Hypoparathyroidism (hypoPT) is the most common complication following bilateral thyroid operations. Thyroid surgeons must employ strategies for minimizing and preventing post-thyroidectomy hypoPT. ...The objective of this American Thyroid Association Surgical Affairs Committee Statement is to provide an overview of its diagnosis, prevention, and treatment.
HypoPT occurs when a low intact parathyroid hormone (PTH) level is accompanied by hypocalcemia. Risk factors for post-thyroidectomy hypoPT include bilateral thyroid operations, autoimmune thyroid disease, central neck dissection, substernal goiter, surgeon inexperience, and malabsorptive conditions. Medical and surgical strategies to minimize perioperative hypoPT include optimizing vitamin D levels, preserving parathyroid blood supply, and autotransplanting ischemic parathyroid glands. Measurement of intraoperative or early postoperative intact PTH levels following thyroidectomy can help guide patient management. In general, a postoperative PTH level <15 pg/mL indicates increased risk for acute hypoPT. Effective management of mild to moderate potential or actual postoperative hypoPT can be achieved by administering either empiric/prophylactic oral calcium and vitamin D, selective oral calcium, and vitamin D based on rapid postoperative PTH level(s), or serial serum calcium levels as a guide. Monitoring for rebound hypercalcemia is necessary to avoid metabolic and renal complications. For more severe hypocalcemia, inpatient management may be necessary. Permanent hypoPT has long-term consequences for both objective and subjective well-being, and should be prevented whenever possible.
In 2010, this Journal published my comprehensive review of the literature on hypertrophic scars and keloids. In that article, I presented evidence-based algorithms for the prevention and treatment of ...these refractory pathologic scars. In the ensuing decade, substantial progress has been made in the field, including many new randomized controlled trials. To reflect this, I have updated my review.
All studies were evaluated for methodologic quality. Baseline characteristics of patients were extracted along with the interventions and their outcomes. Systematic reviews, meta-analyses, and comprehensive reviews were included if available.
Risk factors that promote hypertrophic scar and keloid growth include local factors (tension on the wound/scar), systemic factors (e.g., hypertension), genetic factors (e.g., single-nucleotide polymorphisms), and lifestyle factors. Treatment of hypertrophic scars depends on scar contracture severity: if severe, surgery is the first choice. If not, conservative therapies are indicated. Keloid treatment depends on whether they are small and single or large and multiple. Small and single keloids can be treated radically by surgery with adjuvant therapy (e.g., radiotherapy) or multimodal conservative therapy. For large and multiple keloids, volume- and number-reducing surgery is a choice. Regardless of the treatment(s), patients should be followed up over the long term. Conservative therapies, including gel sheets, tape fixation, topical and injected external agents, oral agents, and makeup therapy, should be administered on a case-by-case basis.
Randomized controlled trials on pathologic scar management have increased markedly over the past decade. Although these studies suffer from various limitations, they have greatly improved hypertrophic scar and keloid management. Future high-quality trials are likely to improve the current hypertrophic scar and keloid treatment algorithms further.
The Banff Classification of Allograft Pathology is an international consensus classification for the reporting of biopsies from solid organ transplants. Since its initial conception in 1991 for renal ...transplants, it has undergone review every 2 years, with attendant updated publications. The rapid expansion of knowledge in the field has led to numerous revisions of the classification. The resultant dispersal of relevant content makes it difficult for novices and experienced pathologists to faithfully apply the classification in routine diagnostic work and in clinical trials. This review shall provide a complete and simple illustrated reference guide of the Banff Classification of Kidney Allograft Pathology based on all publications including the 2017 update. It is intended as a concise desktop reference for pathologists and clinicians, providing definitions, Banff Lesion Scores and Banff Diagnostic Categories. An online website reference guide hosted by the Banff Foundation for Allograft Pathology (www.banfffoundation.org) is being developed, which will be updated with future refinement of the Banff Classification from 2019 onward.
Abstract Introduction Revision surgery for failed total knee arthroplasty (TKA) continues to pose a substantial burden for patients, providers, and the United States healthcare system. Historically, ...leading causes for revision have included infection, osteolysis, loosening, stiffness, and instability. However, the predominant etiology of TKA failure has changed over time and may vary between reports based on many factors including study design, patient demographics and other regional factors. In order to effectively acknowledge modes of implant failure and maximize postoperative outcomes, it is essential to understand the present epidemiology of revision TKAs. This study aims to update the current literature on this topic by using a large national database. Specifically, we analyzed: 1) etiologies for revision TKA; 2) frequencies of revision TKA procedures; 3) various demographics including payer type and region; and 4) the length of stay (LOS) and total charges based on type of revision TKA procedure. Methods The Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) database was used to identify all revision TKA procedures performed between January 1, 2009 and December 31, 2013. The NIS is the largest publicly available all-payer inpatient healthcare database in the United States, yielding national estimates of hospital inpatient stays. Clinical, economic, and demographic data were collected and analyzed for 337,597 procedures. Patients were stratified according to etiology of failure, age, sex, race, US census region, and primary payor class. The mean length of stay and total charges were also calculated for each type of revision TKA procedure. Results Infection was the most common etiology for revision TKA (20.4%), closely followed by mechanical loosening (20.3%). The most common revision TKA procedure performed was all component revision (31.3%). Medicare was the primary payor for the greatest proportion of revision procedures (57.7%). The South census region performed the most revision TKA procedures (33.2%). The overall mean LOS was 4.5 days, with arthrotomy for removal of prosthesis without replacement procedures accounting for the longest stays (7.8 days). The mean total charge for revision TKA procedures was $75,028.07, with femoral component revisions demonstrating the highest charges ($90,065.11). Conclusion Infection and mechanical loosening are the leading indications for revision total knee arthroplasty in the United States. Additionally our analysis demonstrated higher rates of TKA revision in the South census region. Patients who underwent arthrotomy for removal of prosthesis without replacement procedures had the longest lengths of stay, and femoral component revisions incurred the highest charges. With the projected increase in primary TKAs performed annually, it is essential for orthopaedists to understand the factors contributing to implant failure and revision. Continued insight into the etiology and epidemiology of revision TKA procedures may be the principle step towards improving outcomes and mitigating the need for future revisions.
Intraoperative hypotension is a common side effect of general anaesthesia and might lead to inadequate organ perfusion. It is unclear to what extent hypotension during noncardiac surgery is ...associated with unfavourable outcomes.
We conducted a systematic search in PubMed, Embase, Web of Science, and CINAHL, and classified the quality of retrieved articles according to predefined adapted STROBE and CONSORT criteria. Reported strengths of associations from high-quality studies were classified into end-organ specific injury risks, such as acute kidney injury, myocardial injury, and stroke, and overall organ injury risks for various arterial blood pressure thresholds.
We present an overview of 42 articles on reported associations between various absolute and relative intraoperative hypotension definitions and their associations with postoperative adverse outcomes after noncardiac surgery. Elevated risks of end-organ injury were reported for prolonged exposure (≥10 min) to mean arterial pressures <80 mm Hg and for shorter durations <70 mm Hg. Reported risks increase with increased durations for mean arterial pressures <65–60 mm Hg or for any exposure <55–50 mm Hg.
The reported associations suggest that organ injury might occur when mean arterial pressure decreases <80 mm Hg for ≥10 min, and that this risk increases with blood pressures becoming progressively lower. Given the retrospective observational design of the studies reviewed, reflected by large variability in patient characteristics, hypotension definitions and outcomes, solid conclusions on which blood pressures under which circumstances are truly too low cannot be drawn. We provide recommendations for the design of future studies.
(PROSPERO ID). CRD42013005171.
A multicenter, prospective review of surgical patients with adult spine deformity.
Assessment of the incidence, risk factor, and impact of radiographical and implant-related complications (RIC) on ...health-related quality of life measures.
This study provides assessment of the incidence of RIC in adult spinal deformity surgery and impact of these complications on need for reoperation. Risk factors for development of RIC are also assessed, as well as the impact of these complications on health-related quality of life (HRQOL) outcomes measures.
A multicenter, prospective database of surgical patients with adult spinal deformity was reviewed. All patients with complete 2-year follow-up were included. HRQOL was measured using the Oswestry Disability Index, General Health Survey (36-Item Short Form Health Survey SF-36), and Scoliosis Research Society-22 (SRS-22r) at baseline, 6 weeks, 1 year, and 2 years postoperatively. Univariate testing was performed as appropriate. Multivariate logistic regression modeling was used to determine independent predictors of RIC. Multivariate repeated-measures mixed models were used to examine HRQOL, accounting for confounders.
A total of 245 patients met inclusion criteria. The incidence of RIC was 31.7% and 52.6% of those patients required reoperation. Rod breakage accounted for 47% of the implant-related complications, and proximal junctional kyphosis accounted for 54.5% of radiographical complications. Univariate analysis identified the following potential risk factors for RIC: weight, American Society of Anesthesiologists score, revision, stopping the fusion in the lower thoracic spine, worse SRS-Schwab classification modifiers (pelvic tilt++, pelvic incidence minus lumbar lordosis++, sagittal vertical axis++), higher T1 spinopelvic inclination, and higher T1 slope. Independent predictors of RIC as identified on multivariate logistic regression included American Society of Anesthesiologists (odds ratio: 1.75, P = 0.029) and sagittal vertical axis modifier ++ (odds ratio 3.43, P = 0.0001). The RIC and no RIC groups each experienced significant improvement over time, as measured on the Oswestry Disability Index (P = 0.0001), SF-36 (P = 0.0001), and SRS-22r (P = 0.0001). However, the rate of improvement over time was less for patients with RIC (SRS-22r P = 0.043, SF-36 P = 0.0001).
This study identified that nearly one-third of patients undergoing adult spinal deformity surgery experienced a radiographical or implant-related complication, and that just more than one-half of these patients experiencing complication required a reoperation within 2 years of surgery. These complications significantly affected HRQOL measures. Baseline patient characteristics and parameters of the SRS-Schwab classification can be used to help identify those patients at greater risk.
3.
Short-term patient and graft outcomes continue to improve after kidney and liver transplantation, with 1-year survival rates over 80%; however, improving longer-term outcomes remains a challenge. ...Improving the function of grafts and health of recipients would not only enhance quality and length of life, but would also reduce the need for retransplantation, and thus increase the number of organs available for transplant. The clinical transplant community needs to identify and manage those patient modifiable factors, to decrease the risk of graft failure, and improve longer-term outcomes.COMMIT was formed in 2015 and is composed of 20 leading kidney and liver transplant specialists from 9 countries across Europe. The group's remit is to provide expert guidance for the long-term management of kidney and liver transplant patients, with the aim of improving outcomes by minimizing modifiable risks associated with poor graft and patient survival posttransplant.The objective of this supplement is to provide specific, practical recommendations, through the discussion of current evidence and best practice, for the management of modifiable risks in those kidney and liver transplant patients who have survived the first postoperative year. In addition, the provision of a checklist increases the clinical utility and accessibility of these recommendations, by offering a systematic and efficient way to implement screening and monitoring of modifiable risks in the clinical setting.
Biology and Biomarkers for Wound Healing Lindley, Linsey E; Stojadinovic, Olivera; Pastar, Irena ...
Plastic and reconstructive surgery (1963),
2016-September, Letnik:
138, Številka:
3 Suppl
Journal Article
Recenzirano
Odprti dostop
As the population grows older, the incidence and prevalence of conditions that lead to a predisposition for poor wound healing also increase. Ultimately, this increase in nonhealing wounds has led to ...significant morbidity and mortality with subsequent huge economic ramifications. Therefore, understanding specific molecular mechanisms underlying aberrant wound healing is of great importance. It has and will continue to be the leading pathway to the discovery of therapeutic targets, as well as diagnostic molecular biomarkers. Biomarkers may help identify and stratify subsets of nonhealing patients for whom biomarker-guided approaches may aid in healing.
A series of literature searches were performed using Medline, PubMed, Cochrane Library, and Internet searches.
Currently, biomarkers are being identified using biomaterials sourced locally from human wounds and/or systemically using high-throughput "omics" modalities (genomic, proteomic, lipidomic, and metabolomic analysis). In this review, we highlight the current status of clinically applicable biomarkers and propose multiple steps in validation and implementation spectrum, including those measured in tissue specimens, for example, β-catenin and c-myc, wound fluid, matrix metalloproteinases and interleukins, swabs, wound microbiota, and serum, for example, procalcitonin and matrix metalloproteinases.
Identification of numerous potential biomarkers using different avenues of sample collection and molecular approaches is currently underway. A focus on simplicity and consistent implementation of these biomarkers, as well as an emphasis on efficacious follow-up therapeutics, is necessary for transition of this technology to clinically feasible point-of-care applications.
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