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Sample records for surgically high-risk patients

  1. [Anesthesiological management of the high-risk surgical patient].

    PubMed

    Bertoldi, G; Avalle, M

    1980-03-01

    Evaluation of the anaesthesiological risk in surgical patients is described and an account is given of results obtained with an association of ketamin and NLA II in 57 high-risk patients subjected to general surgical management.

  2. Reducing mortality for high risk surgical patients in the UK.

    PubMed

    Rogers, B A; Carrothers, A D; Jones, Chris

    2012-06-01

    Over 40 million surgical procedures are performed per annum in the USA and Europe, including several million patients who are considered to be high risk (Bennett-Guerrero et al 2003). Overall, the risk of death or major complications after surgery in the general surgical patient population is low, with a post-operative mortality rate of less than1% during the same hospital admission (Niskanen et al 2001).

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

    PubMed

    Mueck, Krislynn M; Kao, Lillian S

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

  4. Transcatheter versus surgical aortic-valve replacement in high-risk patients.

    PubMed

    Smith, Craig R; Leon, Martin B; Mack, Michael J; Miller, D Craig; Moses, Jeffrey W; Svensson, Lars G; Tuzcu, E Murat; Webb, John G; Fontana, Gregory P; Makkar, Raj R; Williams, Mathew; Dewey, Todd; Kapadia, Samir; Babaliaros, Vasilis; Thourani, Vinod H; Corso, Paul; Pichard, Augusto D; Bavaria, Joseph E; Herrmann, Howard C; Akin, Jodi J; Anderson, William N; Wang, Duolao; Pocock, Stuart J

    2011-06-09

    The use of transcatheter aortic-valve replacement has been shown to reduce mortality among high-risk patients with aortic stenosis who are not candidates for surgical replacement. However, the two procedures have not been compared in a randomized trial involving high-risk patients who are still candidates for surgical replacement. At 25 centers, we randomly assigned 699 high-risk patients with severe aortic stenosis to undergo either transcatheter aortic-valve replacement with a balloon-expandable bovine pericardial valve (either a transfemoral or a transapical approach) or surgical replacement. The primary end point was death from any cause at 1 year. The primary hypothesis was that transcatheter replacement is not inferior to surgical replacement. The rates of death from any cause were 3.4% in the transcatheter group and 6.5% in the surgical group at 30 days (P=0.07) and 24.2% and 26.8%, respectively, at 1 year (P=0.44), a reduction of 2.6 percentage points in the transcatheter group (upper limit of the 95% confidence interval, 3.0 percentage points; predefined margin, 7.5 percentage points; P=0.001 for noninferiority). The rates of major stroke were 3.8% in the transcatheter group and 2.1% in the surgical group at 30 days (P=0.20) and 5.1% and 2.4%, respectively, at 1 year (P=0.07). At 30 days, major vascular complications were significantly more frequent with transcatheter replacement (11.0% vs. 3.2%, P<0.001); adverse events that were more frequent after surgical replacement included major bleeding (9.3% vs. 19.5%, P<0.001) and new-onset atrial fibrillation (8.6% vs. 16.0%, P=0.006). More patients undergoing transcatheter replacement had an improvement in symptoms at 30 days, but by 1 year, there was not a significant between-group difference. In high-risk patients with severe aortic stenosis, transcatheter and surgical procedures for aortic-valve replacement were associated with similar rates of survival at 1 year, although there were important differences in

  5. 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

  6. 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

  7. 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

  8. 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.

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

    PubMed Central

    Kim, Yong Joo; Shin, Tae Beom

    2011-01-01

    Objective To evaluate the technical feasibility and clinical efficacy of percutaneous transhepatic cholecystolithotomy under fluoroscopic guidance in high-risk surgical patients with acute cholecystitis. Materials and Methods Sixty-three consecutive patients of high surgical risk with acute calculous cholecystitis underwent percutaneous transhepatic gallstone removal under conscious sedation. The stones were extracted through the 12-Fr sheath using a Wittich nitinol stone basket under fluoroscopic guidance on three days after performing a percutaneous cholecystostomy. Large or hard stones were fragmented using either the snare guide wire technique or the metallic cannula technique. Results Gallstones were successfully removed from 59 of the 63 patients (94%). Reasons for stone removal failure included the inability to grasp a large stone in two patients, and the loss of tract during the procedure in two patients with a contracted gallbladder. The mean hospitalization duration was 7.3 days for acute cholecystitis patients and 9.4 days for gallbladder empyema patients. Bile peritonitis requiring percutaneous drainage developed in two patients. No symptomatic recurrence occurred during follow-up (mean, 608.3 days). Conclusion Fluoroscopy-guided percutaneous gallstone removal using a 12-Fr sheath is technically feasible and clinically effective in high-risk surgical patients with acute cholecystitis. PMID:21430938

  10. 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

  11. 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.

  12. Quality of life after transcatheter aortic valve implantation and surgical replacement in high-risk elderly patients.

    PubMed

    Kala, Petr; Tretina, Martin; Poloczek, Martin; Ondrasek, Jiri; Malik, Petr; Pokorny, Petr; Parenica, Jiri; Spinar, Jindrich; Jarkovsky, Jiri; Littnerova, Simona; Nemec, Petr

    2013-03-01

    The aim of this study was to compare the quality of life after transcatheter aortic valve implantation (TAVI) and surgical replacement (SAVR) at one year. The study included 45 consecutive high-risk patients (average age 82.0 years; logistic Euroscore 22.3%) with symptomatic severe aortic stenosis allocated to TAVI transfemoral, TAVI transapical using the Edwards-Sapien valve or SAVR with the Edwards Perimount bioprosthesis (n=15 in each). The pre-operative characteristics were similar except for more myocardial infarctions in TAVI. The quality of life was assessed using the standardized EQ-5D questionnaire at baseline and on days 30, 90 and 360. The protocol was approved by the local ethics committee and an informed consent was signed. A total of 7 patients (15.5%) died during follow-up. At baseline no significant differences in any of the quality-of-life parameters were found except for usual activities described as "best" (46.7% in SAVR vs. 10.0% in TAVI; P=0.002). At 30 and 90 days surviving patients were similar and at 360 days only the anxiety/depression score was "best" in 83.3% SAVR vs. 59.1% (P=0.046). Functional status improved in all patients (NYHA class I-II in 13.3% at baseline vs. 78.9% at 360-days) and the general health median significantly improved in TAVI patients (from 50 to 67; P=0.001) with a positive trend in SAVR patients (P=0.060). At one year, the general quality of life of high-risk patients had significantly improved after transcatheter aortic valve implantation with a positive trend in surgically treated patients.

  13. Central venous-to-arterial carbon dioxide difference as a prognostic tool in high-risk surgical patients.

    PubMed

    Robin, Emmanuel; Futier, Emmanuel; Pires, Oscar; Fleyfel, Maher; Tavernier, Benoit; Lebuffe, Gilles; Vallet, Benoit

    2015-05-13

    The purpose of this study was to evaluate the clinical relevance of high values of central venous-to-arterial carbon dioxide difference (PCO2 gap) in high-risk surgical patients admitted to a postoperative ICU. We hypothesized that PCO2 gap could serve as a useful tool to identify patients still requiring hemodynamic optimization at ICU admission. One hundred and fifteen patients were included in this prospective single-center observational study during a 1-year period. High-risk surgical inclusion criteria were adapted from Schoemaker and colleagues. Demographic and biological data, PCO2 gap, central venous oxygen saturation, lactate level and postoperative complications were recorded for all patients at ICU admission, and 6 hours and 12 hours after admission. A total of 78 (68%) patients developed postoperative complications, of whom 54 (47%) developed organ failure. From admission to 12 hours after admission, there was a significant difference in mean PCO2 gap (8.7 ± 2.8 mmHg versus 5.1 ± 2.6 mmHg; P = 0.001) and median lactate values (1.54 (1.1-3.2) mmol/l versus 1.06 (0.8-1.8) mmol/l; P = 0.003) between patients who developed postoperative complications and those who did not. These differences were maximal at admission to the ICU. At ICU admission, the area under the receiver operating characteristic curve for occurrence of postoperative complications was 0.86 for the PCO2 gap compared to Sequential Organ Failure Assessment score (0.82), Simplified Acute Physiology Score II score (0.67), and lactate level (0.67). The threshold value for PCO2 gap was 5.8 mmHg. Multivariate analysis showed that only a high PCO2 gap and a high Sequential Organ Failure Assessment score were independently associated with the occurrence of postoperative complications. A high PCO2 gap (≥6 mmHg) was associated with more organ failure, an increase in duration of mechanical ventilation and length of hospital stay. A high PCO2 gap at admission in the postoperative ICU

  14. A cost-effectiveness analysis of postoperative goal-directed therapy for high-risk surgical patients.

    PubMed

    Ebm, Claudia; Cecconi, Maurizio; Sutton, Les; Rhodes, Andrew

    2014-05-01

    Patients undergoing major surgery are at high risk of increased postoperative morbidity and mortality. Goal-directed therapy has been shown to improve outcomes when commenced in the early postoperative period, yet the economic impact remains unclear. The aim of our study was to assess the cost effectiveness of goal-directed therapy as part of postoperative management. Cost-effectiveness analysis to determine short and long term clinical and financial benefits. A decision tree was constructed to determine short-term "in-hospital" costs, based on outcome data derived from a previous study. For a long-term cost-effectiveness analysis, we created a simulation model to estimate life expectancy (quality-adjusted) and lifetime costs for a hypothetical cohort of major noncardiac surgical patients. Cost and outcome comparisons were made between postoperative goal-directed therapy and best standard therapy and described as cost/hospital survivor and cost/patient for the short-term analysis and as incremental cost/quality-adjusted life year for the long-term model. One-way, multiway, and probabilistic analyses were performed to address uncertainties in the model input values, and results were presented graphically in a cost-effectiveness acceptability curve. Simulation of a tertiary care department in the United Kingdom. A hypothetical cohort of high risk surgical patients. Patients undergoing high-risk surgery were stratified to receive goal-directed therapy or standard best practice to improve tissue oxygenation in the postoperative setting. In our short-term model, goal-directed therapy decreased costs by £2,631.77/patient and by £2,134.86/hospital survivor. The most sensitive variables were relative risk of complication and length of stay. When assuming the worst-case scenario (prolonged ICU and in-hospital stay, highest complication costs, and maximum cost for monitoring), goal-directed therapy still achieved cost savings (£471.70). Our findings also predict that goal

  15. Patient-reported Limitations to Surgical Buy-in: A Qualitative Study of Patients Facing High-risk Surgery.

    PubMed

    Nabozny, Michael J; Kruser, Jacqueline M; Steffens, Nicole M; Pecanac, Kristen E; Brasel, Karen J; Chittenden, Eva H; Cooper, Zara; McKneally, Martin F; Schwarze, Margaret L

    2017-01-01

    To characterize how patients buy-in to treatments beyond the operating room and what limits they would place on additional life-supporting treatments. During a high-risk operation, surgeons generally assume that patients buy-in to life-supporting interventions that might be necessary postoperatively. How patients understand this agreement and their willingness to participate in additional treatment is unknown. We purposively sampled surgeons in Toronto, Ontario, Boston, Massachusetts, and Madison, Wisconsin, who are good communicators and routinely perform high-risk operations. We audio-recorded their conversations with patients considering high-risk surgery. For patients who were then scheduled for surgery, we performed open-ended preoperative and postoperative interviews. We used directed qualitative content analysis to analyze the interviews and surgeon visits, specifically evaluating the content about the use of postoperative life support. We recorded 43 patients' conversations with surgeons, 34 preoperative, and 27 postoperative interviews. Patients expressed trust in their surgeon to make decisions about additional treatments if a serious complication occurred, yet expressed a preference for significant treatment limitations that were not discussed with their surgeon preoperatively. Patients valued the existence or creation of an advance directive preoperatively, but they did not discuss this directive with their surgeon. Instead they assumed it would be effective if needed and that family members knew their wishes. Patients implicitly trust their surgeons to treat postoperative complications as they arise. Although patients may buy-in to some additional postoperative interventions, they hold a broad range of preferences for treatment limitations that were not discussed with the surgeon preoperatively.

  16. 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

  17. Prophylactic beta-blockade to prevent myocardial infarction perioperatively in high-risk patients who undergo general surgical procedures.

    PubMed

    Taylor, Rebecca C; Pagliarello, Giuseppe

    2003-06-01

    The benefit of administering beta-adrenergic blocking agents perioperatively to surgical patients at high risk for myocardial ischemia has been demonstrated in several well-designed randomized controlled trials. These benefits have included a reduction in the incidence of myocardial complications and an improvement in overall survival for patients with evidence of or at risk for coronary artery disease (CAD). We designed a retrospective study at the Ottawa Civic Hospital to investigate the use of beta-blockers in the perioperative period for high-risk general surgery patients who underwent laparotomy and to explore the reasons for failure to prescribe or administer beta-blockers when indicated. All 236 general surgery patients over the age of 50 years who underwent laparotomy for major gastrointestinal surgery between Jan. 1, 2001, and Dec. 31, 2001, were assigned a cardiac risk classification using the risk stratification described by Mangano and colleagues. The perioperative prescription and administration of beta-blockers were noted as were the patient's heart rate and blood pressure parameters for the first postoperative week, in-hospital adverse cardiac events and death. Of the 143 patients classified as being at risk for CAD or having definite evidence of CAD, 87 (60.8%) did not receive beta-blockers perioperatively. Of those who did, 43 were previously on beta-blockers and 13 had them ordered preoperatively. Patients with definite CAD were significantly more likely than others to receive beta-blockers perioperatively (p < 0.001), as were patients seen by an anesthesiologist or an internist preoperatively (p < 0.001). Twenty (33%) of the 61 patients who were already taking beta-blockers preoperatively had them inappropriately discontinued postoperatively. Once prescribed by the physician, beta-blockers were administered by the nurses irrespective of nil par os status. The mean heart rate and blood pressure parameters for patients receiving beta

  18. 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

  19. 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

  20. Conventional surgery and transcatheter closure via surgical transapical approach for paravalvular leak repair in high-risk patients: results from a single-centre experience.

    PubMed

    Taramasso, Maurizio; Maisano, Francesco; Latib, Azeem; Denti, Paolo; Guidotti, Andrea; Sticchi, Alessandro; Panoulas, Vasileios; Giustino, Gennaro; Pozzoli, Alberto; Buzzatti, Nicola; Cota, Linda; De Bonis, Michele; Montorfano, Matteo; Castiglioni, Alessandro; Blasio, Andrea; La Canna, Giovanni; Colombo, Antonio; Alfieri, Ottavio

    2014-10-01

    Paravalvular leaks (PVL) occur in up to 17% of all surgically implanted prosthetic valves. Re-operation is associated with high morbidity and mortality. Transcatheter closure via a surgical transapical approach (TAp) is an emerging alternative for selected high-risk patients with PVL. The aim of this study was to compare the in-hospital outcomes of patients who underwent surgery and TA-closure for PVL in our single-centre experience. From October 2000 to June 2013, 139 patients with PVL were treated in our Institution. All the TA procedures were performed under general anaesthesia in a hybrid operative room: in all but one case an Amplatzer Vascular Plug III device was utilized. Hundred and thirty-nine patients with PVL were treated: 122 patients (87.3%) underwent surgical treatment (68% mitral PVL; 32% aortic PVL) and 17 patients (12.2%) underwent a transcatheter closure via a surgical TAp approach (all the patients had mitral PVL; one case had combined mitral and aortic PVLs); in 35% of surgical patients and in 47% of TAp patients, multiple PVLs were present. The mean age was 62.5 ± 11 years; the Logistic EuroScore was 15.4 ± 3. Most of the patients were in New York Heart Association (NYHA) functional class III-IV (57%). Symptomatic haemolysis was present in 35% of the patients, and it was particularly frequent in the TAp (70%). Many patients had >1 previous cardiac operation (46% overall and 82% of TAp patients were at their second of re-operation). Acute procedural success was 98%. In-hospital mortality was 9.3%; no in-hospital deaths occurred in patients treated through a TAp approach. All the patients had less than moderate residual valve regurgitation after the procedure. Surgical treatment was identified as a risk factor for in-hospital death at univariate analysis (OR: 8, 95% CI: 1.8-13; P = 0.05). Overall actuarial survival at follow-up was 39.8 ± 7% at 12 years and it was reduced in patients who had >1 cardiac re-operation (42 ± 8 vs. 63 ± 6% at 9

  1. Stroke volume variation to guide fluid therapy: is it suitable for high-risk surgical patients? A terminated randomized controlled trial.

    PubMed

    Jammer, Ib; Tuovila, Mari; Ulvik, Atle

    2015-01-01

    Perioperative goal-directed fluid therapy (GDFT) may improve outcome after high-risk surgery. Minimal invasive measurement of stroke volume variation (SVV) has been recommended to guide fluid therapy. We intended to study how perioperative GDFT with arterial-based continuous SVV monitoring influences postoperative complications in a high-risk surgical population. From February 1st 2012, all ASA 3 and 4 patients undergoing abdominal surgery in two university hospitals were assessed for randomization into a control group or GDFT group. An arterial-line cardiac output monitor was used to measure SVV, and fluid was given after an algorithm in the intervention group. Restrictions of the method excluded patients undergoing laparoscopic surgery, patients with atrial fibrillation and patients with severe mitral/aortal stenosis. To detect a decrease in number of complication from 40 % in the control group to 20 % in the GDFT group, n = 164 patients were needed (power 80 %, alpha 0.05, two-sided test). To include the needed amount of patients, the study was estimated to last for 2 years. After 1 year, 30 patients were included and the study was halted due to slow inclusion rate. Of 732 high-risk patients scheduled for abdominal surgery, 391 were screened for randomization. Of those, n = 249 (64 %) were excluded because a laparoscopic technique was preferred and n = 95 (24 %) due to atrial fibrillation. Our study was stopped due to a slow inclusion rate. Methodological restrictions of the arterial-line cardiac output monitor excluded the majority of patients. This leaves the question if this method is appropriate to guide fluid therapy in high-risk surgical patients. ClinicalTrials.gov: NCT01473446.

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

    PubMed

    Kortram, Kirsten; van Ramshorst, Bert; Bollen, Thomas L; Besselink, Marc G H; Gouma, Dirk J; Karsten, Tom; Kruyt, Philip M; Nieuwenhuijzen, Grard A P; Kelder, Johannes C; Tromp, Ellen; Boerma, Djamila

    2012-01-12

    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. 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. 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. Netherlands Trial Register (NTR): NTR2666.

  3. 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

  4. 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.

  5. Effectiveness of Intermittent Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis in High-Risk Surgical Patients: A Systematic Review.

    PubMed

    Pavon, Juliessa M; Adam, Soheir S; Razouki, Zayd A; McDuffie, Jennifer R; Lachiewicz, Paul F; Kosinski, Andrzej S; Beadles, Christopher A; Ortel, Thomas L; Nagi, Avishek; Williams, John W

    2016-02-01

    Thromboprophylaxis regimens include pharmacologic and mechanical options such as intermittent pneumatic compression devices (IPCDs). There are a wide variety of IPCDs available, but it is uncertain if they vary in effectiveness or ease of use. This is a systematic review of the comparative effectiveness of IPCDs for selected outcomes (mortality, venous thromboembolism [VTE], symptomatic or asymptomatic deep vein thrombosis, major bleeding, ease of use, and adherence) in postoperative surgical patients. We searched MEDLINE (via PubMed), Embase, CINAHL, and Cochrane CENTRAL from January 1, 1995, to October 30, 2014, for randomized controlled trials, as well as relevant observational studies on ease of use and adherence. We identified 14 eligible randomized controlled trials (2633 subjects) and 3 eligible observational studies (1724 subjects); most were conducted in joint arthroplasty patients. Intermittent pneumatic compression devices were comparable to anticoagulation for major clinical outcomes (VTE: risk ratio, 1.39; 95% confidence interval, 0.73-2.64). Limited data suggest that concurrent use of anticoagulation with IPCD may lower VTE risk compared with anticoagulation alone, and that IPCD compared with anticoagulation may lower major bleeding risk. Subgroup analyses did not show significant differences by device location, mode of inflation, or risk of bias elements. There were no consistent associations between IPCDs and ease of use or adherence. Intermittent pneumatic compression devices are appropriate for VTE thromboprophylaxis when used in accordance with current clinical guidelines. The current evidence base to guide selection of a specific device or type of device is limited. Copyright © 2016 Elsevier Inc. All rights reserved.

  6. 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

  7. 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.

  8. A pragmatic multi-centre randomised controlled trial of fluid loading in high-risk surgical patients undergoing major elective surgery--the FOCCUS study.

    PubMed

    Cuthbertson, Brian H; Campbell, Marion K; Stott, Stephen A; Elders, Andrew; Hernández, Rodolfo; Boyers, Dwayne; Norrie, John; Kinsella, John; Brittenden, Julie; Cook, Jonathan; Rae, Daniela; Cotton, Seonaidh C; Alcorn, David; Addison, Jennifer; Grant, Adrian

    2011-01-01

    Fluid strategies may impact on patient outcomes in major elective surgery. We aimed to study the effectiveness and cost-effectiveness of pre-operative fluid loading in high-risk surgical patients undergoing major elective surgery. This was a pragmatic, non-blinded, multi-centre, randomised, controlled trial. We sought to recruit 128 consecutive high-risk surgical patients undergoing major abdominal surgery. The patients underwent pre-operative fluid loading with 25 ml/kg of Ringer's solution in the six hours before surgery. The control group had no pre-operative fluid loading. The primary outcome was the number of hospital days after surgery with cost-effectiveness as a secondary outcome. A total of 111 patients were recruited within the study time frame in agreement with the funder. The median pre-operative fluid loading volume was 1,875 ml (IQR 1,375 to 2,025) in the fluid group compared to 0 (IQR 0 to 0) in controls with days in hospital after surgery 12.2 (SD 11.5) days compared to 17.4 (SD 20.0) and an adjusted mean difference of 5.5 days (median 2.2 days; 95% CI -0.44 to 11.44; P = 0.07). There was a reduction in adverse events in the fluid intervention group (P = 0.048) and no increase in fluid based complications. The intervention was less costly and more effective (adjusted average cost saving: £2,047; adjusted average gain in benefit: 0.0431 quality adjusted life year (QALY)) and has a high probability of being cost-effective. Pre-operative intravenous fluid loading leads to a non-significant reduction in hospital length of stay after high-risk major surgery and is likely to be cost-effective. Confirmatory work is required to determine whether these effects are reproducible, and to confirm whether this simple intervention could allow more cost-effective delivery of care. Prospective Clinical Trials, ISRCTN32188676.

  9. Interaction Effects of Acute Kidney Injury, Acute Respiratory Failure, and Sepsis on 30-Day Postoperative Mortality in Patients Undergoing High-Risk Intraabdominal General Surgical Procedures.

    PubMed

    Kim, Minjae; Brady, Joanne E; Li, Guohua

    2015-12-01

    Acute kidney injury (AKI), acute respiratory failure, and sepsis are distinct but related pathophysiologic processes. We hypothesized that these 3 processes may interact to synergistically increase the risk of short-term perioperative mortality in patients undergoing high-risk intraabdominal general surgery procedures. We performed a retrospective, observational cohort study of data (2005-2011) from the American College of Surgeons-National Surgical Quality Improvement Program, a high-quality surgical outcomes data set. High-risk procedures were those with a risk of AKI, acute respiratory failure, or sepsis greater than the average risk in all intraabdominal general surgery procedures. The effects of AKI, acute respiratory failure, and sepsis on 30-day mortality were assessed using a Cox proportional hazards model. Additive interactions were assessed with the relative excess risk due to interaction. Of 217,994 patients, AKI, acute respiratory failure, and sepsis developed in 1.3%, 3.7%, and 6.8%, respectively. The 30-day mortality risk with sepsis, acute respiratory failure, and AKI were 11.4%, 24.1%, and 25.1%, respectively, compared with 0.85% without these complications. The adjusted hazard ratios and 95% confidence intervals for a single complication (versus no complication) on mortality were 7.24 (6.46-8.11), 10.8 (8.56-13.6), and 14.2 (12.8-15.7) for sepsis, AKI, and acute respiratory failure, respectively. For 2 complications, the adjusted hazard ratios were 30.8 (28.0-33.9), 42.6 (34.3-52.9), and 65.2 (53.9-78.8) for acute respiratory failure/sepsis, AKI/sepsis, and acute respiratory failure/AKI, respectively. Finally, the adjusted hazard ratio for all 3 complications was 105 (92.8-118). Positive additive interactions, indicating synergism, were found for each combination of 2 complications. The relative excess risk due to interaction for all 3 complications was not statistically significant. In high-risk general surgery patients, the development of AKI

  10. Single-port versus conventional multiport access prophylactic laparoscopic bilateral salpingo-oophorectomy in high-risk patients for ovarian cancer: a comparison of surgical outcomes

    PubMed Central

    Angioni, Stefano; Pontis, Alessandro; Sedda, Federica; Zampetoglou, Theodoros; Cela, Vito; Mereu, Liliana; Litta, Pietro

    2015-01-01

    Bilateral salpingo-oophorectomy (BSO) in carriers of BRCA1 and BRCA2 mutations is widely recommended as part of a risk-reduction strategy for ovarian or breast cancer due to an underlying genetic predisposition. BSO is also performed as a therapeutic intervention for patients with hormone-positive premenopausal breast cancer. BSO may be performed via a minimally invasive approach with the use of three to four 5 mm and/or 12 mm ports inserted through a skin incision. To further reduce the morbidity associated with the placement of multiple port sites and to improve cosmetic outcomes, single-port laparoscopy has been developed with a single access point from the umbilicus. The purpose of this study was to evaluate the surgical outcomes associated with reducing the risks of salpingo-oophorectomy performed in a single port, while comparing multiport laparoscopy in women with a high risk for ovarian cancer. Single-port laparoscopy–BSO is feasible and safe, with favorable surgical and cosmetic outcomes when compared to conventional laparoscopy. PMID:26170692

  11. 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

  12. 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

  13. High Risk of Surgical Glove Perforation From Surgical Rotatory Instruments.

    PubMed

    Goldman, Ashton H; Haug, Emanuel; Owen, John R; Wayne, Jennifer S; Golladay, Gregory J

    2016-11-01

    Surgical gloves can be damaged during the course of a procedure, which can place the surgeon and patient at risk. Glove perforation may not always be readily apparent, and determining the risk factors for glove perforation can aid the surgeon in deciding when a glove change is advisable. Time of wear and needle sticks have been well studied; however, other mechanisms including mechanical stress from surgical equipment have had limited evaluation to date. We evaluated the risk of glove perforation in gloves that were caught in a surgical rotatory device (such as drills and reamers). The aims of our study were (1) to determine the percentage of undetected microperforations after entanglement on a rotatory tool during orthopaedic procedures, (2) to determine which kinds of rotatory devices most commonly cause such microperforations, and (3) to assess whether time of wear had an effect on the risk of perforation. From July 2014 to September 2015, 33 gloves were obtained from all orthopaedic subspecialties at our Level I trauma center if they were caught in a rotatory device greater than one revolution. Time of glove wear and location of the glove that was caught in a rotatory device were recorded. After an evaluation for macroperforations (≥ 5 mm), the gloves were evaluated for microperforations (< 5 mm) via the American Society for Testing and Materials (ASTM) one-liter load test. Time of wear was compared among gloves with macroperforations, microperforations, and no perforations. The 33 gloves obtained came from 33 procedures. Seventeen of 33 (52 %) gloves had perforations. Seven of the 17 perforated gloves had macroperforations while 10 had microperforations. Eleven of 33 entanglements were caught by drills, nine by reamers, eight by K-wires, and the remaining five gloves were caught by various other instruments. Eight of 17 perforations were caused by drills, three by reamers, three by K-wires, and three by various other instruments. The average time of wear was

  14. 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.

  15. 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.

  16. Surgical specimen handover from the operating theatre to laboratory-Can we improve patient safety by learning from aviation and other high-risk organisations?

    PubMed

    Brennan, Peter A; Brands, Marieke T; Caldwell, Lucy; Fonseca, Felipe Paiva; Turley, Nic; Foley, Susie; Rahimi, Siavash

    2017-07-10

    Essential communication between healthcare staff is considered one of the key requirements for both safety and quality care when patients are handed over from one clinical area to other. This is particularly important in environments such as the operating theatre and intensive care where mistakes can be devastating. Health care has learned from other high-risk organisations (HRO) such as aviation where the use of checklists and human factors awareness has virtually eliminated human error and mistakes. To our knowledge, little has been published around ways to improve pathology specimen handover following surgery, with pathology request forms often conveying the bare minimum of information to assist the laboratory staff. Furthermore, the request form might not warn staff about potential hazards. In this article, we provide a brief summary of the factors involved in human error and introduce a novel checklist that can be readily completed at the same time as the routine pathology request form. This additional measure enhances safety, can help to reduce processing and mislabelling errors and provides essential information in a structured way assisting both laboratory staff and pathologists when handling head and neck surgical specimens. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

  17. 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.

  18. Surgical management of severe scoliosis with high risk pulmonary dysfunction in Duchenne muscular dystrophy: patient function, quality of life and satisfaction.

    PubMed

    Takaso, Masashi; Nakazawa, Toshiyuki; Imura, Takayuki; Okada, Takamitsu; Fukushima, Kensuke; Ueno, Masaki; Takahira, Naonobu; Takahashi, Kazuhisa; Yamazaki, Masashi; Ohtori, Seiji; Okamoto, Hirotsugu; Okutomi, Toshiyuki; Okamoto, Makihito; Masaki, Takashi; Uchinuma, Eijyu; Sakagami, Hiroyuki

    2010-06-01

    In a previous study, the authors reported the clinical and radiological results of Duchenne muscular dystrophy (DMD) scoliosis surgery in 14 patients with a low FVC of <30%. The purpose of this study was to determine if surgery improved function and QOL in these patients. Furthermore, the authors assessed the patients' and parents' satisfaction. %FVC increased in all patients after preoperative inspiratory muscle training. Scoliosis surgery in this group of patients presented no increased risk of major complications. All-screw constructions and fusion offered the ability to correct spinal deformity in the coronal and pelvic obliquity initially, intermediate and long-term. All patients were encouraged to continue inspiratory muscle training after surgery. The mean rate of %FVC decline after surgery was 3.6% per year. Most patients and parents believed scoliosis surgery improved their function, sitting balance and quality of life even though patients were at high risk for major complications. Their satisfaction was also high.

  19. Surgical management of severe scoliosis with high risk pulmonary dysfunction in Duchenne muscular dystrophy: patient function, quality of life and satisfaction

    PubMed Central

    Nakazawa, Toshiyuki; Imura, Takayuki; Okada, Takamitsu; Fukushima, Kensuke; Ueno, Masaki; Takahira, Naonobu; Takahashi, Kazuhisa; Yamazaki, Masashi; Ohtori, Seiji; Okamoto, Hirotsugu; Okutomi, Toshiyuki; Okamoto, Makihito; Masaki, Takashi; Uchinuma, Eijyu; Sakagami, Hiroyuki

    2010-01-01

    In a previous study, the authors reported the clinical and radiological results of Duchenne muscular dystrophy (DMD) scoliosis surgery in 14 patients with a low FVC of <30%. The purpose of this study was to determine if surgery improved function and QOL in these patients. Furthermore, the authors assessed the patients’ and parents’ satisfaction. %FVC increased in all patients after preoperative inspiratory muscle training. Scoliosis surgery in this group of patients presented no increased risk of major complications. All-screw constructions and fusion offered the ability to correct spinal deformity in the coronal and pelvic obliquity initially, intermediate and long-term. All patients were encouraged to continue inspiratory muscle training after surgery. The mean rate of %FVC decline after surgery was 3.6% per year. Most patients and parents believed scoliosis surgery improved their function, sitting balance and quality of life even though patients were at high risk for major complications. Their satisfaction was also high. PMID:20155495

  20. 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.

  1. Repositionable percutaneous aortic valve implantation with the LOTUS valve: 30-day and 1-year outcomes in 250 high-risk surgical patients.

    PubMed

    Meredith, Ian T; Dumonteil, Nicolas; Blackman, Daniel J; Tchétché, Didier; Walters, Darren L; Hildick-Smith, David; Manoharan, Ganesh; Harnek, Jan; Worthley, Stephen G; Rioufol, Gilles; Lefèvre, Thierry; Modine, Thomas; Van Mieghem, Nicolas M; Feldman, Ted; Allocco, Dominic J; Dawkins, Keith D

    2017-09-20

    The REPRISE IIE trial aimed to evaluate outcomes following transcatheter aortic valve implantation of the fully repositionable and retrievable LOTUS valve with a unique seal designed to minimise paravalvular leak (PVL). This prospective, multicentre study enrolled 250 patients with severe aortic stenosis considered high-risk for surgery by a multidisciplinary Heart Team. An independent clinical events committee adjudicated events per Valve Academic Research Consortium criteria. Mean age was 84 years; 77% were in NYHA Class III/IV. LOTUS valve implantation produced significant haemodynamic improvements at one year without valve embolisation, ectopic valve deployment, or additional valve implantation. Primary endpoints were met as the 30-day mortality rate in the extended cohort (4.4%, N=250), and mean valve gradient in the main cohort (11.5±5.2 mmHg, N=120) were below (p<0.001) their predefined performance objectives. At 30 days, disabling stroke was 2.8% and new pacemaker implantation was 28.9% in all patients and 32.0% in pacemaker-naïve patients. By one year, all-cause mortality was 11.6%, disabling stroke was 3.6%, 95% of patients alive were in NYHA Class I/II, and there was no core laboratory-adjudicated moderate/severe PVL. LOTUS valve implantation produced good valve haemodynamics, minimal PVL, sustained significant improvement in functional status, and good clinical outcomes one year post implant.

  2. Adjuvant Chemoradiation After Surgical Resection in Elderly Patients With High-Risk Squamous Cell Carcinoma of the Head and Neck: A National Cancer Database Analysis.

    PubMed

    Woody, Neil M; Ward, Matthew C; Koyfman, Shlomo A; Reddy, Chandana A; Geiger, Jessica; Joshi, Nikhil; Burkey, Brian; Scharpf, Joseph; Lamarre, Eric; Prendes, Brandon; Adelstein, David J

    2017-07-15

    To determine the patterns of adjuvant chemoradiotherapy use in elderly patients treated with definitive surgical resection for squamous cell carcinoma of the head and neck with extracapsular extension (ECE) or positive margins and determine whether an association with overall survival (OS) exists with adjuvant concurrent chemoradiotherapy (CRT). The National Cancer Database was queried to identify patients with SCC of the oral cavity, oropharynx, larynx, and hypopharynx who were treated with primary definitive surgery and adjuvant radiation therapy between 2004 and 2012. For elderly patients (aged >70 years) with pathology revealing ECE or positive margin, the benefit of concurrent chemotherapy was explored using multivariable Cox proportional hazards modeling. A total of 7349 patients were identified meeting study criteria, of whom 1187 were elderly (aged >70 years) with a median follow-up of 30.6 months. Of these elderly patients, 445 had ECE or positive margin and represent the study population, of whom 187 (42%) received CRT. Delivery of CRT in this cohort increased over the study period, and intensity modulated radiation therapy was associated with increased use of CRT (odds ratio 2.07; P=.004). Increasing age was associated with reduced use of CRT (odds ratio 0.88; P<.001). Chemoradiotherapy was associated with a significant improvement in OS on multivariable analysis (hazard ratio 0.74; P=.04) and a trend toward significance on inverse propensity score analysis (hazard ratio 0.78; P=.051). Three-year OS was 53.8% in the CRT group, compared with 44.6% in the adjuvant radiation therapy-alone patients. The use of adjuvant CRT is increasing among elderly patients with resected squamous cell carcinoma of the head and neck exhibiting ECE or positive margins. Chemoradiotherapy was associated with an improvement in OS on multivariable analysis but not propensity-weighted analysis. Among fit elderly patients with ECE or positive margins after definitive surgical

  3. 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

  4. [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.

  5. The effectiveness of high dependency unit in the management of high risk thoracic surgical cases.

    PubMed

    Ghosh, Shilajit; Steyn, Richard S; Marzouk, Joseph F K; Collins, Frank J; Rajesh, Palababu B

    2004-01-01

    To assess the effectiveness of high dependency unit (HDU) in the management of high-risk thoracic surgical cases at a single dedicated thoracic surgical unit. There is a strong drive to improve postoperative management in a cost-effective way. The number of high-risk thoracic surgical procedures undertaken is increasing rapidly. The HDU can be an effective weapon in the armoury of thoracic surgeons to treat these patients effectively without the need for managing in the extreme environment of expensive intensive care beds. Patients who had undergone lobectomy, pneumonectomy and oesophagectomy were included in the study, as they formed the bulk of the high risk thoracic surgical procedures undertaken by our unit. All data were collected retrospectively from case notes and computerised patient tracking system, for the period between April 2000 and March 2001. One hundred and ninety-one lobectomies (174 for malignancy), 86 pneumonectomies and 50 oesophagectomies were performed during the time period of the study. Of these, 189 (99%) lobectomies, 82 (95%) pneumonectomies and 47 (94%) oesophagectomies were electively admitted to HDU. The mean HDU stay was 21.8 h. Operation discharge time was 7.3 days for lung resections and 9.1 days for oesophagectomy. The overall 30-day mortality was 1.9% for lobectomy, 11% for pneumonectomy and 2% for oesophagectomy. Two oesophagectomies, one lobectomy and three pneumonectomies had to be transferred from HDU to ITU for either mechanical ventilation or more invasive monitoring. Four pneumonectomies, two lobectomies and two oesophagectomies had to be readmitted to HDU with respiratory failure or cardiac instability. Of all the readmitted patients, one pneumonectomy and one lobectomy died. The causes of death were myocardial infarction, pulmonary embolism, adult respiratory distress syndrome and septicaemia. The above results clearly demonstrate that a well-equipped and properly manned HDU can greatly facilitate management of high-risk

  6. Systematic review of the clinical effectiveness and cost-effectiveness of oesophageal Doppler monitoring in critically ill and high-risk surgical patients.

    PubMed

    Mowatt, G; Houston, G; Hernández, R; de Verteuil, R; Fraser, C; Cuthbertson, B; Vale, L

    2009-01-01

    owing to the low number of events and low overall number of patients in the combined totals. Three studies compared ODM plus conventional assessment with conventional assessment during surgery. There was no evidence of a difference in mortality (fixed-effects OR 0.81, 95% CI 0.23-2.77). Length of hospital stay was shorter in all three studies in the ODM group. Two studies compared ODM plus CVP monitoring plus conventional assessment vs CVP monitoring plus conventional assessment in critically ill patients. The patient groups were quite different (cardiac surgery and major trauma) and neither study, nor a meta-analysis, showed a statistically significant difference in mortality (fixed-effects OR 0.84, 95% CI 0.41-1.70). Fewer patients in the ODM group experienced complications (OR 0.49, 95% CI 0.30-0.81) and both studies reported a statistically significant shorter median length of hospital stay in that group. No economic evaluations that met the inclusion criteria were identified from the existing literature so a series of balance sheets was constructed. The results show that ODM strategies are likely to be cost-effective. More formal economic evaluation would allow better use of the available data. All identified studies were conducted in unconscious patients. However, further research is needed to evaluate new ODM probes that may be tolerated by awake patients. Given the paucity of the existing economic evidence base, any further primary research should include an economic evaluation or should provide data suitable for use in an economic model.

  7. Prospective evaluation of clinical outcomes in all-comer high-risk patients with aortic valve stenosis undergoing medical treatment, transcatheter or surgical aortic valve implantation following heart team assessment

    PubMed Central

    Dubois, Christophe; Coosemans, Mark; Rega, Filip; Poortmans, Gert; Belmans, Ann; Adriaenssens, Tom; Herregods, Marie-Christine; Goetschalckx, Kaatje; Desmet, Walter; Janssens, Stefan; Meyns, Bart; Herijgers, Paul

    2013-01-01

    OBJECTIVES Transcatheter aortic valve implantation (TAVI) has been proposed as a treatment alternative for patients with aortic valve stenosis (AS) at high or prohibitive risk for surgical aortic valve replacement (AVR). We aimed to assess real-world outcomes after treatment according to the decisions of the multidisciplinary heart team. METHODS At a tertiary centre, all high-risk patients referred between 1 March 2008 and 31 October 2011 for symptomatic AS were screened and planned to undergo AVR, TAVI or medical treatment. We report clinical outcomes as defined by the Valve Academic Research Consortium. RESULTS Of 163 high-risk patients, those selected for AVR had lower logistic EuroSCORE and STS scores when compared with TAVI or medical treatment (median [interquartile range] 18 [12–26]; 26 [17–36]; 21 [14–32]% (P = 0.015) and 6.5 [5.1–10.7]; 7.6 [5.8–10.5]; 7.6 [6.1–15.7]% (P = 0.056)). All-cause mortalities at 1 year in 35, 73 and 55 patients effectively undergoing AVR, TAVI and medical treatment were 20, 21 and 38%, respectively (P = 0.051). Cardiovascular death and major stroke occurred in 9, 8 and 33% (P < 0.001) and 6, 4 and 2% (P = 0.62), respectively. For patients undergoing valve implantation, device success was 91 and 92% for AVR and TAVI, respectively. The combined safety endpoint at 30 days was in favour of TAVI (29%) vs AVR (63%) (P = 0.001). In contrast, the combined efficacy endpoint at 1 year tended to be more favourable for AVR (10 vs 24% for TAVI, P = 0.12). CONCLUSIONS Patients who are less suitable for AVR can be treated safely and effectively with TAVI with similar outcomes when compared with patients with a lower-risk profile undergoing AVR. Patients with TAVI or AVR have better survival than those undergoing medical treatment only. PMID:23702465

  8. 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.

  9. How can we identify the high-risk patient?

    PubMed

    Sankar, Ashwin; Beattie, W Scott; Wijeysundera, Duminda N

    2015-08-01

    Accurate and early identification of high-risk surgical patients allows for targeted use of perioperative monitoring and interventions that may improve their outcomes. This review summarizes current evidence on how information from the preoperative, operative, and immediate postoperative periods can help identify such individuals. Simple risk indices, such as the Revised Cardiac Risk Index or American Society of Anesthesiologists Physical Status scale, and online calculators allow risk to be estimated with moderate accuracy using readily available preoperative clinical information. Both specific specialized tests (i.e., cardiopulmonary exercise testing and cardiac stress testing) and promising novel biomarkers (i.e., troponins and natriuretic peptides) can help refine these risk estimates before surgery. Estimates of perioperative risk can be further informed by information acquired during the operative and immediate postoperative periods, such as risk indices (i.e., surgical Apgar score), individual risk factors (i.e., intraoperative hypotension), or postoperative biomarkers (i.e., troponins and natriuretic peptides). Preoperative clinical risk indices and risk calculators estimate surgical risk with moderate accuracy. Although novel biomarkers, specialized preoperative testing, and immediate postoperative risk indices show promise as methods to refine these risk estimates, more research is needed on how best to integrate risk information from these different sources.

  10. Minimally invasive aortic valve replacement in high risk patient groups

    PubMed Central

    Lewis, Harriet; Benedetto, Umberto; Caputo, Massimo; Angelini, Gianni; Vohra, Hunaid A.

    2017-01-01

    Minimally invasive aortic valve replacement (AVR) aims to preserve the sternal integrity and improve postoperative outcomes. In low risk patients, this technique can be achieved with comparable mortality to the conventional approach and there is evidence of possible reduction in intensive care and hospital length of stay, transfusion requirement, renal dysfunction, improved respiratory function and increased patient satisfaction. In this review, we aim to asses if these benefits can be transferred to the high risk patient groups. We therefore, discuss the available evidence for the following high risk groups: elderly patients, re-operative surgery, poor lung function, pulmonary hypertension, obesity, concomitant procedures and high risk score cohorts. PMID:28740685

  11. Trainees operating on high-risk patients without cardiopulmonary bypass: a high-risk strategy?

    PubMed

    Ascione, Raimondo; Reeves, Barnaby C; Pano, Marco; Angelini, Gianni D

    2004-07-01

    The safety of teaching off-pump coronary artery bypass grafting to trainees is best tested in high-risk patients, who are more likely to experience significant morbidity after surgery. This study compared outcomes of off-pump coronary artery bypass grafting operations performed by consultants and trainees in high-risk patients. Data for consecutive patients undergoing off-pump coronary artery bypass grafting were collected prospectively. Patients satisfying at least one of the following criteria were classified as high-risk: age older than 75 years, ejection fraction less than 0.30, myocardial infarction in the previous month, current congestive heart failure, previous cerebrovascular accident, creatinine greater than 150 micromol/L, respiratory impairment, peripheral vascular disease, previous cardiac surgery, and left main stem stenosis greater than 50%. Early morbidity, 30-day mortality, and late survival were compared. From April 1996 to December 2002, 686 high-risk patients underwent off-pump coronary artery bypass grafting revascularization. Operations by five consultants (416; 61%) and four trainees (239; 35%) were the focus of subsequent analyses. Nine visiting or research fellows performed the other 31 operations. Prognostic factors were more favorable in trainee-led operations. On average, consultants and trainees grafted the same number of vessels. There were 18 (4.3%) and 5 (1.9%) deaths within 30 days, and 14 (3.4%) and 5 (1.9%) myocardial infarctions in consultant and trainee groups, respectively. After adjusting for imbalances in prognostic factors, odd ratios for almost all adverse outcomes implied no increased risk with trainee operators, although patients operated on by trainees had longer postoperative stays and were more likely to have a red blood cell transfusion. Kaplan-Meier cumulative mortality estimates at 24-month follow-up were 10.5% (95% confidence interval, 7.7% to 14.2%) and 6.4% (95% confidence interval, 3.8% to 10.9%) in consultant

  12. 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.

  13. [The high risk cardiac patient in anesthesia].

    PubMed

    Francke, A

    1996-01-01

    As a result of more offensive therapeutic measures and the given abilities of modern medicine and the increasing number of geriatric patients who are characterized by multimorbidity, more perioperative complications, in particular those of cardiac origin, can be expected. As in any other medical discipline, the safety of anaesthesiological care of the patient very much depends on the individual professional qualification and competence of the physician. For the field of anaesthesiology it can be concluded that it is necessary to tackle the specific problems of this risk group in order to reduce the rate of complications to a minimum. In line with a number of studies showing equal manifestation of cardiac risk factors during the pre-, intra- and postoperative periods, we should concentrate on the consistent use of all preventive and therapeutic measures available during these three periods. Besides evaluation of the cardiac risk factors and planning of the intra- and postoperative management, premedication is of particular importance in the preoperative period. To avoid sympathicoadrenergic contraregulations, benzodiazepines are particularly recommended because of their anxiolytic and sedative effects. The selection of a special anaesthetic method suitable for the patient with high cardiac risk should be influenced not only by anaesthesiological aspects but also by the complex effects of anaesthetic drugs on the determinants of the myocardial oxygen balance. In this connection, an increased sympathicoadrenergic tonus is of particular importance, i.e. extreme changes in blood pressure or heart rate--compared to preanaesthetic values--and an increase in diastolic wall tension should be avoided. An anaesthetic regime comprising gentle general anaesthesia combined with epidural block and small doses of opioids or local anaesthetics meets these requirements, as does a combination of opioids with low doses of volatile anaesthetics or intravenous hypnotics. The quality of

  14. What is High Risk Surgery? Development of a List of High Risk Operations for Patients Age 65 and Older

    PubMed Central

    Schwarze, Margaret L.; Barnato, Amber E.; Rathouz, Paul J.; Zhao, Qianqian; Neuman, Heather B.; Winslow, Emily R.; Kennedy, Gregory D.; Hu, Yue-Yung; Dodgion, Christopher M.; Kwok, Alvin C.; Greenberg, Caprice C.

    2015-01-01

    Importance No consensus exists regarding the definition of “high risk” surgery in older adults. An inclusive and precise definition of high risk surgery may be useful for surgeons, patients, researchers and hospitals. Objectives To develop a list of “high risk” operations. Design 1) Retrospective cohort study; and 2) Modified Delphi procedure. Setting All Pennsylvania acute care hospitals (Pennsylvania Health Care Cost Containment Council [PHC4], 2001–2007) and a nationally-representative sample of U.S. acute care hospitals (Nationwide Inpatient Sample [NIS], HCUP, AHRQ 2001–2006). Patients Admissions 65 and older to PHC4 hospitals and admissions 18 and older to NIS hospitals. Methods We identified ICD-9 CM procedure codes associated with >1% inpatient mortality in PHC4. We used a modified Delphi technique with 5 board certified surgeons to further refine this list by excluding non-operative procedures and operations that were unlikely to be the proximate cause of mortality and were instead a marker of critical illness (e.g., tracheostomy). We then cross-validated this list of ICD-9CM codes in the NIS. Main Outcomes Measures 1) Delphi consensus of at least 4/5 panelists; 2) proportion agreement in the NIS. Results Among 4,739,522 admissions 65 and older in PHC4, 2,569,589 involved a procedure, encompassing 2,853 unique procedures. Of 1,130 procedures associated with a crude inpatient mortality of at least 1%, 264 achieved consensus as high risk operations by Delphi. The observed inpatient mortality in the NIS was ≥ 1% for 227/264 (86%) of the procedures in patients age 65 and older. The pooled inpatient mortality rate for these identified high risk procedures performed on patients age ≥65 was double the inpatient mortality for correspondingly identified high risk operations for patients less than 65 (6% vs. 3%). Conclusions We developed a list of procedure codes that can be used to identify “high risk” surgical procedures in claims data. This

  15. 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

  16. 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.

  17. 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

  18. High-risk surgical stage 1 endometrial cancer: analysis of treatment outcome.

    PubMed

    Viani, Gustavo A; Patia, Barbara F; Pellizzon, Antonio C; De Melo, Marcel D; Novaes, Paulo E; Fogaroli, Ricardo C; Conte, Maria A; Salvajoli, Joao V

    2006-08-03

    To report the relapse and survival rates associated to treatment for patients with stage IC, grade 2 or grade 3 and IB grade 3 diseases considered high risk patients group for relapse. From January 1993 to December 2003, 106 patients with endometrial cancer stage I were managed surgically in our institution. Based on data from the medical records, 106 patients with epithelial endometrial cancer met the following inclusion criteria: stage IC grade 2 or 3 and IB grade 3 with or without lymphovascular invasion. Staging was defined according to the FIGO surgical staging system. Postoperative adjuvant radiotherapy consisted of external beam pelvic radiation, vaginal brachytherapy alone or both. The median age was 65 years (range, 32-83 years), lymph node dissection was performed in 45 patients (42.5%) and 14 patients (13.2%) received vaginal brachytherapy only, and 92 (86.8%) received combined vaginal brachytherapy and external beam radiotherapy. The median dose of external beam radiotherapy administered to the pelvis was 4500 cGy (range 4000-5040). The median dose to vaginal surface was 2400 cGy (range 2000-3000). Predominant pathological stage and histological grade were IC (73.6%) and grade 3 (51.9%). The lymphovascular invasion was present in 33 patients (31.1%) and pathological stage IC grade 2 was most common (48. 1%) combination of risk factors in this group. With a follow up median of 58.3 months (range 12.8-154), five year overall survival and event free survival were 78.5% and 72.4%, respectively. Locoregional control in five year was 92.4%. Prognostic factors related with survival in univariate analyses were: lymphadenectomy (p = 0.045), lymphovascular invasion (p = 0.047) and initial failure site (p < 0.0001). In multivariate analyses the initial failure in distant sites (p < 0.0001) was the only factor associated with poor survival. Acute and chronic gastrointestinal and genitourinary toxicity grades 3 were not observed. In conclusion, our results showed

  19. High-risk surgical stage 1 endometrial cancer: analysis of treatment outcome

    PubMed Central

    Viani, Gustavo A; Patia, Barbara F; Pellizzon, Antonio C; De Melo, Marcel D; Novaes, Paulo E; Fogaroli, Ricardo C; Conte, Maria A; Salvajoli, Joao V

    2006-01-01

    Purpose To report the relapse and survival rates associated to treatment for patients with stage IC, grade 2 or grade 3 and IB grade 3 diseases considered high risk patients group for relapse. Materials and methods From January 1993 to December 2003, 106 patients with endometrial cancer stage I were managed surgically in our institution. Based on data from the medical records, 106 patients with epithelial endometrial cancer met the following inclusion criteria: stage IC grade 2 or 3 and IB grade 3 with or without lymphovascular invasion. Staging was defined according to the FIGO surgical staging system. Postoperative adjuvant radiotherapy consisted of external beam pelvic radiation, vaginal brachytherapy alone or both. The median age was 65 years (range, 32–83 years), lymph node dissection was performed in 45 patients (42.5%) and 14 patients (13.2%) received vaginal brachytherapy only, and 92 (86.8%) received combined vaginal brachytherapy and external beam radiotherapy. The median dose of external beam radiotherapy administered to the pelvis was 4500 cGy (range 4000 – 5040). The median dose to vaginal surface was 2400 cGy (range 2000 – 3000). Predominant pathological stage and histological grade were IC (73.6%) and grade 3 (51.9%). The lymphovascular invasion was present in 33 patients (31.1%) and pathological stage IC grade 2 was most common (48. 1%) combination of risk factors in this group. Results With a follow up median of 58.3 months (range 12.8 – 154), five year overall survival and event free survival were 78.5% and 72.4%, respectively. Locoregional control in five year was 92.4%. Prognostic factors related with survival in univariate analyses were: lymphadenectomy (p = 0.045), lymphovascular invasion (p = 0.047) and initial failure site (p < 0.0001). In multivariate analyses the initial failure in distant sites (p < 0.0001) was the only factor associated with poor survival. Acute and chronic gastrointestinal and genitourinary toxicity grades 3

  20. 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

  1. Management of Skin Cancer in the High-Risk Patient.

    PubMed

    Behan, James W; Sutton, Adam; Wysong, Ashley

    2016-12-01

    Skin cancer is the most common of human cancers and outnumbers all other types of cancer combined in the USA by over threefold. The majority of non-melanoma skin cancers are easily treated with surgery or locally destructive techniques performed under local anesthesia in the cost-effective outpatient setting. However, there is a subset of "high-risk" cases that prove challenging in terms of morbidity, mortality, adjuvant treatment required, as well as overall cost to the health care system. In our opinion, the term "high risk" when applied to skin cancer can mean one of three things: a high-risk tumor with aggressive histologic and/or clinical features with an elevated risk for local recurrence or regional/distant metastasis, a high-risk patient with the ongoing development of multiple skin cancers, and a high-risk patient based on immunosuppression. We have recently proposed classifying NMSC as a chronic disease in a certain subset of patients. Although no consensus definition exists for a chronic disease in medicine, there are three components that are present in most definitions: duration of at least 1 year, need for ongoing medical care, and functional impairment and/or alteration of activities of daily living (ADLs) and quality of life (QOL). Immunosuppression can refer to exogenous (organ or stem cell transplant patients,) or endogenous (HIV, leukemia, lymphoma, genodermatoses with DNA mismatch repair problems or other immunosuppression) causes. These patients are at risk for high-risk tumors and/or the development of multiple tumors.

  2. 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.

  3. Prospective study of surveillance testing for metastasis in 100 high-risk uveal melanoma patients.

    PubMed

    Piperno-Neumann, S; Servois, V; Mariani, P; Plancher, C; Lévy-Gabriel, C; Lumbroso-Le Rouic, L; Couturier, J; Asselain, B; Desjardins, L; Cassoux, N

    2015-06-01

    Despite advances in the local treatment of UM, half of patients develop metastases typically to the liver with poor survival. Microscopic complete surgical resection (R0) of liver metastases improves survival in high selected patients. Early identification of high-risk patients might allow detection of asymptomatic metastases, and increase R0 liver surgery rate. From October 2006 to December 2009, we conducted a prospective study to detect early minimal lesions with 6-monthly liver function tests (LFTs) and liver MRI in 100 high-risk patients. High risk was defined by primary tumor clinical or genomic criteria: thickness>8mm or diameter>15 mm, or extra-scleral extension, or monosomy 3 by FISH or aCGH. With a median follow-up of 49 months, the 5-year metastasis-free survival and overall survival were 47 and 33%, respectively. Of the 60 patients who became metastatic, 50 (83%) had exclusive liver metastasis. LFTs screening had no sufficient accurary, but biannual MRI showed high predictive value to detect metastasis and select patients eligible for curative surgery: 25/50 underwent laparotomy and among them, 8/25 (32%) had a R0 surgery. Median survival after metastasis was 14 months, mean survival reached 40 months in the R0 resected population. Six-monthly liver MRI screening is recommended in patients with large tumors or genomic high risk in order to detect early patient candidates to complete resection of liver metastases. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

  4. Effective median sternotomy closure in high-risk open heart patients.

    PubMed

    Bek, Eugene L; Yun, Kwok L; Kochamba, Gary S; Pfeffer, Thomas A

    2010-04-01

    We describe a novel surgical technique with a median sternotomy closure in high-risk open heart patients. In contrast to conventional sternal closure, in which sternal wires are passed through the intercostal space, the novel technique in sternal closure passes sternal wires transcostally or through costo-chondral joints. Copyright (c) 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

  5. 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.

  6. Positive predictive value of breast lesions of uncertain malignant potential (B3): Can we identify high risk patients? The value of a multidisciplinary team and implications in the surgical treatment.

    PubMed

    M, Taffurelli; A, Pellegrini; F, Ghignone; D, Santini; S, Zanotti; M, Serra

    2016-06-01

    The use of conventional needle core biopsy for palpable masses and vacuum-assisted needle core biopsy for microcalcifications has significantly increased the preoperative diagnosis rate, but the strategy for those patients with lesions of uncertain malignant potential (B3) still remains controversial. The aim of this study was to evaluate the positive predictive value (PPV) of the malignancy of B3 lesions in order to establish their correct management in the setting of a multidisciplinary care pathway. Data from all patients who had a Needle Core Biopsy (NCB) or a Vacuum-Assisted Needle Core Biopsy (VANCB) between 2005 and 2014 were retrospectively collected and analyzed. The B3 patients were discussed by the Multidisciplinary Team (MDT) deciding for surgery or for follow-up, based on a score in which clinical-instrumental factors and environmental factors were considered. The PPV of malignancy of all surgically excised B3 lesions was calculated. One hundred and seventy-eight B3 NCBs were included in the study and Atypical Epithelial Proliferation of Ductal Type (AEDPT) was the most represented subcategory. The final histopathology report of the 128 patients operated on showed 94 benign and 34 malignant lesions. The PPV of B3 patients referred to surgery was 26.5%. B3 patients should be evaluated by a breast MDT in order to make the right therapeutic decision, in particular for patients with contrasting clinical/diagnostic findings. Larger prospective studies are required to assess the definitive PPV of each B3 subcategory. Copyright © 2016 Elsevier Ltd. All rights reserved.

  7. 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.

  8. “And I think that we can fix it”: Mental Models used in High-Risk Surgical Decision Making

    PubMed Central

    Kruser, Jacqueline M; Pecanac, Kristen E; Brasel, Karen J; Cooper, Zara; Steffens, Nicole; McKneally, Martin; Schwarze, Margaret L

    2014-01-01

    Objective To examine how surgeons use the “fix-it” model to communicate with patients before high-risk operations. Background The “fix-it” model characterizes disease as an isolated abnormality that can be restored to normal form and function through medical intervention. This mental model is familiar to patients and physicians, but it is ineffective for chronic conditions and treatments that cannot achieve normalcy. Overuse may lead to permissive decision making favoring intervention. Efforts to improve surgical decision making will need to consider how mental models function in clinical practice, including “fix-it”. Methods We observed surgeons who routinely perform high-risk surgery during preoperative discussions with patients. We used qualitative content analysis to explore the use of “fix-it” in 48 audio-recorded conversations. Results Surgeons used the “fix-it” model for two separate purposes during preoperative conversations; 1) as an explanatory tool to facilitate patient understanding of disease and surgery and 2) as a deliberation framework to assist in decision making. Although surgeons commonly used “fix-it” as an explanatory model, surgeons explicitly discussed limitations of the “fix-it” model as an independent rationale for operating as they deliberated about the value of surgery. Conclusions While the use of “fix-it” is familiar for explaining medical information to patients, surgeons recognize that the model can be problematic for determining the value of an operation. Whether patients can transition between understanding how their disease is fixed with surgery to a subsequent deliberation about whether they should have surgery is unclear and may have broader implications for surgical decision making. PMID:25749396

  9. Development of a list of high-risk operations for patients 65 years and older.

    PubMed

    Schwarze, Margaret L; Barnato, Amber E; Rathouz, Paul J; Zhao, Qianqian; Neuman, Heather B; Winslow, Emily R; Kennedy, Gregory D; Hu, Yue-Yung; Dodgion, Christopher M; Kwok, Alvin C; Greenberg, Caprice C

    2015-04-01

    the pooled inpatient mortality for correspondingly identified high-risk operations for patients younger than 65 years (6% vs 3%). We developed a list of procedure codes to identify high-risk surgical procedures in claims data. This list of high-risk operations can be used to standardize the definition of high-risk surgery in quality and outcomes-based studies and to design targeted clinical interventions.

  10. Embolization as treatment of choice for bleeding peptic ulcers in high-risk patients.

    PubMed

    van Vugt, Raoul; Bosscha, Koop; van Munster, Ivo P; de Jager, Cornelis P C; Rutten, Matthieu J C M

    2009-01-01

    Peptic ulcers are the most common cause of acute upper gastrointestinal bleedings in the digestive tract. Most patients are poor surgical candidates. The aim was to describe the efficacy of embolization as the treatment of choice for bleeding peptic ulcers in high-risk patients when endoscopic treatment failed. All patients who underwent a selective embolization of branches of the superior mesenteric artery and/or branches of the gastroduodenal artery for a bleeding peptic ulcer in the period January 2004 until December 2007 were included in this retrospective descriptive study. We examined the known risk factors for surgery and mortality in upper gastrointestinal bleeding due to peptic ulcers and describe the clinical course and outcome. Primary endpoints were the primary technical success and the clinical success rates. The secondary endpoint was the 30-day mortality. 16 patients were included. All patients had at least two risk factors for surgery and mortality. The clinical success rate was 81% (13/16). The first embolization failed in 3 patients, 1 was successful re-embolized and 2 were operated upon without re-embolization. The primary technical success rate, i.e. bleedings controlled by radiologic intervention, was 88% (14/16). 6 patients died due to non-embolization-related problems; 5 of them developed upper gastrointestinal bleeding during a stay in the hospital. Embolization was a successful, minimal invasive alternative for surgical intervention in high-risk patients with upper gastrointestinal bleeding after failure of endoscopic treatment. Copyright (c) 2009 S. Karger AG, Basel.

  11. Maintenance antimicrobials in high risk urologic pediatric patients.

    PubMed

    McCann, T M; Churchill, B M; Hardy, B E; Arbus, G S

    1982-03-01

    As an alternative to the practice of obtaining repeated laboratory cultures for patients at high risk of renal impairment from recurrent UTI, a program of bone monitoring using a mail-in culture dipspoon was started. A study involving 454 children with neurogenic bladder or other urologic abnormalities showed (1) that the incidence of UTI infection in patients for whom long term antimicrobial therapy had been prescribed was not significantly lower than that in patients who were not on antimicrobials and (2) that at least 50% of dipspoons inoculated due to presentation of UTI symptoms showed no or insignificant growth. These findings suggest that need for further assessment of the efficacy of long term prophylactic antimicrobials in preventing recurrent UTI and the advisability of obtaining a urine culture result before initiating treatment when symptoms are not severe.

  12. "Best Case/Worst Case": Training Surgeons to Use a Novel Communication Tool for High-Risk Acute Surgical Problems.

    PubMed

    Kruser, Jacqueline M; Taylor, Lauren J; Campbell, Toby C; Zelenski, Amy; Johnson, Sara K; Nabozny, Michael J; Steffens, Nicole M; Tucholka, Jennifer L; Kwekkeboom, Kris L; Schwarze, Margaret L

    2017-04-01

    Older adults often have surgery in the months preceding death, which can initiate postoperative treatments inconsistent with end-of-life values. "Best Case/Worst Case" (BC/WC) is a communication tool designed to promote goal-concordant care during discussions about high-risk surgery. The objective of this study was to evaluate a structured training program designed to teach surgeons how to use BC/WC. Twenty-five surgeons from one tertiary care hospital completed a two-hour training session followed by individual coaching. We audio-recorded surgeons using BC/WC with standardized patients and 20 hospitalized patients. Hospitalized patients and their families participated in an open-ended interview 30 to 120 days after enrollment. We used a checklist of 11 BC/WC elements to measure tool fidelity and surgeons completed the Practitioner Opinion Survey to measure acceptability of the tool. We used qualitative analysis to evaluate variability in tool content and to characterize patient and family perceptions of the tool. Surgeons completed a median of 10 of 11 BC/WC elements with both standardized and hospitalized patients (range 5-11). We found moderate variability in presentation of treatment options and description of outcomes. Three months after training, 79% of surgeons reported BC/WC is better than their usual approach and 71% endorsed active use of BC/WC in clinical practice. Patients and families found that BC/WC established expectations, provided clarity, and facilitated deliberation. Surgeons can learn to use BC/WC with older patients considering acute high-risk surgical interventions. Surgeons, patients, and family members endorse BC/WC as a strategy to support complex decision making. Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

  13. 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.

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

    PubMed

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

    2017-06-01

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

  15. 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

  16. Compliance with adjuvant treatment guidelines in endometrial cancer: room for improvement in high risk patients.

    PubMed

    Eggink, F A; Mom, C H; Boll, D; Ezendam, N P M; Kruitwagen, R F P M; Pijnenborg, J M A; van der Aa, M A; Nijman, H W

    2017-08-01

    Compliance of physicians with guidelines has emerged as an important indicator for quality of care. We evaluated compliance of physicians with adjuvant therapy guidelines for endometrial cancer patients in the Netherlands in a population-based cohort over a period of 10years. Data from all patients diagnosed with endometrial cancer between 2005 and 2014, without residual tumor after surgical treatment, were extracted from the Netherlands Cancer Registry (N=14,564). FIGO stage, grade, tumor type and age were used to stratify patients into risk groups. Possible changes in compliance over time and impact of compliance on survival were assessed. Patients were stratified into low/low-intermediate (52%), high-intermediate (21%) and high (20%) risk groups. Overall compliance with adjuvant therapy guidelines was 85%. Compliance was highest in patients with low/low-intermediate risk (98%, no adjuvant therapy indicated). The lowest compliance was determined in patients with high risk (61%, external beam radiotherapy with/without chemotherapy indicated). Within this group compliance decreased from 64% in 2005-2009 to 57% in 2010-2014. In high risk patients with FIGO stage III serous disease compliance was 55% (chemotherapy with/without radiotherapy indicated) and increased from 41% in 2005-2009 to 66% in 2010-2014. While compliance of physicians with adjuvant therapy guidelines is excellent in patients with low and low-intermediate risk, there is room for improvement in high risk endometrial cancer patients. Eagerly awaited results of ongoing randomized clinical trials may provide more definitive guidance regarding adjuvant therapy for high risk endometrial cancer patients. Copyright © 2017 Elsevier Inc. All rights reserved.

  17. Identifying High-Risk Patients without Labeled Training Data: Anomaly Detection Methodologies to Predict Adverse Outcomes

    PubMed Central

    Syed, Zeeshan; Saeed, Mohammed; Rubinfeld, Ilan

    2010-01-01

    For many clinical conditions, only a small number of patients experience adverse outcomes. Developing risk stratification algorithms for these conditions typically requires collecting large volumes of data to capture enough positive and negative for training. This process is slow, expensive, and may not be appropriate for new phenomena. In this paper, we explore different anomaly detection approaches to identify high-risk patients as cases that lie in sparse regions of the feature space. We study three broad categories of anomaly detection methods: classification-based, nearest neighbor-based, and clustering-based techniques. When evaluated on data from the National Surgical Quality Improvement Program (NSQIP), these methods were able to successfully identify patients at an elevated risk of mortality and rare morbidities following inpatient surgical procedures. PMID:21347083

  18. Identifying High-Risk Patients without Labeled Training Data: Anomaly Detection Methodologies to Predict Adverse Outcomes.

    PubMed

    Syed, Zeeshan; Saeed, Mohammed; Rubinfeld, Ilan

    2010-11-13

    For many clinical conditions, only a small number of patients experience adverse outcomes. Developing risk stratification algorithms for these conditions typically requires collecting large volumes of data to capture enough positive and negative for training. This process is slow, expensive, and may not be appropriate for new phenomena. In this paper, we explore different anomaly detection approaches to identify high-risk patients as cases that lie in sparse regions of the feature space. We study three broad categories of anomaly detection methods: classification-based, nearest neighbor-based, and clustering-based techniques. When evaluated on data from the National Surgical Quality Improvement Program (NSQIP), these methods were able to successfully identify patients at an elevated risk of mortality and rare morbidities following inpatient surgical procedures.

  19. Outcomes of preoperative weight loss in high-risk patients undergoing gastric bypass surgery.

    PubMed

    Still, Christopher D; Benotti, Peter; Wood, G Craig; Gerhard, Glenn S; Petrick, Anthony; Reed, Mary; Strodel, William

    2007-10-01

    Modest, preoperative weight loss will improve perioperative outcomes among high-risk, morbidly obese patients undergoing Roux-en-Y gastric bypass. A prospective, longitudinal assessment of characteristics and outcomes of gastric bypass patients. All patients undergoing open or laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity or its comorbid medical problems at Geisinger Medical Center in Danville, Pennsylvania, during a 3-year period from May 31, 2002, to February 24, 2006, were included in this analysis. Patients were required to participate in a standardized multidisciplinary preoperative program that encompasses medical, psychological, nutritional, and surgical interventions and education. In addition, patients were encouraged to achieve a 10% loss of excess body weight prior to surgical intervention. Of the 884 subjects, 425 (48%) lost more than 10% of their excess body weight prior to the operation. After surgery (mean follow-up, 12 months), this group was more likely to achieve 70% loss of excess body weight (P < .001). Those who lost more than 5% of excess body weight prior to surgery were statistically less likely to have a length of stay of greater than 4 days (P = .03). This study shows that high-risk morbidly obese candidates for bariatric surgery who are able to achieve a loss of 5% to 10% excess body weight prior to surgery have a higher probability of a shorter length of hospital stay and more rapid postoperative weight loss.

  20. 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.

  1. 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.

  2. Prevention of VTE in Nonorthopedic Surgical Patients

    PubMed Central

    Garcia, David A.; Wren, Sherry M.; Karanicolas, Paul J.; Arcelus, Juan I.; Heit, John A.; Samama, Charles M.

    2012-01-01

    Background: VTE is a common cause of preventable death in surgical patients. Methods: We developed recommendations for thromboprophylaxis in nonorthopedic surgical patients by using systematic methods as described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. Results: We describe several alternatives for stratifying the risk of VTE in general and abdominal-pelvic surgical patients. When the risk for VTE is very low (< 0.5%), we recommend that no specific pharmacologic (Grade 1B) or mechanical (Grade 2C) prophylaxis be used other than early ambulation. For patients at low risk for VTE (∼1.5%), we suggest mechanical prophylaxis, preferably with intermittent pneumatic compression (IPC), over no prophylaxis (Grade 2C). For patients at moderate risk for VTE (∼3%) who are not at high risk for major bleeding complications, we suggest low-molecular-weight heparin (LMWH) (Grade 2B), low-dose unfractionated heparin (Grade 2B), or mechanical prophylaxis with IPC (Grade 2C) over no prophylaxis. For patients at high risk for VTE (∼6%) who are not at high risk for major bleeding complications, we recommend pharmacologic prophylaxis with LMWH (Grade 1B) or low-dose unfractionated heparin (Grade 1B) over no prophylaxis. In these patients, we suggest adding mechanical prophylaxis with elastic stockings or IPC to pharmacologic prophylaxis (Grade 2C). For patients at high risk for VTE undergoing abdominal or pelvic surgery for cancer, we recommend extended-duration, postoperative, pharmacologic prophylaxis (4 weeks) with LMWH over limited-duration prophylaxis (Grade 1B). For patients at moderate to high risk for VTE who are at high risk for major bleeding complications or those in whom the consequences of bleeding are believed to be particularly severe, we suggest

  3. [Prophylactic Effectiveness of Vacuum-assisted Closure for High-risk Patients Undergoing Cardiovascular Surgery through Median Sternotomy].

    PubMed

    Takazawa, Ippei; Misawa, Yoshio; Uesugi, Satoshi; Sugaya, Akira; Akutsu, Hirohiko; Kurumisawa, Souki; Satoh, Hirotaka; Muraoka, Arata; Aizawa, Kei; Ohki, Shinichi; Kawahito, Koji

    2017-08-01

    Vacuum-assisted closure(VAC) therapy is mainly used for tissue defects. VAC therapy can remove exudate that could impair the healing process. We applied VAC therapy in patients considered at high risk of surgical site infection who underwent cardiovascular surgery via standard median sternotomy. Risk factors included advanced heart failure, obesity, diabetes mellitus, steroid administration, immunosuppressant administration, and chronic renal failure, etc. VAC therapy was used in 134 patients. Only 3 of these patients (2.2%) developed surgical site infection caused by Staphylococcus epidermidis;2 patients fully recovered after prolonged VAC therapy for 2 weeks, and the other required an additional sternal fixation after the sternal wires were removed for wound infection control. No patient developed infective mediastinitis. Prophylactic VAC therapy can reduce postoperative wound infection in high risk patients undergoing open heart surgery via full sternotomy.

  4. 1-Year Outcomes With the Fully Repositionable and Retrievable Lotus Transcatheter Aortic Replacement Valve in 120 High-Risk Surgical Patients With Severe Aortic Stenosis: Results of the REPRISE II Study.

    PubMed

    Meredith, Ian T; Walters, Darren L; Dumonteil, Nicolas; Worthley, Stephen G; Tchétché, Didier; Manoharan, Ganesh; Blackman, Daniel J; Rioufol, Gilles; Hildick-Smith, David; Whitbourn, Robert J; Lefèvre, Thierry; Lange, Rüdiger; Müller, Ralf; Redwood, Simon; Feldman, Ted E; Allocco, Dominic J; Dawkins, Keith D

    2016-02-22

    This analysis presents the first report of 1-year outcomes of the 120 patients enrolled in the REPRISE II (Repositionable Percutaneous Placement of Stenotic Aortic Valve Through Implantation of Lotus Valve System-Evaluation of Safety and Performance) study. The fully repositionable and retrievable Lotus Valve (Boston Scientific, Marlborough, Massachusetts) was designed to facilitate accurate positioning, early valve function, and hemodynamic stability during deployment and to minimize paravalvular regurgitation in patients undergoing transcatheter aortic valve replacement. The study enrolled 120 symptomatic patients 70 years of age or older at 14 centers in Australia and Europe. Patients had severe calcific aortic stenosis and were deemed to be at high or extreme risk of surgery based on assessment by the heart team. The mean age was 84.4 ± 5.3 years, 57% (68 of 120) of patients were women, and the mean Society of Thoracic Surgeons score was 7.1 ± 4.6. The mean baseline aortic valve area was 0.7 ± 0.2 cm(2), and the mean transvalvular pressure gradient was 46.4 ± 15.0 mm Hg. All patients were successfully implanted with a Lotus Valve, and 1-year clinical follow-up was available for 99.2% (119 of 120 of patients). The mean 1-year transvalvular aortic pressure gradient was 12.6 ± 5.7 mm Hg, and the mean valve area was 1.7 ± 0.5 cm(2). A total of 88.6% patients had no or trivial paravalvular aortic regurgitation at 1 year by independent core lab adjudication, and 97.1% of patients were New York Heart Association functional class I or II. At 1 year, the all-cause mortality rate was 10.9% (13 of 119 patients), disabling stroke rate was 3.4% (4 of 119 patients), disabling bleeding rate was 5.9% (7 of 119 patients), with no repeat procedures for valve-related dysfunction. A total of 31.9% (38 of 119 patients) underwent new permanent pacemaker implantation at 1 year. At 1 year of follow-up, the Lotus Valve demonstrated excellent valve hemodynamics, no moderate or

  5. 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.

  6. Hemodynamic monitoring and management of patients undergoing high-risk surgery: a survey among Chinese anesthesiologists

    PubMed Central

    Chen, Guo; Zuo, Yunxia; Yang, Lei; Chung, Elena; Cannesson, Maxime

    2014-01-01

    Abstract Hemodynamic monitoring and optimization improve postoperative outcome during high-risk surgery. However, hemodynamic management practices among Chinese anesthesiologists are largely unknown. This study sought to evaluate the current intraoperative hemodynamic management practices for high-risk surgery patients in China. From September 2010 to November 2011, we surveyed anesthesiologists working in the operating rooms of 265 hospitals representing 28 Chinese provinces. All questionnaires were distributed to department chairs of anesthesiology or practicing anesthesiologists. Once completed, the 29-item questionnaires were collected and analyzed. Two hundred and 10 questionnaires from 265 hospitals in China were collected. We found that 91.4% of anesthesiologists monitored invasive arterial pressure, 82.9% monitored central venous pressure (CVP), 13.3% monitored cardiac output (CO), 10.5% monitored mixed venous saturation, and less than 2% monitored pulse pressure variation (PPV) or systolic pressure variation (SPV) during high-risk surgery. The majority (88%) of anesthesiologists relied on clinical experience as an indicator for volume expansion and more than 80% relied on blood pressure, CVP and urine output. Anesthesiologists in China do not own enough attention on hemodynamic parameters such as PPV, SPV and CO during fluid management in high-risk surgical patients. The lack of CO monitoring may be attributed largely to the limited access to technologies, the cost of the devices and the lack of education on how to use them. There is a need for improving access to these technologies as well as an opportunity to create guidelines and education for hemodynamic optimization in China. PMID:25332709

  7. Surgical management of severe scoliosis with high-risk pulmonary dysfunction in Duchenne muscular dystrophy.

    PubMed

    Takaso, Masashi; Nakazawa, Toshiyuki; Imura, Takayuki; Takahira, Naonobu; Itoman, Moritoshi; Takahashi, Kazuhisa; Yamazaki, Masashi; Otori, Seiji; Akazawa, Tsutomu; Minami, Shohei; Kotani, Toshiaki

    2010-03-01

    Between 2005 and 2007, 14 patients who had severe scoliosis in Duchenne muscular dystrophy (DMD) and a poor forced vital capacity (FVC) of <30% at admission underwent scoliosis surgery. FVC on admission was 21.6% (range, 16-27%). The patients were given respiratory muscle training using a pulmonary trainer (Threshold IMT, Philips Respironics, Inc.) for six weeks before operation. FVC increased to 26.2% (range, 22-31%) the day before operation. The mean preoperative scoliosis was 98 degrees (range, 81 degrees-130 degrees). All patients underwent posterior fusion and all-screw construction and were extubated on the operative day. No patients developed any respiratory complications. The postoperative scoliosis was 34 degrees (range, 20 degrees-40 degrees) (65%). FVC remained stable at six weeks after operation. FVC decreased to 19.8% (range, 16-25%) and the mean scoliosis was 35 degrees (range, 23 degrees-40 degrees) (64%) at two years after operation. DMD patients with severe scoliosis and FVC considered too low to permit reasonable surgical risk could undergo surgery and could benefit from surgery.

  8. Surgical management of severe scoliosis with high-risk pulmonary dysfunction in Duchenne muscular dystrophy

    PubMed Central

    Nakazawa, Toshiyuki; Imura, Takayuki; Takahira, Naonobu; Itoman, Moritoshi; Takahashi, Kazuhisa; Yamazaki, Masashi; Otori, Seiji; Akazawa, Tsutomu; Minami, Shohei; Kotani, Toshiaki

    2009-01-01

    Between 2005 and 2007, 14 patients who had severe scoliosis in Duchenne muscular dystrophy (DMD) and a poor forced vital capacity (FVC) of <30% at admission underwent scoliosis surgery. FVC on admission was 21.6% (range, 16–27%). The patients were given respiratory muscle training using a pulmonary trainer (Threshold IMT, Philips Respironics, Inc.) for six weeks before operation. FVC increased to 26.2% (range, 22–31%) the day before operation. The mean preoperative scoliosis was 98° (range, 81°–130°). All patients underwent posterior fusion and all-screw construction and were extubated on the operative day. No patients developed any respiratory complications. The postoperative scoliosis was 34° (range, 20°–40°) (65%). FVC remained stable at six weeks after operation. FVC decreased to 19.8% (range, 16–25%) and the mean scoliosis was 35° (range, 23°–40°)(64%) at two years after operation. DMD patients with severe scoliosis and FVC considered too low to permit reasonable surgical risk could undergo surgery and could benefit from surgery. PMID:19340426

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

    PubMed

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

    2016-06-01

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

  10. 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

  11. 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

  12. Improving early identification of the high-risk elderly trauma patient by emergency medical services.

    PubMed

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

    2016-01-01

    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. 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. 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. 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. Copyright © 2015 Elsevier Ltd. All rights reserved.

  13. Neoadjuvant Chemotherapy with Capecitabine, Oxaliplatin and Bevacizumab Followed by Concomitant Chemoradiation and Surgical Resection in Locally Advanced Rectal Cancer with High Risk of Recurrence - A Phase II Study.

    PubMed

    Eisterer, Wolfgang; Piringer, Gudrun; DE Vries, Alexander; Öfner, Dietmar; Greil, Richard; Tschmelitsch, Jörg; Samonigg, Hellmut; Sölkner, Lidija; Gnant, Michael; Thaler, Josef

    2017-05-01

    To evaluate feasibility and safety of neoadjuvant chemotherapy with capecitabine, oxaliplatin and bevacizumab followed by concomitant standard chemoradiation and surgical resection in patients with high-risk locally advanced rectal cancer. Magnetic resonance imaging (MRI)-defined high-risk cT3/4 rectal cancer patients were treated with 3 cycles of neoadjuvant chemotherapy with capecitabine (1,000 mg/m(2) twice daily days 1-14, 22-35, 43-56), oxaliplatin (130 mg/sqm on days 1, 22, 43) and bevacizumab (7.5 mg/kg on days 1, 22, 43) followed by capecitabine (825 mg/m(2) twice daily on radiotherapy days week 1-4) concomitantly with radiotherapy (1.8 Gy daily up to 45 Gy in 5 weeks) and surgical resection by total mesorectal excision. Feasibility, safety, response rate and postoperative morbidity were evaluated. Twenty-five patients were recruited. Median age was 62 years (range=24-78 years) and all patients had Eastern Cooperation Oncology Group (ECOG) performance status 0. From all patients, 79.2% finished neoadjuvant chemotherapy. Twenty patients underwent surgery. Pathologic complete remission rate, R0 resection and T-downstaging were achieved in 25%, 95% and 54.2% of the "intention to treat" (ITT) patients. The most common grade 3 adverse events (AEs) during neoadjuvant chemotherapy were diarrhea (16.6%) and mucositis (12.5%). In one patient, a grade 4 acute renal failure occurred (4.2%). During chemoradiation, skin reactions (5.3%) were the most common grade 3 AEs. Two major perioperative complications required re-intervention. Neoadjuvant chemotherapy with bevacizumab, capecitabine and oxaliplatin followed by concomitant standard chemoradiation is feasible in patients with high-risk locally advanced rectal cancer (LARC) and resulted in complete pathologic remission (pCR) rate of 25% and neoadjuvant chemotherapy completion rate of 80%. Copyright© 2017, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.

  14. A Pilot Randomized Controlled Trial Using Prophylactic Dressings to Minimize Sacral Pressure Injuries in High-Risk Hospitalized Patients.

    PubMed

    Walker, Rachel; Huxley, Leisa; Juttner, Melanie; Burmeister, Elizabeth; Scott, Justin; Aitken, Leanne M

    2016-02-12

    This pilot randomized controlled trial examined the effect of prophylactic dressings to minimize sacral pressure injuries (PIs) in high-risk hospitalized patients and assessed feasibility criteria to inform a larger study. Eighty patients were recruited at admission points (the emergency department and surgical care unit) or directly from participating wards in the general medical-surgical setting following the assessment of high risk of sacral PI. Participants were randomized into either the routine care or routine care and silicone foam border dressing group. Outcome assessment comprised digital photographs of each participant's sacrum every 72 hr for evaluation by a blind-to-intervention assessor. Sixty-seven participants had at least one sacral photograph taken and assessed by a blind-to-intervention assessor. Three participants were assessed as having a Stage I PI. Although the use of photography was effective, feasibility criteria identified challenges related to bias, blinding, weight assessment, preparation of nursing staff, and sample size estimation.

  15. 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.

  16. 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.

  17. Outcomes for split-thickness skin transplantation in high-risk patients using octenidine.

    PubMed

    Matiasek, J; Djedovic, G; Unger, L; Beck, H; Mattesich, M; Pierer, G; Koller, R; Rieger, U M

    2015-06-01

    Skin transplantation is a commonly used surgical technique; however, the complication rate, including postoperative infection and delayed wound healing due to inefficient perfusion, is significantly higher in patients suffering from comorbidities. Hence, a subsequent repeat procedure is often necessary. In this report, two case studies are presented in which an octenidine-based antiseptic is used with a tie-over dressing (TOD) instead of povidone iodine (PVP-iodine), following a split-thickness skin graft. The two patients selected were deemed to be at high risk of impaired wound healing due to comorbidities. The first patient, a confirmed smoker with diabetes, presented with a nodular melanoma that was resected and covered with a split-thickness skin graft. After 5 days of negative pressure wound therapy as a TOD, in combination with PVP-iodine, the graft became necrotic. A second split-thickness skin graft was performed and an antiseptic regimen with octenidine in combination with the same TOD resulted in a completely healed transplant. The second patient, also a confirmed smoker with diabetes and receiving oral corticosteroid treatment, was diagnosed with a skin necrosis on her leg. Following the split-thickness skin graft, octenidine and TOD were applied. The patient's skin graft completely healed without any adverse events. These two case studies indicate that the combination of octenidine and TOD following split-thickness skin transplantation is safe, well-tolerated and appears to have positive benefits in the reconstruction of defects in patients with impaired wound healing.

  18. Superior patency of upper arm arteriovenous fistulae in high risk patients.

    PubMed

    Chiulli, Larissa C; Vasilas, Penny; Dardik, Alan

    2011-09-01

    Despite an increased propensity to primary failure in forearm arteriovenous fistulae compared with upper arm fistulae, forearm fistulae remain the preferred primary access type for chronic hemodialysis patients. In a high risk patient population with multiple medical comorbidities associated with requirement for intravenous access we compared the rates of access failure in forearm and upper arm fistulae. The records of all patients having primary native arteriovenous fistulae placed between 2004 and 2009 at the VA Connecticut Healthcare system were reviewed (n = 118). Primary and secondary patency of upper arm and forearm fistulae were evaluated using Kaplan-Meier survival analysis. The effects of medical comorbidities on access patency were analyzed with Cox regression. The median time to primary failure of the vascular access was 0.288 y in the forearm group compared with 0.940 y in the upper arm group (P = 0.028). Secondary patency was 52% at 4.9 y in upper arm fistulae compared with 52% at 1.1 y in the forearm group (P = 0.036). There was no significant effect of patient comorbidities on fistula failure; however, there was a trend toward upper arm surgical site as a protective factor for primary fistula patency (hazard ratio = 0.573, P = 0.076). In veterans needing hemodialysis, a high risk population with extensive comorbid factors often requiring intravascular access, upper arm fistulae are not only a viable option for primary vascular access, but are likely to be a superior option to classic forearm fistulae. Published by Elsevier Inc.

  19. Superior Patency of Upper Arm Arteriovenous Fistulae in High Risk Patients

    PubMed Central

    Chiulli, Larissa C; Vasilas, Penny; Dardik, Alan

    2011-01-01

    Background Despite an increased propensity to primary failure in forearm arteriovenous fistulae compared to upper arm fistulae, forearm fistulae remain the preferred primary access type for chronic hemodialysis patients. In a high risk patient population with multiple medical comorbidities associated with requirement for intravenous access we compared the rates of access failure in forearm and upper arm fistulae. Materials and Methods The records of all patients having primary native arteriovenous fistulae placed between 2004 and 2009 at the VA Connecticut Healthcare system were reviewed (n=118). Primary and secondary patency of upper arm and forearm fistulae were evaluated using Kaplan-Meier survival analysis. The effects of medical comorbidities on access patency were analyzed with Cox regression. Results The median time to primary failure of the vascular access was 0.288 years in the forearm group compared to 0.940 years in the upper arm group (p=0.028). Secondary patency was 52% at 4.9 years in upper arm fistulae compared to 52% at 1.1 years in the forearm group (p=0.036). There was no significant effect of patient comorbidities on fistula failure; however, there was a trend toward upper arm surgical site as a protective factor for primary fistula patency (Hazard Ratio=0.573, p=0.076). Conclusions In veterans needing hemodialysis, a high risk population with extensive comorbid factors often requiring intravascular access, upper arm fistulae are not only a viable option for primary vascular access, but are likely to be a superior option to classic forearm fistulae. PMID:21571318

  20. Innovative approach using interprofessional simulation to educate surgical residents in technical and nontechnical skills in high-risk clinical scenarios.

    PubMed

    Nicksa, Grace A; Anderson, Cristan; Fidler, Richard; Stewart, Lygia

    2015-03-01

    The Accreditation Council for Graduate Medical Education core competencies stress nontechnical skills that can be difficult to evaluate and teach to surgical residents. During emergencies, surgeons work in interprofessional teams and are required to perform certain procedures. To obtain proficiency in these skills, residents must be trained. To educate surgical residents in leadership, teamwork, effective communication, and infrequently performed emergency surgical procedures with the use of interprofessional simulations. SimMan 3GS was used to simulate high-risk clinical scenarios (15-20 minutes), followed by debriefings with real-time feedback (30 minutes). A modified Oxford Non-Technical Skills scale (score range, 1-4) was used to assess surgical resident performance during the first half of the academic year (July-December 2012) and the second half of the academic year (January-June 2013). Anonymous online surveys were used to solicit participant feedback. Simulations were conducted in the operating room, intensive care unit, emergency department, ward, and simulation center. A total of 43 surgical residents (postgraduate years [PGYs] 1 and 2) participated in interdisciplinary clinical scenarios, with other health care professionals (nursing, anesthesia, critical care, medicine, respiratory therapy, and pharmacy; mean number of nonsurgical participants/session: 4, range 0-9). Thirty seven surgical residents responded to the survey. Simulation of high-risk clinical scenarios: postoperative pulmonary embolus, pneumothorax, myocardial infarction, gastrointestinal bleeding, anaphylaxis with a difficult airway, and pulseless electrical activity arrest. Evaluation of resident skills: communication, leadership, teamwork, problem solving, situation awareness, and confidence in performing emergency procedures (eg, cricothyroidotomy). A total of 31 of 35 (89%) of the residents responding found the sessions useful. Additionally, 28 of 33 (85%) reported improved confidence

  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. Primary treatment options for high risk/medically inoperable early stage NSCLC patients

    PubMed Central

    Jones, Guy C.; Kehrer, Jason D.; Kahn, Jenna; Koneru, Bobby N.; Narayan, Ram; Thomas, Tarita O.; Camphausen, Kevin; Mehta, Minesh P; Kaushal, Aradhana

    2015-01-01

    Lung cancer is among the most common cancers worldwide, and the leading cause of cancer death in both men and women. For patients with early stage (AJCC T1-2, N0) non-small cell lung cancer the current standard of care is lobectomy with systematic lymph node evaluation. Unfortunately, medical comorbities often present in patients with lung cancer, may preclude the option of surgical resection . In such cases, a number of minimal to non-invasive treatment options have gained popularity in the treatment of these high-risk patients. These modalities provide significant advantages including patient convenience, treatment in an outpatient setting, and acceptable toxicities including reduced impact on lung function and a modest risk of post-procedure chest wall pain. This manuscript seeks to provide a comprehensive review of the literature including reported outcomes, complications and limitations of sublobar resection with or without intraoperative brachytherapy, radiofrequency ablation, microwave ablation, percutaneous cryoablation, photodynamic therapy and stereotactic body radiation therapy. PMID:26027433

  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. 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

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

    PubMed

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

    2013-01-01

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

  6. 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.

  7. Care coordination and provider stress in primary care management of high-risk patients.

    PubMed

    Okunogbe, Adeyemi; Meredith, Lisa S; Chang, Evelyn T; Simon, Alissa; Stockdale, Susan E; Rubenstein, Lisa V

    2017-10-02

    Care coordination is a critical component of managing high-risk patients, who tend to have complex and multiple medical and psychosocial problems and are typically at high risk for increased hospitalization and incur high health care expenditures. Primary care models such as the patient-centered medical homes (PCMHs) are designed to improve care coordination and reduce care fragmentation. However, little is known about how the burden of care coordination for high-risk patients influences PCMH team members' stress. To evaluate the relationship between provider stress and care coordination time in high-risk patient care and whether availability of help is associated with reduced stress. Multivariable regression analysis of a cross-sectional survey of PCMH primary care providers (PCPs) and nurses. A total of 164 PCPs and 272 nurses in primary care practices at five geographically diverse Veteran Health Administration (VA) medical center health systems. The main outcome variable was provider stress due to high-risk patient care. Independent variables were the reported proportion of high-risk patients in PCP/nurse patient panels, time spent coordinating care for these patients, and provider satisfaction with help received in caring for them. The response rate was 44%. Spending more than 8 h per week coordinating care was significantly associated with a 0.21-point increase in reported provider stress compared to spending 8 h or less per week (95% CI: 0.04-0.39; p = 0.015). The magnitude of the association between stress and care coordination time was diminished when provider satisfaction with help received was included in the model. Perceived provider stress from care of high-risk patients may arise from challenges related to coordinating their care. Our findings suggest that the perception of receiving help for high-risk patient care may be valuable in reducing provider stress.

  8. 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.

  9. 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

  10. High-risk human papillomavirus and cervical lymph node metastasis in patients with oropharyngeal cancer.

    PubMed

    Joo, Young-Hoon; Jung, Chan-Kwon; Sun, Dong-Il; Park, Jun-Ook; Cho, Kwang-Jae; Kim, Min-Sik

    2012-01-01

    The purpose of this study was to determine the role of high-risk human papillomavirus (HPV) in lymph node metastasis and the depth of invasion in oropharyngeal cancer. The study included patients with 90 oral carcinomas and 66 oropharyngeal carcinomas. High-risk HPV in situ hybridization was performed to detect HPV infection. The positive rate of high-risk HPV in situ hybridization was 15.4% (24 of 156). There was a significant difference in the fraction of positive high-risk HPV between oral (6.7%) and oropharyngeal (27.3%) cancers (p < .000). Significant correlations were found between positive high-risk HPV and cervical lymph node metastasis, tumor depth of invasion in patients with oropharyngeal cancer (p = .002, p = .016, respectively). There was a statistically significant association between high-risk HPV positivity and the disease-specific survival in patients with oropharyngeal cancer (p = .035). High-risk HPV infection was significantly related to cervical lymph node metastasis and depth of invasion in patients with oropharyngeal cancer. © 2011 Wiley Periodicals, Inc. Head Neck, 2012. Copyright © 2011 Wiley Periodicals, Inc.

  11. [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. Copyright © 2012 Instituto Nacional de Cardiología Ignacio Chávez. Published by Masson Doyma México S.A. All rights reserved.

  12. [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.

  13. Overall rate, location, and predictive factors for positive surgical margins after robot-assisted laparoscopic radical prostatectomy for high-risk prostate cancer

    PubMed Central

    Kang, Sung Gu; Schatloff, Oscar; Haidar, Abdul Muhsin; Samavedi, Srinivas; Palmer, Kenneth J; Cheon, Jun; Patel, Vipul R

    2016-01-01

    We report the overall rate, locations and predictive factors of positive surgical margins (PSMs) in 271 patients with high-risk prostate cancer. Between April 2008 and October 2011, we prospectively collected data from patients classified as D’Amico high-risk who underwent robot-assisted laparoscopic radical prostatectomy. Overall rate and location of PSMs were reported. Stepwise logistic regression models were fitted to assess predictive factors of PSM. The overall rate of PSMs was 25.1% (68 of 271 patients). Of these PSM, 38.2% (26 of 68) were posterolateral (PL), 26.5% (18 of 68) multifocal, 16.2% (11 of 68) in the apex, 14.7% (10 of 68) in the bladder neck, and 4.4% (3/68) in other locations. The PSM rate of patients with pathological stage pT2 was 8.6% (12 of 140), 26.6% (17 of 64) of pT3a, 53.3% (32/60) of pT3b, and 100% (7 of 7) of pT4. In a logistic regression model including pre-, intra-, and post-operative parameters, body mass index (odds ratio [OR]: 1.09; 95% confidence interval [CI]: 1.01–1.19, P= 0.029), pathological stage (pT3b or higher vs pT2; OR: 5.14; 95% CI: 1.92–13.78; P = 0.001) and percentage of the tumor (OR: 46.71; 95% CI: 6.37–342.57; P< 0.001) were independent predictive factors for PSMs. The most common location of PSMs in patients at high-risk was the PL aspect, which reflects the reported tumor aggressiveness. The only significant predictive factors of PSMs were pathological outcomes, such as percentage of the tumor in the specimen and pathological stage. PMID:25966623

  14. 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.

  15. 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.

  16. Effects of subcutaneous drain for the prevention of incisional SSI in high-risk patients undergoing colorectal surgery.

    PubMed

    Fujii, Takaaki; Tabe, Yuichi; Yajima, Reina; Yamaguchi, Satoru; Tsutsumi, Soichi; Asao, Takayuki; Kuwano, Hiroyuki

    2011-09-01

    We have previously demonstrated that the risk of incisional surgical site infection (SSI) increases with obesity and that the most useful predictor of incisional SSI is the thickness of subcutaneous fat. Based on this finding, we have recently attempted a closure technique in surgery for the obese in which a subcutaneous drain is inserted for the prevention of incisional SSI. The aim of this study was to assess the utility of a subcutaneous drain for preventing incisional SSI in patients undergoing colorectal surgery who are at high risk for incisional SSI. Seventy-nine patients who underwent colorectal resection with high risk for incisional SSI, including patients with obesity (thick subcutaneous fat tissue, >20 mm) and those undergoing emergency operations, were enrolled in this study. The clinical features of these cases with or without a subcutaneous drain were reviewed, and statistical analysis was performed. In these high-risk cases, the overall incidence of incisional SSI was 27.8%. The incidences of incisional SSI in these cases with or without a subcutaneous drain were 14.3% and 38.6%, respectively. Our results suggest that subcutaneous drains are effective for preventing incisional SSI in patients with thick subcutaneous fat in colorectal surgery. Therefore, incisional SSI surveillance for obese patients should be performed separately, which should lead to a further reduction in incisional SSIs.

  17. 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.

  18. 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

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

    PubMed

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

    2015-08-01

    intraoperative adverse events (9.8%) including: arrhythmias requiring treatment (n = 4), conversion from sedation to a general anesthetic (n = 2), difficult airway (n = 1), inadvertent extubation with desaturation and bradycardia (n = 1), hypotension and desaturation (n = 1), and cardiac arrest (n = 1). Postoperative events (<48 h) included ST segment changes requiring cardiac catheterization (n = 1), and cardiorespiratory arrest (n = 1). Age, size, gender, type of cardiac palliation, patient location, procedure location, and type of procedure were not associated with adverse outcome. After 62 anesthetics (60.8%), patients went postoperatively to the cardiac ICU. There were no deaths at 48 h. We observed no mortality during or after noncardiac surgery in a high-risk subgroup of palliated cardiac patients with single ventricle physiology. However, 11.8% of patients had an adverse event associated with their anesthetic. © 2015 John Wiley & Sons Ltd.

  20. Rationale for aggressive lipid lowering in high-risk patients.

    PubMed

    Cohen, Jerome D

    2011-04-01

    According to current guidelines from the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III), the target low-density lipoprotein cholesterol (LDL-C) level for patients with established coronary heart disease (CHD) or CHD risk equivalents is less than 100 mg/dL, with an optional target of less than 70 mg/dL. More recent data suggest, however, that the physiologically normal level of LDL-C and the level at which atherogenesis is initiated is much lower. Overall, the data convincingly demonstrate that LDL-C lowering is associated with a significant reduction in CHD events, regardless of preexisting CHD. The NCEP ATP III treatment guidelines, published in 2002 and updated in 2004, do not reflect more recent findings on intensive lipid-lowering therapy, which are likely be addressed in the NCEP ATP IV guidelines, scheduled to be released in 2011. Drug options for LDL-C lowering include statins (the drug of choice), bile acid sequestrants, nicotinic acid, fibrates, and selective cholesterol absorption inhibitors.

  1. 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

  2. [Efficiency and safety of carvedilol treatment in high risk hypertensive patients].

    PubMed

    Zhao, Xiu-li; Hu, Dai-yi

    2006-01-01

    To evaluate the efficiency and safety of carvedilol treatment in high risk hypertensive patients. Carvedilol was administered in 379 hypertensive patients with high risk factors such as NIDDM, lipid disorders or abnormal serum creatinine level and 364 primary hypertensive patients without risk factors. Before and after treatment with carvedilol, blood pressure, heart rate, serum glucose, lipid profile and serum creatinine level were tested. After treatment, the blood pressure and heart rate were reduced significantly and there was no difference between the two groups. After treatment, the serum glucose, TC, TG and LDL in the high risk group, were reduced from 6.13, 5.37, 2.29 mmol/L and 3.04 to 5.80, 5.11, 2.05 and 2.87 mmol/L respectively (P < 0.001). TC was also reduced in the primary hypertensive group after treatment from 4.73 mmol/L to 4.69 mmol/L (P < 0.01). The efficiency rate of treatment in the high risk group and the primary hypertensive group was 97.75% and 98.32%; there is no statistical difference. The efficiency and safety of carvedilol in the high risk hypertensive patients is same as in the primary hypertensive patients.

  3. 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

  4. Identify high risk estrogen receptor-positive breast cancer patients for extended endocrine therapy.

    PubMed

    Li, JunJie; Jiang, Yizhou; Liu, Yirong; Shao, Zhimin

    2017-02-01

    To demonstrate the patterns of breast cancer-specific mortality (BCSM) in estrogen receptor (ER)-positive diseases and to identify high-risk candidates for extended endocrine therapy. Using the Surveillance, Epidemiology and End Results database, we identified ER-positive patients diagnosed between 1990 and 2000 (cohort 1 [C1]) and between 2001 and 2005 (cohort 2 [C2]). The patterns of BCSM were calculated using Cox proportional hazard regression models. A risk classification model was developed, and X-tile software was used to divide patients with high BCSM rates into 3 risk groups. The annual BCSM rate of C2 was decreased by one-third and was maintained at 10-15 (per 1000 persons per year) from year 2 to year 10. Long-term mortality risks still persisted in C2, especially in patients with node-positive, grade 3 or T3 disease, who should be considered as "clinical-high-risk". These patients were further divided into 3 risk groups through our model: for C1, 42.2% were in the low-risk group, 38.9% in the medium-risk group, and 18.9% in the high-risk group; and for C2, 45.5% were in the low-risk group, 38.2% in the medium-risk group and 16.2% in the high-risk group (p < 0.001). The BCSM rates of the patients in each group within C2 decreased, and fewer patients in C2 were classified into the clinical high-risk group. ER-positive patients with node-positive, grade 3 or T3 diseases had sustained risks of death throughout the 10-year time frame, and our model is helpful to identify patients with high risk who are candidates for extended endocrine therapy. Copyright © 2016 Elsevier Ltd. All rights reserved.

  5. Prevalence of sleep apnea syndrome and high-risk characteristics among keratoconus patients.

    PubMed

    Saidel, Michael A; Paik, Jeanie Y; Garcia, Christine; Russo, Peter; Cao, Dingcai; Bouchard, Charles

    2012-06-01

    To determine the prevalence and risk factors for sleep apnea in a keratoconus population. Ninety-two keratoconus patients and 92 controls were classified as high risk or low risk for sleep apnea, using the Berlin Questionnaire (BQ) or individual history of sleep apnea. Logistic regression was used to investigate the risk factors associated with high risk of sleep apnea in keratoconus patients and controls. Of the 92 keratoconus patients, 18 (19.6%) had a positive known history for sleep apnea, and 49 (53.3%) were categorized to be at high risk by the BQ. Of the 92 control patients, 6 (6.5%) had a positive known history for sleep apnea, and 25 (27.2%) were categorized to be at high risk by the BQ. In keratoconus patients, body mass index was the only risk factor for sleep apnea, whereas in control patients, age, body mass index, and family history of sleep apnea were the risk factors for sleep apnea. Keratoconus patients are at increased risk for sleep apnea, and different risk factors are associated with sleep apnea in keratoconus patients and controls. Ophthalmologists should consider screening keratoconus patients for obstructive sleep apnea, if appropriate.

  6. 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.

  7. Substance Misuse Treatment for High Risk Chronic Pain Patients on Opioid Therapy: A Randomized Trial

    PubMed Central

    Jamison, Robert N.; Ross, Edgar L.; Michna, Edward; Chen, Li Q.; Holcomb, Caroline; Wasan, Ajay D.

    2010-01-01

    Chronic pain patients who show aberrant drug-related behavior often are discontinued from treatment when they are noncompliant with their use of opioids for pain. The purpose of this study was to conduct a randomized trial in patients prescribed opioids for noncancer back pain who showed risk potential for or demonstration of opioid misuse to see if close monitoring and cognitive behavioral substance misuse counseling could increase overall compliance with opioids. Forty two patients meeting criteria for high risk for opioid misuse were randomized to either standard control (High-Risk Control; N=21) or experimental compliance treatment consisting of monthly urine screens, compliance checklists, and individual and group motivational counseling (High-Risk Experimental; N=21). Twenty patients who met criteria indicating low potential for misuse were recruited to a low-risk control group (Low-Risk Control). Patients were followed for 6 months and completed pre- and post-study questionnaires and monthly electronic diaries. Outcomes consisted of the percent with a positive Drug Misuse Index (DMI), which was a composite score of self-reported drug misuse (Prescription Drug Use Questionnaire), physician-reported abuse behavior (Addiction Behavior Checklist), and abnormal urine toxicology results. Significant differences were found between groups with 73.7 % of the High-Risk Control patients demonstrating positive scores on the DMI compared with 26.3% from the High-Risk Experimental group and 25.0% from the Low-Risk Controls (p<0.05). The results of this study demonstrate support for the benefits of a brief behavioral intervention in the management of opioid compliance among chronic back pain patient at high-risk for prescription opioid misuse. PMID:20334973

  8. 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.

  9. 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

  10. 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.

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

    PubMed

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

    2015-11-01

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

  12. Implementation of a Q fever vaccination program for high-risk patients in the Netherlands.

    PubMed

    Isken, Leslie D; Kraaij-Dirkzwager, Marleen; Vermeer-de Bondt, Patricia E; Rümke, Hans C; Wijkmans, Clementine; Opstelten, Wim; Timen, Aura

    2013-05-28

    Between 2007 and 2011 the Netherlands was faced with an unprecedented Q fever outbreak with more than 4000 people affected. Dairy goats were considered the main source of infection. In addition to taking veterinary measures, the Dutch government offered an unlicensed vaccine against the causative bacterium Coxiella burnetii to patient groups at high-risk of Q fever complications. This article describes the complexity of the vaccination program for Q fever in 2010-2011. High-risk patients were selected and referred mainly by their general practitioner to a publicly funded centralized screening and vaccination program. In addition, cardiovascular specialists and the public were informed. Patients were screened for previous infection with C. burnetii by serology and skin-tests. Patients who tested positive were excluded from vaccination. Of the 2741 referred high-risk patients (1669 male, 1957 from the high-risk area), 955 were excluded because vaccination was considered unnecessary or the distance to the vaccination clinic too far. 388 (22% of those screened) were excluded because of a positive skin-test or serology. 1368 patients (77% of those screened) were vaccinated between January and June 2011. Two-thirds of the vaccinees reported an adverse event. 89 patients (6.6%) reported serious adverse events. In just one patient, with an injection site reaction, a possible causal relationship was considered. This Q fever vaccination program posed challenges to the Dutch Health Care system. Creating clarity on the roles and responsibilities of those involved precluded timely vaccination. Targeting the high-risk population through GPs was challenging but appeared to be efficient. The vaccination was considered to be safe and compliance of the screened patients was high. Copyright © 2013 Elsevier Ltd. All rights reserved.

  13. 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.

  14. Role of Surgical Margin on Local Recurrence in High Risk Extremity Osteosarcoma: A Case-Controlled Study

    PubMed Central

    Song, Won Seok; Kong, Chang-Bae; Cho, Wan Hyeong; Cho, Sang Hyun; Lee, Jeong Dong; Lee, Soo-Yong

    2013-01-01

    Background The relationship between surgical margin and local recurrence (LR) in osteosarcoma patients with poor responses to chemotherapy is unclear. Moreover, the incidences of LR according to three different resection planes (bone, soft tissue, and perineurovascular) are not commonly known. Methods We evaluated the incidence of LR in three areas. To assess whether there is a role of surgical margin on LR in patients resistant to preoperative chemotherapy, we designed a case (35 patients with LR) and control (70 patients without LR) study. Controls were matched for age, location, initial tumor volume, and tumor volume change during preoperative chemotherapy. Results LR occurred at the soft tissues in 18 cases (51.4%), at the perineurovascular tissues in 11 cases (31.4%), and at the bones in six cases (17.2%). The proportion of inadequate perineurovascular margin was higher in the case group than in the control group (p = 0.01). Within case-control group (105 patients), a correlation between each margin status and LR at corresponding area was found in the bone (p < 0.001) and perineurovascular area (p = 0.001). Conclusions LR is most common in soft tissues. In patients showing similar unfavorable responses to chemotherapy, the losses of perineurovascular fat plane on preoperative magnetic resonance imaging may be a valuable finding in predicting LR. PMID:24009908

  15. Role of surgical margin on local recurrence in high risk extremity osteosarcoma: a case-controlled study.

    PubMed

    Jeon, Dae-Geun; Song, Won Seok; Kong, Chang-Bae; Cho, Wan Hyeong; Cho, Sang Hyun; Lee, Jeong Dong; Lee, Soo-Yong

    2013-09-01

    The relationship between surgical margin and local recurrence (LR) in osteosarcoma patients with poor responses to chemotherapy is unclear. Moreover, the incidences of LR according to three different resection planes (bone, soft tissue, and perineurovascular) are not commonly known. We evaluated the incidence of LR in three areas. To assess whether there is a role of surgical margin on LR in patients resistant to preoperative chemotherapy, we designed a case (35 patients with LR) and control (70 patients without LR) study. Controls were matched for age, location, initial tumor volume, and tumor volume change during preoperative chemotherapy. LR occurred at the soft tissues in 18 cases (51.4%), at the perineurovascular tissues in 11 cases (31.4%), and at the bones in six cases (17.2%). The proportion of inadequate perineurovascular margin was higher in the case group than in the control group (p = 0.01). Within case-control group (105 patients), a correlation between each margin status and LR at corresponding area was found in the bone (p < 0.001) and perineurovascular area (p = 0.001). LR is most common in soft tissues. In patients showing similar unfavorable responses to chemotherapy, the losses of perineurovascular fat plane on preoperative magnetic resonance imaging may be a valuable finding in predicting LR.

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

    PubMed

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

    2015-01-01

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

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

    PubMed

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

    2015-01-01

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

  18. 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

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

    PubMed

    Avet-Loiseau, Hervé; 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

    2016-09-01

    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. © 2016 by The American Society of Hematology.

  20. 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.

  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. 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

  3. 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.

  4. Cost-Effectiveness of Staphylococcus aureus Decolonization Strategies in High-Risk Total Joint Arthroplasty Patients.

    PubMed

    Williams, Devin M; Miller, Andy O; Henry, Michael W; Westrich, Geoffrey H; Ghomrawi, Hassan M K

    2017-09-01

    The risk of prosthetic joint infection increases with Staphylococcus aureus colonization. The cost-effectiveness of decolonization is controversial. We evaluated cost-effectiveness decolonization protocols in high-risk arthroplasty patients. An analytical model evaluated risk under 3 protocols: 4 swabs, 2 swabs, and nasal swab alone. These were compared to no-screening and universal decolonization strategies. Cost-effectiveness was evaluated from the hospital, patient, and societal perspective. Under base case conditions, universal decolonization and 4-swab strategies were most effective. The 2-swab and universal decolonization strategy were most cost-effective from patient and societal perspectives. From the hospital perspective, universal decolonization was the dominant strategy (much less costly and more effective). S aureus decolonization may be cost-effective for reducing prosthetic joint infections in high-risk patients. These results may have important implications for treatment of patients and for cost containment in a bundled payment system. Copyright © 2017 Elsevier Inc. All rights reserved.

  5. 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

  6. Goal-directed therapy improves the outcome of high-risk cardiac patients undergoing off-pump coronary artery bypass.

    PubMed

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

    2017-01-01

    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. 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 (ScVO 2 ), 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. 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. 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 ± 0.68 h, P = 0.005) was also significantly lower

  7. 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

  8. 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.

  9. 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. PMID:28408919

  10. 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.

  11. Pharmacy compounding of high-risk level products and patient safety.

    PubMed

    Mullarkey, Tamira

    2009-09-01

    Issues surrounding pharmacy compounding as well as patient safety concerns surrounding compounding of high-risk level products are discussed. The practice of traditional pharmacy compounding is an established activity of pharmacists that serves a vital function to meet the prescribed medical needs of individual patients. However, legal and regulatory debate concerning the oversight of pharmacy compounding has arisen in recent decades, driven mostly by patient harm that has occurred as a result of compounding errors or deceptive practices. Federal and state government agencies and professional organizations have reported errors in pharmacy compounding, including subpotent and contaminated products that have caused patient harm. The United States Pharmacopeia (USP) chapter 797 serves to protect patients by requiring best practice and quality standards for the safe preparation and handling of compounded sterile preparations (CSPs). High-risk level CSPs pose the greatest risk to patients since non-sterile ingredients or containers are used, which mandates final product sterilization prior to dispensing. Pharmacists should understand and comply with federal, state, and USP chapter 797 requirements when preparing CSPs, particularly high-risk level CSPs. Professional pharmacy organizations, such as the American Society of Health-System Pharmacists (ASHP) and the National Association of Boards of Pharmacy (NABP), continue to support the practice of traditional pharmacy compounding through their guidelines, with patient safety as a central theme. Until the regulatory debate is resolved, pharmacists engaged in pharmacy compounding, particularly in the preparation of high-risk level CSPs, should remain competent in their skills and practice in accordance with federal, state, and USP chapter 797 requirements and, thereby, protect patients and the professionalism of pharmacy.

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

    PubMed

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

    2017-07-25

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

  13. [Greenlight photoselective vaporization prostatectomy versus thulium laser vaporesection of the prostate for aged high-risk BPH patients with the prostate heavier than 80 g].

    PubMed

    Liu, Chun-lai; Xue, Dong-wei; Liu, Yi-li; Wang, Ping

    2011-05-01

    To compare the effects of greenlight photoselective vaporization prostatectomy (PVP) and thulium laser vaporesection of the prostate (TmLRP) in the treatment of aged high-risk BPH patients with the prostate weighing > 80 g. We included in this study 118 high-risk BPH patients aged 62-96 (mean 76) years with the prostate heavier than 80 g, 82 treated by PVP and the other 36 by TmLRP. Then we compared the operation time, intraoperative bleeding, complications, short-term effectiveness, and surgical cost between the two groups. All the patients tided over the perioperative period without blood transfusion and serious complications. The mean operation time, postoperative bladder irrigation time and surgical cost were significantly less in the TmLRP than in the PVP group (P < 0.05). Both the procedures remarkably improved the international prostatic symptom score (IPSS), quality of life (QOL), post void residual urine (PVR) and Qmax of the patients (P < 0.05), but with no significant differences between the two groups (P > 0.05). Both PVP and TmLRP are effective and safe for the treatment of aged high-risk BPH patients with the prostate heavier than 80 g, but the latter is superior for its shorter operation time and lower surgical cost.

  14. The "T-MIDCAB" procedure. Use of extension grafts from the undisturbed internal mammary artery in high-risk patients.

    PubMed

    Coulson, A S; Bakhshay, S A

    1998-01-01

    Minimally invasive direct coronary artery bypass grafting (MIDCAB) is an attractive new alternative for revascularizing patients with high perioperative risk for standard coronary surgery. However, limited surgical exposure through a small thoracotomy makes harvesting the full length of the internal mammary artery (IMA) very difficult and time consuming. We are now employing a new alternative with a "T" shaped bridge graft constructed from the undisturbed IMA using a 4 centimeter interposition segment of donor vessel. We prefer this approach in high risk cases in order to reduce the trauma of the thoracotomy, minimize pain and narcotic use, promote early extubation, and achieve immediate post-operative mobilization and recovery in patients who would otherwise be at risk for a poor outcome with conventional grafting techniques. From September 10, 1997 to December 19, 1997 eight high-risk patients underwent at least one "T-MIDCAB" graft from the undisturbed IMA to the coronary artery using a short segment of either radial artery or saphenous vein. All cases were performed using a limited access anterior thoracotomy through the bed of the resected costal cartilage and without intercostal retraction. Five males and three females ranging from 58 to 83 years (average 73 years) were operated using this new concept. Pre-operative ejection fractions ranged from 25% to 80% (mean 43%). Parsonnet scores ranged from 21 to 43 (average 34) with predicted mortalities ranging from 30 to 40%. Eleven "T" grafts were placed (1.38 distals/patient). All 8 patients survived. Postoperative complications were minimal. The average length of stay was only 8 days (range 3 to 9 days). Intensive care unit stay averaged 3 days (range 1 to 4 days). One patient underwent postoperative angiography which demonstrated full patency of the conduit and all anastomoses. "T-MIDCAB" using a bridge graft of free radial artery or saphenous vein appears to be successful in high risk patients. The authors

  15. Percutaneous mitral valve repair for mitral regurgitation in high-risk patients: results of the EVEREST II study.

    PubMed

    Glower, Donald D; Kar, Saibal; Trento, Alfredo; Lim, D Scott; Bajwa, Tanvir; Quesada, Ramon; Whitlow, Patrick L; Rinaldi, Michael J; Grayburn, Paul; Mack, Michael J; Mauri, Laura; McCarthy, Patrick M; Feldman, Ted

    2014-07-15

    The EVEREST II (Endovascular Valve Edge-to-Edge REpair STudy) High-Risk registry and REALISM Continued Access Study High-Risk Arm are prospective registries of patients who received the MitraClip device (Abbott Vascular, Santa Clara, California) for mitral regurgitation (MR) in the United States. The purpose of this study was to report 12-month outcomes in high-risk patients treated with the percutaneous mitral valve edge-to-edge repair. Patients with grades 3 to 4+ MR and a surgical mortality risk of ≥12%, based on the Society of Thoracic Surgeons risk calculator or the estimate of a surgeon coinvestigator following pre-specified protocol criteria, were enrolled. In the studies, 327 of 351 patients completed 12 months of follow-up. Patients were elderly (76 ± 11 years of age), with 70% having functional MR and 60% having prior cardiac surgery. The mitral valve device reduced MR to ≤2+ in 86% of patients at discharge (n = 325; p < 0.0001). Major adverse events at 30 days included death in 4.8%, myocardial infarction in 1.1%, and stroke in 2.6%. At 12 months, MR was ≤2+ in 84% of patients (n = 225; p < 0.0001). From baseline to 12 months, left ventricular (LV) end-diastolic volume improved from 161 ± 56 ml to 143 ± 53 ml (n = 203; p < 0.0001) and LV end-systolic volume improved from 87 ± 47 ml to 79 ± 44 ml (n = 202; p < 0.0001). New York Heart Association functional class improved from 82% in class III/IV at baseline to 83% in class I/II at 12 months (n = 234; p < 0.0001). The 36-item Short Form Health Survey physical and mental quality-of-life scores improved from baseline to 12 months (n = 191; p < 0.0001). Annual hospitalization rate for heart failure fell from 0.79% pre-procedure to 0.41% post-procedure (n = 338; p < 0.0001). Kaplan-Meier survival estimate at 12 months was 77.2%. The percutaneous mitral valve device significantly reduced MR, improved clinical symptoms, and decreased LV dimensions at 12 months in this high-surgical-risk cohort

  16. Reliability of sentinel node procedure for lymph node staging in prostate cancer patients at high risk for lymph node involvement.

    PubMed

    Van den Bergh, Laura; Joniau, Steven; Haustermans, Karin; Deroose, Christophe M; Isebaert, Sofie; Oyen, Raymond; Mottaghy, Felix M; Ameye, Filip; Berkers, Joost; Van Poppel, Hendrik; Lerut, Evelyne

    2015-06-01

    To investigate the reliability of a sentinel node (SN) procedure for nodal staging in prostate cancer (PCa) patients at high risk for lymph node (LN) involvement. Seventy-four patients with localized prostate adenocarcinoma, who were clinically node-negative and had a risk of LN involvement of ≥ 10% (Partin tables), were prospectively enrolled. Upon intraprostatic 99mTc-nanocolloid injection, they underwent planar scintigraphy and SPECT imaging. Surgical removal of the SN, located by means of a gamma probe, was completed with a superextended LN dissection (seLND) as a reference and followed by radical prostatectomy. In total, 470 SN (median 6, IQR 3-9) were scintigraphically detected of which 371 (median 4, IQR 2-6) were located by gamma probe and selectively removed during surgery (79%). Histopathology confirmed LN metastases in 37 patients (50%) having 106 affected LN in total (median number per patient 2, IQR 1-4). Twenty-eight patients were node positive (N+) based on the analysis of the resected SN. However, the seLND that was performed as a reference revealed nine additional N+ patients resulting in a sensitivity of 76% (28/37). In total, 15 of 37 patients (41%) had metastases in SN only and could have been spared seLND to remove all affected nodes. We found a relatively low sensitivity when addressing the SN procedure for nodal staging in PCa patients at high risk for LN involvement. Importantly, only less than half of the N+ patients could have been spared a seLND to remove all affected lymphoid tissue.

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

    PubMed

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

    2017-02-27

    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. 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. 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. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

  18. A clinical model to identify patients with high-risk coronary artery disease.

    PubMed

    Yang, Yelin; Chen, Li; Yam, Yeung; Achenbach, Stephan; Al-Mallah, Mouaz; Berman, Daniel S; Budoff, Matthew J; Cademartiri, Filippo; Callister, Tracy Q; Chang, Hyuk-Jae; Cheng, Victor Y; Chinnaiyan, Kavitha; Cury, Ricardo; Delago, Augustin; Dunning, Allison; Feuchtner, Gudrun; Hadamitzky, Martin; Hausleiter, Jörg; Karlsberg, Ronald P; Kaufmann, Philipp A; Kim, Yong-Jin; Leipsic, Jonathon; LaBounty, Troy; Lin, Fay; Maffei, Erica; Raff, Gilbert L; Shaw, Leslee J; Villines, Todd C; Min, James K; Chow, Benjamin J W

    2015-04-01

    This study sought to develop a clinical model that identifies patients with and without high-risk coronary artery disease (CAD). Although current clinical models help to estimate a patient's pre-test probability of obstructive CAD, they do not accurately identify those patients with and without high-risk coronary anatomy. Retrospective analysis of a prospectively collected multinational coronary computed tomographic angiography (CTA) cohort was conducted. High-risk anatomy was defined as left main diameter stenosis ≥50%, 3-vessel disease with diameter stenosis ≥70%, or 2-vessel disease involving the proximal left anterior descending artery. Using a cohort of 27,125, patients with a history of CAD, cardiac transplantation, and congenital heart disease were excluded. The model was derived from 24,251 consecutive patients in the derivation cohort and an additional 7,333 nonoverlapping patients in the validation cohort. The risk score consisted of 9 variables: age, sex, diabetes, hypertension, current smoking, hyperlipidemia, family history of CAD, history of peripheral vascular disease, and chest pain symptoms. Patients were divided into 3 risk categories: low (≤7 points), intermediate (8 to 17 points) and high (≥18 points). The model was statistically robust with area under the curve of 0.76 (95% confidence interval [CI]: 0.75 to 0.78) in the derivation cohort and 0.71 (95% CI: 0.69 to 0.74) in the validation cohort. Patients who scored ≤7 points had a low negative likelihood ratio (<0.1), whereas patients who scored ≥18 points had a high specificity of 99.3% and a positive likelihood ratio (8.48). In the validation group, the prevalence of high-risk CAD was 1% in patients with ≤7 points and 16.7% in those with ≥18 points. We propose a scoring system, based on clinical variables, that can be used to identify patients at high and low pre-test probability of having high-risk CAD. Identification of these populations may detect those who may benefit

  19. Off-pump coronary artery bypass grafting versus optimal medical therapy alone: effectiveness of incomplete revascularization in high risk patients

    PubMed Central

    Prestipino, Filippo; Spadaccio, Cristiano; Nenna, Antonio; Sutherland, Fraser WH; Beattie, Gwyn W; Lusini, Mario; Nappi, Francesco; Chello, Massimo

    2016-01-01

    Background Geriatric patients with multivessel coronary artery disease (CAD) are a challenging group to treat; these cases elicit discussion within heart teams regarding the actual benefit of undertaking major surgery on these patients and often lead to abandon the surgical option. Percutaneous procedures represent an important option, but coronary anatomy may be unfavorable. Off-pump coronary artery bypass (OPCAB) provides good quality graft on left anterior descending (LAD) without exposing the patient to cardiopulmonary bypass, and might be the ideal choice in patients with multiple comorbidities, not eligible to percutaneous or on-pump procedures. The objective of this study was to compare survival during a mid-term follow-up in high-risk patients with no percutaneous alternative, either treated with OPCAB or discharged in medical therapy. Methods We retrospectively evaluated from June 2008 to June 2013, 83 high-risk patients with multivessel CAD were included: 42 were treated with incomplete off-pump revascularization using left internal mammary artery (LIMA) on LAD; 41 were discharged in optimal medical therapy (OMT), having refused surgery. Follow-up ended in March 2015, with a telephonic interview. Primary endpoint was survival from all-cause mortality; secondary endpoints were survival from cardiac-related mortality and freedom from non-fatal major adverse cardiac events (MACEs). Results During follow up, 11 deaths in OPCAB group and 27 deaths in OMT group occurred. Death was due to cardiac factors in 6 and 15 patients, respectively. MACEs were observed in 6 patients in OPCAB group and in 4 patients in OMT group. With regards to survival from all-cause mortality, patients who underwent OPCAB survived more than those discharged in OMT (Log Rank < 0.001), and OMT group carries a propensity score-adjusted hazard ratio of 3.862 (P < 0.001). With regards to survival from cardiac-related events, patients who underwent OPCAB survived more than those discharged in

  20. Double mobility cup total hip arthroplasty in patients at high risk for dislocation: a single-center analysis.

    PubMed

    Kaiser, Dominik; Kamath, Atul F; Zingg, Patrick; Dora, Claudio

    2015-12-01

    Double mobility cup systems (DMCS) have gained increasing acceptance, especially in patients at high risk for dislocation. The aim of this investigation was to analyze the frequency and indications of the DMCS use in our praxis and to evaluate dislocation and cup revision rates after a minimum follow-up of 2 years. All patients implanted with a DMCS from May 2008 to August 2011 were identified from our institutional database of primary and revision THA procedures. Patient demographics, including ASA score, were recorded, along with details of the surgical procedures, indications for DMCS use, and post-operative clinical course and any complications. Radiographs were analyzed for implant positioning and radiological signs of loosening. 1046 primary THA were implanted, of these 39 (4 %) primary DMCS. Indications were severe neuromuscular disease (SND) (14), hip abductor degeneration (HAD) (9), cognitive dysfunction (CD) (8) and others. 345 revision THA were performed, of these 50 (14 %) revision DMCS. Indications were recurrent dislocations (27), multiple prior hip surgeries (13), HAD (5), CD (3) and others. Overall dislocation rate was 2/89 (2 %); both in revision THA. Overall cup revision rate was 5/89 (6 %): 3 septic, 1 periprosthetic acetabular fracture, 1 "intraprosthetic dissociation". 67 patients were available for the standardized questionnaire at a median follow-up of 43 months (range 25-78). 19 patients were not available for two-year follow-up: 17 died and two were lost to follow-up. This study supports the use of DMCS constructs in primary and revision hip arthroplasty for specific high-risk patients. We continue to indicate DMCS in this patient group. We do caution against extending indications for DMCS to lower risk patient groups due to unknown issues surrounding wear and component longevity.

  1. 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

  2. Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): a systematic review.

    PubMed

    Mallee, Wouter H; Weel, Hanneke; van Dijk, C Niek; van Tulder, Maurits W; Kerkhoffs, Gino M; Lin, Chung-Wei Christine

    2015-03-01

    To compare surgical and conservative treatment for high-risk stress fractures of the anterior tibial cortex, navicular and proximal fifth metatarsal. Systematic searches of CENTRAL, MEDLINE, EMBASE, CINAHL, SPORTDiscus and PEDro were performed to identify relevant prospective and retrospective studies. Two reviewers independently extracted data and assessed methodological quality. Main outcomes were return to sport and complication rate. 18 studies were included (2 anterior tibia (N=31), 8 navicular (N=200) and 8 fifth metatarsal (N=246)). For anterior tibial fracture, no studies on initial surgery were eligible. Conservative treatment resulted in high complication rates and few cases returned to sport. For navicular fracture, a weighted mean return to sport of 22 for conservative and 16 weeks for surgical treatment was found. Six weeks of non-weightbearing cast was mostly used as conservative treatment. Surgical procedures varied widely. For the fifth metatarsal fracture, weighted mean return to sport was 19 for conservative and 14 weeks for surgical treatment. Surgery consisted of intramedullary screw fixation or tension band wiring. For conservative methods, insufficient details were reported. Overall, there was a high risk of bias; sample sizes were small and GRADE level of evidence was low. Strong conclusions for surgical or conservative therapy for these high-risk stress fractures cannot be drawn; quality of evidence is low and subjected to a high risk of bias. However, there are unsatisfying outcomes of conservative therapy in the anterior tibia. The role of initial surgery is unknown. For the navicular, surgery provided an earlier return to sport; and when treated conservatively, weightbearing should be avoided. For the fifth metatarsal, surgery provided the best results. Treatment decision-making would greatly benefit from further prospective research. PROSPERO database of systematic reviews: CRD42013004201. Published by the BMJ Publishing Group Limited

  3. High Risk Human Papillomavirus Infection of the Foreskin in Asymptomatic Men and Patients with Phimosis.

    PubMed

    Afonso, Larissa A; Cordeiro, Thaissa I; Carestiato, Fernanda N; Ornellas, Antonio Augusto; Alves, Gilda; Cavalcanti, Sílvia M B

    2016-06-01

    There has been increasing interest in understanding the natural history of HPV and the diseases that it causes in men. HPV infection is strongly associated with penile cancer, lack of neonatal circumcision and phimosis. We investigated the incidence of HPV infection in asymptomatic men and patients with phimosis. We assessed 110 asymptomatic men and 30 patients who underwent circumcision due to phimosis. DNA was extracted from swabbed samples collected from asymptomatic men and from foreskin samples collected at circumcision. Polymerase chain reaction using consensus primers for detecting HPV-MY09/11 was performed to detect generic HPV DNA. HPV genotyping was done by polymerase chain reaction amplification with primers for the E6 gene DNA sequences HPV6, HPV11, HPV16, HPV18, HPV31, HPV33, HPV35, HPV45 and HPV58. HPV was present in 46.66% of patients with phimosis, of whom 50% had high risk HPV genotypes. Of asymptomatic cases 16.36% were HPV positive but only 1 sample showed high risk HPV. We detected a significantly high rate of HPV genital infection in patients presenting with phimosis compared with asymptomatic men (p = 0.00167). The prevalence of high risk HPV genotypes in patients with phimosis was also statistically significant (p = 0.0004). We found a robust association between phimosis and the genital HPV prevalence in men and a significant frequency of high risk HPV. Other studies are needed to investigate the occurrence of factors that can increase the incidence of penile carcinoma and determine its impact on female genital infection in cervical cancer. Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

  4. 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.

  5. 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.

  6. Hemodynamic monitoring and management in patients undergoing high risk surgery: a survey among North American and European anesthesiologists.

    PubMed

    Cannesson, Maxime; Pestel, Gunther; Ricks, Cameron; Hoeft, Andreas; Perel, Azriel

    2011-08-15

    Several studies have demonstrated that perioperative hemodynamic optimization has the ability to improve postoperative outcome in high-risk surgical patients. All of these studies aimed at optimizing cardiac output and/or oxygen delivery in the perioperative period. We conducted a survey with the American Society of Anesthesiologists (ASA) and the European Society of Anaesthesiology (ESA) to assess current hemodynamic management practices in patients undergoing high-risk surgery in Europe and in the United States. A survey including 33 specific questions was emailed to 2,500 randomly selected active members of the ASA and to active ESA members. Overall, 368 questionnaires were completed, 57.1% from ASA and 42.9% from ESA members. Cardiac output is monitored by only 34% of ASA and ESA respondents (P = 0.49) while central venous pressure is monitored by 73% of ASA respondents and 84% of ESA respondents (P < 0.01). Specifically, the pulmonary artery catheter is being used much more frequently in the US than in Europe in the setup of high-risk surgery (85.1% vs. 55.3% respectively, P < 0.001). Clinical experience, blood pressure, central venous pressure, and urine output are the most widely indicators of volume expansion. Finally, 86.5% of ASA respondents and 98.1% of ESA respondents believe that their current hemodynamic management could be improved. In conclusion, these results point to a considerable gap between the accumulating evidence about the benefits of perioperative hemodynamic optimization and the available technologies that may facilitate its clinical implementation, and clinical practices in both Europe and the United States.

  7. Hemodynamic monitoring and management in patients undergoing high risk surgery: a survey among North American and European anesthesiologists

    PubMed Central

    2011-01-01

    Introduction Several studies have demonstrated that perioperative hemodynamic optimization has the ability to improve postoperative outcome in high-risk surgical patients. All of these studies aimed at optimizing cardiac output and/or oxygen delivery in the perioperative period. We conducted a survey with the American Society of Anesthesiologists (ASA) and the European Society of Anaesthesiology (ESA) to assess current hemodynamic management practices in patients undergoing high-risk surgery in Europe and in the United States. Methods A survey including 33 specific questions was emailed to 2,500 randomly selected active members of the ASA and to active ESA members. Results Overall, 368 questionnaires were completed, 57.1% from ASA and 42.9% from ESA members. Cardiac output is monitored by only 34% of ASA and ESA respondents (P = 0.49) while central venous pressure is monitored by 73% of ASA respondents and 84% of ESA respondents (P < 0.01). Specifically, the pulmonary artery catheter is being used much more frequently in the US than in Europe in the setup of high-risk surgery (85.1% vs. 55.3% respectively, P < 0.001). Clinical experience, blood pressure, central venous pressure, and urine output are the most widely indicators of volume expansion. Finally, 86.5% of ASA respondents and 98.1% of ESA respondents believe that their current hemodynamic management could be improved. Conclusions In conclusion, these results point to a considerable gap between the accumulating evidence about the benefits of perioperative hemodynamic optimization and the available technologies that may facilitate its clinical implementation, and clinical practices in both Europe and the United States. PMID:21843353

  8. Patient hand hygiene practices in surgical patients.

    PubMed

    Ardizzone, Laura L; Smolowitz, Janice; Kline, Nancy; Thom, Bridgette; Larson, Elaine L

    2013-06-01

    Little is known about the hand hygiene practices of surgical patients. Most of the research has been directed at the health care worker, and this may discount the role that hand hygiene of the surgical patient might play in surgical site infections. A quasiexperimental, pretest/post-test study was conducted in which patients (n = 72) and nurses (n = 42) were interviewed to examine perceptions and knowledge about patient hand hygiene. Concurrently, observations were conducted to determine whether surgical patients were offered assistance by the nursing staff. Following an initial observation period, nursing staff received an educational session regarding general hand hygiene information and observation results. One month after the education session, patient/nurse dyads were observed for an additional 6 weeks to determine the impact of the educational intervention. Eighty observations, 72 patient interviews, and 42 nurse interviews were completed preintervention, and 83 observations were completed postintervention. In response to the survey, more than half of patients (n = 41, 55%) reported that they were not offered the opportunity to clean their hands, but a majority of the nursing staff reported (n = 25, 60%) that they offered patients the opportunity to clean their hands. Prior to the educational intervention, nursing staff assisted patients in 14 of 81 hand hygiene opportunities. Following the intervention, nursing staff assisted patients 37 out of 83 opportunities (17.3% vs 44.6%, respectively, [χ(2)1 = 13.008, P = .0003]). This study suggests that efforts to increase hand hygiene should be directed toward patients as well as health care workers. Copyright © 2013 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.

  9. 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.

  10. 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

  11. 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

  12. 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

  13. 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.

  14. Preventing heel pressure ulcers and plantar flexion contractures in high-risk sedated patients.

    PubMed

    Meyers, Tina R

    2010-01-01

    An intervention using heel pressure ulcer and plantar flexion contracture prevention protocols for high-risk patients was established to promote earlier recognition of heel skin issues and provide effective prevention of both conditions. Fifty-three patients who were sedated, managed in an intensive care unit for 5 days or more, and had a Braden Scale score of 16 or less were treated with heel protector devices that maintained the foot in a neutral position and floated the heel off the bed. On admission to the intensive care unit, heel skin assessment and the Braden Scale were administered to all patients. Initial ankle range of motion was measured with a goniometer on admission and before the application of the heel protector. Goniometric measurements were documented every other day. Heel assessments and the Braden Scale for Predicting Pressure Sore Prevention and Ramsay Sedation Scale scores were recorded in every shift and recorded as part of the study every other day. Measurements continued until the patient was transferred, the heel protector boot was discontinued by the physician, or the patient's Braden Scale score rose above 16. Application of the heel protectors led to a 50% reduction in prevalence of abnormal heel position. No patients developed plantar flexion contractures or new heel ulcers. Patients with normal heels had significantly higher Braden Scale scores compared to those with abnormal heels (P 5 .0136). Despite their high risk, no patients using the heel protector device developed a heel pressure ulcer or plantar flexion contracture.

  15. Identification of vascular patients at very high risk for recurrent cardiovascular events: validation of the current ACC/AHA very high risk criteria.

    PubMed

    van den Berg, M Johanneke; Bhatt, Deepak L; Kappelle, L Jaap; de Borst, Gert J; Cramer, Maarten J; van der Graaf, Yolanda; Steg, Ph Gabriel; Visseren, Frank L J

    2017-03-28

    To validate and assess performance of the current ACC/AHA very high risk criteria in patients with clinically manifest arterial disease. Data were used from the SMART study (n = 7216) and REACH Registry (n = 48 322), two prospective cohorts of patients with manifest atherosclerotic arterial disease. Prevalence and incidence rates of recurrent major adverse cardiovascular events (MACE) were calculated, according to the ACC/AHA VHR criteria (cardiovascular disease combined with diabetes, smoking, dyslipidaemia, and/or recent recurrent coronary events). Performance of the ACC/AHA criteria was compared with single very high risk factors in terms of C-statistics and Net Reclassification Index. All patients were at VHR according to the ESC guidelines (incidence of recurrent MACE in SMART was 2.4/100PY, with 95% CI 2.3-2.5/100PY and in REACH 5.1/100PY with 95% CI 5.0-5.3/100PY). In SMART 57% of the patients were at VHR according to the ACC/AHA criteria (incidence of recurrent MACE 2.7/100PY, 95% CI 2.5-2.9/100PY) and in REACH this was 64% (5.9/100PY, 95% CI 5.7-6.1/100PY). The C-statistic for the ACC/AHA VHR criteria was 0.53 in REACH and 0.54 in SMART. Very high risk factors with comparable or slightly better performance were eGFR < 45, polyvascular disease and age >70 years. Around two third of the patients meeting the ACC/AHA VHR criteria had a predicted 10-year risk of recurrent MACE <30%. The ACC/AHA VHR criteria have limited discriminative power. Identifying patients with clinically manifest arterial disease at VHR for recurrent vascular events using eGFR <45, polyvascular disease, or age >70 years performs as well as the ACC/AHA VHR criteria.

  16. Theory of Mind in Patients at Clinical High Risk for Psychosis

    PubMed Central

    Stanford, Arielle D.; Messinger, Julie; Malaspina, Dolores; Corcoran, Cheryl M.

    2011-01-01

    Background Patients with schizophrenia have a decreased ability to interpret the intentions of other individuals, called Theory of Mind (ToM). As capacity for ToM normally advances with brain maturation, research on ToM in individuals at heightened clinical risk for psychosis may reveal developmental differences independent of disease based differences. Methods We examined ToM in at clinical high risk and schizophrenia patients as well as healthy controls: 1) 63 clinical high risk (CHR) patients and 24 normal youths ascertained by a CHR program; and 2) in 13 schizophrenia cases and 14 normal adults recruited through a schizophrenia program. ToM measures included first- and second-order false belief cartoon tasks (FBT) and two “higher order” tasks (“Strange Stories Task” (SST) and the “Reading the Mind in the Eyes” task). In the first study, CHR patients and normal youths were also assessed for cognition, “prodromal” symptoms and social function. Results Errors on first- and second-order false belief tasks were made primarily by patients. CHR patients and their young comparison group had equivalent performance on higher order ToM, which was not significantly different from the worse ToM performance of schizophrenia patients and the higher performance of normal adult controls. In the combined dataset from both studies, all levels of ToM were associated with IQ, controlling for age and sex. ToM bore no relation to explicit memory, prodromal symptoms, social function, or later transition to psychosis. Conclusions Higher order ToM capacity was equally undeveloped in high risk cases and younger controls, suggesting performance on these tasks is not fully achieved until adulthood. This study also replicates the association of IQ with ToM performance described in previous studies of schizophrenia. PMID:21757324

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

    PubMed

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

    2017-10-06

    Many individuals with diabetes remain undiagnosed, leading to delays in treatment and higher risk for subsequent diabetes complications. Despite recommendations for diabetes screening in high risk groups, the optimal approach is not known. We evaluated the utility of inpatient glucose levels as an opportunistic screening tool for identifying patients at high risk for diabetes. We retrospectively examined 462,421 patients in the national VA healthcare system, hospitalized on medical/surgical services in 2000-2010, for ≥3 days, with ≥2 inpatient random plasma glucose (RPG) measurements. All had continuity of care - ≥1 primary care visit and ≥1 glucose measure within 2 years before hospitalization and yearly for ≥3 years after discharge. Glucose levels during hospitalization and incidence of diabetes within 3 years after discharge in patients without diabetes were evaluated. Patients had mean age 65.0 years, BMI 29.9, and were 96% male, 71% white, and 18% black. Preexisting diabetes was present in 39.4%, 1.3% were diagnosed during hospitalization, 8.1% diagnosed <5 years post-discharge, and 51.3% never diagnosed (NonDM). The NonDM group had the lowest mean hospital RPG (112 mg/dl [6.2 mmol/L]). Having at least two RPGs >140 mg/dl (>7.8 mmol/L), the 95(th) percentile of NonDM hospital glucose, provided 81% specificity for identifying incident diabetes <3 years post-discharge. Screening for diabetes could be considered in patients with at least two hospital glucoses at/above the 95th percentile of the nondiabetic range (141 mg/dl [7.8 mmol/L]). Copyright © 2017. Published by Elsevier Inc.

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

    PubMed

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

    2017-08-01

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

  20. Adjuvant leuprolide with or without docetaxel in patients with high-risk prostate cancer after radical prostatectomy (TAX-3501): important lessons for future trials.

    PubMed

    Schweizer, Michael T; Huang, Peng; Kattan, Michael W; Kibel, Adam S; de Wit, Ronald; Sternberg, Cora N; Epstein, Jonathan I; Eisenberger, Mario A

    2013-10-15

    The current trial evaluated 2 common therapies for patients with advanced prostate cancer, docetaxel and hormonal therapy (HT), in the surgical adjuvant setting. TAX-3501 was a randomized, phase 3, adjuvant study post-radical prostatectomy (RP) in high-risk patients with prostate cancer (n=228) comparing 18 months of HT with (CHT) without docetaxel chemotherapy either immediately (I) or deferred (D). High-risk disease was defined as a 5-year freedom-from-disease-progression rate of ≤ 60% as predicted by a post-RP nomogram. Progression-free survival (PFS), including prostate-specific antigen disease recurrence, was the primary endpoint. The authors also assessed the accuracy of the nomogram and analyzed testosterone recovery in 108 patients treated with HT who had at least 1 posttreatment testosterone value. Between December 2005 and September 2007, 228 patients were randomized between the treatment cohorts. TAX-3501 was terminated prematurely because of enrollment challenges, leaving it underpowered to detect differences in PFS. After a median follow-up of 3.4 years (interquartile range, 2.3-3.8 years), 39 of 228 patients (17%) demonstrated PSA disease progression, and metastatic disease progression occurred in 1 patient. The median time to baseline testosterone recovery after the completion of treatment was prolonged at 487 days (95% confidence interval, 457-546 days). The nomogram's predicted versus observed freedom from disease progression was significantly different for the combination D(HT) and D(CHT) group (P<.00001). TAX-3501 illustrated several difficulties involved in conducting postoperative adjuvant systemic trials in men with high-risk prostate cancer: the lack of consensus regarding patient selection and treatment, the need for long follow-up time, nonvalidated intermediate endpoints, evolving standard approaches, and the need for long-term research support. Except for selected patients at very high-risk of disease recurrence and death, surgical

  1. 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.

  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. Laparoscopic retroperitoneal lymph node dissection for high-risk pediatric patients with paratesticular rhabdomyosarcoma.

    PubMed

    Tomaszewski, Jeffrey J; Sweeney, Danielle D; Kavoussi, Louis R; Ost, Michael C

    2010-01-01

    Retroperitoneal lymph node dissection (RPLND) is recommended in children 10 years or older with paratesticular rhabdomyosarcoma (PTRMS). Primary tumors >5 cm are an additional risk factor for disease recurrence in the retroperitoneum. We report our experience with laparoscopic RPLND (LRPLND) in high-risk pediatric patients with PTRMS. Three patients, mean age 13.6 years (range 10-16 yrs), underwent modified template LRPLND after radical orchiectomy for preoperative rhabdomyosarcoma stage T(1a)N(0)M(0), T(1b)N(0)M(0), and T(2b)N(0)M(0), respectively. Primary paratesticular masses measured a mean 7.5 cm (range 4-10 cm). LRPLND was performed a mean of 8.6 days (range 7-12 d) after radical orchiectomy using four trocars that were placed equidistant in the midline. Average operative time was 382 minutes (range 245-656 minutes). Mean estimated blood loss was 53 mL (range 10-75 mL), and mean postoperative hospital stay was 2.5 days (range 2-3 d). There were no postoperative complications. Retroperitoneal nodes had negative findings for microscopic disease in two patients and positive findings in one patient. All patients received adjuvant chemotherapy with vincristine, actinomycin, and cyclophosphamide. LRPLND for high-risk pediatric patients with PTRMS is a safe diagnostic and therapeutic procedure with the benefit of rapid convalescence, enabling early commencement of adjuvant chemotherapy.

  4. Gastric ESD under Heparin Replacement at High-Risk Patients of Thromboembolism Is Technically Feasible but Has a High Risk of Delayed Bleeding: Osaka University ESD Study Group.

    PubMed

    Yoshio, Toshiyuki; Nishida, Tsutomu; Kawai, Naoki; Yuguchi, Kiyonori; Yamada, Takuya; Yabuta, Takamasa; Komori, Masato; Yamaguchi, Shinjiro; Kitamura, Shinji; Iijima, Hideki; Tsutsui, Shusaku; Michida, Tomoki; Mita, Eiji; Tsujii, Masahiko; Takehara, Tetsuo

    2013-01-01

    Objectives. Heparin replacement (HR) is often performed in patients with a high risk of thrombosis undergoing endoscopic procedures. However, information about the influence of HR is scarce. The aim of this study is to assess the clinical impact of HR for gastric endoscopic submucosal dissection (ESD). Methods. This is a retrospective study comprising approximately 1310 consecutive gastric neoplasms in 1250 patients, who underwent ESD in 5 institutes. We assessed the clinical findings and outcomes of ESD under HR, compared to ESD without HR as control. Results. A total of 24 EGC lesions in 24 patients were treated by ESD under HR. In the HR group, the complete en-bloc resection rate was 100%. The delayed bleeding rate was, however, higher in the HR group than in the controls (38% versus 4.6%). The timing of bleeding in the HR group was significantly later than in controls. In the control group, 209 patients discontinued antithrombotic therapy during perioperative period, and their delayed bleeding rate was not different from those without antithrombotic therapy (5.7% versus. 4.4%). A thromboembolic event was encountered in 1 patient under HR after delayed bleeding. Conclusion. ESD under HR is technically feasible but has a high risk of delayed bleeding.

  5. 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

  6. 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.

  7. 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

  8. Symptom experiences of family members of intensive care unit patients at high risk for dying.

    PubMed

    McAdam, Jennifer L; Dracup, Kathleen A; White, Douglas B; Fontaine, Dorothy K; Puntillo, Kathleen A

    2010-04-01

    To describe the symptom experiences of family members of patients at high risk for dying in the intensive care unit and to assess risk factors associated with higher symptom burden. Prospective, cross-sectional study. Three intensive care units at a large academic medical center. A sample of 74 family members of 74 intensive care unit patients who had a grave prognosis and were judged to be at high risk for dying. Patients at high risk for dying were identified as having Acute Physiology and Chronic Health Evaluation II scores >20, an intensive care unit length of stay >72 hrs, and being mechanically ventilated. None. We assessed the degree of symptom burden approximately 4 days after the patient's admission to the intensive care unit in the following domains: traumatic stress, anxiety, and depression. Overall, the prevalence of symptoms was high, with more than half (57%) of family members having moderate to severe levels of traumatic stress, 80% having borderline symptoms of anxiety, and 70% having borderline symptoms of depression. More than 80% of family members had other physical and emotional symptoms, such as fatigue, sadness, and fear, and these were experienced at the moderate to severe levels of distress. Factors independently associated with greater severity of symptoms included younger age, female gender, and non-white race of the family member. The only patient factor significantly associated with symptom severity was younger age. Despite their symptom experience, the majority of the family members were coping at moderate to high levels and functioning at high levels during the intensive care unit experience. We document a high prevalence of psychological and physical symptoms among family members during an intensive care unit admission. These data complement existing data on long-term symptom burden and highlight the need to improve family centered care in intensive care units.

  9. Short article: Negative small-bowel cross-sectional imaging does not exclude capsule retention in high-risk patients.

    PubMed

    Rondonotti, Emanuele; Soncini, Marco; Girelli, Carlo M; Russo, Antonio; de Franchis, Roberto

    2016-08-01

    Both Agile patency capsule (PC) and small-bowel cross-sectional imaging (SBCSI) techniques have been used to assess small-bowel patency in patients at high risk of capsule retention. The present study aimed to compare capsule retention rates in high-risk patients with negative PC or SBCSI. Between January 2011 and December 2013, consecutive patients undergoing small-bowel capsule endoscopy (SBCE) in the Lombardia region were prospectively entered into a dedicated registry. They were classified as being at high or low risk of capsule retention by the local investigator according to predefined clinical criteria. High-risk patients underwent either PC or SBCSI depending on local expertise and availability; those who tested negative underwent SBCE. Out of 3117 patients (male/female: 1667/1450, mean age: 63.1±17.7), 2942 (94.4%) were classified as being at low risk and 175 (5.6%) were classified as being at high risk for capsule retention. Among 175 high-risk patients, 151 (86.3%) had negative PC and 24 (13.7%) had negative SBCSI: capsule retention occurred in two patients with negative SBCSI (8.3%) and in one patient (0.7%) with negative PC (P=0.049). The capsule retention rates in high-risk patients with negative PC and in low-risk patients (20/2942; 0.7%) were comparable (P=1.0). The capsule retention rate is similar in low-risk and negative PC high-risk patients. Conversely, high-risk patients with negative SBCSI have a significantly higher capsule retention rate. Our data suggest that in high-risk patients, negative SBCSI examination is not reassuring and, when SBCE is indicated, PC should be performed.

  10. 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.

  11. 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

  12. 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.

  13. Outcomes and Cost Analysis in High-Risk Patients Undergoing Simultaneous Free Flap Breast Reconstruction and Gynecologic Procedures.

    PubMed

    Del Corral, Gabriel A; Wes, Ari M; Fischer, John P; Serletti, Joseph M; Wu, Liza C

    2015-11-01

    statistically significant difference in the average total cost when comparing the group of patients receiving prophylactic mastectomy/FFR/total abdominal hysterectomy and/or BSO versus the patients who did not have combined gynecologic procedures at the time of reconstruction ($22,994.52 vs $21,029.23, P = 0.0004). For the high-risk breast cancer patient, a combined mastectomy, free flap reconstruction, and gynecologic procedure represents an attractive and safe option.

  14. 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.

  15. High risk of primary liver cancer in a cohort of 179 patients with Acute Hepatic Porphyria.

    PubMed

    Sardh, Eliane; Wahlin, Staffan; Björnstedt, Mikael; Harper, Pauline; Andersson, Dan E H

    2013-11-01

    Previous studies have indicated a high risk of hepatocellular carcinoma in acute hepatic porphyrias. In this retrospective study we present the incidence of primary liver cancer and clinical characteristics in a cohort of 179 acute porphyria patients above the age of 50 years. Twenty-three cases with primary liver cancer were found either by a surveillance program or due to clinical suspicion. Standardized rate ratio was used to estimate the relative risk of primary liver cancer after indirect standardization. Survival data were calculated using the Kaplan-Meier method. The mean age at diagnosis was 69 years. Hepatocellular carcinoma was found in 19 patients while four patients had cholangiocarcinoma or a combination of the two. Four patients had underlying cirrhosis. Mean tumour size was 4.3 cm in the surveillance group and 10.3 cm in the non-surveillance group (p = 0.01). The overall relative risk of primary liver cancer was 86 above the age of 50: 150 for women and 37 for men. Mean survival time was 5.7 years. Acute hepatic porphyria carries a high risk of primary liver cancer above the age of 50 which warrants ultrasound surveillance. Sex distribution and frequency of cirrhosis differs from more common aetiologies of primary liver cancer.

  16. Effects of carotid endarterectomy and carotid artery stenting on high-risk carotid stenosis patients.

    PubMed

    Wang, Peifu; Liang, Chunyang; Du, Jichen; Li, Jilai

    2013-11-01

    To analyze the clinical effects and safety of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in the treatment of high-risk carotid stenosis patients. Total 63 patients who underwent CEA or CAS in our hospitals from January 2007 to December 2012 were selected in this study, and were randomly divided into an observation group and a control group. The patients in the observation group were subjected to CAS and those in the control group were subjected to CEA to compare the primary and secondary endpoints of the treatment. The arrival rates of the primary and secondary endpoints were 7.14% and 10.71% respectively in the observation group, while those were 11.43% and 11.43% respectively in the control group. There were no significant differences in the arrival rates of primary and secondary endpoints between the two groups (P>0.05). The efficacies and safety of CAS and CEA are similar in treating high-risk carotid stenosis patients.

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

    PubMed

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

    2016-10-07

    Survival for patients with idiopathic pulmonary fibrosis (IPF) and high lung allocation score (LAS) values may be significantly reduced in comparison to those with lower LAS values. To evaluate outcomes for high-risk IPF patients as defined by LAS values ≥46 (N=42) versus recipients with LAS values <46 (N=89). We retrospectively reviewed records of 131 consecutive patients with IPF who received lung transplants at our institution between 1999 and 2013. The mean LAS was significantly higher (59.5, interquartile range 43.9-75.9 vs. 39.3, interquartile range 37.7-44.3; p<0.01) for the high-risk cohort. The higher LAS cohort had significantly lower percent predicted forced vital capacity (FVC) versus recipients with LAS <46 (41.3±14.1% vs. 53.2±16.2%; p<0.01) and required more supplemental oxygen (7±5 vs. 4±2 L/min, p<0.01) prior to transplant versus recipients with LAS <46. Although the incidence of early post-LTX pulmonary complications was increased for the higher LAS group versus recipients with LAS <46, 30-day mortality and actuarial survival did not differ between the two cohorts. Although lung transplantation in patients with IPF and high LAS values is associated with increased risk of early post-transplant complications, long-term post-transplant survival for our high-LAS cohort was equivalent to that for the lower LAS recipients.

  18. Prognostic impact of adjuvant chemotherapy in high-risk nasopharyngeal carcinoma patients.

    PubMed

    Liu, Yi-Chun; Wang, Wen-Yi; Twu, Chih-Wen; Jiang, Rong-San; Liang, Kai-Li; Wu, Ching-Te; Lin, Po-Ju; Huang, Jing-Wen; Hsieh, He-Yuan; Lin, Jin-Ching

    2017-01-01

    To investigate the prognostic impact of adjuvant chemotherapy (AdjCT) in patients with high-risk nasopharyngeal carcinoma (NPC). A total 403 NPC patients with at least one of the following criteria (1) neck node>6cm; (2) supraclavicular node metastasis; (3) skull base destruction/intracranial invasion plus multiple nodes metastasis; or (4) multiple neck nodes metastasis with one of nodal size>4cm were retrospectively reviewed. All patients finished curative radiotherapy±neoadjuvant/concurrent chemotherapy. Post-radiation AdjCT consisted of tegafur-uracil (two capsules twice daily) for 12months. We analyzed the treatment outcome between patients with (n=154) and without (n=249) AdjCT. Baseline patient characteristics at diagnosis (age, gender, pathological type, performance status, T-classification, N-classification, and overall stage) were comparable in both arms. After a median follow-up of 72months for surviving patients, 31.8% (49/154) and 42.2% (105/249) in patients with and without AdjCT developed tumor relapse respectively (P=0.0377). AdjCT improved both overall survival (HR 1.89, 95% CI 1.37-2.61, P=0.0001) and progression-free survival (HR 1.42, 95% CI 1.03-1.96, P=0.0322). There were significant reduction in distant failures (P=0.0016) but not in local (P=0.8587) or regional (P=0.8997) recurrences for patients who received AdjCT. AdjCT can reduce distant failure and improve overall survival in high-risk NPC patients after curative radiotherapy±neoadjuvant/concurrent chemotherapy. Copyright © 2016 Elsevier Ltd. All rights reserved.

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

    PubMed

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

    2015-12-01

    To explore the association between vitamin B12 deficiency and dementia in patients at high risk for vitamin B12 deficiency. Chart review. Emergency, critical care/ trauma, neurology, medicine, and rehabilitation units of two hospitals in Southwestern Ontario, Canada. Adult patients (n = 666) admitted from 2010 to 2012. Data collection included: reason for admission, gender, age, clinical signs and symptoms of B12 deficiency, serum B12 concentration, and B12 supplementation. Patients with dementia were identified based on their medication profile and medical history. Vitamin B12 deficiency (pmol/L) was defined as serum B12 concentration <148; marginal deficiency: ≥148-220 and adequate >220. Comparisons between B12-deficient patients with and without dementia were examined using parametric and non-parametric tests. Serum B12 values were available for 60% (399/666) of the patients, of whom 4% (16/399) were B12-deficient and 14% (57/399) were marginally deficient. Patients with dementia were not more likely to be B12-deficient or marginally deficient [21% (26/121)] compared to those with no dementia [17% (47/278), p=0.27)]. Based on documentation, 34% (25/73) of the B12-deficient and marginally-deficient patients did not receive B12 supplementation, of whom 40% (10/25) had dementia. In this sample of patients, there was no association between B12 deficiency and dementia. However, appropriate B12 screening protocols are necessary for high risk patient to identify deficiency and then receive B12 supplementation as needed.

  20. Perioperative outcome of laparoscopic sleeve gastrectomy for high-risk patients.

    PubMed

    Borbély, Yves; Juilland, Olivier; Altmeier, Julia; Kröll, Dino; Nett, Philipp C

    2017-02-01

    Morbidly obese patients with excessive concomitant disease carry a significantly increased perioperative risk. Although they may benefit most from a bariatric intervention, they are often denied surgery. Laparoscopic sleeve gastrectomy (LSG), as it is less complication-prone than other bariatric procedures, suits the needs of those patients. To review the short-term outcome of LSG for high-risk patients SETTING: University hospital, Switzerland. A total of 110 patients with high perioperative risk undergoing LSG between January 2008 and December 2014 were prospectively recorded. Patients were defined as "high-risk" if they met 2 of the following criteria: American Society of Anesthesiologists physical status score (ASA)>III, Obesity Surgery Mortality Risk Score (OS-MRS)≥4, Revised Cardiac Risk Index (RCRI) class IV, Obstructive Sleep Apnea-Severity Index (OSA-SI)≥5, renal insufficiency chronic kidney disease ≥3, liver cirrhosis, or history of life-threatening perioperative events. Of the patients, 59 (54%) were male. Median age was 49 years (range: 18-69), and median BMI was 51.7 kg/m(2) (38.7-89.2). Median operating time was 65 minutes (27-260). Eighty-six patients (78%) were classified as ASA IV, 65 (59%) as RCRI class IV, 51 (46%) as OS-MRS≥4 and 63 (57%) as OSA-SI≥5. Eighty-nine (81%) had type 2 diabetes, 70 (64%) were under antiplatelet and or anticoagulant therapy. Four patients (4%) were converted to open. Length of stay was 5 days (1-70). Major complications occurred in 12 patients (11%), including 1 mortality (1%). "High-risk"-patients identified using a combination of established obesity- and co-morbidity-related risk scores profit from LSG as part of a uniform treatment pathway. Given the severity of co-morbidities, LSG can be performed safely. (Surg Obes Relat Dis 2016;X:XXX-XXX.) © 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved. Copyright © 2016. Published by Elsevier Inc.

  1. The slot graft technique for foot and ankle arthrodesis in a high-risk patient group.

    PubMed

    Klein, Sandra E; Putnam, Ryan M; McCormick, Jeremy J; Johnson, Jeffrey E

    2011-07-01

    High rates of arthrodesis nonunion have been described in the ankle, hindfoot and midfoot in patients with significant risk factors. The purpose of this study was to evaluate fusion rates, risk of reoperation, postoperative pain scores and patient satisfaction for a slot graft inlay arthrodesis technique used in a high-risk group of foot and ankle patients. We retrospectively reviewed all ankle, hindfoot and midfoot arthrodeses by two foot and ankle surgeons in our institution between January 2000 and January 2009. Seventeen arthrodesis procedures in 16 patients using the slot graft technique were identified. Patient charts were reviewed for medical history, risk factors, previous surgery and postoperative complications. Time to union was evaluated on radiographs. Patients provided final followup by phone with an assessment of pain, overall satisfaction and use of orthotic or assistive devices. Union occurred in 13 arthrodesis procedures (77%) with an average time to union of 5 months. Postoperative infection occurred in one patient. Additional surgery was performed in nine patients. At final followup patients reported low pain scores (3 of 10) and high satisfaction (8 of 10). Fourteen of 15 patients contacted indicated that they would choose to undergo the procedure again. The slot graft arthrodesis technique provided satisfactory results in this small group of patients with a low complication rate. Patient satisfaction rates were high with low pain scores at an average of 62 months postoperatively.

  2. Clinician considerations when selecting high-risk patients for care management.

    PubMed

    Haime, Vivian; Hong, Clemens; Mandel, Laura; Mohta, Namita; Iezzoni, Lisa I; Ferris, Timothy G; Vogeli, Christine

    2015-10-01

    Hybrid approaches to case finding show promise as a method to increase the success of care management programs (CMPs). A large healthcare system implemented a hybrid approach in which clinicians review algorithm-generated lists of potential high-risk patients within their practice and select the patients most appropriate for the CMP. We sought to understand the criteria clinicians used when selecting patients. We conducted 20 semi-structured interviews with a convenience sample of primary care clinicians and their care managers from a diverse set of practices. Two independent reviewers thematically coded interview responses through an iterative process. In addition to clinical need (eg, disease severity or multiple comorbidities), interviewees considered a number of nonclinical patient characteristics that they felt placed patients at risk for suboptimal healthcare utilization and poor adherence. These include patients' predisposing (eg, health literacy or navigation challenges, physical vulnerabilities, insight regarding their health) and enabling characteristics (eg, social and home environment, coping skills, financial resources). Interviewees also considered patients' existing linkages with the health system and whether other clinicians were already meeting a patient's care needs. In selecting patients for a CMP, clinicians considered patient characteristics that are not easily captured in standard clinical and administrative data. A hybrid approach to case finding concentrates clinician review on patients who meet standard clinical and healthcare utilization criteria, and allows clinicians to incorporate knowledge of patients' predisposing and enabling characteristics that are not readily maintained in clinical data.

  3. 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?

  4. [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.

  5. 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.

  6. Genital warts in 250 Iranian patients and their high- risk sexual behaviors.

    PubMed

    Soori, Tahereh; Hallaji, Zahra; Noroozi-Nejad, Esmat

    2013-09-01

    Genital wart is the most common sexually transmitted disease worldwide. Sexual risk factors and sexual behavior pattern may be different in various countries. In this study, we tried to evaluate demographic information and some sexual behaviors and risk factors in Iranian patients with genital warts. In this cross-sectional study, 250 patients with anogenital warts were evaluated. They had been referred to the Sexually Transmitted Diseases Clinic of Razi Hospital. Demographic information and sexual risk factors and pattern of sexual behaviors were recorded in the questionnaires. One hundred twenty-five men and 125 women with genital warts were evaluated. The most common age group was 20- 30 years old; 24.8% were single; 29.6% had academic education; 35 (14%) of the patients had started sexual activity before 15 years of age; 92% reported unsafe sex;  seven (2.8%) of them were HIV infected; two cases (0.8%) were homosexual; and seven cases (2.8%) were bisexual. Genital herpes simplex type 2 was the most common coincident sexually transmitted disease (6.4%). Genital wart in men may be as common as women, married and singles, and mostly involves younger people. Sexual high-risk behaviors and unsafe sex make them at risk for HIV infection. Sexual health education should be considered in high-risk groups.

  7. [Remifentanil bolus for cesarean section in high-risk patients: study of 12 cases].

    PubMed

    Palacio, F J; Ortiz-Gómez, J R; Fornet, I; López, M A; Morillas, P

    2008-02-01

    To evaluate the utility and safety of remifentanil for hemodynamic control during cesarean section in high-risk patients ineligible for spinal anesthesia. One minute before induction we injected a bolus of 1 microg x kg(-1) of remifentanil, followed by propofol (2.5 mg x kg(-1)), succinylcholine (1 mg x kg(-1)), cisatracurium, sevoflurane in oxygen and nitrous oxide, and fentanyl (5 microg x kg(-1)) after clamping the umbilical cord. We recorded maternal hemodynamic variables, pulse oximetry, capnography, bispectral index, and presence of muscular rigidity. In the neonate we assessed fetal wellbeing, weight, and requirement for naloxone. Hemodynamic stability was defined as no more than 15% variation in arterial pressure with respect to baseline. Twelve patients undergoing surgery because of placenta abruptio, subarachnoid hemorrhage, HELLP syndrome, or preeclampsia were enrolled. Hemodynamic variables were consistently stable during surgery in all patients. No cases of neonatal rigidity were noted and there was no need for naloxone. The mean Apgar score was 6.42 (1.5) at 1 minute and 8.42 (0.9) at 5 minutes. Bolus injection of 1 microg x kg(-1) of remifentanil may be useful for maintaining maternal hemodynamic stability in high-risk obstetric cases. Given the risk of neonatal depression, this resource should be used selectively and the means for neonatal resuscitation should be available.

  8. Pragmatic fluid optimization in high-risk surgery patients: when pragmatism dilutes the benefits.

    PubMed

    Reuter, Daniel A

    2012-01-31

    There is increasing evidence that hemodynamic optimization by fluid loading, particularly when performed in the early phase of surgery, is beneficial in high-risk surgery patients: it leads to a reduction in postoperative complications and even to improved long-term outcome. However, it is also true that goal- directed strategies of fluid optimization focusing on cardiac output optimization have not been applied in the clinical routine of many institutions. Reasons are manifold: disbelief in the level of evidence and on the accuracy and practicability of the required monitoring systems, and economics. The FOCCUS trial examined perioperative fluid optimization with a very basic approach: a standardized volume load with 25 ml/kg crystalloids over 6 hours immediately prior to scheduled surgery in high-risk patients. The hypothesis was that this intervention would lead to a compensation of preoperative fluid deficit caused by overnight fasting, and would result in improved perioperative fluid homeostasis with less postoperative complications and earlier hospital discharge. However, the primary study endpoints did not improve significantly. This observation points towards the facts that: firstly, the differentiation between interstitial fluid deficit caused by fasting and intravascular volume loss due to acute blood loss must be recognized in treatment strategies; secondly, the type of fluid replacement may play an important role; and thirdly, protocolized treatment strategies should also always be tailored to suit the patients' individual needs in every individual clinical situation.

  9. Staircase falls: high-risk groups and injury characteristics in 464 patients.

    PubMed

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

    2009-08-01

    Few data are available about the epidemiology and injury characteristics in staircase falls. The available literature mainly concerns children and autopsy studies. To describe the epidemiology and injury characteristics of staircase falls, and to identify high-risk groups for these falls. All patients who reported to an academic Accident & Emergency (A&E) department in 2005 after a staircase fall were selected in the Dutch Injury Surveillance System These data were linked to the hospital Trauma Registry database. Four hundred and sixty-four patients (42% male, p=0.001), with a median age of 35 years were included. Children under five suffered significantly more head injuries. Male patients showed significantly more thoracic injuries than female patients. Spinal column fractures were only seen in patients over 25 years of age. Older patients tended to accumulate more rib fractures and lower extremity fractures and were admitted more frequently than the younger patients. Sixty-one patients (13%) required admission. Two patients, both with severe traumatic brain injury (TBI), died. National data on staircase falls were comparable with our hospital data. However, in comparison to the national population data, senior citizens in this study had an incidence that was markedly higher than in the younger patients. Injuries due to staircase falls occur in all age groups, however, children under five years are relatively over-represented with higher rates of head injury. Senior citizens showed a markedly higher incidence than younger patients. Most injuries occur to the distal extremities and are relatively mild.

  10. 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

  11. 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.

  12. Dalteparin thromboprophylaxis in cancer patients at high risk for venous thromboembolism: A randomized trial.

    PubMed

    Khorana, Alok A; Francis, Charles W; Kuderer, Nicole M; Carrier, Marc; Ortel, Thomas L; Wun, Ted; Rubens, Deborah; Hobbs, Susan; Iyer, Renuka; Peterson, Derick; Baran, Andrea; Kaproth-Joslin, Katherine; Lyman, Gary H

    2017-03-01

    Ambulatory cancer patients at high-risk for venous thromboembolism (VTE) can be identified using a validated risk score (Khorana score). We evaluated the benefit of outpatient thromboprophylaxis with dalteparin in high-risk patients in a multicenter randomized study. Cancer patients with Khorana score≥3 starting a new systemic regimen were screened for VTE and if negative randomized to dalteparin 5000units daily or observation for 12weeks. Subjects were screened with lower extremity ultrasounds every 4weeks on study and with chest CT at 12weeks. The primary efficacy endpoint was all VTE over 12weeks and primary safety endpoint was clinically relevant bleeding events over 13weeks. The study was terminated early due to low accrual. Of 117 enrolled patients, 10 (8.5%) had VTE on baseline screening and were not randomized. Of 98 randomized patients, VTE occurred in 12% (N=6/50) of patients on dalteparin and 21% (N=10/48) on observation (hazard ratio, HR 0.69, 95% CI 0.23-1.89). Major bleeding was similar (N=1) in each arm but clinically relevant bleeding was higher in dalteparin arm (N=7 versus 1 on observation) (HR=7.0, 95% CI 1.2-131.6). There was no difference in overall survival. Thromboprophylaxis is associated with a non-significantly reduced risk of VTE and significantly increased risk of clinically relevant bleeding in this underpowered study. The Khorana score successfully identifies patients with high incidence of VTE both at baseline and during treatment. Future studies should continue to focus on risk-adapted approaches to reduce the burden of VTE in cancer. clinicaltrials.gov identifier: NCT00876915. Copyright © 2017 Elsevier Ltd. All rights reserved.

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

    PubMed

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

    2016-01-01

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

  14. 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.

  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. Hospitalist-orthopedic co-management of high-risk patients undergoing lower extremity reconstruction surgery.

    PubMed

    Pinzur, Michael S; Gurza, Edward; Kristopaitis, Theresa; Monson, Rebecca; Wall, Michael J; Porter, Anne; Davidson-Bell, Victoria; Rapp, Timothy

    2009-07-01

    The introduction of the hospitalist co-management model represents an opportunity to improve care by changing the system as it applies to a small group of patients. Eighty-six consecutive patients with multiple comorbidities were selectively enrolled in an academic medical center hospitalist-orthopedic surgery co-management patient care program. Patients were stratified by all patient refined diagnosis-related groups, severity of illness, and risk of mortality. Hospital length of stay, cost of care, in-hospital mortality, complications, and intensive care unit admissions were compared with a retrospectively constructed control group of 54 patients undergoing similar surgery during the period immediately preceding initiation of the program. The University Health System Consortium observed-to-expected ratio for hospital length of stay was 0.693 compared to 0.862 for the control group. The severity of illness and risk of mortality scores represented a relatively higher risk stratification in the study group. While the overall observed-to-expected cost of care remained virtually unchanged, the positive impact of the study model revealed an increased positive effect on the more severely affected severity of illness and risk of mortality patients. The results of this study suggest that a proactive, cooperative, co-management model for the perioperative management of high-risk patients undergoing complex surgery can improve the quality and efficiency metrics associated with the delivery of service to patients.

  18. [Coronary surgery without extracorporeal circulation: the short-term results in high-risk patients].

    PubMed

    Pompilio, G; Antona, C; Cannata, A; Lotto, A; Alamanni, F; Gelpi, G; Tartara, P; Biglioli, P

    1999-03-01

    This study was conducted to assess the impact of coronary bypass surgery (CABG) without cardiopulmonary bypass (CPB) on high-risk patients. From February 1997 to July 1998, 71 patients considered at high-risk underwent a CABG off-pump. Using the "Higgins score", eleven preoperative risk factors were identified and stratified in this group of patients. Among 1271 patients who underwent CABG with CPB in the same period, using a computer-based matched comparison, a second identical group of patients was selected according to the 11 risk variables and the number with coronary disease, so that complete preoperative matching included the year of operation, score index and coronary target. Moreover, among seven other preoperative variables that were not included in the matching comparison, the two groups differed only in mean age (64 +/- 10.9 vs 61.6 +/- 7.3 in groups off and on-pump, respectively, p < 0.05). Postoperative outcome and complications and blood requirement were compared. Myocardial cell injury and left ventricular performance were also assessed in the two groups. The global incidence of neurologic complications in the off-pump group was significantly lower (9.8 vs 0%, in on and off-pump groups, respectively; p = 0.02). Patients undergoing CABG off-pump required blood far less often (% of transfused patients: 26.7% for the patients with CPB and 11.2% for the patients without CPB; p = 0.032). Three patients from the on-pump group (4.2%) had a perioperative myocardial infarction (AMI), versus 0% of the off-pump cases (p = ns). Postoperative atrial fibrillation accounted for 14.1% in off-pump patients and 30.9% in on-pump patients (p = 0.027). One patient in both groups (1.4%) suffered from postoperative heart failure. Mean ventilation time and ICU stay did not differ significantly between the two groups. However, hospital discharge occurred earlier in the off-pump group (9.3 +/- 3 vs 12.6 +/- 8, p = 0.007). In-hospital death occurred in one case from the on

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

    PubMed

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

    2011-01-01

    Dopexamine has been shown to reduce both mortality and morbidity in major surgery when it is used as part of a protocol to increase oxygen delivery in the perioperative period. A European multicenter study has examined the use of dopexamine in patients undergoing major abdominal surgery, showing a trend toward improved survival and reduced complications in high-risk patients when receiving low-dose dopexamine (0.5 μg · kg(-1) · min(-1)). A reduced oxygen uptake at the anaerobic threshold (AT) has been shown to confer a significant risk of mortality in patients undergoing major abdominal surgery and allows objective identification of a high-risk operative group. In this study, we assessed the effects of low-dose dopexamine on morbidity after major abdominal surgery in patients who were at increased risk by virtue of a reduced AT. Patients undergoing elective major colorectal or urological surgery who had an AT of <11 mL · kg(-1) · min(-1) or an AT of 11 to 14 mL · kg(-1) · min(-1) with a history of ischemic heart disease were recruited. Before surgery, a radial arterial cannula was placed and attached to an Edwards Lifesciences FloTrac/Vigileo system for measuring cardiac output. Patients were given a 250-mL bolus of Voluven (6% hydroxyethyl starch 130/0.4 in 0.9% sodium chloride) until the stroke volume no longer increased by 10%, then received either dopexamine (0.5 μg · kg(-1) · min(-1)) or saline 0.9% for 24 hours. During surgery, fluid boluses of Voluven were given if the stroke volume variation was >10%. No crystalloid was given during surgery. A standardized postoperative fluid regime with Hartmann solution was prescribed at 1.5 mL · kg(-1) · h(-1) for 24 hours. The primary outcome measure was postoperative morbidity measured by the Postoperative Morbidity Survey. One hundred twenty-four patients were recruited over a 23-month period. The incidence of morbidity as measured by the Postoperative Morbidity Survey on day 5 was 55% in the control group

  20. Left atrial appendage occlusion in high-risk patients with non-valvular atrial fibrillation.

    PubMed

    Berti, Sergio; Pastormerlo, Luigi Emilio; Rezzaghi, Marco; Trianni, Giuseppe; Paradossi, Umberto; Cerone, Elisa; Ravani, Marcello; De Caterina, Alberto Ranieri; Rizza, Antonio; Palmieri, Cataldo

    2016-12-15

    Percutaneous left atrial appendage (LAA) occlusion has been developed as a viable option for stroke and thromboembolism prevention in patients with non-valvular atrial fibrillation (NVAF) and at high risk for cerebral cardioembolic events. Data on device implantation and long-term follow-up from large cohorts are limited. 110 consecutive patients with NVAF and contraindications to oral anticoagulants (OACs) underwent LAA occlusion procedures and achieved a longer than 1 year follow-up. All patients were enrolled in a prospective registry. Procedures were performed using the Amplatzer Cardiac Plug or Amulet guided by fluoroscopy and intracardiac echocardiography. Mean age of the population was 77±6 years old; 68 were men. Atrial fibrillation was paroxysmal in 20%, persistent in 15.5% and permanent in 64.5% of cases, respectively. Mean CHA2DS2-VASc and HAS-BLED scores were 4.3±1.3 and 3.4±1, respectively. Technical success (successful deployment and implantation of device) was achieved in 100% of procedures. Procedural success (technical success without major procedure-related complications) was achieved in 96.4%, with a 3.6% rate of major procedural complications (three cases of pericardial tamponade requiring drainage and one case of major bleeding). Mean follow-up was 30±12 months (264 patient-years). Annual rates for ischaemic stroke and for other thromboembolic events were respectively 2.2% and 0%, and annual rate for major bleeding was 1.1%. Our data suggest LAA occlusion in high-risk patients with NVAF not suitable for OACs is feasible and associated with low complication rates as well as low rates of stroke and major bleeding at long-term follow-up. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

  1. Can hospitals "game the system" by avoiding high-risk patients?

    PubMed

    Chang, David C; Anderson, Jamie E; Yu, Peter T; Cajas, Luis C; Rogers, Selwyn O; Talamini, Mark A

    2012-07-01

    It has been suggested that implementation of quality-improvement benchmarking programs can lead to risk-avoidance behaviors in some physicians and hospitals in an attempt to improve their rankings, potentially denying patients needed treatment. We hypothesize that avoidance of high-risk patients will not change risk-adjusted rankings. We conducted a simulation analysis of 6 complex operations in the Nationwide Inpatient Sample, including abdominal aortic aneurysm repair, aortic valve replacement, coronary artery bypass grafting, percutaneous coronary intervention, esophagectomy, and pancreatic resection. Primary outcomes included in-hospital mortality. Hospitals were ranked into quintiles based on observed-to-expected (O/E) mortality ratios, with their expected mortalities calculated based on models generated from the previous 3 years. Half of the hospitals were then randomly selected to undergo risk avoidance by avoiding 25% of patients with higher than median risks (ie, Charlson, Elixhauser, age, minority, or uninsured status). Their new O/E ratios and hospital-rank categories were compared with their original values. A total of 2,235,298 patients were analyzed, with an overall observed mortality rate of 1.9%. Median change in O/E ratios across all simulations was zero, and O/E ratios did not change in 97.5% to 99.3% of the hospitals, depending on the risk definitions. Additionally, 70.5% to 98.0% of hospital rankings remained unchanged, 1.3% to 13.1% of hospital rankings improved, and 0.7% to 14.3% of hospital rankings worsened after risk avoidance. Risk-adjusted rankings of hospitals likely cannot be changed by simply avoiding high-risk patients. In the minority of scenarios in which risk-adjusted rankings changed, they were as likely to improve as worsen after risk avoidance. Copyright © 2012 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

  2. 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

  3. Telmisartan, ramipril, or both in high-risk Chinese patients: analysis of ONTARGET China data.

    PubMed

    Yu, Li-Tian; Zhu, Jun; Tan, Hui-Qiong; Wang, Guo-Gan; Teo, Koon K; Liu, Li-Sheng

    2011-06-01

    The results from the ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) indicated that the angiotensin-receptor blocker telmisartan was not inferior to the angiotensin-converting-enzyme inhibitor ramipril in reducing the composite endpoint of cardiovascular death, myocardial infarction, stroke or hospitalization for congestive heart failure in high-risk patients, and telmisartan was associated with slightly superior tolerability. The combination of the two drugs was associated with more adverse events without an increase in benefit. This study aimed to analyze the data from ONTARGET obtained from a subgroup of patients enrolled in China and to evaluate the demographic and baseline characteristics, the compliance, efficacy, and safety of the different treatment strategies in randomized patients in China. A total of 1159 high-risk patients were randomized into three treatment groups: with 390 assigned to receive 80 mg of telmisartan, 385 assigned to receive 10 mg of ramipril and 384 assigned to receive both study medications. The median follow-up period was 4.3 years. The mean age of Chinese patients was 65.6 years, 73.6% of patients were male. The proportion of patients with stroke/transient ischemic attacks at baseline in China was two times more than the entire study population (47.7% vs. 20.9%). In Chinese patients the proportion of permanent discontinuation of study medication due to cough was 0.5% in the telmisartan group, which was much less than that in the combination or the ramipril group. There were no significant differences in the incidence of primary outcome among three treatment groups of Chinese patients. More strokes occurred in Chinese patients than in the entire study population (8.5% vs. 4.5%). Greater systolic blood pressure reduction (-9.8 mmHg), and more renal function failure were noted in the combination treatment group than in the ramipril or telmisartan group (2.6% vs. 1.6% and 1.0%). There was no

  4. 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

  5. Retroperitoneal sarcoma (RPS) high risk gross tumor volume boost (HR GTV boost) contour delineation agreement among NRG sarcoma radiation and surgical oncologists.

    PubMed

    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

    2015-09-01

    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. 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. 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. 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.

  6. 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.

  7. 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

  8. 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

    2017-05-01

    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. Copyright © 2017 Elsevier B.V. and ECNP. All rights reserved.

  9. 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.

  10. Practice, Knowledge, and Barriers for Screening of Hepatocellular Carcinoma Among High-Risk Chinese Patients.

    PubMed

    Xu, Kerui; Watanabe-Galloway, Shinobu; Rochling, Fedja A; Zhang, Jianjun; Farazi, Paraskevi A; Peng, Hongyan; Wang, Hongmei; Luo, Jiangtao

    Hepatocellular carcinoma (HCC) is among the leading causes of cancer deaths in China. Considering its poor prognosis when diagnosed late, Chinese guidelines recommend biannual screening for HCC with abdominal ultrasound and serum α-fetoprotein (AFP) test for high-risk populations. To investigate the practice, knowledge, and self-perceived barriers for HCC screening among high-risk hospital patients in China. An interview-based questionnaire was conducted among Chinese patients with chronic hepatitis B and/or chronic hepatitis C infection from outpatient clinics at 2 tertiary medical institutions in Shanghai and Wuhan, China. Among 352 participating patients, 50.0% had routine screening, 23.3% had irregular screening, and 26.7% had incomplete or no screening. Significant determinants for screening included higher level of education, underlying liver cirrhosis, a family history of HCC, and better knowledge concerning viral hepatitis, HCC, and HCC screening guidelines. Moreover, factors associated with better knowledge were younger age, female gender, urban residency, education level of college or above, annual household income of greater than 150,000 RMB, and longer duration of hepatitis infection. The 3 most common barriers reported for not receiving screening were not aware that screening for HCC exists (41.5%), no symptoms or discomfort (38.3%), and lack of recommendation from physicians (31.9%). Health care professionals and community leaders should actively inform patients regarding the benefits of HCC screening through design of educational programs. Such interventions are expected to increase knowledge about HCC and HCC screening, as well as improve screening adherence and earlier diagnosis. Copyright © 2017 Icahn School of Medicine at Mount Sinai. Published by Elsevier Inc. All rights reserved.

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

    PubMed

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

    2017-01-01

    Objective The Kyoto gastritis classification categorizes the endoscopic characteristics of Helicobacter pylori (H. pylori) infection-associated gastritis and identifies patterns associated with a high risk of gastric cancer. We investigated its efficacy, comparing scores in patients with H. pylori-associated gastritis and with gastric cancer. Methods A total of 1,200 patients with H. pylori-positive gastritis alone (n=932), early-stage H. pylori-positive gastric cancer (n=189), and successfully treated H. pylori-negative cancer (n=79) were endoscopically graded according to the Kyoto gastritis classification for atrophy, intestinal metaplasia, fold hypertrophy, nodularity, and diffuse redness. Results The prevalence of O-II/O-III-type atrophy according to the Kimura-Takemoto classification in early-stage H. pylori-positive gastric cancer and successfully treated H. pylori-negative cancer groups was 45.1%, which was significantly higher than in subjects with gastritis alone (12.7%, p<0.001). Kyoto gastritis scores of atrophy and intestinal metaplasia in the H. pylori-positive cancer group were significantly higher than in subjects with gastritis alone (all p<0.001). No significant differences were noted in the rates of gastric fold hypertrophy or diffuse redness between the two groups. In a multivariate analysis, the risks for H. pylori-positive gastric cancer increased with intestinal metaplasia (odds ratio: 4.453, 95% confidence interval: 3.332-5.950, <0.001) and male sex (1.737, 1.102-2.739, p=0.017). Conclusion Making an appropriate diagnosis and detecting patients at high risk is crucial for achieving total eradication of gastric cancer. The scores of intestinal metaplasia and atrophy of the scoring system in the Kyoto gastritis classification may thus be useful for detecting these patients.

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

    PubMed Central

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

    2017-01-01

    Objective The Kyoto gastritis classification categorizes the endoscopic characteristics of Helicobacter pylori (H. pylori) infection-associated gastritis and identifies patterns associated with a high risk of gastric cancer. We investigated its efficacy, comparing scores in patients with H. pylori-associated gastritis and with gastric cancer. Methods A total of 1,200 patients with H. pylori-positive gastritis alone (n=932), early-stage H. pylori-positive gastric cancer (n=189), and successfully treated H. pylori-negative cancer (n=79) were endoscopically graded according to the Kyoto gastritis classification for atrophy, intestinal metaplasia, fold hypertrophy, nodularity, and diffuse redness. Results The prevalence of O-II/O-III-type atrophy according to the Kimura-Takemoto classification in early-stage H. pylori-positive gastric cancer and successfully treated H. pylori-negative cancer groups was 45.1%, which was significantly higher than in subjects with gastritis alone (12.7%, p<0.001). Kyoto gastritis scores of atrophy and intestinal metaplasia in the H. pylori-positive cancer group were significantly higher than in subjects with gastritis alone (all p<0.001). No significant differences were noted in the rates of gastric fold hypertrophy or diffuse redness between the two groups. In a multivariate analysis, the risks for H. pylori-positive gastric cancer increased with intestinal metaplasia (odds ratio: 4.453, 95% confidence interval: 3.332-5.950, <0.001) and male sex (1.737, 1.102-2.739, p=0.017). Conclusion Making an appropriate diagnosis and detecting patients at high risk is crucial for achieving total eradication of gastric cancer. The scores of intestinal metaplasia and atrophy of the scoring system in the Kyoto gastritis classification may thus be useful for detecting these patients. PMID:28321054

  13. High-risk use by patients prescribed opioids for pain and its role in overdose deaths.

    PubMed

    Gwira Baumblatt, Jane A; Wiedeman, Caleb; Dunn, John R; Schaffner, William; Paulozzi, Leonard J; Jones, Timothy F

    2014-05-01

    From January 1, 2003, through December 31, 2010, drug overdose deaths in Tennessee increased from 422 to 1059 per year. More of these deaths involved prescription opioids than heroin and cocaine combined. To assess the contribution of certain opioid-prescribing patterns to the risk of overdose death. We performed a matched case-control study that analyzed opioid prescription data from the Tennessee Controlled Substances Monitoring Program (TNCSMP) from January 1, 2007, through December 31, 2011, to identify risk factors associated with opioid-related overdose deaths from January 1, 2009, through December 31, 2010. Case patients were ascertained from death certificate data. Age- and sex-matched controls were randomly selected from among live patients in the TNCSMP. We defined a high-risk number of prescribers or pharmacies as 4 or more per year and high-risk dosage as a daily mean of more than 100 morphine milligram equivalents (MMEs) per year. The main outcome was opioid-related overdose death. From January 1, 2007, through December 31, 2011, one-third of the population of Tennessee filled an opioid prescription each year, and opioid prescription rates increased from 108.3 to 142.5 per 100 population per year. Among all patients in Tennessee prescribed opioids during 2011, 7.6% used more than 4 prescribers, 2.5% used more than 4 pharmacies, and 2.8% had a mean daily dosage greater than 100 MMEs. Increased risk of opioid-related overdose death was associated with 4 or more prescribers (adjusted odds ratio [aOR], 6.5; 95% CI, 5.1-8.5), 4 or more pharmacies (aOR, 6.0; 95% CI, 4.4-8.3), and more than 100 MMEs (aOR, 11.2; 95% CI, 8.3-15.1). Persons with 1 or more risk factor accounted for 55% of all overdose deaths. High-risk use of prescription opioids is frequent and increasing in Tennessee and is associated with increased overdose mortality. Use of prescription drug–monitoring program data to direct risk-reduction measures to the types of patients overrepresented

  14. An emergency department registration kiosk can increase HIV screening in high risk patients.

    PubMed

    Hsieh, Yu-Hsiang; Gauvey-Kern, Megan; Peterson, Stephen; Woodfield, Alonzo; Deruggiero, Katherine; Gaydos, Charlotte A; Rothman, Richard E

    2014-12-01

    We evaluated the feasibility and the patient acceptability of integrating a kiosk into routine emergency department (ED) practice for offering HIV testing. The work was conducted in four phases: phase 1 was a baseline, in which external testing staff offered testing at the bedside; phase 2 was a pilot assessment of a prototype kiosk; phase 3 was a pilot implementation and phase 4 was the full implementation with automated login. Feasibility was assessed by the proportion of offering HIV tests, acceptance, completion and result reporting. During the study period, the number of ED patients and eligible patients for screening were similar in the three main phases. However, the number and proportion of patients offered testing of those eligible for screening increased significantly from phase 1 (32%) to phase 3 (37%) and phase 4 (40%). There were slightly higher prevalences of newly diagnosed HIV with kiosk versus bedside testing (phase 1, 0%; phase 3, 0.2%; phase 4, 0.5%). Compared to patients tested at the bedside, patients tested via the kiosk were significantly younger, more likely to be female, to be black, and to report high risk behaviours. ED-based HIV screening via a registration-based kiosk was feasible, yielded similar proportions of testing, and increased the proportion of engagement of higher-risk patients in testing. © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

  15. An emergency department registration kiosk can increase HIV screening in high risk patients

    PubMed Central

    Hsieh, Yu-Hsiang; Gauvey-Kern, Megan; Peterson, Stephen; Woodfield, Alonzo; Deruggiero, Katherine; Gaydos, Charlotte A; Rothman, Richard E

    2015-01-01

    Summary We evaluated the feasibility and the patient acceptability of integrating a kiosk into routine emergency department (ED) practice for offering HIV testing. The work was conducted in four phases: phase 1 was a baseline, in which external testing staff offered testing at the bedside; phase 2 was a pilot assessment of a prototype kiosk; phase 3 was a pilot implementation and phase 4 was the full implementation with automated login. Feasibility was assessed by the proportion of offering HIV tests, acceptance, completion and result reporting. During the study period, the number of ED patients and eligible patients for screening were similar in the three main phases. However, the number and proportion of patients offered testing of those eligible for screening increased significantly from phase 1 (32%) to phase 3 (37%) and phase 4 (40%). There were slightly higher prevalences of newly diagnosed HIV with kiosk versus bedside testing (phase 1, 0%; phase 3, 0.2%; phase 4, 0.5%). Compared to patients tested at the bedside, patients tested via the kiosk were significantly younger, more likely to be female, to be black, and to report high risk behaviours. ED-based HIV screening via a registration-based kiosk was feasible, yielded similar proportions of testing, and increased the proportion of engagement of higher-risk patients in testing. PMID:25316041

  16. Surveillance versus adjuvant radiotherapy for patients with high-risk stage I seminoma.

    PubMed

    Mortensen, Mette S; Bandak, Mikkel; Kier, Maria G G; Lauritsen, Jakob; Agerbaek, Mads; Holm, Niels V; von der Maase, Hans; Daugaard, Gedske

    2017-04-01

    The optimal treatment strategy for patients with clinical stage I (CS-1) seminoma is controversial. The objective of the current study was to evaluate the outcomes for patients considered to be at high risk of disease recurrence with a tumor size ≥6 cm. Patients were treated with either adjuvant radiotherapy (RT) or followed with surveillance. From the Danish Testicular Cancer database, the authors identified 473 patients with CS-1 seminoma with a tumor size ≥6 cm. Of these, 254 patients underwent adjuvant RT and 219 were followed with surveillance. Cumulative incidence function was applied to estimate the risk of disease recurrence, risk of second malignant neoplasm, and risk of receiving >1 line of treatment. Survival of the 2 groups was compared with the log-rank test and Cox model including age at diagnosis. No significant differences were found with regard to overall survival or risk of a second malignant neoplasm. Patients undergoing adjuvant RT received more treatments per patient than patients followed with surveillance, but there was no significant difference noted with regard to the risk of receiving >1 line of treatment. The 10-year cumulative incidence of disease recurrence was 32% versus 2.8%, respectively, for patients followed with surveillance and adjuvant RT. In patients followed with surveillance who developed disease recurrence, there was a high incidence of second recurrences after RT. The 10-year overall survival was found to be similar irrespective of primary treatment. Adjuvant RT was found to effectively reduce the rate of disease recurrence but resulted in the overtreatment of approximately two-thirds of the patients. The high incidence of second disease recurrences after RT in the patients followed with surveillance needs be addressed in future studies. Cancer 2017;123:1212-1218. © 2016 American Cancer Society. © 2016 American Cancer Society.

  17. 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.

  18. 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.

  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 Central

    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. PMID:26323560

  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. Prognostic factors in acute promyelocytic leukemia: strategies to define high-risk patients.

    PubMed

    Testa, Ugo; Lo-Coco, Francesco

    2016-04-01

    All trans retinoic acid (ATRA) has revolutionized the therapy of acute promyelocytic leukemia (APL). Treatment of this leukemia with ATRA in combination with chemotherapy has resulted in complete remission rates >90 % and long-term remission rates above 80 %. Furthermore, the combination of ATRA and arsenic trioxide (ATO) was shown to be safe and effective in frontline treatment and, for patients with low and intermediate risk disease, possibly superior to the standard ATRA and anthracycline-based regimen. However, in spite of this tremendous progress, APL still remains associated with a high incidence of early death due to the frequent occurrence of an abrupt bleeding diathesis. This hemorrhagic syndrome more frequently develops in high-risk APL patients, currently defined as those exhibiting >10 × 10(9)/L WBC at presentation. In addition to high WBC count, other molecular and immunophenotypic features have been associated with high-risk APL. Among them, the expression in APL blasts of the stem/progenitor cell antigen CD34, the neural adhesion molecule (CD56), and the T cell antigen CD2 help to identify a subset of patients at higher risk of relapse and often the expression of these markers is associated with high WBC count. At the molecular level, the short PML/RARA isoform and FLT3-internal tandem duplication (ITD) mutations have been associated with increased relapse risk. These observations indicate that extended immunophenotypic and molecular characterization of APL at diagnosis including evaluation of CD2, CD56, and CD34 antigens and of FLT3 mutations may help to better design risk-adapted treatment in this disease.

  2. 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.

  3. 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.

  4. 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

  5. Mechanical circulatory support: balancing bleeding and clotting in high-risk patients.

    PubMed

    Baumann Kreuziger, Lisa; Massicotte, M Patricia

    2015-01-01

    Mechanical circulatory support (MCS) provides a bridge to heart transplant in children and adults with life-threatening heart failure and sustains patients ineligible for transplant. Extracorporeal membrane oxygenation (ECMO) provides temporary support for patients in cardiac or pulmonary failure through external gas exchange and continuous flow of blood. Because the median time to heart transplant exceeds event-free time on ECMO, pulsatile left ventricular assist devices (LVADs) are used to support infants and children. Continuous flow LVADs are preferred in adolescents and adults due to increased pump durability and improved overall survival. The shear stress created by the mechanical pumps cause changes in the hematologic system; acquired von Willebrand syndrome occurs in almost all patients treated with MCS. Despite the improvements in survival, major bleeding occurs in one-third of patients with a LVAD and ischemic stroke and LVAD thrombosis can affect 12% of adults and 29% of children. An antithrombotic strategy to mitigate LVAD bleeding and thrombotic complications has been tested in a randomized trial in children, but intensity of antithrombotic therapy in adults varies widely. Consensus guidelines for antithrombotic therapy during ECMO were created due to significant differences in management across centers. Because of the high risk for both bleeding and thrombotic complications, experts in hemostasis can significantly impact care of patients requiring mechanical circulatory support and are a necessary part of the management team. © 2015 by The American Society of Hematology. All rights reserved.

  6. Validation of a Predictive Model to Identify Patients at High Risk for Hospital Readmission.

    PubMed

    Spiva, LeeAnna; Hand, Marti; VanBrackle, Lewis; McVay, Frank

    2016-01-01

    Hospital readmission is an adverse patient outcome that is serious, common, and costly. For hospitals, identifying patients at risk for hospital readmission is a priority to reduce costs and improve care. The purposes were to validate a predictive algorithm to identify patients at a high risk for preventable hospital readmission within 30 days after discharge and determine if additional risk factors enhance readmission predictability. A retrospective study was conducted on a randomized sample of 598 patients discharged from a Southeast community hospital. Data were collected from the organization's database and manually abstracted from the electronic medical record using a structured tool. Two separate logistic regression models were fit for the probability of readmission within 30 days after discharge. The first model used the LACE index as the predictor variable, and the second model used the LACE index with additional risk factors. The two models were compared to determine if additional risk factors increased the model's predictive ability. The results indicate both models have reasonable prognostic capability. The LACE index with additional risk factors did little to improve prognostication, while adding to the model's complexity. Findings support the use of the LACE index as a practical tool to identify patients at risk for readmission.

  7. 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.

  8. 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

  9. Orbit fractures: Identifying patient factors indicating high risk for ocular and periocular injury.

    PubMed

    Andrews, Brian T; Jackson, Anee Sophia; Nazir, Niaman; Hromas, Alan; Sokol, Jason A; Thurston, Todd E

    2016-02-01

    Maxillofacial trauma frequently involves the bony orbit that surrounds the ocular globe. Concomitant globe injury is a concern whenever orbit trauma occurs and in severe cases can occasionally result in vision loss. The mechanism of injury, physical exam findings, and radiographic imaging can provide useful information concerning the severity of the injury and concerns for vision loss. Using these three tools, it is hypothesized that the patient's history, physical exam, and radiographic findings can identify high-risk maxillofacial trauma patients with concomitant ocular injury. Identification of high risk patients who require comprehensive ophthalmologic evaluation may alter management and possibly preserve or restore vision. A retrospective clinical chart review was performed at a tertiary academic medical center. Subjects were identified using the institutional trauma registry. Data collected included subject demographics, patient medical records and notes, ophthalmologic testing, and radiographic imaging. The incidence of orbit fracture and concomitant ocular injury associated with the mechanism of injury, physical exam findings, and radiographic imaging was determined. Statistical analysis was performed using a chi-square and Fisher exact test. In this study, 279 subjects with orbit fractures were identified and the incidence of concomitant ocular injury was 27.6% (77 of 279). Mechanism of injury was statistically associated with an increased risk of ocular injury (P = 0.0340), with penetrating trauma being the most likely etiology. The physical exam findings of visual acuity and an afferent pupillary defect were statistically associated with ocular injury (P = 0.0029 and 0.0001, respectively). Depth of orbit fracture on radiographic imaging was statistically associated with ocular injury (P = 0.0024), with fractures extending to the posterior third of the orbit being most likely to have associated ocular injury. Maxillofacial trauma patients with orbit

  10. Do ACE inhibitors all provide the same outcomes benefits in high-risk cardiovascular patients?

    PubMed

    Lala, Anu; McLaughlin, Mary Ann

    2008-08-01

    The Heart Outcomes Prevention (HOPE) trial was the first to demonstrate the benefits of the angiotensin-converting enzyme (ACE) inhibitor ramipril for high-risk cardiovascular patients. Whether the cardioprotective effects seen in HOPE and other trials are specific to distinct ACE inhibitors remains controversial. Evidence of a lack of class effect for ACE inhibitors has policy and financial implications related to reference pricing by insurers and inclusion on pharmacy formularies. Because head-to-head trials comparing the different ACE inhibitors are unforeseen, clinicians and administrators must rely on secondary-level data and observational studies. Only a handful of studies have sought to address the dispute over a class effect among ACE inhibitors, which is reviewed in this article.

  11. Structural brain alterations in patients with major depressive disorder and high risk for suicide: evidence for a distinct neurobiological entity?

    PubMed

    Wagner, Gerd; Koch, Kathrin; Schachtzabel, Claudia; Schultz, C Christoph; Sauer, Heinrich; Schlösser, Ralf G

    2011-01-15

    Major depressive disorder (MDD) is associated with a considerably increased risk for suicide. There is evidence to suggest that a predisposition to suicidal behavior may exist which is independent of the disorder itself. Furthermore, suicide attempters with mood disorders have an up to sixfold higher rate of suicidal behavior in first-degree relatives than non-suicidal patients. Genetic and nongenetic factors may play a role in the familial transmission of suicidal behavior. One of these factors may be neurobiological alterations, the knowledge about which is still limited. The main goal was therefore to study morphometric brain abnormalities in the hypothesized fronto-limbic network in depressed patients with high risk for suicide in contrast to non-high risk depressed patients. 15 patients with MDD and with own suicidal behavior and/or with suicidal behavior in first-degree relatives defined as a high risk group, 15 depressed patients with non-high risk for suicide and 30 matched healthy controls participated in the study. We applied the voxel-based morphometry protocol to structural T1-weighted volumes. Patients with high risk for suicide showed significantly decreased gray matter density in a fronto-striato-limbic network in contrast to matched healthy controls and in caudate and rostral anterior cingulate cortex in contrast to non-high risk patients. In the latter patient group no significant gray matter alterations were detected. This new finding provides evidence for structural brain alterations in depressed patients with high risk for suicide in a brain network strongly involved in emotional and motivational control reflecting a potentially distinct neurobiological entity.

  12. 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

  13. Health expenditures among high-risk patients after gastric bypass and matched controls.

    PubMed

    Maciejewski, Matthew L; Livingston, Edward H; Smith, Valerie A; Kahwati, Leila C; Henderson, William G; Arterburn, David E

    2012-07-01

    To determine whether bariatric surgery is associated with reduced health care expenditures in a multisite cohort of predominantly older male patients with a substantial disease burden. Retrospective cohort study of bariatric surgery. Outpatient, inpatient, and overall health care expenditures within Department of Veterans Affairs (VA) medical centers were examined via generalized estimating equations in the propensity-matched cohorts. Bariatric surgery programs in VA medical centers. Eight hundred forty-seven veterans who were propensity matched to 847 nonsurgical control subjects from the same 12 VA medical centers. Bariatric surgical procedures. Health expenditures through December 2006. Outpatient, inpatient, and total expenditures trended higher for bariatric surgical cases in the 3 years leading up to the procedure and then converged back to the lower expenditure levels of nonsurgical controls in the 3 years after the procedure. Based on analyses of a cohort of predominantly older men, bariatric surgery does not appear to be associated with reduced health care expenditures 3 years after the procedure.

  14. What Do High-Risk Patients Value? Perspectives on a Care Management Program.

    PubMed

    Ganguli, Ishani; Orav, E John; Weil, Eric; Ferris, Timothy G; Vogeli, Christine

    2017-10-05

    There is growing interest in coordinating care for high-risk patients through care management programs despite inconsistent results on cost reduction. Early evidence suggests patient-centered benefits, but we know little about how participants engage with the programs and what aspects they value. To explore care management program participants' awareness and perceived utility of program offerings. Cross-sectional telephone survey administered December 2015-January 2016. Patients enrolled in a Boston-area primary care-based care management program. Our main outcome was the number of topics in which patients reported having "very helpful" interactions with their care team in the past year. We analyzed awareness of one's care manager as an intermediate outcome, and then as a primary predictor of the main outcome, along with patient demographics, years in the program, attitudes, and worries as secondary predictors. The survey response rate was 45.8% (n = 1220); non-respondents were similar to respondents. More respondents reported worrying about family (72.8%) or financial issues (52.5%) than about their own health (41.6%). Seventy-four percent reported care manager awareness, particularly women (OR 1.33, 95% CI 1.01-1.77) and those with more years in the program (OR 1.16, 95% CI 1.03-1.30). While interaction rates ranged from 19.8% to 72.4% across topics, 81.3% rated at least one interaction as very helpful. Those who were aware of their care manager reported very helpful interactions on more topics (OR 2.77, 95% CI 2.15-3.56), as did women (OR 1.25, 95% CI 1.00-1.55), younger respondents (OR 0.98 for older age, 95% CI 0.97-0.99), and those with higher risk scores (OR 1.04, 95% CI 1.02-1.06), preference for deferring treatment decisions to doctors (OR 2.00, 95% CI 1.60-2.50), and reported control over their health (OR 1.67, 95% CI 1.33-2.10). High-risk patients reported helpful interactions with their care team around medical and social determinants of health

  15. Prognostic Implications of Non-Invasive Vascular Function Tests in High-Risk Atherosclerosis Patients.

    PubMed

    Kusunose, Kenya; Sato, Mitsuyo; Yamada, Hirotsugu; Saijo, Yoshihito; Bando, Mika; Hirata, Yukina; Nishio, Susumu; Hayashi, Shuji; Sata, Masataka

    2016-01-01

    The aim of this study was to assess the role of clinically available vascular function tests as predictors of cardiovascular events and decline in kidney function. One hundred and fourteen patients who had at least 2 cardiovascular risk factors were recruited for vascular function assessment including ankle-brachial blood pressure index (ABI), brachial-ankle pulse wave velocity (baPWV), cardio-ankle vascular index (CAVI) and flow-mediated vasodilatation (%FMD). During a median period of 51 months, 35 patients reached the primary endpoint (29 cardiovascular events and 6 cardiac deaths), and 30 patients reached the secondary endpoint (decline in kidney function: defined as a 5% per year decline of estimated glomerular filtration rate). In sequential Cox models, a model on the basis of the Framingham risk score, hemoglobin, and high-sensitivity C-reactive protein (chi-squared, 16.6) was improved by the ABI (chi-squared: 21.5; P=0.047). The baPWV (hazard ratio: 1.42 per 1 SD increase; P=0.025) and the CAVI (hazard ratio: 1.52 per 1 SD increase; P=0.040) were associated with the secondary endpoint. The %FMD was only slightly associated with the primary and secondary endpoints. Both ABI and baPWV are significantly associated with future cardiovascular events in high-risk patients with cardiovascular disease. The predictive capabilities of these parameters are greater than that of other parameters in this cohort.

  16. 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

  17. 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

  18. 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

  19. 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

  20. Efficacy of Prophylactic B-Lynch Suture during Lower Segment Caesarian Section in High Risk Patients for Atonic Postpartum Haemorrhage.

    PubMed

    Vijayasree, M

    2016-01-01

    Background Postpartum Haemorrhage causes significant maternal mortality and morbidity all over the world. Active management of the third stage of labour with oxytocics is come into practice. If postpartum haemorrhage is anticipated conservative surgical procedures like B-lynch suture is being applied. Objective To evaluate the effect of elective B-Lynch suture in preventing atonic postpartum haemorrhage during emergency caesarian section with high risk factors for atonicity. Method Forty antenatal women undergoing emergency caesarean section with risk factors for atony of the uterus were selected in our study. Thirty five women were selected before starting Lower segment caesarian section with risk factors like general anaesthesia, chorio-amnionitis, preeclampsia, prolonged labour, second stage arrest, multiple gestation and use of magnesium sulphate. Five women were selected during the caesarean section where uterus remained atonic despite of post delivery oxytocics. Before the closure of uterus B-Lynch suture was applied. Need for additional intervention or use of blood transfusion was evaluated. The results were analysed by using appropriate statistical method. Result Seventy five percent of patients were in the age group of 18 to 23 years. Ninety percent were nulliparous and ten percent were parous women. Risk factors involved were eclampsia in 20/40 (50%), multiple gestation in 6/40 (15%), hydramnios in 6/40 (15%) and prolonged second stage of labour in 4/40 (10%) patients. Other risk factors were Chorio-amnionitis in 2/40 (5%) patients and use of magnesium sulphate in 2/40 (5%) patients causing uterine atony. The average haemoglobin level was 9.8 gms/dl. Pre and post operative haemoglobin levels differed by 0.4 to 1.8 gms/dl. There were no complications during the procedure and at three months follow up. All women resumed normal menstruation within 40 days after delivery. Conclusion Elective B-Lynch suture is cheap, quick and effective in preventing atonic

  1. Partial Calcanectomy Facilitates Wound Closure of Heel Defects in High-Risk Patients.

    PubMed

    Lin, Chin-Ta; Chen, Shyi-Gen; Chen, Tim-Mo; Chang, Shun-Cheng

    2016-06-01

    Heel ulcers in patients with severe peripheral artery occlusive disease represent a challenge to the treating physician. They become more difficult to treat with underlying medical comorbidities. The purpose of this report is to document evidence that partial calcanectomy is simple to perform and clears infected bone, tissue, and ulceration. Between July 2011 and August 2013, 30 consecutive patients presented to our department with heel wounds caused by diabetes mellitus and pressure. After evaluation by a vascular surgeon, 12 patients diagnosed with near total occlusive peripheral vascular disease were included in this report. Of the 12 patients, 7 were women. Their ages ranged from 65 to 79 years (mean, 73.3 years). After admission, surgical debridement was performed emergently with subsequent partial calcanectomy and wound closure. Eight heel wounds (75%) healed completely with no further surgery to achieve defect coverage. Wound dehiscence developed in 4 patients (25%). The mean number of debridements was 1.75 (range, 1-3) with a total operation time of 71.5 minutes (range, 45-114 min). One patient died of acute myocardial infarction 2 weeks after discharge. The mean length of hospital stay was 8.3 days (range, 5-16 days). In this study, we demonstrate that partial calcanectomy is practical for the treatment of plantar heel ulcers in patients with severe comorbidities. With proper surgical planning and postoperative care, partial calcanectomy is a viable alternative to below-the-knee amputation and may better serve the patient who would otherwise be restricted to a sedentary lifestyle.

  2. Localized Gastric or Gastroesophageal Cancer – Chemoradiation Is a Pertinent Component of Adjuvant Treatment for Patients at High Risk of Relapse

    PubMed Central

    Callister, Matthew D.; Jaroszewski, Dawn E.; Ross, Helen J.; Borad, Mitesh J.; Gray, Richard J.; Lanza, Louis A.; Harold, Kristi L.; Pockaj, Barbara A.; Trastek, Victor F.

    2009-01-01

    The standard of care for resectable gastric or gastroesophageal (GE) junction cancer for patients who can tolerate a surgical procedure is surgical resection, but surgery alone is not optimal treatment for patients at high risk for relapse. For patients with lower-risk lesions (confined to gastric wall, nodes negative; T1-2N0M0), local-regional relapse risks are low, and adjuvant radiotherapy is usually not recommended, except in select instances. Since both local-regional and systemic relapses are common after resection of high-risk gastric or GE junction cancers (beyond wall, nodes positive, or both; T3-4N0, TanyN+), adjuvant treatment is indicated for these patients. The results of phase III trials that demonstrate a survival benefit for adjuvant preoperative radiotherapy, postoperative chemoradiation, or preoperative chemoradiation vs. surgery alone will be presented and compared with the results of adjuvant perioperative chemotherapy. Results of Surveillance, Epidemiology, and End Results (SEER) analyses and meta-analyses that support the role of adjuvant radiotherapy or chemoradiation will be summarized. PMID:19461920

  3. Perceptions of care among high-risk geriatric patients, families, and caregivers in a patient-centered medical home.

    PubMed

    Gavini, Madhavi; Gennari, Amelia S; Ruby, Christine M

    2015-03-01

    A survey was conducted by the pharmacy team to identify improvement areas in the delivery of care in high-risk patients at a patient-centered medical home (PCMH) at the University of Pittsburgh Medical Center (UPMC). This survey was a quality improvement project. The survey was conducted at UPMC Senior Care, a level-three accredited PCMH. The survey was conducted in a sample of preidentified high-risk patients. Pharmacy performed a survey, analyzed responses for common themes, and conducted follow-up phone calls to determine the degree of goal-achievement and efficacy of educational materials provided during the initial survey. The primary goal for conducting the survey was to identify needed areas for improvement in three specific domains, namely, medication decisions, communication with providers, and goals of care. Medication reviews were provided for 23 of 24 surveyed, leading to medication discrepancy resolution in 58%. Almost 80% of the respondents were satisfied with the team's communication. More than 85% of respondents verbalized the goals they wanted to achieve in three months. The follow-up phone calls were conducted in 20 of those initially surveyed. Only 5 patients did not meet their goals. The following improvement areas were identified: need to provide medication lists and correct medication inaccuracies, need for medication review, patient goals documentation, and patient education and the appropriate medium of education. Future appointments for high-risk patients at the PCMH should include the pharmacist. The team should focus education on families/caregivers and utilize alternate patient education methods.

  4. Percutaneous radiofrequency ablation of renal tumors in high-risk patients: 10 years' experience.

    PubMed

    Alguersuari, A; Mateos, A; Falcó, J; Criado, E; Fortuño, J R; Guitart, J

    2016-01-01

    To retrospectively evaluate the efficacy and safety of percutaneous radiofrequency ablation (RFA) done to treat renal tumors in patients with high surgical risk or with the risk of developing multiple renal tumors in the medium term at our center over a period of 10 years. Between 2005 and 2015, we used RFA to treat 89 T1a or T1b tumors in 87 patients (mean age, 73.7±10.87 years) with high surgical risk. We excluded patients treated with radiofrequency and embolization or microwave ablation. The tumors treated were clear cell carcinomas (43.6%), papillary renal carcinomas (17.2%), chromophobe renal cell carcinomas (10.3%), cystic tumors (2.2%), and an angiomyolipoma (1.1%). The mean size of the tumors was 2.6cm. Computed tomography and/or ultrasonography were used to guide the procedure. We analyzed the relation between the efficacy of the procedure and patients' age, the type of needle, the source of the patients, the size and location of the tumor, and the number of sessions required to achieve ablation. We recorded all complications. The RFA procedure was completed in all patients. The mean follow-up period was 32.1 months. The efficacy was 93.7%. A single session was sufficient in 87.5% of patients; 8% required two sessions and 4.5% required three sessions. The only factor associated with worse efficacy was the size of the tumor (p=0.03). The rate of complications was 5.6%. RFA is efficacious and safe, with results comparable to those reported in the literature. Copyright © 2016 SERAM. Publicado por Elsevier España, S.L.U. All rights reserved.

  5. 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).

  6. 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

  7. Clinical monitoring and high-risk conditions among patients with SUD newly prescribed opioids and benzodiazepines.

    PubMed

    Grossbard, Joel R; Malte, Carol A; Saxon, Andrew J; Hawkins, Eric J

    2014-09-01

    Opioid therapy alone or in combination with benzodiazepines poses safety concerns among patients with substance use disorders (SUD). Guidelines for opioid therapy recommend SUD treatment and enhanced monitoring, especially in patients with additional risk factors, but information on monitoring practices is sparse. This study estimated high-risk conditions - psychiatric comorbidity, suicide risk, and age <35 and ≥65 - and described clinical monitoring among patients with SUD who were newly prescribed opioids alone and concurrent with benzodiazepines long-term. This study included VA Northwest Veterans Network patients with SUD who started opioids only (n=980) or benzodiazepines and opioids concurrently (n=353) long-term (≥90 days) in 2009-2010. Clinical characteristics, outpatient visits and urine drug screens (UDS) documented within 7-months after starting medications were extracted from VA data. Approximately 67% (95% CI: 64-70) of opioids only and 94% (92-97) of concurrent medications groups had ≥1 psychiatric diagnoses. Prevalences of suicide risk and age <35 and ≥65 were 7% (5-8), 6% (5-8) and 18% (15-20) among the opioids only group, and 20% (16-24), 8% (5-11) and 13% (9-16) among the concurrent medications group. Among patients prescribed opioids only and medications concurrently, 87% and 91% attended primary care, whereas 28% and 26% attended SUD specialty-care. Overall, 30% and 48% of opioids only and concurrent medications groups engaged in mental health or SUD care, and 35% and 39% completed UDS. Improvements in clinical monitoring are needed as many VA patients with SUD and comorbid risks who initiate opioid therapy do not receive sufficient mental health/SUD care or UDS monitoring. Published by Elsevier Ireland Ltd.

  8. 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.

  9. 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.

  10. Relationship between patient complaints and surgical complications

    PubMed Central

    Murff, H J; France, D J; Blackford, J; Grogan, E L; Yu, C; Speroff, T; Pichert, J W; Hickson, G B

    2006-01-01

    Background Patient complaints are associated with increased malpractice risk but it is unclear if complaints might be associated with medical complications. The purpose of this study was to determine whether an association exists between patient complaints and surgical complications. Methods A retrospective analysis of 16 713 surgical admissions was conducted over a 54 month period at a single academic medical center. Surgical complications were identified using administrative data. The primary outcome measure was unsolicited patient complaints. Results During the study period 0.9% of surgical admissions were associated with a patient complaint. 19% of admissions associated with a patient complaint included a postoperative complication compared with 12.5% of admissions without a patient complaint (p = 0.01). After adjusting for surgical specialty, co‐morbid illnesses and length of stay, admissions with complications had an odds ratio of 1.74 (95% confidence interval 1.01 to 2.98) of being associated with a complaint compared with admissions without complications. Conclusions Admissions with surgical complications are more likely to be associated with a complaint than surgical admissions without complications. Further research is necessary to determine if patient complaints might serve as markers for poor clinical outcomes. PMID:16456204

  11. 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

  12. Renal Function Outcomes of High-risk Neuroblastoma Patients Undergoing Radiation Therapy.

    PubMed

    Beckham, Thomas H; Casey, Dana L; LaQuaglia, Michael P; Kushner, Brian H; Modak, Shakeel; Wolden, Suzanne L

    2017-10-01

    To analyze the renal function outcomes in patients undergoing radiation therapy for neuroblastoma. The clinical metrics of renal function were analyzed in patients undergoing radiation therapy for high-risk neuroblastoma from 2000 to 2015. The blood urea nitrogen (BUN) and creatinine values before radiation therapy were compared with last available follow-up values and analyzed with the clinical circumstances, including follow-up length, age at primary irradiation, nephrectomy, and radiation technique. The creatinine clearance was estimated using the Shull method. With a median follow-up period of 3.5 years, none of the 266 patients studied developed a chronic renal insufficiency. For all patients, the creatinine level increased from 0.44 to 0.51 mg/dL and the BUN increased from 10.53 to 15.52 mg/dL. Three patients required antihypertensive medication. The patients who underwent intensity modulated radiation therapy did not experience increased creatinine levels during the follow-up period; however, they had a reduced median follow-up length compared with patients treated with anteroposterior/posteroanterior beams (4.7 vs 3.3 years). A longer follow-up length was associated with an increased creatinine level. The preradiation therapy creatinine level increased with patient age, similar to that of the last follow-up creatinine level, suggesting that the changes in creatinine could likely be explained by physiologic increases associated with aging rather than radiation-induced renal damage. The creatinine clearance did not decrease in any circumstance. The present cohort had excellent renal outcomes after radiation therapy for neuroblastoma. No patient developed chronic renal insufficiency, and the small increases in BUN and creatinine we observed correlated, as expected, with increases in patient age. The results of the present study revealed a possible advantage for intensity modulated radiation therapy in preserving renal function; however, the follow

  13. 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.

  14. 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

  15. 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

  16. 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

  17. Outcomes of thoracic endovascular aortic repair using aortic arch chimney stents in high-risk patients.

    PubMed

    Voskresensky, Igor; Scali, Salvatore T; Feezor, Robert J; Fatima, Javairiah; Giles, Kristina A; Tricarico, Rosamaria; Berceli, Scott A; Beck, Adam W

    2017-07-01

    Aortic arch disease is a challenging clinical problem, especially in high-risk patients, in whom open repair can have morbidity and mortality rates of 30% to 40% and 2% to 20%, respectively. Aortic arch chimney (AAC) stents used during thoracic endovascular aortic repair (TEVAR) are a less invasive treatment strategy than open repair, but the current literature is inconclusive about the role of this technology. The focus of this analysis is on our experience with TEVAR and AAC stents. All TEVAR procedures performed from 2002 to 2015 were reviewed to identify those with AAC stents. Primary end points were technical success and 30-day and 1-year mortality. Secondary end points included complications, reintervention, and endoleak. Technical success was defined as a patient's surviving the index operation with deployment of the AAC stent at the intended treatment zone with no evidence of type I or type III endoleak on initial postoperative imaging. The Kaplan-Meier method was used to estimate survival. Twenty-seven patients (age, 69 ± 12 years; male, 70%) were identified, and all were described as being at prohibitive risk for open repair by the treating team. Relevant comorbidity rates were as follows: coronary artery disease/myocardial infarction, 59%; oxygen-dependent emphysema, 30%; preoperative creatinine concentration >1.8 mg/dL, 19%; and congestive heart failure, 15%. Presentations included elective (67%; n = 18), symptomatic (26%; n = 7), and ruptured (7%; n = 2). Eleven patients (41%) had prior endovascular or open arch/descending thoracic repair. Indications were degenerative aneurysm (49%), chronic residual type A dissection with aneurysm (15%), type Ia endoleak after TEVAR (11%), postsurgical pseudoaneurysm (11%), penetrating ulcer (7%), and acute type B dissection (7%). Thirty-two brachiocephalic vessels were treated: innominate (n = 7), left common carotid artery (LCCA; n = 24), and left subclavian artery (n = 1). Five patients (19%) had

  18. 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.

  19. 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

  20. Healthcare utilization in patients with esophageal cancer in a high risk area in northeast of Iran.

    PubMed

    Roshandel, Gholamreza; Majdzadeh, Reza; Keshtkar, Abbasali; Aramesh, Kiarash; Sedaghat, Seyed Mehdi; Semnani, Shahryar

    2011-01-01

    Golestan, a province located north of Persian Gulf in northeastern part of Iran is a well known area for high risk of esophageal cancer (EC) in the world. There is no information about healthcare utilization in populations residing in the area. This study was conducted to assess utilization of healthcare and its associated factors among esophageal cancer patients in this region as well as to address ethical implication of this utilization. All new cases of EC in Golestan province during year of 2007 were recruited. Seven diagnostic and five therapeutic services were used to assess diagnostic utilization index (DUI), and therapeutic utilization index (TUI), respectively. Multivariate regression analysis was used to assess the relationship between variables and DUI or TUI. P-value of less than 0.05 was considered as statistically significant. Tow hundred twenty three, patients were enrolled with mean (Standard Deviation) age of 64.3 (12.5) years with 57.8% male. We observed that occupation (P<0.01), ethnicity (P<0.01) and sex (P=0.03) were strongly associated with DUI. Insurance coverage (P<0.01), place of residency (P<0.01), and occupation (P=0.01) were associated with TUI. We concluded that several factors contribute to disparity in healthcare utilization in the studied population.

  1. Patient reasoning in palliative surgical oncology.

    PubMed

    Collins, Lindsey K; Goodwin, Julia A; Spencer, Horace J; Guevara, Caesar; Ferrell, Betty; McSweeney, Jean; Badgwell, Brian D

    2013-03-01

    The purpose of this study was to determine the patient reasoning behind treatment choice after palliative surgical consultation. Patients undergoing palliative surgical consultation were prospectively enrolled in this observational cohort study (11/2009-5/2011) and administered an open-ended questionnaire asking for their reasoning in choosing their treatment strategy. Of 98 patients enrolled, 54 were treated non-operatively and 44 with surgery. Patient responses indicating their reason for treatment selection were categorized into (1) quality of life or symptom relief, (2) unclear or response not related to treatment strategy, (3) increase length of life, (4) treat the cancer, (5) concerns over surgical complications, (6) doctor's recommendation, (7) religious reasons for treatment choice, and (8) for family. The most frequently cited reason for treatment selection was symptom relief or quality of life improvement in 46 patients. Thirty-eight patients cited their doctor's recommendation while 20 patients selected their treatment to increase length of life or treat their cancer. Only 2 patients cited concerns over surgical complications as their reason for choosing their treatment strategy. The most common reasons for treatment selection in palliative surgical consultation include symptom relief or improvement in quality of life and the doctor's recommendation with few patients listing concerns over surgical morbidity. Copyright © 2012 Wiley Periodicals, Inc.

  2. 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

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

    PubMed

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

    2008-12-04

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

  4. High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study.

    PubMed

    Perry, Jeffrey J; Stiell, Ian G; Sivilotti, Marco L A; Bullard, Michael J; Lee, Jacques S; Eisenhauer, Mary; Symington, Cheryl; Mortensen, Melodie; Sutherland, Jane; Lesiuk, Howard; Wells, George A

    2010-10-28

    To identify high risk clinical characteristics for subarachnoid haemorrhage in neurologically intact patients with headache. Multicentre prospective cohort study over five years. Six university affiliated tertiary care teaching hospitals in Canada. Data collected from November 2000 until November 2005. Neurologically intact adults with a non-traumatic headache peaking within an hour. Subarachnoid haemorrhage, as defined by any of subarachnoid haemorrhage on computed tomography of the head, xanthochromia in the cerebrospinal fluid, or red blood cells in the final sample of cerebrospinal fluid with positive results on angiography. Physicians completed data collection forms before investigations. In the 1999 patients enrolled there were 130 cases of subarachnoid haemorrhage. Mean (range) age was 43.4 (16-93), 1207 (60.4%) were women, and 1546 (78.5%) reported that it was the worst headache of their life. Thirteen of the variables collected on history and three on examination were reliable and associated with subarachnoid haemorrhage. We used recursive partitioning with different combinations of these variables to create three clinical decisions rules. All had 100% (95% confidence interval 97.1% to 100.0%) sensitivity with specificities from 28.4% to 38.8%. Use of any one of these rules would have lowered rates of investigation (computed tomography, lumbar puncture, or both) from the current 82.9% to between 63.7% and 73.5%. Clinical characteristics can be predictive for subarachnoid haemorrhage. Practical and sensitive clinical decision rules can be used in patients with a headache peaking within an hour. Further study of these proposed decision rules, including prospective validation, could allow clinicians to be more selective and accurate when investigating patients with headache.

  5. 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

  6. [Role of compression bandage with elevated level of pressure in decreasing incidence of venous thrombosis in high-risk patients].

    PubMed

    Barinov, V E; Lobastov, K V; Tsaplin, S N; Schastlivtsev, I V; Boiarintsev, V V; Laberko, L A

    2014-01-01

    The study was aimed at assessing efficacy and safety of using graduated compression bandage with the level of pressure in the area of the middle ankle amounting to 20-40 mm Hg as compared to the conventional profile (10-20 mm Hg in the ankle area) in the composition of comprehensive prevention of postoperative venous thromboembolic complications (VTEC) in patients of a high-risk group. For this purpose we carried out a prospective randomized clinical study including a total of 100 surgical patients (general surgery, neurosurgery) from a group of high risk for the development of VTEC with the presence of 3 and more conditions predisposing to venous thrombosis. All patients were subdivided into two subgroups 50 patients each. Patients in both groups received anticoagulants in standard preventive doses from the first day after surgery or in the remote period. The Study group patients were treated by applying on the ankle a bandage of medium distensibility with the target pressure in the ankle area of 20-40 mm Hg measured by means of a portable manometer. The control group patients were treated by a similar bandage applied onto the ankle and femur with a pressure of 10-20 mm Hg. In all cases a special lining material was placed under the bandage. With the purpose of active screening of postoperative VTECs, prior to the beginning of the study and then each 3-5 days we performed ultrasound angioscanning and in case thrombosis was revealed we performed static perfusion scintigraphy of the lungs and/or echocardiography for verification of pulmonary embolism. The patients who died were subjected to post-mortem examination. We also assessed the frequency of correcting the bandage on the femur and crus. The incidence rate of postoperative venous thrombosis in the Study Group amounted to 16.0% (95% CI: 5.8-26.2%) and in the Control Group 36.0% (95% CI: 22.7-49.3%, p=0.039), with no significant differences in the incidence of proximal thrombosis or pulmonary embolism revealed

  7. 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.

  8. 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…

  9. 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…

  10. 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…

  11. 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.

  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. [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.

  14. 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

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

    PubMed

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

    2017-10-03

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

  16. 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

  17. 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

  18. Incidence of vancomycin-resistant enterococci (VRE) infection in high-risk febrile neutropenic patients colonized with VRE.

    PubMed

    Bossaer, John B; Hall, Philip D; Garrett-Mayer, Elizabeth

    2010-02-01

    This study seeks to determine the incidence of vancomycin-resistant enterococci (VRE) infection in high-risk neutropenic fever patients colonized with VRE and to determine patient characteristics associated with VRE infection. We conducted a retrospective, single-center, unmatched case-control study. Fifty-three VRE-colonized, high-risk patients with neutropenic fever were identified between January 2006 and February 2009. The two most common diagnoses/conditions included acute myeloid leukemia and hematopoietic stem cell transplantation. Data collected included days of neutropenia, days of fever, demographic data, culture results, and antimicrobial therapy. Twenty of the 53 patients (38%) with VRE colonization developed a VRE infection. The most common VRE infections were bacteremias (26%). The presence of neutropenia lasting longer than 7 days was associated with the development of VRE infection in this high-risk population colonized with VRE. The timeframe to develop VRE infection varied from 1 day to 2 weeks. For patients colonized with VRE, approximately 38% of high-risk neutropenic patients developed a VRE infection. This is the first study to specifically evaluate the incidence of VRE infections in febrile neutropenic patients colonized with VRE. Future research into the use and efficacy of empiric VRE coverage is needed.

  19. Carotid angioplasty and stenting in anatomically high-risk patients: Safe and durable except for radiation-induced stenosis.

    PubMed

    Shin, Susanna H; Stout, Christopher L; Richardson, Albert I; DeMasi, Richard J; Shah, Rasesh M; Panneton, Jean M

    2009-10-01

    Carotid angioplasty and stenting (CAS) is used in patients considered high-risk for carotid endarterectomy (CEA). Patients qualify as high-risk because of medical comorbid conditions or for anatomic considerations (previous CEA, radical neck dissection, radiation). We compared the technical feasibility and durability of CAS in medically high-risk patients (MED) vs anatomically high-risk patients (ANAT). A retrospective review was performed of all consecutive patients undergoing CAS by a single vascular surgery group. All patients were high risk and evaluated with duplex ultrasound imaging and angiography. Primary end points were technical success, 30-day stroke, myocardial infarction (MI), death, and in-stent restenosis. Standard statistical analysis included Kaplan-Meier life tables. From January 2003 to December 2007, 230 CAS (98 ANAT, 132 MED) procedures were attempted. The ANAT cohort comprised 84 patients with a single anatomic risk factor: 71 with a previous ipsilateral CEA, 6 high lesions, 6 history of neck radiation, and 1 with a tracheostomy. Ten patients had two or three anatomic risk factors: nine with radical neck dissection and radiation and one with neck radiation and ipsilateral CEA. The mean age was 71.1 years for ANAT vs 73.9 years for MED (P = .021). Technical success rates were 98% in ANAT and 98.5% in MED (P = .76). Thirty-day stroke rate was 1.0% in ANAT and 5.3% in MED (P = .14); the mortality rate was 2.0% in ANAT and 0.8% in MED (P = .79). The 2-year survival free from stroke was MED, 93.6% and ANAT, 98.9% (P = .118); and from restenosis was MED, 91.9%; and ANAT, 91.0% (P = .98). Two-year overall survival was significantly better in ANAT (84.6%) vs MED (70.1%; P = .026). Four of the seven restenoses in the ANAT group occurred in patients with previous neck radiation. The restenosis rate for radiation-induced (RAD) stenosis treated with CAS was significantly higher at 22.2% (4 of 18) compared with 3.8% (3 of 78) in ANAT group patients without

  20. 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.

  1. Angiotensin II receptor blocker-based therapy in Japanese elderly, high-risk, hypertensive patients.

    PubMed

    Ogawa, Hisao; Kim-Mitsuyama, Shokei; Matsui, Kunihiko; Jinnouchi, Tomio; Jinnouchi, Hideaki; Arakawa, Kikuo

    2012-10-01

    It is unknown whether high-dose angiotensin II receptor blocker therapy or angiotensin II receptor blocker + calcium channel blocker combination therapy is better in elderly hypertensive patients with high cardiovascular risk. The objective of the study was to compare the efficacy of these treatments in elderly, high-risk Japanese hypertensive patients. The OlmeSartan and Calcium Antagonists Randomized (OSCAR) study was a multicenter, prospective, randomized, open-label, blinded-end point study of 1164 hypertensive patients aged 65 to 84 years with type 2 diabetes or cardiovascular disease. Patients with uncontrolled hypertension during treatment with olmesartan 20 mg/d were randomly assigned to receive 40 mg/d olmesartan (high-dose angiotensin II receptor blocker) or a calcium channel blocker + 20 mg/d olmesartan (angiotensin II receptor blocker + calcium channel blocker). The primary end point was a composite of cardiovascular events and noncardiovascular death. During a 3-year follow-up, blood pressure was significantly lower in the angiotensin II receptor blocker + calcium channel blocker group than in the high-dose angiotensin II receptor blocker group. Mean blood pressure at 36 months was 135.0/74.3 mm Hg in the high-dose angiotensin II receptor blocker group and 132.6/72.6 mm Hg in the angiotensin II receptor blocker + calcium channel blocker group. More primary end points occurred in the high-dose angiotensin II receptor blocker group than in the angiotensin II receptor blocker + calcium channel blocker group (58 vs 48 events, hazard ratio [HR], 1.31, 95% confidence interval, 0.89-1.92; P=.17). In patients with cardiovascular disease at baseline, more primary events occurred in the high-dose angiotensin II receptor blocker group (HR, 1.63, P=.03); in contrast, fewer events were observed in the subgroup without cardiovascular disease (HR, 0.52, P=.14). This treatment-by-subgroup interaction was significant (P=.02). The angiotensin II receptor blocker and

  2. Clinical characteristics and prognosis of ultra high-risk gestational trophoblastic neoplasia patients: A retrospective cohort study.

    PubMed

    Kong, Yujia; Yang, Junjun; Jiang, Fang; Zhao, Jun; Ren, Tong; Li, Jie; Wang, Xiaoyu; Feng, Fengzhi; Wan, Xirun; Xiang, Yang

    2017-07-01

    The gestational trophoblastic neoplasia (GTN) patients with the International Federation of Gynecology and Obstetrics (FIGO) score≥12 are defined as ultra high-risk GTN. This study aims to investigate the clinical characteristics, the treatment efficiency, and the prognosis of ultra high-risk GTN patients. Between January 2002 and December 2015, medical record data of 143 GTN patients with FIGO score≥12 at Peking Union Medical College Hospital (PUMCH) were reviewed. Ratios were compared using chi-square test, and prognostic risk factors were analyzed by univariate analysis and multivariate analysis. Among the 143 ultra high-risk GTN patients, 94 (65.7%) patients had achieved complete remission and 15.9% (15/94) patients relapsed after complete remission. The 5-year overall survival (OS) rate of the entire cohort approached 67.9%. The results of the multivariate analysis revealed that non-molar antecedent pregnancy [Relative risk (RR) 4.689, 95% CI 1.448-15.189, P=0.010], brain metastases (RR 2.280, 95% CI 1.248-4.163, P=0.007), previous failed multiagent chemotherapy (RR 5.345, 95% CI 2.222-12.857, P=0.000) and surgery (RR 0.336, 95% CI 0.177-0.641, P=0.001) all had influence on the prognosis of ultra high-risk GTN patients. GTN patients with FIGO score≥12 have a poor prognosis. More emphasis should be placed on non-molar antecedent pregnancy, brain metastases, and previous multiagent chemotherapy failure. Moreover, salvage surgery may improve the prognosis. Floxuridine-based multiagent chemotherapy is effective with manageable toxicity for ultra high-risk GTN patients. Copyright © 2017. Published by Elsevier Inc.

  3. Organ motion in pediatric high-risk neuroblastoma patients using four-dimensional computed tomography.

    PubMed

    Kannan, Sneha; Teo, Boon-Keng Kevin; Solberg, Timothy; Hill-Kayser, Christine

    2017-01-01

    High-risk neuroblastoma (HR-NBL) requires multimodality treatment, including external beam radiation of the primary tumor site following resection. Radiotherapy planning must take into account motion of the target and adjacent normal anatomy, both of which are poorly understood in the pediatric population, and which may differ significantly from those in adults. We examined 4DCT scans of 15 consecutive pediatric patients treated for HR-NBL, most with tumors in the abdominal cavity. The diaphragm and organs at risk were contoured at full inhale, full exhale, and on free-breathing scans. Maximum displacement of organs between full inhale and full exhale was measured in the anterior, posterior, superior, inferior, left, and right directions, as was displacement of centroids in the A/P, S/I, and L/R axes. Contours on free-breathing scans were compared to those on 4D scans. Maximum displacement was along the S/I axis, with the superior aspects of organs moving more than the inferior, implying organ compression with respiration. Liver and spleen exhibited the largest motion, which correlated strongly with the S/I motion of the diaphragm. The maximum organ motion observed in the abdomen and thorax were 4.5 mm and 7.4 mm, respectively, while maximum diaphragm displacement was 5.7 mm. Overall findings mirrored observations in adults, but with smaller magnitudes, as expected. No consistent margins could be added to the free-breathing scans to encompass the motion determined using 4DCT. Organ motion within the pediatric abdomen and pelvis is similar to that observed in adults, but with smaller magnitude. Precise margins to accommodate motion are patient-specific, underscoring the need for 4DCT scanning when possible. © 2016 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, Inc. on behalf of American Association of Physicists in Medicine.

  4. 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

  5. Safety of anacetrapib in patients with or at high risk for coronary heart disease.

    PubMed

    Cannon, Christopher P; Shah, Sukrut; Dansky, Hayes M; Davidson, Michael; Brinton, Eliot A; Gotto, Antonio M; Stepanavage, Michael; Liu, Sherry Xueyu; Gibbons, Patrice; Ashraf, Tanya B; Zafarino, Jennifer; Mitchel, Yale; Barter, Philip

    2010-12-16

    Anacetrapib is a cholesteryl ester transfer protein inhibitor that raises high-density lipoprotein (HDL) cholesterol and reduces low-density lipoprotein (LDL) cholesterol. We conducted a randomized, double-blind, placebo-controlled trial to assess the efficacy and safety profile of anacetrapib in patients with coronary heart disease or at high risk for coronary heart disease. Eligible patients who were taking a statin and who had an LDL cholesterol level that was consistent with that recommended in guidelines were assigned to receive 100 mg of anacetrapib or placebo daily for 18 months. The primary end points were the percent change from baseline in LDL cholesterol at 24 weeks (HDL cholesterol level was a secondary end point) and the safety and side-effect profile of anacetrapib through 76 weeks. Cardiovascular events and deaths were prospectively adjudicated. A total of 1623 patients underwent randomization. By 24 weeks, the LDL cholesterol level had been reduced from 81 mg per deciliter (2.1 mmol per liter) to 45 mg per deciliter (1.2 mmol per liter) in the anacetrapib group, as compared with a reduction from 82 mg per deciliter (2.1 mmol per liter) to 77 mg per deciliter (2.0 mmol per liter) in the placebo group (P<0.001)--a 39.8% reduction with anacetrapib beyond that seen with placebo. In addition, the HDL cholesterol level increased from 41 mg per deciliter (1.0 mmol per liter) to 101 mg per deciliter (2.6 mmol per liter) in the anacetrapib group, as compared with an increase from 40 mg per deciliter (1.0 mmol per liter) to 46 mg per deciliter (1.2 mmol per liter) in the placebo group (P<0.001)--a 138.1% increase with anacetrapib beyond that seen with placebo. Through 76 weeks, no changes were noted in blood pressure or electrolyte or aldosterone levels with anacetrapib as compared with placebo. Prespecified adjudicated cardiovascular events occurred in 16 patients treated with anacetrapib (2.0%) and 21 patients receiving placebo (2.6%) (P = 0.40). The

  6. Late Outcomes of Transcatheter Aortic Valve Replacement in High-Risk Patients: The FRANCE-2 Registry.

    PubMed

    Gilard, Martine; Eltchaninoff, Hélène; Donzeau-Gouge, Patrick; Chevreul, Karine; Fajadet, Jean; Leprince, Pascal; Leguerrier, Alain; Lievre, Michel; Prat, Alain; Teiger, Emmanuel; Lefevre, Thierry; Tchetche, Didier; Carrié, Didier; Himbert, Dominique; Albat, Bernard; Cribier, Alain; Sudre, Arnaud; Blanchard, Didier; Rioufol, Gilles; Collet, Frederic; Houel, Remi; Dos Santos, Pierre; Meneveau, Nicolas; Ghostine, Said; Manigold, Thibaut; Guyon, Philippe; Grisoli, Dominique; Le Breton, Herve; Delpine, Stephane; Didier, Romain; Favereau, Xavier; Souteyrand, Geraud; Ohlmann, Patrick; Doisy, Vincent; Grollier, Gilles; Gommeaux, Antoine; Claudel, Jean-Philippe; Bourlon, Francois; Bertrand, Bernard; Laskar, Marc; Iung, Bernard

    2016-10-11

    Transcatheter aortic valve replacement (TAVR) has revolutionized management of high-risk patients with severe aortic stenosis. However, survival and the incidence of severe complications have been assessed in relatively small populations and/or with limited follow-up. This report details late clinical outcome and its determinants in the FRANCE-2 (FRench Aortic National CoreValve and Edwards) registry. The FRANCE-2 registry prospectively included all TAVRs performed in France. Follow-up was scheduled at 30 days, at 6 months, and annually from 1 to 5 years. Standardized VARC (Valve Academic Research Consortium) outcome definitions were used. A total of 4,201 patients were enrolled between January 2010 and January 2012 in 34 centers. Approaches were transarterial (transfemoral 73%, transapical 18%, subclavian 6%, and transaortic or transcarotid 3%) or, in 18% of patients, transapical. Median follow-up was 3.8 years. Vital status was available for 97.2% of patients at 3 years. The 3-year all-cause mortality was 42.0% and cardiovascular mortality was 17.5%. In a multivariate model, predictors of 3-year all-cause mortality were male sex (p < 0.001), low body mass index, (p < 0.001), atrial fibrillation (p < 0.001), dialysis (p < 0.001), New York Heart Association functional class III or IV (p < 0.001), higher logistic EuroSCORE (p < 0.001), transapical or subclavian approach (p < 0.001 for both vs. transfemoral approach), need for permanent pacemaker implantation (p = 0.02), and post-implant periprosthetic aortic regurgitation grade ≥2 of 4 (p < 0.001). Severe events according to VARC criteria occurred mainly during the first month and subsequently in <2% of patients/year. Mean gradient, valve area, and residual aortic regurgitation were stable during follow-up. The FRANCE-2 registry represents the largest database available on late results of TAVR. Late mortality is largely related to noncardiac causes. Incidence rates of severe events are low after the

  7. 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.

  8. 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.

  9. Impact of a patient-centered pharmacy program and intervention in a high-risk group.

    PubMed

    Moore, Janice M; Shartle, Deborah; Faudskar, Larry; Matlin, Olga S; Brennan, Troyen A

    2013-04-01

    with hypertension and dyslipidemia had pre-post increases in MPR of 2.29% and 2.10%, respectively, while the control group had decreases of 2.31% and 2.61% (both P  less than  0.001). The mean MPRs for members with diabetes, depression, and asthma did not change in either group. Program costs per patient in 2009 were estimated to be $478. The program had a return on investment (ROI) of 2.0 in 2009. This study found that the pharmacist-managed MTM program to reconcile the medication therapies of high-risk patients and improve adherence, as measured by MPR, was effective in reducing total health care costs. The results show that those patients in the intervention group with hypertension and dyslipidemia had significant improvements in medication adherence, as compared with the control group. In fact, the intervention group used significantly more days of therapy in the intervention period, and the control group used significantly fewer days than either group used during the baseline period. MTM interventions were associated with a significant decrease in the MTM members' overall plan-paid health care costs, driven largely by decreases in inpatient utilization and mediated by increases in average days supply and in MPR increases for hypertension and dyslipidemia. Overall, the MTM program was cost-effective. The ROI estimated for this program of 2.0 is only slightly lower than the average disease management ROIs reported in the literature.

  10. Service Implications of Providing Intensive Monitoring During High-Risk Periods for Suicide Among VA Patients With Depression

    PubMed Central

    Valenstein, Marcia; Eisenberg, Daniel; McCarthy, John F.; Austin, Karen L.; Ganoczy, Dara; Kim, Hyungjin Myra; Zivin, Kara; Piette, John D.; Olfson, Mark; Blow, Frederic C.

    2013-01-01

    Objectives Department of Veterans Affairs (VA) patients in depression treatment have high suicide rates after psychiatric hospitalization, antidepressant starts, and dosage changes. Policy makers have recommended closer monitoring during these periods to reduce suicide. This study assessed the frequency of high-risk periods in clinical settings, the levels of monitoring provided during these periods, and the estimated costs of providing monitoring consistent with the most stringent Food and Drug Administration recommendation for treatment periods after antidepressant change (seven visits in the first 12 weeks). Methods Monitoring visits were identified in the 12-week period after antidepressant starts and dosage changes and after discharge from psychiatric hospitalization for 100,000 randomly selected VA patients in depression treatment between April 1, 1999, and September 30, 2004. Incremental costs of providing intensive monitoring were estimated by using VA Health Economics Resource Center average cost data. Results Patients averaged less than one high-risk period each year. They completed an average of 2.4 monitoring visits during the 12-week period after antidepressant treatment events and 4.9 visits after psychiatric hospitalization. Providing intensive monitoring would cost an additional $408–$537 for each high-risk period after antidepressant treatment events and $313–$341 for each high-risk period after psychiatric hospitalization. During fiscal year 2004 providing intensive monitoring during all high-risk periods would have cost an additional $183–$270 million. Providing intensive monitoring only after psychiatric hospitalizations would have cost an additional $15–$17 million. Conclusions Providing intensive monitoring for VA patients in depression treatment during all high-risk periods for suicide would require substantial services reorganization and incremental expenditures. Modest expenditures would support intensive monitoring during the

  11. Quality of life after contralateral prophylactic mastectomy in newly diagnosed high-risk breast cancer patients who underwent BRCA1/2 gene testing.

    PubMed

    Tercyak, Kenneth P; Peshkin, Beth N; Brogan, Barbara M; DeMarco, Tiffani; Pennanen, Marie F; Willey, Shawna C; Magnant, Colette M; Rogers, Sarah; Isaacs, Claudine; Schwartz, Marc D

    2007-01-20

    Recent studies indicate that high-risk breast cancer patients (ie, women who carry mutations in BRCA1/2 genes) who opt for contralateral prophylactic mastectomy (CPM) have a substantially reduced risk of developing contralateral breast cancer. However, the immediate and long-term impact of this decision on women's quality of life and psychosocial functioning is largely unknown. In this study, we compared the impact of BRCA1/2 genetic test result and CPM on these outcomes among newly diagnosed breast cancer patients who opted for CPM at the time of their definitive surgical treatment versus patients who did not. Participants were 149 high-risk women who underwent genetic counseling and testing for alterations in the BRCA1/2 genes. We measured self-reported quality of life, cancer-specific distress, and genetic testing-specific distress using standardized instruments before receipt of genetic test results and again 1 and 12 months later. Compared with patients who chose breast conservation or unilateral mastectomy, those who chose mastectomy of the affected breast and CPM of the unaffected breast did not report diminished quality of life or elevated distress. With respect to quality of life and distress, patients who choose CPM fare as well as those who do not in the first year after surgery.

  12. First-line endoscopic treatment with OTSC in patients with high-risk non-variceal upper gastrointestinal bleeding: preliminary experience in 40 cases.

    PubMed

    Manno, Mauro; Mangiafico, Santi; Caruso, Angelo; Barbera, Carmelo; Bertani, Helga; Mirante, Vincenzo G; Pigò, Flavia; Amardeep, Khanna; Conigliaro, Rita

    2016-05-01

    The over-the-scope clip (OTSC; Ovesco, Tübingen, Germany) is a novel endoscopic clipping device designed for tissue approximation. The device has been used in the closure of fistulas and perforations. We hereby report a series of patients with high-risk non-variceal upper gastrointestinal bleeding (NVUGIB) lesions in whom OTSCs were used as first-line endoscopic treatment. We prospectively collected and retrospectively analysed data over a period of 12 months from October 2013 to November 2014 from all consecutive patients who underwent emergency endoscopy for acute severe high-risk NVUGIB and were treated with OTSC as primary first-line therapy. We included forty consecutive patients with mean age 69 years (range 25-94 years). All patients were treated with the non-traumatic version of the OTSC system (23 with the 11 mm version and 17 with the 12 mm version). Indications for OTSC treatment included gastric ulcer with large vessel (Forrest IIa) (n = 8, 20 %), duodenal ulcer (Forrest Ib) (n = 7, 18 %), duodenal ulcer with large vessel (Forrest IIa) (n = 6, 15 %), Dieulafoy's lesion (n = 6, 15 %) and other secondary indications (n = 13, 32 %). Technical success and primary haemostasis were achieved in all patients (100 %). No re-bleeding, need for surgical or radiological embolization treatment or other complications were observed during the follow-up period of 30 days. We conclude OTSC placement as a first-line endoscopic treatment seems to be effective, safe and easy to perform and should be considered in patients with high-risk NVUGIB lesions.

  13. 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

  14. C-reactive protein and the MASCC risk index identify high-risk patients with febrile neutropenia and hematologic neoplasms.

    PubMed

    Combariza, Juan F; Lombana, Milton; Pino, Luis E; Arango, Marcos

    2015-04-01

    The objective of this study is to assess the prognostic usefulness of the Multinational Association of Supportive Care in Cancer (MASCC) risk score in association with the value of C-reactive protein (CRP) to identify high-risk patients with febrile neutropenia and hematologic neoplasms. A retrospective cohort study in which the MASCC score and the CRP values were used to assess the mortality risk at 30 days among patients with febrile neutropenia and hematologic malignancies was performed. Two hundred thiry-seven patients with febrile neutropenia were analyzed; the mortality rate within 30 days was 9 %. High-risk patients according to the MASCC score were significantly more likely to experience adverse outcomes, such as being transferred to the intensive care unit (RR 3.55; CI 95 % 2.73-6.62, p < 0.001) and death (RR 2.21; CI 95 % 1.74-2.79, p < 0.001). Multivariate analysis showed a strong association between the high-risk group identified by the MASCC score (HR 3.0; CI 95 % 1.12-13.54, p = 0.032) and the mean levels of CRP (HR 17; CI 95 % 2.21-136.48, p = 0.007) and survival. The survival rate within 30 days was 100 % for the patients with a low-risk MASCC score and a mean CRP less than 15 mg/dL. This rate was only 64 % for high-risk patients with a mean CRP greater than 15 mg/dL. The MASCC risk score combined with the mean CRP value successfully identifies patients with febrile neutropenia and hematological malignancies and a high risk of death.

  15. 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

  16. 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.

  17. Applying PRIM (Patient Rule Induction Method) and logistic regression for selecting high-risk subgroups in very elderly ICU patients.

    PubMed

    Nannings, Barry; Abu-Hanna, Ameen; de Jonge, Evert

    2008-04-01

    To apply the Patient Rule Induction Method (PRIM) to identify very elderly Intensive Care (IC) patients at high risk of mortality, and compare the results with those of a conventional logistic regression model. A database containing all 12,993 consecutive admissions of patients aged at least 80 between January 1997 and October 2005 from intensive care units (n=33) of mixed type taking part in the National Intensive Care Evaluation (NICE) registry. Demographic, diagnostic, physiologic, laboratory, discharge and prognostic score data were collected. After application of the SAPS II inclusion criteria 6617 patients remained. In these data we searched PRIM subgroups requiring at least 85% mortality and coverage of at least 3% of the patients. Equally sized subgroups were derived from a recalibrated (second level customization) Simplified Acute Physiology Score II model, where new coefficients were fitted. Subgroups were compared on an independent validation set using the positive predictive value (PPV), here equaling the subgroup mortality. We identified four subgroups with a positive predictive value (PPV) of 92%, 90%, 87% and 87%, covering, respectively, 3%, 3.5%, 7% and 10% of the patients in the validation set. Urine production, lowest pH, lowest systolic blood pressure, mechanical ventilation, all measured within 24 h after admission, and admission type and Glasgow Coma Score were used to define these subgroups. SAPS and PRIM subgroups had equal PPVs. PRIM successfully identified high-risk subgroups. The subgroups compare in performance to SAPS II, but require less data to collect, result in more homogenous groups and are likely to be more useful for decision makers.

  18. The high-risk polytrauma patient and inferior vena cava filter use.

    PubMed

    Berber, Onur; Vasireddy, Aswin; Nzeako, Obi; Tavakkolizadeh, Adel

    2017-07-01

    The aim of this study was to assess the impact on practice of vena cava filter insertion guidelines (Eastern Association for the Surgery of Trauma: practice management guidelines). The study was performed at a level 1 trauma centre with data from the 'Trauma Audit and Research Network' cross-referenced to hospital data. A total of 1138 specific 'high-risk' major trauma patients were identified over a 6-year period. The mean age was 46 years (18-102) and the male to female ratio was 3.3:1. The average Injury Severity Score was 23.6 (4-75). The overall DVT rate was 2.6% and the PE rate was 1.8%. A retrievable IVC filter was inserted in 42 cases (3.8%). The filter retrieval rate was 23.8% at a mean of 68.5days (4-107). Only one complication was reported of a breakthrough PE despite filter. Applying the EAST guidelines to this cohort would have suggested filter insertion in 279 (24.6%) cases. The kappa concordance value between observed practice and the 'EAST filter group' was 0.103 (poor). The PE rate in the 'EAST filter group' was 2.2% vs 1.6% in the 'no filter group' (p=0.601, no statistical difference) and the observed odds ratio was 0.814 (95% CI 0.413, 1.602). The EAST guidelines are useful but may be overestimating the need for filter insertion. Copyright © 2017 Elsevier Ltd. All rights reserved.

  19. 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.

  20. 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. |

  1. Long-term outcomes of high-risk elderly male patients with multivessel coronary disease: optimal medical therapy versus revascularization.

    PubMed

    Tao, Tao; Wang, Hao; Wang, Shu-Xia; Guo, Yu-Tao; Zhu, Ping; Wang, Yu-Tang

    2016-02-01

    Many studies have indicated that medical therapy and percutaneous coronary intervention have similar effects in terms of the long-term prognosis of patients with stable coronary artery disease. This study investigated the effects of optimal medical therapy (OMT) and revascularization-plus-OMT in elderly patients with high-risk angina. In this prospective non-randomized study, 241 consecutive high-risk elderly male patients (65-92 years of age) with angiographically confirmed multivessel disease were enrolled in the registry from January 2004 to April 2005. Of these, 98 patients underwent OMT and 143 underwent revascularization therapy plus OMT. After 6.5 years of follow-up, we found that the rate of long-term cardiac mortality was significantly higher in patients who underwent OMT than in those who underwent revascularization (6.5-year unadjusted mortality rate, 14.3% for OMT vs. 7.0% for revascularization patients; log-rank P = 0.04). However, the overall risks of major adverse cardiac cerebrovascular events (MACCE) were similar among all patients (6.5-year unadjusted mortality rate, 29.6% for OMT vs. 27.3% for revascularization patients; log-rank P = 0.67). OMT was associated with an increase in cardiac death but a similar 6.5-year risk of MACCE compared with revascularization in high-risk elderly male patients with coronary multivessel disease.

  2. Long-term outcomes of high-risk elderly male patients with multivessel coronary disease: optimal medical therapy versus revascularization

    PubMed Central

    Tao, Tao; Wang, Hao; Wang, Shu-Xia; Guo, Yu-Tao; Zhu, Ping; Wang, Yu-Tang

    2016-01-01

    Background Many studies have indicated that medical therapy and percutaneous coronary intervention have similar effects in terms of the long-term prognosis of patients with stable coronary artery disease. This study investigated the effects of optimal medical therapy (OMT) and revascularization-plus-OMT in elderly patients with high-risk angina. Methods In this prospective non-randomized study, 241 consecutive high-risk elderly male patients (65–92 years of age) with angiographically confirmed multivessel disease were enrolled in the registry from January 2004 to April 2005. Of these, 98 patients underwent OMT and 143 underwent revascularization therapy plus OMT. Results After 6.5 years of follow-up, we found that the rate of long-term cardiac mortality was significantly higher in patients who underwent OMT than in those who underwent revascularization (6.5-year unadjusted mortality rate, 14.3% for OMT vs. 7.0% for revascularization patients; log-rank P = 0.04). However, the overall risks of major adverse cardiac cerebrovascular events (MACCE) were similar among all patients (6.5-year unadjusted mortality rate, 29.6% for OMT vs. 27.3% for revascularization patients; log-rank P = 0.67). Conclusions OMT was associated with an increase in cardiac death but a similar 6.5-year risk of MACCE compared with revascularization in high-risk elderly male patients with coronary multivessel disease. PMID:27168741

  3. Novel methylation panel for the early detection of neoplasia in high-risk ulcerative colitis and Crohn's colitis patients.

    PubMed

    Azuara, Daniel; Rodriguez-Moranta, Francisco; de Oca, Javier; Sanjuan, Xavier; Guardiola, Jordi; Lobaton, Triana; Wang, Alex; Boadas, Jaume; Piqueras, Marta; Monfort, David; Galter, Sara; Esteller, Manel; Moreno, Victor; Capellá, Gabriel

    2013-01-01

    Patients with ulcerative colitis and Crohn's colonic disease are at increased risk of developing colorectal cancer (CRC). The aim of the study was to analyze the methylation status of selected genes as a risk marker for CRC in inflammatory bowel disease (IBD) patients. We evaluated the methylation status of four genes (TGFB2, SLIT2, HS3ST2, and TMEFF2) in biopsies of four groups of patients: 60 patients with sporadic CRC, 32 patients with IBD-associated neoplasia, 85 patients with IBD without associated neoplasia (20 at high risk and 65 at low risk), and 28 healthy controls. Methylation-specific melting curve analysis (MS-MCA) was used. Methylation status of these genes was also assessed in stool DNA from 60 IBD patients without neoplasia. Methylation of the panel of genes analyzed was a very common phenomenon (78%) in IBD-associated neoplasia. The prevalence of methylation in adjacent nonneoplastic mucosa was also high (12/30). This prevalence was higher than in mucosa from healthy controls (2/28;7.1%; P < 0.05). Methylation of SLIT2 and TMEFF2 was more frequently detected in the mucosa of IBD patients at high risk of dysplasia or cancer (15/20) than patients at low risk (32/63) (P = 0.05 and P = 0.03, respectively). When stool samples were assessed, only SLIT2 gene methylation was more frequently methylated in the group of patients at high risk of dysplasia or cancer (4/16) compared to low risk (0/37) (P = 0.006). Analysis of a panel of methylation markers may help in the early identification of colorectal dysplasia or cancer in high-risk IBD patients.

  4. “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

  5. 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.

  6. [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.

  7. Effect of low-dose aspirin on primary prevention of cardiovascular events in Japanese diabetic patients at high risk.

    PubMed

    Okada, Sadanori; Morimoto, Takeshi; Ogawa, Hisao; Sakuma, Mio; Soejima, Hirofumi; Nakayama, Masafumi; Sugiyama, Seigo; Jinnouchi, Hideaki; Waki, Masako; Doi, Naofumi; Horii, Manabu; Kawata, Hiroyuki; Somekawa, Satoshi; Soeda, Tsunenari; Uemura, Shiro; Saito, Yoshihiko

    2013-01-01

    Benefit of low-dose aspirin for primary prevention of cardiovascular events in diabetes remains controversial. The American Diabetes Association (ADA), the American Heart Association (AHA), and the American College of Cardiology Foundation (ACCF) recommend aspirin for high-risk diabetic patients: older patients with additional cardiovascular risk factors. We evaluated aspirin's benefit in Japanese diabetic patients stratified by cardiovascular risk. In the JPAD trial, we enrolled 2,539 Japanese patients with type 2 diabetes and no history of cardiovascular disease. We randomly assigned them to aspirin (81-100 mg daily) or no aspirin groups. The median follow-up period was 4.4 years. We stratified the patients into high-risk or low-risk groups, according to the US recommendation: age (older; younger) and coexisting cardiovascular risk factors. The risk factors included smoking, hypertension, dyslipidemia, family history of coronary artery disease, and proteinuria. Most of the patients were classified into the high-risk group, consisting of older patients with risk factors (n=1,804). The incidence of cardiovascular events was higher in this group, but aspirin did not reduce cardiovascular events (hazard ratio [HR], 0.83; 95% confidence interval [CI]: 0.58-1.17). In the low-risk group, consisting of older patients without risk factors and younger patients (n=728), aspirin did not reduce cardiovascular events (HR, 0.55; 95% CI: 0.23-1.21). These results were unchanged after adjusting for potential confounding factors. Low-dose aspirin is not beneficial in Japanese diabetic patients at high risk.

  8. [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.

  9. 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.

  10. 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

  11. 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.

  12. Disparities in Treatment of Patients With High-risk Prostate Cancer: Results From a Population-based Cohort.

    PubMed

    Wang, Elyn H; Yu, James B; Abouassally, Robert; Meropol, Neal J; Cooper, Gregory; Shah, Nilay D; Williams, Stephen B; Gonzalez, Christopher; Smaldone, Marc C; Kutikov, Alexander; Zhu, Hui; Kim, Simon P

    2016-09-01

    To assess the variation in primary treatment of high-risk prostate cancer (PCa) by different hospital characteristics in the United States. We used the National Cancer Data Base to identify patients diagnosed with pretreatment high-risk PCa from 2004 to 2011. The primary outcomes were different forms of primary therapy or watchful waiting (WW) across different types of hospitals (community, comprehensive cancer community, and academic hospitals). Multivariable logistic regression analyses were used to test for differences in treatment by hospital type. During the study period, we identified 102,701 men diagnosed with high-risk PCa. Overall, the most common treatment was radical prostatectomy (37.0%) followed by radiation therapy (33.2%) and WW (8.5%). Compared with white men with high-risk PCa, black men had lower adjusted odds ratios (OR) for surgery at comprehensive community (OR: 0.64; P <.001) and academic (OR: 0.62; P <.001) hospitals. Similarly, black men were also more likely to be managed with WW at community (OR: 1.49; P <.001), comprehensive cancer community (OR: 1.24; P <.001), and academic (OR: 1.55; P <.001) hospitals, as well as with radiation therapy at comprehensive cancer community (OR: 1.27; P <.001) and academic hospitals (OR: 1.23; P <.001). Disparities in the use of WW and different primary treatments among patients with high-risk PCa persisted across different types of hospitals and over time. Our findings highlight a significant racial disparity in the use of curative therapy for high-risk PCa that should be urgently addressed to ensure that all men with PCa receive appropriate care across all racial groups and cancer care facilities. Copyright © 2016 Elsevier Inc. All rights reserved.

  13. 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.

  14. Phase I study of concurrent vinorelbine and radiation therapy in high-risk postmastectomy breast cancer patients.

    PubMed

    Honda, Kazunori; Riku, Miho; Iwase, Madoka; Hirasawa, Naoki; Yamada, Tetsuya; Goto, Yasutomo; Kawada, Kenji

    2016-09-01

    Postmastectomy chest wall irradiation is recommended for high-risk breast cancer patients, such as those with ≥4 positive nodes. Irradiation is performed sequentially rather than concurrently with chemotherapy. However, the 5-year locoregional recurrence-free survival was statistically better in the concurrent method in node-positive patients in a prior study. The benefit of concurrent chemoradiotherapy for postmastectomy breast cancer patients is uncertain. Vinorelbine is often used as concurrent chemoradiotherapy for non-small cell lung cancer in Japan and has antitumor activity in breast cancer as well. Thus, we planned this dose-finding study of concurrent vinorelbine and radiation therapy in high-risk postmastectomy breast cancer patients. High-risk postmastectomy breast cancer patients were recruited. Patients received weekly vinorelbine administered concurrently with radiation therapy. The radiation dose was 50 Gy in 25 fractions over 5 weeks. Vinorelbine was administered weekly without a break, so the maximum number of vinorelbine cycles was five. A 3 + 3 dose-escalation design was used for determining maximal tolerable dose, recommended dose and safety. A total of 10 patients were enrolled in cohorts of 10 and 15 mg/m(2). Dose-limiting toxicity was observed in one case in 10 mg/m(2) and two cases in 15 mg/m(2). Therefore, the maximal tolerable dose was defined at 15 mg/m(2) and the recommended dose was determined at 10 mg/m(2). The main adverse events included radiation dermatitis and neutropenia. Recurrence was observed in one patient with a median follow-up of 40 months. Concurrent vinorelbine and radiation therapy has a manageable safety profile at 10 mg/m(2) in high-risk postmastectomy breast cancer patients.

  15. Iodine-131-meta-iodobenzylguanidine therapy for patients with newly diagnosed high-risk neuroblastoma.

    PubMed

    Kraal, Kathelijne Cjm; van Dalen, Elvira C; Tytgat, Godelieve Am; Van Eck-Smit, Berthe Lf

    2017-04-21

    Patients with newly diagnosed high-risk (HR) neuroblastoma (NBL) still have a poor outcome, despite multi-modality intensive therapy. This poor outcome necessitates the search for new therapies, such as treatment with (131)I-meta-iodobenzylguanidine ((131)I-MIBG). To assess the efficacy and adverse effects of (131)I-MIBG therapy in patients with newly diagnosed HR NBL. We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library 2016, Issue 3), MEDLINE (PubMed) (1945 to 25 April 2016) and Embase (Ovid) (1980 to 25 April 2016). In addition, we handsearched reference lists of relevant articles and reviews. We also assessed the conference proceedings of the International Society for Paediatric Oncology, Advances in Neuroblastoma Research and the American Society of Clinical Oncology; all from 2010 up to and including 2015. We scanned the International Standard Randomized Controlled Trial Number (ISRCTN) Register (www.isrctn.com) and the National Institutes of Health Register for ongoing trials (www.clinicaltrials.gov) on 13 April 2016. Randomised controlled trials (RCTs), controlled clinical trials (CCTs), non-randomised single-arm trials with historical controls and cohort studies examining the efficacy of (131)I-MIBG therapy in 10 or more patients with newly diagnosed HR NBL. Two review authors independently performed the study selection, risk of bias assessment and data extraction. We identified two eligible cohort studies including 60 children with newly diagnosed HR NBL. All studies had methodological limitations, with regard to both internal (risk of bias) and external validity. As the studies were not comparable with regard to prognostic factors and treatment (and often used different outcome definitions), pooling of results was not possible. In one study, the objective response rate (ORR) was 73% after surgery; the median overall survival was 15 months (95% confidence interval (CI) 7 to 23

  16. Performance of the LACE index to identify elderly patients at high risk for hospital readmission in Singapore.

    PubMed

    Low, Lian Leng; Liu, Nan; Ong, Marcus Eng Hock; Ng, Eileen Yining; Ho, Andrew Fu Wah; Thumboo, Julian; Lee, Kheng Hock

    2017-05-01

    Unplanned readmissions may be avoided by accurate risk prediction and appropriate resources could be allocated to high risk patients. The Length of stay, Acuity of admission, Charlson comorbidity index, Emergency department visits in past six months (LACE) index was developed to predict hospital readmissions in Canada. In this study, we assessed the performance of the LACE index in a Singaporean cohort by identifying elderly patients at high risk of 30-day readmissions. We further investigated the use of additional risk factors in improving readmission prediction performance.Data were extracted from the hospital's electronic health records (EHR) for all elderly patients ≥ 65 years, with alive-discharge episodes from Singapore General Hospital in 2014. In addition to LACE, we also collected patients' data during the index admission, including demographics, medical history, laboratory results, and previous medical utilization.Among the 17,006 patients analyzed, 2051 or 12.1% of them were observed 30-day readmissions. The final predictive model was better than the LACE index in terms of discriminative ability; c-statistic of LACE index and final logistic regression model was 0.595 and 0.628, respectively.The LACE index had poor discriminative ability in identifying elderly patients at high risk of 30-day readmission, even if it was augmented with additional risk factors. Further studies should be conducted to discover additional factors that may enable more accurate and timely identification of patients at elevated risk of readmissions, so that necessary preventive actions can be taken.

  17. 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

  18. 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. |

  19. 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

  20. 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

  1. 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.

  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. Consensus statement on definition, diagnosis, and management of high-risk prostate cancer patients on behalf of the Spanish Groups of Uro-Oncology Societies URONCOR, GUO, and SOGUG.

    PubMed

    Henríquez, I; Rodríguez-Antolín, A; Cassinello, J; Gonzalez San Segundo, C; Unda, M; Gallardo, E; López-Torrecilla, J; Juarez, A; Arranz, J

    2017-08-07

    Prostate cancer (PCa) is the most prevalent malignancy in men and the second cause of mortality in industrialized countries. Based on Spanish Register of PCa, the incidence of high-risk PCa is 29%, approximately. In spite of the evidence-based beneficial effect of radiotherapy and androgen deprivation therapy in high-risk PCa, these patients (pts) are still a therapeutic challenge for all specialists involved, in part due to the absence of comparative studies to establish which of the present disposable treatments offer better results. Nowadays, high-risk PCa definition is not well consensual through the published oncology guides. Clinical stage, tumour grade, and number of risk factors are relevant to be considered on PCa prognosis. However, these factors are susceptible to change depending on when surgical or radiation therapy is considered to be the treatment of choice. Other factors, such as reference pathologist, different diagnosis biopsy schedules, surgical or radiotherapy techniques, adjuvant treatments, biochemical failures, and follow-up, make it difficult to compare the results between different therapeutic options. This article reviews important issues concerning high-risk PCa. URONCOR, GUO, and SOGUG on behalf of the Spanish Groups of Uro-Oncology Societies have reached a consensus addressing a practical recommendation on definition, diagnosis, and management of high-risk PCa.

  4. [Evaluation of 80-W and 120-W GreenLight laser vaporization for benign prostatic hyperplasia in high-risk patients].

    PubMed

    Zang, Ya-Chen; Shan, Yu-Xi; Xue, Bo-Xin; Yang, Dong-Rong; Gao, Jie; Sun, Chuan-Yang; Cui, Yong

    2012-05-01

    To investigate and compare the effectiveness and safety of 80-W GreenLight laser vaporization and GreenLight high-performance system (HPS) 120-W laser vaporization for the treatment of benign prostatic hyperplasia (BPH) in high-risk patients. We allocated 290 high-risk patients with BPH to two groups to receive 80-W (n = 220) and HPS 120-W GreenLight laser vaporization (n = 70). We recorded and compared the pre-, intra- and post-operative clinical data of the two groups. The operations were successful in both of the groups. There were statistically significant differences in the prostate volume, IPSS, Qmax and PVR before and after surgery (P < 0.01), but not between the two groups (P > 0.05). The operation time, lasing time and energy consumption were (56.5 +/- 22.6) min, (31.2 +/- 10.3) min and (159.8 +/- 29.0) kJ in the 80-W group, as compared with (45.1 +/- 20.4) min, (24.6 +/- 8.3) min and (134.2 +/- 23.3) kJ in the 120 W group, with significant differences between the two (P < 0.01). GreenLight laser vaporization of the prostate is a safe and effective procedure for the treatment of BPH, and the new HPS 120-W laser therapy, with its advantages of easier operation and shorter surgical time, is an even better minimally invasive option for elderly high-risk patients.

  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. Adjuvant Immunotherapy for Patients at High Risk of Recurrence Following Radiation Therapy for Prostate Cancer

    DTIC Science & Technology

    2005-08-01

    as the TAA target because it was a foreign Ag (from human papilloma virus ) so that we would be testing the effect of aging separated from the effects...mo-old mice. We chose the E7 protein as the TAA target because it was a foreign Ag (from human papilloma virus ) so that we would be testing the effect...High Risk of Recurrence Following Radiation Therapy for Prostate Cancer PRINCIPAL INVESTIGATOR: Albert B. Deisseroth, M.D., Ph.D

  7. Haploidentical, unmanipulated, G-CSF-primed bone marrow transplantation for patients with high-risk hematologic malignancies.

    PubMed

    Di Bartolomeo, Paolo; Santarone, Stella; De Angelis, Gottardo; Picardi, Alessandra; Cudillo, Laura; Cerretti, Raffaella; Adorno, Gaspare; Angelini, Stefano; Andreani, Marco; De Felice, Lidia; Rapanotti, Maria Cristina; Sarmati, Loredana; Bavaro, Pasqua; Papalinetti, Gabriele; Di Nicola, Marta; Papola, Franco; Montanari, Mauro; Nagler, Arnon; Arcese, William

    2013-01-31

    Eighty patients with high-risk hematologic malignancies underwent unmanipulated, G-CSF–primed BM transplantation from an haploidentical family donor. Patients were transplanted in first or second complete remission (CR, standard-risk: n =45) or in > second CR or active disease (high-risk: n =35). The same regimen for GVHD prophylaxis was used in all cases. The cumulative incidence (CI) of neutrophil engraftment was 93% 0.1%. The 100-day CIs for II-IV and III-IV grade of acute GVHD were 24% 0.2% and 5% 0.6%, respectively. The 2-year CI of extensive chronic GVHD was 6% 0.1%. The 1-year CI of treatment-related mortality was 36% 0.3%. After a median follow-up of 18 months, 36 of 80 (45%) patients are alive in CR. The 3-year probability of overall and disease-free survival for standard-risk and high-risk patients was 54% 8% and 33% 9% and 44% 8% and 30% 9%, respectively. In multivariate analysis, disease-free survival was significantly better for patients who had standard-risk disease and received transplantations after 2007. We conclude that unmanipulated, G-CSF–primed BM transplantation from haploidentical family donor provides very encouraging results in terms of engraftment rate, incidence of GVHD and survival and represents a feasible, valid alternative for patients with high-risk malignant hematologic diseases, lacking an HLA identical sibling and in need to be urgently transplanted. Haploidentical, unmanipulated, G-CSF-primed bone marrow transplantation. Haploidentical hematopoietic stem cell transplantation for hematologic malignancies.

  8. Low-dose cranial boost in high-risk adult acute lymphoblastic leukemia patients undergoing bone marrow transplant.

    PubMed

    Su, William; Thompson, Marcher; Sheu, Ren-Dih; Steinberg, Amir; Isola, Luis; Stock, Richard; Bakst, Richard L

    Acute lymphoblastic leukemia (ALL) has a predilection for CNS involvement. Patients with high-risk ALL are often managed with transplant using a radiation-based conditioning regimen. Historically, a high-dose prophylactic cranial boost (CB) of ≥12 Gy was given to reduce risk of central nervous system (CNS) recurrence. However, the use of CB has fallen out of favor because of toxicity concerns. In high-risk adults undergoing transplant at our institution, we have used a low-dose 6 Gy CB to reduce toxicity while conditioning adults with fully developed brains. The safety, efficacy, and utility of a low-dose CB in adults are poorly studied; herein, we report their outcomes and toxicity. We identified all high-risk ALL patients undergoing total body irradiation as part of their conditioning regimen. Those who received 6 Gy CB or no CB were included (55 total). Their charts were reviewed and statistical analyses were completed with R, version 2.15.2. In patients undergoing CB, 3-year CNS disease-free survival and overall survival were 94.7% and 62.7%. In those not undergoing CBs, survivals were 81.8% and 51.5%. Notably, within the CB cohort, patients without prior CNS involvement had no CNS failures. In contrast, in the non-CB cohort, there were 2 CNS failures in patients with no history of CNS involvement. In the CB cohort, the only notable acute toxicity was parotitis (2.8%). Late toxicity in the CB cohort included 1 instance of cataracts (2.8%) without any evidence of cognitive impairment or potential radiation induced secondary malignancy. A dose of 6 Gy CB is well-tolerated in the adult ALL population as part of a radiation-based conditioning regimen. Low-dose CB may be considered in adult patients with high-risk ALL without prior CNS involvement to reduce the likelihood of recurrence. Copyright © 2016. Published by Elsevier Inc.

  9. 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

  10. The effect of revascularization in patients with anatomically significant atherosclerotic renovascular disease presenting with high-risk clinical features.

    PubMed

    Vassallo, Diana; Ritchie, James; Green, Darren; Chrysochou, Constantina; Kalra, Philip A

    2017-03-23

    Patients with atherosclerotic renovascular disease (ARVD) and high-risk clinical presentations have largely been excluded from randomized controlled trials comparing renal revascularization and optimal medical therapy. Here, we explore the effect of revascularization on death, progression to end-stage kidney disease (ESKD) and cardiovascular events (CVE) in a highly selected cohort of patients with ARVD. All patients with a radiological diagnosis of ARVD referred to our tertiary centre have been recruited into a single-centre cohort study between 1986 and 2014. Patients with ≥70% unilateral or bilateral ARVD together with one or more of the following putative high-risk presentations were designated 'high-risk': flash pulmonary oedema (FPE), severe hypertension, rapidly deteriorating renal function. The effect of revascularization on clinical outcomes in high-risk patients, patients with bilateral severe ARVD and those with <1 g proteinuria at baseline was compared with 'control' patients who had the same degree of renal artery stenosis (RAS) but did not exhibit these features. Median follow-up was 58.4 months [interquartile range (IQR) 25.4-97.3]. Revascularization was associated with a reduced risk of progression to ESKD, CVE and all combined events in patients with rapidly deteriorating renal function [ESKD: hazard ratio (HR) 0.47 (95% confidence interval, CI, 0.25-0.85), P = 0.01; CVE: HR 0.51 (95% CI 0.29-0.91), P = 0.02; Any: HR 0.51 (95% CI 0.29-0.90), P = 0.02]. High-risk patients with bilateral ≥70% RAS and those with <1 g/day baseline proteinuria also had significantly better renal and cardiovascular outcomes post-revascularization when compared with controls. Our results indicate that revascularization may be of benefit in patients with anatomically significant RAS who present with rapidly deteriorating renal function, especially in the presence of severe bilateral ARVD or <1 g/day proteinuria.

  11. Olmesartan medoxomil-based antihypertensive therapy evaluated by ambulatory blood pressure monitoring: efficacy in high-risk patient subgroups.

    PubMed

    Chrysant, Steven G; Germino, F Wilford; Neutel, Joel M

    2012-12-01

    Hypertension affects approximately 26% of the world's adult population and is a recognized major risk factor for morbidity and mortality associated with cardiovascular, cerebrovascular, and renal diseases. However, despite the availability of a range of effective antihypertensive agents and a growing awareness of the consequences of high blood pressure (BP), the treatment and control of hypertension remains suboptimal. A number of patient subgroups are categorized as 'high risk' and may have hypertension that is more difficult to treat, including obese individuals, patients with stage 2 hypertension, those with type 2 diabetes mellitus (T2DM), patients with coronary artery disease or a history of stroke, and Black patients. As the benefits of lowering BP in patients with hypertension are unequivocal, particularly in high-risk patients, treating high-risk patients with hypertension to BP goals and maintaining 24-hour BP control is important to help reduce cardiovascular risk and improve outcomes. Although the BP goals recommended in current consensus guidelines for the management of patients with hypertension are based on cuff BP measurements, ambulatory BP monitoring (ABPM) provides a valuable diagnostic tool and allows a more accurate assessment of BP levels throughout the 24-hour dosing period. ABPM is a better predictor of prognosis than office BP measurement and is also useful for assessing whether antihypertensive therapy remains effective in the critical last few hours of the dosing period, which usually coincides with the morning BP surge associated with arousal and arising. ABPM has been adopted by new evidence-based guidelines in the United Kingdom to confirm a suspected diagnosis of hypertension, which is an indication of the growing importance of ABPM in the management of hypertension. This review provides an overview of the efficacy and safety of antihypertensive therapy based on olmesartan medoxomil ± hydrochlorothiazide and amlodipine

  12. A Predictive Model Using Histopathologic Characteristics of Early-Stage Type 1 Endometrial Cancer to Identify Patients at High Risk for Lymph Node Metastasis.

    PubMed

    Bendifallah, Sofiane; Canlorbe, Geoffroy; Laas, Enora; Huguet, Florence; Coutant, Charles; Hudry, Delphine; Graesslin, Olivier; Raimond, Emilie; Touboul, Cyril; Collinet, Pierre; Cortez, Annie; Bleu, Géraldine; Daraï, Emile; Ballester, Marcos

    2015-12-01

    This study aimed to develop a predictive model using histopathologic characteristics of early-stage type 1 endometrial cancer (EC) to identify patients at high risk for lymph node (LN) metastases. The data of 523 patients who received primary surgical treatment between January 2001 and December 2012 were abstracted from a prospective multicenter database (training set). A multivariate logistic regression analysis of selected prognostic features was performed to develop a nomogram predicting LN metastases. To assess its accuracy, an internal validation technique with a bootstrap approach was adopted. The optimal threshold in terms of clinical utility, sensitivity, specificity, negative predictive values (NPVs), and positive predictive values (PPVs) was evaluated by the receiver-operating characteristics (ROC) curve area and the Youden Index. Overall, the LN metastasis rate was 12.4 % (65/523). Lymph node metastases were associated with histologic grade, tumor diameter, depth of myometrial invasion, and lymphovascular space involvement status. These variables were included in the nomogram. Discrimination of the model was 0.83 [95 % confidence interval (CI) 0.80-0.85] in the training set. The area under the curve ROC for predicting LN metastases after internal validation was 0.82 (95 % CI 0.80-0.84). The Youden Index provided a value of 0.2, corresponding to a cutoff of 140 points (total score in the algorithm). At this threshold, the model had a sensitivity of 0.73 (95 % CI 0.62-0.83), a specificity of 0.84 (95 % CI 0.82-0.85), a PPV of 0.40 (95 % CI 0.34-0.45), and an NPV of 0.95 (95 % CI 0.94-0.97). The results show that the risk of LN metastases can be predicted correctly so that patients at high risk can benefit from adapted surgical treatment.

  13. 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

  14. 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.

  15. Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions.

    PubMed

    Merkkola-von Schantz, Päivi A; Jahkola, Tiina A; Krogerus, Leena A; Kauhanen, Susanna M C

    2017-10-01

    Contralateral reduction mammaplasty is regularly included in the treatment of breast cancer patients. We analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammaplasty specimens of women with previous breast cancer. We also analyzed if timing of reduction mammaplasty in relation to oncological treatment influenced the incidence of abnormal findings, and compared if patients with abnormal contralateral histopathology differed from the study population in terms of demographics. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammaplasty between 1/2007 and 12/2011. The data was retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and postoperative follow-up. Reduction mammaplasty specimens revealed abnormal findings in 68 (21.5%) patients. High-risk lesions (ADH, ALH, and LCIS) were revealed in 37 (11.7%), and cancer in six (1.9%) patients. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). Abnormal histopathological findings were more frequent in patients with reduction mammaplasty performed prior to oncological treatment (p < 0.001), and in patients with immediate reconstruction (p = 0.0064). The incidences of malignant and high-risk lesions are doubled compared to patients without prior breast cancer. Patients with abnormal histopathology cannot be preoperatively identified based on demographics. If reduction mammaplasty is performed before oncological treatment, the incidence of abnormal findings is higher. In the light of our results, contralateral reduction mammaplasty with histopathological evaluation in breast cancer patients offers a sophisticated tool to catch those patients whose contralateral breast needs increased attention. Copyright © 2017 Elsevier Ltd. All rights reserved.

  16. A phase II study evaluating neo-/adjuvant EIA chemotherapy, surgical resection and radiotherapy in high-risk soft tissue sarcoma

    PubMed Central

    2011-01-01

    Abstract Background The role of chemotherapy in high-risk soft tissue sarcoma is controversial. Though many patients undergo initial curative resection, distant metastasis is a frequent event, resulting in 5-year overall survival rates of only 50-60%. Neo-adjuvant and adjuvant chemotherapy (CTX) has been applied to achieve pre-operative cytoreduction, assess chemosensitivity, and to eliminate occult metastasis. Here we report on the results of our non-randomized phase II study on neo-adjuvant treatment for high-risk STS. Method Patients with potentially curative high-risk STS (size ≥ 5 cm, deep/extracompartimental localization, tumor grades II-III [FNCLCC]) were included. The protocol comprised 4 cycles of neo-adjuvant chemotherapy (EIA, etoposide 125 mg/m2 iv days 1 and 4, ifosfamide 1500 mg/m2 iv days 1 - 4, doxorubicin 50 mg/m2 day 1, pegfilgrastim 6 mg sc day 5), definitive surgery with intra-operative radiotherapy, adjuvant radiotherapy and 4 adjuvant cycles of EIA. Result Between 06/2005 and 03/2010 a total of 50 subjects (male = 33, female = 17, median age 50.1 years) were enrolled. Median follow-up was 30.5 months. The majority of primary tumors were located in the extremities or trunk (92%), 6% originated in the abdomen/retroperitoneum. Response by RECIST criteria to neo-adjuvant CTX was 6% CR (n = 3), 24% PR (n = 12), 62% SD (n = 31) and 8% PD (n = 4). Local recurrence occurred in 3 subjects (6%). Distant metastasis was observed in 12 patients (24%). Overall survival (OS) and disease-free survival (DFS) at 2 years was 83% and 68%, respectively. Multivariate analysis failed to prove influence of resection status or grade of histological necrosis on OS or DFS. Severe toxicities included neutropenic fever (4/50), cardiac toxicity (2/50), and CNS toxicity (4/50) leading to CTX dose reductions in 4 subjects. No cases of secondary leukemias were observed so far. Conclusion The current protocol is feasible for achieving local control rates, as well as OS and

  17. 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

  18. Nutritional risk and status of surgical patients; the relevance of nutrition training of medical students.

    PubMed

    Ferreira, C; Lavinhas, C; Fernandes, L; Camilo, Ma; Ravasco, P

    2012-01-01

    The prevalence of undernutrition among surgical patients is thought to be high, and negatively influencing outcomes. However, recent evidence shows the increase of overweight/obesity in hospitalised patients. A pilot cross-sectional study was conducted in 50 patients of a Surgical Department of the University Hospital of Santa Maria (CHLN) that aimed: 1) to assess nutritional risk and status through validated methods; 2) to explore the presence of overweight/obesity; 3) to evaluate the prevalence of metabolic risk associated with obesity. Nutritional risk was assessed by Malnutrition Universal Screening Tool (MUST), nutritional status by Body Mass Index (BMI), waist circumference (WC), & Subjective Global Assessment (SGA). Statistical significance was set for p < 0.05. 58% of patients were overweight/obese and 54% had high cardio-metabolic risk, according to waist circumference; 30% of patients had significantly lost weight (≥ 5%), whereas 28% gained weight. By MUST, 46% of patients were at low risk and 34% at high risk. By SGA, 58% patients were well nourished and 40% had moderate/severe undernutrition. A longer length of stay was associated with moderate/high risk by MUST, and undernutrition by SGA (p = 0.01). Undernutrition or obesity pose surgical risks. The lack of nutrition discipline in the medical curricula, limits the multiprofessional management and a better understanding of the more adequate approaches to these patients. Further, the change in the clinical scenario argues for more studies to clarify the prevalence and consequences of sarcopenic obesity in surgical patients.

  19. Anti-Xa-guided enoxaparin thromboprophylaxis reduces rate of deep venous thromboembolism in high-risk trauma patients.

    PubMed

    Singer, George A; Riggi, Gina; Karcutskie, Charles A; Vaghaiwalla, Tanaz M; Lieberman, Howard M; Ginzburg, Enrique; Namias, Nicholas; Lineen, Edward B

    2016-12-01

    Appropriate prophylaxis against venous thromboembolism (VTE) remains undefined. This study evaluated an anti-Xa-guided enoxaparin thromboprophylaxis (TPX) protocol on the incidence of VTE in high-risk trauma patients based on Greenfield's Risk Assessment Profile (RAP) score. This is a retrospective observational study of patients admitted to a trauma intensive care unit over a 12-month period. Patients were included if they received anti-Xa-guided enoxaparin TPX. Dosage was adjusted to a prophylactic peak anti-Xa level of 0.2 to 0.4 IU/mL. Subgroup analysis was performed on high-risk patients (RAP score ≥10) who received lower-extremity duplex ultrasound surveillance for deep vein thrombosis (DVT). Data are expressed as mean ± SD. Significance was assessed at p < 0.05. One hundred thirty-one patients received anti-Xa-guided enoxaparin TPX. Four patients were excluded for age or acute VTE on admission. Fifty-six patients with RAP score of ≥10 and surveillance duplex evaluations were included in the subgroup analysis with mean age 43 ± 20 years, Injury Severity Score of 25 ± 10, and RAP score of 16 ± 4. Prophylactic anti-Xa levels were initially achieved in 34.6% of patients. An additional 25.2% required 40 to 60 mg twice daily to reach prophylactic levels; 39.4% never reached prophylactic levels. Weight, body mass index, ISS, and RAP score were significantly higher with subprophylactic anti-Xa levels. One patient developed bleeding complications (0.8%). No patient developed intracerebral bleeding or heparin-induced thrombocytopenia.Nine VTE events occurred in the high-risk subgroup, including four DVT (7.1%), all asymptomatic, and five pulmonary emboli (8.9%). The historical rate of DVT in similar patients (ISS 31 ± 12 and RAP score 16 ± 5) was 20.5%, a significant decrease (p = 0.031). Mean chest Abbreviated Injury Scale scores were significantly higher for patients developing pulmonary emboli than DVT, 3.0 ± 1.1 vs. 0.0 (p < 0.001). Mean chest

  20. 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

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

    PubMed

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

    2016-09-01

    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.

  2. Clinical and economic effectiveness of percutaneous ventricular assist devices for high-risk patients undergoing percutaneous coronary intervention.

    PubMed

    Shah, Atman P; Retzer, Elizabeth M; Nathan, Sandeep; Paul, Jonathan D; Friant, Janet; Dill, Karin E; Thomas, Joseph L

    2015-03-01

    Comparative effectiveness research (CER) is taking a more prominent role in formalizing hospital treatment protocols and health-care coverage policies by having health-care providers consider the impact of new devices on costs and outcomes. CER balances the need for innovation with fiscal responsibility and evidence-based care. This study compared the clinical and economic impact of percutaneous ventricular assist devices (pVAD) with intraaortic balloon pumps for high-risk patients undergoing percutaneous coronary intervention (PCI). This study conducted a review of all comparative randomized control trials of the pVADS (Impella and TandemHeart) vs IABP for patients undergoing high-risk percutaneous coronary intervention (PCI). A retrospective analysis of the 2010 and 2011 Medicare MEDPAR data files was also performed to compare procedural costs and hospital length of stay (LOS). Readmission rates between the devices were also studied. Based on available trials, there is no significant clinical benefit with pVAD compared to IABP. Use of pVADs is associated with increased length of Intensive Care Unit stay and a total longer LOS. The incremental budget impact for pVADs was $33,957,839 for the United States hospital system (2010-2011). pVADs are not associated with improved clinical outcomes, reduced hospital length of stay, or reduced readmission rates. Management of high-risk PCI and cardiogenic shock patients with IABP is more cost effective than a routine use of pVADS. Use of IABP as initial therapy in high-risk PCI and cardiogenic shock patients may result in savings of up to $2.5 billion annually of incremental costs to the hospital system.

  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. 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.

  5. Bevacizumab for Ovarian Cancer at High Risk of Progression: Reproducibility of Trial Results in 'Real-world' Patients.

    PubMed

    Bertelli, Gianfilippo; Drews, Florian; Lutchman-Singh, Kerryn

    2016-09-01

    Bevacizumab has become a 'community standard' at many UK centres as part of first-line treatment of patients with ovarian cancer at high risk of progression [International Federation of Gynecology and Obstetrics (FIGO) stage IV, or suboptimally debulked stage III] based on the results of phase III trials such as ICON-7. Its impact in patients treated outside clinical trials is, however, still unknown. In this study, we investigated patient characteristics, treatment patterns, adverse events and progression-free survival in 'real-world' patients in South West Wales. A total of 60 patients, treated between 2012 and 2015, were included in the study. Patient characteristics were less favourable compared to the bevacizumab-treated high-risk group in the ICON-7 trial (median age: 66 vs. 60 years; stage IV: 58% vs. 42%; performance status 0: 18% vs. 41%); 75% had received neoadjuvant chemotherapy before starting bevacizumab. After a median treatment duration of 8 months (range=0-34 months), 45 patients (75%) had experienced disease progression and 34 (56.7%) had died. Median progression-free survival was 16 months (95% confidence interval=14.4-17.6 months). The most common toxicities consisted of proteinuria (66.7%, all grade 1) and grade 1-2 hypertension (15%). Cardiovascular incidents, two of which were fatal, occurred in 6.7% of patients. In conclusion, our study provides encouraging evidence that the routine use of bevacizumab as part of first-line treatment of patients with ovarian cancer at high risk of progression may be associated with outcomes comparable with those obtained in clinical trials. Copyright© 2016 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.

  6. 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.

  7. 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.

  8. 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

  9. Fungal Septicemia in Surgical Patients

    PubMed Central

    Rodrigues, Roberto J.; Wolff, William I.

    1974-01-01

    Opportunistic systemic fungal infections are more frequent than generally realized. Increased awareness and a high index of suspicion of fungal super-infection in the presence of sepsis is required to bring about recognition and therapy. The intravenous catheter is an important portal of entry or may act as a foreign body favoring localization of a septic process. In its presence, fungemia must be guarded against. Whenever an intravenous catheter is removed, its tip should be cultured. Removal alone may be a critical item in therapy. In febrile patients, in whom the course of fever is not established, frequent blood cultures with attention directed specifically at fungi should be obtained. Fungi are not easily isolated and identified and only by requesting special attention from the microbiologist can the diagnosis be established in the average institutional laboratory in time to permit appropriate therapy. Since available therapeutic measures are strikingly effective when instituted early, awareness and alertness on the part of the clinician constitute the key to cure. PMID:4213622

  10. 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.

  11. 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

  12. 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.

  13. [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.

  14. Long-term Outcomes of Thoracoscopic Anatomic Resections and Systematic Lymphadenectomy for Elderly High-risk Patients with Stage IB Non-small-cell Lung Cancer.

    PubMed

    Fang, Ziwen; He, Jianxing; Fang, Wanqiang; Ruan, Lingling; Fang, Fang

    2016-04-01

    To evaluate the efficacy and long-term survival outcomes of complete video-assisted thoracoscopic surgery (C-VATS) for the resection of anatomic pulmonary segments and systematic lymphadenectomy in the treatment of elderly and high-risk patients with stage IB for non-small cell lung cancer (NSCLC). 242 elderly patients (≥65 years), who were operated on by the same operational team, were divided into high-risk group and conventional risk group from August 2008 to December 2010. All patients were diagnosed in stage IB (pT status: >2 to ≤3) NSCLC by biopsy and examination of PET-CT before operation. The high-risk patients were identified with severe cardiopulmonary and other system dysfunctions as follow-up criteria. They were treated with VATS anatomic pulmonary segments and systematic lymphadenectomy. The conventional risk patients with adequate cardiopulmonary reserve were treated with VATS radical lobectomy and systematic lymphadenectomy. The clinical and pathological data were recorded. The total survival, tumour-free survival, recurrence time and character of patients were followed-up. Appropriate statistical analyses involved the χ(2) test and Kaplan-Meier estimates of total survival and tumour-free survival. A total of 242 patients underwent surgical resection during our study period: Anatomic pulmonary segments in 116 patients and lobectomy in 126. The operative time and blood loss of the VATS anatomic pulmonary segments group (78.0±35.0 min, 95.6±30.4 ml) were significantly less than those of the VATS radical resection group (108.0±25.0 min, 165.6±58.4 ml). Neither group experienced post-operative death. The overall and tumour-free survival rate of the VATS anatomic pulmonary segments group within five years were 62.07% and 29.31%, and those of the VATS radical resection group were 63.49% and 33.33%,%; there was no significant difference (P>0.5). The recurrence rates of the VATS anatomic pulmonary segment group and VATS radical resection group were

  15. 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.

  16. 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

  17. Outcomes of corticosteroid prophylaxis for hypersensitivity reactions to low osmolar contrast media in high-risk patients.

    PubMed

    Jung, Jae-Woo; Choi, Young Hun; Park, Chang Min; Park, Heung Woo; Cho, Sang-Heon; Kang, Hye-Ryun

    2016-09-01

    Corticosteroid prophylaxis has been widely adopted for the prevention of acute allergic-like reactions to iodinated contrast media, but its use is still controversial because there is no strong evidence supporting its efficacy before administration of nonionic low osmolar contrast media (LOCM). To assess the outcomes of premedication in patients with previous acute allergic-like reactions to LOCM in clinical practice. A retrospective study was performed on 322 high-risk patients who were reexposed to LOCM after premedication composed of antihistamines and/or systemic corticosteroids because of a previous history of acute allergic-like reactions to LOCM. After premedication, 275 patients (85.4%) did not experience any reaction, but 47 patients (14.6%) still experienced a breakthrough reaction. The premedication rate and amount of corticosteroid administered were significantly higher in the nonrecurrence group than in the recurrence group (P = .04 and P = .04, respectively), and a linear trend was observed in the use of corticosteroid premedication and the efficacy of prevention (P for trend = .02). Multivariate binary logistic regression revealed that corticosteroid premedication was effective in preventing recurrence (odds ratio, 0.284; 95% confidence interval, 0.103-0.784). Nonetheless, despite corticosteroid premedication, 3.4% of high-risk patients still experienced moderate to severe reactions, and 14.3% of patients with a severe index reaction again had a severe reaction. Premedication with corticosteroids seems to be helpful in reducing the overall rate of recurrence of acute allergic-like reactions to LOCM in high-risk patients, but patients with severe index reactions are still at risk of developing severe reactions despite corticosteroid premedication. Copyright © 2016 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

  18. Targeted Reminder Phone Calls to Patients at High Risk of No-Show for Primary Care Appointment: A Randomized Trial.

    PubMed

    Shah, Sachin J; Cronin, Patrick; Hong, Clemens S; Hwang, Andrew S; Ashburner, Jeffrey M; Bearnot, Benjamin I; Richardson, Calvin A; Fosburgh, Blair W; Kimball, Alexandra B

    2016-12-01

    No-shows, or missed appointments, are a problem for many medical practices. They result in fragmented care and reduce access for all patients. To determine whether telephone reminder calls targeted to patients at high risk of no-show can reduce no-show rates. Single-center randomized controlled trial. A total of 2247 primary care patients in a hospital-based primary care clinic at high risk of no-show (>15 % risk) for their appointment in 7 days. Seven days prior to their appointment, intervention arm patients were placed in a calling queue to receive a reminder phone call from a patient service coordinator. Coordinators were trained to engage patients in concrete planning. All patients received an automated phone call (usual care). Primary outcome was no-show rate. Secondary outcomes included arrival rate, cancellation rate, reschedule rate, time to cancellation, and change in revenue. The no-show rate in the intervention arm (22.8 %) was significantly lower (absolute risk difference -6.4 %, p < 0.01, 95 % CI [-9.8 to -3.0 %]) than that in the control arm (29.2 %). Arrival, cancellation, and reschedule rates did not differ significantly. In the intervention arm, rescheduling and cancellations occurred further in advance of the appointment (mean difference, 0.35 days; 95 % CI [0.07-0.64]; p = 0.01). Reimbursement did not differ significantly. A phone call 7 days prior to an appointment led to a significant reduction in no-shows and increased reimbursement among patients at high risk of no-show. The use of targeted interventions may be of interest to practices taking on increased accountability for population health.

  19. 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.

  20. [Effects of essential periodontal treatment on serum level of sCD40L and periodontal clinical parameters in patients with moderate to severe periodontitis at high risk of stroke].

    PubMed

    Gao, Lei; Sun, Xiao-Ju; Xie, Hong; Nan, Shun-Hua; Xie, Hui-Xin

    2016-10-01

    To investigate the effect of periodontal treatment on patients with moderate to severe periodontitis at high risk of stroke, by detecting the level of serum soluble cell differentiation antigen 40 ligand (sCD40L) before and after periodontal non-surgical treatment. Seventy-six patients with moderate to severe periodontitis at high risk of stroke were collected and randomly divided into 2 groups, 40 patients in group A received essential periodontal treatment + routine maintenance therapy, 36 cases in group B only received routine maintenance therapy. Another 36 patients with moderate and severe periodontitis were selected as group C, and received essential periodontal treatment. Bleeding on probing (BOP), periodontal probing depth (PD) and attachment loss (AL) in 6 loci were examined by the same dentists, and enzyme linked immunosorbent assay (ELISA) was used to detect the level of serum sCD40L before treatment and 3 months after treatment. The data were analyzed by SPSS 17.0 software package. Compared with pre-treatment, serum level of sCD40L and periodontal clinical indexes of the three groups decreased. Compared with group B, serum SCD40L in group A significantly decreased(P<0.05). Periodontal treatment can reduce the serum level of sCD40L in patients with moderate to severe periodontitis at high risk of stroke, and improve the patient's inflammatory state. To a certain extent, periodontal treatment may reduce the risk of high-risk stroke population to develop stroke.

  1. [Nutritional status of elderly surgical patients].

    PubMed

    Damuleviciene, Gyte; Lesauskaite, Vita; Macijauskiene, Jūrate

    2008-01-01

    The aim of this study was to assess nutritional status of aged surgical patients, to determine the prevalence of malnutrition and factors associated with it. A total of 156 patients aged 45 years and more, treated at the Departments of Surgery and Urology of Kaunas 2nd Clinical Hospital, were enrolled in the study. Elderly group (aged 65 years and more) consisted of 99 patients, and middle-aged group (45 to 64 years old) of 57 patients. The following anthropometric measurements were performed: weight, height, mid-arm circumference; hemoglobin, serum albumin level, and total lymphocyte count were determined. Standard assessment scales included Instrumental Activities of Daily Living, Geriatric Depression Scale, and Mini Mental State Exam. Statistical analysis was performed with the help of SPSS 12.0. Malnutrition was diagnosed in 53.5% of older patients and in 15.8% of middle-aged patients (P<0.05). Obesity was diagnosed in 32.3% of elderly patients and in 40.4% of middle-aged patients (P<0.05). Among men, obese patients made up 20%, among women - 54.4% (P<0.05). Malnutrition was more prevalent among elderly patients who underwent urgent operations than in patients who underwent planned operations (69.6% and 34.1%, respectively; P<0.05) and among elderly patients with impaired cognitive functions than among those without impaired cognitive functions (in 100% of patients with medium impaired cognitive function, in 59.3% of patients with mild impaired cognitive function, and in 44.4% of patients with unimpaired cognitive function, P<0.05). Malnourished elderly patients had lower functional level than the remaining (IADL score of 3.97 and 4.75 for men, 5.38 and 6.89 for women, respectively; P<0.05). The prevalence of malnutrition did not differ significantly in the groups of older patients with depression, probable depression and not depressed patients - 75.0%, 57.7%, and 46.7%, respectively (P>0.05). Malnutrition was diagnosed more frequently in elderly surgical

  2. 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.

  3. 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

  4. 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.

  5. Oropharyngeal and laryngeal but not oral cancers are strongly associated with high-risk human papillomavirus in 172 Greek patients.

    PubMed

    Tsimplaki, Elpida; Argyri, Elena; Sakellaridis, Athanassios; Kyrodimos, Efthimios; Xesfyngi, Dimitra; Panotopoulou, Efstathia

    2017-01-01

    A strong and consistent association has been reported between human papillomavirus (HPV) infection and oropharyngeal cancer, whereas a similar link has not yet been clarified in oral and laryngeal cancer. The purpose of this study was to investigate the association between HPV infection and head and neck squamous cell carcinoma (HNSCC) in Greek patients. Cytological or tissue specimens from 172 cases patients with HNSCC and cytological specimens from 91 control subjects were analyzed for HPV DNA detection and genotyping using a microarray-based assay. Multivariate logistic regression was used to estimate odds ratios (ORs) for the association between the presence of HPV infection and HNSCC for each of the tumor site, after adjustment for potential confounders. The adjusted ORs for positivity to high-risk HPV infection for oropharyngeal and laryngeal cancer were 20.3 (95% CI: 1.7-250.1) and 22.8 (95% CI: 2.5-206.2), respectively. High-risk HPV infection was not significantly associated with oral cancer. HPV infection was independently associated with poorly differentiated tumors (OR = 2.8; 95% CI: 1.1-7.5). Our results suggest a strong association of high-risk HPV infection with oropharyngeal and laryngeal cancer. J. Med. Virol. 89:170-176, 2017. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

  6. 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.

  7. 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

  8. Peri-operative management of high-risk paediatric adenotonsillectomy patients: A survey of 35 UK tertiary referral centres.

    PubMed

    Cheong, Ryan Chin Taw; Bowles, Philippe; Moore, Andrew; Watts, Simon

    2017-05-01

    Peri-operative management of high-risk paediatric patients undergoing adenotonsillectomy for treatment of obstructive sleep apnoea varies between tertiary referral hospitals. 'Day of surgery cancellation' (DoSC) rates of up to 11% have been reported due to pre-booked critical care being unavailable on the day of surgery as a result of competing needs from other hospital departments. We report the results of a survey of peri-operative management in UK tertiary care centres of high-risk paediatric patients undergoing adenotonsillectomy for obstructive sleep apnoea (OSA). An 8-point questionnaire was developed using a cloud-based software platform (www.surveymonkey.com). A web-link to the survey was embedded in a customised e-mail which was sent via secure server to the Clinical Leads for Paediatric Otolaryngology at 35 United Kingdom (UK) Tertiary referral centres. The survey response rate was 60% (n = 21). Almost all (94.1%) of centres considered paediatric critical care facilities to be limited, with 70.6% (n = 12) stating that DoSC often occurred due to unavailable paediatric critical care capacity. There was variation between tertiary referral units in the practice applied for pre-booking critical care beds (our survey identifies 6 variations) (Table 1). The most frequent selection method reported (47.1%) was at the discretion of the booking clinician at the time of listing the patient for surgery. In the context of limited critical care resources, variation in practice and difficulty in accurately predicting which patients will require post-operative critical care beds, a review and consensus on best practice in the peri-operative management of high risk paediatric adenotonsillectomy patients may offer a safe means of reducing cancellations and improving patient care, resource allocation and hospital efficiency. Copyright © 2017 Elsevier B.V. All rights reserved.

  9. Safety and Tolerability of Anthracycline-Containing Adjuvant Chemotherapy in Elderly High-Risk Breast Cancer Patients.

    PubMed

    Karavasilis, Vasilios; Papadimitriou, Christos; Gogas, Helen; Kouvatseas, George; Pentheroudakis, George; Koutras, Angelos; Christodoulou, Christos; Bafaloukos, Dimitrios; Samantas, Epaminontas; Pisanidis, Nikolaos; Papakostas, Pavlos; Aravantinos, Gerasimos; Karanikiotis, Charisios; Kosmidis, Paris; Pectasides, Dimitrios; Dimopoulos, Meletios-Athanassios; Fountzilas, George

    2016-08-01

    Intensive chemotherapy confers benefit to patients with high-risk early breast cancer (BC). We characterized the feasibility and toxicity profile of anthracycline-containing adjuvant chemotherapy (ACAC) in older women with early BC. Available data from women who received ACAC for BC in 3 randomized trials were retrieved. We identified women aged >65 years and we examined differences in tolerability and delivery of chemotherapy, toxicity, and treatment outcome. From a total of 2640 patients, we identified 453 patients (17%) as being >65 years old, 89% of whom had tumors that were node-positive, with 77% who were hormone receptor-positive. At least 90% of the planned doses were delivered in 37% of the elderly, compared with 49% in the younger patients (P < .0001). Grade 3 and 4 hematological toxicity was observed in 32% of elderly patients, compared with 21% of the younger (P < .0001). Febrile neutropenia occurred in 4.5% of the elderly patients, as opposed to 2.0% in the younger patients (P < .002). Elderly patients experienced more frequent Grade 3 and 4 fatigue, mucositis, and sensory neuropathy. Relative dose intensities were significantly lower in elderly patients. Treatment discontinuation was not different in the 2 groups. At a median follow-up of 120 months, competing risks analysis showed a significant benefit in disease-free survival for elderly patients. Elderly BC patients treated with ACAC derive clinical benefit comparable to that in younger patients, mainly at the cost of increased risk of hematological toxicity. This should be taken into account in decision-making and treatment individualization in high-risk BC patients. Copyright © 2015 Elsevier Inc. All rights reserved.

  10. [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.

  11. [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.

  12. Beating-heart coronary artery bypass surgery with the help of mini extracorporeal circulation for very high-risk patients.

    PubMed

    Munos, Emmanuel; Calderon, Joachim; Pillois, Xavier; Lafitte, Stéphane; Ouattara, Alexandre; Labrousse, Louis; Roques, Xavier; Barandon, Laurent

    2011-03-01

    Left ventricle dysfunction and co-morbidities are responsible for a large number of complications after coronary artery bypass graft (CABG) surgery. The best strategy for these patients, including the use or not and type of extracorporeal circulation (ECC), the use of minimized ECC (MECC), or conventional ECC (CECC), remains unclear. The aim of the present study was to investigate the potential effect of on-pump beating-heart (OPBH) surgery with the help of MECC for CABG in patients with a high-risk EuroSCORE and to compare this strategy to three other different procedures, including OPCAB and MECC or CECC with cardiac arrest. Patients were included if their EuroSCORE was strictly >" xbd="1427" xhg="1404" ybd="1477" yhg="1440"/>9. Four groups were retrospectively compared: an OPCAB, an OPBH, a MECC and a CECC group under cardiac arrest. 214 patients, mean age 74.26 ± 8.5 years, 68.7% male, were operated. Mean EuroSCORE was 12.1 ± 2.9, left ventricular (LV) function 37.4 ± 12.3%, recent myocardial infarction (MI) 49.5%, renal failure 48.1%, chronic obstructive pulmonary disease (COPD) 42.2%, and peripheral vascular disease (PVD) 55.6%. Mean number of grafts per patient was 2.4 ± 0.7. Our study showed that it was possible, in very high-risk patients, to carry out revascularisation with OPBH similar to that using MECC or CECC under cardiac arrest (p=NS). This technique reduces troponin release (3.23 vs 6.56, p<0.01), postoperative myocardial complications (2% vs 8%, p<0.01), cardiotonic drug prescription (15.7% vs 31.3%, p<0.01), ventilation time (4.57H vs 6.48H, p<0.01) and length of stay (LOS) in ICU (2.16 vs 2.53, p=0.02). The OPBH method seems to be safe, secure and effective in this population of very high-risk patients, reducing early complications and multi-organ failure. OPBH surgery, combining MECC without aortic cross-clamping, makes it possible to perform complete revascularization and is an interesting alternative for CABG in high-risk patients.

  13. Arteriovenous fistula combined with brachial artery superficialization is effective in patients with a high risk of maturation failure.

    PubMed

    Murakami, Masaaki; Sakaguchi, Genichi; Mori, Noriko

    2017-02-01

    In patients with a high risk of fistula immaturity, we created arteriovenous fistulas (AVFs) combined with brachial artery superficialization. With this procedure, the superficialized arteries are used as drawing routes and the AVFs as returning routes. This is a technical report about AVFs combined with brachial artery superficialization. Twenty-four consecutive patients with a high risk of fistula immaturity who underwent AVFs with brachial artery superficialization were included in this single-center retrospective study. High risk for maturation failure was defined with a combination of the vessel size measured by ultrasound and the length of the straight segment for cannulation. The indications were as follows: (1) a vein diameter of <2 mm or an artery diameter at the point of anastomosis of <2 mm (n = 9); and (2) a vein cannulation site of <10 cm long, which is too short for two cannulations (n = 15). Initially, after careful examination of the vessels by duplex ultrasound imaging, we created an AVF at an appropriate site. Subsequently, the brachial artery was exposed and the side branches were ligated. The brachial artery was mobilized to the ventral aspect of the upper arm, and the subcutaneous tissue under the brachial artery was sutured. A skin flap was then placed over the transposed brachial artery. One patient died of sepsis due to central venous catheter infection before the initial cannulation. All other patients underwent successful two-needle cannulation with a prescribed blood flow. The median age of the patients was 78 years. The first successful cannulation was achieved at a median of 17 days (range, 12-547) after AVF creation. Two patients underwent cannulation >30 days after surgery (58 and 547 days) because their vascular accesses were created before initiation of hemodialysis treatment. Median postoperative follow-up duration was 524 days (range, 15-1394 days). Nine patients (38%) died during follow-up of unrelated causes. At 12

  14. 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.

  15. An fMRI study of visual lexical decision in patients with schizophrenia and clinical high-risk individuals.

    PubMed

    Natsubori, Tatsunobu; Hashimoto, Ryu-Ichiro; Yahata, Noriaki; Inoue, Hideyuki; Takano, Yosuke; Iwashiro, Norichika; Koike, Shinsuke; Gonoi, Wataru; Sasaki, Hiroki; Takao, Hidemasa; Abe, Osamu; Kasai, Kiyoto; Yamasue, Hidenori

    2014-08-01

    Disturbances in semantic and phonological aspects of language processing are indicated in patients with schizophrenia, and in high-risk individuals for schizophrenia. To uncover neural correlates of the disturbances, a previous functional magnetic resonance imaging (fMRI) study using a visual lexical decision task in block design reported less leftward lateralization in the inferior frontal cortices, in patients with schizophrenia and individuals with high genetic risk for psychosis compared with normal control subjects. However, to our knowledge, no previous study has investigated contrasts between word and non-word processing that allow dissociation between semantic and phonological processing using event-related design visual lexical decision fMRI tasks in subjects with ultra-high-risk for psychosis (UHR) and patients with schizophrenia. In the current study, 20 patients with schizophrenia, 11 UHR, and 20 demographically matched controls underwent lexical decision fMRI tasks. Compared with controls, both schizophrenia and UHR groups showed significantly decreased activity in response to non-words compared with words in the inferior frontal regions. Additionally, decreased leftward lateralization in the non-word compared with word activity contrast was found in subjects with UHR compared with controls, which was not evident in patients with schizophrenia. The present findings suggest neural correlates of difficulty in phonological aspects of language processing during non-word processing in contrast to word, which at least partially commonly underlies the pathophysiology of schizophrenia and UHR. Together with a previous study in genetic high-risk subjects, the current results also suggest that reduced functional lateralization in the language-related frontal cortex may be a vulnerability marker for schizophrenia. Furthermore, the current result may suggest that the genetic basis of psychosis is presumed to be related to the evolution of the language capacity

  16. 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.

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

    PubMed

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

    2017-07-24

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

  18. Role of Montgomery salivary stent placement during pharyngolaryngectomy, to prevent pharyngocutaneous fistula in high-risk patients.

    PubMed

    Bondi, S; Giordano, L; Limardo, P; Bussi, M

    2013-01-01

    To evaluate the incidence of pharyngocutaneous fistula after pharyngolaryngectomy with and without a Montgomery salivary stent. Retrospective analysis of patients with factors that predispose to the development of pharyngocutaneous fistula (i.e. disease extending to the supraglottic region, base of the tongue or pyriform sinuses, and/or radiochemotherapy). Between 2002 and 2008, 85 pharyngolaryngectomies were performed in our clinic. Of these patients, 31 were at increased risk of fistula development, of whom 45 per cent developed fistulas post-operatively. This subgroup of 31 patients was compared with a second subgroup of 22 patients at high risk of fistula development, treated between 2009 and 2011 with pharyngolaryngectomy and with a Montgomery salivary stent placed in advance during closure of the neopharynx. Statistical analysis showed a significant reduction in the rate of fistula development, from 45 to 9 per cent (p < 0.01), with application of the salivary stent. These data confirm the preventive effect of a salivary stent placed during pharyngolaryngectomy, for patients at high risk of fistula development.

  19. Integrating patient safety and clinical pharmacy services into the care of a high-risk, ambulatory population: a collaborative approach.

    PubMed

    Robbins, Carolyn M; Stillwell, Tracy; Johnson, Deborah; Wilson, Sally; Fitzgerald, Lynn

    2013-06-01

    Lincoln Community Health Center participated in a Health Resources and Services Administration-sponsored Patient Safety and Clinical Pharmacy Services Collaborative aimed at facilitating integration of pharmacy services proven to enhance patient safety into care provided to a high-risk, ambulatory population. The Collaborative used the Plan-Do-Study-Act (PDSA) cycle of learning from the Model for Improvement endorsed by the Institute for Healthcare Improvement to guide changes. Outcomes targeted for improvement included medication reconciliation, obesity screening and follow-up planning, adverse drug events (patient safety), and delivery of clinical pharmacy services. Primary changes that resulted from conducting 54 PDSA cycles of learning included enhanced data access, centralized medication access through formulary expansion, implemented a medication reconciliation guideline, designated a single point of accountability in the pharmacy, improved efficiency, staff performed nontraditional roles, extended the existing adverse drug event program, and improved communication. Changes made to integrate patient safety and clinical pharmacy services into the care of a high-risk, ambulatory population not only improved all targeted outcomes but also helped establish Lincoln Community Health Center as the patient's medical home.

  20. 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.

  1. 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

  2. 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

  3. 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

  4. Intensive case management for high-risk patients with first-episode psychosis: service model and outcomes.

    PubMed

    Brewer, Warrick J; Lambert, Timothy J; Witt, Katrina; Dileo, John; Duff, Cameron; Crlenjak, Carol; McGorry, Patrick D; Murphy, Brendan P

    2015-01-01

    The first episode of psychosis is a crucial period when early intervention can alter the trajectory of the young person's ongoing mental health and general functioning. After an investigation into completed suicides in the Early Psychosis Prevention and Intervention Centre (EPPIC) programme, the intensive case management subprogramme was developed in 2003 to provide assertive outreach to young people having a first episode of psychosis who are at high risk owing to risk to self or others, disengagement, or suboptimal recovery. We report intensive case management model development, characterise the target cohort, and report on outcomes compared with EPPIC treatment as usual. Inclusion criteria, staff support, referral pathways, clinical review processes, models of engagement and care, and risk management protocols are described. We compared 120 consecutive referrals with 50 EPPIC treatment as usual patients (age 15-24 years) in a naturalistic stratified quasi-experimental real-world design. Key performance indicators of service use plus engagement and suicide attempts were compared between EPPIC treatment as usual and intensive case management, and psychosocial and clinical measures were compared between intensive case management referral and discharge. Referrals were predominately unemployed males with low levels of functioning and educational attainment. They were characterised by a family history of mental illness, migration and early separation, with substantial trauma, history of violence, and forensic attention. Intensive case management improved psychopathology and psychosocial outcomes in high-risk patients and reduced risk ratings, admissions, bed days, and crisis contacts. Characterisation of intensive case management patients validated the clinical research focus and identified a first episode of psychosis high-risk subgroup. In a real-world study, implementation of an intensive case management stream within a well-established first episode of psychosis

  5. Meaning of low-density lipoprotein-apheresis for hypercholesterolemic patients at high risk for recurrence of coronary heart disease.

    PubMed

    Koga, Nobuhiko

    2002-10-01

    The goal of cholesterol-lowering therapy in hypercholesterolemic patients at high risk for recurrence of coronary heart disease (CHD) is the prevention of acute coronary syndrome by stabilization of coronary atheromatous plaque. We often encounter patients in whom it is difficult to maintain the serum cholesterol level at a desirable level with dietary