Your browser doesn't support javascript.
loading
Show: 20 | 50 | 100
Results 1 - 12 de 12
Filter
Add more filters










Publication year range
1.
Cureus ; 15(10): e46809, 2023 Oct.
Article in English | MEDLINE | ID: mdl-37954725

ABSTRACT

Background Severe acute pancreatitis (SAP) has a mortality rate as high as 40%. Early identification of SAP is required to appropriately triage and direct initial therapies. The purpose of this study was to develop a prognostic model that identifies patients at risk for developing SAP of patients managed according to a guideline-based standardized early medical management (EMM) protocol. Methods This single-center study included all patients diagnosed with acute pancreatitis (AP) and managed with the EMM protocol Methodist Acute Pancreatitis Protocol (MAPP) between April 2017 and September 2022. Classification and regression tree (CART®; Professional Extended Edition, version 8.0; Salford Systems, San Diego, CA), univariate, and logistic regression analyses were performed to develop a scoring system for AP severity prediction. The accuracy of the scoring system was measured by the area under the receiver operating characteristic curve. Results A total of 516 patients with mild (n=436) or moderately severe and severe (n=80) AP were analyzed. CART analysis identified the cutoff values: creatinine (CR) (1.15 mg/dL), white blood cells (WBC) (10.5 × 109/L), procalcitonin (PCT) (0.155 ng/mL), and systemic inflammatory response system (SIRS). The prediction model was built with a multivariable logistic regression analysis, which identified CR, WBC, PCT, and SIRS as the main predictors of severity. When CR and only one other predictor value (WBC, PCT, or SIRS) met thresholds, then the probability of predicting SAP was >30%. The probability of predicting SAP was 72% (95%CI: 0.59-0.82) if all four of the main predictors were greater than the cutoff values. Conclusions Baseline laboratory cutoff values were identified and a logistic regression-based prognostic model was developed to identify patients treated with a standardized EMM who were at risk for SAP.

2.
Tissue Eng Part C Methods ; 29(8): 361-370, 2023 08.
Article in English | MEDLINE | ID: mdl-37409411

ABSTRACT

Cathepsins are a family of cysteine proteases responsible for a variety of homeostatic functions throughout the body, including extracellular matrix remodeling, and have been implicated in a variety of degenerative diseases. However, clinical trials using systemic administration of cathepsin inhibitors have been abandoned due to side effects, so local delivery of cathepsin inhibitors may be advantageous. In these experiments, a novel microfluidic device platform was developed that can synthesize uniform, hydrolytically degradable microparticles from a combination of poly(ethylene glycol) diacrylate (PEGDA) and dithiothreitol (DTT). Of the formulations examined, the 10-polymer weight percentage 10 mM DTT formulation degraded after 77 days in vitro. A modified assay using the DQ Gelatin Fluorogenic Substrate was used to demonstrate sustained release and bioactivity of a cathepsin inhibitor (E-64) released from hydrogel microparticles over 2 weeks in vitro (up to ∼13 µg/mL released with up to ∼40% original level of inhibition remaining at day 14). Altogether, the technologies developed in this study will allow a small-molecule, broad cathepsin inhibitor E-64 to be released in a sustained manner for localized inhibition of cathepsins for a wide variety of diseases.


Subject(s)
Cathepsins , Microfluidics , Polyethylene Glycols/chemistry , Polymers
3.
Int J Med Robot ; 19(3): e2508, 2023 Jun.
Article in English | MEDLINE | ID: mdl-36808427

ABSTRACT

BACKGROUND: Describe the outcomes and safety of robotic-assisted kidney auto-transplantation (RAKAT) in the treatment of nutcracker syndrome (NCS) and loin pain haematuria syndrome (LPHS). METHODS: This retrospective study included 32 cases of NCS and LPHS seen during December 2016 to June 2021. RESULTS: Three (9%) patients had LPHS and 29 (91%) NCS. All were non-Hispanic whites, and 31 (97%) women. The mean age was 32 years (SD = 10) and the BMI 22.8 (SD = 5). The RAKAT was completed in all patients, 63% had a total improvement of pain. According to the Clavien-Dindo classification, 47% presented with type 1, and 9% with type 3 complications with a mean follow-up of 10.9 months. The incidence of acute kidney injury in post-procedure was 28%. No one required blood transfusions, and there were no deaths during the follow-up. CONCLUSION: RAKAT was a feasible procedure with a similar complication rate to those reported for other surgical techniques.


Subject(s)
Hematuria , Robotic Surgical Procedures , Humans , Female , Adult , Male , Hematuria/surgery , Hematuria/complications , Robotic Surgical Procedures/methods , Retrospective Studies , Pain/complications , Kidney/surgery
4.
J Robot Surg ; 17(3): 1085-1096, 2023 Jun.
Article in English | MEDLINE | ID: mdl-36581740

ABSTRACT

The purpose of this study was to compare the survival, recurrence, and complication rates in patients with pancreatic ductal adenocarcinoma (PDAC) who underwent robotic pancreaticoduodenectomy (RPD) or open pancreaticoduodenectomy (OPD) and who received adjuvant therapy. The study was a single-center retrospective analysis of consecutive PDAC patients who underwent RPD/OPD. Patient characteristics, tumor findings, neoadjuvant therapy, adjuvant therapies, overall survival (OS) and recurrence-free survival (RFS) were compared between the OPD and RPD cohorts. Cox proportional hazard regression with and without propensity score matching was used to establish the association between predictors and outcomes. One hundred PDAC patients underwent OPD (n = 36) or RPD (n = 64) from 2013 to 2019. Cox proportional hazard models showed that baseline bilirubin (HR 1.6, p = 0.0006) and operative characteristics such as the number of positive lymph nodes (HR 1.1, p = 0.002), lymph node ratio (HR 1.6, p = 0.001), tumor grade (HR 1.7, p = 0.02), and TNM classification (HR 2.3, p = 0.01) were associated with OS. The independent predictors post-intervention associated with mortality were adjuvant therapy (HR 0.4, p = 0.0003), ISGPS complications (HR 2.8, p = 0.02), and 90-day readmission (HR 2, p = 0.004). After adjustment for these predictors, adjuvant therapy, baseline bilirubin, lymph node ratio, and tumor grade remained the main predictors of mortality. Baseline bilirubin, adjuvant therapy, lymph node ratio, and tumor grade were the main determinants of mortality after OPD or RPD. There was no significant difference in OS and RFS after RPD or OPD in PC patients who received adjuvant therapy.


Subject(s)
Carcinoma, Pancreatic Ductal , Pancreatic Neoplasms , Robotic Surgical Procedures , Humans , Pancreaticoduodenectomy , Propensity Score , Retrospective Studies , Robotic Surgical Procedures/methods , Pancreatic Neoplasms/surgery , Carcinoma, Pancreatic Ductal/surgery , Survival Analysis , Bilirubin , Postoperative Complications , Pancreatic Neoplasms
5.
Cureus ; 15(12): e50949, 2023 Dec.
Article in English | MEDLINE | ID: mdl-38249287

ABSTRACT

Background Pancreatic ductal adenocarcinoma (PDAC) is the most common type of pancreatic cancer (PC) in the United States. In patients with resectable PC, identification of pretreatment biomarkers before surgery can help in the decision-making process by weighing the benefits of neo-adjuvant therapy, surgical procedure, and adjuvant therapy. The purpose of this study was to determine if the albumin-bilirubin (ALBI) score and immune-inflammatory marker levels can be used in combination as pretreatment predictors of mortality risk in patients undergoing the Whipple procedure (alternatively, pancreatoduodenectomy (PD)) for PDAC. Methods This retrospective study included 115 patients with PDAC who underwent open or robotic Whipple procedures between January 2013 and December 2022 at a single tertiary medical center. Logistic regression analysis was used to find the association between predictors and mortality. Machine learning algorithms were used to calculate the performance of the different models. Results Bivariate analysis showed that the variables "sex" and "body mass index (BMI)" had a potential association with mortality, although statistical significance was not achieved for sex (p = 0.07). Patients with BMIs >25 kg/m2 had a higher risk of mortality compared to patients with BMIs ≤24.9 kg/m2 (odds ratio (OR) = 2.2, 95% CI = 1.03-4.8, p = 0.04). Higher (more positive) ALBI scores (>-2.24) were also associated with increased mortality risk (OR = 4.6, 95% CI = 2-10.5, p = 0.0003). When the cutoff values of the inflammatory markers were used to categorize these variables, values greater than the cutoff values were associated with an increased risk of mortality. In the multivariate logistic regression model, an ALBI score >-2.24 (OR = 4.3, 95% CI = 1.8-10.3, p = 0.0008), neutrophil-to-lymphocyte ratio (NLR) >3.5 (OR = 3.3, 95% CI = 1.4-7.9, p = 0.007), and being a woman (OR = 2.6, 95% CI = 1.1-6.4, p = 0.03) remained influential predictors of increased mortality (c value = 0.77). Conclusion The ALBI score and the NLR are easily accessible markers; their use, combined with a patient's sex, can provide useful pre-surgical information regarding mortality risk after PD. This can aid in treatment planning as well as expedite decisions about the type of Whipple procedure, adjuvant therapy, and surveillance, which can subsequently improve a patient's outcomes and survival.

6.
Medicine (Baltimore) ; 101(9): e28970, 2022 Mar 04.
Article in English | MEDLINE | ID: mdl-35244064

ABSTRACT

ABSTRACT: Neuroendocrine tumors (NETs) are rare, but the incidence and prevalence of NETs are increasing in the United States. While surgery is the preferred treatment for NETs, it is not a viable option for metastatic disease. Lutathera (177Lu-DOTATATE) is approved by the United States Food and Drug Administration and the European Medicines Agency for the treatment of gastroenteropancreatic (GEP)-NETs in adults. There is limited information on GEP-NET treatment responses to Lutathera.Our institution launched a peptide receptor radionuclide therapy (PRRT) service line using Lutathera with involvement from a multidisciplinary team and complete collaboration between hospital administration and clinical providers. A prospective registry study was also established in order to collect patient demographics and clinical data regarding the treatment of GEP primary NETs with Lutathera.Between August 2018 and July 2020, 35 GEP-NET patients were treated with Lutathera, of which 65.71% received 4 complete cycles and 25.71% received 3 cycles; 5.71% and 2.86% received 2 and 1 cycles of PRRT, respectively. Most adverse events during the course of our study were low grade using the common terminology criteria for adverse events system. Of the patients who completed all 4 cycles: 22% showed partial response to Lutathera, 44% showed stable disease, and 13% showed disease progression based on a qualitative assessment of positron emission tomography/computed tomography imaging.From our experience, Lutathera was well tolerated in patients with GEP-NET. Additional studies are needed to examine long-term clinical and patient-reported outcomes associated with GEP-NET treatment as well as financial considerations for hospitals embarking on a PRRT program.


Subject(s)
Intestinal Neoplasms/pathology , Intestinal Neoplasms/radiotherapy , Neuroendocrine Tumors/radiotherapy , Neuroendocrine Tumors/therapy , Octreotide/analogs & derivatives , Octreotide/therapeutic use , Organometallic Compounds/therapeutic use , Pancreatic Neoplasms/therapy , Stomach Neoplasms/therapy , Adult , Aged , Aged, 80 and over , Female , Humans , Intestinal Neoplasms/diagnostic imaging , Intestinal Neoplasms/metabolism , Intestinal Neoplasms/therapy , Male , Middle Aged , Neuroendocrine Tumors/metabolism , Neuroendocrine Tumors/pathology , Pancreatic Neoplasms/pathology , Positron-Emission Tomography , Prospective Studies , Radioactive Tracers , Radioisotopes/therapeutic use , Receptors, Peptide , Stomach Neoplasms/pathology , Treatment Outcome
7.
Healthcare (Basel) ; 9(9)2021 Sep 03.
Article in English | MEDLINE | ID: mdl-34574927

ABSTRACT

Patient experience is critically important on both clinical and business levels to healthcare organizations, medical groups, and physician practices. We sought to understand whether a relationship exists between patient satisfaction scores in different settings for medical providers who practice in multiple settings (such as in the ambulatory setting and the hospital) within a system. Press Ganey (PG) ambulatory and hospital-based patient satisfaction surveys of a neurosurgery practice were retrospectively compared. Questions and sections related to the care provider, likelihood to recommend, and overall experience were examined. The ambulatory dataset included 2270 surveys, and the hospital dataset included 376. Correlation analysis of hospital survey patients who also completed an ambulatory survey (N = 120) was conducted, and weak, yet statistically significant, negative correlations between hospital "Likelihood to Recommend" and ambulatory "Care Provider Overall" (r = -0.20421, p = 0.0279), "Likelihood to Recommend" (r = -0.19622, p = 0.0356), and "Survey Overall" (r = -0.28482, p = 0.0019) were found. Our analyses found weak, yet significant, negative correlations between ambulatory and hospital PG scores. This could suggest that patient perception established in ambulatory and clinic settings could translate to a patient's perception of their hospital experience and subsequent satisfaction scores.

8.
J Gastrointest Oncol ; 12(4): 1718-1731, 2021 Aug.
Article in English | MEDLINE | ID: mdl-34532122

ABSTRACT

BACKGROUND: A previous study of patients with unresectable hepatocellular carcinoma (HCC) was extended to further examine factors associated with overall survival (OS) after selective internal radiation therapy with yttrium-90 resin microspheres (Y90 SIRT). METHODS: Data from patients of any age diagnosed with unresectable HCC and treated with Y90 SIRT at our institution from 2004 through 2017 were retrospectively analyzed. Among other criteria, patients had to have Eastern Cooperative Oncology Group performance status 0 to 2, not have received Y90 SIRT previously, and not have extrahepatic disease. Primary outcome was OS; secondary outcomes included tumor response and adverse events (AEs). Kaplan-Meier survival analyses and multivariable Cox proportional hazards models were used to evaluate prognostic factors for OS. RESULTS: Of the 226 patients, 59% were White, 77% were male, and the mean age at first SIRT procedure was 65.1±9.4 years. More than half had received previous treatment for HCC. The most common etiology was hepatitis C (n=138/224 available, 62%), followed by alcohol use (n=45, 20%), and nonalcoholic steatohepatitis (n=27, 12%). The mean model for end-stage liver disease score at baseline was 8.8±2.2. Patients were followed-up for a median of 12.2 months (95% CI, 0.0-62.6). Median OS was 16.6 months (95% CI, 13.1 to not reached). Bilobar disease, higher albumin-bilirubin score at baseline, prior treatment with sorafenib, alcohol use etiology, and higher administered dose were associated with shorter survival, whereas subsequent liver transplant [in 26 patients (11.5%)] was associated with longer survival. Of the 186 patients with AEs data, 75 (40.3%) patients reported an event and, of these, 13 (17.3%) patients had grade 4 bilirubin values. CONCLUSIONS: In a large, diverse population treated at a single center over 13 years, Y90 SIRT produced a median OS of 16.6 months in patients with unresectable HCC and enabled subsequent transplantation in a subset of patients. Factors affecting the length of survival should be considered when making treatment decisions for unresectable HCC.

9.
Healthcare (Basel) ; 9(6)2021 Jun 21.
Article in English | MEDLINE | ID: mdl-34205635

ABSTRACT

Pancreatic surgery is one of the more challenging procedures performed by surgeons. The operations are technically complex and have historically been accompanied by a substantial risk for mortality and postoperative complications. Other pancreatic pathologies require advanced therapeutic procedures that are highly endoscopist-dependent, requiring specific, knowledge-based training for optimal outcomes. An increase in diagnosed pancreatic pathologies every year reinforces a critical need for experienced surgeons, gastroenterologists/endoscopists, hospitals, and support personnel in the management of complex pancreatic cases and thus, well-designed Centers of Excellence (CoE). In this paper, we outline the framework for a Pancreas CoE across three developmental domains: (1) establishing the foundation; (2) formalizing the program; (3) solidifying the CoE status. This framework can likely be translated to any disease or procedure-specific service-line and facilitate the development of a successful CoE.

10.
Pancreas ; 50(3): 293-299, 2021 03 01.
Article in English | MEDLINE | ID: mdl-33835958

ABSTRACT

OBJECTIVES: We aimed to define perfect care index (PCI) metrics and to evaluate whether implementation of standardized order sets would improve outcomes without increasing hospital-based charges in patients with acute pancreatitis (AP). METHODS: This is a retrospective, pre-post, observational study measuring clinical quality, processes of care, and hospital-based charges at a single tertiary care center. The first data set included AP patients from August 2011 to December 2014 (n = 219) before the implementation of a standardized order set (Methodist Acute Pancreatitis Protocol [MAPP]) and AP patients after MAPP implementation from January 2015 to September 2018 (n = 417). The second data set included AP patients (n = 150 in each group) from January 2013 to September 2014 (pre-MAPP) and January 2018 to September 2019 (post-MAPP) to evaluate perfect care between the 2 cohorts after controlling for systemic inflammatory response syndrome at baseline. Length of stay, PCI, and hospital-based charges were measured. RESULTS: The post-MAPP cohort had a significantly shorter length of stay (median, 3 days vs 4 days; P = 0.01). In the second data set, PCI significantly increased after implementation of MAPP order sets (5.3%-35.3%, P < 0.0001). CONCLUSIONS: The MAPP order sets increased the value of care by improving clinical outcomes without increasing hospital-based charges.


Subject(s)
Hospitalization/statistics & numerical data , Length of Stay/statistics & numerical data , Pancreatitis/therapy , Tertiary Care Centers , Acute Disease , Adult , Hospital Mortality , Humans , Middle Aged , Pancreatitis/mortality , Pancreatitis/pathology , Retrospective Studies
11.
Pancreas ; 49(5): 668-674, 2020.
Article in English | MEDLINE | ID: mdl-32433405

ABSTRACT

OBJECTIVES: The value of robotic pancreaticoduodenectomy (RPD) remains undefined. The aim of this retrospective study was to compare and assess clinical outcomes and financial variables of patients undergoing RPD versus open pancreaticoduodenectomy (OPD) at a single high-volume center. METHODS: The study design is a retrospective analysis of a prospectively maintained database of consecutive PD patients from 2013 to 2019. Clinical variables and total hospital charges were evaluated as an unadjusted and adjusted intention-to-treat analysis. RESULTS: A total of 156 patients (54 OPD, 102 RPD) were identified. In the RPD group, patients were significantly older (P = 0.0304) and had shorter length of stay (mean, 7 vs 11.8 days; P < 0.0001) and longer operative times (mean, 352.7 vs 211.5 minutes; P < 0.0001) compared with OPD. There was no significant difference in 90-day readmissions, bleeding, or complications between OPD and RPD. Adjusted charge analyses show no difference in total charges (P = 0.057). CONCLUSIONS: Robotic pancreaticoduodenectomy is safe, feasible, and valid alternative to OPD. Because of comparable results within each group, randomized trials may be indicated. High-volume RPD centers should collaborate to better understand the differences and advantages over laparoscopic or OPD.


Subject(s)
Pancreatic Diseases/surgery , Pancreatic Neoplasms/surgery , Pancreaticoduodenectomy/methods , Robotic Surgical Procedures/methods , Adult , Aged , Aged, 80 and over , Female , Humans , Length of Stay/statistics & numerical data , Logistic Models , Male , Middle Aged , Operative Time , Outcome Assessment, Health Care/economics , Outcome Assessment, Health Care/methods , Outcome Assessment, Health Care/statistics & numerical data , Pancreaticoduodenectomy/adverse effects , Pancreaticoduodenectomy/economics , Postoperative Complications/diagnosis , Postoperative Complications/etiology , Retrospective Studies , Robotic Surgical Procedures/adverse effects , Robotic Surgical Procedures/economics , Young Adult
12.
Surg Endosc ; 34(1): 339-348, 2020 01.
Article in English | MEDLINE | ID: mdl-30937618

ABSTRACT

BACKGROUND: Minimally Invasive Liver Resection (MILR) techniques range from a hybrid-technique to full robotic approaches. When compared with open techniques, MILR has been shown to be advantageous by reducing pain, complications, length of stay and blood loss. The aim of this study was to compare clinical outcomes and hospital resource utilization between full laparoscopic, hand-assisted, and robotic liver resections among major (≥ 3 segments) and minor (≤ 2 segments) resections. METHODS: A single-center comparative retrospective review was completed on 214 patients undergoing full laparoscopic, hand-assisted, or robotic liver resection procedures between 2005 and 2018. RESULTS: Among minor resections: 85 full laparoscopic, 40 hand-assisted, and 35 robotic liver resection cases were analyzed; and among major resections: 13, 33, and 8 cases were analyzed, respectively. In the adjusted subgroup analysis of minor resections, OR time was significantly longer for the minor hand-assisted group ([Formula: see text] = 181 min; p < 0.05), and the average lesion size was smaller for the minor full laparoscopic group ([Formula: see text] = 4.2 cm; p < 0.05). Overall, direct hospital charges were lowest in the group of patients who underwent a minor resection using the full laparoscopic technique ([Formula: see text] = $39,054.90; p < 0.05), compared to the robotic technique. Due to the smaller sample size (n = 54) in the major resection subgroup, only two significant observations were made - the full laparoscopic group had the least amount of blood loss ([Formula: see text] = 227 cc; p < 0.05) and incurred the least amount of room and board charges compared to the other two techniques. CONCLUSIONS: The robotic approach appears favorable for minor resections as evidenced by shorter length of stay but more costly than full laparoscopy. Clinical outcomes appear to be more dependent upon the magnitude of the resection (i.e. major vs. minor) than the MILR technique chosen. Randomized trials may be indicated to discern the best indications and advantages of each technique.


Subject(s)
Hepatectomy/methods , Laparoscopy/methods , Robotic Surgical Procedures/methods , Adult , Aged , Female , Hepatectomy/economics , Hospital Charges/statistics & numerical data , Humans , Laparoscopy/economics , Length of Stay/economics , Length of Stay/statistics & numerical data , Male , Middle Aged , Outcome Assessment, Health Care , Retrospective Studies , Robotic Surgical Procedures/economics , Texas
SELECTION OF CITATIONS
SEARCH DETAIL
...