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ABSTRACT: OBJECTIVE: To study whether patients with HIV-1 associated lipodystrophy (LD) on highly active antiretroviral treatment (HAART) have more psychopathology and worse psychosocial adjustment than a similar group without this syndrome. METHODS: In a cross-sectional, observational study we compared 47 HIV-1 infected patients with LD (LD group) with 39 HIV-1 infected patients without LD (non-LD group). All participants were on HAART. The Beck Depression Inventory (BDI), the State and Trait Anxiety Inventory (STAI) and the Goldberg Health Questionnaire (GHQ-60) were administered. Levels of familial, work and social adjustment and adjustment to stressful events were evaluated in a semi-structured interview. Clinical information was extracted from the clinical records. RESULTS: In the univariate analysis patients with LD showed higher state anxiety scores (p=0.009) and worse work adjustment (p=0.019) than those without LD. A total of 45.3% of LD patients scored above the cut-off point on the trait anxiety scale, and over 33.3% scored above the cut-off point on the BDI, GHQ and state anxiety scales. However, in multivariate analyses LD was not independently associated with psychopathology or with worse adjustment in the studied areas. CONCLUSIONS: The finding that LD was not a predictor of greater psychopathology or worse psychosocial adjustment in HIV-1 infected patients, despite the high scores found, suggests that factors not taken into account in this study, such as LD severity and self-perception should have been included in the analysis. Further studies including a greater number of variables and a larger sample size will advance our understanding of this complex condition.
The Brazilian journal of infectious diseases: an official publication of the Brazilian Society of Infectious Diseases 06/2013; · 0.55 Impact Factor
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ABSTRACT: ABSTRACT BACKGROUND: The quality and potential impact of available clinical guidelines for asthma management has not been systematically evaluated. We therefore evaluated the quality of clinical practice guidelines (CPGs) for asthma. METHODS: We performed a systematic search of scientific literature published between 2000 and 2010 to identify and select CPGs related to asthma management. We searched guideline databases, guideline developers' websites and MEDLINE. Four independent reviewers assessed the eligible guidelines using the AGREE II instrument. We calculated the overall agreement among reviewers with the Intraclass Correlation Coefficient (ICC). RESULTS: Eighteen CPGs published between the years 2000-2010 were selected from a total of 1,005 references. The overall agreement among reviewers was moderate (ICC: 0.78; 95%CI 0.62-0.90). The mean scores for each AGREE domain were: Scope and Purpose 44.1% (range: 10.0-79.0%); stakeholder involvement 33.8% (range: 4.0-66.0%); rigor of development 32.4% (range: 8.0-64.0%); clarity and presentation 52.1% (range: 17.0-85.0%); applicability 21.1% (range: 3-55%); and editorial independence 25% (range: 0-58%). None of the appraised guidelines had a score higher than 60% (recommended). Half of the appraised guidelines were recommended with modifications (9/18) or not recommended (9/18) for using in clinical practice. We observed improvement over time in guidelines' overall quality (p=0.01; guidelines from 2001-2006 vs. 2007-2009). CONCLUSIONS: The quality of guidelines for asthma care is low although it has improved over time. Greater efforts are needed to provide high quality guidelines that can be used as a reliable tool for clinical decision-making in this field.
Chest 02/2013; · 5.25 Impact Factor
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ABSTRACT: Alzheimer's disease dementia (AD dementia) is one of the most common neurodegenerative diseases worldwide, with a growing incidence during the last decades. Clinical diagnosis of cognitive impairment and presence of AD biomarkers have become important issues for early and adequate treatment. We performed a systematic literature search and quality appraisal of AD dementia guidelines, published between 2005 and 2011, which contained diagnostic recommendations on AD dementia. We also analyzed diagnostic recommendations related to the use of brief cognitive tests, neuropsychological evaluation, and AD biomarkers. Of the 537 retrieved references, 15 met the selection criteria. We found that Appraisal of Guidelines Research and Evaluation (AGREE)-II domains such as applicability and editorial independence had the lowest scores. The wide variability on assessment of quality of evidence and strength of recommendations were the main concerns identified regarding diagnostic testing. Although the appropriate methodology for clinical practice guideline development is well known, the quality of diagnostic AD dementia guidelines can be significantly improved.
American Journal of Alzheimer s Disease and Other Dementias 01/2013; · 1.45 Impact Factor
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Rafael Calvo,
Ma José Martínez-Zapata,
Gerard Urrútia, Ignasi Gich,
Marcos Jordán,
Alejandro Del Arco,
Francisco Javier Aguilera,
Fernando Celaya,
Juan Sarasquete,
Joan Majó,
Xavier Bonfill
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ABSTRACT: The aim of this study was to assess the efficacy of continuous low-pressure suction drainage compared with closed high-pressure suction following total knee arthroplasty.
Closed wound drainage systems are used in surgical interventions to reduce the incidence of haematomas, promote wound healing and reduce infections. However, evidence shows that using a closed wound drainage system can increase transfusion requirements.
A randomized, double-blind and parallel controlled trial was performed. Adult knee replacement patients recruited between May 2006 and March 2007 were assigned to receive low-pressure suction of 50 mmHg (experimental drainage) or high-pressure suction of 700 mmHg (comparator drainage).
The primary outcome was total blood loss after surgery. Secondary outcomes were incidence of transfusion, complications and mortality. Statistical analysis was based on an intention-to-treat approach. Linear regression was performed to account for factors that could influence blood loss.
A total of 169 patients were included. Mean age was 73 (±6) years, 128 women and 41 men. A total of 84 patients were randomized to the experimental drainage and 85 to the comparator drainage. Analysis showed a total postoperative blood loss of 541·8 mL in the experimental group and 524·4 mL in the comparator group (P = 0·734). The only factor that showed an association with blood loss was the length of surgery. Linear regression did not show differences between the groups.
Continuous low-pressure suction of 50 mmHg is not more effective than the higher aspiration pressure system to diminish the blood loss in total knee arthroplasty. The results do not support any change in current nursing practice relating to the use of this drain system.
Journal of Advanced Nursing 11/2011; 68(4):758-66. · 1.48 Impact Factor
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ABSTRACT: To evaluate and compare BNP and NT-proBNP concentrations to predict weaning failure from mechanical ventilation (MV) due to heart failure (HF) before a spontaneous breathing trial (SBT) and to identify HF as the cause of failure.
Prospective, observational study in a university hospital. The sample included 100 patients on MV for over 48 h who underwent an SBT. Echocardiography and sampling for natriuretic peptides were performed immediately before and at the end of SBT. HF was diagnosed by pulmonary artery occlusion pressure >18 mm Hg or signs of elevated filling pressures in echocardiography.
Thirty-two patients failed the SBT, 12 due to HF and 20 due to respiratory failure (RF). Before SBT, BNP and NT-proBNP were higher in patients failing due to HF than RF or in successfully weaned patients. Cut-off values using ROC curve analyses to predict HF were 263 ng/L for BNP (p < 0.001) and 1,343 ng/L for NT-proBNP (p = 0.08). BNP and NT-proBNP increased significantly during SBT in patients failing due to HF. Increases in BNP and NT-proBNP of 48 and 21 ng/L, respectively, showed a diagnostic accuracy for HF of 88.9 and 83.3% (p < 0.001). BNP performed better than NT-proBNP for HF prediction (p = 0.01) and diagnosis (p = 0.009).
B-type natriuretic peptides, particularly BNP, can predict weaning failure due to HF before an SBT; increases in natriuretic peptides during SBT are diagnostic of HF as the cause of weaning failure. BNP performs better than NT-proBNP in prediction and diagnosis of HF.
European Journal of Intensive Care Medicine 03/2011; 37(3):477-85. · 5.17 Impact Factor
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ABSTRACT: Triflusal is an antiplatelet agent that irreversibly acetylates cyclooxygenase isoform 1 (COX-1) and therefore inhibits thromboxane biosynthesis. It was initially marketed as capsules containing 300 mg of active substance. In 2006 a new 600 mg (10 ml) oral solution form of triflusal was authorized in Spain. The primary aim of this study was to compare the gastrointestinal safety of the new triflusal oral solution with triflusal capsules in healthy volunteers.
Sixty healthy subjects were randomly assigned, in a 2.5:2.5: 1 ratio, into one of three groups, with 25 subjects receiving one bottle of triflusal oral solution (600 mg) daily, 25 subjects receiving two triflusal capsules (600 mg) once daily, and ten subjects receiving two placebo capsules once daily, respectively, during 7 consecutive days. Gastroscopy was performed at baseline before the administration of study drugs and after 4-8 h of the last dose of study drugs. Effects on the esophagus, stomach, and duodenum were measured in accordance with a modified Lanza scale.
No differences between groups were detected at baseline. After treatment, median global scores in the placebo, triflusal solution, and triflusal capsules groups were, respectively, 0, 1, and 3 (p = 0.003 for comparison between placebo and triflusal capsules and p = 0.042 for comparison between triflusal solution and triflusal capsules). There were no significant differences between the scores on the triflusal solution and placebo groups. All treatments were well tolerated.
In healthy subjects, triflusal solution induced less endoscopically apparent gastrointestinal mucosal damage than triflusal capsules and did not induce more damage than the placebo in healthy volunteers.
European Journal of Clinical Pharmacology 02/2011; 67(7):663-9. · 2.85 Impact Factor
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ABSTRACT: RO-14 is a novel ultra low molecular heparin. The purpose of this study was to evaluate the safety and pharmacodynamic profile of RO-14 in healthy males.
We conducted a two-stage, single-center, open-label, randomized study. Two cohorts of 6 volunteers were randomly assigned to 12 single, ascending subcutaneous doses (1750-19950IU of anti-FXa activity) in an alternating crossover fashion. Safety was assessed by spontaneous/elicited adverse events, medical examination and laboratory tests. Anti-FXa activity and anti-FIIa activity were assessed throughout the 24hours after dosing. Dose proportionality and linearity of the anti-FXa activity were evaluated.
All doses were well tolerated and there were no bleeding events. At the lowest dose, anti-FXa activity A(max) was 0.16 (±0.02) IU/mL and AUC(0-24) was 1.11 (±0.24) IU*h/mL, At the highest dose anti-FXa activity A(max) was 1.67 (±0.15) IU/mL; AUC(0-24) was 21.48 (±4.46) IU*h/mL and t½ was 8.05h. Mean T(max) (all doses) was 2.86 (±0.39) h. RO-14 showed proportional and linear pharmacodynamics [normalized A(max) among doses (p=0.594) and normalized AUC(0-24) (p=0.092), correlations between A(max-)dose (R(2)=0.89, p<0.001) and AUC(0-24)-dose (R(2)=0.86, p<0.001)]. Anti-FIIa activity was below the detection limit (0.1IU/ml) at all dose levels. No clinically significant changes were observed in the platelet count, APTT, PT, TT, fibrinogen and antithrombin.
In this phase I study, RO-14 exhibited a good safety profile, anti-FXa activity for either prophylaxis or treatment of venous thromboembolism, linear pharmacodynamics, a longer elimination half-life than currently marketed low molecular weight heparin and no anti-FIIa activity.
Thrombosis Research 01/2011; 127(4):292-8. · 2.44 Impact Factor
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ABSTRACT: Despite the increasing number of manuals on how to develop clinical practice guidelines (CPGs) there remain concerns about their quality. The aim of this study was to review the quality of CPGs across a wide range of healthcare topics published since 1980.
The authors conducted a literature search in MEDLINE to identify publications assessing the quality of CPGs with the Appraisal of Guidelines, Research and Evaluation (AGREE) instrument. For the included guidelines in each study, the authors gathered data about the year of publication, institution, country, healthcare topic, AGREE score per domain and overall assessment.
In total, 42 reviews were selected, including a total of 626 guidelines, published between 1980 and 2007, with a median of 25 CPGs. The mean scores were acceptable for the domain 'Scope and purpose' (64%; 95% CI 61.9 to 66.4) and 'Clarity and presentation' (60%; 95% CI 57.9 to 61.9), moderate for domain 'Rigour of development' (43%; 95% CI 41.0 to 45.2), and low for the other domains ('Stakeholder involvement' 35%; 95% CI 33.9 to 37.5, 'Editorial independence' 30%; 95% CI 27.9 to 32.3, and 'Applicability' 22%; 95% CI 20.4 to 23.9). From those guidelines that included an overall assessment, 62% (168/270) were recommended or recommended with provisos. There was a significant improvement over time for all domains, except for 'Editorial independence.'
This review shows that despite some increase in quality of CPGs over time, the quality scores as measured with the AGREE Instrument have remained moderate to low over the last two decades. This finding urges guideline developers to continue improving the quality of their products. International collaboration could help increasing the efficiency of the process.
Quality and Safety in Health Care 12/2010; 19(6):e58. · 1.68 Impact Factor
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ABSTRACT: Surgical care is an important burden in healthcare, and the complications and harm related to surgery are of special concern. Clinical practice guidelines in perioperative care should provide the opportunity to minimise these risks and improve surgical outcomes, but their quality has not yet been evaluated systematically.
To evaluate the quality of clinical practice guidelines (CPGs) for the prevention of perioperative adverse events.
A systematic search of scientific literature published between 1990 and 2008 was undertaken to identify and select CPGs related to the treatment of surgical patients, particularly those seeking to prevent surgical adverse events. The authors searched the main guideline databases and guideline developer websites, and completed the search in MEDLINE. Three independent reviewers assessed the eligible guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. Their degree of agreement was evaluated with the intraclass correlation coefficient (ICC).
Twenty-two CPGs were chosen for evaluation from a total of 6181 references. The overall agreement among reviewers was moderate (ICC: 0.68; 95% CI 0.46 to 0.84). The scores for each of the AGREE domains were: scope and purpose 80.9% (range: 40.7-100%); stakeholder involvement 51.3% (range: 8.3-88.8%); rigour of development 61.2% (range: 26.9-96.8%); clarity and presentation 69.7% (range: 33.3-94.4%); applicability 42.5% (range: 7.4-92.5%); and editorial independence 57% (range: 27.7-100%). Most of the appraised guidelines could be recommended (n = 10) or recommended with provisos (n = 10) for use in clinical practice. Guidelines developed by research agencies or guideline developers were of a higher quality than those developed by scientific societies. The authors did not detect any improvement over time in guideline quality.
The quality of guidelines for perioperative care is moderate. Measures should be taken to guarantee that CPGs are based on the best available evidence and rigorously developed and reported. Greater efforts are needed to provide high-quality guidelines that serve as a useful and reliable tool for clinical decision-making in this field.
Quality and Safety in Health Care 12/2010; 19(6):e50. · 1.68 Impact Factor
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ABSTRACT: The prediction of mortality in internal medicine departments may help in taking diagnostic and therapeutic decisions. We analyzed the usefulness of two mortality prediction models, one physiological and the other mainly clinical, and determined whether one approach is better than the other to predict mortality at admission.
This is a prospective observational cohort study in patients admitted to an acute internal medicine ward in a tertiary care, urban, university teaching hospital in Spain. Five hundred consecutive patients either electively admitted or coming from the emergency department from May to December 2008 were analyzed. Medical history, physical examination and routine clinical laboratory tests were performed on admission. At discharge, diagnosis and dead or survived status was recorded. Logistic regression analyses were used to test variables that emerged as independent predictors of mortality. The area under the curve was used to determine which model best predicted mortality.
Mortality in the ward was 13.0%. Age, chronic respiratory failure, creatinine, mean arterial pressure, respiratory rate and Glasgow coma scale independently predicted mortality. ROC curves showed that the physiological model was superior to the clinical model, but differences were not statistically significant. The predictive capacity improved when the two models were combined but the improvement was not significant.
Both models are satisfactory predictors of in-hospital mortality for management purposes but neither proved to be a useful tool for individual predictions. Complementary approaches need to be considered.
European Journal of Internal Medicine 10/2009; 20(6):636-9. · 2.00 Impact Factor
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ABSTRACT: A decrease in noradrenergic activity in Parkinson's disease might play a critical role in long-term motor complications associated with chronic dopaminergic replacement. Using the rat model of parkinsonism with an additional noradrenergic degeneration induced by the N-(-2-chloroethyl)-N-ethyl-2-bromobenzylamine (DSP-4) toxin we evaluated whether the circling motor activity and dose-failure episodes induced by levodopa (L-DOPA) differ between single (6-OHDA) and double (6-OHDA + DSP-4) denervated animals challenged with a single daily dose of L-DOPA. While single-lesioned animals showed a sensitization-desensitization turning response with a significant increase on day 15 and a decrease on day 22, in double-lesioned animals, the turning activity was maximal from day 1 and did not decay on day 22. Double-lesioned rats exhibited significantly higher number of turns on days 15 and 22 and a significantly lower percentage of dose-failure episodes during treatment. Noradrenergic denervation appears to be associated with prolonged long-term dopaminergic sensitization. This type of response appears to be comparable to that in the clinical setting with intermittent L-DOPA administration where no desensitization occurs once the abnormal response is established.
Acta Neurovegetativa 08/2009; 116(7):867-74. · 2.73 Impact Factor
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ABSTRACT: The loss and degeneration of spinal cord motor neurons result in muscle denervation in spinal muscular atrophy (SMA), but whether there are primary pathogenetic abnormalities of muscle in SMA is not known. We previously detected increased DNA fragmentation and downregulation of Bcl-2 and Bcl-X(L) expression but no morphological changes in spinal motor neurons of SMA fetuses. Here, we performed histological and morphometric analysis of myotubes and assessed DNA fragmentation and Bcl-2/Bcl-X(L) expression in skeletal muscle from fetuses with type I SMA (at approximately 12 and 15 weeks' gestational ages, n = 4) and controls (at approximately 10-15 weeks' gestational ages, n = 7). Myotubes were smaller in the SMA than in control samples at all ages analyzed (p < 0.001) and were often arranged in clusters close to isolated and larger myotubes. Numbers of terminal deoxynucleotidyl transferase dUTP nick end labeling-positive cells in control and SMA fetuses were similar, and no differences in Bcl-2 or Bcl-X(L) immunostaining between control and SMA muscle were identified. Areas with smaller myotubes and the morphometric analysis suggested a delay in growth and maturation in SMA muscle. These results suggest that spinal motor neurons and skeletal muscle undergo different pathogenetic processes in SMA during development; they imply that muscle as well as motor neurons may be targets for early therapeutic intervention in SMA.
Journal of Neuropathology and Experimental Neurology 06/2009; 68(5):474-81. · 4.26 Impact Factor
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ABSTRACT: The purpose of the study was to evaluate the prevalence of cardiovascular disease (CVD), cardiovascular risk factors (CVRFs), and their control in patients with type 2 diabetes mellitus (T2DM) at primary care settings from the North Catalonia Diabetes Study (NCDS). Data sources: In this multicentre cross-sectional descriptive study, data were collected from a random sample of 307 patients with T2DM. The prevalence of CVD, CVRF, metabolic syndrome (MS), coronary heart disease (CHD) risk at 10 years (Framingham Point Scores), and CVRF control was evaluated. MS and lipid profiles were established according to Adult Treatment Panel III criteria.
CVD prevalence was 22.0% (CHD: 18.9% and peripheral ischemia: 4.5%) and more frequent in men. The prevalence of selected CVRF was: hypertension: 74.5%; dyslipidemia: 77.7%; smoking: 14.9%; obesity 44.9%, and familial CVD: 38.4%. Three or more CVRFs, including T2DM, were observed in 91.3%. MS prevalence was 68.7%. Framingham score was 10.0%, higher in men than in women. CVD prevalence was related to: age, number of CVRFs, duration of diabetes, familial history of CVD, waist circumference, hypertension, lipid profile, kidney disease, and Framingham score, but not to MS by itself. Correct lipid profiles and blood pressure were only observed in 18.9% and 24.0%, respectively, whereas platelet aggregation inhibitors were only recorded in 16.1% of the patient cohort. MS presence was not an independent risk factor of CVD in our study.
The high prevalence of CVD and an inadequate control of CVRF, which were apparent in the NCDS population, would suggest that advanced practice nurses should consider incorporating specific cardiovascular assessment in their routine care of persons with T2DM.
Journal of the American Academy of Nurse Practitioners 04/2009; 21(3):140-8. · 0.82 Impact Factor
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Pablo Alonso-Coello,
Victor M Montori,
Ivan Solà,
Holger J Schünemann,
Philipe Devereaux,
Cathy Charles,
Mercè Roura,
M Gloria Díaz,
Juan Carlos Souto,
Rafael Alonso,
Sven Oliver,
Rafael Ruiz,
Blanca Coll-Vinent,
Ana Isabel Diez, Ignasi Gich,
Gordon Guyatt
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ABSTRACT: Oral anticoagulation prevents strokes in patients with atrial fibrillation but, for reasons that remain unclear, less than 40% of all patients with atrial fibrillation receive warfarin. The literature postulates that patient and clinician preferences may explain this low utilization.
The proposed research seeks to answer the following questions: i) When assessed systematically, do patients' and clinicians' preferences explain the utilization of warfarin to prevent strokes associated with atrial fibrillation? ii) To what extent do patients' and clinicians' treatment preferences differ? iii) What factors explain any differences that exist in treatment preferences between patients and clinicians? To answer these questions we will conduct a two-phase study of patient and clinician preferences for health states and treatments. In the first phase of this study we will conduct structured interviews to determine their treatment preferences for warfarin vs. aspirin to prevent strokes associated with atrial fibrillation using the probability trade-off technique. In the same interview, we will conduct preference-elicitation exercises using the feeling thermometer to identify the utilities that patients place on taking medication (warfarin and aspirin), and on having a mild stroke, a severe stroke, and a major bleed. In the second phase of the study we will convene focus groups of clinicians and patients to explore their answers to the exercises in the first phase.
This is a study of patient and clinician preferences for health states and treatments. Because of its clinical importance and our previous work in this area, we will conduct our study in the clinical context of the decision to use antithrombotic agents to reduce the risk of stroke in patients with non-valvular chronic atrial fibrillation.
BMC Health Services Research 11/2008; 8:221. · 1.66 Impact Factor
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ABSTRACT: Parkinson's disease (PD) patients may experience fluctuations in executive performance after oral levodopa (LD). Their relationship with the pharmacokinetic profile of LD and with distinct cognitive processes associated with frontal-basal ganglia circuits is not well understood. In this randomized, double-blind, crossover study we plotted acute cognitive changes in 14 PD patients challenged with faster (immediate-release, IR) versus slower (controlled-release, CR) increases in LD plasma concentrations. We monitored motor status, LD plasma levels, and performance on four tasks of executive function (Wisconsin Card Sorting Test-WCST, Sternberg test, Stroop and Tower of Hanoi), 1 hr before and over +6 hr after IR and CR-LD dose. Analysis of variance demonstrated significant but divergent changes in the Sternberg (6-digit but not 2- and 4-digit) test: improvement after CR-LD and worsening after IR-LD. Marginal improvement (p = .085) was observed with CR-LD in the WCST, while no significant differences were seen for the Stroop or Tower of Hanoi tests. Executive-related performance after LD challenge may differ depending on the LD time-to-peak plasma concentration and specific task demands. A slower rise in LD levels appears to have a more favorable impact on more difficult working memory tests. These results require replication to determine their generalization.
Journal of the International Neuropsychological Society 10/2008; 14(5):832-41. · 2.76 Impact Factor
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ABSTRACT: The prevalence of childhood overweight and obesity is increasing at dramatic rates in children and adolescents worldwide. Clinical practice guidelines (CPGs) are "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances." Their objective is to provide explicit recommendations for clinical practice based on current evidence for best practice in the management of diseases.
The aim of this study was to identify and assess the quality of CPGs for the prevention and treatment of obesity and overweight in childhood. We developed a search to identify CPGs published between January 1998 and August 2007. We considered for inclusion documents that provided recommendations for clinical practice referring to children and adolescents. Three independent appraisers assessed the quality of the1 CPGs using the AGREE (Appraisal of Guidelines Research and Evaluation) instrument. We identified 376 references and selected 22 for further assessment.
The overall agreement among reviewers using the intraclass correlation coefficient was 0.856 (95% confidence interval [CI] 0.731-0.932). Six of the 22 initial guidelines were recommended and a further eight were recommended with conditions or provisos. We concluded that the number of documents with recommendations on the prevention and treatment of childhood obesity published during the 10-year study period was considerable, but only a few of them could be considered as high quality. CPGs were deficient in areas such as applicability, editorial independence and rigor in development.
Due to the increasing burden of obesity among children and the potential for long-term comorbidities, clinicians need to be critical in assessing the rigor of how these are developed and their appropriateness for use in the clinician's own practice. There is a need to improve the methodology and the quality of CPGs on childhood obesity to help clinicians and other decision-makers to tackle this disease.
European Journal of Pediatrics 10/2008; 168(7):789-99. · 1.88 Impact Factor
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ABSTRACT: The laparoscopic approach for colon resection is widely accepted but its definitive role in rectal tumors is controversial due to the technical difficulties associated with this procedure. Tumor size and volume, and pelvic dimensions may influence intraoperative and/or immediate outcome. This study aimed to evaluate the predictive value of anatomic and pathologic features on immediate outcome after laparoscopic rectal resection.
The study included a prospective series of 60 patients submitted to laparoscopic resection for rectal tumors. A preoperative computed tomography was performed in all patients. Three-dimension reconstruction of the pelvis, rectal tumor, and prostate was computed. Tumor and prostate volume and diameters were calculated, as were main pelvic diameters (subsacrum-retropubic, coccyx pubis, and promontorium coccyx), and lateral diameters, at the tumor level (3D Doctor Software package). Age, sex, body mass index (BMI), tumor height, previous radiotherapy treatment, and type of procedure (anterior resection, low anterior resection, and abdominoperineal resection) were recorded. Immediate outcome (morbidity, mortality, and stay) was also collected. Dependent variables were operative time, intraoperative difficulty, conversion, and postoperative morbidity. Univariate and multivariate analyses were performed (SPSS package).
The series included 36 men and 24 women, with a mean age of 72 years (range, 38-87). Surgical procedures were 10 anterior resections, 31 low anterior resections, and 19 abdominoperineal resections. Conversion rate was 9 of 60 (15%), operative time: 172 minutes (range, 90-360), morbidity: 31% and stay: 9 days (range, 6-43). Multivariate analysis showed tumor craniocaudal length was an independent predictive factor for conversion (P < 0.04, odds ratio [OR]: 1.5, confidence interval [CI]95%: 1-2.2). Pubic coccyx axis (P < 0.005) and sex (P < 0.009) showed independent values for operative time, and BMI (P < 0.02, OR: 1.2, CI 95%:1-1.5) was related to postoperative morbidity. When a subanalysis was performed in relation to sex, independent factors differed between males and females, with a predominance of anatomic and tumor measures in men.
Local anatomy and pathologic features directly affect surgical outcome in the laparoscopic approach to the rectum. Sex, BMI, lower pelvis diameter, and tumor size are independent predictors for conversion, operative time, and morbidity. These data should be taken into account when planning this kind of procedure.
Annals of Surgery 04/2008; 247(4):642-9. · 7.49 Impact Factor
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BMJ (Clinical research ed.). 02/2008; 337:a2474.
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ABSTRACT: Spinal muscular atrophy (SMA) is an autosomal recessive disorder characterised by degeneration and loss of the motor neurons of the anterior horn of the spinal cord. The absence of SMN1 is determinant to have SMA and parents of SMA patients are regarded as carriers of the disease. We compared the segregation ratio of the mutated allele and the wild-type allele of all the confirmed carrier parents assuming Mendelian proportions. Results of transmissions in 235 prenatal tests and in 128 unaffected siblings showed a statistically significant deviation in favour of the wild-type SMN1 allele. The number of affected foetuses and carriers were lower than that expected. No significant differences in the sex ratio or in the progenitor origin of the transmitted allele to the carriers were found. One hypothesis that has been advanced to account for the distortion observed in affected foetuses is the negative postzygote selection due to early miscarriage. However, given that the number of carriers in our series was lower than expected, prezygote events such as meiotic drive, survival of gametes or preferential fertilisation should also be considered.
European Journal of HumanGenetics 11/2007; 15(10):1090-3. · 4.40 Impact Factor
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ABSTRACT: To evaluate short- and long-term outcomes of elderly patients (>or=65 years) treated at an intermediate care unit (IMCU) and to identify outcome predictors.
Prospective observational study in the IMCU of a university teaching hospital.
We studied 412 patients over 8 months, classified into three groups: under 65years (control group, n=158), 65-80 (n=186), and >80 (n=68).
At admission: APACHE II, TISS-28 first day, Charlson Index, diagnosis, and prior Barthel Index. Outcome measures: in-hospital mortality, length of stay, discharge destination, and 2-year mortality and readmissions. Data analysis included multivariate logistic regression and receiver operating characteristics area under the curve (ROC AUC).
No statistically significant differences between groups were observed in hospital mortality (14.1%), discharge to a long-term facility (2.7%), or 2-year readmissions (1.2+/-2.1). However, hospital stay was longer in patients aged 65-80years (14 vs.10 days) and 2-year mortality was higher in those 65 or over (34% vs.10.6%). In the overall series in-hospital mortality was predicted by APACHE II, first-day TISS-28, and diagnosis (ROC AUC 0.81), and 2-year mortality by Charlson Index and age (ROC AUC 0.77). In the elderly patients 2-year mortality was predicted by Charlson and Barthel indices (ROC AUC 0.70).
Illness severity and therapeutic intervention at admission to IMCU were predictors of short-term mortality, whereas the strongest predictor of long-term mortality was comorbidity. Our results suggest that comprehensive assessment of elderly patients at admission to IMCUs may improve outcome prediction.
Intensive Care Medicine 08/2006; 32(7):1052-9. · 5.40 Impact Factor
