Most patients with colorectal liver metastases present to general surgeons and oncologists without a specialist interest in their management. Since treatment strategy is frequently dependent on the ...response to earlier treatments, our aim was to create a therapeutic decision model identifying appropriate procedure sequences.
We used the RAND Corporation/University of California, Los Angeles Appropriateness Method (RAM) assessing strategies of resection, local ablation and chemotherapy. After a comprehensive literature review, an expert panel rated appropriateness of each treatment option for a total of 1,872 ratings decisions in 252 cases. A decision model was constructed, consensus measured and results validated using 48 virtual cases, and 34 real cases with known outcomes.
Consensus was achieved with overall agreement rates of 93.4 to 99.1%. Absolute resection contraindications included unresectable extrahepatic disease, more than 70% liver involvement, liver failure, and being surgically unfit. Factors not influencing treatment strategy were age, primary tumor stage, timing of metastases detection, past blood transfusion, liver resection type, pre-resection carcinoembryonic antigen (CEA), and previous hepatectomy. Immediate resection was appropriate with adequate radiologically-defined resection margins and no portal adenopathy; other factors included presence of < or = 4 or > 4 metastases and unilobar or bilobar involvement. Resection was appropriate postchemotherapy, independent of tumor response in the case of < or = 4 metastases and unilobar liver involvement. Resection was appropriate only for > 4 metastases or bilobar liver involvement, after tumor shrinkage with chemotherapy. When possible, resection was preferred to local ablation.
The results were incorporated into a decision matrix, creating a computer program (OncoSurge). This model identifies individual patient resectability, recommending optimal treatment strategies. It may also be used for medical education.
Early presentation and prompt diagnosis of acute appendicitis are necessary to prevent progression of disease leading to complicated appendicitis. We hypothesize that patients had a delayed ...presentation of acute appendicitis during the COVID-19 pandemic, which affected severity of disease on presentation and outcomes.
We conducted a retrospective review of all patients who were treated for acute appendicitis at Morgan Stanley Children's Hospital (MSCH) between March 1, 2020 and May 31, 2020 when the COVID-19 pandemic was at its peak in New York City (NYC). For comparison, we reviewed patients treated from March 1, 2019 to May 31, 2019, prior to the pandemic. Demographics and baseline patient characteristics were analyzed for potential confounding variables. Outcomes were collected and grouped into those quantifying severity of illness on presentation to our ED, type of treatment, and associated post-treatment outcomes. Fisher's Exact Test and Kruskal-Wallis Test were used for univariate analysis while cox regression with calculation of hazard ratios was used for multivariate analysis.
A total of 89 patients were included in this study, 41 patients were treated for appendicitis from March 1 to May 31 of 2019 (non-pandemic) and 48 were treated during the same time period in 2020 (pandemic). Duration of symptoms prior to presentation to the ED was significantly longer in patients treated in 2020, with a median of 2 days compared to 1 day (p = 0.003). Additionally, these patients were more likely to present with reported fever (52.1% vs 24.4%, p = 0.009) and had a higher heart rate on presentation with a median of 101 beats per minute (bpm) compared to 91 bpm (p = 0.040). Findings of complicated appendicitis on radiographic imaging including suspicion of perforation (41.7% vs 9.8%, p < 0.001) and intra-abdominal abscess (27.1% vs 7.3%, p = 0.025) were higher in patients presenting in 2020. Patients treated during the pandemic had higher rates of non-operative treatment (25.0% vs 7.3%, p = 0.044) requiring increased antibiotic use and image-guided percutaneous drain placement. They also had longer hospital length of stay by a median of 1 day (p = 0.001) and longer duration until symptom resolution by a median of 1 day (p = 0.004). Type of treatment was not a predictor of LOS (HR = 0.565, 95% CI = 0.357–0.894, p = 0.015) or duration until symptom resolution (HR = 0.630, 95% CI = 0.405–0.979, p = 0.040).
Patients treated for acute appendicitis at our children's hospital during the peak of the COVID-19 pandemic presented with more severe disease and experienced suboptimal outcomes compared to those who presented during the same time period in 2019.
III
In this issue of Obesity, Wadden and colleagues offer a gift to struggling health care providers (HCPs), in the form of the blueprint for their MODEL-IBT program, with its curriculum, resources, and ...scripts to be published online, freely available for HCPs to use in their practices (10). The Managing Obesity with Diet, Exercise, and Liraglutide (MODEL) behavioral counseling curriculum, based on the Diabetes Prevention Program (DPP), was developed to structure intensive obesity counseling to be consistent with the Medicare IBT benefit of four weekly (15-minute) sessions over the first month, followed by biweekly visits for 2 to 6 months, followed by monthly counseling thereafter. A randomized trial of MODEL-IBT, published earlier this year in Obesity, showed a loss of 6.1% from baseline body weight over 12 months, a magnitude of weight loss that is impressive in itself, but even more so in that it was implemented by primary care providers and registered dietitians with little or no background in IBT (11). Using the MODEL-IBT protocol after a brief 4- to 6-hour training, these providers facilitated nearly identical weight loss in their patients as did the much more robust-and costly- DPP intervention. Another group that received antiobesity pharmacotherapy (liraglutide 3.0 mg), in addition to IBT, achieved nearly double the weight loss, compared with IBT alone. If long-term outcomes of MODEL-IBT approach that of DPP (most notably, the substantially reduced development of type 2 diabetes) we may ultimately regard the MODEL-IBT trial as one of the most impactful translational studies in recent memory.
The Van Gorder approach for total elbow arthroplasty Kahan, Joseph B.; Schneble, Christopher A.; Simcock, Xavier ...
Journal of shoulder and elbow surgery,
March 2022, 2022-Mar, 2022-03-00, 20220301, Letnik:
31, Številka:
3
Journal Article
Recenzirano
Surgical management of the triceps during exposure for total elbow arthroplasty (TEA) is critical to a successful outcome. Previously described techniques include elevating the triceps insertion from ...one side or leaving the triceps insertion attached and dislocating the joint. Another approach to the elbow, first described in 1933 by Willis Campbell, MD, and subsequently modified by George Van Gorder, MD, involves turning down the triceps tendon without disrupting the triceps insertion. This approach offers complete visualization of the joint and provides excellent exposure for TEA. Only the original report of the technique and a small series of patients using this technique for TEA exist in the literature. The goal of this study was to evaluate outcomes of the Van Gorder approach in a large series of patients undergoing TEA.
All patients who underwent TEA from 2008 to 2016 were retrospectively reviewed. Only patients who underwent primary TEA performed through the Van Gorder approach with at least 6 months' follow-up were included for analysis. Patients with prior elbow surgery were excluded. Demographic data, indication for surgery, postoperative range of motion, triceps function, and need for additional surgery were recorded. Prospectively collected visual analog scale (VAS) and Global Health Quality of Life scores were also analyzed.
A total of 53 patients met inclusion criteria. The mean age was 62 years, 81% were female, and the average follow-up was 30.2 months. The most common surgical indications included inflammatory arthritis (47%), osteoarthritis (24%), and fracture (19%). Postoperatively, average elbow arc of motion was an 8°-137°. There was 1 patient (1.89%) who developed failure of their triceps extension mechanism. A total of 10 patients (19%) underwent additional elbow surgery most commonly for superficial wound complications. Preoperative VAS scores decreased significantly, starting at 3 months postoperatively (6.76 to 3.37, P < .001), and remained constant at the 12- and 24-month postoperative visits.
This is the largest study evaluating the Van Gorder surgical approach to the elbow for primary TEA with an average follow-up of 32 months. Overall rates of triceps failure and reoperation are consistent with other approaches for TEA.
Acute rejection episodes after renal transplantation are an important clinical challenge, despite use of multidrug immunosuppressive regimens. We did a prospective, multicentre, randomised, ...double-blind trial to investigate the impact of the addition of sirolimus, compared with azathioprine, to a ciclosporin and prednisone regimen.
719 recipients of primary HLA-mismatched cadaveric or living-donor renal allografts who displayed initial graft function were randomly assigned, after transplantation, sirolimus 2 mg daily (n=284) or 5 mg daily (n=274), or azathioprine (n=161). We assessed the primary composite endpoint of efficacy failure, occurrence of biopsy-confirmed acute rejection episodes, graft loss, or death, and various secondary endpoints that characterise these episodes at 6 months and 12 months. Analyses were done by intention to treat.
The rate of efficacy failure at 6 months was lower in the two sirolimus groups (2 mg 18·7%, p=0·002; 5 mg 16·8%, p<0·001) than in the azathioprine group (32·3%). The frequency of biopsy-confirmed acute rejection episodes was also lower (2 mg 16·9%, p=0·002; 5 mg 12·0%, p<0·001; azathioprine 29·8%). At 12 months, survival was similar in all groups for grafts (97·2%, 96·0%, and 98·1%) and patients (94·7%, 92·7%, and 93·8%). Patients on sirolimus showed a delay in the time to first acute rejection episode and decreased frequency of moderate and severe histological grades of rejection episodes and related antibody treatment, compared with the azathioprine group. Rates of infection and malignant disorders were similar in all groups.
Use of sirolimus reduced occurrence and severity of biopsy-confirmed acute rejection episodes with no increase in complications. Further studies are needed to establish the optimum doses for the combined regimen.
This study reports the 12-month results of the RADIANCE-HTN (A Study of the ReCor Medical Paradise System in Clinical Hypertension) SOLO trial following unblinding of patients at 6 months.
The blood ...pressure (BP)–lowering efficacy and safety of endovascular ultrasound renal denervation (RDN) in the absence (2 months) and presence (6 months) of antihypertensive medications were previously reported.
Patients with daytime ambulatory BP ≥135/85 mm Hg after 4 weeks off medication were randomized to RDN (n = 74) or sham (n = 72) and maintained off medication for 2 months. A standardized medication escalation protocol was instituted between 2 and 5 months (blinded phase). Between 6 and 12 months (unblinded phase), patients received antihypertensive medications at physicians’ discretion. Outcomes at 12 months included medication burden, change in daytime ambulatory systolic BP (dASBP) and office or home systolic BP (SBP), visit-to-visit variability in SBP, and safety.
Sixty-five of 74 RDN patients and 67 of 72 sham patients had 12-month dASBP measurements. The proportion of patients on ≥2 medications (27.7% vs. 44.8%; p = 0.041), the number of medications (1.0 vs. 1.4; p = 0.015), and defined daily dose (1.4 vs. 2.2; p = 0.007) were less with RDN versus sham. The decrease in dASBP from baseline in the RDN group (−16.5 ± 12.9 mm Hg) remained stable at 12 months. The RDN versus sham adjusted difference at 12 months was −2.3 mm Hg (95% confidence interval CI: −5.9 to 1.3 mm Hg; p = 0.201) for dASBP, −6.3 mm Hg (95% CI: −11.1 to −1.5 mm Hg; p = 0.010) for office SBP, and −3.4 mm Hg (95% CI: −6.9 to 0.1 mm Hg; p = 0.062) for home SBP. Visit-to-visit variability in SBP was smaller in the RDN group. No renal artery injury was detected on computed tomographic or magnetic resonance angiography.
Despite unblinding, the BP-lowering effect of RDN was maintained at 12 months with fewer prescribed medications compared with sham.
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