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risk management [keywords]
- Migraine and stroke: In search of shared mechanisms. [REVIEW]
- Cephalalgia 2014 Sep 16.
Migraine, particularly with aura, increases the risk for ischemic stroke, at least in a subset of patients. The underlying mechanisms are poorly understood and probably multifactorial.We carried out an extended literature review of experimental and clinical evidence supporting the association between migraine and ischemic stroke to identify potential mechanisms that can explain the association.Observational, imaging and genetic evidence support a link between migraine and ischemic stroke. Based on clinical and experimental data, we propose mechanistic hypotheses to explain the link, such as microembolic triggers of migraine and enhanced sensitivity to ischemic injury in migraineurs.We discuss the possible practical implications of clinical and experimental data, such as aggressive risk factor screening and management, stroke prophylaxis and specific acute stroke management in migraineurs. However, evidence from prospective clinical trials is required before modifying the practice in this patient population.
- Computerized Clinical Decision Support Improves Warfarin Management and Decreases Recurrent Venous Thromboembolism. [JOURNAL ARTICLE]
- Clin Appl Thromb Hemost 2014 Sep 16.
An explicit approach to warfarin dose adjustment using computerized clinical decision support (CDS) improves warfarin management. We report metrics of quality for warfarin management before and after implementation of CDS in a large health care system.A total of 2591 chronically anticoagulated patients were eligible for inclusion. We compared interpatient time in therapeutic range (TTR) and international normalized ratio (INR) variability before and after implementation of CDS. We report outcomes of major bleeding, thrombosis, and health care utilization.Implementation of CDS significantly improved TTR (from 63.99% to 65.13%; P = .04) and reduced out-of-range INRs (from 42.39% to 39.97%; P < .001). Venous thromboembolism (relative risk [RR] 0.41; P < .001) emergency department utilization (RR 0.62; P < .001), and hospitalization (RR 0.62; P < .001) were reduced after CDS implementation. Major hemorrhage was more frequent after CDS implementation (RR 1.42; P = .01).The CDS warfarin management was associated with improved TTR and decreased INR variability in a large cohort of chronically anticoagulated patients. Clinically relevant outcomes were broadly improved, although more bleeding events were observed.
- Calcium Use in the Management of Osteoporosis: Continuing Questions and Controversies. [JOURNAL ARTICLE]
- Curr Osteoporos Rep 2014 Sep 17.
Calcium is a vital element in the health and maintenance of growing and mature bone. The amount of calcium recommended for ingestion varies by age, and these requirements can be met by dietary sources or calcium supplementation. This article reviews the role of calcium in the body and the benefits and risks to calcium supplementation. The effects of calcium on fracture risk reduction, bone density, and bone turnover markers as well as the conflicting data on cardiovascular events and increased risk of nephrolithiasis associated with supplementation are discussed.
- A review of current progress in acquired cholesteatoma management. [JOURNAL ARTICLE]
- Eur Arch Otorhinolaryngol 2014 Sep 17.
The aim of this study was to review recent advances in the management of acquired cholesteatoma. All papers referring to acquired cholesteatoma management were identified in Medline via OVID (1948 to December 2013), PubMed (to December 2013), and Cochrane Library (to December 2013). A total of 86 papers were included in the review. Cholesteatoma surgery can be approached using either a canal wall up (CWU) or canal wall down (CWD) mastoidectomy with or without reconstruction of the middle ear cleft. In recent decades, a variety of surgical modifications have been developed including various "synthesis" techniques that combine the merits of CWU and CWD. The application of transcanal endoscopy has also recently gained popularity; however, difficulties associated with this approach remain, such as the need for one-handed surgery, the inability to provide continuous irrigation/suction, and limitations regarding endoscopic accessibility to the mastoid cavity. Additionally, several recent studies have reported successes in the application of laser-assisted cholesteatoma surgery, which overcomes the conflicting goals of eradicating disease and the preservation of hearing. Nevertheless, the risk of residual disease remains a challenge. Each of the techniques examined in this study presents pros and cons regarding final outcomes, such that any pronouncements regarding the superiority of one technique over another cannot yet be made. Flexibility in the selection of surgical methods according to the context of individual cases is essential in optimizing the outcomes.
- Planning magnetic resonance imaging for prostate cancer intensity-modulated radiation therapy: Impact on target volumes, radiotherapy dose and androgen deprivation administration. [JOURNAL ARTICLE]
- Asia Pac J Clin Oncol 2014 Sep 16.
Magnetic resonance imaging (MRI) scans are increasingly utilized for radiotherapy planning to contour the primary tumors of patients undergoing intensity-modulated radiation therapy (IMRT). These scans may also demonstrate cancer extent and may affect the treatment plan. We assessed the impact of planning MRI detection of extracapsular extension, seminal vesicle invasion, or adjacent organ invasion on the staging, target volume delineation, doses, and hormonal therapy of patients with prostate cancer undergoing IMRT.The records of 509 consecutive patients with planning MRI scans being treated with IMRT for prostate cancer between January 2010 and July 2012 were retrospectively reviewed. Tumor staging and treatment plans before and after MRI were compared.Of the 509 patients, 103 (20%) were upstaged and 44 (9%) were migrated to a higher risk category as a result of findings at MRI. In 94 of 509 patients (18%), the MRI findings altered management. Ninety-four of 509 patients (18%) had a change to their clinical target volume (CTV) or treatment technique, and in 41 of 509 patients (8%) the duration of hormone therapy was changed because of MRI findings.The use of radiotherapy planning MRI altered CTV design, dose and/or duration of androgen deprivation in 18% of patients in this large, single institution series of men planned for dose-escalated prostate IMRT. This has substantial implications for radiotherapy target volumes and doses, as well as duration of androgen deprivation. Further research is required to investigate whether newer MRI techniques can simultaneously fulfill staging and radiotherapy contouring roles.
- A mixed methods epidemiological investigation of preventable deaths among U.S. Army soldiers assigned to a rehabilitative warrior transition unit. [JOURNAL ARTICLE]
- Work 2014 Sep 16.
The prevalence of medical risk factors for suicide (e.g., mental disorders, severe disability, social disruption) may be higher among WTs compared to traditional Army units. Likewise, the extent to which traditional factors that protect soldiers from developing serious mental disorders (e.g., social support, unit cohesion, leadership) are present among soldiers assigned to the WTU is unclear.An epidemiological consultation (EPICON) was conducted in 2010 to assess potential causes for a perceived high rate of suicides and preventable deaths in U.S. Army Warrior Transition Units (WTUs) and to identify potential improvements to the system of care.The EPICON focused on: (1) risk factors for suicide/preventable deaths; (2) chronic pain management; (3) utilization of and access to WTU medical and behavioral health (BH) services; and (4) the impact of the WTU environment on mission focus and warrior disposition. BH history was examined for soldiers who died by suicide or preventable death while assigned to the WTU (index cases) and a representative comparison group of non-index case soldiers. Surveys and focus groups were conducted at four WTUs with Warriors in Transition (WTs) and key support staff.The use of psychotropic and/or CNS depressant medications, prevalence of BH diagnoses and substance use disorders, polypharmacy, alcohol use, and a high cumulative number of stressors were identified as important risk factors for preventable deaths in the WTC. Areas of potential improvement to the system of care included addressing negative perceptions of the WTU environment, lack of social support, barriers to accessing BH services and issues related to coordination of care.There was no one single risk factor found to be associated with an increased likelihood of preventable deaths within the WTU. The unique design and operation of the WTUs as environments focused on treatment and rehabilitation provide both benefits and challenges to recovery and risk mitigation.
- Increased subsequent risk of myasthenia gravis in children with allergic diseases. [JOURNAL ARTICLE]
- J Neuroimmunol 2014 Sep 4.
Myasthenia gravis (MG) is an autoimmune disorder that affects the neuromuscular junction. The initiating factors of MG remain unclear. However, allergy has been regarded as a potential risk factor. We included 410 children with MG diagnosed between 2000 and 2008, as well as 1640 randomly selected controls. The odds ratios of MG were calculated to determine the association between MG and preexisting allergic diseases. The children with allergic diseases were at increased subsequent risk of MG, which was associated with the cumulative effect of the concurrent allergic diseases and the frequency of seeking medical care.
- Mind-body practices for patients with cardiac disease: a systematic review and meta-analysis. [REVIEW]
- Eur J Prev Cardiol 2014 Sep 16.
Due to new treatment modalities in the last decades, a decline in cardiovascular deaths has been observed. There is an emerging field of secondary prevention and behavioural programmes with increased interest in the use of mind-body practices. Until now, these have not been established in cardiovascular disease treatment programmes.We performed a systematic review and meta-analysis of the available evidence on the effectiveness of mind-body practices for patients with diagnosed cardiac disease.We included randomized controlled trials (RCTs), published in English, reporting mind-body practices for patients with diagnosed cardiac disease. EMBASE, MEDLINE, Pubmed, Web of Science, The Cochrane Central Register of Controlled Trials and PsycINFO were searched up to July 2013. Two reviewers independently identified studies for inclusion and extracted data on study characteristics, outcomes (Quality of Life, anxiety, depression, physical parameters and exercise tolerance) and quality assessment. Standardized effect sizes (Cohen's d) were calculated comparing the outcomes between the intervention and control group and random effects meta-analysis was conducted.We identified 11 unique RCTs with an overall low quality. The studies evaluated mindfulness-based stress reduction, transcendental meditation, progressive muscle relaxation and stress management. Pooled analyses revealed effect sizes of 0.45 (95%CI 0.20-0.72) for physical quality of life, 0.68 (95%CI 0.10-1.26) for mental quality of life, 0.61 (95%CI 0.23-0.99) for depression, 0.52 (95%CI 0.26-0.78) for anxiety, 0.48 (95%CI 0.27-0.69) for systolic blood pressure and 0.36 (95%CI 0.15-0.57) for diastolic blood pressure.Mind-body practices have encouraging results for patients with cardiac disease. Our review demonstrates the need for high-quality studies in this field.
- Diabetes. [Journal Article]
- Nurs Stand 2014 Sep 17; 29(3):21.
Essential facts Type 1 and type 2 diabetes affect 3.2 million people in the UK. Diabetes is associated with serious complications, including heart disease and stroke, which can lead to disability and premature death. It is the leading cause of preventable sight loss in people of working age in the UK. A quarter of people with diabetes will have kidney disease at some point in their lives, and the condition increases the risk of amputation. Good diabetes management has been shown to reduce the incidence of these serious complications.
- Robotic Total Thyroidectomy with Modified Radical Neck Dissection via Unilateral Retroauricular Approach. [JOURNAL ARTICLE]
- Ann Surg Oncol 2014 Sep 17.
Traditionally, total thyroidectomy was performed through an open transcervical incision; in cases where there was evident nodal metastasis, the conventional surgical approach was to extend the incision into a large single transverse incision to complete the required neck dissection. However, recent innovation in the surgical technique of thyroidectomy has offered the opportunity to reduce the patient's burden from these prominent surgical scars in the neck. Minimally invasive surgical techniques have been developed and applied by many institutions worldwide, and more recently, various techniques of remote access surgery have been suggested and actively applied.1-6 Since the advent of robotic surgical systems, some have adopted the concept of remote access surgery into developing various robotic thyroidectomy techniques. The more former and widely acknowledged robotic thyroidectomy technique uses a transaxillary (TA) approach, which has been developed by Chung et al. in Korea.7,8 This particular technique has some limitations in the sense that accessing the lymph nodes of the central compartment is troublesome. Terris et al. realized some shortcomings of robotic TA thyroidectomy, especially in their patients in the United States, and developed and reported the feasibility of robotic facelift thyroidectomy.9-13 In cases of thyroid carcinomas with lateral neck node metastases, most abandoned the concept of minimally invasive or remote access surgery and safely adopted conventional open surgical methods to remove the tumor burden. However, Chung et al. have attempted to perform concomitant modified radical neck dissection (MRND) after robotic thyroidectomy through the same TA port.14 This type of robot-assisted neck dissection (RAND) had some inherent limitations, due to fact that lymph nodes of the upper neck were difficult to remove. Over the past few years, we have developed a RAND via modified facelift (MFL) or retroauricular (RA) approach and reported the feasibility and safety of this technique.15, 16 Since then, we have actively applied such RAND techniques in various head and neck cancers. In our country, almost all cases of robotic total thyroidectomy utilize the TA approach. According to the reports made by Terris et al., robotic facelift thyroidectomy technique has been solely applied for ipsilateral hemithyroidectomy. For total thyroidectomy, Terris et al. performed the robotic surgery with bilateral RA incisions. Here, we intend to introduce our novel surgical method after successfully attempting simultaneous robotic total thyroidectomy and RAND via a single RA approach without an axillary incision. To our knowledge, this is the first to report in the medical literature.We present four cases of our surgical experience since the beginning of 2013. All patients received robotic total thyroidectomy with MRND via single RA port without axillary incision after approval from the institutional review board at Severance Hospital, Yonsei University College of Medicine. The inclusion criteria for this operation were as follows: (1) patients with malignant carcinomas of the thyroid gland with evident cervical lymph node metastasis on preoperative imaging studies which are indicated for surgery; (2) patients with no previous history of treatment for thyroid carcinoma. The exclusion criteria were as follows: (1) patients with recurred thyroid tumors; (2) patients with thyroid carcinomas that showed gross invasion to local structures or extensive extrathyroidal capsular spread; (3) patients with clinically evident neck nodal metastasis with extracapsular spread; (4) patients with past history of neck surgery of any kind. In order to assess the extent of disease, neck ultrasonography with fine needle aspiration, neck CT or MRI and PET-CT were performed as preoperative evaluation. All patients were given full information of the possible treatment options for their thyroid cancer comprising of open transcervical approach and robotic surgery via RA approach, including the advantages and disadvantages of each treatment choice and provided written, informed consents before the surgery. General clinical information of the patients is outlined in Table 1. The skin incision for the operation was designed just like the approach for robotic facelift thyroidectomy by Terris et al. and RAND, which has been first reported by our institution.11 (,) 16 The operation was performed by the following sequence. Initially, the skin-subplatysmal flap was elevated after making the skin incision to create sufficient working space. During this process, the elevated skin flap was retracted and maintained by retractors held by the assistant. After application of the self-retaining retractor (Sangdosa Inc., Seoul), neck dissection of the upper neck levels was performed under gross vision. Next, RAND through the RA incision was conducted followed by ipsilateral thyroidectomy with central compartment neck dissection (CCND) via the same approach. Finally, contralateral thyroidectomy with CCND was performed via the single RA port. During these steps, the operator is aided by the bedside assistant with long-suction tips to manipulate and direct the dissected specimen to maintain optimal surgical view or to suck out the fume created by the thermocoagulation from the Harmonic shears. The da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA) was introduced via the RA port with a facedown 30° dual-channel endoscopic arm placed in the center, and two instrument arms equipped at either side with 5-mm Maryland forceps and Harmonic curved shears. During the step of robotic contralateral thyroidectomy, a ProGrasp forceps was utilized at times, instead of 5-mm Maryland forceps. The rest of the surgery was completed with the robotic system (see Video for demonstration of operation for patient 2). Table 1 Clinical characteristics of the patients Patient Sex/age (yr) BMI Side(a) Approach Pathology(b) Tumor size(c) (cm) CCND(d) MRND(d) Drain removal day Drainage amount (ml) Hospital stay (days) 1 F/38 23.8 L RA PC 0.7 2/5 8/23 8 788 11 2 F/18 18.3 L RA PC 0.8 2/8 7/35 6 398 9 3 F/44 23.1 L RA PC 0.9 5/12 5/27 6 607 9 4 F/26 32.9 L RA PC 1.4 3/14 9/48 7 476 15 BMI body mass index, RA retroauricular approach, PC papillary carcinoma, CCND central compartment neck dissection, MRND modified radical neck dissection (a)Side refers to the site of main lesion (b)Pathology refers to the primary tumor within the thyroid gland (c)Tumor size refers to the diameter of the largest tumor in the thyroid gland (d)For each type of lymph node dissection, the number of positive nodes/total number of retrieved nodes is stated RESULTS: For all of the patients, robotic total thyroidectomy with MRND (levels II, III, IV, V) via unilateral RA approach was successfully completed without any significant intraoperative complications or conversion to open or other approach methods. The total operation time was defined as the time from initial skin incision to removal of the final specimen, which was an average 306.1 ± 11.1 min (Table 2). This included the time for skin flap elevation and neck dissection under gross vision (87 ± 2.8 min), setting up the robotic system for RAND (6.8 ± 2.4 min), console time using the robotic system for RAND (59.3 ± 2.2 min), flap elevation for thyroidectomy (11.3 ± 2.5 min), robotic arms docking for ipsilateral thyroidectomy (6.3 ± 2.5 min), console time for ipsilateral thyroidectomy (61.3 ± 2.1 min), robotic arms docking for contralateral thyroidectomy (6.3 ± 2.5 min), and console time for contralateral thyroidectomy (61.8 ± 2.1 min). The working space created from RA incision was sufficient, and manipulations of the robotic instruments through this approach were technically feasible and safe without any mutual collisions throughout the entire operation. It also allowed for an excellent magnified surgical view enabling visualization of important local anatomical structures. There was no postoperative vocal cord palsy due to recurrent laryngeal nerve injury. However, two patients developed transient hypoparathyroidism, which resolved in the end without the need for calcium or vitamin D supplementation after certain period of medical management (Table 3). Also, there was no incidence of postoperative hemorrhage or hematoma formation, although a single patient developed a postoperative seroma on postoperative day 9, which was managed conservatively without the need for further surgical intervention. On average, the wound catheter was removed 6.8 ± 1 days after surgery and the patient was discharged from the hospital at an average 11 ± 2.8 days from admission (Table 1). Final surgical pathology confirmed the diagnosis of papillary carcinoma for every patient. The total number of cervical nodes retrieved from CCND and MRND was 9.8 ± 4 and 33.1 ± 11 respectively, and the number of positive metastatic nodes was 3 ± 1.4 and 7.3 ± 1.7 respectively (Table 1). In three patients (patients 2, 3, and 4), the presence of one parathyroid gland was each verified in the pathology specimen. All four patients have received high-dose (150 mCi) radioiodine ablation (RAI) therapy after the operation and are being followed up (average 11.3 months, range 9-13 months) on a regular basis with no evidence of recurrence (post-RAI, most recent, nonsuppressed thyroglobulin range 0.1-0.4 ng/ml, antithyroglobulin antibody range 13.7-147.5 IU/ml). Table 2 Operation times for the patients Patient Total operation time (min) Flap elevation and dissection under direct vision (min) Robot docking for RAND (min) Console time for RAND (min) Flap elevation for TT (min) Robot docking for iT (min) Console time for iT (min) Robot docking for cT (min) Console time for cT (min) 1 320 85 5 62 10 10 63 10 60 2 310 91 10 60 10 5 60 5 63 3 300 87 7 58 10 5 63 5 60 4 295 85 5 57 15 5 59 5 64 RAND robot-assisted neck dissection, TT total thyroidectomy, iT ipsilateral thyroidectomy, cT contralateral thyroidectomy Table 3 Postoperative complications Patient Hematoma/hemorrhage Seroma Hypoparathyroidism Chyle leakage RLN injury Other CN injury(a) 1 - - - - - - 2 - - + - - - 3 - + + - - - 4 - - - + - - RLN recurrent laryngeal nerve, CN cranial nerve (a)Other cranial nerve injuries include marginal branch of facial nerve, hypoglossal nerve, lingual nerve or spinal accessory nerve DISCUSSION: Robotic total thyroidectomy and MRND via unilateral RA approach without axillary incision was technically feasible. This integrates the surgical technique of robotic facelift thyroidectomy as described by Terris et al. and the surgical technique of RAND via a MFL or RA approach as reported by our institution. Appropriate positioning of the patient and configuration of the robotic arms are keys to successful operation. When performing the thyroidectomy, the surgical procedure could be greatly facilitated if the patient's neck is relaxed from previous status of neck extension for RAND. Also, during the process of contralateral thyroidectomy, it is considered important that the patient should be tilted or rotated 15-30° towards the surgeon (ipsilateral downwards, contralateral upwards) at the patient's table for optimal exposure. The SCM muscle should be retracted posteriorly and inferiorly with a retractor to improve the surgical view from the console. It is essential for the assistant to push down the trachea with the suction tip to facilitate the robotic dissection. The Maryland dissector forceps may be changed to ProGrasp forceps to enhance handling of the thyroid gland tissue. It is important that sufficient working space must be created for comfortable movements of the robotic arms through the RA port during both total thyroidectomy and neck dissection. As can be recognized from the general clinical information of the patients (Table 1), the size of the thyroid carcinoma and the BMI affects little in performing the operation via this particular approach. The greatest initial advantage offered by this operative procedure would be of cosmetic value. In comparison with conventional transcervical open methods, by placing the surgical incision behind the auricle and within the hairline, an obvious cervical incision would be completely eliminated, however, at the cost of more extensive dissections just like any other remote access surgical techniques. Among other approach methods of remote access surgery, this specific operative procedure is thought to be superior. It would gain easier access to the lymph node basin of the upper neck than when TA approach is adopted and as Terris et al. have previously reported, the area of dissection required would be 38 % lesser than the TA approach, making it a less invasive technique.9 In our earlier periods, we have utilized the transaxillary and retroauricular (TARA) approach for MRND with or without thyroidectomy, but after accumulation of surgical experiences, the operation could be managed with a single RA approach, thereby minimizing the extent of invasiveness.17 Also, from the head and neck surgeon's point of view, the operation would be more comfortable due to familiar local anatomical structures, easier to address the spinal accessory nerve, and the thyroid gland and lymph node tissues at the central neck could be easily reached due to the decreased area of dissection compared with the TA. The risk of intraoperative brachial plexus injury or any other physical sequelae resulting from the specific positioning of the patient for TA approach would be avoided and incidence of postoperative lymphedema commonly resulting from long transcervical operation scars could be decreased with this technique. This operative procedure, however, has a disadvantage of longer operation times. It is contemplated that the operation time would be significantly decreased through accumulation of surgical experience. This is a clinical report of our successful yet initial surgical experiences of robotic total thyroidectomy and RAND via single RA port. Despite our promising operative results, an expanded population from careful selection of eligible patients is mandatory, and future prospective trials should be conducted to evaluate long-term outcomes and to overcome potential limitations.