Risk of Melanoma.

    PubMed

    Watts, Caroline G; Cust, Anne E; Menzies, Scott W; Mann, Graham J; Morton, Rachael L

    2017-01-01

    Purpose Clinical guidelines recommend that people at high risk of melanoma receive regular surveillance to improve survival through early detection. A specialized High Risk Clinic in Sydney, Australia was found to be effective for this purpose; however, wider implementation of this clinical service requires evidence of cost-effectiveness and data addressing potential overtreatment of suspicious skin lesions. Patients and Methods A decision-analytic model was built to compare the costs and benefits of specialized surveillance compared with standard care over a 10-year period, from a health system perspective. A high-risk standard care cohort was obtained using linked population data, comprising the Sax Institute's 45 and Up cohort study, linked to Medicare Benefits Schedule claims data, the cancer registry, and hospital admissions data. Benefits were measured in quality-adjusted life-years gained. Sensitivity analyses were undertaken for all model parameters. Results Specialized surveillance through the High Risk Clinic was both less expensive and more effective than standard care. The mean saving was A$6,828 (95% CI, $5,564 to $8,092) per patient, and the mean quality-adjusted life-year gain was 0.31 (95% CI, 0.27 to 0.35). The main drivers of the differences were detection of melanoma at an earlier stage resulting in less extensive treatment and a lower annual mean excision rate for suspicious lesions in specialized surveillance (0.81; 95% CI, 0.72 to 0.91) compared with standard care (2.55; 95% CI, 2.34 to 2.76). The results were robust when tested in sensitivity analyses. Conclusion Specialized surveillance was a cost-effective strategy for the management of individuals at high risk of melanoma. There were also fewer invasive procedures in specialized surveillance compared with standard care in the community.

  5. Spirituality and high-risk pregnancy: another aspect of patient care.

    PubMed

    Breen, Glenn V; Price, Sheri; Lake, Margaret

    A high-risk pregnancy can be a stressful situation for a woman, her partner and her family. Many women utilize their spiritual beliefs as a way to make sense of their situation. Health care professionals, including nurses, midwives and physicians, can provide effective spiritual care and support consistent with their professional scopes of practice. Spiritually focused interventions can help to reduce stress and anxiety and create a more open and confident approach to the management of pregnancy complications.

  6. Lipid management in 13,000 high risk cardiovascular patients treated under daily practice conditions: LIMA Registry

    PubMed Central

    Schaefer, Juergen R; Gitt, Anselm K; Sonntag, Frank; Weizel, Achim; Jannowitz, Christina; Karmann, Barbara; Pittrow, David; Bestehorn, Kurt

    2013-01-01

    Aims We aimed to document the drug management of patients at high cardiovascular risk in daily practice, with the special focus on lipid-lowering treatment. Methods and results In this prospective noninterventional study in 2387 outpatient centers throughout Germany, a total of 13,942 high-risk patients (mean age 65.7 years, 61.6% males) were treated with simvastatin 40 mg/day at entry as monotherapy. All patients were followed up for 12 months in terms of drug utilization, laboratory values, target attainment, and clinical events (including death, hospitalization, vascular events, and dialysis). Patients had coronary heart disease in 35.0%, diabetes mellitus in 24.4%, and the combination of coronary heart disease plus diabetes mellitus in 25.7%. In 21% of patients, a cholesterol absorption inhibitor was added to statin therapy at the entry visit, and in 23%, this was added at the follow up visit 6 months later. The target values for low-density lipoprotein-cholesterol (<2.6 mmol/L) were reached by 31.8% of patients at entry and by 50.0% at the end of this registry after 12 months. Mean blood pressure decreased (from 135.9/80.5 mmHg at baseline) by 3.1/1.9 mmHg after 12 months. In patients with documented diabetes, the targeted glycated hemoglobin (HbA1c <6.5%) was reached by 33.5% at baseline and by 40.0% after 12 months. Clinical events occurred in 11.7% of patients between baseline and month 6, and in 12.0% between months 6 and 12. Conclusion In patients at high risk for cardiovascular events, comprehensive management under daily practice conditions leads to improvement of lipid, glucose, and blood pressure parameters. There is a need to improve secondary prevention among high-risk patients. PMID:23459022

  7. The meaning of anti-Müllerian hormone levels in patients at a high risk of poor ovarian response

    PubMed Central

    Park, Hyun Jong; Lee, Geun Ho; Gong, Du Sik; Yoon, Tae Ki

    2016-01-01

    Measurements of ovarian reserve play an important role in predicting the clinical results of assisted reproductive technology (ART). The ideal markers of ovarian reserve for clinical applications should have high specificity in order to determine genuine poor responders. Basal follicle-stimulating hormone levels, antral follicle count, and serum anti-Müllerian hormone (AMH) levels have been suggested as ovarian reserve tests that may fulfill this requirement, with serum AMH levels being the most promising parameter. Serum AMH levels have been suggested to be a predictor of clinical pregnancy in ART for older women, who are at a high risk for decreased ovarian response. We reviewed the prognostic significance of ovarian reserve tests for patients undergoing ART treatment, with a particular focus on the significance of serum AMH levels in patients at a high risk of poor ovarian response. PMID:27689035

  8. 10-Year Survival and Quality of Life in Patients With High-Risk {sub P}N{sub 0} Prostate Cancer Following Definitive Radiotherapy

    SciTech Connect

    Berg, Arne Lilleby, Wolfgang; Bruland, Oyvind Sverre; Fossa, Sophie Dorothea

    2007-11-15

    Purpose: To evaluate long-term overall survival (OS), cancer-specific survival (CSS), clinical progression-free survival (cPFS), and health-related quality of life (HRQoL) following definitive radiotherapy (RT) given to T{sub 1-4p}N{sub 0}M{sub 0} prostate cancer patients provided by a single institution between 1989 and 1996. Methods and Materials: We assessed outcome among 203 patients who had completed three-dimensional conformal RT (66 Gy) without hormone treatment and in whom staging by lymphadenectomy had been performed. OS was compared with an age-matched control group from the general population. A cross-sectional, self-report survey of HRQoL was performed among surviving patients. Results: Median observation time was 10 years (range, 1-16 years). Eighty-one percent had high-risk tumors defined as T{sub 3-4} or Gleason score (GS) {>=}7B (4+3). Among these, 10-year OS, CSS, and cPFS rates were 52%, 66%, and 39%, respectively. The corresponding fractions in low-risk patients (T{sub 1-2} and GS {<=}7A [3+4]) were 79%, 95%, and 73%, respectively. Both CSS and cPFS were predicted by GS and T-classification; OS was associated with GS only. High-risk, but not low-risk, patients had reduced OS compared with the general population (p < 0.0005). When pelvis-related side effects were included in multivariate analyzes together with physical function and pain, sexual, urinary, and bowel function were not independently associated with self-reported global quality of life. Conclusions: Despite surgically proven {sub p}N{sub 0}, RT with dosage <70 Gy as monotherapy does not give satisfactory CSS rates after 10 years in patients with T{sub 3-4} or GS {>=}7B.

  9. High-risk angina patient: identification by clinical features, hospital course, electrocardiography, and technetium-99m stannous pyrophosphate scintigraphy

    SciTech Connect

    Olson, H.G.; Lyons, K.P.; Aronow, W.S.; Stinson, P.J.; Kuperus, J.; Waters, H.J.

    1981-10-01

    We evaluated 193 consecutive unstable angina patients by clinical features, hospital course and electrocardiography. All patients were managed medically. Of the 193 patients, 150 (78%) had a technetium-99m pyrophosphate (Tc-PYP) myocardial scintigram after hospitalization. Of these, 49 (33%) had positive scintigrams. At a follow-up of 24.9 +- 10.8 months after hospitalization, 16 of 49 patients (33%) with positive scintigrams died from cardiac causes, compared with six of 101 patients (6%) with negative scintigrams (p < 0.001). Of 49 patients with positive scintigrams, 11 (22%) had had nonfatal myocardial infarction at follow-up, compared with seven of 101 patients (7%) with negative scintigrams (p < 0.01). Age, duration of clinical coronary artery disease, continuing angina during hospitalization, ischemic ECG, cardiomegaly and a history of heart failure also correlated with cardiac death at follow-up. Ischemic ECG and a history of angina with a crescendo pattern also correlated with nonfatal infarction at follow-up. Patients with continuing angina, an ischemic ECG and a positive scintigram constituted a high-risk unstable angina subgroup, with a survival rate of 58% at 6 months, 47% at 12 months and 42% at 24 and 36 months. We conclude that the assessment of clinical features, hospital course, ECG and Tc-PYP scintigraphy may be useful in identifying high-risk unstable angina patients.

  10. High-risk angina patient. Identification by clinical features, hospital course, electrocardiography and technetium-99m stannous pyrophosphate scintigraphy

    SciTech Connect

    Olson, H.G.; Lyons, K.P.; Aronow, W.S.; Stinson, P.J.; Kuperus, J.; Waters, H.J.

    1981-10-01

    We evaluated 193 consecutive unstable angina patients by clinical features, hospital course and electrocardiography. All patients were managed medically. Of the 193 patients, 150 (78%) had a technetium-99m pyrophosphate (Tc-PYP) myocardial scintigram after hospitalization. Of these, 49 (33%) had positive scintigrams. At a follow-up of 24.9 +/- 10.8 months after hospitalization, 16 of 49 patients (33%) with positive scintigrams died from cardiac causes, compared with six of 101 patients (6%) with negative scintigrams (p less than 0.001). Of 49 patients with positive scintigrams, 11 (22%) had had nonfatal myocardial infarction at follow-up, compared with seven of 101 patients (7%) with negative scintigrams (p less than 0.01). Age, duration of clinical coronary artery disease, continuing angina during hospitalization, ischemic ECG, cardiomegaly and a history of heart failure also correlated with cardiac death at follow-up. Ischemic ECG and a history of angina with a crescendo pattern also correlated with nonfatal infarction at follow-up. Patients with continuing angina, an ischemic ECG and a positive scintigram constituted a high-risk unstable angina subgroup with a survival rate of 58% at 6 months, 47% at 12 months and 42% at 24 and 36 months. We conclude that the assessment of clinical features, hospital course, ECG and Tc-PYP scintigraphy may be useful in identifying high-risk unstable angina patients.

  11. Implications of malnutrition in the surgical patient.

    PubMed

    Mullen, J L; Gertner, M H; Buzby, G P; Goodhart, G L; Rosato, E F

    1979-02-01

    The substantial prevalence of malnutrition in the hospitalized patient population has only been recently recognized. Preoperative nutritional and immunological assessment was performed prospectively on admission in 64 consecutive surgical patients. Factors measured included weight loss, triceps skinfold, midarm muscle circumference, creatinine-height index, serum albumin level, serum transferrin level, total lymphocyte count, serum complement level, serum immunoelectrophoresis, lymphocyte T rosettes formation, neutrophil migration, and delayed hypersensitivity. Using these criteria for malnutrition, 97% of the patients had at least one abnormal measurement and 35% had at least three abnormal measurements. Patients were monitored for complications during their hospital course. Serum albumin level, serum transferrin level, and delayed hypersensitivity reactions were the only accurate prognostic indicators of postoperative morbidity and mortality. Substantial unrecognized malnutrition exists in the surgical patient population. An isolated indicator of malnutrition should be interpreted with caution. The visceral protein compartment (serum albumin and serum transferrin levels and delayed hypersensitivity) is the most accurate prognostic indicator of postoperative morbidity and mortality. Perioperative nutritional support may reduce operative morbidity and mortality in the malnourished operative candidate.

  12. Ovarian cancer patients at high risk of BRCA mutation: the constitutional genetic characterization does not change prognosis.

    PubMed

    Sabatier, Renaud; Lavit, Elise; Moretta, Jessica; Lambaudie, Eric; Noguchi, Tetsuro; Eisinger, François; Cherau, Elisabeth; Provansal, Magali; Livon, Doriane; Rabayrol, Laetitia; Popovici, Cornel; Charaffe-Jauffret, Emmanuelle; Sobol, Hagay; Viens, Patrice

    2016-10-01

    Ovarian neoplasms secondary to germline BRCA mutations had been described to have a more favourable survival. There is only few data concerning the prognosis of non mutated patients presenting clinical features evocative of BRCA alterations. We retrospectively collected data from patients treated in our institution for an invasive ovarian carcinoma between 1995 and 2011. Patients considered at high risk of BRCA mutation were tested for BRCA1/2 germline mutations. We described clinical, pathological and therapeutic features and compared prognosis of BRCA mutation carriers and non-mutated patients. Out of 617 ovarian cancer patients, we identified 104 patients who were considered at high risk of mutation. The 33 mutated patients were more likely to present a personal (33 vs. 10 %, p = 0.003) or a family (42 vs. 24 %, p = 0.06) history of breast/ovarian cancers. BRCA1/2 mutation carriers and wild type patients displayed similar prognosis: median progression-free survival (PFS) of 20.9 versus 37.7 months (p = 0.21); median overall survival (OS) of 151.2 versus 122.5 months (p = 0.52). Personal history of breast cancer increased both PFS [HR = 0.45 (95CI 0.25-0.81)] and OS [HR = 0.35 (95CI 0.16-0.75)]. In multivariate analysis, this parameter was an independent prognostic feature, whereas the identification of a BRCA1/2 mutation was not. In our cohort, all patients at high risk of BRCA mutation share a similar prognosis, whatever is their germline mutation status. Prognosis seems to be more influenced by clinical history than by germline mutations identification. If it is confirmed in larger and independent series, this result suggests that the hypothesis of other BRCA pathway alterations (BRCAness phenotype) deserves to be deeply explored.

  13. Treatment of retinal tears and lattice degenerations in fellow eyes in high risk patients suffering retinal detachment: a prospective study

    PubMed Central

    Mastropasqua, L.; Carpineto, P.; Ciancaglini, M.; Falconio, G.; Gallenga, P.

    1999-01-01

    BACKGROUND/AIMS—Fellow eye prophylaxis for retinal detachment (RD) is still a controversial issue since opinions are not unanimous regarding the kind of lesions to be treated or the method of treatment. This prospective clinical study aimed to follow the course of vitreoretinal conditions in 150 high risk fellow eyes.
METHODS—150 consecutive patients with unilateral rhegmatogenous RD were included in this study. Inclusion criteria were good explorability of fellow eye retinal periphery and one of the following conditions in the fellow eye—aphakia, pseudophakia with capsulotomy, high myopia (>−6D), contralateral eye to a giant retinal tear. Prophylactic treatment (photocoagulation or scleral buckling) was performed in the presence of retinal tears and lattice degenerations. The state of the vitreous body was determined at the beginning of the study and at the end, when RD occurred.
RESULTS—Follow up ranged from 36 to 132 months. 95 fellow eyes were subjected to laser treatment; five eyes underwent prophylactic surgical treatment. Initially, in the treated group posterior vitreous detachment (PVD) was present in 100 eyes (100% of cases), but as a complete PVD only in 42 of them (42%). 10 eyes in the treated group developed RD during the follow up period. In five of these cases the partial PVD had progressed and a retinal tear in a previously healthy area was the cause of the retinal detachment. In the other five eyes RD apparently developed from previously treated lesions. Progression of PVD was evident in four out of these five eyes. The untreated eyes had no visible degenerative lesions. During follow up eight eyes developed RD. These eyes had no PVD at the beginning of the study, but showed a partial PVD at the time of the diagnosis of RD.
CONCLUSION—Fellow eyes with pre-existing retinal tears and PVDs can go on to retinal detachment in spite of laser prophylactic treatment. When PVD is not detectable or a partial PVD is present, the

  14. Voxel-wise meta-analysis of fMRI studies in patients at clinical high risk for psychosis

    PubMed Central

    Fusar-Poli, Paolo

    2012-01-01

    Background Reliable neurofunctional markers of increased vulnerability to psychosis are needed to improve the predictive value of psychosis risk syndrome and inform preventive interventions. Methods I performed a signed differential mapping (SDM) voxel-wise meta-analysis of functional magnetic resonance imaging (fMRI) studies of patients at clinical high risk for psychosis. Results Ten studies were included in the analysis. Compared with controls, high-risk patients showed reduced neural activation in the left inferior frontal gyrus (Brodmann area [BA] 9) and in a cluster spanning the bilateral medial frontal gyrus (BA 8,6), bilateral superior frontal gyrus (BA 8,6) and the left anterior cingulate (BA 32). There was no publication bias. Heterogeneity across studies was low. Sensitivity analysis confirmed the robustness of the findings. Limitations The cross-sectional nature of the included studies prevented the comparison of high-risk patients who later experienced a psychotic episode with those who did not. Other caveats are reflected in methodologic heterogeneity across tasks employed by different individual imaging studies. Conclusion Reduced neurofunctional activation in prefrontal regions may represent a neurophysiologic correlate of increased vulnerability to psychosis. PMID:22146150

  15. Noninvasive assessment of coronary vasodilation using cardiovascular magnetic resonance in patients at high risk for coronary artery disease

    PubMed Central

    Nguyen, Patricia K; Meyer, Craig; Engvall, Jan; Yang, Phillip; McConnell, Michael V

    2008-01-01

    Background Impaired coronary vasodilation to both endothelial-dependent and endothelial-independent stimuli have been associated with atherosclerosis. Direct measurement of coronary vasodilation using x-ray angiography or intravascular ultrasound is invasive and, thus, not appropriate for asymptomatic patients or for serial follow-up. In this study, high-resolution coronary cardiovascular magnetic resonance (CMR) was used to investigate the vasodilatory response to nitroglycerine (NTG) of asymptomatic patients at high risk for CAD. Methods A total of 46 asymptomatic subjects were studied: 13 high-risk patients [8 with diabetes mellitus (DM), 5 with end stage renal disease (ESRD)] and 33 age-matched controls. Long-axis and cross-sectional coronary artery images were acquired pre- and 5 minutes post-sublingual NTG using a sub-mm-resolution multi-slice spiral coronary CMR sequence. Coronary cross sectional area (CSA) was measured on pre- and post-NTG images and % coronary vasodilation was calculated. Results Patients with DM and ESRD had impaired coronary vasodilation to NTG compared to age-matched controls (17.8 ± 7.3% vs. 25.6 ± 7.1%, p = 0.002). This remained significant for ESRD patients alone (14.8 ± 7.7% vs. 25.6 ± 7.1%; p = 0.003) and for DM patients alone (19.8 ± 6.3% vs. 25.6 ± 7.1%; p = 0.049), with a non-significant trend toward greater impairment in the ESRD vs. DM patients (14.8 ± 7.7% vs. 19.8 ± 6.3%; p = 0.23). Conclusion Noninvasive coronary CMR demonstrates impairment of coronary vasodilation to NTG in high-risk patients with DM and ESRD. This may provide a functional indicator of subclinical atherosclerosis and warrants clinical follow up to determine prognostic significance. PMID:18513419

  16. Identifying high-risk post-infarction patients by autonomic testing - Below the tip of the iceberg.

    PubMed

    Bauer, Axel

    2017-03-18

    Despite major advances in medical therapies late mortality after myocardial infarction (MI) is still high. A substantial proportion of post-MI patients die from sudden cardiac death. Prophylactic implantable-cardioverter defibrillator (ICD) therapy has been established for post-MI patients with reduced left ventricular ejection fraction (LVEF ≤35%). However, most patients who die after MI have an LVEF >35%. For this large group of patients, no specific prophylactic strategies exist. There is strong evidence that measures of cardiac autonomic dysfunction after MI provide important prognostic information in post-MI patients with preserved LVEF. Combinations of autonomic markers can identify high-risk patients after MI with LVEF >35% whose prognosis is equally worse than that of patients with LVEF ≤35%. The ongoing REFINE-ICD (NCT00673842) and SMART-MI trials (NCT02594488) test different preventive strategies in high-risk post-MI patients with cardiac autonomic dysfunction and LVEF 36-50%. While REFINE-ICD follows the traditional concept of ICD-implantation, SMART-MI uses implantable cardiac monitors with remote monitoring capabilities to sensitively detect asymptomatic, but prognostically relevant arrhythmias that could trigger specific diagnostic and therapeutic interventions.

  17. The efficacy and safety of 2-μm continuous laser in the treatment of high-risk patients with benign prostatic hyperplasia.

    PubMed

    Tao, Wei; Sun, Chuanyang; Xue, Boxin; Yang, Dongrong; Wang, Mingchao; Cai, Chunjie; Shan, Yuxi

    2017-02-01

    Two-micrometer laser resection of prostate-tangerine technique dissects whole prostatic lobes off the surgical capsular, similar to peeling a tangerine. The present study aimed to evaluate the safety and efficacy of 2-μm continuous laser vaporization in the treatment of high-risk patients with benign prostatic hyperplasia (BPH) during the 24-month follow-up. The study included 248 patients with moderate to severe lower urinary tract symptoms who underwent 2-μm continuous laser vaporization of the prostate. All patients were accompanied with different degree comorbidities and 94 patients were taking oral anticoagulants. BPH was successfully treated with 2-μm continuous laser vaporization in all patients. Mean pre-operative prostate volume was 76 ± 25.3 ml and mean operative time was 49.8 ± 16.5 min. There were no major complications intra-operatively or postoperatively, and no blood transfusions were needed. About 20 patients (8.1%) needed bladder irrigation postoperatively. Average catheterization time was 2.0 ± 1.8 days (range 1-5 days). Four patients required reoperation due to enlarged prostates from residual adenoma. At 3-, 6-, 12-, and 24-month follow-ups, maximum urinary flow rates (Qmax) increased from 6.9 ± 1.7 to 19.1 ± 4.2, 19.5 ± 4.6, 19.4 ± 4.6, and 19.5 ± 4.1 ml/s, respectively. Mean International Prostate Symptom Scores (IPSS) decreased from 27.6 ± 5.1 (pre-operation) to 9.2 ± 2.6, 7.12 ± 1.42, 6.18 ± 1.32, and 6.25 ± 1.30 at 3-, 6-, 12-, and 24-month post-operation, respectively. Two-micrometer continuous laser vaporization is a safe and effective surgical endoscopic technique associated with low complication rate in BPH patients at high risk and those on anticoagulation therapy who have severe LUTS caused by BPH.

  18. Use of fluoride products for young patients at high risk of dental caries.

    PubMed

    Croll, Theodore P; Berg, Joel H

    2014-09-01

    Extensive education in oral hygiene home care, nutrition counseling, and routine reinforcement of home-care instructions at periodic check-ups lead to better oral health for many young children and teenagers. In addition, resistance to dental caries infection can be increased significantly by intelligent use of bonded resin sealants and systemic and topical fluoride products. This article discusses protocols for use of in-office applied topical fluoride and daily at-home use of topical fluoride products for children and teens at high risk of dental caries.

  19. Prediction of positron emission tomography/computed tomography (PET/CT) positivity in patients with high-risk primary melanoma.

    PubMed

    Danielsen, Maria; Kjaer, Andreas; Wu, Max; Martineau, Lea; Nosrati, Mehdi; Leong, Stanley Pl; Sagebiel, Richard W; Iii, James R Miller; Kashani-Sabet, Mohammed

    2016-01-01

    Positron emission tomography/computed tomography (PET/CT) is an important tool to identify occult melanoma metastasis. To date, it is controversial which patients with primary cutaneous melanoma should have staging PET/CT. In this retrospective analysis of more than 800 consecutive patients with cutaneous melanoma, we sought to identify factors predictive of PET/CT positivity in the setting of newly-diagnosed high-risk primary melanoma to determine those patients most appropriate to undergo a PET/CT scan as part of their diagnostic work up. 167 patients with newly-diagnosed high-risk primary cutaneous melanoma underwent a PET/CT scan performed as part of their initial staging. Clinical and histologic factors were evaluated as possible predictors of melanoma metastasis identified on PET/CT scanning using both univariate and multivariate logistic regression. In all, 32 patients (19.2%) had a positive PET/CT finding of metastatic melanoma. In more than half of these patients (56.3%), PET/CT scanning identified disease that was not detectable on clinical examination. Mitotic rate, tumor thickness, lymphadenopathy, and bleeding were significantly predictive of PET/CT positivity. A combinatorial index constructed from these factors revealed a significant association between number of high-risk factors observed and prevalence of PET/CT positivity, which increased from 5.8% (with the presence of 0-2 factors) to 100.0%, when all four factors were present. These results indicate that combining clinical and histologic prognostic factors enables the identification of patients with a higher likelihood of a positive PET/CT scan.

  20. Prediction of positron emission tomography/computed tomography (PET/CT) positivity in patients with high-risk primary melanoma

    PubMed Central

    Danielsen, Maria; Kjaer, Andreas; Wu, Max; Martineau, Lea; Nosrati, Mehdi; Leong, Stanley PL; Sagebiel, Richard W; III, James R Miller; Kashani-Sabet, Mohammed

    2016-01-01

    Positron emission tomography/computed tomography (PET/CT) is an important tool to identify occult melanoma metastasis. To date, it is controversial which patients with primary cutaneous melanoma should have staging PET/CT. In this retrospective analysis of more than 800 consecutive patients with cutaneous melanoma, we sought to identify factors predictive of PET/CT positivity in the setting of newly-diagnosed high-risk primary melanoma to determine those patients most appropriate to undergo a PET/CT scan as part of their diagnostic work up. 167 patients with newly-diagnosed high-risk primary cutaneous melanoma underwent a PET/CT scan performed as part of their initial staging. Clinical and histologic factors were evaluated as possible predictors of melanoma metastasis identified on PET/CT scanning using both univariate and multivariate logistic regression. In all, 32 patients (19.2%) had a positive PET/CT finding of metastatic melanoma. In more than half of these patients (56.3%), PET/CT scanning identified disease that was not detectable on clinical examination. Mitotic rate, tumor thickness, lymphadenopathy, and bleeding were significantly predictive of PET/CT positivity. A combinatorial index constructed from these factors revealed a significant association between number of high-risk factors observed and prevalence of PET/CT positivity, which increased from 5.8% (with the presence of 0-2 factors) to 100.0%, when all four factors were present. These results indicate that combining clinical and histologic prognostic factors enables the identification of patients with a higher likelihood of a positive PET/CT scan. PMID:27766186

  1. Predictors of basal cell carcinoma in high-risk patients in the VATTC (VA Topical Tretinoin Chemoprevention) trial.

    PubMed

    Dyer, Robert K; Weinstock, Martin A; Cohen, Tobias S D; Rizzo, Amilcar E; Bingham, Stephen F

    2012-11-01

    Basal cell carcinoma (BCC) is the most common cancer in the United States today, and patients who have had one are likely to have multiple carcinomas over time. Predictors of new BCCs on the face and ears among those at very high risk have not been studied in detail. We sought to do so prospectively in the context of a 6-year trial. We found that the number of BCCs in the prior 5 years was the most important predictor. Age, sun sensitivity, occupational sun exposure before the age of 30 years (but not afterward), lower educational level, history of eczema, the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and more sunscreen use in the week, but not the 6 months, before enrollment were also independent predictors, but sunburns, baseline sun exposure, and other sun-protective measures, other skin cancers, and actinic keratoses were not. None of the eczema patients had a history of topical calcineurin use. The cumulative risk of BCC was 55% at 5 years. These findings document the key risk factors in this very high-risk population, suggesting that the history of eczema may increase the risk in those at high risk and that early sun exposure is important even in this group, and underscoring the need for chemopreventive strategies.

  2. Improving medication safety: Development and impact of a multivariate model-based strategy to target high-risk patients

    PubMed Central

    Nguyen, Tri-Long; Leguelinel-Blache, Géraldine; Kinowski, Jean-Marie; Roux-Marson, Clarisse; Rougier, Marion; Spence, Jessica; Le Manach, Yannick; Landais, Paul

    2017-01-01

    Background Preventive strategies to reduce clinically significant medication errors (MEs), such as medication review, are often limited by human resources. Identifying high-risk patients to allow for appropriate resource allocation is of the utmost importance. To this end, we developed a predictive model to identify high-risk patients and assessed its impact on clinical decision-making. Methods From March 1st to April 31st 2014, we conducted a prospective cohort study on adult inpatients of a 1,644-bed University Hospital Centre. After a clinical evaluation of identified MEs, we fitted and internally validated a multivariate logistic model predicting their occurrence. Through 5,000 simulated randomized controlled trials, we compared two clinical decision pathways for intervention: one supported by our model and one based on the criterion of age. Results Among 1,408 patients, 365 (25.9%) experienced at least one clinically significant ME. Eleven variables were identified using multivariable logistic regression and used to build a predictive model which demonstrated fair performance (c-statistic: 0.72). Major predictors were age and number of prescribed drugs. When compared with a decision to treat based on the criterion of age, our model enhanced the interception of potential adverse drug events by 17.5%, with a number needed to treat of 6 patients. Conclusion We developed and tested a model predicting the occurrence of clinically significant MEs. Preliminary results suggest that its implementation into clinical practice could be used to focus interventions on high-risk patients. This must be confirmed on an independent set of patients and evaluated through a real clinical impact study. PMID:28192533

  3. [Comparative efficacy of fixed dose combinations of perindopril with indapamide and captopril with hydrochlorothiazide in patients with high risk hypertension].

    PubMed

    Nedogoda, S V; Marchenko, I V; Chaliabi, T A; Tsoma, V V; Brel', U A; Prokhorova, E A

    2005-01-01

    Clinical effectiveness and tolerability of o.d. use of fixed dose combinations of perindopril (4 mg) with indapamide (1.25 mg) (Noliprel forte) and captopril (50 mg) with hydrochlorothiazide (25 mg) (Capozide) were compared in a randomized study on 40 patients with I-II degree high and very high risk hypertension. Study duration was 6 months, number of patients in each of parallel groups -- 20. Antihypertensive activity, ability to decrease left ventricular hypertrophy, to improve arterial elasticity and T/P parameter of perindopril (4 mg) -- indapamide (1.25 mg) combination was found to be superior to those of captopril (50 mg) -- hydrochlorothiazide (25 mg) combination.

  4. [Comparative efficacy of fixed dose combinations of enalapril with hydrochlorothiazide and captopril with hydrochlorothiazide in patients with high risk hypertension].

    PubMed

    Nedogoda, S V

    2005-01-01

    Clinical effectiveness and tolerability of o.d. use of fixed dose combinations of enalapril (10 mg) with hydrochlorothiazide (25 mg) (Enap H) and captopril (50 mg) with hydrochlorothiazide (25 mg) (Capozide) were compared in a randomized study on 60 patients with I-II degree high and very high risk hypertension. Study duration was 6 months, number of patients in each of parallel groups -- 30. Antihypertensive activity, ability to improve arterial elasticity and T/P parameter, cost/efficacy index of enalapril (10 mg) plus hydrochlorothiazide (25 mg) combination was found to be superior to those of captopril (50 mg) plus hydrochlorothiazide (25 mg) combination.

  5. Tension-free Polypropylene Mesh-related Surgical Repair for Pelvic Organ Prolapse has a Good Anatomic Success Rate but a High Risk of Complications

    PubMed Central

    Zhang, Lei; Zhu, Lan; Chen, Juan; Xu, Tao; Lang, Jing-He

    2015-01-01

    Background: Food and Drug Administration announcements have highlighted the standard rate of mesh-related complications. We aimed to report the short-term results and complications of tension-free polypropylene mesh (PROSIMA™) surgical repair of pelvic organ prolapse (POP) using the standard category (C), timing (T), and site (S) classification system. Methods: A prospective cohort study of 48 patients who underwent PROSIMA™ mesh kit-related surgical repairs were followed for two years at Peking Union Medical College Hospital. Recurrence was defined as symptomatic POP quantification (POP-Q) Stage II or higher (leading edge ≥ −1 cm). The Patient Global Impression of Change Questionnaire, the Chinese version of the Pelvic Floor Impact Questionnaire short-form-7 and POP/Urinary Incontinence Sexual Questionnaire short-form-12 were used to evaluate the self-perception and sexual function of each patient. Mesh-related complications conformed to the International Urogynecological Association/International Continence Society joint terminology. The paired-sample t-test, one-way analysis of variance, Fisher's exact test, Kaplan-Meier survival analysis and log-rank test were used to analyze data. Results: All patients were followed up for ≥12 months; 30 (62.5%) patients completed the 24 months study. We observed a 93.8% (45/48) positive anatomical outcome rate at 12 months and 90.0% (27/30) at 24 months. Recurrence most frequently involved the anterior compartment (P < 0.05). Pelvic symptoms improved significantly from baseline (P < 0.05), although the patients’ impressions of change and sexual function were not satisfying. Vaginal complication was the main complication observed (35.4%, 17/48). The survival analysis did not identify any relationship between vaginal complication and anatomical recurrent prolapse (POP-Q ≥ Stage II) (P = 0.653). Conclusions: Tension-free polypropylene mesh (PROSIMA™)-related surgical repair of POP has better short-term anatomical

  6. Surgical jejunostomy in aspiration risk patients.

    PubMed Central

    Weltz, C R; Morris, J B; Mullen, J L

    1992-01-01

    One hundred patients underwent laparotomy for independent jejunal feeding tube placement. Neurologic disease was present in 50%, and obtundation (28) and oropharyngeal dysmotility (25) were the most common indications for enteral feeding. The post-pyloric route was chosen because of aspiration risk in almost all (94%) patients. Postoperative (30-day) mortality rate was 21%, because of cardiopulmonary failure in most (18). One death resulted directly from aspiration of tube feeds. Two surgical complications required reoperation: one wound dehiscence and one small bowel obstruction. Four wound infections occurred. Two patients underwent reoperation after tube removal, and four tubes required fluoroscopically guided reinsertion for peritubular drainage (2), removal (1), and occlusion (1). Aspiration pneumonia was present in 18 patients preoperatively and in eight postoperatively. None of the patients with feeding-related preoperative aspiration pneumonia (13) had a recurrence while fed by jejunostomy. Three patients developed postoperative aspiration pneumonia before initiation of jejunostomy feedings. Jejunostomy may be performed with low morbidity rate and substantial reduction of feeding-related aspiration pneumonia, and is the feeding route of choice in aspiration risk patients. PMID:1546899

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

    SciTech Connect

    Jing, Hao; Wang, Shu-Lian; Li, Jing; Xue, Mei; Xiong, Zu-Kun; Jin, Jing; Wang, Wei-Hu; Song, Yong-Wen; Liu, Yue-Ping; Ren, Hua; Fang, Hui; Yu, Zi-Hao; Liu, Xin-Fan; Li, Ye-Xiong

    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.

  8. Preclinical activity of anti-CCR7 immunotherapy in patients with high-risk chronic lymphocytic leukemia.

    PubMed

    Cuesta-Mateos, Carlos; Loscertales, Javier; Kreutzman, Anna; Colom-Fernández, Beatriz; Portero-Sáinz, Itxaso; Pérez-Villar, Juan José; Terrón, Fernando; Muñoz-Calleja, Cecilia

    2015-06-01

    Chronic lymphocytic leukemia (CLL) with deletions of the p53 locus on chromosome 17 and/or refractory to fludarabine chemoimmunotherapy remains a major clinical problem with few therapeutic options. Currently, these types of CLL are treated with approaches that do not target the p53 pathway, such as small molecules and monoclonal antibodies (mAb). We have previously postulated anti-CCR7 mAb therapy as a novel CLL treatment. In the present study, we evaluated the in vitro efficacy of anti-CCR7 mAb as a single agent in CLL patients with high-risk cytogenetics and/or refractory to fludarabine, by measuring CCR7 surface expression and complement-dependent cytotoxicity. Our results demonstrate that CCR7 is highly expressed in challenging and heavily treated CLL patients. In addition, the complement-mediated mechanism of action of this mAb effectively eradicates CLL cells while sparing subsets of T cells in these patients. Moreover, this mAb outperformed the activity of alemtuzumab, the mAb with the highest efficacy in these groups. Finally, in vitro activity was also demonstrated in patients with a disease refractory to both fludarabine and alemtuzumab, and patients harboring 11q22 deletion. Our results propose that anti-CCR7 mAb is an effective and promising future treatment in high-risk CLL.

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

    SciTech Connect

    Elshaikh, Mohamed A.; Vance, Sean; Suri, Jaipreet S.; Mahan, Meredith; Munkarah, Adnan

    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

  10. Monitoring the critically ill surgical patient.

    PubMed Central

    Holliday, R L; Doris, P J

    1979-01-01

    Critically ill surgical patients account for approximately half the patients in an active multidisciplinary critical care unit. Hypovolemia and sepsis are common in such patients and affect a number of organ systems. Monitoring these systems provides therapeutically relevant information that may decrease morbidity and improve patient survival. Circulatory hemodynamics may be assessed by direct measurement of the arterial blood pressure, central venous and pulmonary artery pressure monitoring and cardiac output determination; the data thus obtained are valuable in guiding fluid replacement in the hypovolemic individual. The respiratory status may be assessed by bedside spirometry and measurement of arterial blood gas tensions to gauge pulmonary function and the need for assisted ventilation. Renal dysfunction is common in such patients; careful analysis of both urine and blood may identify prerenal as opposed to renal and postrenal factors. Monitoring of the gastrointestinal tract, especially for hemorrhage, is important. Finally, careful attention to nutritional status and provision of adequate protein and energy intake by mouth or by vein is a vital component of the optimal care of these patients. PMID:115566

  11. Ibrutinib plus rituximab for patients with high-risk chronic lymphocytic leukaemia: a single-arm, phase 2 study

    PubMed Central

    Burger, Jan A.; Keating, Michael J.; Wierda, William G.; Hartmann, Elena; Hoellenriegel, Julia; Rosin, Nathalie Y.; de Weerdt, Iris; Jeyakumar, Ghayathri; Ferrajoli, Alessandra; Cardenas-Turanzas, Marylou; Lerner, Susan; Jorgensen, Jeffrey L; Nogueras-González, Graciela M.; Zacharian, Gracy; Huang, Xuelin; Kantarjian, Hagop; Garg, Naveen; Rosenwald, Andreas; O’Brien, Susan

    2014-01-01

    Summary Background Ibrutinib, an orally administered covalent inhibitor of Bruton tyrosine kinase (BTK), is an effective therapy for patients with relapsed chronic lymphocytic leukemia (CLL). We investigated the activity and safety of the combination of ibrutinib with the monoclonal antibody rituximab (iR) in patients with high-risk CLL. Methods In this single-arm, phase 2 studywe enrolled 40 patients with high-risk CLL at MD Anderson Cancer Center, Houston, Texas, USA. Patients with symptomatic CLL requiring therapy received 28 day cycles of once-daily ibrutinib 420 mg , together with rituximab (weekly during cycle 1, then once per cycle until cycle 6), followed by continuous single-agent ibrutinib. The primary endpoint was progression-free survival (PFS) in the intention-to-treat population. This study is registered with ClinicalTrials.gov, number NCT01520519 and is no longer accruing patients. Findings Between February 28, 2012 and September 11, 2012, we enrolled 40 CLL patients with high-risk disease features. 20 patients had del17p or TP53 mutations (16 previously treated, 4 untreated), 13 had relapsed CLL with del11q, and 7 patients a PFS < 36 months after frontline chemo-immunotherapy. Toxicity was mainly of mild to moderate severity (grade 1–2). 10 (25%) patients had diarrhea (grade 1 in 9 [22.5%] patients, grade 2 in 1 [2.5%]), bleeding events occurred in 14 (35%) patients (8 [20%] patients with grade 1, 5 [12.5%] patients grade 2, and 1 [2.5%] grade 3), nausea in 15 (37.5) patients (10 [25%] grade 1, 5 [12.5%] grade 2), and fatigue in 7 (17.5%) patients (4 [10%] grade 1, 3 [7.5%] grade 2). Grade 3 infections occurred in 4 patients (10%), no grade 4 or 5 infections occurred. At 18 months, the Kaplan Meier estimate of progression-free survival was 78% (95% CI 60.6–88.5) (del[17p] or TP53 mutation: 72%, 95% CI: 45.6–87.6) Interpretation Ibrutinib in combination with rituximab is a well-tolerated regimen for patients with high-risk CLL. It induces high

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

    SciTech Connect

    Hoskin, Peter; Rojas, Ana; Lowe, Gerry; Bryant, Linda; Ostler, Peter; Hughes, Rob; Milner, Jessica; Cladd, Helen

    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.

  13. [Pharmacoepidemiological study of the use of non-steroid antiinflamatory drugs in high-risk cardiovascular patients].

    PubMed

    Machado-Alba, Jorge Enrique; Alzate-Carvajal, Verónica; Echeverri-Cataño, Luis

    2013-01-01

    In order to determine the frequency of extended use of non-steroidal anti-inflammatory drugs (NSAID) in Colombian patients with high cardiovascular risk (HCVR), a retrospective study was developed which identified HCVR patients who used NSAID for over five continuous months from January 2011 and March 2013. Patients chronically receiving nitrates, digitalis and clopidogrel and acetylsalicylic acid (ASA), known as HCVR, were identified. An analysis of the frequencies of use based on the co-medication received was performed. Concomitant use of NSAID was found in 0,35% of consumers of nitrates (average time: 9,5 ± 4,4 months), in 0,36% of consumers of clopidogrel and ASA (average time: 9,3 ± 3,4 months), and in 0,4% of consumers of digitalis (10,2 ± 4,6 months). It is concluded that there is a low proportion of chronic use of NSAID in high-risk cardiovascular patients.

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

    PubMed

    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 <0.01). In conclusion, CCTA has incremental prognostic value and risk reclassification benefit beyond CACS in patients without CAD symptoms but with high risk of developing CVD.

  15. Acute Toxicity in High-Risk Prostate Cancer Patients Treated With Androgen Suppression and Hypofractionated Intensity-Modulated Radiotherapy

    SciTech Connect

    Pervez, Nadeem; Small, Cormac; MacKenzie, Marc; Yee, Don; Parliament, Matthew; Ghosh, Sunita; Mihai, Alina; Amanie, John; Murtha, Albert; Field, Colin; Murray, David; Fallone, Gino; Pearcey, Robert

    2010-01-15

    Purpose: To report acute toxicity resulting from radiotherapy (RT) dose escalation and hypofractionation using intensity-modulated RT (IMRT) treatment combined with androgen suppression in high-risk prostate cancer patients. Methods and Materials: Sixty patients with a histological diagnosis of high-risk prostatic adenocarcinoma (having either a clinical Stage of >=T3a or an initial prostate-specific antigen [PSA] level of >=20 ng/ml or a Gleason score of 8 to 10 or a combination of a PSA concentration of >15 ng/ml and a Gleason score of 7) were enrolled. RT prescription was 68 Gy in 25 fractions (2.72 Gy/fraction) over 5 weeks to the prostate and proximal seminal vesicles. The pelvic lymph nodes and distal seminal vesicles concurrently received 45 Gy in 25 fractions. The patients were treated with helical TomoTherapy-based IMRT and underwent daily megavoltage CT image-guided verification prior to each treatment. Acute toxicity scores were recorded weekly during RT and at 3 months post-RT, using Radiation Therapy Oncology Group acute toxicity scales. Results: All patients completed RT and follow up for 3 months. The maximum acute toxicity scores were as follows: 21 (35%) patients had Grade 2 gastrointestinal (GI) toxicity; 4 (6.67%) patients had Grade 3 genitourinary (GU) toxicity; and 30 (33.33%) patients had Grade 2 GU toxicity. These toxicity scores were reduced after RT; there were only 8 (13.6%) patients with Grade 1 GI toxicity, 11 (18.97%) with Grade 1 GU toxicity, and 5 (8.62%) with Grade 2 GU toxicity at 3 months follow up. Only the V60 to the rectum correlated with the GI toxicity. Conclusion: Dose escalation using a hypofractionated schedule to the prostate with concurrent pelvic lymph node RT and long-term androgen suppression therapy is well tolerated acutely. Longer follow up for outcome and late toxicity is required.

  16. Postoperative vascular complications in unrecognised Obstructive Sleep apnoea (POSA) study protocol: an observational cohort study in moderate-to-high risk patients undergoing non-cardiac surgery

    PubMed Central

    Chan, Matthew T V; Wang, Chew-Yin; Seet, Edwin; Tam, Stanley; Lai, Hou-Yee; Walker, Stuart; Short, Timothy G; Halliwell, Richard; Chung, Frances

    2014-01-01

    Introduction Emerging epidemiological data suggest that obstructive sleep apnoea (OSA) is common in the general surgical population. Unfortunately, the majority of these patients are unrecognised and untreated at the time of surgery. There is substantial biological rationale to indicate that patients with unrecognised OSA are at a higher risk of postoperative vascular events. However, the extent of this morbidity is currently unknown. We have initated the postoperative vascular complications in the unrecognised obstructive sleep apnoea (POSA) study to determine the associations between OSA, nocturnal hypoxia and major postoperative vascular events in 1200 moderate-to-high risk patients undergoing major non-cardiac surgery. Methods and analysis The POSA study is an international prospective observational cohort study. Using a type 3 portable sleep monitoring device and ambulatory oximetry, we will quantify the severity of OSA. The primary outcome is a composite of vascular death, myocardial infarction; non-fatal cardiac arrest; stroke; pulmonary embolism; congestive heart failure and new arrhythmia within 30 days of surgery. As of November 2013, we have recruited over 700 patients from nine centres in six countries. The mean age is 68 years, the mean body mass index is 27 kg/m2 and 55% of patients are men. 27.9% of patients have known coronary artery disease, over 76% have diabetes. The majority of patients underwent orthopaedic surgery (28%) and colorectal resection (18.5%). Ethics and dissemination The POSA study has received ethics approval from all study sites before patient recruitment. Informed consent will be obtained from all patients. The POSA study will determine the risk of unrecognised OSA in major non-cardiac surgery. We will publish these findings in peer-reviewed journals. Trial Registration: ClinicalTrials.gov Identifier: NCT01494181 PMID:24413351

  17. A prospective two-armed trial assessing the efficacy and performance of a silver dressing used postoperatively on high-risk, clean surgical wounds.

    PubMed

    Schwartz, Jamie; Goss, Selena; Facchin, Federico; Manizate, Fotini; Gendics, Cynthia; Braitman, Elissa; Lantis, John

    2014-04-01

    Surgical site infections (SSI) are a known complication of surgery. Silver-containing wound treatments are popular, despite the lack of evidence of SSI reduction. A two-armed study was conducted between July 2007 and November 2008 to evaluate the efficacy and ease of use of a postoperative silver dressing. In the first arm of the study, patients undergoing clean general, vascular, orthopedic, and neurosurgical procedures were allocated to receive a postoperative silver dressing (POSD) or a standard dressing of nonstick gauze under a fluid occlusive dressing. Outcome variables included the incidence of antibiotic initiation for SSI, clinical signs of infection, and leukocyte counts. The second arm of the study was a prospective case series designed to evaluate the performance and handling characteristics of the POSD. Onehundred- ninety-nine (199) patients (mean age 59.2 [range 21-94] years) were enrolled in the first arm of the study. Three out of 99 (3%) patients in the POSD and six out of 100 (6%) control group patients received antibiotic therapy for SSI (P = 0.498). Differences in the percentage of patients with clinical signs of infection following surgery also were not statistically significant (POSD: n = 24, 24.2%; control: n = 30, 30%; P = 0.426). In the second arm, 34 out of 36 patients rated the study dressing easy to apply in (94%), and no pain on removal was noted in 38 out of 57 (66.7%) assessments. No patients in the dressing performance cohort developed an SSI. Prospective, randomized, controlled clinical studies with large sample sizes are warranted to evaluate the efficacy and cost-effectiveness of the POSD.

  18. A practical guide to defining high-risk myeloma for clinical trials, patient counseling and choice of therapy.

    PubMed

    Stewart, A K; Bergsagel, P L; Greipp, P R; Dispenzieri, A; Gertz, M A; Hayman, S R; Kumar, S; Lacy, M Q; Lust, J A; Russell, S J; Witzig, T E; Zeldenrust, S R; Dingli, D; Reeder, C B; Roy, V; Kyle, R A; Rajkumar, S V; Fonseca, R

    2007-03-01

    Clinical outcomes for multiple myeloma (MM) are highly heterogeneous and it is now clear that pivotal genetic events are the primary harbingers of such variation. These findings have broad implications for counseling, choice of therapy and the design and interpretation of clinical investigation. Indeed, as in acute leukemias and non-hodgkins lymphoma, we believe it is no longer acceptable to consider MM a single disease entity. As such, the accurate diagnosis of MM subtypes and the adoption of common criteria for the identification and stratification of MM patients has become critical. Herein, we provide a consensus high-risk definition and offer practical guidelines for the adoption of routine diagnostic testing. Although acknowledging that more refined classifications will continue to be developed, we propose that the definition of high-risk disease (any of the t(4;14), t(14;16), t(14;20), deletion 17q13, aneuploidy or deletion chromosome 13 by metaphase cytogenetics, or plasma cell labeling index >3.0) be adopted. This classification will identify most of the 25% of MM patients for whom current therapies are inadequate and for whom investigational regimens should be vigorously pursued. Conversely, the 75% of patients remaining have more favorable outcomes using existing - albeit non-curative - therapeutic options.

  19. Pathologic High-risk Lesions, Diagnosis and Management.

    PubMed

    Murray, Melissa

    2016-12-01

    Percutaneous imaging-guided core needle biopsy (CNB) is a less invasive and less expensive alternative to surgical biopsy for the evaluation of breast lesions. After a CNB the radiologist determine if there is concordance between the pathology, imaging, and clinical findings. Patient management after CNB diagnosis of high-risk breast lesion varies. Surgical excision is warranted for lesions yielding a CNB diagnosis of ADH; however controversy exists regarding the need for surgical excision after CNB diagnosis of radial scar, papillary lesion, atypical lobular hyperplasia (ALH), or lobular carcinoma in situ (LCIS). Repeat CNB or surgical excision is warranted if histologic findings and imaging findings are discordant.

  20. Does a gentamicin-impregnated collagen sponge reduce sternal wound infections in high-risk cardiac surgery patients?

    PubMed Central

    Birgand, Gabriel; Radu, Costin; Alkhoder, Soleiman; Al Attar, Nawwar; Raffoul, Richard; Dilly, Marie-Pierre; Nataf, Patrick; Lucet, Jean-Christophe

    2013-01-01

    OBJECTIVES Sternal wound infections occurring after cardiac surgery have a critical impact on morbidity, mortality and hospital costs. This study evaluated the efficacy of a gentamicin–collagen sponge in decreasing deep sternal-wound infections in high-risk cardiac surgery patients. METHODS We conducted a quasi-experimental single-centre prospective cohort study in diabetic and/or overweight patients undergoing coronary-artery bypass surgery with bilateral internal mammary artery grafts. The end-point was the rate of reoperation for deep sternal wound infection. The period from January 2006 to October 2008, before the introduction of the gentamicin sponge, was compared with the period from November 2008 to December 2010. RESULTS Of 552 patients (median body mass index, 31.5; 37.7% with diabetes requiring insulin), 68 (12.3%) had deep sternal wound infections. Reoperation for deep sternal wound infections occurred in 40/289 (13.8%) preintervention patients and 22/175 (12.6%) patients managed with the sponge. Independent risk factors were female sex and longer time on mechanical ventilation, but not use of the sponge (adjusted odds ratio, 0.95; 95% confidence interval, 0.52–1.73; P = 0.88). The group managed with the sponge had a higher proportion of gentamicin-resistant micro-organisms (21/27, 77.8%) compared with the other patients (23/56, 41.1%; P < 0.01). The median time to reoperation for wound infection was higher with the sponge (21 vs 17 days, P < 0.01). CONCLUSIONS A gentamicin–collagen sponge was not effective in preventing deep sternal wound infections in high-risk patients. Our results suggest that a substantial proportion of wound contaminations occur after bypass surgery with bilateral internal mammary artery grafts. PMID:23115102

  1. Are ACE-inhibitors or ARB's still needed for cardiovascular prevention in high risk patients? Insights from profess and transcend.

    PubMed

    Van Mieghem, W; Billiouw, J M; Brohet, C; Dupont, A G; Gazagnes, M D; Heller, F; Krzesinski, J M; Missault, L; Persu, A; Piérard, L; Rottiers, R; Vanhooren, G; Vervaet, P; Herman, A G

    2010-01-01

    The HOPE and EUROPA clinical studies have shown that treatment with the angiotensin-converting enzyme (ACE) inhibitors, ramipril and perindopril, may reduce the occurrence of major cardiovascular events in patients with proven atherosclerotic disease. The recently published results of the PRoFESS and TRANSCEND trials completed the much needed information concerning the use of an angiotensin receptor blocker for patients at high risk of cardiovascular events. PROFESS compared a therapy of telmisartan 80 mg daily with placebo in patients with a recent ischemic stroke. The difference in the primary outcome of first recurrent stroke was not statistically significant between telmisartan and placebo. The secondary outcome of major cardiovascular events showed a relative risk reduction (RRR) of 7% in favour of telmisartan. This tended to be significant (p = 0.06) despite a rather short follow-up period of only 28 months. In TRANSCEND 5926 patients at high risk for cardiovascular events were randomized to a treatment with telmisartan 80 mg daily or placebo for a mean duration of follow-up of 56 months. The primary composite outcome of cardiovascular death, myocardial infarction, stroke or hospitalization for heart failure showed a non-significant 8% RRR in favour of the telmisartan treated patients. The main secondary outcome of cardiovascular death and myocardial infarction or stroke as used in the HOPE trial showed a non-significant RRR of 13% in favour of telmisartan treated patients (p = 0.068 adjusted for multiplicity of comparisons). In comparing the Kaplan-Meier curves for the endpoint of major cardiovascular events used in HOPE, EUROPA, TRANSCEND and PRoFESS, the trends are similar. Results of most of the recently published trials have been neutral.This could partly be explained by major improvements in the optimal background therapy of the patients included. Nevertheless, the results of PRoFESS and TRANSCEND do not contradict the results from previous studies with

  2. hERG1 positivity and Glut-1 negativity identifies high-risk TNM stage I and II colorectal cancer patients, regardless of adjuvant chemotherapy

    PubMed Central

    Muratori, Leonardo; Petroni, Giulia; Antonuzzo, Lorenzo; Boni, Luca; Iorio, Jessica; Lastraioli, Elena; Bartoli, Gianluca; Messerini, Luca; Di Costanzo, Francesco; Arcangeli, Annarosa

    2016-01-01

    Background The identification of early-stage colorectal cancer (CRC) with high risk of progression is one major clinical challenge, mainly due to lack of validated biomarkers. The aims of the present study were to analyze the prognostic impact of three molecular markers belonging to the ion channels and transporters family: the ether-à-go-go-related gene 1 (hERG1) and the calcium-activated KCa3.1 potassium channels, as well as the glucose transporter 1 (Glut-1); and to define the impact of adjuvant chemotherapy in conjunction with the abovementioned biomarkers, in a cohort of radically resected stage I–III CRC patients. Patients and methods The expressions of hERG1, KCa3.1, and Glut-1 were tested by immunohistochemistry on 162 surgical samples of nonmetastatic, stage I–III CRC patients. The median follow-up was 32 months. The association between biological markers, clinicopathological features, and survival outcomes was investigated by evaluating both disease-free survival and overall survival. Results Although no prognostic valence emerged for KCa3.1, evidence of a negative impact of hERG1 expression on survival outcomes was provided. On the contrary, Glut-1 expression had a positive impact. According to the results of the multivariate analysis, patients were stratified in four risk groups, based on TNM stage and hERG1/Glut-1 expression. After adjusting for adjuvant therapy, stage I and II, Glut-1-negative, and hERG1-positive patients showed the worst survival experience. Conclusion This study strongly indicates that the combination of hERG1 positivity and Glut-1 negativity behaves as a prognostic biomarker in radically resected CRC patients. This combination identifies a group of stage I and II CRC patients with a bad prognosis, even worse than that of stage III patients, regardless of adjuvant therapy accomplishment. PMID:27789963

  3. [Surgical approach to posthepatitic cirrhotic patient today].

    PubMed

    Meriggi, F; Forni, E

    1996-01-01

    A posthepatitic cirrhotic patient may undergo elective or urgent abdominal operation for an extra-hepatic or hepatic disease. According to the high postoperative morbidity (61%), surgery is indicated only for symptomatic or complicated cholelithiasis. A surgical procedure for refractory ascites has been devised to create a permanent peritoneo-venous shunt by a one way pressure-sensitive valve (Leveen). The procedure is simple and brings a long lasting relief with recovery in strength and nutrition and improved kidney function. Sclerotherapy is widely used to treat acute variceal bleeding while repeated sclerotherapy is used in the long-term management to eradicate varices. When indicated, liver transplantation is the best treatment to prevent variceal bleeding recurrence. Also portosystemic shunts effectively prevent recurrent variceal bleeding. They are, however, major operations with an important morbidity and mortality, particularly in poor risk patients. The most advocated shunts today are the Warren distal splenorenal shunt and the Sarfeh portacaval shunt using a small diameter prosthetic H-graft. The transjugular intrahepatic portosystemic stent-shunt (TIPSS) is a new treatment for portal hypertension and its complications. From a haemodynamic point of view it allows balanced hepatic perfusion. Postoperative mortality is rare; further bleeding and encephalopathy are reasonably acceptable. The most relevant complications concern dislocation of the prosthesis, stenosis and thrombosis of the shunt, which can be corrected by non-invasive dilatation. Encephalopathy is the main complication of surgical portosystemic shunts. It is usually controlled by protein diet restriction, and administration of lactulose or oral antibiotics. In severe forms the patients may be treated by an oesophageal transection with oesophagogastric devascularization, and by a postoperative suppression of the portosystemic shunt using external maneuvers. Posthepatitic liver cirrhosis is

  4. The Benefits of Perioperative Screening for Sleep Apnea in Surgical Patients.

    PubMed

    Subramani, Yamini; Wong, Jean; Nagappa, Mahesh; Chung, Frances

    2017-03-01

    Obstructive sleep apnea (OSA) is a chronic disease affecting millions of people worldwide. Untreated OSA can lead to about a 2-fold increase in medical expenses, mainly because of cardiovascular morbidity. OSA is highly prevalent in the surgical population, with an increased risk of perioperative complications. This article describes the perioperative and long-term social and economic benefits of preoperative screening for OSA. Screening patients to identify high-risk OSA is important to decrease the adverse outcomes and associated health care costs in the perioperative period. Screening for OSA is particularly relevant because most patients are undiagnosed at the time of surgery.

  5. The challenge of individualised risk assessment and therapy planning in elderly high-risk myelodysplastic syndromes (MDS) patients.

    PubMed

    Stauder, Reinhard

    2012-09-01

    Myelodysplastic syndromes (MDS) represent one of the most frequent and serious haematologic diseases of the elderly. Effective therapies exist ranging from best supportive care to haematologic stem cell transplantation (HSCT). Decision making, however, is rather complex in this group of patients because ageing is a multidimensional process involving not only physiological changes but also changes in functional, social, emotional and cognitive capacities. All these factors can have a significant impact on the efficacy and tolerability of a potential therapy and therefore have to be thoroughly assessed before deciding on individual treatment regimens. Risk assessment tools are available both to classify the stage and prognosis of MDS and to meet the needs of elderly patients. A tool explicitly focussing on elderly MDS patients, however, is still missing. The current report approached this issue by combining the well established MDS-risk score 'International Prognostic Scoring System' (IPSS) with the 'Multidimensional Geriatric Assessment' (MGA). As decision making is most complex in high-risk MDS patients, the new algorithm is presented exemplarily for this group of patients. In a first step, MDS-related risk is identified using IPSS, in a second step, patients are assigned to one of three risk categories of the MGA (go-go/fit, slow-go/vulnerable, no-go/frail). While go-go patients might be subjected to therapies comparable to those given to younger patients, in no-go patients, a palliative therapy combined with best supportive care will probably be most appropriate. In slow-go patients, age-related life expectancy taken from public age statistics should be compared to the MDS-related life expectancy. Based on this combined assessment procedure and also on treatment tolerance in terms of the expectations/wishes of the patient and his/her family, an individualised therapeutic approach should be developed. Specific treatment recommendations for these three groups of

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

    SciTech Connect

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

    2011-03-01

    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.

  7. Experience With the Wearable Cardioverter-Defibrillator in Patients at High Risk for Sudden Cardiac Death

    PubMed Central

    Günther, Michael; Quick, Silvio; Pfluecke, Christian; Rottstädt, Fabian; Szymkiewicz, Steven J.; Ringquist, Steven; Strasser, Ruth H.; Speiser, Uwe

    2016-01-01

    Background: This study evaluated the wearable cardioverter-defibrillator (WCD) for use and effectiveness in preventing sudden death caused by ventricular tachyarrhythmia or fibrillation. Methods: From April 2010 through October 2013, 6043 German WCD patients (median age, 57 years; male, 78.5%) were recruited from 404 German centers. Deidentified German patient data were used for a retrospective, nonrandomized analysis. Results: Ninety-four patients (1.6%) were treated by the WCD in response to ventricular tachyarrhythmia/fibrillation. The incidence rate was 8.4 (95% confidence interval, 6.8–10.2) per 100 patient-years. Patients with implantable cardioverter-defibrillator explantation had an incidence rate of 19.3 (95% confidence interval, 12.2–29.0) per 100 patient-years. In contrast, an incidence rate of 8.2 (95% confidence interval, 6.4–10.3) was observed in the remaining cardiac diagnosis groups, including dilated cardiomyopathy, myocarditis, and ischemic and nonischemic cardiomyopathies. Among 120 shocked patients, 112 (93%) survived 24 hours after treatment, whereas asystole was observed in 2 patients (0.03%) with 1 resulting death. ConclusionS: This large cohort represents the first nationwide evaluation of WCD use in patients outside the US healthcare system and confirms the overall value of the WCD in German treatment pathways. PMID:27458236

  8. Patients who return to care after tracking remain at high risk of attrition: experience from a large HIV clinic, Uganda.

    PubMed

    Nakiwogga-Muwanga, A; Musaazi, J; Katabira, E; Worodria, W; Talisuna, S Alamo; Colebunders, R

    2015-01-01

    We determined the retention rate of patients infected with HIV who resumed care after being tracked at the Infectious Diseases Clinic (IDC) in Kampala, Uganda. Between April 2011 and September 2013, patients who missed their clinic appointment for 8-90 days were tracked, and those who returned to the clinic within 120 days were followed up. The proportion of patients retained among tracked patients, and those who resumed care before tracking started was compared. At 18 months of follow up, 33 (39%) of the tracked patients and 72 (61%) of those who had resumed care before tracking started were retained in care. The most important cause of attrition among the traceable was self-transfer to another clinic (38 [73%] patients), whereas among those who resumed care before tracking was loss to follow up (LTFU) (32 [71%] patients). Tracked patients who resume care following a missed appointment are at high risk of attrition. To increase retention, antiretroviral therapy clinics need to adopt a chronic care model which takes into consideration patients' changing needs and their preference for self-management.

  9. Nutrition support in surgical patients with colorectal cancer

    PubMed Central

    Chen, Yang; Liu, Bao-Lin; Shang, Bin; Chen, Ai-Shan; Liu, Shi-Qing; Sun, Wei; Yin, Hong-Zhuan; Yin, Jian-Qiao; Su, Qi

    2011-01-01

    AIM: To review the application of nutrition support in patients after surgery for colorectal cancer, and to propose appropriate nutrition strategies. METHODS: A total of 202 consecutive surgical patients admitted to our hospital with a diagnosis of colon cancer or rectal cancer from January 2010 to July 2010, meeting the requirements of Nutrition Risk Screening 2002, were enrolled in our study. Laboratory tests were performed to analyze the nutrition status of each patient, and the clinical outcome variables, including postoperative complications, hospital stay, cost of hospitalization and postoperative outcome, were analyzed. RESULTS: The “non-risk” patients who did not receive postoperative nutrition support had a higher rate of postoperative complications than patients who received postoperative nutrition support (2.40 ± 1.51 vs 1.23 ± 0.60, P = 0.000), and had a longer postoperative hospital stay (23.00 ± 15.84 d vs 15.27 ± 5.89 d, P = 0.009). There was higher cost of hospitalization for patients who received preoperative total parenteral nutrition (TPN) than for patients who did not receive preoperative TPN (62 713.50 ± 5070.66 RMB Yuan vs 43178.00 ± 3596.68 RMB Yuan, P = 0.014). Applying postoperative enteral nutrition significantly shortened postoperative fasting time (5.16 ± 1.21 d vs 6.40 ± 1.84 d, P = 0.001) and postoperative hospital stay (11.92 ± 4.34 d vs 15.77 ± 6.03 d, P = 0.002). The patients who received postoperative TPN for no less than 7 d had increased serum glucose levels (7.59 ± 3.57 mmol/L vs 6.48 ± 1.32 mmol/L, P = 0.006) and cost of hospitalization (47 724.14 ± 16 945.17 Yuan vs 38 598.73 ± 8349.79 Yuan, P = 0.000). The patients who received postoperative omega-3 fatty acids had a higher rate of postoperative complications than the patients who did not (1.33 ± 0.64 vs 1.13 ± 0.49, P = 0.041). High level of serum glucose was associated with a high risk of postoperative complications of infection. CONCLUSION: Appropriate

  10. Transcatheter aortic valve implantation with Core Valve: First Indian experience of three high surgical risk patients with severe aortic stenosis

    PubMed Central

    Seth, Ashok; Rastogi, Vishal; Kumar, Vijay; Maqbool, Syed; Mustaqueem, Arif; Sekar, V. Ravi

    2013-01-01

    The prevalence of aortic stenosis is increasing with aging population. However with multiple co-morbidities and prior procedures in this aging population, more and more patients are being declared unfit for the ‘Gold Standard’ treatment i.e. surgical aortic valve replacement (AVR). Among the patients who are unfit or high risk for aortic valve replacement (AVR) by open heart surgery, transcatheter aortic valve implantation (TAVI) has been proven to be a valuable alternative improving survival and quality of life. We report first Indian experience of Core Valve (Medtronic Inc.) implantation in three high surgical risk patients performed on 22nd and 23rd February 2012. PMID:23993000

  11. Aprepitant in a multimodal approach for prevention of postoperative nausea and vomiting in high-risk patients: is there such a thing as "too many modalities"?

    PubMed

    Hache, John J; Vallejo, Manuel C; Waters, Jonathan H; Williams, Brian A

    2009-04-28

    Postoperative and postdischarge nausea and vomiting (PONV and PDNV, respectively) add morbidity to perioperative outcomes. Combining some antiemetic agents of different mechanisms is more effective than using single agents, although this concept has not yet been tested extensively with aprepitant. Consecutive high-risk patients for PONV (n = 100) were given preoperative aprepitant 40 mg before surgery and were followed perioperatively. Female patients receiving general anesthesia (n = 81) were selected for data analysis. The primary endpoints were PONV/PDNV in the 48 h after surgery. For patients included in the data analysis, using Apfel PONV risk factors, the median risk count was four out of four. PONV and PDNV incidences were 21% (95% CI: 14-31%) and 37% (95% CI: 27-48%), respectively. Two patients experienced PACU (postanesthesia care unit) vomiting and two patients experienced emesis postdischarge. When using regression modeling and comparing patients who received one or two vs. three or four mechanistically unique antiemetics (added to preoperative aprepitant), while adjusting for surgical case duration, the three or four additional antiemetic group showed more PONV/PDNV (Odds Ratio 3.73, 95% CI 1.3-10.9, p = 0.016) than did the one or two additional drug group. There were no other predictors of PONV/PDNV (transabdominal surgery, four vs. three Apfel risk factors) in these patients. The low incidence of vomiting (2-5%) suggests the potential importance of aprepitant in a multimodal antiemetic regimen. However, there may be the potential that too many unique antiemetic mechanisms combined with preoperative aprepitant may actually increase the incidence of perioperative nausea.

  12. NOTCH1 mutations identify a genetic subgroup of chronic lymphocytic leukemia patients with high risk of transformation and poor outcome.

    PubMed

    Villamor, N; Conde, L; Martínez-Trillos, A; Cazorla, M; Navarro, A; Beà, S; López, C; Colomer, D; Pinyol, M; Aymerich, M; Rozman, M; Abrisqueta, P; Baumann, T; Delgado, J; Giné, E; González-Díaz, M; Hernández, J M; Colado, E; Payer, A R; Rayon, C; Navarro, B; José Terol, M; Bosch, F; Quesada, V; Puente, X S; López-Otín, C; Jares, P; Pereira, A; Campo, E; López-Guillermo, A

    2013-04-01

    NOTCH1 has been found recurrently mutated in a subset of patients with chronic lymphocytic leukemia (CLL). To analyze biological features and clinical impact of NOTCH1 mutations in CLL, we sequenced this gene in 565 patients. NOTCH1 mutations, found in 63 patients (11%), were associated with unmutated IGHV, high expression of CD38 and ZAP-70, trisomy 12, advanced stage and elevated lactate dehydrogenase. Sequential analysis in 200 patients demonstrated acquisition of mutation in one case (0.5%) and disappearance after treatment in two. Binet A and B patients with NOTCH1-mutated had a shorter time to treatment. NOTCH1-mutated patients were more frequently refractory to therapy and showed shorter progression-free and overall survival after complete remission. Overall survival was shorter in NOTCH1-mutated patients, although not independently from IGHV. NOTCH1 mutation increased the risk of transformation to diffuse large B-cell lymphoma independently from IGHV, with this being validated in resampling tests of replicability. In summary, NOTCH1 mutational status, that was rarely acquired during the course of the disease, identify a genetic subgroup with high risk of transformation and poor outcome. This recently identified genetic subgroup of CLL patients deserves prospective studies to define their best management.

  13. Screening Magnetic Resonance Imaging Recommendations and Outcomes in Patients at High Risk for Breast Cancer

    PubMed Central

    Ehsani, Sima; Strigel, Roberta M; Pettke, Erica; Wilke, Lee; Tevaarwerk, Amye J; DeMartini, Wendy; Wisinski, Kari B

    2014-01-01

    Objective The purpose of this study was to determine MRI screening recommendations and the subsequent outcomes in women with increased risk for breast cancer evaluated by oncology subspecialists at an academic center. Patients and Methods Patients evaluated between 1/1/2007– 3/1/2011 under diagnosis codes for family history of breast or ovarian cancer, genetic syndromes, lobular carcinoma in situ or atypical hyperplasia were included. Patients with a history of breast cancer were excluded. Retrospective review of prospectively acquired demographics, lifetime risk of breast cancer and screening recommendations were obtained from the medical record. Retrospective review of the results of prospectively interpreted breast imaging examinations and image-guided biopsies were analyzed. Results 282 women were included. The majority of patients were premenopausal with a median age of 43. Most (69%) were referred due to a family history of breast or ovarian cancers. MRI was recommended for 84% of patients based on a documented lifetime risk > 20%. Most women referred for MRI screening (88%) were compliant with this recommendation. A total of 299 breast MRI examinations were performed in 146 patients. Biopsy was performed for 32 (11%) exams and 10 cancers were detected for a PPV of 31% (based on biopsy performed) and an overall per exam cancer yield of 3.3%. Three cancers were detected in patients who did not undergo screening MRI. The 13 cancers were Stage 0-II; all patients were without evidence of disease with a median follow-up of 22 months. Conclusion In a cohort of women seen by breast subspecialty providers, screening breast MRI was recommended according to guidelines, and used primarily premenopausal women with a family history or genetic predisposition to breast cancer. Adherence to MRI screening recommendations was high and cancer yield from breast MRI was similar to that in clinical trials. PMID:25789917

  14. High Risk of Depressive Disorders in Patients With Gout: A Nationwide Population-Based Cohort Study.

    PubMed

    Changchien, Te-Chang; Yen, Yung-Chieh; Lin, Cheng-Li; Lin, Ming-Chia; Liang, Ji-An; Kao, Chia-Hung

    2015-12-01

    Metabolic abnormalities are common in patients with depressive disorders. However, the relationship between gout and depression is unclear. We explored the causal relationship among gout, antigout medication, and the associated risk of incidental depressive disorders.In this nationwide cohort study, we sampled data from the National Health Insurance Research Database to recruit 34,050 patients with gout as the gout cohort and 68,100 controls (without gout) as the nongout cohort. Our primary endpoint was the diagnosis of depressive disorders during follow-up. The overall study population was followed up until depression diagnosis, withdrawal from the NHI program, or the end of the study. The differences in demographic and clinical characteristics between both cohorts were determined using the Chi-square test for categorical variables and the t-test for continuous variables. Cox proportional hazard regression models were used to examine the effect of gout on the risk of depression, represented using the hazard ratio with the 95% confidence interval.Patients with gout exhibited a higher risk of depressive disorders than controls did. The risk of depressive disorders increased with age and was higher in female patients and those with hypertension, stroke, and coronary artery disease. Nonsteroidal antiinflammatory drug and prednisolone use was associated with a reduced risk of depression. Patients with gout who had received antigout medication exhibited a reduced risk of depressive disorders compared with nongout patients.Our findings support that gout increases the risk of depressive disorders, and that antigout medication use reduces the risk.

  15. Telehealth for patients at high risk of cardiovascular disease: pragmatic randomised controlled trial

    PubMed Central

    O’Cathain, Alicia; Thomas, Clare; Edwards, Louisa; Gaunt, Daisy; Dixon, Padraig; Hollinghurst, Sandra; Nicholl, Jon; Large, Shirley; Yardley, Lucy; Fahey, Tom; Foster, Alexis; Garner, Katy; Horspool, Kimberley; Man, Mei-See; Rogers, Anne; Pope, Catherine; Montgomery, Alan A

    2016-01-01

    Objective To assess whether non-clinical staff can effectively manage people at high risk of cardiovascular disease using digital health technologies. Design Pragmatic, multicentre, randomised controlled trial. Setting 42 general practices in three areas of England. Participants Between 3 December 2012 and 23 July 2013 we recruited 641 adults aged 40 to 74 years with a 10 year cardiovascular disease risk of 20% or more, no previous cardiovascular event, at least one modifiable risk factor (systolic blood pressure ≥140 mm Hg, body mass index ≥30, current smoker), and access to a telephone, the internet, and email. Participants were individually allocated to intervention (n=325) or control (n=316) groups using automated randomisation stratified by site, minimised by practice and baseline risk score. Interventions Intervention was the Healthlines service (alongside usual care), comprising regular telephone calls from trained lay health advisors following scripts generated by interactive software. Advisors facilitated self management by supporting participants to use online resources to reduce risk factors, and sought to optimise drug use, improve treatment adherence, and encourage healthier lifestyles. The control group comprised usual care alone. Main outcome measures The primary outcome was the proportion of participants responding to treatment, defined as maintaining or reducing their cardiovascular risk after 12 months. Outcomes were collected six and 12 months after randomisation and analysed masked. Participants were not masked. Results 50% (148/295) of participants in the intervention group responded to treatment compared with 43% (124/291) in the control group (adjusted odds ratio 1.3, 95% confidence interval 1.0 to 1.9; number needed to treat=13); a difference possibly due to chance (P=0.08). The intervention was associated with reductions in blood pressure (difference in mean systolic −2.7 mm Hg (95% confidence interval −4.7 to −0.6 mm Hg

  16. A Multidisciplinary Clinical Pathway Decreases Rib Fracture-Associated Infectious Morbidity and Mortality in High-Risk Trauma Patients

    DTIC Science & Technology

    2006-01-01

    monitored bed (Surgical Intermediate Care Unit or Shock Trauma Intensive Care Unit) where they received patient-controlled analgesia and incentive ...cough. Pain was assessed during incentive spirometry or coughing using a visual analogue scale (score from 1 to 10) with failure being a score...greater thann 6. Inspiratory volume was determined using the in- centive spirometer . A volume less than 15 mL/kg was con- sidered failure [14]. For the

  17. Phase II Trial of Radiosurgery to Magnetic Resonance Spectroscopy-Defined High-Risk Tumor Volumes in Patients With Glioblastoma Multiforme

    SciTech Connect

    Einstein, Douglas B.; Wessels, Barry; Bangert, Barbara; Fu, Pingfu; Nelson, A. Dennis; Cohen, Mark; Sagar, Stephen; Lewin, Jonathan; Sloan, Andrew; Zheng Yiran; Williams, Jordonna; Colussi, Valdir; Vinkler, Robert; Maciunas, Robert

    2012-11-01

    Purpose: To determine the efficacy of a Gamma Knife stereotactic radiosurgery (SRS) boost to areas of high risk determined by magnetic resonance spectroscopy (MRS) functional imaging in addition to standard radiotherapy for patients with glioblastoma (GBM). Methods and Materials: Thirty-five patients in this prospective Phase II trial underwent surgical resection or biopsy for a GBM followed by SRS directed toward areas of MRS-determined high biological activity within 2 cm of the postoperative enhancing surgical bed. The MRS regions were determined by identifying those voxels within the postoperative T2 magnetic resonance imaging volume that contained an elevated choline/N-acetylaspartate ratio in excess of 2:1. These voxels were marked, digitally fused with the SRS planning magnetic resonance image, targeted with an 8-mm isocenter per voxel, and treated using Radiation Therapy Oncology Group SRS dose guidelines. All patients then received conformal radiotherapy to a total dose of 60 Gy in 2-Gy daily fractions. The primary endpoint was overall survival. Results: The median survival for the entire cohort was 15.8 months. With 75% of recursive partitioning analysis (RPA) Class 3 patients still alive 18 months after treatment, the median survival for RPA Class 3 has not yet been reached. The median survivals for RPA Class 4, 5, and 6 patients were 18.7, 12.5, and 3.9 months, respectively, compared with Radiation Therapy Oncology Group radiotherapy-alone historical control survivals of 11.1, 8.9, and 4.6 months. For the 16 of 35 patients who received concurrent temozolomide in addition to protocol radiotherapeutic treatment, the median survival was 20.8 months, compared with European Organization for Research and Treatment of Cancer historical controls of 14.6 months using radiotherapy and temozolomide. Grade 3/4 toxicities possibly attributable to treatment were 11%. Conclusions: This represents the first prospective trial using selective MRS-targeted functional SRS

  18. Hyperfractionated Low-Dose (21 Gy) Radiotherapy for Cranial Skeletal Metastases in Patients With High-Risk Neuroblastoma

    SciTech Connect

    Kushner, Brian H.; Cheung, Nai-Kong V.; Barker, Christopher A.; Kramer, Kim; Modak, Shakeel; Yataghene, Karima; Wolden, Suzanne L.

    2009-11-15

    Purpose: To present a large experience (73 patients) using a standard radiotherapy (RT) protocol to prevent relapse in cranial sites where measurable metastatic neuroblastoma (NB), an adverse prognostic marker, is common. Methods and Materials: High-risk NB patients with measurable cranial disease at diagnosis or residual cranial disease after induction therapy had those sites irradiated with hyperfractionated 21 Gy; a brain-sparing technique was used for an extensive field. The patients were grouped according to the response to systemic therapy. Thus, when irradiated, Group 1 patients were in complete remission and Group 2 patients had primary refractory disease. Follow-up was from the start of cranial RT. Results: At 3 years, the 39 Group 1 patients had a progression-free survival rate of 51%; control of cranial disease was 79%. Two relapses involved irradiated cranial sites. Two other patients relapsed in the irradiated cranial sites 6 and 12 months after a systemic relapse. At 3 years, the 34 Group 2 patients had a progression-free survival rate of 33%; control of cranial disease was 52%. Group 2 included 19 patients who had residual cranial (with or without extracranial) disease. The cranial sites showed major (n = 13), minor (n = 2), or no response (n = 4) to RT. Five patients had progression in the cranial RT field at 10-27 months. Group 2 also included 15 patients who had persistent NB in extracranial, but not cranial, sites. Of these 15 patients, 2 relapsed in the irradiated cranial sites and elsewhere at 8 and 14 months. Cranial RT was well tolerated, with no Grade 2 or greater toxicity. Conclusion: Hyperfractionated 21-Gy cranial RT might help control NB and is feasible without significant toxicity in children.

  19. Outcomes of patients undergoing radical hysterectomy for cervical cancer of high-risk histologic subtypes

    PubMed Central

    Agarwal, Sonika; Schmeler, Kathleen M.; Ramirez, Pedro T.; Sun, Charlotte C.; Nick, Alpa; dos Reis, Ricardo; Brown, Jubilee; Frumovitz, Michael

    2014-01-01

    Structured Abstract Introduction The most common types of cervical cancer are squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinoma, referred to here collectively as SA cervical cancer. Other types of cervical cancer, referred to here collectively as nonsquamous/nonadenocarcinoma (NSNA) cervical cancer, include neuroendocrine, small cell, clear cell, sarcomatoid, and serous tumors. Anecdotally, NSNA tumors seem to have a worse prognosis than their SA counterparts. We sought to determine whether patients with early-stage NSNA have a worse prognosis than those with early-stage SA cervical cancer. Methods We retrospectively reviewed charts of women with stage IA1-IB2 NSNA cervical cancer treated by radical hysterectomy and lymph node staging at MD Anderson Cancer Center from 1990 to 2006. NSNA patients were matched 1:2 to patients with grade 3 SA lesions on the basis of stage, age at diagnosis, tumor size, and date of diagnosis. Results Eighteen patients with NSNA primary cervical cancer subtypes [neuroendocrine (n=7), small cell (5), clear cell (4), papillary serous (1), and sarcomatoid (1)] were matched to 36 patients with grade 3 SA lesions. There were no differences between the 2 groups in age, body mass index, clinical stage, or lesion size. The 2 groups also did not differ with respect to number of nodes resected, lymphovascular space invasion, margin status, lymph node metastasis, or adjuvant radiation therapy or chemotherapy. At a median follow-up of 44 months, median progression-free and overall survivals had not been reached; however, both progression-free survival (p=0.018) and overall survival (p=0.028) were worse for the NSNA group. The 5-year progression-free and overall survival rates were 61.2% and 67.6%, respectively, for the NSNA group, compared to 90.1% and 88.3%, respectively, for the SA group. Conclusions Patients with early-stage NSNA cervical cancer undergoing radical hysterectomy and pelvic lymphadenectomy have a worse prognosis

  20. Staging of Bilateral Lung Transplantation for High-Risk Patients With Interstitial Lung Disease: One Lung at a Time.

    PubMed

    Hartwig, M G; Ganapathi, A M; Osho, A A; Hirji, S A; Englum, B R; Speicher, P J; Palmer, S M; Davis, R D; Snyder, L D

    2016-11-01

    The choice of a single or bilateral lung transplant for interstitial lung disease (ILD) is controversial, as surgical risk, long-term survival and organ allocation are competing factors. In an effort to balance risk and benefit, our center adopted a staged bilateral lung transplant approach for higher surgical risk ILD patients where the patient has a single lung transplant followed by a second single transplant at a later date. We sought to understand the surgical risk, organ allocation and early outcomes of these staged bilateral recipients as a group and in comparison to matched single and bilateral recipients. Our analysis demonstrates that staged bilateral lung transplant recipients (n = 12) have a higher lung allocation score (LAS), lower pulmonary function tests and a lower glomerular filtration rate prior to the first transplant compared to the second (p < 0.01). There was a shorter length of hospital stay for the second transplant (p = 0.02). The staged bilateral compared to the single and bilateral case-matched controls had comparable short-term survival (p = 0.20) and pulmonary function tests at 1 year. There was a higher incidence of renal injury in the conventional bilateral group compared to the single and staged bilateral groups. The staged bilateral procedure is a viable option in select ILD patients.

  1. Safety and efficacy of azacitidine in elderly patients with intermediate to high-risk myelodysplastic syndromes

    PubMed Central

    Navada, Shyamala C.; Silverman, Lewis R.

    2016-01-01

    Myelodysplastic syndromes (MDS) represent a clonal hematopoietic stem cell disorder characterized by morphologic features of dyspoiesis, a hyperproliferative bone marrow, and one or more peripheral blood cytopenias. In patients classified according to the Revised International Prognostic Scoring System (R-IPSS) with intermediate or higher-risk disease, there is an increased risk of death due to progressive bone marrow failure or transformation to acute myeloid leukemia (AML). Azacitidine was the first DNA hypomethylating agent approved by the United States (US) Food and Drug Administration (FDA) for the treatment of MDS and the only therapy that has demonstrated a significant survival benefit over conventional care regimens (CCRs) in patients with intermediate or higher-risk disease. Prolonged survival is independent of achieving a complete remission. Azacitidine has been used in older patients with both clinical and hematological improvement as well as an acceptable side effect profile. The most common adverse effect is myelosuppression. These findings support the use of azacitidine as an effective treatment in older patients with higher-risk MDS. PMID:28042456

  2. Improving the quality of patient handover on a surgical ward.

    PubMed

    Bradley, Alison

    2014-01-01

    The European Working Time Directive means safe patient hand over is imperative. It is the responsibility of every doctor and an issue of patient safety and clinical governance [1]. The aims of this project were to improve the quality of patient handover between combined assessment unit (CAU) and surgical ward FY1 doctors. The Royal College of Surgeons England (RCSEng) guidelines on surgical patient handover [1] were used as the standard. Data was collected throughout November 2013. A handover tool was then introduced and attached to the front of patient notes when a patient was transferred from CAU to the surgical ward. The doctor handing over the patient and the ward doctor receiving the handover signed this document. Policy was also changed so that handover should take place once the patient had received senior review on the CAU and was deemed appropriate for transfer to the surgical ward. Data from the handover tool was collated and checked against the list of surgical admission for February 2014. The number of patients handed over improved from 15 % to 45%. The quality of patient handover also improved. 0 patient handovers in November 2013 included all of the information recommended by the RCSEng guidelines. 100% of the patient handovers in February 2014 contained all the recommended information. Introduction of a handover tool and formalisation of timing of patient handover helped to improve quality and number of patients being handed over. Further work needs to be done to improve safe handover of surgical patients, particularly out of hours.

  3. [Comparison of international recommendations for the recognition of asymptomatic high risk patients for a heart attack in Germany].

    PubMed

    von Eckardstein, A; Schulte, H; Assmann, G

    2005-01-01

    The recommendations of the International Task Force for the Prevention of Coronary Heart Disease/International Atherosclerosis Society (ITF/IAS), the US-American Adult Treatment Panel III of the National Cholesterol Education Programs (ATP III) and the 3rd Joint European Guidelines (3JE) for the prevention coronary heart disease (CHD) show good agreement in tertiary prevention. All three guidelines recommend that patients with manifest CHD should have a blood pressure below 140/90 mm Hg and LDL-cholesterol below 2.6 mmol/l (100 mg/dl). By contrast, the three recommendations differ with respect to the prevention of cardiovascular events in asymptomatic high risk patients (secondary prevention), notably in the strategy to be used for risk assessment. Both the ITF/IAS guidelines and the 3JE guidelines can be adapted and realized in the various European countries. We therefore compared the prognostic values of the three recommendations by applying them to the data of male participants of the Prospective Cardiovascular Munster (PROCAM) Study. The ITF/IAS recommendations show the highest specificity (94.5%), positive predictive value (32.0%) and diagnostic efficacy (90.5%); the 3JE guidelines have the highest sensitivity (64.6%) but lowest specificity (77.9%), positive predictive value (17.5%) and diagnostic efficacy (77.0%). The application of the 3JE recommendations would target 25% of German men aged 35-65 years as cardiovascular high risk patients, by contrast to 7.5% through application of the ITF/IAS guidelines. In view of the limited resources in the public health systemthe application of the ITF/IAS guidelines in Germany appears more appropriate.

  4. Management of a patient at high risk of type 2 diabetes

    PubMed Central

    Howells, Lara; McKay, Ailsa J.; Hussain, Sufyan; Majeed, Azeem

    2016-01-01

    Abstract Rates of type 2 diabetes mellitus have risen rapidly over the past three to four decades. This article describes a typical patient presenting with intermediate hyperglycaemia in primary care. We suggest the appropriate action to reduce the risk of diabetes developing. Population-level preventive interventions, and adequate recognition and early management of those at risk of developing diabetes, could mitigate the impact of this evolving health epidemic.

  5. Febrile morbidity and hospital stay in high-risk cesarian section patients at a non-teaching hospital.

    PubMed

    Persad

    1998-07-01

    Objective: The objective of the study was to determine the incidence of postcesarian febrile morbidity and relate this to hospital stay in a high-risk indigent population treated at a private non-teaching hospital.Methods: This was a retrospective chart review of all patients done between January 1995 and December 1996. Discharge summaries, antepartums, progress notes, and labs were reviewed for each patient. Of 257 charts reviewed, 5 were inadequate for various reasons. Board-certified surgeons performed and assisted in the operations. Twenty-one patients had scant prenatal care and 6 had no prenatal care. All patients had the abdomen scrubbed with Betadine soap prior to painting. No shaving was done. Gloves were changed after closure of uterine incision. The pelvis was copiously irrigated with 3-4 L of saline. The subcutaneous layer was irrigated from a height of 6-12" with 12 to 1 L of fluid. After this step, this layer is not touched by anything from the operating field.Results: Of 162 patients with primary cesarian, 20 had postoperative fever, 18 with endometritis, 2 with wound infections. All but 5 of these patients had labor as ruptured membranes of 12 hours or more. Four had prolonged 2nd stage. Of 28 failed VBACs, 2 had fever vs none for 59 elective repeat cesarians. The average hospital stay for febrile patients was 4.4 days vs 2.7 for afebrile patients. The incidence of wound infection was 0.8%. The incidence of fever was 12.2% for primary cesarians and 8.8% in the total study group of 249 patients.Conclusion: This study demonstrates that the adoption of simple measures presented in Methods can dramatically decrease the incidence and severity of postcesarian fever, especially wound infection, thereby allowing safe, early hospital discharge.

  6. A Patient Safety Dilemma: Obesity in the Surgical Patient.

    PubMed

    Goode, Victoria; Phillips, Elayne; DeGuzman, Pamela; Hinton, Ivora; Rovnyak, Virginia; Scully, Kenneth; Merwin, Elizabeth

    2016-12-01

    Patient safety and the delivery of quality care are major concerns for healthcare in the United States. Special populations (eg, obese patients) need study in order to support patient safety, quantify risks, advance education for healthcare-workers, and establish healthcare policy. Obesity is a complex chronic disease and is considered the second leading cause of preventable death in the United States with approximately 300,000 deaths per year. Obesity is recognized by the Agency for Healthcare Research and Quality (AHRQ) as a comorbid condition. These concerns emphasize the need to focus further research on the obese patient. Through the use of clinical and administrative data, this study examines the incidence of adverse outcomes in the obese surgical population through AHRQ Patient Safety Indicators (PSI) and allows for the engagement PSIs as measures to guide and improve performance. In this study, the surgical population was overwhelmingly positive for obesity. Body mass index (BMI) was also a significant positive predictor for 2 of 3 postoperative outcomes. This finding suggests that as BMI reaches the classification of obesity, the risk of these adverse outcomes increases. It further suggests there exists a threshold BMI that requires anticipation of alterations to systems and processes to revise outcomes.

  7. Short-term clinicopathological outcome of neoadjuvant chemohormonal therapy comprising complete androgen blockade, followed by treatment with docetaxel and estramustine phosphate before radical prostatectomy in Japanese patients with high-risk localized prostate cancer

    PubMed Central

    2012-01-01

    Background To assess the outcome of neoadjuvant chemohormonal therapy comprising complete androgen blockade followed by treatment with docetaxel and estramustine phosphate before radical prostatectomy in Japanese patients with a high risk of localized prostate cancer (PCa). Methods Complete androgen blockade followed by 6 cycles of docetaxel (30 mg/m2) with estramustine phosphate (560 mg) were given to 18 PCa patients before radical prostatectomy. Subsequently, the clinical and pathological outcomes were analyzed. Results No patients had severe adverse events during chemohormonal therapy, and hence they were treated with radical prostatectomy. Two patients (11.1%) achieved pathological complete response. Surgical margins were negative in all patients. At a median follow-up of 18 months, 14 patients (77.8%) were disease-free without PSA recurrence. All 4 patients with PSA recurrence had pathologic T3b or T4 disease and 3 of these 4 patients had pathologic N1 disease. Conclusion We found that neoadjuvant chemohormonal therapy with complete androgen blockade followed by treatment with docetaxel and estramustine phosphate before radical prostatectomy was safe, feasible, and associated with favorable pathological outcomes in patients with a high risk of localized PCa. PMID:22214417

  8. Comparison between loop-tip guidewire-assisted and conventional endoscopic cannulation in high risk patients

    PubMed Central

    Masci, Enzo; Mangiavillano, Benedetto; Luigiano, Carmelo; Bizzotto, Alessandra; Limido, Eugenio; Cantù, Paolo; Manes, Gianpiero; Viaggi, Paolo; Spinzi, Giancarlo; Radaelli, Franco; Mariani, Alberto; Virgilio, Clara; Alibrandi, Angela; Testoni, Pier Alberto

    2015-01-01

    Background: The guidewire biliary cannulation (GWC) technique may increase the cannulation rate and decrease the risk for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. The aim of our multicenter prospective randomized controlled trial was to determine if the use of an atraumatic loop-tip guidewire reduces the rate of post-ERCP pancreatitis (PEP) compared with the standard contrast-assisted cannulation (CC) technique. Methods: From June 2012 to December 2013, a total of 320 patients who had a naïve papilla and were referred for ERCP were randomly assigned to the GWC group (n = 160) or the CC group (n = 160). GWC or CC was randomly used. In cases of failed cannulation in both arms after crossover, biliary access was attempted with alternative techniques (e. g., dual-wire technique, pancreatic duct stenting, precut). Results: The biliary cannulation rates were 81 % in the GWC group and 73 % in the CC group (P = n. s.). Following crossover, cannulation was successful in 8 % and 11 % of patients in the GWC and CC groups, respectively. With use of an alternative technique, the cannulation rates were 98 % in the GWC group and 96 % in the CC group, respectively. The rates of PEP were 5 % in the GWC group and 12 % in the CC group (P = 0.027). The post-interventional complication rates did not differ between the two groups. Conclusion: GWC with the new wire guide is associated with a lower rate of PEP in comparison with the CC technique. Clinical trial reference number: NCT01771419 PMID:26528503

  9. Solitary pulmonary metastases in high-risk melanoma patients: a prospective comparison of conventional and computed tomography

    SciTech Connect

    Heaston, D.K.; Putman, C.E.; Rodan, B.A.; Nicholson, E.; Ravin, C.E.; Korobkin, M.; Chen, J.T.; Seigler, H.F.

    1983-07-01

    A prospective comparison of chest radiography, conventional tomography, and computed tomography (CT) in the detection or confirmation of solitary pulmonary nodules was made in 42 patients with high propensity for pulmonary metastases due to advanced local (Clark level IV or V) or regional malignant melanoma. Unequivocal nodules were revealed by chest radiography in 11 patients, conventional tomograhy in 16, and computed tomography in 20 patients. Both plain films and tomography in three of these 20 were normal, but follow-up verified pulmonary metastases. Computed tomography detected more pulmonary nodules than conventional tomography in 11 patients in addition to identifying lesions in extrapulmonary sites. Therefore, chest CT is recommended before institution of immunotherapy or surgical removal of a solitary pulmonary melanoma metastasis. Once chemotherapy had been instituted for bulky regional or cutaneous involvement, however, the findings of either conventional or computed tomography were comparable in this study.

  10. Ex vivo-expanded natural killer cells demonstrate robust proliferation in vivo in high-risk relapsed multiple myeloma patients.

    PubMed

    Szmania, Susann; Lapteva, Natalia; Garg, Tarun; Greenway, Amy; Lingo, Joshuah; Nair, Bijay; Stone, Katie; Woods, Emily; Khan, Junaid; Stivers, Justin; Panozzo, Susan; Campana, Dario; Bellamy, William T; Robbins, Molly; Epstein, Joshua; Yaccoby, Shmuel; Waheed, Sarah; Gee, Adrian; Cottler-Fox, Michele; Rooney, Cliona; Barlogie, Bart; van Rhee, Frits

    2015-01-01

    Highly activated/expanded natural killer (NK) cells can be generated by stimulation with the human leukocyte antigen-deficient cell line K562, genetically modified to express 41BB-ligand and membrane-bound interleukin (IL)15. We tested the safety, persistence, and activity of expanded NK cells generated from myeloma patients (auto-NK) or haploidentical family donors (allo-NK) in heavily pretreated patients with high-risk relapsing myeloma. The preparative regimen comprised bortezomib only or bortezomib and immunosuppression with cyclophosphamide, dexamethasone, and fludarabine. NK cells were shipped overnight either cryopreserved or fresh. In 8 patients, up to 1×10⁸ NK cells/kg were infused on day 0 and followed by daily administrations of IL2. Significant in vivo expansion was observed only in the 5 patients receiving fresh products, peaking at or near day 7, with the highest NK-cell counts in 2 subjects who received cells produced in a high concentration of IL2 (500 U/mL). Seven days after infusion, donor NK cells comprised >90% of circulating leukocytes in fresh allo-NK cell recipients, and cytolytic activity against allogeneic myeloma targets was retained in vitro. Among the 7 evaluable patients, there were no serious adverse events that could be related to NK-cell infusion. One patient had a partial response and in another the tempo of disease progression decreased; neither patient required further therapy for 6 months. In the 5 remaining patients, disease progression was not affected by NK-cell infusion. In conclusion, infusion of large numbers of expanded NK cells was feasible and safe; infusing fresh cells was critical to their expansion in vivo.

  11. Taking charge of high-risk and high-cost patients in the public healthcare system.

    PubMed

    Denis, Jean-Louis; Cambourieu, Caroline; Roy, Denis A

    2014-01-01

    Many healthcare systems are struggling with the issue of providing high-quality care to high-needs patients at lower costs. Our comments in this paper draw on insights that we have gained from the development and implementation of integrated models of care in Québec. This experience highlights the importance of developing a clear clinical approach to the delivery and coordination of care and to support providers in new roles. Our second insight is that system-level policy guidelines may help to focus the attention of organizations and providers on key priorities, but they need to take into account differing needs in various contexts. Third, a crucial factor for success over the longer term is the ability of local networks to reshape the allocation and use of resources to bring about change in day-to-day operations. We conclude by highlighting key characteristics of high-performing health systems and with the final observation that politicians and policymakers need to allow enough time to harness the full benefit of change initiatives.

  12. Feasibility of Neoadjuvant Ad-REIC Gene Therapy in Patients with High-Risk Localized Prostate Cancer Undergoing Radical Prostatectomy.

    PubMed

    Kumon, Hiromi; Sasaki, Katsumi; Ariyoshi, Yuichi; Sadahira, Takuya; Araki, Motoo; Ebara, Shin; Yanai, Hiroyuki; Watanabe, Masami; Nasu, Yasutomo

    2015-12-01

    In a phase I/IIa study of in situ gene therapy using an adenovirus vector carrying the human REIC/Dkk-3 gene (Ad-REIC), we assessed the inhibitory effects of cancer recurrence after radical prostatectomy (RP), in patients with high risk localized prostate cancer (PCa). After completing the therapeutic interventions with initially planned three escalating doses of 1.0 × 10(10) , 1.0 × 10(11) , and 1.0 × 10(12) viral particles (VP) in 1.0-1.2 mL (n = 3, 3, and 6), an additional higher dose of 3.0 × 10(12) VP in 3.6 mL (n = 6) was further studied. Patients with recurrence probability of 35% or more within 5 years after RP as calculated by Kattan's nomogram, were enrolled. They received two ultrasound-guided intratumoral injections at 2-week intervals, followed by RP 6 weeks after the second injection. Based on the findings of MRI and biopsy mapping, as a rule, one track injection to the most prominent cancer area was given to initial 12 patients and 3 track injections to multiple cancer areas in additional 6 patients. As compared to the former group, biochemical recurrence-free survival of the latter showed a significantly favorable outcome. Neoadjuvant Ad-REIC, mediating simultaneous induction of cancer selective apoptosis and augmentation of antitumor immunity, is a feasible approach in preventing cancer recurrence after RP. (199).

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

    PubMed

    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 <65 years trial. Moreover, CD81(+) SMM (n=34/56, 57%) patients had a shorter time to progression to MM (P=0.02). Overall, our results show that CD81 may have a relevant role in MM pathogenesis and represent a novel adverse prognostic marker in myeloma.

  14. Depression and social anxiety in help-seeking patients with an ultra-high risk for developing psychosis.

    PubMed

    Rietdijk, Judith; Ising, Helga K; Dragt, Sara; Klaassen, Rianne; Nieman, Dorien; Wunderink, Lex; Cuijpers, Pim; Linszen, Don; van der Gaag, Mark

    2013-10-30

    Knowledge on associations between ultra-high risk (UHR) for developing psychosis and on non-psychotic psychopathology in help-seeking populations is limited with respect to differences between male and female patients. The present study tests the hypothesis that both social anxiety and depression are highly prevalent in an UHR population, particularly among women. From February 2008 to February 2010 baseline data were collected from help-seeking subjects (14-35 years) who were included in the Dutch Early Detection and Intervention Evaluation (EDIE-NL) trial. Two recruiting strategies were used: a two-stage screening strategy in a population of consecutive help-seeking and distressed subjects of secondary mental health services, and a referral strategy. This study included 201 patients with a mean age of 22.7 years. Of these, 102 (51%) were female, 58% of the patients met the criteria for clinical depression on the Beck Depression Inventory and 42% met the criteria for clinical social phobia on the Social Interaction Anxiety Scale. Women showed more depression and social anxiety than men. The results support the hypothesis that UHR is associated with depression and social anxiety, particularly in women. Screening a help-seeking population with depression and anxiety may be effective in detecting patients at UHR for developing psychosis.

  15. Patient satisfaction with doctor-patient interaction and its association with modifiable cardiovascular risk factors among moderately-high risk patients in primary healthcare

    PubMed Central

    Masseni, Abd Aziz; Azlina, Ishak

    2017-01-01

    Background The outcomes of the physician-patient discussion intervene in the satisfaction of cardiovascular disease risk patients. Adherence to treatment, provision of continuous care, clinical management of the illness and patients’ adjustment are influenced by satisfaction with physician-patient interaction. This study aims to determine the patient satisfaction with doctor-patient interaction and over six months after following prevention counselling, its associations with modifiable cardiovascular risk factors amongst moderately-high risk patients in a primary healthcare clinic in Kelantan, Malaysia. Methods A prospective survey was conducted amongst patients with moderately-high cardiovascular risk. A total of 104 moderately-high risk patients were recruited and underwent structured prevention counselling based on the World Health Organization guideline, and their satisfaction with the doctor-patient interaction was assessed using ‘Skala Kepuasan Interaksi Perubatan-11,’ the Malay version of the Medical Interview Satisfaction Scale-21. Systolic blood pressure, total cholesterol and high-density lipoprotein cholesterol were measured at baseline and at a follow-up visit at six months. Descriptive analysis, paired t test and linear regression analyses were performed. Results A total of 102 patients responded, giving a response rate of 98.1%. At baseline, 76.5% of the respondents were satisfied with the relation with their doctor, with the favourable domain of distress relief (85.3%) and rapport/confidence (91.2%). The unfavourable domain was interaction outcome, with satisfaction in only 67.6% of the respondents. Between the two visits, changes had occurred in total cholesterol (P = 0.022) and in systolic blood pressure (P < 0.001). Six months after the initial visits, no relationship existed between patient satisfaction scores and changes in modifiable cardiovascular risks. Discussion The ‘Skala Kepuasan Interaksi Perubatan-11’ which represents a

  16. Non-surgical periodontal management in scleroderma disease patients.

    PubMed

    Laforgia, A; Corsalini, M; Stefanachi, G; Tafuri, S; Ballini, A; Pettini, F; Di Venere, D

    2016-01-01

    The aim of the present study is to investigate the periodontal status of people with scleroderma and their response to non-surgical treatment protocol aimed at controlling the evolution of the disease. The response to non-surgical periodontal treatment was tested on patients belonging to a scleroderma group and a control group: the data show an improvement of the periodontal conditions of all these patients in response to treatment. When compared on the same diagram, a slight remission of the periodontal disease was obtained in both scleroderma and healthy patients. This highlights the benefit to soft tissues produced by non-surgical periodontal treatment also in patients affected by systemic diseases.

  17. Evaluating the performance of National Comprehensive Cancer Network (NCCN) breast and ovarian genetic/familial high risk assessment referral criteria for breast cancer women in an Asian surgical breast clinic

    PubMed Central

    Borje, Eillen; Allen, John C.

    2017-01-01

    Background Globally, resources for genomic services vary. Current National Comprehensive Cancer Network (NCCN) breast and ovarian genetic/familial high risk assessment criteria for further genetic risk evaluation are useful, but lack specificity for reliably excluding patients with low a priori risk. This may result in patient overload in lesser-equipped genetics clinics. Since we use Manchester and the Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA) risk assessment models in our genetics clinic to determine whether genetic testing is warranted, we chose Manchester and BOADICEA as the reference standard to compare how the NCCN breast and ovarian genetic/familial high risk assessment criteria for further genetic risk evaluation performs against these two risk assessment models in referring breast cancer patients for genetic evaluation. Methods Breast cancer patients diagnosed from 2009–2011 were assessed using the NCCN criteria, Manchester and BOADICEA. Logistic regression and receiver operating characteristic (ROC) analysis were used to compare the NCCN criteria versus the Manchester and BOADICEA scoring systems in identifying high-risk patients. Results A total of 666 patients were included in the study. Percentages of high-risk patients resulting from Manchester and BOADICEA were 1.80% and 2.55%, respectively. Among the NCCN criteria, breast cancer and ≥1 close relatives with breast cancer at ≤50 years of age correlated best with Manchester and/or BOADICEA (c-statistic =0.831) with a false negative rate of 1.0%. Conclusions Breast cancer at any age and ≥1 close relative with breast cancer at ≤50 years of age exhibited the highest correlation with Manchester and/or BOADICEA, promising greater specificity compared to the other NCCN criteria for segregating high risk, Asian breast cancer patients for referral to a genetics clinic, nevertheless recognizing the inherent limitations of the scoring systems. PMID

  18. Occult gastrointestinal bleeding in high-risk intensive care unit patients receiving antacid prophylaxis: frequency and significance.

    PubMed

    Derrida, S; Nury, B; Slama, R; Marois, F; Moreau, R; Soupison, T; Sicot, C

    1989-02-01

    Gastroccult reagent was used every 4 h to detect blood in gastric juice in 41 ICU patients at risk of GI bleeding (GB) and receiving antacid prophylaxis (gastric pH greater than 3.5). Of the present patients, 27% (11/41) had at least one episode of occult GB (three consecutive positive determinations; a total of 14 episodes). Endoscopy identified acute gastroduodenal mucosal lesions (stress ulcers) as the most frequent lesion in this group (eight patients). Sepsis was the most frequent underlying condition associated with occult GB due to stress ulcer. Hematemesis occurred in 36% (4/11) of patients with occult GB and was due to stress ulcer in three patients and to benign gastric tumor in one. No overt GB occurred in the absence of previous occult GB. We conclude that: a) risk of GB persists in critically ill ICU patients in spite of antacid prophylaxis (gastric pH greater than 3.5); b) high-risk patients can be identified through periodic testing for the presence of blood in gastric juice using the reagent; c) when occult GB occurs, treatment should be based on the endoscopy results. In the absence of acute gastroduodenal mucosal lesions, antacid prophylaxis should not be modified, and specific treatment of the identified lesion(s) should be initiated. In the presence of stress lesions, antacid prophylaxis should be reinforced if the pH of the gastric content is less than 3.5 and a septic complication should be actively sought if the pH is greater than 3.5.

  19. Perioperative utility of goal-directed therapy in high-risk cardiac patients undergoing coronary artery bypass grafting: “A clinical outcome and biomarker-based study”

    PubMed Central

    Kapoor, Poonam Malhotra; Magoon, Rohan; Rawat, Rajinder; Mehta, Yatin

    2016-01-01

    Goal-directed therapy (GDT) encompasses guidance of intravenous (IV) fluid and vasopressor/inotropic therapy by cardiac output or similar parameters to help in early recognition and management of high-risk cardiac surgical patients. With the aim of establishing the utility of perioperative GDT using robust clinical and biochemical outcomes, we conducted the present study. This multicenter randomized controlled study included 130 patients of either sex, with European system for cardiac operative risk evaluation ≥3 undergoing coronary artery bypass grafting on cardiopulmonary bypass. The patients were randomly divided into the control and GDT group. All the participants received standardized care; arterial pressure monitored through radial artery, central venous pressure (CVP) through a triple lumen in the right internal jugular vein, electrocardiogram, oxygen saturation, temperature, urine output per hour, and frequent arterial blood gas (ABG) analysis. In addition, cardiac index (CI) monitoring using FloTrac™ and continuous central venous oxygen saturation (ScVO2) using PreSep™ were used in patients in the GDT group. Our aim was to maintain the CI at 2.5–4.2 L/min/m2, stroke volume index 30–65 ml/beat/m2, systemic vascular resistance index 1500–2500 dynes/s/cm5/m2, oxygen delivery index 450–600 ml/min/m2, continuous ScVO2 >70%, and stroke volume variation <10%; in addition to the control group parameters such as CVP 6–8 mmHg, mean arterial pressure 90–105 mmHg, normal ABG values, oxygen saturation, hematocrit value >30%, and urine output >1 ml/kg/h. The aims were achieved by altering the administration of IV fluids and doses of inotropes or vasodilators. The data of sixty patients in each group were analyzed in view of ten exclusions. The average duration of ventilation (19.89 ± 3.96 vs. 18.05 ± 4.53 h, P = 0.025), hospital stay (7.94 ± 1.64 vs. 7.17 ± 1.93 days, P = 0.025), and Intensive Care Unit (ICU) stay (3.74 ± 0.59 vs. 3.41 ± 0

  20. Results of high-risk neutropenia therapy of hematology–oncology patients in a university hospital in Uruguay

    PubMed Central

    Boada Burutaran, Matilde; Guadagna, Regina; Grille, Sofia; Stevenazzi, Mariana; Guillermo, Cecilia; Diaz, Lilian

    2014-01-01

    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 isolated 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 (front-line 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. PMID:25638764

  1. Is a biomarker-based diagnostic strategy for invasive aspergillosis cost effective in high-risk haematology patients?

    PubMed

    Macesic, N; Morrissey, C O; Liew, D; Bohensky, M A; Chen, S C-A; Gilroy, N M; Milliken, S T; Szer, J; Slavin, M A

    2017-01-27

    Empirical antifungal therapy is frequently used in hematology patients at high risk of invasive aspergillosis (IA), with substantial cost and toxicity. Biomarkers for IA aim for earlier and more accurate diagnosis and targeted treatment. However, data on the cost-effectiveness of a biomarker-based diagnostic strategy (BDS) are limited. We evaluated the cost effectiveness of BDS using results from a randomized controlled trial (RCT) and individual patient costing data. Data inputs derived from a published RCT were used to construct a decision-analytic model to compare BDS (Aspergillus galactomannan and PCR on blood) with standard diagnostic strategy (SDS) of culture and histology in terms of total costs, length of stay, IA incidence, mortality, and years of life saved. Costs were estimated for each patient using hospital costing data to day 180 and follow-up for survival was modeled to five years using a Gompertz survival model. Treatment costs were determined for 137 adults undergoing allogeneic hematopoietic stem cell transplant or receiving chemotherapy for acute leukemia in four Australian centers (2005-2009). Median total costs at 180 days were similar between groups (US[Formula: see text] for SDS [IQR US[Formula: see text

  2. Phase I clinical trial of curcumin, a chemopreventive agent, in patients with high-risk or pre-malignant lesions.

    PubMed

    Cheng, A L; Hsu, C H; Lin, J K; Hsu, M M; Ho, Y F; Shen, T S; Ko, J Y; Lin, J T; Lin, B R; Ming-Shiang, W; Yu, H S; Jee, S H; Chen, G S; Chen, T M; Chen, C A; Lai, M K; Pu, Y S; Pan, M H; Wang, Y J; Tsai, C C; Hsieh, C Y

    2001-01-01

    Curcumin (diferuloylmethane), a yellow substance from the root of the plant Curcuma longa Linn., has been demonstrated to inhibit carcinogenesis of murine skin, stomach, intestine and liver. However, the toxicology, pharmacokinetics and biologically effective dose of curcumin in humans have not been reported. This prospective phase-I study evaluated these issues of curcumin in patients with one of the following five high-risk conditions: 1) recently resected urinary bladder cancer; 2) arsenic Bowen's disease of the skin; 3) uterine cervical intraepithelial neoplasm (CIN); 4) oral leucoplakia; and 5) intestinal metaplasia of the stomach. Curcumin was taken orally for 3 months. Biopsy of the lesion sites was done immediately before and 3 months after starting curcumin treament. The starting dose was 500 mg/day. If no toxicity > or = grade II was noted in at least 3 successive patients, the dose was then escalated to another level in the order of 1,000, 2,000, 4,000, 8,000, and 12,000 mg/day. The concentration of curcumin in serum and urine was determined by high pressure liquid chromatography (HPLC). A total of 25 patients were enrolled in this study. There was no treatment-related toxicity up to 8,000 mg/day. Beyond 8,000 mg/day, the bulky volume of the drug was unacceptable to the patients. The serum concentration of curcumin usually peaked at 1 to 2 hours after oral intake of crucumin and gradually declined within 12 hours. The average peak serum concentrations after taking 4,000 mg, 6,000 mg and 8,000 mg of curcumin were 0.51 +/- 0.11 microM, 0.63 +/- 0.06 microM and 1.77 +/- 1.87 microM, respectively. Urinary excretion of curcumin was undetectable. One of 4 patients with CIN and 1 of 7 patients with oral leucoplakia proceeded to develop frank malignancies in spite of curcumin treatment. In contrast, histologic improvement of precancerous lesions was seen in 1 out of 2 patients with recently resected bladder cancer, 2 out of 7 patients of oral leucoplakia, 1 out

  3. Surgical Management of the Pediatric Cochlear Implant Patient.

    ERIC Educational Resources Information Center

    Cohen, Seth M.; Haynes, David S.

    2003-01-01

    This article discusses the surgical management of children receiving cochlear implants. It identifies preoperative considerations to select patients likely to benefit, contraindications, some new surgical techniques, complications, special considerations (otitis media, meningitis, head growth, inner ear malformations, and cochlear obstruction).…

  4. Can Saliva Proteins Be Used to Predict the Onset of Acute Myocardial Infarction among High-Risk Patients?

    PubMed Central

    Rahim, Mohd Aizat Abdul; Rahim, Zubaidah Haji Abdul; Ahmad, Wan Azman Wan; Hashim, Onn Haji

    2015-01-01

    Human saliva plays a pivotal role in digesting food and maintaining oral hygiene. The presence of electrolytes, mucus, glycoproteins, enzymes, antibacterial compounds, and gingival crevicular fluid in saliva ensures the optimum condition of oral cavity and general health condition. Saliva collection has been proven non-invasive, convenient, and inexpensive compared to conventional venipuncture procedure. These distinctive advantages provide a promising potential of saliva as a diagnostic fluid. Through comprehensive analysis, an array of salivary proteins and peptides may be beneficial as biomarkers in oral and systemic diseases. In this review, we discuss the utility of human salivary proteomes and tabulate the recent salivary biomarkers found in subjects with acute myocardial infarction as well as respective methods employed. In a clinical setting, since acute myocardial infarction contributes to large cases of mortality worldwide, an early intervention using these biomarkers will provide an effective solution to reduce global heart attack incidence particularly among its high-risk group of type-2 diabetes mellitus patients. The utility of salivary biomarkers will make the prediction of this cardiac event possible due to its reliability hence improve the quality of life of the patients. Current challenges in saliva collection are also addressed to improve the quality of saliva samples and produce robust biomarkers for future use in clinical applications. PMID:25897294

  5. Predicting the onset of psychosis in patients at clinical high risk: practical guide to probabilistic prognostic reasoning.

    PubMed

    Fusar-Poli, P; Schultze-Lutter, F

    2016-02-01

    Prediction of psychosis in patients at clinical high risk (CHR) has become a mainstream focus of clinical and research interest worldwide. When using CHR instruments for clinical purposes, the predicted outcome is but only a probability; and, consequently, any therapeutic action following the assessment is based on probabilistic prognostic reasoning. Yet, probabilistic reasoning makes considerable demands on the clinicians. We provide here a scholarly practical guide summarising the key concepts to support clinicians with probabilistic prognostic reasoning in the CHR state. We review risk or cumulative incidence of psychosis in, person-time rate of psychosis, Kaplan-Meier estimates of psychosis risk, measures of prognostic accuracy, sensitivity and specificity in receiver operator characteristic curves, positive and negative predictive values, Bayes' theorem, likelihood ratios, potentials and limits of real-life applications of prognostic probabilistic reasoning in the CHR state. Understanding basic measures used for prognostic probabilistic reasoning is a prerequisite for successfully implementing the early detection and prevention of psychosis in clinical practice. Future refinement of these measures for CHR patients may actually influence risk management, especially as regards initiating or withholding treatment.

  6. Risk Assessment of Postoperative Nausea and Vomiting in the Intravenous Patient-Controlled Analgesia Environment: Predictive Values of the Apfel's Simplified Risk Score for Identification of High-Risk Patients

    PubMed Central

    Kim, Shin Hyung; Shin, Yang-Sik; Oh, Young Jun; Lee, Jeong Rim; Chung, Sung Chan

    2013-01-01

    Purpose Opioid-based intravenous patient-controlled analgesia (IV PCA) is popular method of postoperative pain control, but many patients suffer from IV PCA-related postoperative nausea and vomiting (PONV). In this retrospective observational study, we have determined independent predictors of IV PCA-related PONV and predictive values of the Apfel's simplified risk score in pursuance of identifying high-risk patients. Materials and Methods We analyzed 7000 patients who received IV PCA with background infusion after elective surgery. Patients who maintained IV PCA for a postoperative period of 48 hr (completion group, n=6128) were compared with those who have discontinued IV PCA within 48 hr of surgery due to intractable PONV (cessation group, n=872). Patients, anesthetics, and surgical factors known for predicting PONV were evaluated by logistic regression analysis to identify independent predictors of IV PCA related intractable PONV. Results In a stepwise multivariate analysis, weight, background infusion dose of fentanyl, addition of ketolorac to PCA, duration of anesthesia, general anesthesia, head and neck surgery, and Apfel's simplified risk score were revealed as independent risk factors for intractable PONV followed by the cessation of IV PCA. In addition, Apfel's simplified risk score, which demonstrated the highest odds ratio among the predictors, was strongly correlated with the cessation rate of IV PCA. Conclusion Multimodal prophylactic antiemetic strategies and dose reduction of opioids may be considered as strategies for the prevention of PONV with the use of IV PCA, especially in patients with high Apfel's simplified risk scores. PMID:23918581

  7. Rapid Response Team Activations in Pediatric Surgical Patients.

    PubMed

    Acker, Shannon N; Wathen, Beth; Roosevelt, Genie E; Hill, Lauren R S; Schubert, Anna; Reese, Jenny; Bensard, Denis D; Kulungowski, Ann M

    2017-02-01

    Introduction The rapid response team (RRT) is a multidisciplinary team who evaluates hospitalized patients for concerns of nonemergent clinical deterioration. RRT evaluations are mandatory for children whose Pediatric Early Warning System (PEWS) score (assessment of child's behavior, cardiovascular and respiratory status) is ≥4. We aimed to determine if there were differences in characteristics of RRT calls between children who were admitted primarily to either medical or surgical services. We hypothesized that RRT activations would be called for less severely ill children with lower PEWS score on surgical services compared with children admitted to a medical service. Materials and Methods We performed a retrospective review of all children with RRT activations between January 2008 and April 2015 at a tertiary care pediatric hospital. We evaluated the characteristics of RRT calls and made comparisons between RRT calls made for children admitted primarily to medical or surgical services. Results A total of 2,991 RRT activations were called, and 324 (11%) involved surgical patients. Surgical patients were older than medical patients (median: 7 vs. 4 years; p < 0.001). RRT evaluations were called for lower PEWS score in surgical patients compared with medical (median: 3 vs. 4, p < 0.001). Surgical patients were more likely to remain on the inpatient ward following the RRT (51 vs. 39%, p < 0.001) and were less likely to require an advanced airway than medical patients (0.9 vs. 2.1%; p = 0.412). RRT evaluations did not differ between day and night shifts (52% day vs. 48% night; p = 0.17). All surgical patients and all but one medical patient survived the event; surgical patients were more likely to survive to hospital discharge (97 vs. 91%, p < 0.001) Conclusions RRT activations are rare events among pediatric surgical patients. When compared with medical patients, RRT evaluation is requested for surgical patients with a lower PEWS

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

    PubMed Central

    Vavvas, Demetrios G.; Daniels, Anthony B.; Kapsala, Zoi G.; Goldfarb, Jeremy W.; Ganotakis, Emmanuel; Loewenstein, John I.; Young, Lucy H.; Gragoudas, Evangelos S.; Eliott, Dean; Kim, Ivana K.; Tsilimbaris, Miltiadis K.; Miller, Joan W.

    2016-01-01

    Importance Age-related macular degeneration (AMD) remains the leading cause of blindness in developed countries, and affects more than 150 million worldwide. Despite effective anti-angiogenic therapies for the less prevalent neovascular form of AMD, treatments are lacking for the more prevalent dry form. Similarities in risk factors and pathogenesis between AMD and atherosclerosis have led investigators to study the effects of statins on AMD incidence and progression with mixed results. A limitation of these studies has been the heterogeneity of AMD disease and the lack of standardization in statin dosage. Objective We were interested in studying the effects of high-dose statins, similar to those showing regression of atherosclerotic plaques, in AMD. Design Pilot multicenter open-label prospective clinical study of 26 patients with diagnosis of AMD and the presence of many large, soft drusenoid deposits. Patients received 80 mg of atorvastatin daily and were monitored at baseline and every 3 months with complete ophthalmologic exam, best corrected visual acuity (VA), fundus photographs, optical coherence tomography (OCT), and blood work (AST, ALT, CPK, total cholesterol, TSH, creatinine, as well as a pregnancy test for premenopausal women). Results Twenty-three subjects completed a minimum follow-up of 12 months. High-dose atorvastatin resulted in regression of drusen deposits associated with vision gain (+ 3.3 letters, p = 0.06) in 10 patients. No subjects progressed to advanced neovascular AMD. 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. PMID:27077128

  9. Resiquimod as an immunologic adjuvant for NY-ESO-1 protein vaccination in patients with high-risk melanoma.

    PubMed

    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 D; 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.

  10. Dexamethasone, cyclophosphamide, idarubicin and etoposide (DC-IE): a novel, intensive induction chemotherapy regimen for patients with high-risk multiple myeloma.

    PubMed

    Ballester, O F; Moscinski, L C; Fields, K K; Hiemenz, J W; Zorsky, P E; Goldstein, S C; Saba, H I; Spiers, A S; Kronish, L; Sullivan, P; Elfenbein, G J

    1997-03-01

    We evaluated toxicities and responses to a novel, dose intensive and time sequenced, chemotherapy programme (DC-IE) in 45 patients with high-risk myeloma. DC-IE consisted of: dexamethasone (days 1-4); cyclophosphamide (day 5); idarubicin and etoposide (days 8-10). Complete response (CR) was achieved in four patients, six patients achieved near complete responses (nCR) and 21 patients achieved a partial remission (PR). Overall response rate was 76% (CI 56-94%) for newly diagnosed patients (n = 21) and 62% (CI 36-81%) for relapsed/refractory patients (n = 24). Toxicities were limited to myelosuppression; two patients died of sepsis during neutropenia (4%). DC-IE is active and tolerable for high-risk multiple myeloma, including patients with relapsed or refractory disease to anthracycline containing regimens.

  11. Behind the Curtain: Keeping Surgical Patients Warmer Fights Infection

    MedlinePlus

    ... found that just a few degrees of body cooling tripled the risk of surgical wound infection. His ... of wound infections. Sessler has found simple, risk-free and inexpensive interventions that improve patient health after ...

  12. [Lipid profiles and therapy status in the secondary prevention of high risk patients with cardiovascular disease and/or diabetes mellitus: the Austrian Hospital Screening Project (HSP)].

    PubMed

    Roden, Michael; Huber, Kurt

    2008-01-01

    Cardiovascular disease is the major cause of morbidity and premature death in most European populations. Due to its prominent role as a risk factor for cardiovascular mortality, lowering of low density lipoprotein cholesterol (LDL-C) levels is the main goal for management of dyslipidemia. To evaluate lipid profiles and management of high risk patients with hyperlipidemia, we performed an observational study in 20 Austrian Departments of Medicine specialized in cardiology, diabetes and/or metabolism from July 2006 to February 2007. Out of 9152 patients [age (mean +/- SD): women 69 +/- 13, men 65 +/- 12 years) 6838 were considered at "very high risk" (group 1; LDL-C: 99 +/- 38 mg/dl) and 2314 at "high risk" (group 2; LDL-C: 108 +/- 39 mg/dl), respectively. Of 4886 patients on statins, 48% of did not reach their LDL-C goals (<70 mg/dl and <100 mg/dl for group 1 and 2, respectively). In 68% of these patients statin therapy was not intensified subsequently. Among patients without lipid-lowering drugs at study entry, 62% did not meet their targets, and despite treatment in the center 1555 of these patients (58%) remained without medication. With regard to national and international guidelines, there is still a need to improve the clinical practice of lowering LDL-C for secondary prevention in high risk patients in Austria.

  13. Screening for latent TB in patients with rheumatic disorders prior to biologic agents in a 'high-risk' TB population: comparison of two interferon gamma release assays.

    PubMed

    Melath, Sunil; Ismajli, Mediola; Smith, Robin; Patel, Ishita; Steuer, Alan

    2014-01-01

    Patients with rheumatic disorders treated with TNF inhibitors are at increased risk of developing TB. There is no 'gold-standard' for the diagnosis of latent TB prior to initiation of biologic agents. We report our own experience of comparing two interferon gamma release assays (IGRAs) in screening for latent TB in a 'high-risk' TB area in patients with rheumatic disorders. The study demonstrated good concordance between the two tests. We believe the additional cost of these assays is justified in high-risk populations prior to biologic agents, with 16% of the current study population with at least one positive IGRA assay.

  14. Potential of a Pharmacogenetic-Guided Algorithm to Predict Optimal Warfarin Dosing in a High-Risk Hispanic Patient

    PubMed Central

    Hernandez-Suarez, Dagmar F.; Claudio-Campos, Karla; Mirabal-Arroyo, Javier E.; Torres-Hernández, Bianca A.; López-Candales, Angel; Melin, Kyle; Duconge, Jorge

    2016-01-01

    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. PMID:28210634

  15. Abstinence and Teenagers: Prevention Counseling Practices of Health Care Providers Serving High-Risk Patients in the United States

    PubMed Central

    Harper, Cynthia C.; Henderson, Jillian T.; Schalet, Amy; Becker, Davida; Stratton, Laura; Raine, Tina R.

    2010-01-01

    CONTEXT 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. METHODS 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. RESULTS 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. CONCLUSIONS 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. PMID:20618752

  16. Implications of Public Reporting of Risk-Adjusted Mortality Following Percutaneous Coronary Intervention: Misperceptions and Potential Consequences for High-Risk Patients Including Nonsurgical Patients.

    PubMed

    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.

  17. Enhancing risk stratification for use in integrated care: a cluster analysis of high-risk patients in a retrospective cohort study

    PubMed Central

    Vuik, Sabine I; Mayer, Erik; Darzi, Ara

    2016-01-01

    Objective To show how segmentation can enhance risk stratification tools for integrated care, by providing insight into different care usage patterns within the high-risk population. Design A retrospective cohort study. A risk score was calculated for each person using a logistic regression, which was then used to select the top 5% high-risk individuals. This population was segmented based on the usage of different care settings using a k-means cluster analysis. Data from 2008 to 2011 were used to create the risk score and segments, while 2012 data were used to understand the predictive abilities of the models. Setting and participants Data were collected from administrative data sets covering primary and secondary care for a random sample of 300 000 English patients. Main measures The high-risk population was segmented based on their usage of 4 different care settings: emergency acute care, elective acute care, outpatient care and GP care. Results While the risk strata predicted care usage at a high level, within the high-risk population, usage varied significantly. 4 different groups of high-risk patients could be identified. These 4 segments had distinct usage patterns across care settings, reflecting different levels and types of care needs. The 2008–2011 usage patterns of the 4 segments were consistent with the 2012 patterns. Discussion Cluster analyses revealed that the high-risk population is not homogeneous, as there exist 4 groups of patients with different needs across the care continuum. Since the patterns were predictive of future care use, they can be used to develop integrated care programmes tailored to these different groups. Conclusions Usage-based segmentation augments risk stratification by identifying patient groups with different care needs, around which integrated care programmes can be designed. PMID:27993905

  18. Application of Autologous Platelet-Rich Plasma (PRP) on Wound Healing After Caesarean Section in High-Risk Patients

    PubMed Central

    Tehranian, Afsaneh; Esfehani-Mehr, Bahareh; Pirjani, Reihaneh; Rezaei, Negar; Sadat Heidary, Somaye; Sepidarkish, Mahdi

    2016-01-01

    Background Platelet-rich plasma (PRP) is a human plasma product enriched by platelets, growth factors, and fibrinogen with high hemostatic and healing properties. Objectives The aim of this study was to evaluate the effect of autologous PRP on wound healing in high-risk women undergoing cesarean sections. Patients and Methods In this balanced, randomized, and controlled trial, 140 patients were admitted to Arash women’s hospital, Tehran, Iran from May of 2013 to November of 2014 for elective cesarean surgery. The patients were randomly assigned into two groups. The intervention group received PRP after surgery, whereas the control group received the usual care. All patients were evaluated at baseline, five days, and eight weeks after the cesarean section. The primary endpoint used the REEDA scale for assessing the changes in wound healing. The secondary outcome measures used were the Vancouver scar scale (VSS) and the visual analog scale (VAS). All scale scores were analyzed using a repeated measures test for variance. Results At the end of study, the PRP group showed a greater reduction in the edema ecchymosed discharge approximation (REEDA) score compared to the control group (85.5% reduction in the PRP group; 72% in the control group) (P < 0.001). Compared with the control group, the PRP group had a significantly greater reduction in the VAN score, beginning on the fifth day after the cesarean section (-0.7, 38% reduction in PRP group; -0.8, 33% in control group) (P < 0.001), and this trend was stable at the end of the eighth week (-0.6, 54% reduction in PRP group; -0.3, 18% in control group). Furthermore, patients treated with PRP experienced a 93% reduction in the VAS score at the end of follow-up, but the control group only observed a 79% reduction (P < 0.001). Conclusions It seems that applying PRP is an effective therapeutic approach for wound healing, and faster wound healing is expected due to the presence of more platelets and growth factors. PMID

  19. Use of Medications and Lifestyles of Hypertensive Patients with High Risk of Cardiovascular Disease in Rural China

    PubMed Central

    Zou, Guanyang; Zhang, Zhitong; Walley, John; Gong, Weiwei; Yu, Yunxian; Hu, Ruying; Yin, Jia; Yu, Min; Wei, Xiaolin

    2015-01-01

    Background Hypertension, with a global prevalence of 40%, is a risk factor for cardiovascular diseases (CVD). We conducted an exploratory study in Zhejiang China to understand the prevention of CVD among hypertensive patients with a 10 year CVD risk of 20% or higher. We assessed current practices in a rural ‘township hospital’ (a primary care facility), and compared them with international evidence-based practice. Methods A questionnaire survey was conducted to examine the use of modern drugs (antihypertensive drugs, statins and aspirin) and traditional drugs, compliance to medications and lifestyle among 274 hypertensive patients aged 40-74, with a CVD risk of 20% or higher (using the Asian Equation). Results The majority (72%) were diagnosed with hypertension at township hospitals. Only 15% of study participants used two anti-hypertensive drugs, 0.7% took statin and 2.9% aspirin. Only 2.9% combined two types of modern drugs, while 0.4% combined three types (antihypertensives, statins and aspirin). Herbal compounds, sometimes with internationally rarely recommended drugs such as Reserpine were taken by 44%. Analysis of drug adherence showed that 9.8% had discontinued their drug therapy by themselves. 16% had missed doses and these were on less anti-hypertensive drugs than those who did not (t=-5.217, P=0.003). Of all participants, 28% currently smoked, 39% drank regularly and only 21% exercised frequently. The average salt intake per day was 7.1 (±3.8) g, while the national recommended level is 6g. Conclusion The study revealed outdated and inadequate treatment and health education for hypertensive patients, especially for those who have high risk scores for CVD. There is a need to review the community-based guidelines for hypertension management. Health providers and patients should make a transition from solely treating hypertension, towards prevention of CVD. Health system issues need addressing including improving rural health insurance cover and primary

  20. Neoadjuvant chemotherapy in locally advanced nasopharyngeal carcinoma: Defining high-risk patients who may benefit before concurrent chemotherapy combined with intensity-modulated radiotherapy

    PubMed Central

    Du, Xiao-Jing; Tang, Ling-Long; Chen, Lei; Mao, Yan-Ping; Guo, Rui; Liu, Xu; Sun, Ying; Zeng, Mu-Sheng; Kang, Tie-Bang; Shao, Jian-Yong; Lin, Ai-Hua; Ma, Jun

    2015-01-01

    The purpose of this study was to create a prognostic model for distant metastasis in patients with locally advanced NPC who accept concurrent chemotherapy combined with intensity-modulated radiotherapy (CCRT) to identify high-risk patients who may benefit from neoadjuvant chemotherapy (NACT). A total of 881 patients with newly-diagnosed, non-disseminated, biopsy-proven locoregionally advanced NPC were retrospectively reviewed; 411 (46.7%) accepted CCRT and 470 (53.3%) accepted NACT followed by CCRT. Multivariate analysis demonstrated N2–3 disease, plasma Epstein–Barr virus (EBV) DNA > 4000 copies/mL, serum albumin ≤46 g/L and platelet count >300 k/cc were independent prognostic factors for distant metastasis in the CCRT group. Using these four factors, a prognostic model was developed, as follows: 1) low-risk group: 0–1 risk factors; and 2) high-risk group: 2–4 risk factors. In the high-risk group, patients who accepted NACT + CCRT had significantly higher distant metastasis-free survival and progression-free survival rates than the CCRT group (P = 0.001; P = 0.011). This simple prognostic model for distant metastasis in locoregionally advanced NPC may facilitate with the selection of high-risk patients who may benefit from NACT prior to CCRT. PMID:26564805

  1. Wound wise: wounds in surgical patients who are obese.

    PubMed

    Baugh, Nancy; Zuelzer, Helen; Meador, Jill; Blankenship, Jolie

    2007-06-01

    The number of surgical patients who are obese in the United States is rising, a trend that's likely to continue. Such patients are at higher risk than nonobese patients are for surgical site infections and other complications such as dehiscence, pressure ulcers, deep tissue injury, and rhabdomyolysis. This article details the factors that can contribute to such complications, including a high number of comorbidities, and offers practical suggestions for preventing them. Nurses should understand that special equipment, precautions, and protocols may be needed at every stage of care, and that obese patients aren't anomalies but rather a part of a growing population with particular needs.

  2. Effects of remote ischemic preconditioning in high-risk patients undergoing cardiac surgery (Remote IMPACT): a randomized controlled trial

    PubMed Central

    Walsh, Michael; Whitlock, Richard; Garg, Amit X.; Légaré, Jean-François; Duncan, Andra E.; Zimmerman, Robert; Miller, Scott; Fremes, Stephen; Kieser, Teresa; Karthikeyan, Ganesan; Chan, Matthew; Ho, Anthony; Nasr, Vivian; Vincent, Jessica; Ali, Imtiaz; Lavi, Ronit; Sessler, Daniel I.; Kramer, Robert; Gardner, Jeff; Syed, Summer; VanHelder, Tomas; Guyatt, Gordon; Rao-Melacini, Purnima; Thabane, Lehana; Devereaux, P.J.

    2016-01-01

    Background: Remote ischemic preconditioning is a simple therapy that may reduce cardiac and kidney injury. We undertook a randomized controlled trial to evaluate the effect of this therapy on markers of heart and kidney injury after cardiac surgery. Methods: Patients at high risk of death within 30 days after cardiac surgery were randomly assigned to undergo remote ischemic preconditioning or a sham procedure after induction of anesthesia. The preconditioning therapy was three 5-minute cycles of thigh ischemia, with 5 minutes of reperfusion between cycles. The sham procedure was identical except that ischemia was not induced. The primary outcome was peak creatine kinase–myocardial band (CK-MB) within 24 hours after surgery (expressed as multiples of the upper limit of normal, with log transformation). The secondary outcome was change in creatinine level within 4 days after surgery (expressed as log-transformed micromoles per litre). Patient-important outcomes were assessed up to 6 months after randomization. Results: We randomly assigned 128 patients to remote ischemic preconditioning and 130 to the sham therapy. There were no significant differences in postoperative CK-MB (absolute mean difference 0.15, 95% confidence interval [CI] −0.07 to 0.36) or creatinine (absolute mean difference 0.06, 95% CI −0.10 to 0.23). Other outcomes did not differ significantly for remote ischemic preconditioning relative to the sham therapy: for myocardial infarction, relative risk (RR) 1.35 (95% CI 0.85 to 2.17); for acute kidney injury, RR 1.10 (95% CI 0.68 to 1.78); for stroke, RR 1.02 (95% CI 0.34 to 3.07); and for death, RR 1.47 (95% CI 0.65 to 3.31). Interpretation: Remote ischemic precnditioning did not reduce myocardial or kidney injury during cardiac surgery. This type of therapy is unlikely to substantially improve patient-important outcomes in cardiac surgery. Trial registration: ClinicalTrials.gov, no. NCT01071265. PMID:26668200

  3. Surgical management in patient with uveitis

    PubMed Central

    Murthy, Somasheila I; Pappuru, Rajeev Reddy; Latha, K Madhavi; Kamat, Sripathi; Sangwan, Virender S

    2013-01-01

    Surgery in the management of uveitis can be divided based on indication: either for therapeutic or can be for diagnostic purposes or to manage complications. The commonest indications include: Visual rehabilitation: surgery for removal of cataract, band keratopathy, corneal scars, pupillary membranes, removal of dense vitreous membranes, management of complications: anti-glaucoma surgery, vitreous hemorrhage, retinal detachment and chronic hypotony and diagnostic: aqueous tap, vitreous biopsy, tissue biopsy (iris, choroid). In this review, we shall describe the surgical technique for visual rehabilitation and for management of complications. PMID:23803480

  4. Determining Toxoplasma high-risk autologous and allogeneic hematopoietic stem cell transplantation patients by systematic pre-transplant PCR screening of stem cell originated buffy coat.

    PubMed

    Caner, Ayşe; Dönmez, Ayhan; Döşkaya, Mert; Değirmenci, Aysu; Tombuloğlu, Murat; Cağirgan, Seçkin; Guy, Edward; Francis, Janet; Soyer, Nur Akad; Gürüz, Yüksel

    2012-12-01

    The diagnosis of Toxoplasma infection or disease in hematopoietic stem cell transplantation (HSCT) patients is achieved mainly by PCR screening; however screening did not find wide field of use in practice due to costly expenditures of PCR. This study aimed to determine patients at high risk of Toxoplasma infection or disease before transplantation by stem cell originated buffy coat PCR and subsequently to screen them. Buffy coats collected from 12 autologous and 18 allogeneic HSCT patients' donors were investigated by PCR before transplantation. After transplantation, blood and sera collected at fixed time intervals were screened by two PCR methods and serological assays. Screening results first time assessed a toxoplasmosis incidence level as 25% in autologous HSCT patients and increased incidence level in allogeneic HSCT patients to 22%. Importantly, buffy coat PCR was first time performed before transplantation, to determine the risk of toxoplasmosis. Buffy coat PCR results showed that four patients were at high risk of toxoplasmosis before transplantation. After transplantation, these patients experienced toxoplasmosis. In conclusion, for the determination of patients at risk of toxoplasmosis, clinicians should consider buffy coat PCR in combination with serology before transplantation. After transplantation, PCR screening can be initiated in high risk patients upon clinical suspicion.

  5. Targeting patients for multimorbid care management interventions: the case for equity in high-risk patient identification

    PubMed Central

    2013-01-01

    Targeting patients for multimorbid care management interventions requires accurate and comprehensive assessment of patients’ need in order to direct resources to those who need and can benefit from them the most. Multimorbid patient selection is complicated due to the lack of clear criteria - unlike disease management programs for which patients with a specific condition are identified. This ambiguity can potentially result in inequitable selection, as biases in selection may differentially affect patients from disadvantaged population groups. Patient selection could in principal be performed in three ways: physician referral, patient screening surveys, or by statistical prediction algorithms. This paper discusses equity issues related to each method. We conclude that each method may result in inequitable selection and bias, such as physicians’ attentiveness or familiarity, or prediction models’ reliance on prior resource use, potentially affected by socio-cultural and economic barriers. These biases should be acknowledged and dealt with. We recommend combining patient selection approaches to achieve high care sensitivity, efficiency and equity. PMID:23962231

  6. A Randomized Phase 2 Trial of 177Lu Radiolabeled Anti-PSMA Biochemically Monoclonal Antibody J591 in Patients with High-Risk Castrate, Biochemically Relapsed Prostate Cancer

    DTIC Science & Technology

    2010-09-01

    assigned a lower priority to the protocol, as they may lose money in the conduct of the study. We are in the process of additional fundraising and...WCMC is also considering adding additional sites and is currently fundraising in anticipation of this strategy (see above). c. High-risk patient

  7. Role of peripheral blood minimum residual disease at day 8 of induction therapy in high-risk pediatric patients with acute lymphocytic leukemia

    PubMed Central

    Salina, Thais Ditolvo da Costa; Ferreira, Yvelise Antunes; Alves, Eliana Brasil; Ferreira, Cristina Motta; De Paula, Erich Vinícius; Mira, Marcelo Távora; Passos, Leny da Mota

    2016-01-01

    Risk stratification and treatment intensification, based on minimal residual disease (MRD) mensurement, changed the prognosis of pediatric patients with acute lymphocytic leukemia (ALL). The main aim of this study was to investigate whether peripheral blood (PB) MRD measurement at day 8 (D8) could predict the risk stratification category determined by bone marrow (BM) MRD at day 15 (D15). The study was performed prospectively, in a cohort of 40 children with B-lineage ALL, adopting the protocol of the Brazilian Cooperative Group of the Treatment Childhood Leukemia (GBTLI-2009). MRD was detected by flow cytometry (FC) using a simplifed panel that can reliably identify MRD at early phases of induction therapy. Upon diagnosis, the proportion of low and high-risk patients, was 24:16 (60%:40%). The main result of our study demonstrated the potential of D8 MRD in anticipating of week the risk stratification of high-risk patients as determined by D15 BM MRD. In these patients D8 MRD level of 1% was able to segregate high risk fast responders from high risk slow responders (p = 0.0097). This result could represent an opportunity for early treatment intensification, as already performed in some protocols. PMID:27526794

  8. A Focus Group Exploration of Automated Case-Finders to Identify High-Risk Heart Failure Patients Within an Urban Safety Net Hospital

    PubMed Central

    Patterson, Mark E.; Miranda, Derick; Schuman, Greg; Eaton, Christopher; Smith, Andrew; Silver, Brad

    2016-01-01

    Background: Leveraging “big data” as a means of informing cost-effective care holds potential in triaging high-risk heart failure (HF) patients for interventions within hospitals seeking to reduce 30-day readmissions. Objective: Explore provider’s beliefs and perceptions about using an electronic health record (EHR)-based tool that uses unstructured clinical notes to risk-stratify high-risk heart failure patients. Methods: Six providers from an inpatient HF clinic within an urban safety net hospital were recruited to participate in a semistructured focus group. A facilitator led a discussion on the feasibility and value of using an EHR tool driven by unstructured clinical notes to help identify high-risk patients. Data collected from transcripts were analyzed using a thematic analysis that facilitated drawing conclusions clustered around categories and themes. Results: From six categories emerged two themes: (1) challenges of finding valid and accurate results, and (2) strategies used to overcome these challenges. Although employing a tool that uses electronic medical record (EMR) unstructured text as the benchmark by which to identify high-risk patients is efficient, choosing appropriate benchmark groups could be challenging given the multiple causes of readmission. Strategies to mitigate these challenges include establishing clear selection criteria to guide benchmark group composition, and quality outcome goals for the hospital. Conclusion: Prior to implementing into practice an innovative EMR-based case-finder driven by unstructured clinical notes, providers are advised to do the following: (1) define patient quality outcome goals, (2) establish criteria by which to guide benchmark selection, and (3) verify the tool’s validity and reliability. Achieving consensus on these issues would be necessary for this innovative EHR-based tool to effectively improve clinical decision-making and in turn, decrease readmissions for high-risk patients. PMID:27683666

  9. Toward strategies for cost containment in surgical patients.

    PubMed Central

    Drucker, W R; Gavett, J W; Kirshner, R; Messick, W J; Ingersoll, G

    1983-01-01

    The University of Rochester, Department of Surgery, in response to an experimental community-wide limit on hospital budgets, studied high-cost general surgical patients as a potential source of leverage for containment of hospital costs. It was found that a small number of patients impact significantly on hospital costs. In 1980, 3935 patients at Strong Memorial Hospital (SMH) had at least one contact with a general surgical patient care or intensive care unit; 261 patients (6.6%) had total 1980 charges of more than $20,000 each. They contributed 32% of the total of both general surgical charges and patient days. A subset of 2021 patients was selected to represent more precisely the general surgical patient. The 85 high-cost patients (4.2%) of this subset were chosen for intensive study. These patients generated a significant and disproportionate per cent of total (2021) general surgical charges (26.8%) and hospital days (27.6%). Average total charges were more than 8 times those of the complementary general surgical subset (1936). Nineteen of the 85 patients (22.3%) died in the hospital and 42 patients (49.4%) were dead within 2 1/2 years. Forty patients (of the 85) were then further identified as "complex", based on multiple, usually unrelated, illnesses and multiple annual admissions. Tending to be elderly with poor prognoses, 60% of them had died by April 1983. The major criterion of complexity was the lack of a well-focused medical problem; the cure for one problem simply relinquished primacy to another. A parallel study of hospital ancillary procedures disclosed a similar high-cost pattern. Of approximately 4000 ancillary procedures, 100 (2.5%) had annual charges of $100,000 or over, accounting for two-thirds of total 1980 ancillary charges. Roughly 20% of a single patient's ordered procedures accounted for 80% of the patient's ancillary charges, thus allowing concentrated study of a relatively small number of charges. Means for cost containment may be

  10. [Communication with surgical patients of older age on the internet].

    PubMed

    Brangan, Sanja; Sonicki, Zdenko

    2013-01-01

    A growing interest of general population to seek health information on the Internet and a growing body of health websites have been well documented in the recent health literature. Moreover, the Internet has become a popular mode of communication between healthcare providers and patients. This has resulted in many efforts to set specific quality guidelines for development of information for patients on the Internet, including different aspects of access to health information. This paper presents results of a study that explored the structure of information sources of surgical patients. Analysis of patient profiles shows that older patients rarely sought surgical information on the Internet, and mostly relied on communication with their doctors. This paper discusses various options of how to make this medium more attractive to patients and how to use the rich experience of the older patient generations to improve the quality of doctor-patient communication.

  11. Neuroleptics under high risk conditions.

    PubMed

    Oyewumi, L K

    1983-08-01

    A critical review of various high risk situations in which neuroleptics could be used and have been used in clinical practice is presented. These high risk situations include: women of child bearing age (pregnant women, lactating and/or nursing mothers), the two extremes of life (children and the elderly), patients with sexual dysfunction, patients with tardive dyskinesia, non-psychotic psychiatric patients, physically ill and suicidal patients. The extraordinary applications of these drugs, such as for rapid tranquilization and megadose regimens are examined. The author provides guidelines for the use of neuroleptics in these clinical situations.

  12. Whole-Pelvic Nodal Radiation Therapy in the Context of Hypofractionation for High-Risk Prostate Cancer Patients: A Step Forward

    SciTech Connect

    Kaidar-Person, Orit; Roach, Mack; Créhange, Gilles

    2013-07-15

    Given the low α/β ratio of prostate cancer, prostate hypofractionation has been tested through numerous clinical studies. There is a growing body of literature suggesting that with high conformal radiation therapy and even with more sophisticated radiation techniques, such as high-dose-rate brachytherapy or image-guided intensity modulated radiation therapy, morbidity associated with shortening overall treatment time with higher doses per fraction remains low when compared with protracted conventional radiation therapy to the prostate only. In high-risk prostate cancer patients, there is accumulating evidence that either dose escalation to the prostate or hypofractionation may improve outcome. Nevertheless, selected patients who have a high risk of lymph node involvement may benefit from whole-pelvic radiation therapy (WPRT). Although combining WPRT with hypofractionated prostate radiation therapy is feasible, it remains investigational. By combining modern advances in radiation oncology (high-dose-rate prostate brachytherapy, intensity modulated radiation therapy with an improved image guidance for soft-tissue sparing), it is hypothesized that WPRT could take advantage of recent results from hypofractionation trials. Moreover, the results from hypofractionation trials raise questions as to whether hypofractionation to pelvic lymph nodes with a high risk of occult involvement might improve the outcomes in WPRT. Although investigational, this review discusses the challenging idea of WPRT in the context of hypofractionation for patients with high-risk prostate cancer.

  13. Value of Coronary Computed Tomography Angiography in Tailoring Aspirin Therapy for Primary Prevention of Atherosclerotic Events in Patients at High Risk With Diabetes Mellitus.

    PubMed

    Dimitriu-Leen, Aukelien C; Scholte, Arthur J H A; van Rosendael, Alexander R; van den Hoogen, Inge J; Kharagjitsingh, Aantje V; Wolterbeek, Ron; Knuuti, Juhani; Kroft, Lucia J M; Delgado, Victoria; Jukema, J Wouter; de Graaf, Michiel A; Bax, Jeroen J

    2016-03-15

    Aspirin use for primary prevention in patients at high risk with diabetes mellitus (DM) is often recommended under the assumption that most patients with DM have coronary artery disease (CAD). However, not all patients may have CAD. The present study evaluated, in 425 patients at high risk with DM (without chest pain syndrome or a history of cardiac disease), the prevalence of CAD on coronary computed tomography angiography (CTA). Moreover, the association between the presence and number of traditional cardiovascular (CV) risk factors and CAD (on coronary CTA) was evaluated. The median coronary artery calcium score was 29 (interquartile range 0 to 298). On coronary CTA, 116 patients (27%) had no CAD (defined as <30% stenosis). Of the 309 patients (73%) with any CAD (≥30% stenosis), 35% had obstructive CAD (≥50% stenosis). The number of traditional CV risk factors was not associated with the presence of any CAD (≥30% stenosis; p = 0.18) or obstructive CAD (≥50% stenosis; p = 0.13). Hypertension was the only traditional CV risk factor associated with a higher frequency of any CAD (≥30% stenosis; odds ratio = 2.21, 95% CI 1.43 to 3.41, p <0.001) and obstructive CAD (≥50% stenosis; odds ratio 2.03, 95% CI 1.33 to 3.11, p = 0.001). In conclusion, in patients at high risk with DM without chest pain syndrome, any CAD was ruled out by coronary CTA in 27%, whereas 65% of the patients did not have obstructive CAD. The number of CV risk factors was not associated with the presence of CAD. Hypertension was the only traditional CV risk factor that was associated with a higher frequency of CAD. These observations support potential use of coronary CTA to tailor aspirin therapy in patients at high risk with DM.

  14. Phase 1b study of new posaconazole tablet for prevention of invasive fungal infections in high-risk patients with neutropenia.

    PubMed

    Duarte, Rafael F; López-Jiménez, Javier; Cornely, Oliver A; Laverdiere, Michel; Helfgott, David; Haider, Shariq; Chandrasekar, Pranatharthi; Langston, Amelia; Perfect, John; Ma, Lei; van Iersel, Marlou L P S; Connelly, Nancy; Kartsonis, Nicholas; Waskin, Hetty

    2014-10-01

    Posaconazole tablets, a new oral formulation of posaconazole, can be effective when given as antifungal prophylaxis to neutropenic patients at high risk for invasive fungal infection (e.g., those with acute myelogenous leukemia or myelodysplastic syndrome). Such effectiveness might be specifically important to patients with poor oral intake because of nausea, vomiting, or chemotherapy-associated mucositis. This was a prospective, global study in high-risk patients to characterize the pharmacokinetics and safety profile of posaconazole tablets and to identify the dose of posaconazole tablets that would provide exposure within a predefined range of exposures (steady-state average concentration [area under the concentration-time curve/24 h] of ≥500 ng/ml and ≤2,500 ng/ml in >90% of patients). The study evaluated two sequential dosing cohorts: 200 mg posaconazole once daily (n = 20) and 300 mg posaconazole once daily (n = 34) (both cohorts had a twice-daily loading dose on day 1) taken without regard to food intake during the neutropenic period for ≤28 days. The exposure target was reached (day 8) in 15 of 19 (79%) pharmacokinetic-evaluable patients taking 200 mg posaconazole once daily and in 31 of 32 (97%) patients taking 300 mg posaconazole once daily; 300 mg posaconazole once daily achieved the desired exposure target. Posaconazole tablets were generally well tolerated in high-risk neutropenic patients. (This study has been registered at ClinicalTrials.gov under registration no. NCT01777763.).

  15. Urinary tract infections in the surgical patient.

    PubMed

    Asher, E F; Oliver, B G; Fry, D E

    1988-07-01

    Urinary tract infection (UTI) continues to be a common nosocomial infection. From a 2-year city-county hospital experience, 212 nosocomial UTI were identified in 153 patients from 3747 admissions. Mean age was 54 years; 102 were men. Foley catheterization was an associated factor in 129 patients (84%). UTI was caused by 40 different species of bacteria. In 28 infections (13%), the UTI was polymicrobial. Only nine patients had bacteremia. The bacteriology of the UTI depended on whether the patient had received systemic antibiotics previously during the hospitalization. Prior antibiotic administration increased the probability of Pseudomonas and Serratia as pathogens. Thus, patients that have had antibiotic therapy demonstrate a distribution of pathogens that are different from patients not receiving antibiotics, and a distribution different from the community-acquired UTI. Continued emphasis on the shorter duration and more judicious use of systemic antibiotics for both prophylaxis and therapy is warranted.

  16. A staged approach to transcatheter aortic valve implantation and mitral valve-in-valve implantation for a degenerated bioprosthesis in a high-risk patient.

    PubMed

    Santarpino, Giuseppe; Fischlein, Theodor; Concistrè, Giovanni; Pfeiffer, Steffen

    2012-10-01

    Recently, small case series have described the successful off-label use of transcatheter valve implantation in patients with degenerated bioprosthetic valves in the mitral position. We report here the case of a 78-year old female patient who underwent transcatheter aortic valve implantation for severe aortic stenosis and transapical valve-in-valve implantation for a degenerated mitral bioprosthesis. There was no evidence of intraprosthetic regurgitation and/or paraprosthetic leakages on control angiography and transoesophageal echocardiography. The postoperative course was uneventful. Following accurate patient selection and evaluation by an experienced multidisciplinary team, the transcatheter approach to double-valve implantation in the aortic and mitral positions may represent a viable treatment option for those high-risk patients who would otherwise be inoperable. We preferred a two-step approach, considering a single procedure to be high-risk.

  17. Hospitalized Patients at High Risk for Obstructive Sleep Apnea Have More Rapid Response System Events and Intervention Is Associated with Reduced Events

    PubMed Central

    Sharma, Sunil; Chowdhury, Anindita; Tang, Lili; Willes, Leslee; Glynn, Brian; Quan, Stuart F.

    2016-01-01

    Background Rapid response system (RRS) is a safety tool designed for early detection and intervention of a deteriorating patient on the general floor in the hospital. Obstructive sleep apnea (OSA) has been associated with significant cardiovascular complications. We hypothesized that patients with high-risk of OSA have higher rate of RRS events and intervention with positive airway pressure therapy in these patients can mitigate the RRS events. Methods As part of a clinical pathway, during a 15 month period, patients with BMI ≥ 30 kg/m2 in select medical services were screened with a validated sleep questionnaire. Patients were characterized as high or low risk based on the screening questionnaire. RRS rates were compared between the groups. Subsequently the impact of PAP therapy on RRS events was evaluated. Results Out of the 2,590 patients screened, 1,973 (76%) were identified as high-risk. RRS rates calculated per 1,000 admissions, were 43.60 in the High-Risk OSA group versus 25.91 in the Low-Risk OSA Group. The PAP therapy compliant group had significantly reduced RRS event rates compared to non-compliant group and group with no PAP therapy (16.99 vs. 53.40 vs. 56.21) (p < 0.01). Conclusion In a large cohort of patients at a tertiary care hospital, we show an association of increased rate of RRS events in high-risk OSA patients and reduction of the risk with PAP intervention in the compliant group. PMID:27168330

  18. A Randomized Phase 2 Trial of 177Lu Radiolabeled Anti-PSMA Monoclonal Antibody J591 in Patients With High-Risk Castrate Biochemically Relapsed Prostate Cancer

    DTIC Science & Technology

    2015-09-01

    Award Number: W81XWH-09-1-0596 TITLE: A Randomized Phase 2 Trial of 177Lu Radiolabeled Anti- PSMA Monoclonal Antibody J591 in Patients With High...1-0596 A Randomized Phase 2 Trial of 177Lu Radiolabeled Anti- PSMA Monoclonal Antibody J591 in Patients With High-Risk Castrat Biochemically Relapsed...in December 2014 with approval to proceed without modifications. 15. SUBJECT TERMS Prostate cancer, PSA, PSMA , monoclonal antibody

  19. Unplanned Intensive Care Unit Admission following Elective Surgical Adverse Events: Incidence, Patient Characteristics, Preventability, and Outcome

    PubMed Central

    Meziane, Mohammed; El Jaouhari, Sidi Driss; ElKoundi, Abdelghafour; Bensghir, Mustapha; Baba, Hicham; Ahtil, Redouane; Aboulaala, Khalil; Balkhi, Hicham; Haimeur, Charki

    2017-01-01

    Context: Adverse events (AEs) are a persistent and an important reason for Intensive Care Unit (ICU) admission. They lead to death, disability at the time of discharge, unplanned ICU admission (UIA), and prolonged hospital stay. They impose large financial costs on health-care systems. Aims: This study aimed to determine the incidence, patient characteristics, type, preventability, and outcome of UIA following elective surgical AE. Settings and Design: This is a single-center prospective study. Methods: Analysis of 15,372 elective surgical procedures was performed. We defined UIA as an ICU admission that was not anticipated preoperatively but was due to an AE occurring within 5 days after elective surgery. Statistical Analysis: Descriptive analysis using SPSS software version 18 was used for statistical analysis. Results: There were 75 UIA (0.48%) recorded during the 2-year study period. The average age of patients was 54.64 ± 18.02 years. There was no sex predominance, and the majority of our patients had an American Society of Anesthesiologist classes 1 and 2. Nearly 29% of the UIA occurred after abdominal surgery and 22% after a trauma surgery. Regarding the causes of UIA, we observed that 44 UIA (58.7%) were related to surgical AE, 24 (32%) to anesthetic AE, and 7 (9.3%) to postoperative AE caused by care defects. Twenty-three UIA were judged as potentially preventable (30.7%). UIA was associated with negative outcomes, including increased use of ICU-specific interventions and high mortality rate (20%). Conclusions: Our analysis of UIA is a quality control exercise that helps identify high-risk patient groups and patterns of anesthesia or surgical care requiring improvement.

  20. Breast Cancer Screening for High-Risk Patients of Different Ages and Risk - Which Modality Is Most Effective?

    PubMed Central

    Vassiliades, Lauren; Abdalla, Reem

    2016-01-01

    While the guidelines for breast cancer screening in average-risk women are well established, screening in high-risk women is not as clear. For women with BRCA1 or BRCA2 mutations, current guidelines recommend screening by clinical breast examination and mammography starting at age 30. For certain high-risk women, additional screening with magnetic resonance imaging (MRI) is encouraged. This review focuses on differentiating imaging modalities used for screening women at high-risk for breast cancer over the age of 50 by discussing the different imaging techniques, cost versus benefit, detection rates, and impact on survival. While mammography is the only imaging modality proven to reduce mortality from breast cancer, MRI is more sensitive in identifying cancers. MRI can often identify smaller malignancies at a greater resolution at an earlier stage. The use of MRI would be more cost effective as there would be less need for invasive therapeutic procedures. Research thus far has not identified an age-specific preference in imaging modality. There are no guidelines for high-risk women that specify screening with respect to age (i.e., older than 50 years old). More research is needed before screening guidelines in different age groups with various risk factors can be established. PMID:28133583

  1. Patient Safety Events and Harms During Medical and Surgical Hospitalizations for Persons With Serious Mental Illness

    PubMed Central

    Daumit, Gail L.; McGinty, Emma E.; Pronovost, Peter; Dixon, Lisa B.; Guallar, Eliseo; Ford, Daniel E.; Cahoon, Elizabeth K.; Boonyasai, Romsai T.; Thompson, David

    2016-01-01

    Objective This study explored the risk of patient safety events and associated nonfatal physical harms and mortality in a cohort of persons with serious mental illness. This group experiences high rates of medical comorbidity and premature mortality and may be at high risk of adverse patient safety events. Methods Medical record review was conducted for medical-surgical hospitalizations occurring during 1994–2004 in a community-based cohort of Maryland adults with serious mental illness. Individuals were eligible if they died within 30 days of a medical-surgical hospitalization and if they also had at least one prior medical-surgical hospitalization within five years of death. All admissions took place at Maryland general hospitals. A case-crossover analysis examined the relationships among patient safety events, physical harms, and elevated likelihood of death within 30 days of hospitalization. Results A total of 790 hospitalizations among 253 adults were reviewed. The mean number of patient safety events per hospitalization was 5.8, and the rate of physical harms was 142 per 100 hospitalizations. The odds of physical harm were elevated in hospitalizations in which 22 of the 34 patient safety events occurred (p<.05), including medical events (odds ratio [OR]=1.5, 95% confidence interval [CI]=1.3–1.7) and procedure-related events (OR=1.6, CI=1.2–2.0). Adjusted odds of death within 30 days of hospitalization were elevated for individuals with any patient safety event, compared with those with no event (OR=3.7, CI=1.4–10.3). Conclusions Patient safety events were positively associated with physical harm and 30-day mortality in nonpsychiatric hospitalizations for persons with serious mental illness. PMID:27181736

  2. Mutation Analysis of the RAD51C and RAD51D Genes in High-Risk Ovarian Cancer Patients and Families from the Czech Republic

    PubMed Central

    Janatova, Marketa; Soukupova, Jana; Stribrna, Jana; Kleiblova, Petra; Vocka, Michal; Boudova, Petra; Kleibl, Zdenek

    2015-01-01

    Recent studies have conferred that the RAD51C and RAD51D genes, which code for the essential proteins involved in homologous recombination, are ovarian cancer (OC) susceptibility genes that may explain genetic risks in high-risk patients. We performed a mutation analysis in 171 high-risk BRCA1 and BRCA2 negative OC patients, to evaluate the frequency of hereditary RAD51C and RAD51D variants in Czech population. The analysis involved direct sequencing, high resolution melting and multiple ligation-dependent probe analysis. We identified two (1.2%) and three (1.8%) inactivating germline mutations in both respective genes, two of which (c.379_380insG, p.P127Rfs*28 in RAD51C and c.879delG, p.C294Vfs*16 in RAD51D) were novel. Interestingly, an indicative family cancer history was not present in four carriers. Moreover, the ages at the OC diagnoses in identified mutation carriers were substantially lower than those reported in previous studies (four carriers were younger than 45 years). Further, we also described rare missense variants, two in RAD51C and one in RAD51D whose clinical significance needs to be verified. Truncating mutations and rare missense variants ascertained in OC patients were not detected in 1226 control samples. Although the cumulative frequency of RAD51C and RAD51D truncating mutations in our patients was lower than that of the BRCA1 and BRCA2 genes, it may explain OC susceptibility in approximately 3% of high-risk OC patients. Therefore, an RAD51C and RAD51D analysis should be implemented into the comprehensive multi-gene testing for high-risk OC patients, including early-onset OC patients without a family cancer history. PMID:26057125

  3. Adjuvant treatment may benefit patients with high-risk upper rectal cancer: A nomogram and recursive partitioning analysis of 547 patients

    PubMed Central

    Wang, Xin; Jin, Jing; Yang, Yong; Liu, Wen-Yang; Ren, Hua; Feng, Yan-Ru; Xiao, Qin; Li, Ning; Deng, Lei; Fang, Hui; Jing, Hao; Lu, Ning-Ning; Tang, Yu; Wang, Jian-Yang; Wang, Shu-Lian; Wang, Wei-Hu; Song, Yong-Wen; Liu, Yue-Ping; Li, Ye-Xiong

    2016-01-01

    Purpose The role of adjuvant chemoradiotherapy (ACRT) or adjuvant chemotherapy (ACT) in treating patients with locally advanced upper rectal cancer (URC) after total mesorectal excision (TME) surgery remains unclear. We developed a clinical nomogram and a recursive partitioning analysis (RPA)-based risk stratification system for predicting 5-year cancer-specific survival (CSS) to determine whether these individuals require ACRT or ACT. Materials and Methods This retrospective analysis included 547 patients with primary URC. A nomogram was developed based on the Cox regression model. The performance of the model was assessed by concordance index (C-index) and calibration curve in internal validation with bootstrapping. RPA stratified patients into risk groups based on their tumor characteristics. Results Five independent prognostic factors (age, preoperative increased carcinoembryonic antigen and carcinoma antigen 19-9, positive lymph node [PLN] number, tumor deposit [TD], pathological T classification) were identified and entered into the predictive nomogram. The bootstrap-corrected C-index was 0.757. RPA stratification of the three prognostic groups showed obviously different prognosis. Only the high-risk group (patients with PLN ≤ 6 and TD, or PLN > 6) benefited from ACRT plus ACT when compared with surgery followed by ACRT or ACT, and surgery alone (5-year CSS: 70.8% vs. 57.8% vs. 15.6%, P < 0.001). Conclusions Our nomogram predicts 5-year CSS after TME surgery for locally advanced rectal cancer and RPA-based stratification indicates that ACRT plus ACT post-surgery may be an important treatment plan with potentially significant survival advantages in high-risk URC. This may help to select candidates of adjuvant treatment in prospective studies. PMID:27449095

  4. Surgical site infection in patients submitted to heart transplantation

    PubMed Central

    Rodrigues, Jussara Aparecida Souza do Nascimento; Ferretti-Rebustini, Renata Eloah de Lucena; Poveda, Vanessa de Brito

    2016-01-01

    Abstract Objectives: to analyze the occurrence and predisposing factors for surgical site infection in patients submitted to heart transplantation, evaluating the relationship between cases of infections and the variables related to the patient and the surgical procedure. Method: retrospective cohort study, with review of the medical records of patients older than 18 years submitted to heart transplantation. The correlation between variables was evaluated by using Fisher's exact test and Mann-Whitney-Wilcoxon test. Results: the sample consisted of 86 patients, predominantly men, with severe systemic disease, submitted to extensive preoperative hospitalizations. Signs of surgical site infection were observed in 9.3% of transplanted patients, with five (62.5%) superficial incisional, two (25%) deep and one (12.5%) case of organ/space infection. There was no statistically significant association between the variables related to the patient and the surgery. Conclusion: there was no association between the studied variables and the cases of surgical site infection, possibly due to the small number of cases of infection observed in the sample investigated. PMID:27579924

  5. Nursing the critically ill surgical patient in Zambia.

    PubMed

    Carter, Chris; Snell, David

    2016-11-10

    Critical illness in the developing world is a substantial burden for individuals, families, communities and healthcare services. The management of these patients will depend on the resources available. Simple conditions such as a fractured leg or a strangulated hernia can have devastating effects on individuals, families and communities. The recent Lancet Commission on Global Surgery and the World Health Organization promise to strengthen emergency and essential care will increase the focus on surgical services within the developing world. This article provides an overview of nursing the critically ill surgical patient in Zambia, a lower middle income country (LMIC) in sub-Saharan Africa.

  6. Pneumothorax, Pneumomediastinum, Pneumoperitoneum and Surgical Emphysema in Mechanically Ventilated Patients

    PubMed Central

    Kamha, A; Alzeer, H; Elithy, M

    2008-01-01

    A 29 year old male patient of Indian ancestry was admitted to an outside hospital with rapid deterioration of his level of consciousness. The patient required mechanical ventilation and transfer to MICU at Hamad Medical Corporation. The patient remained hypoxic. Chest X-ray, CT of chest, abdomen, pelvis and proximal areas of both lower limbs were performed. Pneumomediastinum, pneumoperitoneum, and extensive surgical emphysema were the diagnoses. PMID:21516154

  7. Coronary Arteriovenous Fistulas in Adult Patients: Surgical Management and Outcomes

    PubMed Central

    Albeyoglu, Sebnem; Aldag, Mustafa; Ciloglu, Ufuk; Sargin, Murat; Oz, Tugba Kemaloglu; Kutlu, Hakan; Dagsali, Sabri

    2017-01-01

    Objective The aim of this study was to describe the demographic, clinical and anatomic characteristics of coronary arteriovenous fistulas in adult patients who underwent open cardiac surgery and to review surgical management and outcomes. Methods Twenty-one adult patients (12 female, 9 male; mean age: 56.1±7.9 years) who underwent surgical treatment for coronary arteriovenous fistulas were retrospectively included in this study. Coronary angiography, chest X-ray, electrocardiography and transthoracic echocardiography were preoperatively performed in all patients. Demographic and clinical data were also collected. Postoperative courses of all patients were monitored and postoperative complications were noted. Results A total of 25 coronary arteriovenous fistulas were detected in 21 patients; the fistulas originated mainly from left anterior descending artery (n=9, 42.8%). Four (19.4%) patients had bilateral fistulas originating from both left anterior descending and right coronary artery. The main drainage site of coronary arteriovenous fistulas was the pulmonary artery (n=18, 85.7%). Twelve (57.1%) patients had isolated coronary arteriovenous fistulas and 4 (19.4%), concomitant coronary artery disease. Twenty (95.3%) of all patients were symptomatic. Seventeen patients were operated on with and 4 without cardiopulmonary bypass. There was no mortality. Three patients had postoperative atrial fibrillation. One patient had pericardial effusion causing cardiac tamponade who underwent reoperation. Conclusion The decision of surgical management should be made on the size and the anatomical location of coronary arteriovenous fistulas and concomitant cardiac comorbidities. Surgical closure with ligation of coronary arteriovenous fistulas can be performed easily with on-pump or off-pump coronary artery bypass grafting, even in asymptomatic patients to prevent fistula related complications with very low risk of mortality and morbidity.

  8. Long-term Follow-up of Treatment with Ibrutinib and Rituximab in Patients with High-Risk Chronic Lymphocytic Leukemia.

    PubMed

    Jain, Preetesh; Keating, Michael J; Wierda, William G; Sivina, Mariela; Thompson, Philip A; Ferrajoli, Alessandra; Estrov, Zeev; Kantarjian, Hagop; O'Brien, Susan; Burger, Jan A

    2016-10-19

    Background: Ibrutinib is an active therapy with an acceptable safety profile for patients with chronic lymphocytic leukemia (CLL), including high-risk patients with del17p or with TP53 mutations. Ibrutinib is broadly indicated for the treatment of patients with CLL and specifically including those with 17p deletion. The optimal use of ibrutinib in combination with other agents remains controversial.Methods: We report the long-term outcome [median follow-up of 47 months (range, 36-51 months)] of 40 patients with high-risk CLL, treated on the first ibrutinib combination trial with rituximab (IR). The majority of patients (36/40) were previously treated.Results: Median age was 65 years, and 21 patients (52%) had 17p deletion. Median duration on treatment was 41 months (range, 2-51 months), and median number of treatment cycles was 42 (range, 2-49). Overall response rate was 95%, and 9 patients (23%) attained a complete remission. Twenty-one patients discontinued treatment, 10 due to disease progression, 9 for other causes, and 2 due to stem cell transplantation; the remaining 19 patients continue on ibrutinib. Median progression-free survival for all patients was 45 months, which was significantly shorter in the subgroup of patients with del17p (n = 21, 32.3 months, P = 0.02). Fourteen patients (35%) died, five from progressive disease, five from infections, and four from other causes. Median overall survival has not been reached.Conclusions: IR combination therapy leads to durable remissions in high-risk CLL; the possible benefit from the addition of rituximab is currently explored in a randomized trial. Clin Cancer Res; 1-5. ©2016 AACR.

  9. Evaluation of biochemical recurrence in patients with high-risk prostate cancer treated with radical prostatectomy and radiotherapy plus androgen deprivation therapy

    PubMed Central

    Yamamoto, Yutaka; Kiba, Keisuke; Yoshikawa, Motokiyo; Hirayama, Akihide; Kunikata, Seiji; Uemura, Hirotsugu

    2016-01-01

    Objective The aim of this study was to evaluate the biochemical recurrence (BCR) in patients with high-risk prostate cancer (PCa) treated with radical prostatectomy (RP) or radiotherapy (RT) plus androgen deprivation therapy (ADT). Methods Subjects were patients with National Comprehensive Cancer Network-defined high-risk PCa treated with either RP or RT plus ADT. We calculated BCR-free survival in patients with those treatments and evaluated risk factor against BCR. Results A total of 114 patients, 71 RP and 43 RT plus ADT, were evaluated. A total of 59 and 20.9% of patients experienced BCR in the RP and RT treatment groups, respectively. The 5-year BCR-free survival probabilities improved significantly for patients who received RT compared to those who received RP (81.3 vs 37.3%, P<0.001). According to the number of risk factors, 59.2% of patients in the RP and 51.2% of patients in the RT treatment groups were classified with one risk factor (P<0.014). The 5-year BCR-free survival probabilities for patients treated with RP were 46.6 and 21.7% for one and multiple risk factors, respectively (P=0.008). On univariate analysis, only the number of risk factors had a significant impact on the risk of BCR. Meanwhile, there were no significant differences in the 5-year BCR-free survival probabilities between one and multiple risk factors in patients treated with RT. Conclusion Among patients treated with RP, a marked heterogeneity existed in the oncological outcomes. Based on these findings, the number of risk factors should be emphasized to decide the optimal treatments for patients with high-risk PCa. PMID:27981044

  10. DOC-2/DAB2 Interacting Protein Status in High-Risk Prostate Cancer Correlates With Outcome for Patients Treated With Radiation Therapy

    SciTech Connect

    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

    2014-07-15

    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

  11. Use of a wearable defibrillator in terminating tachyarrhythmias in patients at high risk for sudden death: results of the WEARIT/BIROAD.

    PubMed

    Feldman, Arthur M; Klein, Helmut; Tchou, Patrick; Murali, Srinivas; Hall, W Jackson; Mancini, Donna; Boehmer, John; Harvey, Mark; Heilman, M Stephen; Szymkiewicz, Steven J; Moss, Arthur J

    2004-01-01

    The automatic ICD improves survival in patients with a history of sudden cardiac arrest. However, some patients do not meet the guidelines for ICD implantation or are unable to receive an implantable device. This study tested the hypothesis that these patients could benefit from a wearable cardioverter defibrillator. Patients with symptomatic heart failure and an ejection fraction of <0.30 (WEARIT Study) or patients having complications associated with high risk for sudden death after a myocardial infarction or bypass surgery not receiving an ICD for up to 4 months (BIROAD Study) were enrolled into two studies. After a total of 289 patients had been enrolled in the trial (177 in WEARIT and 112 in BIROAD), prespecified safety and effectiveness guidelines had been met. Six (75%) of eight defibrillation attempts were successful. Six inappropriate shock episodes occurred during 901 months of patient use (0.67% unnecessary shocks per month of use). Twelve deaths occurred during the study 6 sudden deaths: 5 not wearing and 1 incorrectly wearing the device). Most patients tolerated the device although 68 patients quit due to comfort issues or adverse reactions. The results of the present study suggest that a wearable defibrillator is beneficial in detecting and effectively treating ventricular tachyarrhythmias in patients at high risk for sudden death who are not clear candidates for an ICD and may be useful as a bridge to transplantation or ICD in some patients.

  12. Surgical risk in patients with cirrhosis.

    PubMed

    Nicoll, Amanda

    2012-10-01

    Surgery in the patient with cirrhosis is problematic, as encephalopathy, ascites, sepsis and bleeding are common in the postoperative period. Accurate preoperative assessment and planning, and careful postoperative management have the potential to reduce the frequency and severity of such complications, and reduce the length of hospital stay, but there is little literature evidence to prove this. Operative mortality and other risks correlate with the severity of the liver disease, co-morbidities and the type of surgery. The Child-Turcott-Pugh (CTP) score or model for end-stage liver disease (MELD) score may be used to determine the severity of the liver disease, but must also take into account recent changes in the patient's condition. Surgery that does not involve opening the peritoneum may have slightly better outcomes, as the risk of ascitic leak, sepsis and difficult fluid management are reduced. Mortality rates range from 10% in CTP-A patients to 82% in CTP-C patients. The presence of portal hypertension is an important negative predictor, especially in abdominal surgery, as refractory ascites may occur. Careful monitoring in the postoperative period and early intervention of complications are essential. Hepatic resections in cirrhosis are associated with other considerations such as leaving sufficient liver tissue to prevent liver failure, and are beyond the scope of this review.

  13. Obesity-related insulin resistance: implications for the surgical patient.

    PubMed

    Tewari, N; Awad, S; Macdonald, I A; Lobo, D N

    2015-11-01

    In healthy surgical patients, preoperative fasting and major surgery induce development of insulin resistance (IR). IR can be present in up to 41% of obese patients without diabetes and this can rise in the postoperative period, leading to an increased risk of postoperative complications. Inflammation is implicated in the aetiology of IR. This review examines obesity-associated IR and its implications for the surgical patient. Searches of the Medline and Science Citation Index databases were performed using various key words in combinations with the Boolean operators AND, OR and NOT. Key journals, nutrition and metabolism textbooks and the reference lists of key articles were also hand searched. Adipose tissue has been identified as an active endocrine organ and the chemokines secreted as a result of macrophage infiltration have a role in the pathogenesis of IR. Visceral adipose tissue appears to be the most metabolically active, although results across studies are not consistent. Results from animal and human studies often provide conflicting results, which has rendered the pursuit of a common mechanistic pathway challenging. Obesity-associated IR appears, in part, to be related to inflammatory changes associated with increased adiposity. Postoperatively, the surgical patient is in a proinflammatory state, so this finding has important implications for the obese surgical patient.

  14. Intense Androgen-Deprivation Therapy With Abiraterone Acetate Plus Leuprolide Acetate in Patients With Localized High-Risk Prostate Cancer: Results of a Randomized Phase II Neoadjuvant Study

    PubMed Central

    Taplin, Mary-Ellen; Montgomery, Bruce; Logothetis, Christopher J.; Bubley, Glenn J.; Richie, Jerome P.; Dalkin, Bruce L.; Sanda, Martin G.; Davis, John W.; Loda, Massimo; True, Lawrence D.; Troncoso, Patricia; Ye, Huihui; Lis, Rosina T.; Marck, Brett T.; Matsumoto, Alvin M.; Balk, Steven P.; Mostaghel, Elahe A.; Penning, Trevor M.; Nelson, Peter S.; Xie, Wanling; Jiang, Zhenyang; Haqq, Christopher M.; Tamae, Daniel; Tran, NamPhuong; Peng, Weimin; Kheoh, Thian; Molina, Arturo; Kantoff, Philip W.

    2014-01-01

    Purpose Cure rates for localized high-risk prostate cancers (PCa) and some intermediate-risk PCa are frequently suboptimal with local therapy. Outcomes are improved by concomitant androgen-deprivation therapy (ADT) with radiation therapy, but not by concomitant ADT with surgery. Luteinizing hormone–releasing hormone agonist (LHRHa; leuprolide acetate) does not reduce serum androgens as effectively as abiraterone acetate (AA), a prodrug of abiraterone, a CYP17 inhibitor that lowers serum testosterone (< 1 ng/dL) and improves survival in metastatic PCa. The possibility that greater androgen suppression in patients with localized high-risk PCa will result in improved clinical outcomes makes paramount the reassessment of neoadjuvant ADT with more robust androgen suppression. Patients and Methods A neoadjuvant randomized phase II trial of LHRHa with AA was conducted in patients with localized high-risk PCa (N = 58). For the first 12 weeks, patients were randomly assigned to LHRHa versus LHRHa plus AA. After a research prostate biopsy, all patients received 12 additional weeks of LHRHa plus AA followed by prostatectomy. Results The levels of intraprostatic androgens from 12-week prostate biopsies, including the primary end point (dihydrotestosterone/testosterone), were significantly lower (dehydroepiandrosterone, Δ4-androstene-3,17-dione, dihydrotestosterone, all P < .001; testosterone, P < .05) with LHRHa plus AA compared with LHRHa alone. Prostatectomy pathologic staging demonstrated a low incidence of complete responses and minimal residual disease, with residual T3- or lymph node–positive disease in the majority. Conclusion LHRHa plus AA treatment suppresses tissue androgens more effectively than LHRHa alone. Intensive intratumoral androgen suppression with LHRHa plus AA before prostatectomy for localized high-risk PCa may reduce tumor burden. PMID:25311217

  15. Long-term outcomes for patients with prostate cancer having intermediate and high-risk disease, treated with combination external beam irradiation and brachytherapy.

    PubMed

    Dattoli, Michael; Wallner, Kent; True, Lawrence; Bostwick, David; Cash, Jennifer; Sorace, Richard

    2010-01-01

    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 (P = .01) and PSA (P = .03). Hormonal therapy did not affect failure rates (P = .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.

  16. Prevalence of malnutrition in general surgical patients.

    PubMed

    Aoun, J P; Baroudi, J; Geahchan, N

    1993-01-01

    The possibility of protein-calorie malnutrition (PCM) was studied on one hundred consecutive patients admitted to the department of surgery at the Saint Georges Hospital, Beirut, during the months of April and June 1991, regardless of age, sex and socio-economic status. Data was completed on 94 of those cases. Multiple parameters were studied, including measurements of triceps and subscapular skinfold thickness, mid-arm muscle circumference, percent weight loss, creatinine height index, serum albumin and transferrin levels and total lymphocyte count. We found a prevalence of 81%, 65%, 53% and 31% of PCM, if one, two, three or at least four abnormal parameters are used respectively, to assess malnutrition. Defining malnutrition as the presence of at least three abnormal parameters, we conclude that 53% of the patients, on admission to the department of surgery, had evidence of PCM. Further studies are required to assess the impact of this prevalence on length of stay, morbidity and mortality.

  17. NS-018, a selective JAK2 inhibitor, preferentially inhibits CFU-GM colony formation by bone marrow mononuclear cells from high-risk myelodysplastic syndrome patients.

    PubMed

    Kuroda, Junya; Kodama, Ayumi; Chinen, Yoshiaki; Shimura, Yuji; Mizutani, Shinsuke; Nagoshi, Hisao; Kobayashi, Tsutomu; Matsumoto, Yosuke; Nakaya, Yohei; Tamura, Ayako; Kobayashi, Yutaka; Naito, Haruna; Taniwaki, Masafumi

    2014-05-01

    JAK2/STAT signaling promotes survival and expansion of myelodysplastic syndrome (MDS) clones, but little is known about the potential of JAK2/STAT as a therapeutic target in MDS. We investigated the effect of NS-018, a novel antagonist for JAK2, on the colony-forming ability of bone marrow mononuclear cells (BMMNCs) from high-risk MDS patients. NS-018 decreased colony-forming unit-granulocyte/macrophage (CFU-GM) colony numbers from MDS-derived BMMNCs in a dose-dependent manner, and this effect was significantly more potent than against normal BMMNCs. In addition, NS-018 suppressed the phosphorylation of STAT3 in colony-forming cells from MDS patients. Collectively, NS-018 could be a new therapeutic option for high-risk MDS.

  18. Patient outcomes following surgical management of multinodular goiter

    PubMed Central

    Lin, Yann-Sheng; Wu, Hsin-Yi; Yu, Ming-Chin; Hsu, Chih-Chieh; Chao, Tzu-Chieh

    2016-01-01

    Abstract Background: the difference in the risk of thyroid malignancy for patients with multinodular goiter (MNG) and solitary nodular goiter (SNG) remains controversial. Although total thyroidectomy (TT) is the current preferred surgical option for MNG, permanent hypothyroidism in these patients may be a concern. Therefore, we discuss whether nontotal thyroidectomy is a reasonable alternative surgical option. Methods: A retrospective cohort study was performed for 1598 consecutive patients who underwent thyroid surgery for nodular goiter between January 2007 and December 2012. Numerous clinical parameters were collected and analyzed. Results: We reviewed 795 patients with MNG and 803 patients with SNG. The prevalence of malignancy on final pathology was significantly higher in the patients with MNG than in the patients with SNG (15.6% vs 10.1%, P = 0.001). However, a multivariate analysis revealed that this difference was insignificant (P = 0.50). Papillary carcinoma was the predominant type in both groups, but papillary microcarcinoma was more frequently found (41.1%) in the patients with MNG. The only multifocal cancers were of the papillary carcinoma histologic type, and the incidence of multifocal papillary carcinoma was significantly higher in the patients with MNG (23.4% vs 7.4%, P = 0.005). Reoperation was not required for the patients who underwent TT for goiter recurrence or incidental carcinoma. The overall rate of recurrence following nontotal thyroidectomy was 12.2%. Among the patients who underwent reoperation for goiter recurrence, 2 (20.0%) were complicated with permanent hypoparathyroidism. Among the patients who underwent a nontotal bilateral thyroidectomy, an average of 56.5% had permanent hypothyroidism. Conclusions: Multinodularity does not increase the risk of thyroid malignancy. However, patients with MNG who develop papillary carcinoma are at an increased risk of cancer multifocality. If a patient can tolerate lifelong thyroid hormone

  19. Washed cell salvage in surgical patients

    PubMed Central

    Meybohm, Patrick; Choorapoikayil, Suma; Wessels, Anke; Herrmann, Eva; Zacharowski, Kai; Spahn, Donat R.

    2016-01-01

    Abstract Background: Cell salvage is commonly used as part of a blood conservation strategy. However concerns among clinicians exist about the efficacy of transfusion of washed cell salvage. Methods: We performed a meta-analysis of randomized controlled trials in which patients, scheduled for all types of surgery, were randomized to washed cell salvage or to a control group with no cell salvage. Data were independently extracted, risk ratio (RR), and weighted mean differences (WMD) with 95% confidence intervals (CIs) were calculated. Data were pooled using a random effects model. The primary endpoint was the number of patients exposed to allogeneic red blood cell (RBC) transfusion. Results: Out of 1140 search results, a total of 47 trials were included. Overall, the use of washed cell salvage reduced the rate of exposure to allogeneic RBC transfusion by a relative 39% (RR = 0.61; 95% CI 0.57 to 0.65; P < 0.001), resulting in an average saving of 0.20 units of allogeneic RBC per patient (weighted mean differences [WMD] = −0.20; 95% CI −0.22 to −0.18; P < 0.001), reduced risk of infection by 28% (RR = 0.72; 95% CI 0.54 to 0.97; P = 0.03), reduced length of hospital stay by 2.31 days (WMD = −2.31; 95% CI −2.50 to −2.11; P < 0.001), but did not significantly affect risk of mortality (RR = 0.92; 95% CI 0.63 to 1.34; P = 0.66). No statistical difference could be observed in the number of patients exposed to re-operation, plasma, platelets, or rate of myocardial infarction and stroke. Conclusions: Washed cell salvage is efficacious in reducing the need for allogeneic RBC transfusion and risk of infection in surgery. PMID:27495095

  20. [Cervical spine instability in the surgical patient].

    PubMed

    Barbeito, A; Guerri-Guttenberg, R A

    2014-03-01

    Many congenital and acquired diseases, including trauma, may result in cervical spine instability. Given that airway management is closely related to the movement of the cervical spine, it is important that the anesthesiologist has detailed knowledge of the anatomy, the mechanisms of cervical spine instability, and of the effects that the different airway maneuvers have on the cervical spine. We first review the normal anatomy and biomechanics of the cervical spine in the context of airway management and the concept of cervical spine instability. In the second part, we review the protocols for the management of cervical spine instability in trauma victims and some of the airway management options for these patients.

  1. Chemoradiation With Paclitaxel and Carboplatin in High-Risk Cervical Cancer Patients After Radical Hysterectomy: A Korean Gynecologic Oncology Group Study

    SciTech Connect

    Lee, Taek Sang; Kang, Soon Beom; Kim, Young Tak; Park, Byung Joo; Kim, Yong Man; Lee, Jong Min; Kim, Seok Mo; Kim, Young Tae; Kim, Jae Hoon; Kim, Kyung Tai

    2013-06-01

    Purpose: To evaluate the efficacy and toxicity of concurrent chemoradiation with paclitaxel and carboplatin in patients with high-risk cervical cancer. Methods and Materials: Patients after radical hysterectomy for cervical cancer, with at least 1 high-risk characteristic, were administered paclitaxel 135 mg/m{sup 2}, carboplatin area under the curve = 5 every 3 weeks for 3 cycles concomitant with radiation therapy as adjuvant treatment. Results: This prospective study enrolled 71 consecutive patients. Sixty-six patients (93%) completed the planned treatment. The majority of grade 3/4 neutropenia or nonhematologic toxicities were usually self-limited. Diarrhea grades 3/4 were observed in 4 patients (5.6%). One patient developed anaphylactic shock after infusion of paclitaxel. With a median follow-up of 57 months, recurrences occurred in 16 patients. Multivariable analysis indicated that common iliac lymph node involvement is an independent risk factor for disease recurrence (odds ratio 13.48; 95% confidence interval 2.93-62.03). In the intent-to-treat population (n=71), the estimated 5-year disease-free survival and overall survival rates were 77.3% and 80.3% respectively. In the per-protocol population (n=62), disease-free survival was 78.9% and overall survival was 83.9%. Conclusions: Concurrent chemoradiation with paclitaxel/carboplatin is well tolerated and seems to be effective for patients who undergo radical hysterectomy. Therefore, a prospective, randomized controlled study should be designed to evaluate efficacy of this approach for patients with high-risk cervical cancer.

  2. Surgical intervention for esophageal atresia in patients with trisomy 18.

    PubMed

    Nishi, Eriko; Takamizawa, Shigeru; Iio, Kenji; Yamada, Yasumasa; Yoshizawa, Katsumi; Hatata, Tomoko; Hiroma, Takehiko; Mizuno, Seiji; Kawame, Hiroshi; Fukushima, Yoshimitsu; Nakamura, Tomohiko; Kosho, Tomoki

    2014-02-01

    Trisomy 18 is a common chromosomal aberration syndrome involving growth impairment, various malformations, poor prognosis, and severe developmental delay in survivors. Although esophageal atresia (EA) with tracheoesophageal fistula (TEF) is a potentially fatal complication that can only be rescued through surgical correction, no reports have addressed the efficacy of surgical intervention for EA in patients with trisomy 18. We reviewed detailed clinical information of 24 patients with trisomy 18 and EA who were admitted to two neonatal intensive care units in Japan and underwent intensive treatment including surgical interventions from 1982 to 2009. Nine patients underwent only palliative surgery, including six who underwent only gastrostomy or both gastrostomy and jejunostomy (Group 1) and three who underwent gastrostomy and TEF division (Group 2). The other 15 patients underwent radical surgery, including 10 who underwent single-stage esophago-esophagostomy with TEF division (Group 3) and five who underwent two-stage operation (gastrostomy followed by esophago-esophagostomy with TEF division) (Group 4). No intraoperative death or anesthetic complications were noted. Enteral feeding was accomplished in 17 patients, three of whom were fed orally. Three patients could be discharged home. The 1-year survival rate was 17%: 27% in those receiving radical surgery (Groups 3 and 4); 0% in those receiving palliative surgery (Groups 1 and 2). Most causes of death were related to cardiac complications. EA is not an absolute poor prognostic factor in patients with trisomy 18 undergoing radical surgery for EA and intensive cardiac management.

  3. Pilot study evaluating the safety of a combined central venous catheter and inferior vena cava filter in critically ill patients at high risk of pulmonary embolism.

    PubMed

    Cadavid, Carlos A; Gil, Bladimir; Restrepo, Alvaro; Alvarez, Sergio; Echeverry, Santiago; Angel, Luis F; Tapson, Victor; Kaufman, John

    2013-04-01

    The objectives of this pilot trial were to assess the safety of a new device for pulmonary embolism (PE) prophylaxis. The device, the Angel Catheter, was placed in eight patients who were in the intensive care unit and were at high risk of PE. The device was inserted at the bedside without fluoroscopic guidance via a femoral venous approach. All eight devices were inserted and subsequently retrieved without complications (follow-up, 33-36 d). One filter trapped a large clot.

  4. Heterozygous germline mutations in NBS1 among Korean patients with high-risk breast cancer negative for BRCA1/2 mutation.

    PubMed

    Kim, Haeyoung; Cho, Dae-Yeon; Choi, Doo Ho; Jung, Gee Hue; Shin, Inkyung; Park, Won; Huh, Seung Jae; Kim, Sung-Won; Park, Sue K; Lee, Jong Won; Nam, Seok Jin; Lee, Jeong Eon; Gil, Won Ho; Kim, Seok Won

    2015-09-01

    The purpose of the present study was to analyze genetic variations in the NBS1 gene and to evaluate the contribution of heterozygous NBS1 mutation to the risk of breast cancer among Korean patients with high-risk breast cancer negative for BRCA1/2 mutation. We screened 235 non-BRCA1/2 Korean patients with high-risk breast cancer for NBS1 mutations. The entire NBS1 gene was sequenced using fluorescent conformation-sensitive capillary electrophoresis. In silico analysis of the NBS1 variants was performed using PolyPhen-2 and SIFT. The frequency of variants predicted to be deleterious by in silico analysis was compared between breast cancer patients and controls. Twenty-eight sequence variants in the NBS1 gene were identified: 9 exonic variants, including 5 missense mutations (p.R169C, p.I171V, p.E185Q, p.E564K, and p.F603L) and 4 silent mutations, and 19 variants within introns. Among the five missense variants, p.I171V (c.511A > G) was the only variant predicted to be deleterious by in silico analysis. Heterozygosity for p.I171V was found in 4/235 patients with breast cancer and 3/281 individuals in the control group. The frequency of p.I171V was not significantly different between the patient and control groups (1.7 vs. 1.06%, p = 0.7). Heterozygosity of p.I171V in the NBS1 gene was found in a small proportion of Korean patients with high-risk breast cancer. The contribution of the p.I171V variant to the development of breast cancer among Korean patients was not significant.

  5. Effects of a Short Educational Program for the Prevention of Foot Ulcers in High-Risk Patients: A Randomized Controlled Trial

    PubMed Central

    Monami, Matteo; Zannoni, Stefania; Gaias, Marianna; Nreu, Besmir; Marchionni, Niccolò; Mannucci, Edoardo

    2015-01-01

    Background. Patient education is capable of reducing the risk for diabetic foot ulcers. However, specific education on foot ulcer prevention was either included in broader programs addressing different parts of diabetes care or provided with time- and resource-consuming curricula. The aim of the study is to assess the feasibility and efficacy of a brief educational program for the prevention of diabetic foot ulcers in high-risk patients. Methods. The study was performed on type 2 diabetic patients, randomized in a 1 : 1 ratio either to intervention or to control group. The principal endpoint was the incidence of foot ulcers. The intervention was a two-hour program provided to groups of 5–7 patients, including a 30-minute face-to-face lesson on risk factors for foot ulcers, and a 90-minute interactive session with practical exercises on behaviors for reducing risk. Results. The study was prematurely terminated due to a highly significant difference in outcome between the two treatment groups. The final sample was therefore composed of 121 patients. Six patients, all in the control group, developed ulcers during the 6-month follow-up (10% versus 0%, p = 0.012). Conclusions. A brief, 2-hour, focused educational program is effective in preventing diabetic foot ulcers in high-risk patients. PMID:26448748

  6. Fractionated gemtuzumab ozogamicin combined with intermediate-dose cytarabine and daunorubicin as salvage therapy in very high-risk AML patients: a bridge to reduced intensity conditioning transplant?

    PubMed

    Paubelle, Etienne; Ducastelle-Leprêtre, Sophie; Labussière-Wallet, Hélène; Nicolini, Franck Emmanuel; Barraco, Fiorenza; Plesa, Adriana; Salles, Gilles; Wattel, Eric; Thomas, Xavier

    2017-03-01

    Outcome of patients with primary refractory/relapsed (R/R) acute myeloid leukemia (AML) remains dismal. Herein, we present a retrospective monocentric study of 24 very high-risk AML patients who received a combination of fractionated gemtuzumab ozogamicin (GO) with intermediate-dose cytarabine and daunorubicin as salvage therapy. Median age was 55.3 years. Diagnostic was secondary AML for 33% of them. Seven patients had favorable risk, 8 had intermediate-1 or intermediate-2, and 6 had unfavorable risk of AML according to the European LeukemiaNet prognostic index. Complete remission was achieved in 50% of cases (46% in refractory and 55% in relapsed AML) without excessive toxicity. Thirteen patients could be referred for transplant. Only allogeneic hematopoietic stem cell transplantation provided a benefit in this patient cohort with a 1-year overall survival of 50.7 versus 18.1% in the absence of transplantation. Patients treated with reduced intensity conditioning (RIC) showed a longer survival as compared to those undergoing myeloablative conditioning regimen mainly because of decreased toxicity.Our data suggest that salvage therapy with fractionated GO combined with intermediate-dose cytarabine and daunorubicin in very high-risk patients may serve as a potential bridge therapy to RIC transplant.

  7. Histologic changes associated with neoadjuvant chemotherapy are predictive of nodal metastases in patients with high-risk prostate cancer.

    PubMed

    O'Brien, Catherine; True, Lawrence D; Higano, Celestia S; Rademacher, Brooks L S; Garzotto, Mark; Beer, Tomasz M

    2010-04-01

    Clinical trials are evaluating the effect of neoadjuvant chemotherapy on men with high-risk prostate cancer. Little is known about the clinical significance of postchemotherapy tumor histopathologic features. We assessed the prognostic and predictive value of histologic features (intraductal carcinoma, vacuolated cell morphologic features, inconspicuous glands, cribriform architecture, and inconspicuous cancer cells) observed in 50 high-risk prostate cancers treated with preprostatectomy docetaxel and mitoxantrone. At a median follow-up of 65 months, the overall relapse-free survival (RFS) rates at 2 and 5 years were 65% and 49%, respectively. In univariate analyses (using the Kaplan-Meier method and log-rank tests), intraductal (P = .001) and cribriform (P = .014) histologic features were associated with shorter RFS. In multivariate analyses, using the Cox proportional hazards regression, baseline prostate-specific antigen (P = .004), lymph node metastases (P < .001), and cribriform histologic features (P = .007) were associated with shorter RFS. In multivariable logistic regression analysis, only intraductal pattern (P = .007) predicted lymph node metastases. Intraductal and cribriform histologic features apparently predict postchemotherapy outcome.

  8. The importance and provision of oral hygiene in surgical patients.

    PubMed

    Ford, Samuel J

    2008-10-01

    The provision of mouth care on the general surgical ward and intensive care setting has recently gained momentum as an important aspect of patient care. Oropharyngeal morbidity can cause pain and disordered swallowing leading to reluctance in commencing or maintaining an adequate dietary intake. On the intensive care unit, aside from patient discomfort and general well-being, oral hygiene is integral to the prevention of ventilator-associated pneumonia. Chlorhexidine (0.2%) is widely used to decrease oral bacterial loading, dental bacterial plaque and gingivitis. Pineapple juice has gained favour as a salivary stimulant in those with a dry mouth or coated tongue. Tooth brushing is the ideal method of promoting oral hygiene. Brushing is feasible in the vast majority, although access is problematic in ventilated patients. Surgical patients undergoing palliative treatment are particularly prone to oral morbidity that may require specific but simple remedies. Neglect of basic aspects of patient care, typified by poor oral hygiene, can be detrimental to surgical outcome.

  9. Combination effect of calcium channel blocker and valsartan on cardiovascular event prevention in patients with high-risk hypertension: ancillary results of the KYOTO HEART Study.

    PubMed

    Sawada, Takahisa; Yamada, Hiroyuki; Shiraishi, Jun; Kimura, Shinzo; Matsubara, Hiroaki

    2012-01-01

    The ancillary analysis of the KYOTO HEART Study (n = 3031) was designed to assess the combined treatment with calcium channel blocker (CCB) plus valsartan for high-risk hypertension. With-CCB (n = 1807) showed less primary events than without-CCB (n = 1224) (P = .037), in which acute myocardial infarction was significantly reduced. With-CCB plus valsartan (n = 773) showed lower incidence than with-CCB plus non-angiotensin receptor blocker (ARB) (n = 1034) (P = .0002), in which angina pectoris and heart failure were significantly reduced. Without-CCB plus valsartan (n = 744) was superior to without-CCB plus non-ARB (n = 480) (P = .0013), in which stroke was reduced. CCB-based therapy was useful, and CCB plus valsartan combination provided a more efficient prevention for high-risk hypertensive patients.

  10. A Phase II Multi-institutional Trial of Chemoradiation Using Weekly Docetaxel and Erythropoietin for High-Risk Postoperative Head and Neck Cancer Patients

    SciTech Connect

    Willey, Christopher D.; Murphy, Barbara A.; Netterville, James L.; Burkey, Brian B.; Shyr, Yu; Shakhtour, Bashar; Kish, Bonnie; Raben, David; Chen Changhu; Song, John I.; Kane, Madeleine A.; Cmelak, Anthony J. . E-mail: anthony.cmelak@vanderbilt.edu

    2007-04-01

    Purpose: To determine efficacy and toxicities of postoperative concurrent chemoradiation using docetaxel in high-risk head and neck cancer. Methods and Materials: High-risk patients were enrolled 2-8 weeks after surgery. Treatment included 60 Gy for 6 weeks with weekly docetaxel 25 mg/m{sup 2} and erythropoietin alpha 40,000 U for hemoglobin {<=}12 g/dL. Primary endpoints included locoregional control (LC), disease-free survival (DFS), and patterns of failure (POF). Secondary endpoints were toxicity and quality of life. Results: Eighteen patients were enrolled (14 male, 4 female), aged 24-70 years (median, 55 years). Primary site included oropharynx = 7, oral cavity 8, hypopharynx = 1, and larynx = 2. Pathologic American Joint Committee on Cancer Stage was III = 3 patients, IV = 15 patients. High-risk eligibility included {>=}2 positive lymph nodes = 13, extracapsular extension = 10, positive margins = 8 (11 patients with two or more risk factors). Docetaxel was reduced to 20 mg/m{sup 2}/week after 5 patients had prolonged Grade 3 or higher mucositis. Overall, number of doses delivered was 2 of 6 = 1, 3 of 6 2, 4 of 6 = 2, 5 of 6 = 4, 6 of 6 = 9 patients. With median follow-up of 30 months (range, 5-66), 10 (56%) patients are alive and have no evidence of disease (NED); POF: three local recurrences (two with distant) and 1 distant only. One-year survival was 76%, median PFS and DFS had not been reached. Three-year LC was 82%. No Grade 3 or higher late toxicities were observed, although a few cases of prolonged mucositis and taste loss (>3 months) were seen, particularly at 25 mg/m{sup 2}/week. Conclusion: Postoperative radiation therapy with weekly docetaxel 20 or 25 mg/m{sup 2}/week for high-risk postoperative head and neck cancer caused intolerable mucosal toxicity, prompting early study termination. Further studies should consider 15 mg/m{sup 2}. Actuarial 3-year LC is 82%, similar to cisplatin-based chemoradiation regimens. Distant metastasis remains an

  11. Endoscopic retrograde cholangiopancreatography in patients with surgically altered gastrointestinal anatomy.

    PubMed

    Amer, Syed; Horsley-Silva, Jennifer L; Menias, Christine O; Pannala, Rahul

    2015-10-01

    Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered upper gastrointestinal anatomy, such as Roux-en-Y gastric bypass (RYGB), can be more challenging compared to those with a normal anatomy. Detailed assessment of cross-sectional imaging features by the radiologist, especially the pancreaticobiliary anatomy, strictures, and stones, is very helpful to the endoscopist in planning the procedure. In addition, any information on enteral anastomoses (for e.g., gastrojejunal strictures and afferent limb obstruction) is also very useful. The endoscopist should review the operative note to understand the exact anatomy prior to procedure. RYGB, which is performed for medically complicated obesity, is the most commonly encountered altered anatomy ERCP procedure. Other situations include patients who have had a pancreaticoduodenectomy or a hepaticojejunostomy. Balloon-assisted deep enteroscopy (single and double-balloon enteroscopy) or rotational endoscopy is often used to traverse the length of the intestine to reach the papilla. In addition, ERCP in these patients is further challenging due to the oblique orientation of the papilla relative to the forward viewing endoscope and the limited enteroscopy-length therapeutic accessories that are currently available. Overall, reported therapeutic success is approximately 70-75% with a complication rate of 3-4%. Alternative approaches include percutaneous transhepatic cholangiography, laparoscopy-assisted ERCP, or surgery. Given the complexity, ERCP in patients with surgically altered anatomy should be performed in close collaboration with body imagers, interventional radiology, and surgical services.

  12. Surgical approaches to the thymus in patients with myasthenia gravis.

    PubMed

    Magee, Mitchell J; Mack, Michael J

    2009-02-01

    Myasthenia gravis is an autoimmune disorder of neuromuscular transmission affecting 2 out of every 100,000 people. Neurologists and surgeons still debate what role surgery should play in its management. Many patients who might benefit from thymectomy are denied the opportunity because of misconceptions, ignorance, or trepidation. By offering effective methods of less invasive thymectomy to these patients, a significant number of patients and treating neurologists previously unwilling to consider surgery may realize the benefits of this established, proven treatment alternative. The surgical approaches reviewed include: transcervical, videothoracoscopic, robotic-assisted, transsternal, and combined transcervical-transsternal maximal thymectomy.

  13. Surgical Options for Drug-Refractory Overactive Bladder Patients

    PubMed Central

    Starkman, Jonathan S; Smith, Christopher P; Staskin, David R

    2010-01-01

    Overactive bladder (OAB) is a symptom complex of urinary frequency, urinary urgency, and nocturia, with or without urgency incontinence. This syndrome is idiopathic in most instances without clearly defined pathophysiology. Studies clearly show that OAB negatively impacts health-related quality of life and impairs daily functioning in a large proportion of patients. Despite recent advances in drug delivery and improved tolerability of antimuscarinic drug class, a large percentage of patients remain refractory to conventional pharmacological therapy for this chronic condition. There are several unique and effective treatments that are available for this difficult population. We review the various surgical options within the urological armamentarium to treat patients with refractory OAB. PMID:20811558

  14. Diagnostic Potential of Cell-Free and Exosomal MicroRNAs in the Identification of Patients with High-Risk Colorectal Adenomas

    PubMed Central

    Kitajima, Takahito; Kawamura, Mikio; Hiro, Junichiro; Kobayashi, Minako; Tanaka, Koji; Inoue, Yasuhiro; Mohri, Yasuhiko; Mori, Takao; Kato, Toshio; Goel, Ajay; Kusunoki, Masato

    2016-01-01

    Background Although there is a growing interest in developing circulating microRNA (miRNA) as noninvasive diagnostic biomarkers for the detection of high-risk colorectal adenomas and early-stage CRCs, but the comparative diagnostic significance of serum vs. exosomal miRNAs remains unexplored. Methods Based upon published literature, we performed an initial discovery step by investigating the expression of a miRNA panel in 20 normal colonic mucosa, 27 adenomas, and 19 CRC tissues. We performed subsequent validation by quantifying expression of candidate miRNAs in total serum and in exosomes from 26 adenoma patients and 47 healthy controls, and evaluated their clinical significance and potential diagnostic value in colorectal adenomas. Results We observed that the expression of four miRNAs, miR-21, miR-29a, miR-92a, and miR-135b, was significantly higher in colorectal adenomas vs. normal colonic mucosa. During validation, expression of miR-21, miR-29a and miR-92a in serum was significantly higher in adenomas vs. healthy controls, significantly correlated with adenoma size and total adenoma number within the colorectum, and significantly discriminated patients with advanced adenomas. In contrast, although exosomal miR-21 and miR-29a levels in adenoma patients were significantly higher than those of healthy volunteers, only exosomal miR-21 significantly correlated with adenoma size and total adenoma number, and could discriminate patients with high-risk adenomas. Conclusion Compared to exosomal miRNAs, serum levels of miR-21, miR-29a and miR-92a are superior diagnostic biomarkers in patients with high-risk adenomatous polyps. PMID:27760147

  15. A high-risk patient with long-QT syndrome with no response to cardioselective beta-blockers.

    PubMed

    Toyota, Naoki; Miyazaki, Aya; Sakaguchi, Heima; Shimizu, Wataru; Ohuchi, Hideo

    2015-09-01

    We present a case of a high-risk 19-year-old female with long-QT syndrome (LQTS) with compound mutations. She had a history of aborted cardiac arrest and syncope and had received treatment with propranolol for 15 years. However, because she developed adult-onset asthma we tried to switch propranolol, a nonselective beta-blocker, to beta-1-cardioselective agents, bisoprolol and metoprolol. These resulted in both a markedly prolonged corrected QT interval and the development of LQTS-associated arrhythmias. Eventually, propranolol was reinitiated at a higher dose with the addition of verapamil, and she has had no further cardiac or asthmatic events for 5 years.

  16. Endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy

    PubMed Central

    Wang, Fei; Xu, Boming; Li, Quanpeng; Zhang, Xiuhua; Jiang, Guobing; Ge, Xianxiu; Nie, Junjie; Zhang, Xiuyun; Wu, Ping; Ji, Jie; Miao, Lin

    2016-01-01

    Abstract Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is challenging. Results of ERCP in those patients varied. The aim of our study was to evaluate the safety and effectiveness of various endoscopes-assisted ERCP in patients with surgically altered anatomy. Fifty-two patients with Billroth II reconstruction (group A), 20 patients with subtotal or total gastrectomy with Roux-en-Y anastomosis (group B), 25 patients with pancreatoduodenectomy or Roux-en-Y hepaticojejunostomy reconstruction (group C) were included. Gastroscope, duodenoscope, colonoscope, and double-balloon enteroscope were used. The endoscope insertion success rate of groups A, B, C was 96.2% (50/52), 85.0% (17/20), 80% (20/25), respectively. χ2 test showed that there was no significant difference between the 3 groups (P = 0.068). The mean insertion time was 36.7, 68.4, and 84.0 minutes, respectively. One-way ANOVA showed that the insertion time of group C was significantly longer than that of groups B and C (both P <0.001). The endoscopic cannulation success rates of groups A, B, C were 90%, 82.4%, and 100%, respectively. χ2 test showed that there was no significant difference between the 3 groups (P = 0.144). The mean cannulation time was 19.4, 28.1, and 20.4 minutes, respectively. One-way ANOVA showed that the cannulation time of group B was longer than that of groups A and C (P <0.001, P = 0.001, respectively). In total, 74 patients with successful biliary cannulation achieved the therapeutic goal; thus, the clinical success rate was 76.3% (74/97). Our study showed that ERCP in patients with surgically altered anatomy was safe and feasible. PMID:28033284

  17. Quality of surgical care and readmission in elderly glioblastoma patients

    PubMed Central

    Nuño, Miriam; Ly, Diana; Mukherjee, Debraj; Ortega, Alicia; Black, Keith L.; Patil, Chirag G.

    2014-01-01

    Background Thirty-day readmissions post medical or surgical discharge have been analyzed extensively. Studies have shown that complex interactions of multiple factors are responsible for these hospitalizations. Methods A retrospective analysis was conducted using the Surveillance, Epidemiology and End Results (SEER) Medicare database of newly diagnosed elderly glioblastoma multiforme (GBM) patients who underwent surgical resection between 1991 and 2007. Hospitals were classified into high- or low-readmission rate cohorts using a risk-adjusted methodology. Bivariate comparisons of outcomes were conducted. Multivariate analysis evaluated differences in quality of care according to hospital readmission rates. Results A total of 1,273 patients underwent surgery in 338 hospitals; 523 patients were treated in 228 high-readmission hospitals and 750 in 110 low-readmission hospitals. Patient characteristics for high-versus low-readmission hospitals were compared. In a confounder-adjusted model, patients treated in high- versus low-readmission hospitals had similar outcomes. The hazard of mortality for patients treated at high- compared to low-readmission hospitals was 1.06 (95% CI, 0.095%–1.19%). While overall complications were comparable between high- and low-readmission hospitals (16.3% vs 14.3%; P = .33), more postoperative pulmonary embolism/deep vein thrombosis complications were documented in patients treated at high-readmission hospitals (7.5% vs 4.1%; P = .01). Adverse events and levels of resection achieved during surgery were comparable at high- and low-readmission hospitals. Conclusions For patients undergoing GBM resection, quality of care provided by hospitals with the highest adjusted readmission rates was similar to the care delivered by hospitals with the lowest rates. These findings provide evidence against the preconceived notion that 30-day readmissions can be used as a metric for quality of surgical and postsurgical care. PMID:26034614

  18. A High-Risk Screen for Psychiatric Discharge Planning.

    ERIC Educational Resources Information Center

    Christ, Winifred R.; And Others

    1994-01-01

    Tested ability of 16-item high-risk screening list to accurately predict high-risk status by comparing admission and discharge high-risk scores for 448 patients with range of psychiatric disorders. Sixty-six percent of patients rated high risk at admission were identically rated at discharge. (Author/NB)

  19. Surgical management of urolithiasis in spinal cord injury patients.

    PubMed

    Nabbout, Philippe; Slobodov, Gennady; Culkin, Daniel J

    2014-06-01

    Urolithiasis is a common condition in patients with spinal cord injury (SCI). Surgical management of stones in this population is more challenging and associated with lower clearance rates than the general population. The rate of complications - specifically infectious complications - is also high due to the chronic bacterial colonization. Shock wave lithotripsy (SWL) has a low clearance rate of 44-73 %. Percutaneous nephrolithotripsy is indicated for larger nephrolithiasis, but multiple procedures may be required to clear the stones. Ureteroscopy has been associated with low success rates because of difficulty in obtaining ureteral access. Historically, bladder stones were managed with open surgery or SWL. Recently, good results have been reported with the combination of endoscopic and laparoscopic techniques. Surgical management of urolithiasis in patients with SCI should be performed in high-volume centers in light of the technical challenges and higher rate of perioperative complications.

  20. Surgical management of hypothalamic hamartomas in patients with gelastic epilepsy.

    PubMed

    Addas, Bassam; Sherman, Elisabeth M S; Hader, Walter J

    2008-09-01

    Gelastic epilepsy (GE) associated with hypothalamic hamartomas (HHs) is now a well-characterized clinical syndrome consisting of gelastic seizures starting in infancy, medically refractory seizures with or without the development of multiple seizure types, and behavioral and cognitive decline. It has been postulated that the development of the HH-GE syndrome is a result of a progressive epileptic encephalopathy or secondary epileptogenesis, which is potentially reversible with treatment of the HH. A variety of surgical options for the treatment of HHs exist, including open and endoscopic procedures, radiosurgery, interstitial radiotherapy, and stereotactic radiofrequency thermocoagulation. Surgical treatment can result in seizure freedom in up to 50% of patients and can be accompanied by significant improvements in behavior, cognition, and quality of life. Partial treatment of HHs may be sufficient to reduce seizure frequency and improve behavior and quality of life with less risk. A component of reversible cognitive dysfunction may be present in some patients with an HH-GE syndrome.

  1. A comparative study-efficacy and safety of combined spinal epidural anesthesia versus spinal anesthesia in high-risk geriatric patients for surgeries around the hip joint

    PubMed Central

    Tummala, Vengamamba; Rao, Lella Nageswara; Vallury, Manoj Kumar; Sanapala, Anitha

    2015-01-01

    Context: Combined spinal epidural anesthesia (CSEA) has a significant advantage by enabling the use of low dose intrathecal local anesthetic, with knowledge that the epidural catheter may be used to extend the block as necessary. CSEA is useful in high-risk geriatric patients by providing greater hemodynamic stability. Aim: This study is designed to compare the clinical effects of CSEA versus spinal anesthesia in high-risk geriatric patients undergoing surgeries around the hip joint. Materials and Methods: Sixty patients aged >65 years, American Society of Anaesthesiology III and IV were randomly allocated into two equal groups. Group A (n = 30) received CSEA with 1 ml (5 mg) of 0.5% hyperbaric bupivacaine with 25 μg fentanyl through spinal route, and the expected incompleteness of spinal block was managed with small incremental dose of 0.5% isobaric bupivacaine through epidural catheter, 1–1.5 ml for every unblocked segment to achieve T10 sensory level. Group B (n = 30) received spinal anesthesia with 2.5 ml (12.5 mg) of 0.5% hyperbaric bupivacaine and 25 μg fentanyl. Result: Both the groups showed rapid onset, excellent analgesia and good quality motor block. Group A showed a significantly less incidence of hypotension (P < 0.01) along with the provision of prolonging analgesia as compared to Group B. Conclusion: CSEA is a safe, effective, reliable technique with better hemodynamic stability along with the provision of prolonging analgesia compared to spinal anesthesia for high-risk geriatric patients undergoing surgeries around the hip joint. PMID:26417125

  2. Apheresis and intravenous immunoglobulins used in addition to conventional therapy to treat high-risk pregnant antiphospholipid antibody syndrome patients. A prospective study.

    PubMed

    Ruffatti, Amelia; Favaro, Maria; Hoxha, Ariela; Zambon, Alessandra; Marson, Piero; Del Ross, Teresa; Calligaro, Antonia; Tonello, Marta; Nardelli, Giovanni B

    2016-06-01

    Pregnant women with triple antibody positive antiphospholipid syndrome (APS) who have had thrombosis or a history of early, severe pregnancy complications are generally considered at high risk of pregnancy loss. The objectives of this study were to investigate the efficacy and safety of a relatively new treatment protocol used in addition to conventional therapy in high-risk pregnant patients affected with primary APS. The study's two inclusion criteria were: (1) the presence of triple antiphospholipid positivity, (2) previous thrombosis and/or a history of one or more early, severe pregnancy complications. Eighteen pregnancies occurring between 2002 and 2015 in 14 APS patients, (mean age 34.8±3.6 SD) were monitored. All 14 (100%) patients had triple antiphospholipid positivity. In addition, six of them (42.8%) had a history of thrombosis, four (28.6%) had one or more previous early and severe pregnancy complications, and four (30.8%) met both clinical study criteria. The study protocol included weekly plasmapheresis or immunoadsorption and fortnightly 1g/kg intravenous immunoglobulins. Seventeen of the pregnancies (94.4%) produced live neonates, all born between the 26th and 37th weeks of gestation (mean 33.1±3.5 SD). One female (5.5%), born prematurely at 24 weeks, died of sepsis a week after birth. There were two cases (11.1%) of severe pregnancy complications. No treatment side effects were registered. Given the high live birth rate and the safety associated to it, the study protocol described here could be taken into consideration by medical teams treating high-risk APS pregnant patients.

  3. Palonosetron has superior prophylactic antiemetic efficacy compared with ondansetron or ramosetron in high-risk patients undergoing laparoscopic surgery: a prospective, randomized, double-blinded study

    PubMed Central

    Kim, Sung-Hoon; Hong, Jeong-Yeon; Kim, Won Oak; Karm, Myong-Hwan; Hwang, Jai-Hyun

    2013-01-01

    Background Postoperative nausea and vomiting (PONV) continues to be a major problem, because PONV is associated with delayed recovery and prolonged hospital stay. Although the PONV guidelines recommended the use of 5-hydroxy-tryptamine (5-HT3) receptor antagonists as the first-line prophylactic agents in patients categorized as high-risk, there are few studies comparing the efficacies of ondansetron, ramosetron, and palonosetron. The aim of present study was to compare the prophylactic antiemetic efficacies of three 5HT3 receptor antagonists in high-risk patients after laparoscopic surgery. Methods In this prospective, randomized, double-blinded trial, 109 female nonsmokers scheduled for elective laparoscopic surgery were randomized to receive intravenous 4 mg ondansetron (n = 35), 0.3 mg ramosetron (n = 38), or 75 µg palonosetron (n = 36) before anesthesia. Fentanyl-based intravenous patient-controlled analgesia was administered for 48 h after surgery. Primary antiemetic efficacy variables were the incidence and severity of nausea, the frequency of emetic episodes during the first 48 h after surgery, and the need to use a rescue antiemetic medication. Results The overall incidence of nausea/retching/vomiting was lower in the palonosetron (22.2%/11.1%/5.6%) than in the ondansetron (77.1%/48.6%/28.6%) and ramosetron (60.5%/28.9%/18.4%) groups. The rescue antiemetic therapy was required less frequently in the palonosetron group than the other groups (P < 0.001). Kaplan-Meier analysis showed that the order of prophylactic efficacy in delaying the interval to use of a rescue emetic was palonosetron, ramosetron, and ondansetron. Conclusions Single-dose palonosetron is the prophylactic antiemetics of choice in high-risk patients undergoing laparoscopic surgery. PMID:23814652

  4. Identification of high-risk factors as indicators for adjuvant therapy in stage II colon cancer patients treated at a single institution

    PubMed Central

    YAMAGUCHI, KEIZO; OGATA, YUTAKA; AKAGI, YOSHITO; SHIROUZU, KAZUO

    2013-01-01

    Although post-operative adjuvant chemotherapy (ACT) is only recommended for patients with stage II colon cancer who are at a high risk of recurrence, the definition of high risk remains unclear. The present study aimed to identify the risk factors for recurrence, which may also be indicators for adjuvant therapy, using a retrospective analysis of clinicopathological data obtained from stage II colon cancer patients who had undergone a curative resection. The present study also investigated the effects of ACT in patients who displayed the risk factors for recurrence. Univariate and multivariate analyses of the data collected from 377 stage II colon cancer patients, treated at Kurume University Hospital (Fukuoka, Japan) between 1982 and 2005, was conducted in order to determine and compare the risk factors for recurrence between the 163 patients who had undergone adjuvant therapy and the 214 patients who had not undergone adjuvant therapy. The risk factors for recurrence in patients who had not undergone adjuvant therapy were a serum carcinoembryonic antigen (CEA) level that was twice the cut-off value and pre-operative bowel obstruction. Adjuvant therapy provided no benefit to patients who presented with neither risk factor, but significantly decreased the recurrence rate in patients presenting with one or both risk factors. Based on these findings, serum CEA levels of twice the cut-off value and pre-operative bowel obstruction were proposed as indicators in the assessment for adjuvant chemotherapy following a curative resection for stage II colon cancer. These results warrant further clinical study of ACT in patients with one or both risk factors. PMID:24137386

  5. Adding dexmedetomidine to ropivacaine for lumbar plexus and sciatic nerve block for amputation of lower limb in high-risk patient-a case report.

    PubMed

    Wang, Chun-Guang; Ding, Yan-Ling; Han, Ai-Ping; Hu, Chang-Qing; Hao, Shi; Zhang, Fang-Fang; Li, Yong-Wang; Liu, Hu; Han, Zhe; Guo, De-Li; Zhang, Zhi-Qiang

    2015-01-01

    The ischemia necrosis of limb frequently requires surgery of amputation. Lumbar plexus and sciatic nerve block is an ideal intra-operative anesthetic and post-operative antalgic technique for patients of amputation, especially for high-risk patients who have severe cardio-cerebrovascular diseases. However, the duration of analgesia of peripheral nerve block is hardly sufficient to avoid the postoperative pain and the usage of opioids. In this case, a 79-year-old man, with multiple cerebral infarcts, congestive heart failure, atrial flutter and syncope, was treated with an above knee amputation because of ischemia necrosis of his left lower limb. Dexmedetomidine 1 μg/kg was added to 0.33% ropivacaine for lumbar plexus and sciatic nerve block in this case for intra-operative anesthesia and post-operative analgesia. The sensory function was blocked fully for surgery and the duration of analgesia maintained 26 hours with haemodynamic stability and moderate sedation. The patient did not complain pain and require any supplementary analgesics after surgery. This case showed that adding 1 μg/kg dexmedetomidine to ropivacaine for lumbar plexus and sciatic nerve block may be a feasible and safe technique for high-risk patients for lower limb surgery of amputation.

  6. Adding dexmedetomidine to ropivacaine for lumbar plexus and sciatic nerve block for amputation of lower limb in high-risk patient-a case report

    PubMed Central

    Wang, Chun-Guang; Ding, Yan-Ling; Han, Ai-Ping; Hu, Chang-Qing; Hao, Shi; Zhang, Fang-Fang; Li, Yong-Wang; Liu, Hu; Han, Zhe; Guo, De-Li; Zhang, Zhi-Qiang

    2015-01-01

    The ischemia necrosis of limb frequently requires surgery of amputation. Lumbar plexus and sciatic nerve block is an ideal intra-operative anesthetic and post-operative antalgic technique for patients of amputation, especially for high-risk patients who have severe cardio-cerebrovascular diseases. However, the duration of analgesia of peripheral nerve block is hardly sufficient to avoid the postoperative pain and the usage of opioids. In this case, a 79-year-old man, with multiple cerebral infarcts, congestive heart failure, atrial flutter and syncope, was treated with an above knee amputation because of ischemia necrosis of his left lower limb. Dexmedetomidine 1 μg/kg was added to 0.33% ropivacaine for lumbar plexus and sciatic nerve block in this case for intra-operative anesthesia and post-operative analgesia. The sensory function was blocked fully for surgery and the duration of analgesia maintained 26 hours with haemodynamic stability and moderate sedation. The patient did not complain pain and require any supplementary analgesics after surgery. This case showed that adding 1 μg/kg dexmedetomidine to ropivacaine for lumbar plexus and sciatic nerve block may be a feasible and safe technique for high-risk patients for lower limb surgery of amputation. PMID:26550393

  7. The Effect of Radiation Timing on Patients With High-Risk Features of Parameningeal Rhabdomyosarcoma: An Analysis of IRS-IV and D9803

    SciTech Connect

    Spalding, Aaron C.; Hawkins, Douglas S.; Anderson, James R.; Lyden, Elizabeth; Laurie, Fran; Wolden, Suzanne L.; Arndt, Carola A.S.; Michalski, Jeff M.

    2013-11-01

    Purpose: Radiation therapy remains an essential treatment for patients with parameningeal rhabdomyosarcoma (PMRMS), and early radiation therapy may improve local control for patients with intracranial extension (ICE). Methods and Materials: To address the role of radiation therapy timing in PMRMS in the current era, we reviewed the outcome from 2 recent clinical trials for intermediate-risk RMS: Intergroup Rhabdomyosarcoma Study (IRS)-IV and Children's Oncology Group (COG) D9803. The PMRMS patients on IRS-IV with any high-risk features (cranial nerve palsy [CNP], cranial base bony erosion [CBBE], or ICE) were treated immediately at day 0, and PMRMS patients without any of these 3 features received week 6-9 radiation therapy. The D9803 PMRMS patients with ICE received day 0 X-Ray Therapy (XRT) as well; however, those with either CNP or CBBE had XRT at week 12. Results: Compared with the 198 PMRMS patients from IRS-IV, the 192 PMRMS patients from D9803 had no difference (P<.05) in 5-year local failure (19% vs 19%), failure-free-survival (70% vs 67%), or overall survival (75% vs 73%) in aggregate. The 5-year local failure rates by subset did not differ when patients were classified as having no risk features (None, 15% vs 19%, P=.25), cranial nerve palsy/cranial base of skull erosion (CNP/CBBE, 15% vs 28%, P=.22), or intracranial extension (ICE, 21% vs 15%, P=.27). The D9083 patients were more likely to have received initial staging by magnetic resonance imaging (71% vs 53%). Conclusions: These data support that a delay in radiation therapy for high-risk PMRMS features of CNP/CBBE does not compromise clinical outcomes.

  8. Generating patient-specific pulmonary vascular models for surgical planning

    NASA Astrophysics Data System (ADS)

    Murff, Daniel; Co-Vu, Jennifer; O'Dell, Walter G.

    2015-03-01

    Each year in the U.S., 7.4 million surgical procedures involving the major vessels are performed. Many of our patients require multiple surgeries, and many of the procedures include "surgical exploration". Procedures of this kind come with a significant amount of risk, carrying up to a 17.4% predicted mortality rate. This is especially concerning for our target population of pediatric patients with congenital abnormalities of the heart and major pulmonary vessels. This paper offers a novel approach to surgical planning which includes studying virtual and physical models of pulmonary vasculature of an individual patient before operation obtained from conventional 3D X-ray computed tomography (CT) scans of the chest. These models would provide clinicians with a non-invasive, intricately detailed representation of patient anatomy, and could reduce the need for invasive planning procedures such as exploratory surgery. Researchers involved in the AirPROM project have already demonstrated the utility of virtual and physical models in treatment planning of the airways of the chest. Clinicians have acknowledged the potential benefit from such a technology. A method for creating patient-derived physical models is demonstrated on pulmonary vasculature extracted from a CT scan with contrast of an adult human. Using a modified version of the NIH ImageJ program, a series of image processing functions are used to extract and mathematically reconstruct the vasculature tree structures of interest. An auto-generated STL file is sent to a 3D printer to create a physical model of the major pulmonary vasculature generated from 3D CT scans of patients.

  9. Hyponatraemia--a prospective analysis of surgical patients.

    PubMed

    Madiba, T E; Haffejee, A A; Mokoena, T R

    1998-08-01

    A prospective study of 71 patients with hyponatraemia was undertaken over an 18-month period in one surgical unit at King Edward VIII Hospital, Durban, to study the incidence and pattern of hyponatraemia. Electrolytes and urea values were measured serially in all patients. Hyponatraemia was defined as a serum sodium level of < 130 mmol/l. The incidence of hyponatraemia was 2.2%, the most common type being normovolaemic hypotonic hyponatraemia. Hyponatraemia was either mild (sodium level 120-130 mmol/l) or moderate (111-120 mmol/l). No patient had severe hyponatraemia (< 110 mmol/l). Hyponatraemia was corrected within 1-6 days using normal saline; in 73% of patients it was corrected within 24 hours. No patient developed neurological symptoms. A mortality rate of 28% was attributed to underlying illness, and hyponatraemia per se was asymptomatic in this study. Aggressive sodium correction was therefore not indicated.

  10. Managing Opioid-Tolerant Patients in the Perioperative Surgical Home.

    PubMed

    Wenzel, John T; Schwenk, Eric S; Baratta, Jaime L; Viscusi, Eugene R

    2016-06-01

    Management of acute postoperative pain is important to decrease perioperative morbidity and improve patient satisfaction. Opioids are associated with potential adverse events that may lead to significant risk. Uncontrolled pain is a risk factor in the transformation of acute pain to chronic pain. Balancing these issues can be especially challenging in opioid-tolerant patients undergoing surgery, for whom rapidly escalating opioid doses in an effort to control pain can be associated with increased complications. In the perioperative surgical home model, anesthesiologists are positioned to coordinate a comprehensive perioperative analgesic plan that begins with the preoperative assessment and continues through discharge.

  11. Sleep Habits and Symptoms in Male Medical and Surgical Patients

    PubMed Central

    Johns, M. W.; Egan, P.; Gay, T. J. A.; Masterton, J. P.

    1970-01-01

    A questionary survey of symptoms and sleep habits at home among 100 adult male medical and surgical patients showed that the duration of sleep at night was similar to that reported for the general population, decreasing with age from 20 to 50 years and increasing again after 60 years. The duration of daytime sleep increased with age. The degree of sleep disturbance in different patients was compared in terms of the total duration of sleep and the time spent lying awake in bed at night. Increasing age, ischaemic heart disease, and neurotic illness were the main factors associated with long-term disturbances. PMID:5428715

  12. Safety and effectiveness of daily teriparatide in a prospective observational study in patients with osteoporosis at high risk of fracture in Japan: final report

    PubMed Central

    Nishikawa, Atsushi; Ishida, Takehiro; Taketsuna, Masanori; Yoshiki, Fumito; Enomoto, Hiroyuki

    2016-01-01

    This postmarketing surveillance study assessed the safety and effectiveness of teriparatide in patients with osteoporosis at high risk of fracture in Japan. The patients received teriparatide 20 μg daily by subcutaneous injection, for a maximum of 24 months. Safety and effectiveness analyses were based on data from 1,847 patients who were predominantly female (92.6%) with a mean age of 75.4 years. A total of 157 adverse drug reactions (ADRs) were reported in 140 (7.58%) patients; the most common ADRs were hyperuricemia, nausea, and dizziness. Only six (0.32%) patients reported serious ADRs, the most common being nausea (two patients; 0.1%). Persistence with teriparatide treatment was 60.8% and 39.1% at 18 and 24 months, respectively. There were significant increases in biomarkers for bone formation (procollagen type I N-terminal propeptide and bone-specific alkaline phosphatase) and bone resorption (collagen type I cross-linked C telopeptide and tartrate-resistant acid phosphatase 5b) throughout the study. These were accompanied by significant increases in bone mineral density and low incidences of new vertebral and nonvertebral fractures. Patient-reported measurements for health-related quality of life revealed significant improvements from baseline in back pain and overall health-related quality of life (Short Form-8™ health survey). The results of this 24-month postmarketing surveillance study imply that teriparatide has a favorable safety profile and is effective in the treatment of patients with osteoporosis at high risk of fracture in Japan. Teriparatide may also be a useful treatment for osteoporosis in other societies with aging populations. PMID:27462147

  13. Aspergillus Infections in Transplant and Non-Transplant Surgical Patients

    PubMed Central

    Guidry, Christopher; Politano, Amani; Rosenberger, Laura; McLeod, Matthew; Hranjec, Tjasa; Sawyer, Robert

    2014-01-01

    Background: Aspergillus infections are associated commonly with immunocompromised states, such as transplantation and hematologic malignant disease. Although Aspergillus infections among patients having surgery occur primarily in transplant recipients, they are found in non-recipients of transplants, and have a mortality rate similar to that seen among transplant recipients. Methods: We conducted a retrospective analysis of a prospective data base collected from 1996 to 2010, in which we identified patients with Aspergillus infections. We compared demographic data, co-morbidities, and outcomes in non-transplant patients with those in abdominal transplant recipients. Continuous data were evaluated with the Student t-test, and categorical data were evaluated through χ2 analysis. Results: Twenty-three patients (11 transplant patients and 12 non-transplant patients) were identified as having had Aspergillus infections. The two groups were similar with regard to their demographics and co-morbidities, with the exceptions of their scores on the Acute Physiology and Chronic Health Evaluation II (APACHE II), of 23.6±8.1 points for transplant patients vs. 16.8±6.1 points for non-transplant patients (p=0.03); Simplified Acute Physiology Score (SAPS) of 16.6±8.3 points vs. 9.2±4.1 points, respectively (p=0.02); steroid use 91.0% vs. 25.0%, respectively (p=0.003); and percentage of infections acquired in the intensive care unit (ICU) 27.3% vs. 83.3%, respectively (p=0.01). The most common site of infection in both patient groups was the lung. The two groups showed no significant difference in the number of days from admission to treatment, hospital length of stay following treatment, or mortality. Conclusions: Although Aspergillus infections among surgical patients have been associated historically with solid-organ transplantation, our data suggest that other patients may also be susceptible to such infections, especially those in an ICU who are deemed to be critically ill

  14. [Management of High-Risk Prostate Cancer and Left Ectopic Ureter Inserting into Seminal Vesicle with Ipsilateral Hypoplastic Kidney of a Young Patient : A Case Report].

    PubMed

    Matsumoto, Teppei; Koie, Takuya; Soma, Osamu; Kusaka, Ayumu; Hosogoe, Shogo; Hamano, Itsuto; Imai, Atsushi; Hatakeyama, Shingo; Yoneyama, Takahiro; Hashimoto, Yasuhiro; Ohyama, Chikara

    2016-06-01

    A 44-year-old male patient visited our hospital with a chief complaint of macroscopic hematuria. Prostate biopsies were performed due to prostate specific antigen (PSA) 11.6 ng/ml, and he was diagnosed with Gleason score 5+4 prostate cancer. Computed tomography showed a left hypoplastic kidney. T2- weighted magnetic resonance imaging showed the left ureter stump with ectopic insertion into the dilated left seminal vesicle. He was diagnosed with high-risk prostate cancer and left ectopic ureter inserting into the seminal vesicle with ipsilateral hypoplastic kidney. Laparoscopic left nephroureterectomy and open radical prostatectomy were performed.

  15. Successful surgical management of ruptured umbilical hernias in cirrhotic patients

    PubMed Central

    Chatzizacharias, Nikolaos A; Bradley, J Andrew; Harper, Simon; Butler, Andrew; Jah, Asif; Huguet, Emmanuel; Praseedom, Raaj K; Allison, Michael; Gibbs, Paul

    2015-01-01

    Acute umbilical hernia rupture in patients with hepatic cirrhosis and ascites is an unusual, but potentially life-threatening complication, with postoperative morbidity about 70% and mortality between 60%-80% after supportive care and 6%-20% after urgent surgical repair. Management options include primary surgical repair with or without concomitant portal venous system decompression for the control of the ascites. We present a retrospective analysis of our centre’s experience over the last 6 years. Our cohort consisted of 11 consecutive patients (median age: 53 years, range: 36-63 years) with advanced hepatic cirrhosis and refractory ascites. Appropriate patient resuscitation and optimisation with intravenous fluids, prophylactic antibiotics and local measures was instituted. One failed attempt for conservative management was followed by a successful primary repair. In all cases, with one exception, a primary repair with non-absorbable Nylon, interrupted sutures, without mesh, was performed. The perioperative complication rate was 25% and the recurrence rate 8.3%. No mortality was recorded. Median length of hospital stay was 14 d (range: 4-31 d). Based on our experience, the management of ruptured umbilical hernias in patients with advanced hepatic cirrhosis and refractory ascites is feasible without the use of transjugular intrahepatic portosystemic shunt routinely in the preoperative period, provided that meticulous patient optimisation is performed. PMID:25780312

  16. Prevalence of protein calorie malnutrition in general surgical patients.

    PubMed

    Tan, Y S; Nambiar, R; Yo, S L

    1992-05-01

    The prevalence of protein calorie malnutrition (PCM) based on ten nutritional parameters was studied in 307 patients undergoing major elective surgical operations. These parameters included anthropometric measurements (weight/height, triceps skin fold thickness, arm muscle circumference) and biochemical (serum total proteins, albumin, transferrin, prealbumin, retinol binding protein) and immunological tests (total lymphocyte count and delayed hypersensitivity test). Using these criteria, the prevalence of PCM was high. Eighty-six percent of patients had at least one abnormal parameter. The prevalence of PCM as judged by weight/height and arm muscle circumference was 49% and 62% respectively. The incidence was higher in cancer than non cancer patients (63% vs 43%). Although serum albumin and total protein levels were normal in 93.5% of patients, acute serum protein markers such as transferrin, prealbumin and retinol binding protein were low in 20-30%. Lymphopenia of 1500 cells/cu mm or less was found in 18% and abnormal delayed hypersensitivity test in 60%. We found that only weight/height, serum protein, transferrin and lymphopenia had predictive values in postoperative morbidity and mortality. By identifying PCM patients early, adequate nutritional support can be given in order to reduce the risk of major surgical complications.

  17. [Antiplatelet agents and anticoagulants: management of the anticoagulated surgical patient].

    PubMed

    Llau, Juan V; Ferrandis, Raquel; López Forte, Cristina

    2009-06-01

    Among the drugs most widely consumed by patients are both antiplatelet agents (aspirin, clopidogrel, ticlopidine) and anticoagulants (acenocoumarol, warfarin, low molecular weight heparin, fondaparinux). The use of these drugs in the perioperative period is an essential concern in patient care due to the need to balance the risk of bleeding against thrombotic risk (arterial or venous), which is increased in surgical patients. The present review highlights three main aspects. Firstly, withdrawal of antiplatelet agents is recommended between 1 week and 10 days before surgery to minimize perioperative bleeding. However, this practice has been questioned because patients without the required antiplatelet coverage may be at greater risk of developing cardiac, cerebral or peripheral vascular complications. Therefore, the recommendation of systematic antiplatelet withdrawal for a specific period should be rejected. Currently, risks should be evaluated on an individual basis to minimize the time during which the patient remains without adequate antiplatelet protection. Secondly, thromboprophylaxis is required in most surgical patients due to the high prevalence of venous thromboembolic disease. This implies the use of anticoagulants and the practice of regional anesthesia has been questioned in these patients. However, with the safety recommendations established by the various scientific societies, this practice has been demonstrated to be safe. Finally, "bridge therapy" in patients anticoagulated with acenocoumarol should be performed on an individual basis rather than systematically without taking into account the thrombotic risks of each patient. The perioperative period involves high arterial and venous thrombotic risk and the optimal use of antiplatelet agents and anticoagulants should be a priority to minimize this risk without increasing hemorrhagic risk. Multidisciplinary consensus is essential on this matter.

  18. Surgical Management of Rhinosinusitis in Onco-Hematological Patients

    PubMed Central

    Di Girolamo, Stefano; Di Mauro, Roberta; Giacomini, Piergiorgio; Cantonetti, Maria

    2014-01-01

    Objectives In onco-hematological diseases, the incidence of paranasal sinuses infection dramatically increase and requires a combination of medical and surgical therapy. Balloon dilatation surgery (DS) is a minimally invasive, tissue preserving procedure. The study evaluates the results of DS for rhinosinusitis in immunocompromised patients. Methods A retrospective chart review was conducted in 110 hematologic patients with rhinosinusitis. Twenty-five patients were treated with DS technique and 85 patients with endoscopic sinus surgery (ESS). We considered the type of anesthesia and the extent of intra- and postoperative bleeding. Patients underwent Sino-Nasal Outcome Test (SNOT-20) to evaluate changes in subjective symptoms and global patient assessment (GPA) questionnaire to value patient satisfaction. Results Local anesthesia was employed in 8 cases of DS and in 15 of ESS. In 50 ESS patients, an anterior nasal packing was placed and in 12 cases a repacking was necessary. In the DS group, nasal packing was required in 8 cases and in 2 cases a repacking was placed (P=0.019 and P=0.422, respectively). The SNOT-20 change score showed significant improvement of health status in both groups. However the DS group showed a major improvement in 3 voices: need to blow nose, runny nose, and facial pain/pressure. The 3-month follow-up GPA questionnaire showed an higher satisfaction of DS group. Conclusion Balloon DS represents a potentially low aggressive treatment and appears to be relatively safe and effective in onco-hematologic patients. All these remarks may lead the surgeon to consider a larger number of candidates for surgical procedure. PMID:25436050

  19. Radioiodine Thyroid Remnant Ablation after Recombinant Human Thyrotropin or Thyroid Hormone Withdrawal in Patients with High-Risk Differentiated Thyroid Cancer

    PubMed Central

    Pitoia, Fabián; Marlowe, Robert J.; Abelleira, Erika; Faure, Eduardo N.; Bueno, Fernanda; Schwarzstein, Diego; Lutfi, Rubén Julio; Niepomniszcze, Hugo

    2012-01-01

    To supplement limited relevant literature, we retrospectively compared ablation and disease outcomes in high-risk differentiated thyroid carcinoma (DTC) patients undergoing radioiodine thyroid remnant ablation aided by recombinant human thyrotropin (rhTSH) versus thyroid hormone withdrawal/withholding (THW). Our cohort was 45 consecutive antithyroglobulin antibody- (TgAb-) negative, T3-T4/N0-N1-Nx/M0 adults ablated with high activities at three referral centers. Ablation success comprised negative (<1 μg/L) stimulated serum thyroglobulin (Tg) and TgAb, with absent or <0.1% scintigraphic thyroid bed uptake. “No evidence of disease” (NED) comprised negative unstimulated/stimulated Tg and no suspicious neck ultrasonography or pathological imaging or biopsy. “Persistent disease” was failure to achieve NED, “recurrence,” loss of NED status. rhTSH patients (n = 18) were oftener ≥45 years old and higher stage (P = 0.01), but otherwise not different than THW patients (n = 27) at baseline. rhTSH patients were significantly oftener successfully ablated compared to THW patients (83% versus 67%, P < 0.02). After respective 3.3 yr and 4.5 yr mean follow-ups (P = 0.02), NED was achieved oftener (72% versus 59%) and persistent disease was less frequent in rhTSH patients (22% versus 33%) (both comparisons P = 0.03). rhTSH stimulation is associated with at least as good outcomes as is THW in ablation of high-risk DTC patients. PMID:23304637

  20. Successful management of grade III coronary perforation after percutaneous angioplasty in a high-risk patient: a case report.

    PubMed

    Coloma Araniya, Ricardo; Beas, Renato; Maticorena-Quevedo, Jesús; Anduaga-Beramendi, Alexander; Pastrana Castillo, Marco Antonio

    2016-03-03

    Coronary perforation is a rare complication in patients undergoing percutaneous coronary angioplasty. The mortality of this complication varies depending on factors related to the patient and the procedure performed, reaching 44% in patients with Ellis type III perforation. We report the case of an 81 year old male with multiple cardiovascular risk factors, who underwent percutaneous angioplasty for unstable angina management. The patient developed grade III coronary perforation in the anterior descending artery, which was successfully managed with balloon inflation to 6 atmospheres for 10 minutes twice in the affected area, with an interval of 5 minutes between each dilatation. The patient improved and was discharged.

  1. Stents in patients with esophageal cancer before chemoradiotherapy: high risk of complications and no impact on the nutritional status.

    PubMed

    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.

  2. Results from the International Silver Graft Registry for high-risk patients treated with a metallic-silver impregnated vascular graft.

    PubMed

    Zegelman, Max; Guenther, Gisela; Waliszewski, Matthias; Pukacki, Fryderyk; Stanisic, Michal Goran; Piquet, Philippe; Passon, Marius; Halloul, Zuhir; Tautenhahn, Jörg; Claey, Luc; Agostinho, Claudia; Simici, Dragos; Doebrich, Dinah; Mueller, Carsten; Balzer, Kai

    2013-06-01

    The purpose of this postmarket surveillance registry was to document the efficacy of a vascular prosthesis coated with metallic silver in high-risk patients undergoing vascular reconstructions. Patency (primary endpoint) and freedom from graft infection (secondary endpoint) data were assessed at a minimum of 12 months in patients with significant co-morbidity and/or confirmed graft infections or infected native vessels. Between November 2006 and December 2009, 230 patients with high-risk factors underwent aortic,peripheral and/or extra-anatomic reconstructions with Silver Graft® (SG) in six German, one French and one Polish vascular center.All participating centers used the metallic silver-coated polyester graft (SG) in various diameters and lengths including tubular and bifurcate vascular grafts. Doppler ultrasound follow-ups to determine graft patency were planned at 12 months or done at an earlier time in case the patient became symptomatic. A total of 230 patients were studied. Ten of these 230 patients had graft infections at baseline whereas the remaining 220 subjects had significant risk factors such as coronary artery disease (62.7%, 138/220), vascular access in scar tissue (27.3%, 60/220), Fontaine III/IV (38.2%, 84/220), chronic renal insufficiency (26.8%, 59/220) and diabetes (21.0%,46/220). The long-term follow-up at 15.5 ± 8.3 months revealed a secondary patency rate of 93.2% (205/220) and an ‘all cause’ mortality rate of 18.6% (41/220). There was a freedom from de novo graft infection rate of 95.9% (211/220) in the high-risk group without graft infections at baseline. One regraft infection occurred distal of the revisional reconstruction in the 10 patients with graft infection at baseline. The presence of perigraft fluid at follow-up and Fontaine III/IV at baseline were found to be predictors for graft patency whereas perigraft fluid presence was the only predictor for de novo graft infections. This registry revealed favorable patency and

  3. The Duration of Impella 2.5 Circulatory Support and Length of Hospital Stay of Patients Undergoing High-risk Percutaneous Coronary Interventions

    PubMed Central

    Anusionwu, Obiora; Fischman, Daniel; Cheriyath, Pramil

    2012-01-01

    Background To evaluate the impact of duration of Impella 2.5 support (Abiomed, Danvers, MA) on hospitalization of patients after high-risk percutaneous coronary intervention (PCI). There has been a continuous increase in prevalence of coronary artery disease with more patients needing PCI during acute myocardial infarction. Some of these patients have to undergo high-risk revascularization with circulatory support like the Impella 2.5 device. Methods This study was a single center retrospective study of patients admitted to our hospital who required Impella circulatory support during percutaneous coronary intervention. Patients’ medical records, cardiac catheterization laboratory and 2-D echocardiography reports were reviewed to ascertain left ventricular ejection fraction, duration of Impella support, Coronary Care Unit (CCU) days and the length of stay in the hospital. A P-value of ≤ 0.05 was considered statistically significant. Results Over a 15-month period, we had 25 patients with 19 males and 6 females. Mean age of the patient cohort was 68 ± 10 years. Mean LVEF of the group was 32 ± 16%. Mean length of hospital stay was 8 ± 8 days and mean CCU stay was 4 ± 4 days. The Impella was successfully inserted in all cases with a median duration of support of 70 minutes (range, 4 - 5760 minutes). Bleeding complication occurred in 8%. Spearman's rank correlation coefficient between the duration of Impella support and hospital stay was 0.49 (P = 0.023) while it was 0.71 (P = 0.001) between Impella support duration and CCU days. Conclusions Our study suggests that there is a positive correlation between the duration of Impella 2.5 circulatory support and hospital stay and/or CCU days. The correlation seems to be stronger with CCU days.

  4. Are there a guidelines for implantable spinal cord stimulator therapy in patients using chronic anticoagulation therapy? - A review of decision-making in the high-risk patient

    PubMed Central

    Ghaly, Ramsis F.; Lissounov, Alexei; Candido, Kenneth D.; Knezevic, Nebojsa Nick

    2016-01-01

    Background: Spinal cord stimulators (SCSs) are gaining increasing indications and utility in an expanding variety of clinical conditions. Complications and initial expenses have historically prevented the early use of SCS therapy despite ongoing efforts to educate and promote its utilization. At present, there exists no literature evidence of SCS implantation in a chronically anticoagulated patient, and neuromodulation manufacturers are conspicuously silent in providing warnings or recommendations in the face of anticoagulant use chronically. It would appear as through these issues demand scrutiny and industry as well as neuromodulation society advocacy and support in terms of the provision of coherent guidelines on how to proceed. Case Description: A 79-year-old male returned to the neurosurgical clinic with persistent low back pain and leg heaviness due to adjacent level degenerative spondylosis and severe thoracic spinal stenosis. The patient had a notable history of multiple comorbidities along with atrial fibrillation requiring chronic anticoagulation. On initial presentation, he was educated with three choice of conservative medical therapy, intrathecal drug delivery system implantation, or additional lumbar decompression laminectomy with instrumented fusion of T10-L3 and a palliative surgical lead SCS implantation. Description: A 79-year-old male returned to the neurosurgical clinic with persistent low back pain and leg heaviness due to adjacent level degenerative spondylosis and severe thoracic spinal stenosis. The patient had a notable history of multiple comorbidities along with atrial fibrillation requiring chronic anticoagulation. On initial presentation, he was educated with three choice of conservative medical therapy, intrathecal drug delivery system implantation, or additional lumbar decompression laminectomy with instrumented fusion of T10-L3 and a palliative surgical lead SCS implantation. Conclusion: Our literature search did not reveal any

  5. Perioperative challenges in management of a deaf and dumb patient posted for high-risk cardiac surgery.

    PubMed

    Chowdhry, Vivek; Padhi, Manoranjan; Mohanty, B B; Biswal, Suvakanta

    2016-01-01

    Perioperative management of deaf and dumb patients can be a challenging task. For smooth postoperative recovery, proper care should begin in the preoperative period. Understanding the patients' needs and training him to follow the instructions requires to involve a communication specialist. Judicious use of sedatives and analgesics is essential to keep the patient pain-free and comfortable. Postoperatively, the patient should be kept awake, enough to understand the internal need of the body and to make a meaningful response to external stimuli. Adequate preoperative planning and coordinated team efforts with involvement of specialists can help in delivering better postoperative care.

  6. Emerging technologies for the prevention of dental caries. Are current methods of prevention sufficient for the high risk patient?

    PubMed Central

    Bretz, Walter A; Rosa, Odila P S

    2011-01-01

    Fluorides and chlorhexidine are technologies that are 65 and 40 yeas old, respectively. This overview argues that current methods of caries prevention are not effective for the high caries risk patient. In this review examples, arguments and recommendations are provided to address the high caries risk patient that include: failure of comprehensive chemical modalities treatments to address the high caries risk patient; ecological alteration - would this be an effective approach?; and biomaterials and oral microbiome research to address the high caries risk patient. PMID:21726223

  7. Survivin Expression as a Predictive Marker for Local Control in Patients With High-Risk T1 Bladder Cancer Treated With Transurethral Resection and Radiochemotherapy

    SciTech Connect

    Weiss, Christian; Krause, Steffen F.; Sauer, Rolf; Roedel, Claus; Roedel, Franz

    2009-08-01

    Purpose: The objectives of this study were to investigate the expression of survivin in tumor samples from patients with high-risk T1 bladder cancer and to correlate its expression with clinicopathologic features as well as clinical outcomes after initial transurethral resection (TURBT) followed by radiotherapy (RT) or radiochemotherapy (RCT). Methods and Materials: Survivin protein expression was evaluated by immunohistochemistry on tumor specimen (n = 48) from the initial TURBT, and was correlated with clinical and histopathologic characteristics as well as with 5-year rates of local failure, tumor progression, and death from urothelial cancer after primary bladder sparring treatment with RT/RCT. Results: Survivin was not expressed in normal bladder urothelium but was overexpressed in 67% of T1 tumors. No association between survivin expression and clinicopathologic factors (age, gender, grading, multifocality, associated carcinoma in situ) could be shown. With a median follow-up of 27 months (range, 3-140 months), elevated survivin expression was significantly associated with an increased probability of local failure after TURBT and RCT/RT (p = 0.003). There was also a clear trend toward a higher risk of tumor progression (p = 0.07) and lower disease-specific survival (p = 0.10). Conclusions: High survivin expression is a marker of tumor aggressiveness and may help to identify a subgroup of patients with T1 bladder cancer at a high risk for recurrence when treated with primary organ-sparing approaches such as TURBT and RCT.

  8. Examining Noncardiac Surgical Procedures in Patients on Extracorporeal Membrane Oxygenation.

    PubMed

    Taghavi, Sharven; Jayarajan, Senthil N; Mangi, Abeel A; Hollenbach, Kathryn; Dauer, Elizabeth; Sjoholm, Lars O; Pathak, Abhijit; Santora, Thomas A; Goldberg, Amy J; Rappold, Joseph F

    2015-01-01

    As extracorporeal membrane oxygenation (ECMO) is increasingly used for patients with cardiac and/or pulmonary failure, the need for noncardiac surgical procedures (NCSPs) in these patients will continue to increase. This study examined the NCSP required in patients supported with ECMO and determined which variables affect outcomes. The National Inpatient Sample Database was examined for patients supported with ECMO from 2007 to 2010. There were 563 patients requiring ECMO during the study period. Of these, 269 (47.8%) required 380 NCSPs. There were 149 (39.2%) general surgical procedures, with abdominal exploration/bowel resection (18.2%) being most common. Vascular (29.5%) and thoracic procedures (23.4%) were also common. Patients requiring NCSP had longer median length of stay (15.5 vs. 9.2 days, p = 0.001), more wound infections (7.4% vs. 3.7%, p = 0.02), and more bleeding complications (27.9% vs. 17.3%, p = 0.01). The incidences of other complications and inpatient mortality (54.3% vs. 58.2%, p = 0.54) were similar. On logistic regression, the requirement of NCSPs was not associated with mortality (odds ratio [OR]: 0.91, 95% confidence interval [CI]: 0.68-1.23, p = 0.17). However, requirement of blood transfusion was associated with mortality (OR: 1.70, 95% CI: 1.06-2.74, p = 0.03). Although NCSPs in patients supported with ECMO does not increase mortality, it results in increased morbidity and longer hospital stay.

  9. Screening for high risk human papilloma virus (HR-HPV) subtypes, among Sudanese patients with oral lesions

    PubMed Central

    Babiker, Ali Yousif; Eltom, Faris Margani; Abdalaziz, Mohamed S; Rahmani, Arshad; Abusail, Saadalnour; Ahmed, Hussain Gadelkareem

    2013-01-01

    HR-HPV subtypes are strongly linked to etiology of many human cancers including oral cancer. The epidemiology of infection with different HPV genotypes greatly varies in different countries. The aim of this study was to identify and genotype the HR-HPV subtypes in oral tissues obtained from Sudanese patients with oral lesions. In this retrospective study 200 patients with oral lesions were screened by molecular methods (PCR) for the presence of HR-HPV subtypes. Of the 200 patients, 100/200 were patients with oral cancer (ascertained as case group) and 100/200 were patients with non-neoplastic oral lesions (ascertained as control group). Out of the 200 patients, 12/200 (6%) were found with HR-HPV infection. Of the 12 positive patients, 8/12 (66.7%) were among cases and the remaining 4/12 (33.3%) were among control group. The distribution of different genotypes was: type HPV 16 6/12 (50%), HPV18 4/12 (34%), HPV 31 1/12 (8%) and HPV 33 1/12 (8%). In view of these findings, HPV particularly subtypes 16 and 18 play a role in the etiology of oral cancer in the Sudan. PMID:23641304

  10. Final results of a multicenter trial addressing role of CSF flow cytometric analysis in NHL patients at high risk for CNS dissemination.

    PubMed

    Benevolo, Giulia; Stacchini, Alessandra; Spina, Michele; Ferreri, Andrés J M; Arras, Marcella; Bellio, Laura; Botto, Barbara; Bulian, Pietro; Cantonetti, Maria; Depaoli, Lorella; Di Renzo, Nicola; Di Rocco, Alice; Evangelista, Andrea; Franceschetti, Silvia; Godio, Laura; Mannelli, Francesco; Pavone, Vincenzo; Pioltelli, Pietro; Vitolo, Umberto; Pogliani, Enrico M

    2012-10-18

    This prospective study compared diagnostic and prognostic value of conventional cytologic (CC) examination and flow cytometry (FCM) of baseline samples of cerebrospinal fluid (CSF) in 174 patients with newly diagnosed aggressive non-Hodgkin lymphoma (NHL). FCM detected a neoplastic population in the CSF of 18 of 174 patients (10%), CC only in 7 (4%; P < .001); 11 patients (14%) were discordant (FCM(+)/CC(-)). At a median follow-up of 46 months, there were 64 systemic progressions and 10 CNS relapses, including 2 patients with both systemic and CNS relapses. Two-year progression-free and overall survival were significantly higher in patients with FCM(-) CSF (62% and 72%) compared with those FCM(+) CSF (39% and 50%, respectively), with a 2-year CNS relapse cumulative incidence of 3% (95% confidence interval [CI], 0-7) versus 17% (95% CI, 0-34; P = .004), respectively. The risk of CNS progression was significantly higher in FMC(+)/CC(-) versus FCM(-)/CC(-) patients (hazard ratio = 8.16, 95% CI, 1.45-46). In conclusion, FCM positivity in the CSF of patients with high-risk NHL is associated with a significantly higher CNS relapse risk and poorer outcome. The combination of IV drugs with a higher CNS bioavailability and intrathecal chemotherapy is advisable to prevent CNS relapses in FCM(+) patients.

  11. Clinical studies of combined photodynamic therapy using 5-fluorouracil and methyl-aminolevulinate in patients at high risk for squamous cell carcinoma

    NASA Astrophysics Data System (ADS)

    Maytin, Edward V.; Lohser, Sara; Tellez, Alejandra; Wene, Lauren; Ishak, Rim; Anand, Sanjay

    2013-03-01

    Photodynamic therapy (PDT) using aminolevulinic acid or its methyl ester, methyl-aminolevulinate (MAL), is an increasingly recognized approach for treating squamous neoplasia of the skin. Advantages of MAL-PDT include its ability to cover broad diseased areas (field treatment), and to do multiple sessions with little-to-no risk of scarring or mutagenesis. MAL-PDT is especially valuable in certain populations at high risk for skin cancer, including Caucasian patients with extensive solar damage, and organ transplant recipients (OTR) who take immunosuppressive drugs to prevent graft rejection. The latter group has a 65-200 fold increased risk of developing squamous cell carcinoma (SCC), a major cause of mortality. Therapeutic options for those patients, other than frequent surgeries, are very limited. Topical 5-Fluorouracil (5-FU), frequently prescribed in normal patients for pre-SCC of the skin, is only minimally effective in the OTR group. MAL-PDT, however, has ~40% efficacy for pre-SCC in OTR patients. Based upon our preclinical studies in mouse tumor models, which showed that preconditioning with 5-FU can drive higher accumulation of target protoporphyins (PpIX), we proposed a rational combination regimen of 5-FU and MAL-PDT in humans. A clinical trial was designed to test the hypothesis that a combination of 5-FU followed by MAL-PDT will elevate PpIX levels and achieve better clinical outcomes in high-risk OTR patients. Primary endpoints include PpIX levels and biochemical markers (p53) measured noninvasively and in skin biopsies. Lesion clearance and recurrence (via photographs and clinical exam) are secondary endpoints. Ongoing results of this clinical trial are presented.

  12. Perioperative challenges in management of a deaf and dumb patient posted for high-risk cardiac surgery

    PubMed Central

    Chowdhry, Vivek; Padhi, Manoranjan; Mohanty, B. B.; Biswal, Suvakanta

    2016-01-01

    Perioperative management of deaf and dumb patients can be a challenging task. For smooth postoperative recovery, proper care should begin in the preoperative period. Understanding the patients’ needs and training him to follow the instructions requires to involve a communication specialist. Judicious use of sedatives and analgesics is essential to keep the patient pain-free and comfortable. Postoperatively, the patient should be kept awake, enough to understand the internal need of the body and to make a meaningful response to external stimuli. Adequate preoperative planning and coordinated team efforts with involvement of specialists can help in delivering better postoperative care. PMID:27397473

  13. Surgical management of medically refractory epilepsy in patients with polymicrogyria

    PubMed Central

    Wang, Doris D.; Knox, Renatta; Rolston, John D.; Englot, Dario J.; Barkovich, A. James; Tihan, Tarik; Auguste, Kurtis I.; Knowlton, Robert C.; Cornes, Susannah B.; Chang, Edward F.

    2017-01-01

    Objective Polymicrogyria (PMG) is a malformation of cortical development characterized by formation of an excessive number of small gyri. Sixty percent to 85% of patients with PMG have epilepsy that is refractory to medication, but surgical options are usually limited. We characterize a cohort of patient with polymicrogyria who underwent epilepsy surgery and document seizure outcomes. Methods A retrospective study of all patients with PMG who underwent epilepsy surgery (focal seizure foci resection and/or hemispherectomy) at our center was performed by review of all clinical data related to their treatment. Results We identified 12 patients (7 males and 5 female) with mean age of 18 (ranging from 3 months to 44 years) at time of surgery. Mean age at seizure onset was 8 years, with the majority (83%) having childhood onset. Six patients had focal, five had multifocal, and one patient had diffuse PMG. Perisylvian PMG was the most common pattern seen on magnetic resonance imaging (MRI). Eight patients had other cortical malformations including hemimegalencephaly and cortical dysplasia. Scalp electroencephalography (EEG) often showed diffuse epileptic discharges that poorly lateralized but were focal on intracranial electrocorticography (ECoG). Eight patients underwent seizure foci resection and four underwent hemispherectomy. Mean follow-up was 7 years (ranging from one to 19 years). Six patients (50%) were seizure-free at last follow-up. One patient had rare seizures (Engel class II). Three patients were Engel class III, having either decreased seizure frequency or severity, and two patients were Engel class IV. Gross total resection of the PMG cortex trended toward good seizure control. Significance Our study shows that even in patients with extensive or bilateral PMG malformations, some may still be good candidates for surgery because the epileptogenic zone may involve only a portion of the malformation. Intracranial ECoG can provide additional localizing

  14. Surgical management of cleft lip in pedo-patients.

    PubMed

    Taware, C P; Kulkarni, S R

    1991-01-01

    The Present article describes in short etiology of cleft lip and cleft palate. With this in-born defect, patient develops crucial problems with feeding, phonation, overall growth and development of affected and allied soft and hard tissue structures. This in turn results in deformity and asymmetry which is going to affect functional requirements as well as aesthetic outlook. Hence it really becomes mandatory to correct this defect surgically as early as possible, at stipulated timings so as to avoid present and future anticipated problems.

  15. The Economic and Quality of Life Impact of Remote Technologies on High Risk Patients and Their Caregivers

    DTIC Science & Technology

    2009-01-01

    kidney dialysis company permitted research staff to recruit potential subjects from their local patient population. Several informational meetings...Selected peer-reviewed publications (in chronological order) 1. Berman SJ. Chloroquine-pyrimethamine-sulfisoxazole therapy in Plasmodium falciparum

  16. Tissue Banks and Cell Lines Derived from Patients with a High Risk of Breast Cancer and in situ Disease

    DTIC Science & Technology

    1998-05-01

    syndromes and patients with ataxia telangiectasia and Cowden’s. Establishing these cells in culture will provide systems for both primary studies of...material that has been collected on some of the key cases. We also have primary cultures from one patent with Klinefelter’s syndrome and a patient...is not a notable feature of known breast cancer predisposition syndromes such as those due to the BRCA1 or p53 genes and therefore may be an indicator

  17. Basal Tumor Cell Isolation and Patient-Derived Xenograft Engraftment Identify High-Risk Clinical Bladder Cancers

    PubMed Central

    Skowron, K. B.; Pitroda, S. P.; Namm, J. P.; Balogun, O.; Beckett, M. A.; Zenner, M. L.; Fayanju, O.; Huang, X.; Fernandez, C.; Zheng, W.; Qiao, G.; Chin, R.; Kron, S. J.; Khodarev, N. N.; Posner, M. C.; Steinberg, G. D.; Weichselbaum, R. R.

    2016-01-01

    Strategies to identify tumors at highest risk for treatment failure are currently under investigation for patients with bladder cancer. We demonstrate that flow cytometric detection of poorly differentiated basal tumor cells (BTCs), as defined by the co-expression of CD90, CD44 and CD49f, directly from patients with early stage tumors (T1-T2 and N0) and patient-derived xenograft (PDX) engraftment in locally advanced tumors (T3-T4 or N+) predict poor prognosis in patients with bladder cancer. Comparative transcriptomic analysis of bladder tumor cells isolated from PDXs indicates unique patterns of gene expression during bladder tumor cell differentiation. We found cell division cycle 25C (CDC25C) overexpression in poorly differentiated BTCs and determined that CDC25C expression predicts adverse survival independent of standard clinical and pathologic features in bladder cancer patients. Taken together, our findings support the utility of BTCs and bladder cancer PDX models in the discovery of novel molecular targets and predictive biomarkers for personalizing oncology care for patients. PMID:27775025

  18. TP53 mutation in patients with high-risk acute myeloid leukaemia treated with allogeneic haematopoietic stem cell transplantation.

    PubMed

    Middeke, Jan M; Herold, Sylvia; Rücker-Braun, Elke; Berdel, Wolfgang E; Stelljes, Matthias; Kaufmann, Martin; Schäfer-Eckart, Kerstin; Baldus, Claudia D; Stuhlmann, Reingard; Ho, Anthony D; Einsele, Hermann; Rösler, Wolf; Serve, Hubert; Hänel, Mathias; Sohlbach, Kristina; Klesse, Christian; Mohr, Brigitte; Heidenreich, Falk; Stölzel, Friedrich; Röllig, Christoph; Platzbecker, Uwe; Ehninger, Gerhard; Bornhäuser, Martin; Thiede, Christian; Schetelig, Johannes

    2016-03-01

    Treatment success in patients with acute myeloid leukaemia (AML) is heterogeneous. Cytogenetic and molecular alterations are strong prognostic factors, which have been used to individualize treatment. Here, we studied the impact of TP53 mutations on the outcome of AML patients with adverse cytogenetic risk treated with allogeneic haematopoietic stem cell transplantation (HSCT). Samples of 97 patients with AML and adverse-risk cytogenetics who had received a HSCT within three randomized trials were analysed. Complete sequencing of the TP53 coding region was performed using next generation sequencing. The median age was 51 years. Overall, TP53 mutations were found in 40 patients (41%). With a median follow up of 67 months, the three-year probabilities of overall survival (OS) and event-free survival for patients with TP53 wild type were 33% [95% confidence interval (CI), 21% to 45%] and 24% (95% CI, 13% to 35%) compared to 10% (95% CI, 0% to 19%) and 8% (95% CI, 0% to 16%) (P = 0·002 and P = 0·007) for those with mutated TP53, respectively. In multivariate analysis, the TP53-mutation status had a negative impact on OS (Hazard Ratio = 1·7; P = 0·066). Mutational analysis of TP53 might be an important additional tool to predict outcome after HSCT in patients with adverse karyotype AML.

  19. Prevalence of BRCA1 and BRCA2 mutations in non-familial breast cancer patients with high risks in Korea: the Korean Hereditary Breast Cancer (KOHBRA) Study.

    PubMed

    Son, Byung Ho; Ahn, Sei Hyun; Kim, Sung-Won; Kang, Eunyoung; Park, Sue K; Lee, Min Hyuk; Noh, Woo-Chul; Kim, Lee Su; Jung, Yongsik; Kim, Ku Sang; Noh, Dong-Young; Moon, Byung-In; Suh, Young Jin; Lee, Jeong Eon; Choi, Doo Ho; Kim, Sung Yong; Jung, Sung Hoo; Yom, Cha Kyong; Lee, Hyde; Yang, Jung-Hyun

    2012-06-01

    Prevalence and phenotype of BRCA mutation can vary by race. The purpose of this study is to evaluate the prevalence of BRCA1/2 mutations in non-familial breast cancer patients with high risks in Korea. A subset of 758 patients was selected for this study from the KOHBRA nationwide multicenter prospective cohort study. Mutations in BRCA1/2 genes were tested using fluorescent-conformation sensitive gel electrophoresis, denaturing high performance liquid chromatography or direct sequencing. Mutation of BRCA1/2 genes were identified in 65 (8.6%) patients among total 758 patients [BRCA1 mutation: 25 (3.3%), BRCA2 mutation: 40 (5.3%)]. According to risk groups, mutation of BRCA1/2 genes were identified in 53 (8.5%) of 625 early onset patients (age ≤ 40), in 22 (17.7%) of 124 bilateral breast cancer patients, in 3 (50.0%) of 6 breast and ovarian cancer patients, in one (5.9%) of 17 male breast cancer patients, in 5 cases (7.6%) of 66 multiple organ cancer patients. The most common mutation was 509C>A for BRCA1 and 7708C>T for BRCA2. The prevalence of BRCA1/2 mutations by age in early onset patients was significantly different (age <35 vs age ≥35; 10.0 vs 2.9%, p = 0.0007). BRCA1/2 mutations for non-familial Korean breast cancer patients were detected at a high rate, particularly, in patients with early onset of less than 35 years of age, bilateral breast cancer, and breast and ovarian cancer. Individualized genetic counseling should be offered for non-familial breast cancer patients with these risk factors.

  20. A phase II study of AZD2171 (cediranib) in the treatment of patients with acute myeloid leukemia or high-risk myelodysplastic syndrome.

    PubMed

    Mattison, Ryan; Jumonville, Alcee; Flynn, Patrick James; Moreno-Aspitia, Alvaro; Erlichman, Charles; LaPlant, Betsy; Juckett, Mark B

    2015-07-01

    Patients with acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) not fit for intensive treatment need novel therapy options. Vascular endothelial growth factor (VEGF) receptor inhibition is one potential mechanism by which AML and MDS could be treated. The receptor tyrosine kinase inhibitor AZD2171 (cediranib) has activity against VEGF receptors KDR and FLT-1. This multicenter phase II study was designed to test cediranib's activity in patients with AML or high-risk MDS. The primary endpoint was confirmed disease response defined as a composite of complete remission, partial remission or hematologic improvement. The study enrolled 23 subjects in the AML cohort and 16 subjects in the MDS cohort. There were no confirmed responses in either group. Since the study met the stopping rule after the first stage of enrollment, the trial was closed to further accrual. Common adverse events in both cohorts included thrombocytopenia, neutropenia, anemia, fatigue, dyspnea, diarrhea, nausea and dehydration.

  1. The characteristics of sleep in patients with manifest bipolar disorder, subjects at high risk of developing the disease and healthy controls.

    PubMed

    Ritter, Philipp S; Marx, Carolin; Lewtschenko, Natalia; Pfeiffer, Steffi; Leopold, Karolina; Bauer, Michael; Pfennig, Andrea

    2012-10-01

    Sleep is highly altered during affective episodes in patients with bipolar disorder. There is accumulating evidence that sleep is also altered in euthymic states. A deficit in sleep regulation may be a vulnerability factor with aetiological relevance in the development of the disease. This study aims to explore the objective, subjective and lifetime sleep characteristics of patients with manifest bipolar disorder and persons with an elevated risk of developing the disease. Twenty-two patients with bipolar I and II disorder, nine persons with an elevated risk of developing the disorder and 28 healthy controls were evaluated with a structured interview to characterize subjective and lifetime sleeping habits. In addition, participants wore an actimeter for six nights. Patients with bipolar disorder had longer sleep latency and duration compared with healthy controls as determined by actigraphy. The subjective and lifetime sleep characteristics of bipolar patients differed significantly from healthy controls. The results of participants with an elevated risk of developing the disorder had subjective and lifetime characteristics that were largely analogous to those of patients with manifest bipolar disorder. In particular, both groups described recurring insomnia and hypersomnia, sensitivity to shifts in circadian rhythm, difficulties awakening and prolonged sleep latency. This study provides further evidence that sleep and circadian timing are profoundly altered in patients with bipolar disorder. It may also tentatively suggest that sleep may be altered prior to the first manic episode in subjects at high risk.

  2. The Effect of Lactobacillus plantarum 299v on the Incidence of Clostridium difficile Infection in High Risk Patients Treated with Antibiotics

    PubMed Central

    Kujawa-Szewieczek, Agata; Adamczak, Marcin; Kwiecień, Katarzyna; Dudzicz, Sylwia; Gazda, Magdalena; Więcek, Andrzej

    2015-01-01

    Background: Lactobacillus plantarum 299v (LP299v) has been used in order to reduce gastrointestinal symptoms during antibiotic exposure. However, it remains controversial whether or not probiotics are effective in the prevention of Clostridium difficile infections (CDI) among patients receiving antibiotics. The aim of this study was to analyze the CDI among patients receiving antibiotics and hospitalized in the period before and after starting routine use of LP299v as a prevention of this infection. Methods: Among 3533 patients hospitalized in the nephrology and transplantation ward during a two-year period, 23 patients with CDI were diagnosed and enrolled in this retrospective study. Since November 2013, prevention of CDI with oral use of LP299v was performed in all patients treated with antibiotics and who were at a high risk of developing CDI. The observation period was divided into two twelve-month intervals before and after initiation of the use of LP299v as a prophylactic against CDI. Results: A significant (p = 0.0001) reduction of the number of cases of CDI was found after routinely using LP299v (n = 2; 0.11% of all hospitalized patients) compared with the previous twelve-month period of observation (n = 21; 1.21% of all hospitalized patients). Conclusions: Routine use of LP299v during treatment with antibiotics may prevent C. difficile infection in the nephrology and transplantation ward. PMID:26690209

  3. Maintenance treatment with azacytidine for patients with high-risk myelodysplastic syndromes (MDS) or acute myeloid leukaemia following MDS in complete remission after induction chemotherapy.

    PubMed

    Grövdal, Michael; Karimi, Mohsen; Khan, Rasheed; Aggerholm, Anni; Antunovic, Petar; Astermark, Jan; Bernell, Per; Engström, Lena-Maria; Kjeldsen, Lars; Linder, Olle; Nilsson, Lars; Olsson, Anna; Holm, Mette S; Tangen, Jon M; Wallvik, Jonas; Oberg, Gunnar; Hokland, Peter; Jacobsen, Sten E; Porwit, Anna; Hellström-Lindberg, Eva

    2010-08-01

    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 chemotherapy. Sixty patients were enrolled and treated by standard induction chemotherapy. Patients that reached CR started maintenance therapy with subcutaneous azacytidine, 5/28 d until relapse. Promoter-methylation status of CDKN2B (P15 ink4b), CDH1 and HIC1 was examined pre-induction, in CR and 6, 12 and 24 months post CR. Twenty-four (40%) patients achieved CR after induction chemotherapy and 23 started maintenance treatment with azacytidine. Median CR duration was 13.5 months, >24 months in 17% of the patients, and 18-30.5 months in the four patients with trisomy 8. CR duration was not associated with CDKN2B methylation status or karyotype. Median overall survival was 20 months. Hypermethylation of CDH1 was significantly associated with low CR rate, early relapse, and short overall survival (P = 0.003). 5-azacytidine treatment, at a dose of 60 mg/m(2) was well tolerated. Grade III-IV thrombocytopenia and neutropenia occurred after 9.5 and 30% of the cycles, respectively, while haemoglobin levels increased during treatment. 5-azacytidine treatment is safe, feasible and may be of benefit in a subset of patients.

  4. Association between cholesterol synthesis/absorption markers and effects of cholesterol lowering by atorvastatin among patients with high risk of coronary heart disease.

    PubMed

    Qi, Yue; Liu, Jing; Ma, Changsheng; Wang, Wei; Liu, Xiaohui; Wang, Miao; Lv, Qiang; Sun, Jiayi; Liu, Jun; Li, Yan; Zhao, Dong

    2013-11-01

    No indices are currently available to facilitate clinicians to identify patients who need either statin monotherapy or statin-ezetimibe combined treatment. We aimed to investigate whether cholesterol synthesis and absorption markers can predict the cholesterol-lowering response to statin. Total 306 statin-naïve patients with high risk of coronary heart disease (CHD) were treated with atorvastatin 20 mg/day for 1 month. Cholesterol synthesis and absorption markers and LDL cholesterol (LDL-C) levels were measured before and after treatment. Atorvastatin decreased LDL-C by 36.8% (range: decrease of 74.5% to increase of 31.9%). Baseline cholesterol synthesis marker lathosterol and cholesterol absorption marker campesterol codetermined the effect of atorvastatin treatment. The effect of cholesterol lowering by atorvastatin was significantly associated with baseline lathosterol levels but modified bidirectionally by baseline campesterol levels. In patients with the highest baseline campesterol levels, atorvastatin treatment decreased cholesterol absorption by 46.1%, which enhanced the effect of LDL-C lowering. Atorvastatin treatment increased cholesterol absorption by 52.3% in those with the lowest baseline campesterol levels, which attenuated the effect of LDL-C reduction. Especially those with the highest lathosterol but the lowest campesterol levels at baseline had significantly less LDL-C reduction than those with the same baseline lathosterol levels but the highest campesterol levels (27.3% versus 42.4%, P = 0.002). These results suggest that combined patterns of cholesterol synthesis/absorption markers, rather than each single marker, are potential predictors of the LDL-C-lowering effects of atorvastatin in high-risk CHD patients.

  5. Randomized Trial Comparing R-CHOP Versus High-Dose Sequential Chemotherapy in High-Risk Patients With Diffuse Large B-Cell Lymphomas.

    PubMed

    Cortelazzo, Sergio; Tarella, Corrado; Gianni, Alessandro Massimo; Ladetto, Marco; Barbui, Anna Maria; Rossi, Andrea; Gritti, Giuseppe; Corradini, Paolo; Di Nicola, Massimo; Patti, Caterina; Mulé, Antonino; Zanni, Manuela; Zoli, Valerio; Billio, Atto; Piccin, Andrea; Negri, Giovanni; Castellino, Claudia; Di Raimondo, Francesco; Ferreri, Andrés J M; Benedetti, Fabio; La Nasa, Giorgio; Gini, Guido; Trentin, Livio; Frezzato, Maurizio; Flenghi, Leonardo; Falorio, Simona; Chilosi, Marco; Bruna, Riccardo; Tabanelli, Valentina; Pileri, Stefano; Masciulli, Arianna; Delaini, Federica; Boschini, Cristina; Rambaldi, Alessandro

    2016-11-20

    Purpose The benefit of high-dose chemotherapy with autologous stem-cell transplantation (ASCT) as first-line treatment in patients with diffuse large B-cell lymphomas is still a matter of debate. To address this point, we designed a randomized phase III trial to compare rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP)-14 (eight cycles) with rituximab plus high-dose sequential chemotherapy (R-HDS) with ASCT. Patients and Methods From June 2005 to June 2011, 246 high-risk patients with a high-intermediate (56%) or high (44%) International Prognostic Index score were randomly assigned to the R-CHOP or R-HDS arm, and 235 were analyzed by intent to treat. The primary efficacy end point of the study was 3-year event-free survival, and results were analyzed on an intent-to-treat basis. Results Clinical response (complete response, 78% v 76%; partial response, 5% v 9%) and failures (no response, 15% v 11%; and early treatment-related mortality, 2% v 3%) were similar after R-CHOP versus R-HDS, respectively. After a median follow-up of 5 years, the 3-year event-free survival was 62% versus 65% ( P = .83). At 3 years, compared with the R-CHOP arm, the R-HDS arm had better disease-free survival (79% v 91%, respectively; P = .034), but this subsequently vanished because of late-occurring treatment-related deaths. No difference was detected in terms of progression-free survival (65% v 75%, respectively; P = .12), or overall survival (74% v 77%, respectively; P = .64). Significantly higher hematologic toxicity ( P < .001) and more infectious complications ( P < .001) were observed in the R-HDS arm. Conclusion In this study, front-line intensive R-HDS chemotherapy with ASCT did not improve the outcome of high-risk patients with diffuse large B-cell lymphomas.

  6. The Management of Patients after Surgical Treatment of Maxillofacial Tumors

    PubMed Central

    Rolski, D.; Zawadzki, P.; Życińska, K.; Mierzwińska-Nastalska, E.

    2016-01-01

    Morphological and functional disturbances induced by postsurgical defects and loss of tissues in the stomatognathic system due to the treatment of tumors in the maxillofacial region determine the therapeutic needs of patients. The study aimed at clinical and epidemiological evaluation of patients under prosthetic treatment in order to establish the algorithm for rehabilitation. The study group was composed of the patients after midface surgery (45.74%); surgery in a lower part of the face (47.38%); mixed postoperative losses (3.44%); loss of face tissues and surgery in other locations in the head and neck region (3.44%). The supplementary treatment was applied in 69.63% of patients. Clinical and additional examinations were performed to obtain the picture of postoperative loss, its magnitude, and location to plan the strategy of prosthetic rehabilitation. The management algorithm for prosthetic rehabilitation in patients after surgical treatment of maxillofacial neoplasms was based on its division in stages. The location and magnitude of postoperative losses, as well as the implementation of supplementary treatment of the patients after treatment of maxillofacial tumors, influence the planning of prosthetic rehabilitation that plays a key role and facilitates the patients' return to their prior living situation, occupational and family lives. PMID:27747229

  7. The Prevalence of Malnutrition and Effectiveness of STRONGkids Tool in the Identification of Malnutrition Risks among Pediatric Surgical Patients

    PubMed Central

    Durakbaşa, Çiğdem Ulukaya; Fettahoğlu, Selma; Bayar, Ahu; Mutus, Murat; Okur, Hamit

    2014-01-01

    Background: High prevalence of malnutrition along with the risk for the development of malnutrition in hospitalised children has been reported. However, this problem remains largely unrecognised by healthcare workers. Aims: To determine the prevalence of malnutrition and effectiveness of STRONGkids nutritional risk screening (NRS) tool in the identification of malnutrition risk among pediatric surgical patients. Study Design: Cross-sectional study. Methods: A total of 494 pediatric surgical patients (median age 59 months, 75.8% males) were included in this prospective study conducted over 3 months. SD-scores <−2 for Body Mass Index (BMI) for age or weight-for-height (WFH) and height-for-age (HFA) were considered to indicate acute and chronic malnutrition, respectively. The STRONGkids NRS tool was used to determine risk for malnutrition. Results: Malnutrition was detected in 13.4% in this group of pediatric surgical patients. Acute malnutrition was identified in 10.1% of patients and more commonly in patients aged ≤60 months than aged >60 months (13.4 vs. 6.6%, p=0.012). Chronic malnutrition was identified in 23 (4.6%) of patients with no significant difference between age groups. There were 7 (1.4%) children with coexistent acute and chronic malnutrition. The STRONGkids tool revealed that 35.7% of patients were either in the moderate or high risk group for malnutrition. Malnutrition, as revealed by anthropometric measurements, was more likely in the presence of gastrointestinal (26.9%, p=0.004) and inguinoscrotal/penile surgery (4.0%, p=0.031), co-morbidities affecting nutritional status (p<0.001) and inpatient admissions (p=0.014). Among patients categorized as low risk for malnutrition, there were more outpatients than inpatients (89.3 vs. 10.7%, p<0.001) and more elective surgery cases than emergency surgery cases (93.4 vs. 6.6%, p<0.001). Conclusion: Providing data on the prevalence of malnutrition and risk of malnutrition in a prospectively recruited group

  8. The kSORT Assay to Detect Renal Transplant Patients at High Risk for Acute Rejection: Results of the Multicenter AART Study

    PubMed Central

    Hsieh, Sue; Dai, Hong; Bestard, Oriol; Metes, Diana; Zeevi, Andrea; Gritsch, Albin; Cheeseman, Jennifer; Macedo, Camila; Peddy, Ram; Medeiros, Mara; Vincenti, Flavio; Asher, Nancy; Salvatierra, Oscar; Shapiro, Ron; Kirk, Allan; Reed, Elaine; Sarwal, Minnie M.

    2014-01-01

    Background Development of noninvasive molecular assays to improve disease diagnosis and patient monitoring is a critical need. In renal transplantation, acute rejection (AR) increases the risk for chronic graft injury and failure. Noninvasive diagnostic assays to improve current late and nonspecific diagnosis of rejection are needed. We sought to develop a test using a simple blood gene expression assay to detect patients at high risk for AR. Methods and Findings We developed a novel correlation-based algorithm by step-wise analysis of gene expression data in 558 blood samples from 436 renal transplant patients collected across eight transplant centers in the US, Mexico, and Spain between 5 February 2005 and 15 December 2012 in the Assessment of Acute Rejection in Renal Transplantation (AART) study. Gene expression was assessed by quantitative real-time PCR (QPCR) in one center. A 17-gene set—the Kidney Solid Organ Response Test (kSORT)—was selected in 143 samples for AR classification using discriminant analysis (area under the receiver operating characteristic curve [AUC] = 0.94; 95% CI 0.91–0.98), validated in 124 independent samples (AUC = 0.95; 95% CI 0.88–1.0) and evaluated for AR prediction in 191 serial samples, where it predicted AR up to 3 mo prior to detection by the current gold standard (biopsy). A novel reference-based algorithm (using 13 12-gene models) was developed in 100 independent samples to provide a numerical AR risk score, to classify patients as high risk versus low risk for AR. kSORT was able to detect AR in blood independent of age, time post-transplantation, and sample source without additional data normalization; AUC = 0.93 (95% CI 0.86–0.99). Further validation of kSORT is planned in prospective clinical observational and interventional trials. Conclusions The kSORT blood QPCR assay is a noninvasive tool to detect high risk of AR of renal transplants. Please see later in the article for the Editors' Summary PMID

  9. Should we monitor with bispectral index in all patients at high risk for seizures in the operating room?

    PubMed

    Elgueta, M F; Vega, P; Lema, G; Clede, L

    2013-10-01

    We report the case of a patient with a cerebral aneurysm, located in the left middle cerebral artery. During the clipping of this aneurysm, the bispectral index (BIS) increased for no apparent reason. This was then interpreted as intraoperative non-convulsive status epilepticus. This clinical condition may have negative impact in the prognosis of the patient, so it is very important to be able to detect this conditions as early as possible. Measuring the BIS while the patient is anaesthetised could be useful in this situation, considering that an increase in values greater than 60, associated with acidosis and without any other peri-anaesthetic explanation, may provide evidence of a convulsive equivalent state, allowing appropriate action to be taken.

  10. Critical role of bevacizumab scheduling in combination with pre-surgical chemo-radiotherapy in MRI-defined high-risk locally advanced rectal cancer: results of the branch trial

    PubMed Central

    Avallone, Antonio; Pecori, Biagio; Bianco, Franco; Aloj, Luigi; Tatangelo, Fabiana; Romano, Carmela; Granata, Vincenza; Marone, Pietro; Leone, Alessandra; Botti, Gerardo; Petrillo, Antonella; Caracò, Corradina; Iaffaioli, Vincenzo R.; Muto, Paolo; Romano, Giovanni; Comella, Pasquale; Budillon, Alfredo; Delrio, Paolo

    2015-01-01

    Background We have previously shown that an intensified preoperative regimen including oxaliplatin plus raltitrexed and 5-fluorouracil/folinic acid (OXATOM/FUFA) during preoperative pelvic radiotherapy produced promising results in locally advanced rectal cancer (LARC). Preclinical evidence suggests that the scheduling of bevacizumab may be crucial to optimize its combination with chemo-radiotherapy. Patients and methods This non-randomized, non-comparative, phase II study was conducted in MRI-defined high-risk LARC. Patients received three biweekly cycles of OXATOM/FUFA during RT. Bevacizumab was given 2 weeks before the start of chemo-radiotherapy, and on the same day of chemotherapy for 3 cycles (concomitant-schedule A) or 4 days prior to the first and second cycle of chemotherapy (sequential-schedule B). Primary end point was pathological complete tumor regression (TRG1) rate. Results The accrual for the concomitant-schedule was early terminated because the number of TRG1 (2 out of 16 patients) was statistically inconsistent with the hypothesis of activity (30%) to be tested. Conversely, the endpoint was reached with the sequential-schedule and the final TRG1 rate among 46 enrolled patients was 50% (95% CI 35%–65%). Neutropenia was the most common grade ≥3 toxicity with both schedules, but it was less pronounced with the sequential than concomitant-schedule (30% vs. 44%). Postoperative complications occurred in 8/15 (53%) and 13/46 (28%) patients in schedule A and B, respectively. At 5 year follow-up the probability of PFS and OS was 80% (95%CI, 66%–89%) and 85% (95%CI, 69%–93%), respectively, for the sequential-schedule. Conclusions These results highlights the relevance of bevacizumab scheduling to optimize its combination with preoperative chemo-radiotherapy in the management of LARC. PMID:26320185

  11. Carotid Stenting with Distal Protection in High-Surgical-Risk Patients: One-Year Results of the ASTI Trial

    SciTech Connect

    Bosiers, Marc; Scheinert, Dierk; Mathias, Klaus; Langhoff, Ralf; Mudra, Harald; Diaz-Cartelle, Juan

    2015-04-15

    PurposeThis prospective, multicenter, nonrandomized study evaluated the periprocedural and 1-year outcomes in high-surgical-risk patients with carotid artery stenosis treated with the Adapt Carotid Stent plus FilterWire EZ distal protection catheter (Boston Scientific Corporation, Natick, MA).Materials and MethodsThe study enrolled 100 patients (32 symptomatic, 63 asymptomatic, 5 unknown) at high risk for carotid endarterectomy due to prespecified anatomical criteria and/or medical comorbidities. Thirty-day and 1-year follow-up included clinical evaluation, carotid duplex ultrasound, and independent neurologic and NIH stroke scale assessments. One-year endpoints included the composite rate of major adverse events (MAE), defined as death, stroke, and myocardial infarction (MI) and the rates of late ipsilateral stroke (31–365 days), target lesion revascularization, and in-stent restenosis.ResultsOf the 100 enrolled patients, technical success was achieved in 90.9 % (90/99). The 30-day MAE rate (5.1 %) consisted of major stroke (2.0 %) and minor stroke (3.1 %); no deaths or MIs occurred. The 1-year MAE rate (12.2 %) consisted of death, MI, and stroke rates of 4.4, 3.3, and 8.9 %, respectively. Late ipsilateral stroke (31–365 days) rate was 1.1 %. Symptomatic patients had higher rates of death (11.1 vs. 1.7 %) and MI (7.4 vs. 1.7 %), but lower rates of major (7.4 vs. 10.0 %) and minor stroke (0.0 vs. 6.7 %), compared with asymptomatic patients.ConclusionResults through 1 year postprocedure demonstrated that carotid artery stenting with Adapt Carotid Stent and FilterWire EZ is safe and effective in high-risk-surgical patients.

  12. Late Status of Fontan Patients with Persistent Surgical Fenestration

    PubMed Central

    Atz, Andrew M.; Travison, Thomas G.; McCrindle, Brian W.; Mahony, Lynn; Quartermain, Michael; Williams, Richard V.; Breitbart, Roger E.; Lu, Minmin; Radojewski, Elizabeth; Margossian, Renee; Covitz, Wesley; Gersony, Welton M.

    2011-01-01

    Objective To determine the effects of creation of a systemic to pulmonary venous atrial level communication (fenestration) at the time of the Fontan procedure on late outcomes. Background Fenestrations are frequently performed during Fontan procedures but late consequences are not well described. Methods Patient characteristics were compared between those with and without surgical fenestration among 536 subjects (mean 11.9 years) enrolled in the Pediatric Heart Network Fontan Cross-sectional Study. The status of the fenestration and the association of a currently patent fenestration with health status and measures of ventricular performance were investigated. Results Fenestration was performed in 361 patients (67%) and frequency differed by year and center (p<0.001 for each). After adjustment for center, age at Fontan, year of Fontan and prior superior cavopulmonary surgery, the fenestrated group had shorter length of Fontan hospital stay. At time of cross-sectional testing 8±3 years after Fontan, the fenestration remained open in 19% of subjects. Among those with confirmed fenestration closure, 59% were by catheter intervention, 1% by surgical intervention, and 40% had apparent spontaneous closure. Compared to those without evidence of a fenestration, subjects with a current fenestration were taking more medications (p=0.02) and had lower resting oxygen saturation (median 89 vs. 95%, p<.001). Functional health status, exercise performance, echocardiographic variables, prevalence of post Fontan stroke or thrombosis, and growth did not differ by current fenestration status. Discussion Surgical fenestration is associated with well demonstrated early postoperative benefits. This cross-sectional study found few associations between a persistent fenestration and deleterious later outcomes. PMID:21658565

  13. Laparoscopic colostomy for acute left colon obstruction caused by diverticular disease in high risk patient: A case report

    PubMed Central

    Palladino, Elisa; Cappiello, Antonio; Guarino, Vincenzo; Perrotta, Nicola; Loffredo, Domenico

    2015-01-01

    Introduction The colostomy is often necessary in complicated divertcular disease. The laparoscopic colostomy is not widely used for the treatment of complicated diverticular disease. Its use in patients with high operative risk is still on debate. The aim of this case report was to present the benefits of laparoscopic colostomy in patients with high peri-and postoperative risk factors. Presentation of case We present a case of 76-year-old female admitted to emergency unit for left colonic obstruction. The patient had a past history of liver cirrhosis HCV-related with a severe malnutrition, hypertrophic cardiomyopathy, diverticular disease, hiatal ernia, previous appendectomy. Patient was classified according to their preoperative risk ASA 3 (classification of the American society of Anestesia-ASA score). Contrast-enhanced abdominal CT revealed a marked thickening in the sigmoid colon and a marked circumferential stenosis in the sigmoid colon in absence of neoplasm, and/or abscess. The laparoscopic procedure is proposed as first intention. Discussion The operation time was 50 min, and the hospital stay was 4 days. Post operative complications grade I according to the Clavien Dindo Classification. Conclusions Laparoscopic colostomy is safe and feasible procedure in experienced hands. It is associated with low morbidity and short stay in hospital and should be considered a good alternative to a laparotomy. PMID:26036456

  14. Second generation tyrosine kinase inhibitors prevent disease progression in high-risk (high CIP2A) chronic myeloid leukaemia patients.

    PubMed

    Lucas, C M; Harris, R J; Holcroft, A K; Scott, L J; Carmell, N; McDonald, E; Polydoros, F; Clark, R E

    2015-07-01

    High cancerous inhibitor of PP2A (CIP2A) protein levels at diagnosis of chronic myeloid leukaemia (CML) are predictive of disease progression in imatinib-treated patients. It is not known whether this is true in patients treated with second generation tyrosine kinase inhibitors (2G TKI) from diagnosis, and whether 2G TKIs modulate the CIP2A pathway. Here, we show that patients with high diagnostic CIP2A levels who receive a 2G TKI do not progress, unlike those treated with imatinib (P=<0.0001). 2G TKIs induce more potent suppression of CIP2A and c-Myc than imatinib. The transcription factor E2F1 is elevated in high CIP2A patients and following 1 month of in vivo treatment 2G TKIs suppress E2F1 and reduce CIP2A; these effects are not seen with imatinib. Silencing of CIP2A, c-Myc or E2F1 in K562 cells or CML CD34+ cells reactivates PP2A leading to BCR-ABL suppression. CIP2A increases proliferation and this is only reduced by 2G TKIs. Patients with high CIP2A levels should be offered 2G TKI treatment in preference to imatinib. 2G TKIs disrupt the CIP2A/c-Myc/E2F1 positive feedback loop, leading to lower disease progression risk. The data supports the view that CIP2A inhibits PP2Ac, stabilising E2F1, creating a CIP2A/c-Myc/E2F1 positive feedback loop, which imatinib cannot overcome.

  15. Post-Hoc Study: Intravenous Hydration Treatment in Chinese Patients with High Risk of Contrast-Induced Nephropathy Following Percutaneous Coronary Intervention

    PubMed Central

    Bei, Weijie; Li, Hualong; Lin, Kaiyang; Wang, Kun; Chen, Shiqun; Guo, Xiaosheng; Liu, Yong; Tan, Ning; Chen, Jiyan; Yang, Xiangtai; Su, Xi; Du, Zhimin; Zeng, Qiutang; Fang, Zhenfei; Wang, Yan; Jiang, Hong; Xiong, Longgen; Hou, Yuqing; Yuan, Yong; Li, Tianfa; Hong, Lang; Wu, Yanqing; Liu, Yin; Lin, Wenhua; Jiang, Tiemin; Fu, Junhua; An, Yi; Yu, Bo; Tian, Ye; Zheng, Yang; Liu, Bin; Yang, Ping; Jiang, Xianyan; Wang, Hao; Qu, Peng; Cui, Lianqun; Li, Xueqi; Qi, Xiaoyong; Ma, Zengcai; Li, Jifu; Zhang, Lili; Liu, Shengquan; Pang, Wenyue; Li, Yibo; Yang, Manguang; Ji, Zheng; Zhao, Pitian; Li, Lu; Ge, Junbo; Jin, Huigen; Pan, Weimin; Song, Yaoming; Li, Jianmei; Xiao, Jianming; Liu, Hanxiong; Tao, Jianhong; Wu, Zhongdong; Tuo, Buxiong; Li, Wei; Xu, Yixian; Zhang, Zhaoqi; Chen, Yundai; Wang, Lefeng; Zhang, Jinying; Wang, Fengling; Jia, Yongping; Wang, Bin; Tang, Fakuan; Tang, Qiang; Wang, Wei; Sun, Yuemin; Su, Weiqing

    2017-01-01

    Contrast-induced nephropathy (CIN) develops after the injection of iodinated contrast media. This is a post hoc analysis of the data obtained from the TRUST study, which was a prospective, multicentre, observational study conducted to evaluate the safety and tolerability of the contrast medium iopromide in patients undergoing cardiac catheterization from August 2010 to September 2011 in China, conducted to explore the current status, trends and risk predictors of hydration treatment. The status of hydration to prevent CIN in each patient was recorded. Of the total 17,139 patients from the TRUST study (mean age, 60.33 ± 10.38 years), the overall hydration usage was 46.1% in patients undergoing percutaneous coronary intervention (PCI) and 77.4%, 51.7%, and 48.5% in patients with pre-existing renal disease, diabetes mellitus, and hypertension, respectively. The proportion of hydration use increased from 36.5% to 55.5% from August 2010 to September 2011, which was independently associated with risk predictors like older age, pre-existing renal disease, hypertension, diabetes mellitus, prior myocardial infarction, ST segment elevation MI, high contrast dose, multi-vessel disease and reduced LVEF (<45%). Overall, the usage of intravenous hydration treatment for patients with a high risk of CIN following PCI was high in China. PMID:28337989

  16. Airway Management of the Cardiac Surgical Patients: Current Perspective

    PubMed Central

    Choudhury, Arindam; Gupta, Nishkarsh; Magoon, Rohan; Kapoor, Poonam Malhotra

    2017-01-01

    The difficult airway (DA) is a common problem encountered in patients undergoing cardiac surgery. However, the challenge is not only just establishment of airway but also maintaining a definitive airway for the safe conduct of cardiopulmonary bypass from initiation to weaning after surgical correction or palliation, de-airing of cardiac chambers. This review describes the management of the DA in a cardiac theater environment. The primary aims are recognition of DA both anatomical and physiological, necessary preparations for (and management of) difficult intubation and extubation. All patients undergoing cardiac surgery should initially be considered as having potentially DA as many of them have poor physiologic reserve. Making the cardiac surgical theater environment conducive to DA management is as essential as it is to deal with low cardiac output syndrome or acute heart failure. Tube obstruction and/or displacement should be suspected in case of a new onset ventilation problem, especially in the recovery unit. Cardiac anesthesiologists are often challenged with DA while inducing general endotracheal anesthesia. They ought to be familiar with the DA algorithms and possess skill for using the latest airway adjuncts. PMID:28074820

  17. Quality of Life for Patients in Medical-Surgical Wards.

    PubMed

    Ahmad, Muayyad M; Al-Daken, Laila Ismae'l; Ahmad, Huthaifa M

    2015-08-01

    The purpose of this study was to examine the quality of life (QoL) for patients in medical-surgical wards in Jordanian hospitals. A cross-sectional design was performed. The data were collected between January and April 2011 through individual interviews (n = 746) using the Medical Outcome Study 36-item Short-Form (MOS-SF-36) and Charlson's Co-morbidity Index (CCI). The private and public hospitals in the three largest cities in Jordan were represented. The MANOVA test was used to examine the health status based on patients' co-morbidity level. The results showed that QoL for patients with severe co-morbidity has been affected negatively in many aspects more than both patients with no co-morbidity and patients with mild co-morbidity. However, although it is difficult to change the demographic characteristics, it is possible to improve the health status of patients with multiple co-morbidities, which will result in having a better QoL.

  18. Nutritional screening in surgical patients of a teaching hospital from Southern Brazil: the impact of nutritional risk in clinical outcomes

    PubMed Central

    Garcia, Rosane Scussel; Tavares, Léa Regina da Cunha; Pastore, Carla Alberici

    2013-01-01

    ABSTRACT Objective: To assess the prevalence of nutritional risk in surgical patients of a teaching hospital and its associated factors. Methods: A cross-sectional study with secondary data of surgical ward patients of the Hospital Escola da Universidade Federal de Pelotas, from April to October, 2010. Patients were evaluated up to 36 hours after admission using the Malnutrition Screening Tool. Results: The study included 565 patients, with a mean age of 52.8±15.6 years, and the majority (51%) was female. More than 30% of the patients presented with an average or high nutritional risk, and 7% of them were at high risk. Associated with the greater risk were aging, cancer surgery, and mortality. The length of hospital stay showed a linear increase according to nutritional risk. Conclusion: The Malnutrition Screening Tool is a simple and effective tool for nutritional screening that does not require anthropometric measurements. In this study, average or high nutritional risk was prevalent in one third of the sample, and was related to increased mortality, hospital stay, cancer, and aging. Nutritional care outpatients’ protocols could be used prior to elective surgery to reduce the nutritional risk of these patients, improving clinical outcomes and reducing length and costs of hospital stay. PMID:23843052

  19. Molecular evidence-based use of bone resorption-targeted therapy in prostate cancer patients at high risk for bone involvement.

    PubMed Central

    Karamanolakis, Dimitrios; Bogdanos, John; Sourla, Antigone; Milathianakis, Constantine; Tsintavis, Athanassios; Lembessis, Peter; Tenta, Roxane; Tiblalexi, Despina; Koutsilieris, Michael

    2002-01-01

    BACKGROUND: To improve median survival of patients with prostate cancer that has metastasized to bone, we need to better understand the early events of the metastatic process in skeleton and develop molecular tools capable of detecting the early tumor cell dissemination into bones (micrometastasis stage). However, the initial phase of tumor cell dissemination into the bone marrow is promptly followed by the migration of tumor cells into bone matrix, which is a crucial step that signals the transformation of micrometastasis to macrometastasis stage and clinically evident metastasis. The migration of cancer cells into bone matrix requires the activation of local bone resorption. Such an event contributes to tumor cell hiding/ escaping from high immunologic surveillance of bone marrow cells. Within bone matrix, tumor cells are establishing plethoric cell-cell interactions with bone marrow-residing cells, ensuring their survival and growth. Recently, RT-PCR detections of tumor marker transcripts, such as PSA and PSMA mRNA performed in RNA extracts of peripheral blood nucleated cells and bone marrow biopsy, have enabled the stratification of patients with clinically localized prostate cancer being of high risk for extraprostatic disease and bone involvement. Therefore, it is conceivable that bisphosphonate blockade of bone resorption can inhibit the migration of tumor cells into bone matrix during the early phase of disease dissemination into bone marrow (micrometastasis stage). Consequently, assessment of the efficacy and efficiency of bisphosphonates to arrest the evolution of bone lesions in this particular clinical setting of patients with clinically localized prostate cancer and positive molecular staging status (high risk for bone involvement) is warranted. PMID:12520083

  20. Tissue Banks and Cell Lines Derived from Patients with a High Risk of Breast Cancer and in situ Disease.

    DTIC Science & Technology

    1997-11-01

    and Li-Fraumeni syndromes and patients with ataxia telangiectasia and Cowden’s. Establishing these cells in culture will provide systems for both...summarises the material that has been collected on some of the key cases. We also have primary cultures from one patent with Klinefelter’s syndrome and a...notable feature of known breast cancer predisposition syndromes such as those due to the BRCA1 or p53 genes and therefore may be an indicator of a

  1. High Risk of Herpes Zoster among Patients with Advance Acute Kidney Injury--A Population-Based Study.

    PubMed

    Yang, Wei-Shun; Hu, Fu-Chang; Chen, Meng-Kan; Ko, Wen-Je; Chen, Likwang; Wu, Kwan-Dun; Wu, Vin-Cent

    2015-09-03

    The risk for herpes zoster (HZ) in acute kidney injury (AKI) survivors was never explored. We identified 2,387 adults in the Taiwan National Health Insurance Research Database who recovered from dialysis-requiring AKI and matched them with non-recovery and non-AKI patients by propensity score. During a mean follow-up of 2.7 years, the incidences of HZ were 6.9, 8.2 and 4.8 episodes per 1,000 person-years in AKI-non-recovery, AKI-recovery and non-AKI group, respectively. The recovery group was more likely to develop herpes zoster than those without acute kidney injury [incidence-rate ratios 1.71, 95% confidence interval 1.16-2.52; p = 0.007]. Patients without acute kidney injury were less likely to develop herpes zoster than those AKI, recovered from dialysis or not (hazard ratio HR 0.66, 95% CI 0.46-0.95). Dialysis-requiring acute kidney injury poses a long-term risk of herpes zoster after hospital discharge. Even patients who have recovered from dialysis still carry a significantly higher risk of developing herpes zoster.

  2. Improvement in toxicity in high risk prostate cancer patients treated with image-guided intensity-modulated radiotherapy compared to 3D conformal radiotherapy without daily image guidance

    PubMed Central

    2014-01-01

    Background Image-guided radiotherapy (IGRT) facilitates the delivery of a very precise radiation dose. In this study we compare the toxicity and biochemical progression-free survival between patients treated with daily image-guided intensity-modulated radiotherapy (IG-IMRT) and 3D conformal radiotherapy (3DCRT) without daily image guidance for high risk prostate cancer (PCa). Methods A total of 503 high risk PCa patients treated with radiotherapy (RT) and endocrine treatment between 2000 and 2010 were retrospectively reviewed. 115 patients were treated with 3DCRT, and 388 patients were treated with IG-IMRT. 3DCRT patients were treated to 76 Gy and without daily image guidance and with 1–2 cm PTV margins. IG-IMRT patients were treated to 78 Gy based on daily image guidance of fiducial markers, and the PTV margins were 5–7 mm. Furthermore, the dose-volume constraints to both the rectum and bladder were changed with the introduction of IG-IMRT. Results The 2-year actuarial likelihood of developing grade > = 2 GI toxicity following RT was 57.3% in 3DCRT patients and 5.8% in IG-IMRT patients (p < 0.001). For GU toxicity the numbers were 41.8% and 29.7%, respectively (p = 0.011). On multivariate analysis, 3DCRT was associated with a significantly increased risk of developing grade > = 2 GI toxicity compared to IG-IMRT (p < 0.001, HR = 11.59 [CI: 6.67-20.14]). 3DCRT was also associated with an increased risk of developing GU toxicity compared to IG-IMRT. The 3-year actuarial biochemical progression-free survival probability was 86.0% for 3DCRT and 90.3% for IG-IMRT (p = 0.386). On multivariate analysis there was no difference in biochemical progression-free survival between 3DCRT and IG-IMRT. Conclusion The difference in toxicity can be attributed to the combination of the IMRT technique with reduced dose to organs-at-risk, daily image guidance and margin reduction. PMID:24495815

  3. The application of 120-W high-performance system GreenLight laser vaporization of the prostate in high-risk patients.

    PubMed

    Tao, Wei; Xue, BoXin; Zang, Yachen; Sun, ChuanYang; Yang, Dongrong; Zhang, Yuanyuan; Shan, YuXi

    2013-07-01

    The purpose of this study is to evaluate the safety and efficacy of 120-W potassium titanyl phosphate (KTP) laser vaporization in patients with benign prostatic hyperplasia (BPH) who also had cardiopulmonary diseases who were taking long-term anticoagulants and were at high risk of bleeding complications. The prospective study included 188 patients with severe lower urinary tract symptoms who underwent 120-W KTP laser vaporization of the prostate. All patients were at high cardiopulmonary risk, having presented with an American Society of Anesthesiology score of 3 or greater. Of those, 45 patients were taking oral anticoagulants, and 1 had a severe bleeding disorder. BPH was successfully treated with 120-W KTP laser vaporization in all patients. Mean preoperative prostate volume ± SD was 66 ± 23.1 ml, and mean operative time was 50.8 ± 15.5 min. There were no major complications intraoperatively or postoperatively, and no blood transfusions were required. Postoperatively, only 14 patients (7.4 %) required bladder irrigation. Average catheterization time was 1.9 ± 1.5 days (range, 1-5 days). Three patients required reoperation due to enlarged prostates from residual adenoma. At 3-, 6,- 12-, and 24-month follow-ups, mean urinary peak flow increased from 8.0 ± 3.6 ml/s to 19.1 ± 5.6, 19.2 ± 4.7, 19.1 ± 4.65, and 19.2 ± 4.34 ml/s, respectively. Mean International Prostate Symptom Scores decreased over time, from 25.6 ± 5.1 (3 months) to 9.4 ± 2.8, 7.05 ± 1.46, 6.24 ± 1.36, and 6.20 ± 1.32 (24 months), respectively. 120-W HPS KTP laser vaporization is a safe and effective treatment option in BPH patients at high risk and those on anticoagulation therapy who have severe LUTS secondary to BPH.

  4. Predictors of Progression to Cancer in Barrett’s Esophagus: Baseline Histology and Flow Cytometry Identify Low- and High-Risk Patient Subsets

    PubMed Central

    Reid, Brian J.; Levine, Douglas S.; Longton, Gary; Blount, Patricia L.; Rabinovitch, Peter S.

    2006-01-01

    OBJECTIVE Barrett’s esophagus develops in 5–20% of patients with gastroesophageal reflux disease and predisposes to esophageal adenocarcinoma. The value of endoscopic biopsy surveillance is questioned because most patients do not develop cancer. Furthermore, observer variation in histological diagnosis makes validation of surveillance guidelines difficult because varying histological interpretations may lead to different estimated rates of progression. Thus, objective biomarkers need to be validated for use with histology to stratify patients according to their risk for progression to cancer. METHODS We prospectively evaluated patients using a systematic endoscopic biopsy protocol with baseline histological and flow cytometric abnormalities as predictors and cancer as the outcome. RESULTS Among patients with negative, indefinite, or low-grade dysplasia, those with neither aneuploidy nor increased 4N fractions had a 0% 5-yr cumulative cancer incidence compared with 28% for those with either aneuploidy or increased 4N. Patients with baseline increased 4N, aneuploidy, and high-grade dysplasia had 5-yr cancer incidences of 56%, 43%, and 59%, respectively. Aneuploidy, increased 4N, or HGD were detected at baseline in all 35 patients who developed cancer within 5 yr. CONCLUSIONS A systematic baseline endoscopic biopsy protocol using histology and flow cytometry identifies subsets of patients with Barrett’s esophagus at low and high risk for progression to cancer. Patients whose baseline biopsies are negative, indefinite, or low-grade displasia without increased 4N or aneuploidy may have surveillance deferred for up to 5 yr. Patients with cytometric abnormalities merit more frequent surveillance, and management of high-grade displasia can be individualized. PMID:10925966

  5. Prophylactic vacuum sealing drainage (VSD) in the prevention of postoperative surgical site infections in pediatric patients with contaminated laparotomy incisions.

    PubMed

    Chen, Bailin; Hao, Fabao; Yang, Yang; Shang, Qingjuan; Guo, Chunbao

    2017-03-01

    Surgical site infection (SSI) continues to be an issue in abdominal surgery, especially for contaminated (class III) and dirty-infected (class IV) wounds. Vacuum sealing drainage (VSD) was reported effective in the management of various types of wounds or skin grafts. Our goal was to investigate the efficacy of prophylactic VSD to better orient their medicosurgical care of high-risk incisions following laparotomy in a pediatric population.A total of 331 pediatric patients with contaminated (class III) and dirty-infected (class IV) wounds following emergency laparotomy were retrospectively reviewed between January 2005 and January 2013. Among them, 111 cases were placed with prophylactic VSD when incisions were closed. Clinical outcomes, including, overall surgical site complication, device effectiveness, and mean postoperative LOS were evaluated based on VSD usage or not.VSD was applied for an average of 5.8 days (range, 5-7 days), with 3 to 15 mL sucked fluid. The overall SSIs rate was 3% for patients with prophylactic VSD and 17% for patients with convention dressing (OR, 0.27; 95% CI, 0.10-0.71, P = 0.004). In patients with prophylactic VSD, only 1 of 96 wound developed postoperative incision dehiscence, which is significant reduced compared with patients for conventional dressings (OR, 0.12; 95% CI, 0.01-0.95; P = 0.017) (Table 2). It also exhibited a decreased mean postoperative LOS (P < 0.001) for prophylactic VSD over conventional dressings.Our study demonstrated beneficial postoperative clinical effects of prophylactic VSD for high-risk laparotomy incisions following emergency laparotomy, such as shorter length of hospitalization, which may be attributed to the reduced overall SSIs rate.

  6. Prophylactic vacuum sealing drainage (VSD) in the prevention of postoperative surgical site infections in pediatric patients with contaminated laparotomy incisions

    PubMed Central

    Chen, Bailin; Hao, Fabao; Yang, Yang; Shang, Qingjuan; Guo, Chunbao

    2017-01-01

    Abstract Surgical site infection (SSI) continues to be an issue in abdominal surgery, especially for contaminated (class III) and dirty-infected (class IV) wounds. Vacuum sealing drainage (VSD) was reported effective in the management of various types of wounds or skin grafts. Our goal was to investigate the efficacy of prophylactic VSD to better orient their medicosurgical care of high-risk incisions following laparotomy in a pediatric population. A total of 331 pediatric patients with contaminated (class III) and dirty-infected (class IV) wounds following emergency laparotomy were retrospectively reviewed between January 2005 and January 2013. Among them, 111 cases were placed with prophylactic VSD when incisions were closed. Clinical outcomes, including, overall surgical site complication, device effectiveness, and mean postoperative LOS were evaluated based on VSD usage or not. VSD was applied for an average of 5.8 days (range, 5–7 days), with 3 to 15 mL sucked fluid. The overall SSIs rate was 3% for patients with prophylactic VSD and 17% for patients with convention dressing (OR, 0.27; 95% CI, 0.10–0.71, P = 0.004). In patients with prophylactic VSD, only 1 of 96 wound developed postoperative incision dehiscence, which is significant reduced compared with patients for conventional dressings (OR, 0.12; 95% CI, 0.01–0.95; P = 0.017) (Table 2). It also exhibited a decreased mean postoperative LOS (P < 0.001) for prophylactic VSD over conventional dressings. Our study demonstrated beneficial postoperative clinical effects of prophylactic VSD for high-risk laparotomy incisions following emergency laparotomy, such as shorter length of hospitalization, which may be attributed to the reduced overall SSIs rate. PMID:28353606

  7. Patient Participation in Surgical Treatment Decision Making from the Patients' Perspective: Validation of an Instrument

    PubMed Central

    Heggland, Liv-Helen; Øgaard, Torvald; Mikkelsen, Aslaug; Hausken, Kjell

    2012-01-01

    The aim of this paper is to describe the development of a new, brief, easy-to-administer self-reported instrument designed to assess patient participation in decision making in surgical treatment. We describe item generation, psychometric testing, and validity of the instrument. The final scale consisted of four factors: information dissemination (5 items), formulation of options (4 items), integration of information (4 items), and control (3 items). The analysis demonstrated a reasonable level of construct validity and reliability. The instrument applies to patients in surgical wards and can be used to identify the health services that are being provided and the areas that could strengthen patient participation. PMID:22830010

  8. Preoperative intra-aortic counterpulsation in high-risk patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials†.

    PubMed

    Pilarczyk, Kevin; Boening, Andreas; Jakob, Heinz; Langebartels, Georg; Markewitz, Andreas; Haake, Nils; Heringlake, Matthias; Trummer, Georg

    2016-01-01

    In contrast to the results of previous studies, recent randomized controlled trials (RCTs) failed to show a benefit of prophylactic aortic counterpulsation in high-risk patients undergoing cardiac surgery. The present analysis aims to redefine the effects of this treatment modality in the light of this new evidence. MEDLINE, EMBASE, CENTRAL/CCTR, Google Scholar and reference lists of relevant articles were searched for full-text articles of RCTs in English or German. Assessments for eligibility, relevance, study validity and data extraction were performed by two reviewers independently using prespecified criteria. The primary outcome was hospital mortality. A total of nine eligible RCTs with 1171 patients were identified: 577 patients were treated preoperatively with intra-aortic balloon pump (IABP) and 594 patients served as controls. The pooled odds ratio (OR) for hospital mortality (22 hospital deaths in the intervention arm, 54 in the control group) was 0.381 (95% CI 0.230-0.629; P < 0.001). The pooled analyses of five RCTs including only patients undergoing isolated on-pump coronary artery bypass grafting (n[IABP] = 348, n[control] = 347) also showed a statistically significant improvement in mortality for preoperative IABP implantation (fixed-effects model: OR 0.267, 95% CI 0.129-0.552, P < 0.001). The pooled OR for hospital mortality from two randomized off-pump trials was 0.556 (fixed-effects model, 95% CI 0.207-1.493, P = 0.226). Preoperative aortic counterpulsation was associated with a significant reduction in low cardiac output syndrome (LCOS) in the total population (fixed-effects model: OR 0.330, 95% CI 0.214-0.508, P < 0.001) as well as in the subgroup of CAGB patients (fixed-effects model: OR 0.113, 95% CI 0.056-0.226, P < 0.001), whereas there was no benefit in the off-pump population (fixed-effects model: OR 0.555, 95% CI 0.209-1.474, P = 0.238). Preoperative IABP implantation was associated with a reduction of intensive care unit (ICU) stay in

  9. Candidate gene analysis of BRCA1/2 mutation-negative high-risk Russian breast cancer patients.

    PubMed

    Sokolenko, Anna P; Preobrazhenskaya, Elena V; Aleksakhina, Svetlana N; Iyevleva, Aglaya G; Mitiushkina, Natalia V; Zaitseva, Olga A; Yatsuk, Olga S; Tiurin, Vladislav I; Strelkova, Tatiana N; Togo, Alexandr V; Imyanitov, Evgeny N

    2015-04-10

    Twenty one DNA repair genes were analyzed in a group of 95 BC patients, who displayed clinical features of hereditary disease predisposition but turned out to be negative for mutations in BRCA1 and BRCA2 entire coding region as well as for founder disease-predisposing alleles in CHEK2, NBN/NBS1 and ATM genes. Full-length sequencing of CHEK2 and NBN/NBS1 failed to identify non-founder mutations. The analysis of TP53 revealed a woman carrying the R282W allele; further testing of additional 108 BC patients characterized by a very young age at onset (35 years or earlier) detected one more carrier of the TP53 germ-line defect. In addition, this study confirmed non-random occurrence of PALB2 truncating mutations in Russian hereditary BC patients. None of the studied cases carried germ-line defects in recently discovered hereditary BC genes, BRIP1, FANCC, MRE11A and RAD51C. The analysis of genes with yet unproven BC-predisposing significance (BARD1, BRD7, CHEK1, DDB2, ERCC1, EXO1, FANCG, PARP1, PARP2, RAD51, RNF8, WRN) identified single women carrying a protein-truncating allele, WRN R1406X. DNA sequencing of another set of 95 hereditary BC cases failed to reveal additional WRN heterozygous genotypes. Since WRN is functionally similar to the known BC-predisposing gene, BLM, it deserves to be analyzed in future hereditary BC studies. Furthermore, this investigation revealed a number of rare missense germ-line variants, which are classified as probably protein-damaging by online in silico tools and therefore may require further consideration.

  10. Psychological interventions to reduce suicidality in high-risk patients with major depression: a randomized controlled trial

    PubMed Central

    Celano, C. M.; Beale, E. E.; Mastromauro, C. A.; Stewart, J. G.; Millstein, R. A.; Auerbach, R. P.; Bedoya, C. A.; Huffman, J. C.

    2016-01-01

    Background Positive psychological constructs have been associated with reduced suicidal ideation, and interventions to cultivate positive feelings have the potential to reduce suicide risk. This study compares the efficacy of a 6-week, telephone-based positive psychology (PP) intervention against a cognition-focused (CF) control intervention among patients recently hospitalized for depression and suicidal ideation or behavior. Method A total of 65 adults with a current major depressive episode reporting suicidal ideation or a recent suicide attempt were enrolled from participating in-patient psychiatric units. Prior to discharge, participants were randomized to the PP (n = 32) or CF (n = 33) intervention. In both interventions, participants received a treatment manual, performed weekly PP (e.g. gratitude letter) or CF (e.g. recalling daily events) exercises, and completed weekly one-on-one telephone sessions over 6 weeks. Between-group differences in hopelessness (primary outcome), depression, suicidality and positive psychological constructs at 6 and 12 weeks were tested using mixed-effects models accounting for intensity of post-hospitalization psychiatric treatment. Results Compared with PP, the CF intervention was associated with significantly greater improvements in hopelessness at 6 weeks (β = −3.15, 95% confidence interval −6.18 to −0.12, effect size = −0.84, p = 0.04), but not 12 weeks. Similarly, the CF intervention led to greater improvements in depression, suicidal ideation, optimism and gratitude at 6 and 12 weeks. Conclusions Contrary to our hypothesis, the CF intervention was superior to PP in improving hopelessness, other suicide risk factors and positive psychological constructs during a key post-discharge period among suicidal patients with depression. Further study of this CF intervention is warranted in populations at high suicide risk. PMID:27876105

  11. Detection of elements and trace elements in endoscopy biopsies of colonic mucosa in normal and high risks colon cancer patients

    NASA Astrophysics Data System (ADS)

    Buoso, M. C.; Fazinic, S.; Galassini, S.; Lecis, P. E.; Moschini, G.; Makarewicz, M.; Naccarato, R.; Ogris, R.; Shao, H. R.; Sturniolo, G. C.; Valkovic, V.

    1991-05-01

    In the present study efforts are made to obtain a correlation between the trace element (TE) levels in patients and the presence of digestive cancer. The aim of the study is to detect selenium (Se), zinc (Zn) and other TE concentrations in different segments of colonic mucosa and to find out if there is any difference between the normal and pathological colonic mucosa. The concentration data (averages, standard deviations and ranges) obtained by neutron activation analysis and proton induced X-ray emission are presented and the data distribution is analyzed.

  12. Antifungal prophylaxis with liposomal amphotericin B and caspofungin in high-risk patients after liver transplantation: impact on fungal infections and immune system.

    PubMed

    Perrella, A; Esposito, C; Amato, G; Perrella, O; Migliaccio, C; Pisaniello, D; Calise, F; Cuomo, O; Santaniello, W

    2016-02-01

    Antifungal prophylaxis may be required in high-risk patients undergoing liver transplantation and for that reason we aimed to verify its role and its related impact on the graft. From January 2006 throughout 2012, 250 liver transplants were evaluated and 54 patients identified as being at higher risk were randomly selected to undergo the following schedule: 28 patients received liposomal amphotericin B and 26 received caspofungin. We evaluated, throughout 12 months, renal and liver function tests, bacterial and fungal infection episodes, and intensive care unit (ICU) stay, as well as the Th1 and Th2 cytokine network. Differences were analyzed according to non-parametric tests (two-tailed p values). Neither of the groups showed episodes of invasive fungal infection during the 12 months follow-up; however, patients receiving prophylaxis with liposomal amphotericin B had reduced episodes of bacterial infections coupled with an improved immune system response compared with those receiving caspofungin. Finally, a reduced stay in the ICU was also observed. In conclusion, even if the results of liposomal amphotericin B and caspofungin prophylaxis strategies did not differ in terms of invasive fungal infection rate, patients receiving prophylaxis with liposomal amphotericin B had a reduced ICU stay and an improved Th2 status, as well as a reduced number of post-transplant bacterial infections. Further studies are required to better address and evaluate these findings.

  13. Redefining high-risk patients with stage II colon cancer by risk index and microRNA-21: results from a population-based cohort

    PubMed Central

    Hansen, T F; Kjær-Frifeldt, S; Christensen, R D; Morgenthaler, S; Blondal, T; Lindebjerg, J; Sørensen, F B; Jakobsen, A

    2014-01-01

    Background: The aim of the present study was to analyse the prognostic value of microRNA-21 (miRNA-21) in patients with stage II colon cancer aiming at a risk index for this group of patients. Methods: A population-based cohort of 554 patients was included. MicroRNA-21 was analysed by qPCR based on tumour tissue. An index was created using the coefficients obtained from a collective multiple Cox regression. The entire procedure was cross-validated (10-fold). The performance of the index was quantified by time-dependent receiver operating characteristics curves. Results: High miRNA-21 expression was associated with an unfavourable recurrence-free cancer-specific survival (RF-CSS), hazard ratio 1.35 (95% confidence interval, 1.03–1.76) (P=0.028). The generated RF-CSS index divided the traditional high-risk patients into subgroups with 5-year RF-CSS rates of 87% and 73%, respectively (P<0.001). The overall survival (OS) index identified three different subgroups (P<0.001). Cross-validated 5-year OS rates were 88%, 68%, and 50%, respectively. Conclusions: This population-based study supports miRNA-21 as an additional prognostic biomarker in patients with stage II colon cancer. Furthermore, the introduction of a risk index may guide the use of postoperative adjuvant treatment in a more appropriate way compared with current practice. PMID:25051407

  14. Big data in health care: using analytics to identify and manage high-risk and high-cost patients.

    PubMed

    Bates, David W; Saria, Suchi; Ohno-Machado, Lucila; Shah, Anand; Escobar, Gabriel

    2014-07-01

    The US health care system is rapidly adopting electronic health records, which will dramatically increase the quantity of clinical data that are available electronically. Simultaneously, rapid progress has been made in clinical analytics--techniques for analyzing large quantities of data and gleaning new insights from that analysis--which is part of what is known as big data. As a result, there are unprecedented opportunities to use big data to reduce the costs of health care in the United States. We present six use cases--that is, key examples--where some of the clearest opportunities exist to reduce costs through the use of big data: high-cost patients, readmissions, triage, decompensation (when a patient's condition worsens), adverse events, and treatment optimization for diseases affecting multiple organ systems. We discuss the types of insights that are likely to emerge from clinical analytics, the types of data needed to obtain such insights, and the infrastructure--analytics, algorithms, registries, assessment scores, monitoring devices, and so forth--that organizations will need to perform the necessary analyses and to implement changes that will improve care while reducing costs. Our findings have policy implications for regulatory oversight, ways to address privacy concerns, and the support of research on analytics.

  15. Health economics of percutaneous hemodynamic support in the treatment of high-risk cardiac patients: a systematic appraisal of the literature.

    PubMed

    Maini, Brijeshwar; Scotti, Dennis J; Gregory, David

    2014-06-01

    This article systematically appraises the findings and conclusions derived from six recent studies of the economic impact and relative value of using percutaneous ventricular assist devices to render short-term hemodynamic support to high-risk patients with particular attention to the settings of cardiogenic shock and percutaneous coronary interventions. Although the extant body of literature is still growing, these studies offer evidence and insight regarding the health economics of traditional and emerging technologies in this treatment domain, and generally find the latter to be cost-effective in the long term. As the incidence of heart disease rises and the attendant economic burden of healthcare climbs, technologies for mitigating cardiovascular illness will be the target for more robust empirical evidence to justify the comparative value of minimally invasive hemodynamic support interventions in the armamentarium of treatment options available to physicians.

  16. Rates and predictors of consideration for adjuvant radiotherapy among high-risk breast cancer patients: a cohort study.

    PubMed

    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.

  17. Patients with MCI and N400 or P600 abnormalities are at very high risk for conversion to dementia

    PubMed Central

    Olichney, J.M.; Taylor, J.R.; Gatherwright, J.; Salmon, D.P.; Bressler, A.J.; Kutas, M.; Iragui-Madoz, V.J.

    2011-01-01

    Objective We sought cognitive event-related potential (ERP) biomarkers of disease progression and subsequent conversion to dementia in mild cognitive impairment (MCI). Background Two ERP components, the P600 and N400, are sensitive to abnormal episodic/declarative memory and semantic processing. When congruous category-exemplars are repeated, smaller P600s (relative to initial presentation) are normally elicited. Repetitions of semantically incongruous words yield smaller N400 amplitude. In mild Alzheimer disease (AD), abnormalities of both the N400 and P600 repetition effects are present, suggesting a wide-spread failure of synaptic plasticity. Methods Patients with amnestic MCI (n = 32) were longitudinally studied annually with an ERP paradigm in which semantically congruous (50%) and incongruous target words are repeated 10 to 140 seconds after initial presentation. ERP data were analyzed to contrast MCI-to-AD converters (within 3 years) vs nonconverters, using split-plot analyses of variance. Results A statistically significant P600 congruous word repetition effect was found only in the nonconverter group (F = 9.9, p = 0.005 vs MCI converters). This effect correlated with verbal memory measures. Repetition of incongruous words produced a significant N400 amplitude attenuation (across right-hemisphere sites) in nonconverters, but not in converters. Patients with MCI with abnormal/reduced N400 or P600 word repetition effects had an 87 to 88% likelihood of dementia within 3 years while those with normal/spared N400 and P600 repetition effects had only an 11 to 27% likelihood. Conclusions Abnormalities of the P600 or N400 in mild cognitive impairment are associated with an increased risk of subsequent conversion to Alzheimer disease (AD). These event-related potential components may offer useful biomarkers for the detection and staging of very early AD. PMID:18077800

  18. Relationship between Patient Safety and Hospital Surgical Volume

    PubMed Central

    Hernandez-Boussard, Tina; Downey, John R; McDonald, Kathryn; Morton, John M

    2012-01-01

    Objective To examine the relationship between hospital volume and in-hospital adverse events. Data Sources Patient safety indicator (PSI) was used to identify hospital-acquired adverse events in the Nationwide Inpatient Sample database in abdominal aortic aneurysm, coronary artery bypass graft, and Roux-en-Y gastric bypass from 2005 to 2008. Study Design In this observational study, volume thresholds were defined by mean year-specific terciles. PSI risk-adjusted rates were analyzed by volume tercile for each procedure. Principal Findings Overall, hospital volume was inversely related to preventable adverse events. High-volume hospitals had significantly lower risk-adjusted PSI rates compared to lower volume hospitals (p < .05). Conclusion These data support the relationship between hospital volume and quality health care delivery in select surgical cases. This study highlights differences between hospital volume and risk-adjusted PSI rates for three common surgical procedures and highlights areas of focus for future studies to identify pathways to reduce hospital-acquired events. PMID:22091561

  19. Surgical transposition of the ovaries: Imaging findings in 14 patients

    SciTech Connect

    Kier, R.; Chambers, S.K. )

    1989-11-01

    Pelvic radiation therapy for cervical or vaginal cancer often leads to ovarian failure. To remove the ovaries from the radiation portal and preserve their function, they can be transposed to the lateral abdomen. Serial imaging studies in 14 patients who had undergone ovarian transposition (five bilateral, nine unilateral) were reviewed. Images obtained included 32 CT scans, 20 sonograms, and one MR image. Most transposed ovaries were located along the paracolic gutters near the iliac crests, creating an extrinsic mass effect on adjacent bowel. Detection of surgical clips on the ovary on CT scans allowed confident recognition of all 19 transposed ovaries. Cysts in the transposed ovaries, noted on most imaging studies, did not correlate with complications of pain or hormonal dysfunction. In one case, a large physiologic cyst in a transposed ovary distorted the cecum and was mistaken for a mucocele of the appendix. In another case, a large ovarian cyst was thought to be tumor recurrence or a lymphocele. These findings indicate that although the transposed ovaries can be recognized on CT scans by the surgical clips attached to the ovaries, the appearance of the ovary does not predict reliably the development of complications.

  20. Intensive vs. Standard Post-Operative Surveillance in High-Risk Breast Cancer Patients (INSPIRE): Japan Clinical Oncology Group Study JCOG1204.

    PubMed

    Hojo, Takashi; Masuda, Norikazu; Mizutani, Tomonori; Shibata, Taro; Kinoshita, Takayuki; Tamura, Kenji; Hara, Fumikata; Fujisawa, Tomomi; Inoue, Kenichi; Saji, Shigehira; Nakamura, Kenichi; Fukuda, Haruhiko; Iwata, Hiroji

    2015-10-01

    This Phase III trial aims to determine the superiority of intensive follow-up to standard follow-up in terms of overall survival in high-risk breast cancer patients, who are expected to have recurrence rates of over 30% within 5 years after surgery. Eligible patients are randomized either to the intensive follow-up group or to the standard follow-up group; the former will undergo physical examination, bone scintigraphy, chest computed tomography, abdominal computed tomography, brain magnetic resonance imaging/computed tomography and frequent tumor marker evaluations, whereas the latter will undergo physical examination at the same frequency and tumor markers will be evaluated once a year. Mammography once a year is planned for both groups. The primary endpoint is overall survival. Patient accrual was started in November 2013. A total of 1700 patients will be enrolled for 3 years and followed up for 7 years after closure of accrual. This trial has been registered at the UMIN Clinical Trials Registry as UMIN000012429.

  1. Patients with first-episode, drug-naive schizophrenia and subjects at ultra-high risk of psychosis shared increased cerebellar-default mode network connectivity at rest

    PubMed Central

    Wang, Houliang; Guo, Wenbin; Liu, Feng; Wang, Guodong; Lyu, Hailong; Wu, Renrong; Chen, Jindong; Wang, Shuai; Li, Lehua; Zhao, Jingping

    2016-01-01

    Increased cerebellar-default mode network (DMN) connectivity has been observed in first-episode, drug-naive patients with schizophrenia. However, it remains unclear whether increased cerebellar-DMN connectivity starts earlier than disease onset. Thirty-four ultra-high risk (UHR) subjects, 31 first-episode, drug-naive patients with schizophrenia and 37 healthy controls were enrolled for a resting-state scan. The imaging data were analyzed using the seed-based functional connectivity (FC) method. Compared with the controls, UHR subjects and patients with schizophrenia shared increased connectivity between the right Crus I and bilateral posterior cingulate cortex/precuneus and between Lobule IX and the left superior medial prefrontal cortex. There are positive correlations between the right Crus I-bilateral precuneus connectivity and clinical variables (Structured Interview for Prodromal Syndromes/Positive and Negative Symptom Scale negative symptoms/total scores) in the UHR subjects. Increased cerebellar-DMN connectivity shared by the UHR subjects and the patients not only highlights the importance of the DMN in the pathophysiology of psychosis but also may be a trait alteration for psychosis. PMID:27188233

  2. Futility and the care of surgical patients: ethical dilemmas.

    PubMed

    Grant, Scott B; Modi, Parth K; Singer, Eric A

    2014-07-01

    Futility has been a contentious topic in medicine for several decades. Surgery in critical or end-of-life situations often raises difficult questions about futility. In this article, we discuss the definition of futility, methods for resolving futility disputes, and some ways to reframe the futility debate to a more fruitful discussion about the goals of care, better communication between surgeon and patient/surrogate, and palliative surgical care. Many definitions of futile therapy have been discussed. The most controversial of these is "qualitative futility" which describes a situation in which the treatment provided is likely to result in an unacceptable quality of life. This is an area of continued controversy because it has been impossible to identify universally held beliefs about acceptable quality of life. Many authors have described methods for resolving futility disputes, including community standards and legalistic multi-step due process protocols. Others, however, have abandoned the concept of futility altogether as an unhelpful term. Reframing the issue of futility as one of inadequate physician-patient communication, these authors have advocated for methods of improving communication and strengthening the patient-physician relationship. Finally, we discuss the utilization of consultants who may be of use in resolving futility disputes: ethics committees, palliative care specialists, pastoral care teams, and dedicated patient advocates. Involving these specialists in a futility conflict can help improve communication and provide invaluable assistance in arriving at the appropriate treatment decision.

  3. [Surgical prevention of stroke in patients with carotid stenosis].

    PubMed

    Pyshkina, L I; Khatagova, D T; Kabanov, A A; Darvish, N A; Alibekova, Zh M

    2014-01-01

    Objectives. To study the cerebral and central hemodynamics in patients with stenotic lesions of inner carotid arteries (ICA) before and after reconstructive surgery. Material and methods. Fifty-nine patients, aged from 46 to 78 years, with >50% atherosclerotic stenosis of ICA who underwent preventive carotid endarterectomy (CEAE) were examined. The isolate stenosis of ICA was identified in 13.6% of patients, concomitant lesions of brachiocephalic arteries in 86.4%. Atherosclerotic lesions of coronary arteries were found in 91.1% of patients and those of arteries of lower extremities in 45.8%. In 25.5% of patients, the heart surgery was performed before the current hospitalization. Heterogeneous atherosclerotic plaques with dense or hyperdense components were more frequents in symptomatic stenosis (63.3%). The maximal stenosis was identified in heterogeneous hyperechogenic plaques, the minimal ones in homogenous hypoechogenic plaques. Parameters of central hemodynamics were better in patients with 2nd stage of reconstructive surgeries. The emission fraction decreased proportionally to the degree of stenosis. The parameters of cerebral hemodynamics were significantly decreased in ICA stenosis and improved in the early post-surgery period. Results. CEAE promoted the improvement of cognitive functions and the recovery of motor functions. The best positive dynamics was recorded in asymptomatic ICA stenosis. Poor outcome (transitory ischemic attacks, urgent surgery, restenosis) was found in patients with low levels of central and cerebral hemodynamics 12-24 months after the discharge. Moreover, smoking and the degree of stenosis predicted poor outcome. Conclusions. Surgical treatment in combination with the complex pharmacotherapy (hypotensive drugs, antiaggregants and statins) had the maximal effect, including the remote period.

  4. Daily Co-Occurrence of Alcohol Use and High-Risk Sexual Behavior among Heterosexual, Heavy Drinking Emergency Department Patients

    PubMed Central

    Wray, Tyler B.; Celio, Mark A.; Kahler, Christopher W.; Barnett, Nancy P.; Mastroleo, Nadine R.; Operario, Don; Monti, Peter M.

    2015-01-01

    Background Global association and experimental studies suggest that alcohol use may increase sexual behavior that poses risk for exposure to sexually-transmitted infections (STI) among heterosexual men and women. However, results from longitudinal and daily recall studies exploring the co-occurrence of alcohol use with various sexual risk outcomes in more naturalistic contexts have been mixed, and the bulk of this research has focused on college students. Methods The current study enrolled heavy-drinking emergency department (ED) patients and used a cross-sectional, 30-day Timeline Followback (TLFB) method to examine the daily co-occurrence between alcohol use and three sexual behavior outcomes: Any sex, unprotected intercourse (UI), and UI with casual partners (vs. protected intercourse [PI] with casual partners, or UI/PI with steady partners). Results Results indicated that increasing levels of alcohol use on a given day increased the odds of engaging in any sexual activity and that heavy drinking (but not very heavy drinking) on a given day was associated with an increased odds of engaging in UI with either steady or casual partners. However, day-level alcohol use was not associated with an increased odds of UI with casual partners. Conclusions These findings suggest that alcohol may play an important role in increasing risk for HIV/STIs among heterosexuals, and support the continued need to target heavy drinking in sex risk reduction interventions. However, our results also suggest that alcohol may not universally result in unprotected sex with casual partners, a behavior posing perhaps the highest risk for HIV/STI transmission. PMID:25962789

  5. Quality-of-life outcomes in high-risk prostate cancer patients treated with helical tomotherapy in a hypofractionated radiation schedule with long-term androgen suppression

    PubMed Central

    Pervez, N.; Krauze, A.V.; Yee, D.; Parliament, M.; Mihai, A.; Ghosh, S.; Joseph, K.; Murtha, A.; Amanie, J.; Kamal, M.; Pearcey, R.

    2012-01-01

    Purpose We examined the impact of hypofractionated radiation therapy and androgen suppression therapy (ast) on quality of life (qol) in high-risk prostate cancer patients. Methods Between March 2005 and March 2007, 60 patients with high-risk prostate cancer were enrolled in a prospective phase ii study. All patients received 68 Gy (2.72 Gy per fraction) to the prostate gland and 45 Gy (1.8 Gy per fraction) to the pelvic lymph nodes in 25 fractions over 5 weeks. Of the 60 patients, 58 received ast. The University of California–Los Angeles Prostate Cancer Index questionnaire was used to prospectively measure qol at baseline (month 0) and at 1, 6, 12, 18, 24, 30, and 36 months after radiation treatment. The generalized estimating equation approach was used to compare the qol scores at 1, 6, 12, 18, 24, 30, and 36 months with those at baseline. Results We observed a significant decrease in qol items related to bowel and sexual function. Several qol items related to bowel function were significantly adversely affected at both 1 and 6 months, with improvement toward 6 months. Although decreased qol scores persisted beyond the 6-month mark, they began to re-approach baseline at the 18- to 24-month mark. Most sexual function items were significantly adversely affected at both 1 and 6 months, but the effects were not considered to be a problem by most patients. A complete return to baseline was not observed for either bowel or sexual function. Urinary function items remained largely unaffected, with overall urinary function being the only item adversely affected at 6 months, but not at 1 month. Urinary function returned to baseline and remained unimpaired from 18 months onwards. Conclusions In our study population, who received hypofractionated radiation delivered using dynamic intensity-modulated radiotherapy with inclusion of the pelvic lymph nodes, and 2–3 years of ast prescription, qol with respect to bowel and sexual function was significantly affected; qol with

  6. Surgical Management in a Patient With Complex Uveitic Glaucoma

    PubMed Central

    Huang, Zhu; Wang, Xiao-Yu; Han, Wei

    2015-01-01

    Abstract Uveitic glaucoma (UG) is secondary glaucoma, present as a clinical challenge in both diagnosis and management. We report a case of complex UG, which initially presented as pupillary block and rupture of the anterior lens capsule. We performed cataract extraction with preservation of posterior capsule. Then, the case turned to aphakic malignant glaucoma. We performed anterior vitrectomy with posterior capsule resection in this case. After the second operation, the patient had a satisfactory recovery. Specifically, ultrasonographic biomicroscopy was useful during the diagnosis process and follow-up period in this case. UG presenting as pupillary block, rupture of the anterior lens capsule, and aqueous misdirection seldom presents in clinical practice. Earlier and more active surgical intervention may be necessary for effective preservation of visual function in complex cases of UG. PMID:26252285

  7. Surgical and anesthetic management of patients with mitochondrial dysfunction.

    PubMed

    Edmonds, Joseph L

    2004-09-01

    Mitochondrial diseases are primary defects in bio-energy metabolism. They are a heterogeneous group of diseases. The specific constellation of symptoms that will manifest in the effected individual depends on the type of genetic defect in the mitochondria. The goals of medical management, expressed in a highly simplified fashion, are to maintain a normal acid-base balance and to avoid those medical conditions and situations that add extra stress to a compromised bio-energy production system. Infection is a common stress that may cause a crisis in a patient with mitochondrial dysfunction. Treatment and avoidance of infections is a goal of both medical and surgical management. Common childhood illness such as otitis media, tonsillitis and sinusitis are example of such stress inducing infections.

  8. Phase II study of tosedostat with cytarabine or decitabine in newly diagnosed older patients with acute myeloid leukaemia or high-risk MDS.

    PubMed

    Mawad, Raya; Becker, Pamela S; Hendrie, Paul; Scott, Bart; Wood, Brent L; Dean, Carol; Sandhu, Vicky; Deeg, Hans Joachim; Walter, Roland; Wang, Lixia; Myint, Han; Singer, Jack W; Estey, Elihu; Pagel, John M

    2016-01-01

    Tosedostat, an oral aminopeptidase inhibitor, has synergy with cytarabine and hypomethylating agents. We performed a Phase II trial to determine rates of complete remission (CR) and survival using tosedostat with cytarabine or decitabine in older patients with untreated acute myeloid leukaemia (AML) or high-risk myelodysplastic syndrome (MDS). Thirty-four patients ≥60 years old (median age 70 years; range, 60-83) were randomized to receive tosedostat (120 mg on days 1-21 or 180 mg continuously) with 5 d of either cytarabine (1 g/m2 /d) or decitabine (20 mg/m2 /d) every 35 d. Twenty-nine patients (85%) had AML, including 15 (44%) with secondary AML/MDS, and 5 (15%) had MDS-refractory anaemia with excess blasts type 2. The CR/CR with incomplete count recovery (CRi) rate was 53% [9 in each arm; 14 CR (41%) and 4 CRi (12%)], attained in 6 of 14 patients with adverse cytogenetics and 4 of 7 with FLT3-internal tandem duplication mutations. Median follow-up was 11.2 months (range, 0.5-22.3), and median survival was 11.5 months (95% confidence interval, 5.2-16.7). Twenty-three patients (67.6%) were treated as outpatients and 10 of these patients required hospitalization for febrile neutropenia. No Grade 3-4 non-haematological toxicities required withdrawal from study. Tosedostat with cytarabine or decitabine is tolerated in older patients with untreated AML/MDS, results in a CR/CRi rate of >50%, and warrants further study in larger trials.

  9. Treatment of invasive fungal infections in high risk hematological patients. The outcome with liposomal amphotericin B is not negatively affected by prior administration of mold-active azoles.

    PubMed

    De la Serna, Javier; Jarque, Isidro; López-Jiménez, Javier; Fernández-Navarro, Jose María; Gómez, Valle; Jurado, Manuel; Pascual, Adriana; Serrano, Josefina; Romero, Mónica; Vallejo, Carlos

    2013-03-01

    There are concerns of a reduced effect of liposomal amphotericin B (L-AmB) given sequentially after mold-active azoles due to a possible antagonism in their antifungal mechanism. To investigate this possible effect in the clinic, we retrospectively studied 182 high risk hematologic patients with invasive fungal infections (IFI) who were treated with L-AmB. Overall, 96 patients (52.7%) had possible, 52 (28.6%) probable and 34 (18.7%) proven IFI according to EORTC classification. Most had suspected or proven invasive aspergillosis. We compared patients with prior exposure to mold-active azoles (n=100) to those having not (n=82). The group with prior mold-active azoles included more patients with poor risk features for IFI as acute myeloid leukemia (p<0.05) and prolonged neutropenia (p<0.05). A favorable response in the IFI, defined as a complete or partial response, was achieved in 75% and 74.4% of patients in the whole cohort, and in 66% and 74.4% of patients with probable or proven IFI in the two groups. None of these differences were significant. Multivariate analysis showed that refractory baseline disease and renal dysfunction were adverse factors for response in the IFI (p<0.05). Survival was poorer for patients with prior broad spectrum azoles (p<0.05), and for those who did not recover from neutropenia (p<0.05). In conclusion, the effectiveness of treatment of breakthrough fungal infection with L-AmB is not likely to be affected by prior exposure to mold-active azoles prophylaxis, but survival largely depends on host and disease factors.

  10. A large Venous-Arterial PCO2 Is Associated with Poor Outcomes in Surgical Patients

    PubMed Central

    Silva, João M.; Oliveira, Amanda M. Ribas R.; Segura, Juliano Lopes; Ribeiro, Marcel Henrique; Sposito, Carolina Nacevicius; Toledo, Diogo O.; Rezende, Ederlon; Malbouisson, Luiz M. Sá

    2011-01-01

    Background. This study evaluated whether large venous-arterial CO2 gap (PCO2 gap) preoperatively is associated to poor outcome. Method. Prospective study which included adult high-risk surgical patients. The patients were pooled into two groups: wide [P(v-a)CO2] versus narrow [P(v-a)CO2]. In order to determine the best value to discriminate hospital mortality, it was applied a ROC (receiver operating characteristic) curve for the [P(v-a)CO2] values collected preoperatively, and the most accurate value was chosen as cut-off to define the groups. Results. The study included 66 patients. The [P(v-a)CO2] value preoperatively that best discriminated hospital mortality was 5.0 mmHg, area = 0.73. Preoperative patients with [P(v-a)CO2] more than 5.0 mmHg presented a higher hospital mortality (36.4% versus 4.5% P = 0.004), higher prevalence of circulatory shock (56.8% versus 22.7% P = 0.01) and acute renal failure postoperatively (27.3% versus 4.5% P = 0.02), and longer hospital length of stays 20.0 (14.0–30.0) versus 13.5 (9.0–25.0) days P = 0.01. Conclusions. The PCO2 gap values more than 5.0 mmHg preoperatively were associated with worse postoperatively outcome. PMID:22007204

  11. Perioperative Hemoglobin Trajectory in Adult Cardiac Surgical Patients

    PubMed Central

    Scott, David A.; Tung, Hon-Ming Andrew; Slater, Reuben

    2015-01-01

    Abstract: Preoperative anemia and nadir hemoglobin (Hb) during cardiopulmonary bypass (CPB) have been identified as significant risk factors for blood transfusion during cardiac surgery. The aim of this study was to confirm the association between preoperative anemia, perioperative fluid management, and blood transfusion. In addition, the proportion of elective cardiac surgery patients presenting for surgery with anemia was identified to examine whether the opportunity exists for timely diagnosis and intervention. Data from referral until hospital discharge were comprehensively reviewed over a 12-month period for all nonemergency cardiac surgical patients operated on in our institution. Of the 342 patients identified, elective cases were referred a median of 35 days before preoperative clinic and operated on a median of 14 days subsequently. Subacute cases had a median of 3 days from referral to surgery. As per the World Health Organization (WHO) criteria for anemia, 24.2% of elective and 29.6% of subacute patients were anemic. Blood transfusion was administered to 46.2% of patients during their admission. Transfusion was more likely in patients who were female (odds ratio [OR]: 2.45, 95%confidence interval [CI]: 1.28–4.70), had a low body mass index (BMI) (OR: .89, 95% CI: .84–.94), preoperative anemia (OR: 5.15, 95% CI: 2.59–10.24), or renal impairment (OR: 5.44, 95% CI: 2.42–12.22). Hemodilution minimization strategies reduced the Hb fall during CPB, but not transfusion rates. This study identifies a high prevalence of preoperative anemia with sufficient time for elective referrals to undergo appropriate diagnosis and interventions. It also confirms that low red cell mass (anemia and low BMI) and renal impairment are predictors of perioperative blood transfusion. Perfusion strategies to reduce hemodilution are effective at minimizing the intraoperative fall in Hb concentration but did not influence transfusion rate. PMID:26543251

  12. 77 FR 25179 - Patient Safety Organizations: Voluntary Relinquishment From Surgical Safety Institute

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-04-27

    ... the Surgical Safety Institute of its status as a Patient Safety Organization (PSO). The Patient Safety... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Relinquishment From Surgical Safety Institute AGENCY: Agency for Healthcare Research and Quality (AHRQ),...

  13. Comparison of the analytical and clinical performances of Abbott RealTime High Risk HPV, Hybrid Capture 2, and DNA Chip assays in gynecology patients.

    PubMed

    Park, Seungman; Kang, Youjin; Kim, Dong Geun; Kim, Eui-Chong; Park, Sung Sup; Seong, Moon-Woo

    2013-08-01

    The detection of high-risk (HR) HPV in cervical cancer screening is important for early diagnosis of cervical cancer or pre-cancerous lesions. We evaluated the analytical and clinical performances of 3 HR HPV assays in Gynecology patients. A total of 991 specimens were included in this study: 787 specimens for use with a Hybrid Capture 2 (HC2) and 204 specimens for a HPV DNA microarray (DNA Chip). All specimens were tested using an Abbott RealTime High Risk HPV assay (Real-time HR), PGMY PCR, and sequence analysis. Clinical sensitivities for severe abnormal cytology (severe than high-grade squamous intraepithelial lesion) were 81.8% for Real-time HR, 77.3% for HC2, and 66.7% for DNA Chip, and clinical sensitivities for severe abnormal histology (cervical intraepithelial neoplasia grade 2+) were 91.7% for HC2, 87.5% for Real-time HR, and 73.3% for DNA Chip. As compared to results of the sequence analysis, HC2, Real-time HR, and DNA Chip showed concordance rates of 94.3% (115/122), 90.0% (117/130), and 61.5% (16/26), respectively. The HC2 assay and Real-time HR assay showed comparable results to each other in both clinical and analytical performances, while the DNA Chip assay showed poor clinical and analytical performances. The Real-time HR assay can be a good alternative option for HR HPV testing with advantages of allowing full automation and simultaneous genotyping of HR types 16 and 18.

  14. Study to Improve Cardiovascular Outcomes in high-risk older patieNts (ICON1) with acute coronary syndrome: study design and protocol of a prospective observational study

    PubMed Central

    Kunadian, Vijay; Neely, R Dermot G; Sinclair, Hannah; Batty, Jonathan A; Veerasamy, Murugapathy; Ford, Gary A; Qiu, Weiliang

    2016-01-01

    Introduction The ICON1 study (a study to Improve Cardiovascular Outcomes in high-risk older patieNts with acute coronary syndrome) is a prospective observational study of older patients (≥75 years old) with non-ST-elevation acute coronary syndrome managed by contemporary treatment (pharmacological and invasive). The aim of the study was to determine the predictors of poor cardiovascular outcomes in this age group and to generate a risk prediction tool. Methods and analysis Participants are recruited from 2 tertiary hospitals in the UK. Baseline evaluation includes frailty, comorbidity, cognition and quality-of-life measures, inflammatory status assessed by a biomarker panel, including microRNAs, senescence assessed by telomere length and telomerase activity, cardiovascular status assessed by arterial stiffness, endothelial function, carotid intima media thickness and left ventricular systolic and diastolic function, and coronary plaque assessed by virtual histology intravascular ultrasound and optical coherence tomography. The patients are followed-up at 30 days and at 1 year for primary outcome measures of death, myocardial infarction, stroke, unplanned revascularisation, bleeding and rehospitalisation. Ethics and dissemination The study has been approved by the regional ethics committee (REC 12/NE/016). Findings of the study will be presented in scientific sessions and will be published in peer-reviewed journals. Trial registration number NCT01933581: Pre-results. PMID:27554105

  15. Detection of high-risk human papillomavirus type 16/18 in cutaneous warts in immunocompetent patients, using polymerase chain reaction.

    PubMed

    Payal, R; Gupta, S; Aggarwal, R; Handa, S; Radotra, B D; Arora, S K

    2006-10-31

    Cutaneous warts are caused by human papillomavirus (HPV). Prevalence studies of the types of HPV present in cutaneous warts have been carried out more frequently in immunosuppressed patients. The present study was designed to study the association of high-risk HPV in cutaneous warts of immunocompetent patients. A total of 45 cases of cutaneous warts from various sites in immunocompetent subjects were analyzed for HPV. Samples included both archival material i.e., paraffin embedded and fresh tissue. Highly sensitive and comprehensive polymerase chain reaction (PCR) methodology for detection of HPV of high oncogenic potential, HPV 16/18, was employed. Human papillomavirus 16 was detected in 3 (6.6%) patients. None of the lesions demonstrated HPV 18. None of the cutaneous warts demonstrated histopathological features associated with dysplasia or neoplasia. The identification of HPV 16 in cutaneous warts, which are benign proliferations of the skin, further expands the spectrum of HPV-linked lesions. It remains of critical interest to determine whether these types are specifically associated with the development of malignant lesions analogous to those seen in anogenital cancer.

  16. Comparison of PCR and standard cytological staining for detection of Pneumocystis carinii from respiratory specimens from patients with or at high risk for infection by human immunodeficiency virus.

    PubMed Central

    Leibovitz, E; Pollack, H; Moore, T; Papellas, J; Gallo, L; Krasinski, K; Borkowsky, W

    1995-01-01

    The detection of Pneumocystis carinii DNA by PCR was compared with routine cytologic staining techniques (CYT). A total of 284 clinical respiratory specimens, including 137 bronchoalveolar lavage (BAL), 63 bronchoalveolar washing, 63 sputum, and 21 induced sputum samples, obtained from patients with or at high risk for human immunodeficiency virus infection were evaluated. Eighty specimens were positive by PCR, and 69 were positive by CYT. PCR was able to detect P. carinii in more bronchoalveolar washing specimens (15 versus 11) and in comparable BAL specimens (53 versus 54) compared with CYT. PCR was particularly more sensitive than CYT in detecting P. carinii in expectorated sputum (12 versus 4 samples). Of the 19 patients whose respiratory specimens were positive for P. carinii by PCR but negative by CYT, 5 had P. carinii pneumonia (PCP) confirmed by subsequent BAL and transbronchial or mediastinal lymph node biopsy and 9 had a clinical course highly suggestive of acute PCP. Eleven (58%) of the 19 patients with discordant PCR and CYT results had received prior anti-PCP prophylaxis. In this clinical setting in particular and in the evaluation of sputum specimens, the ability of PCR to detect a low parasitic load suggests that this technique may become an important additional tool, along with current cytological methods, for the detection of P. carinii. PMID:8576362

  17. Futility and the Care of Surgical Patients: Ethical Dilemmas

    PubMed Central

    Grant, Scott B.; Modi, Parth K.

    2016-01-01

    Futility has been a contentious topic in medicine for several decades. Surgery in critical or end-of-life situations often raises difficult questions about futility. In this article, we discuss the definition of futility, methods for resolving futility disputes, and some ways to reframe the futility debate to a more fruitful discussion about the goals of care, better communication between surgeon and patient/surrogate, and palliative surgical care. Many definitions of futile therapy have been discussed. The most controversial of these is “qualitative futility” which describes a situation in which the treatment provided is likely to result in an unacceptable quality of life. This is an area of continued controversy because it has been impossible to identify universally held beliefs about acceptable quality of life. Many authors have described methods for resolving futility disputes, including community standards and legalistic multi-step due process protocols. Others, however, have abandoned the concept of futility altogether as an unhelpful term. Reframing the issue of futility as one of inadequate physician–patient communication, these authors have advocated for methods of improving communication and strengthening the patient–physician relationship. Finally, we discuss the utilization of consultants who may be of use in resolving futility disputes: ethics committees, palliative care specialists, pastoral care teams, and dedicated patient advocates. Involving these specialists in a futility conflict can help improve communication and provide invaluable assistance in arriving at the appropriate treatment decision. PMID:24849199

  18. Sunitinib Plus Androgen Deprivation and Radiation Therapy for Patients With Localized High-Risk Prostate Cancer: Results From a Multi-institutional Phase 1 Study

    SciTech Connect

    Corn, Paul G.; Song, Danny Y.; Heath, Elisabeth; Maier, Jordan; Meyn, Raymond; Kuban, Deborah; DePetrillo, Thomas A.; Mathew, Paul

    2013-07-01

    Purpose: To evaluate the feasibility of administering sunitinib in combination with androgen deprivation therapy and external-beam intensity modulated radiation therapy (XRT) in patients with localized high-risk prostate cancer. Methods and Materials: Seventeen men with localized adenocarcinoma of the prostate with cT2c-cT4 or Gleason 8-10 or prostate-specific antigen >20 ng/mL received initial androgen deprivation (leuprolide 22.5 mg every 12 weeks plus oral bicalutamide 50 mg daily) for 4-8 weeks before oral sunitinib 12.5, 25, or 37.5 mg daily for 4 weeks as lead-in, then concurrently with and 4 weeks after XRT (75.6 Gy in 42 fractions to prostate and seminal vesicles). A 3+3 sequential dose-escalation design was used to assess the frequency of dose-limiting toxicity (DLT) and establish a maximal tolerated dose of sunitinib. Results: Sunitinib at 12.5- and 25-mg dose levels was well tolerated. The first 4 patients enrolled at 37.5 mg experienced a DLT during lead-in, and a drug interaction between sunitinib and bicalutamide was suspected. The protocol was revised and concurrent bicalutamide omitted. Of the next 3 patients enrolled at 37.5 mg, 2 of 3 receiving concurrent therapy experienced DLTs during radiation: grade 3 diarrhea and grade 3 proctitis, respectively. Only 1 of 7 patients completed sunitinib at 37.5 mg daily, whereas 3 of 3 patients (25 mg as starting dose) and 3 of 4 patients (25 mg as reduced dose) completed therapy. Conclusions: The feasibility of combined vascular endothelial growth factor receptor (VEGFR)/platelet-derived growth factor receptor (PDGFR) inhibitor therapy, androgen deprivation, and radiation therapy for prostate cancer was established. Using a daily dosing regimen with lead-in, concurrent, and post-XRT therapy, the recommended phase 2 dose of sunitinib is 25 mg daily.

  19. IgH-V(D)J NGS-MRD measurement pre- and early post-allotransplant defines very low- and very high-risk ALL patients.

    PubMed

    Pulsipher, Michael A; Carlson, Chris; Langholz, Bryan; Wall, Donna A; Schultz, Kirk R; Bunin, Nancy; Kirsch, Ilan; Gastier-Foster, Julie M; Borowitz, Michael; Desmarais, Cindy; Williamson, David; Kalos, Michael; Grupp, Stephan A

    2015-05-28

    Positive detection of minimal residual disease (MRD) by multichannel flow cytometry (MFC) prior to hematopoietic cell transplantation (HCT) of patients with acute lymphoblastic leukemia (ALL) identifies patients at high risk for relapse, but many pre-HCT MFC-MRD negative patients also relapse, and the predictive power MFC-MRD early post-HCT is poor. To test whether the increased sensitivity of next-generation sequencing (NGS)-MRD better identifies pre- and post-HCT relapse risk, we performed immunoglobulin heavy chain (IgH) variable, diversity, and joining (V[D]J) DNA sequences J NGS-MRD on 56 patients with B-cell ALL enrolled in Children's Oncology Group trial ASCT0431. NGS-MRD predicted relapse and survival more accurately than MFC-MRD (P < .0001), especially in the MRD negative cohort (relapse, 0% vs 16%; P = .02; 2-year overall survival, 96% vs 77%; P = .003). Post-HCT NGS-MRD detection was better at predicting relapse than MFC-MRD (P < .0001), especially early after HCT (day 30 MFC-MRD positive relapse rate, 35%; NGS-MRD positive relapse rate, 67%; P = .004). Any post-HCT NGS positivity resulted in an increase in relapse risk by multivariate analysis (hazard ratio, 7.7; P = .05). Absence of detectable IgH-V(D)J NGS-MRD pre-HCT defines good-risk patients potentially eligible for less intense treatment approaches. Post-HCT NGS-MRD is highly predictive of relapse and survival, suggesting a role for this technique in defining patients early who would be eligible for post-HCT interventions. The trial was registered at www.clinicaltrials.gov as #NCT00382109.

  20. Intravenous injection of low-dose flurbiprofen axetil for preventing post-ERCP pancreatitis in high-risk patients: An interim analysis of the trial

    PubMed Central

    Fujita, Yuji; Hasegawa, Sho; Kato, Yuri; Ishii, Ken; Iwasaki, Akito; Sato, Takamitsu; Sekino, Yusuke; Hosono, Kunihiro; Nakajima, Atsushi; Kubota, Kensuke

    2016-01-01

    Background and study aims: Several meta-analyses and randomized control trials have demonstrated the efficacy of rectal nonsteroidal anti-inflammatory drugs for preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Diclofenac or indomethacin was administered at a dose of 100 mg in those studies, which may be too high for Asian population. In addition, rectal administration can be considered complicated. Patients and methods: This study was a prospective, randomized, placebo-controlled trial. Patients with a PEP risk score ≥ 1 were randomly assigned to receive intravenous injection of 50 mg flurbiprofen axetil (flurbiprofen group) or saline only (placebo group). The primary outcome was reduced PEP. The secondary outcome was amylase level after 2 hours of ERCP as a predictor of PEP. (Clinical Trials.gov, ID UMIN000011322) Results: In total, 144 patients were enrolled from August 2013 to March 2015. We performed an interim analysis of the first 100 patients: 47 received flurbiprofen axetil and 53 received placebo. PEP occurred in 11 patients (11 %): 2 of 47 (4.3 %) in the flurbiprofen group and 9 of 53 (17 %) in the placebo group (P = 0.042). Relative risk reduction was 62.4 %. Hyperamylasemia did not differ significantly (17.0 % vs. 26.4 %, P = 0.109). This analysis resulted in early termination of the study for ethical reasons. Conclusions: Intravenous injection of low-dose flurbiprofen axetil after ERCP can reduce the incidence of PEP in high-risk patients PMID:27747282

  1. Need for High Radiation Dose (>=70 Gy) in Early Postoperative Irradiation After Radical Prostatectomy: A Single-Institution Analysis of 334 High-Risk, Node-Negative Patients

    SciTech Connect

    Cozzarini, Cesare; Montorsi, Francesco; Fiorino, Claudio; Alongi, Filippo; Bolognesi, Angelo; Da Pozzo, Luigi Filippo; Guazzoni, Giorgio; Freschi, Massimo; Roscigno, Marco; Scattoni, Vincenzo; Rigatti, Patrizio; Di Muzio, Nadia

    2009-11-15

    Purpose: To determine the clinical benefit of high-dose early adjuvant radiotherapy (EART) in high-risk prostate cancer (hrCaP) patients submitted to radical retropubic prostatectomy plus pelvic lymphadenectomy. Patients and Methods: The clinical outcome of 334 hrCaP (pT3-4 and/or positive resection margins) node-negative patients submitted to radical retropubic prostatectomy plus pelvic lymphadenectomy before 2004 was analyzed according to the EART dose delivered to the prostatic bed, <70.2 Gy (lower dose, median 66.6 Gy, n = 153) or >=70.2 Gy (median 70.2 Gy, n = 181). Results: The two groups were comparable except for a significant difference in terms of median follow-up (10 vs. 7 years, respectively) owing to the gradual increase of EART doses over time. Nevertheless, median time to prostate-specific antigen (PSA) failure was almost identical, 38 and 36 months, respectively. At univariate analysis, both 5-year biochemical relapse-free survival (bRFS) and disease-free survival (DFS) were significantly higher (83% vs. 71% [p = 0.001] and 94% vs. 88% [p = 0.005], respectively) in the HD group. Multivariate analysis confirmed EART dose >=70 Gy to be independently related to both bRFS (hazard ratio 2.5, p = 0.04) and DFS (hazard ratio 3.6, p = 0.004). Similar results were obtained after the exclusion of patients receiving any androgen deprivation. After grouping the hormone-naive patients by postoperative PSA level the statistically significant impact of high-dose EART on both 5-year bRFS and DFS was maintained only for those with undetectable values, possibly owing to micrometastatic disease outside the irradiated area in case of detectable postoperative PSA values. Conclusion: This series provides strong support for the use of EART doses >=70 Gy after radical retropubic prostatectomy in hrCaP patients with undetectable postoperative PSA levels.

  2. The Effects of Intra-Aortic Balloon Pumps on Mortality in Patients Undergoing High-Risk Coronary Revascularization: A Meta-Analysis of Randomized Controlled Trials of Coronary Artery Bypass Grafting and Stenting Era

    PubMed Central

    Wan, You-Dong; Sun, Tong-Wen; Kan, Quan-Cheng; Guan, Fang-Xia; Liu, Zi-Qi; Zhang, Shu-Guang

    2016-01-01

    Background Intra-aortic balloon pumps (IABP) have generally been used for patients undergoing high-risk mechanical coronary revascularization. However, there is still insufficient evidence to determine whether they can improve outcomes in reperfusion therapy patients, mainly by percutaneous coronary intervention (PCI) with stenting or coronary artery bypass graft (CABG). This study was designed to determine the difference between high-risk mechanical coronary revascularization with and without IABPs on mortality, by performing a meta-analysis on randomized controlled trials of the current era. Methods Pubmed and Embase databases were searched from inception to May 2015. Unpublished data were obtained from the investigators. Randomized clinical trials of IABP and non-IABP in high-risk coronary revascularization procedures (PCI or CABG) were included. In the case of PCI procedures, stents should be used in more than 80% of patients. Numbers of events at the short-term and long-term follow-up were extracted. Results A total of 12 randomized trials enrolling 2155 patients were included. IABPs did not significantly decrease short-term mortality (relative risk (RR) 0.66; 95% CI, 0.42–1.01), or long-term mortality (RR 0.79; 95% CI, 0.47–1.35), with low heterogeneity across the studies. The findings remained stable in patients with acute myocardial infarction with or without cardiogenic shock. But in high-risk CABG patients, IABP was associated with reduced mortality (71 events in 846 patients; RR 0.40; 95%CI 0.25–0.67). Conclusion In patients undergoing high-risk coronary revascularization, IABP did not significantly decrease mortality. But high-risk CABG patients may be benefit from IABP. Rigorous criteria should be applied to the use of IABPs. PMID:26784578

  3. [Detecting high risk pregnancy].

    PubMed

    Doret, Muriel; Gaucherand, Pascal

    2009-12-20

    Antenatal care is aiming to reduce maternal land foetal mortality and morbidity. Maternal and foetal mortality can be due to different causes. Their knowledge allows identifying pregnancy (high risk pregnancy) with factors associated with an increased risk for maternal and/or foetal mortality and serious morbidity. Identification of high risk pregnancies and initiation of appropriate treatment and/or surveillance should improve maternal and/or foetal outcome. New risk factors are continuously described thanks to improvement in antenatal care and development in biology and cytopathology, increasing complexity in identifying high risk pregnancies. Level of risk can change all over the pregnancy. Ideally, it should be evaluated prior to the pregnancy and at each antenatal visit. Clinical examination is able to screen for intra-uterin growth restriction, pre-eclampsia, threatened for preterm labour; ultrasounds help in the diagnosis of foetal morphological anomalies, foetal chromosomal anomalies, placenta praevia and abnormal foetal growth; biological exams are used to screen for pre-eclampsia, gestational diabetes, trisomy 21 (for which screening method just changed), rhesus immunisation, seroconversion for toxoplasmosis or rubeola, unknown infectious disease (syphilis, hepatitis B, VIH). During pregnancy, most of the preventive strategies have to be initiated during the first trimester or even before conception. Prevention for neural-tube defects, neonatal hypocalcemia and listeriosis should be performed for all women. On the opposite, some measures are concerning only women with risk factors such as prevention for toxoplasmosis, rhesus immunization (which recently changed), tobacco complications and pre-eclampsia and intra-uterine growth factor restriction.

  4. 3-D Storybook: Effects on Surgical Knowledge and Anxiety Among Four- to Six-Year-Old Surgical Patients.

    PubMed

    Macindo, John Rey B; Macabuag, Katherine R; Macadangdang, Carlo Miguel P; Macaranas, Margaux Valerie S; Macarilay, Marianne Jezelle Jem T; Madriñan, Natasha Nikki M; Villarama, Rouena S

    2015-07-01

    Inadequate surgical knowledge potentiates anxiety; however, no methodology simultaneously addresses anxiety and surgical knowledge. Our quasi-experimental study determined the effectiveness of a three-dimensional (3-D) storybook in increasing surgical knowledge and decreasing anxiety among young children scheduled for planned or required major surgeries. We studied 20 randomly assigned participants who received either the 3-D storybook or traditional health teaching. A presurgical knowledge questionnaire and modified Yale Preoperative Anxiety Scale assessed surgical knowledge and anxiety. Data were analyzed with one-way and repeated-measures multivariate analysis of variance. Results showed that both groups had higher knowledge scores (F = 8.94; P = .008) and lower anxiety scores (F = 5.13; P = .036) after the intervention. The children who received information from the 3-D storybook exhibited a significantly higher posttest knowledge score (F = 11.71; P = .003) and lower anxiety score (F = 10.05; P = .005) than the traditionally educated group of children. The 3-D storybook effectively increased surgical knowledge and decreased anxiety and could be used as an alternative method to prepare pediatric surgical patients.

  5. High-risk HPV genotypes and P16INK4a expression in a cohort of head and neck squamous cell carcinoma patients in Singapore.

    PubMed

    Tan, Louise Soo Yee; Fredrik, Petersson; Ker, Liang; Yu, Feng Gang; Wang, De Yun; Goh, Boon Cher; Loh, Kwok Seng; Lim, Chwee Ming

    2016-12-27

    Human papillomavirus (HPV), especially HPV16 genotype, is associated with oropharyngeal squamous cell carcinoma (OPSCC). We aim to determine the prevalence and characterize the high-risk (HR)-HPV genotypes in head and neck SCC (HNSCC) in a South-East Asian multi-ethnic society in Singapore and examine its prognostic significance.159 HNSCC archival tissue samples were retrieved and tumour DNA was screened for 18 HR-HPV genotypes using a PCR-based assay (Qiagen, digene HPV genotyping RH test). P16 protein overexpression was identified using immunohistochemistry (IHC). Statistical correlation between clinical outcomes were performed between HPV-positive and negative HNSCC patients.Six HR-HPVs (HPV16, 18, 31, 45, 56, 68) were detected in 90.6% of HNSCC; and 79.9% had multiple HPV genotypes detected. HPV31 and HPV45 were the most prevalent (79.2% and 87.4%, respectively); and HPV16 was predominantly found in OPSCC (p < 0.001). HPV-DNA PCR assay yielded a high sensitivity (96%) but low specificity (11%) when compared to p16 immunohistochemistry as the reference standard.P16-positive HNSCC was predominantly observed in OPSCC (73.7%; p = 0.005); and p16-positive OPSCC exhibited improved overall survival compared to p16-negative OPSCC (p = 0.022). Similarly, smoking and alcohol consumption were poor prognostic factors of overall survival (p = 0.007; p = 0.01) in OPSCC patients.HR-HPVs were identified in 90.6% of HNSCC patients using the HPV-DNA PCR assay. This test had a poor specificity when compared to p16 IHC; making it an unreliable detection technique in selecting patients for radiation dose de-escalation treatment protocol. P16-positive tumor was predominantly found in the oropharynx these patients demonstrated better overall survival than those with p16-negative OPSCC.

  6. High-risk HPV genotypes and P16INK4a expression in a cohort of head and neck squamous cell carcinoma patients in Singapore

    PubMed Central

    Tan, Louise Soo Yee; Fredrik, Petersson; Ker, Liang; Yu, Feng Gang; Wang, De Yun; Goh, Boon Cher; Loh, Kwok Seng; Lim, Chwee Ming

    2016-01-01

    Human papillomavirus (HPV), especially HPV16 genotype, is associated with oropharyngeal squamous cell carcinoma (OPSCC). We aim to determine the prevalence and characterize the high-risk (HR)-HPV genotypes in head and neck SCC (HNSCC) in a South-East Asian multi-ethnic society in Singapore and examine its prognostic significance. 159 HNSCC archival tissue samples were retrieved and tumour DNA was screened for 18 HR-HPV genotypes using a PCR-based assay (Qiagen, digene HPV genotyping RH test). P16 protein overexpression was identified using immunohistochemistry (IHC). Statistical correlation between clinical outcomes were performed between HPV-positive and negative HNSCC patients. Six HR-HPVs (HPV16, 18, 31, 45, 56, 68) were detected in 90.6% of HNSCC; and 79.9% had multiple HPV genotypes detected. HPV31 and HPV45 were the most prevalent (79.2% and 87.4%, respectively); and HPV16 was predominantly found in OPSCC (p < 0.001). HPV-DNA PCR assay yielded a high sensitivity (96%) but low specificity (11%) when compared to p16 immunohistochemistry