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Surgery has been historically the preferred primary treatment for patients with well-differentiated thyroid carcinoma and for selected locoregional recurrences. Adjuvant therapy with radioactive iodine is typically recommended for patients with an intermediate to high risk of recurrence. Despite these treatments, locally advanced disease and locoregional relapses are not infrequent. These patients have a prolonged overall survival that may result in long periods of active disease and the possibility of requiring subsequent treatments. Recently, many new options have emerged as salvage therapies. This review offers a comprehensive discussion and considerations regarding surgery, active surveillance, radioactive iodine therapy, ultrasonography-guided percutaneous ablation, external beam radiotherapy, and systemic therapy for well-differentiated thyroid cancer based on relevant publications and current reference guidelines. We feel that the surgical member of the thyroid cancer management team is empowered by being aware and facile with all management options.
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Most cases of thyroid carcinoma are classified as low risk. These lesions have been treated with open surgery, remote access thyroidectomy, active surveillance, and percutaneous ablation. However, there is lack of consensus and clear indications for a specific treatment selection. The objective of this study is to review the literature regarding the indications for management selection for low-risk carcinomas. Systematic review exploring inclusion and exclusion criteria used to select patients with low-risk carcinomas for treatment approaches. The search found 69 studies. The inclusion criteria most reported were nodule diameter and histopathological confirmation of the tumor type. The most common exclusions were lymph node metastasis and extra-thyroidal extension. There was significant heterogeneity among inclusion and exclusion criteria according to the analyzed therapeutic approach. Alternative therapeutic approaches in low-risk carcinomas can be cautiously considered. Open thyroidectomy remains the standard treatment against which all other approaches must be compared.
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Carcinoma Papilar , Neoplasias de la Tiroides , Carcinoma Papilar/cirugía , Humanos , Estudios Retrospectivos , Cáncer Papilar Tiroideo/cirugía , Neoplasias de la Tiroides/cirugía , TiroidectomíaRESUMEN
Mucoepidermoid carcinoma (MEC) is one of the most common salivary gland malignancies. Our aim was to evaluate the prognostic impact of primary tumor site in patients with MEC. MATERIAL AND METHODS: This cohort identified 308 patients with MEC who underwent primary surgery between 1985 and 2015. Survival outcomes were determined using the Kaplan-Meier method. Hazard ratios for primary site were determined using the Cox proportional-hazards model. RESULTS: One hundred eighty (58%) patients were diagnosed with minor and 128 (42%) with major salivary gland cancer. Primary site in the minor salivary gland group included 137 (44%) oral cavity, 38 (12%) pharynx, 3 (0.9%) nasal cavity, and 2 (0.6%) trachea and larynx. The major salivary gland group included 118 (38%) parotid, 8 (3%) submandibular, and 2 (0.6%) sublingual. With a median follow-up of 73 months, 5-year overall survival and disease-specific survival were 84% and 91%, respectively. Patients with tumors located in the hard palate and retromolar trigone had the best survival, while patients with tumors located in the paranasal sinuses and submandibular gland had the poorest survival. After controlling for tumor grade and stage, MEC primary site was not predictive of survival or recurrence. On multivariate analysis, worse DSS was associated with stage III-IV tumors (HR: 7,11; 95% CI: 1.19-26.43; p = 0.0034) and high-grade tumors (HR: 19.12; 95% CI: 2.26-162.77; p = 0.0068). CONCLUSIONS: While high grade and advanced overall stage were found to be independent predictors of worse survival, primary tumor site was not predictive of poor outcome.
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Carcinoma Mucoepidermoide , Neoplasias de las Glándulas Salivales , Carcinoma Mucoepidermoide/patología , Carcinoma Mucoepidermoide/cirugía , Humanos , Estadificación de Neoplasias , Pronóstico , Estudios Retrospectivos , Neoplasias de las Glándulas Salivales/patología , Tasa de SupervivenciaRESUMEN
BACKGROUND: Guidelines should provide accessible and reliable information for decision-making. Also, they should be translatable to multiple settings, allowing their use in diverse situations. METHODS: We searched in GOOGLE, PUBMED, SCIELO, and SCOPUS for guidelines on oral squamous cell carcinoma. They were evaluated using the AGREE II protocol. RESULTS: We identified 16 guidelines that fulfilled inclusion criteria. The mean score and range for each AGREE II domain were: "scope and purpose" 74.1% (6-100.0%); "stakeholder" 78.6% (0-100.0%); "rigor of development" 71.4% (0-100.0%); "clarity of presentation" 71.4% (6-100.0%); "applicability" 50.0% (0-85.7%); "editorial independence" 57.1% (14.3-85.7%) and "overall assessment" 57.1% (14.3-100.0%). CONCLUSION: Guidelines for oral cancer present variable quality. Among those available, only four surpassed the 70% AGREE II score threshold.
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Carcinoma de Células Escamosas , Neoplasias de Cabeza y Cuello , Neoplasias de la Boca , Carcinoma de Células Escamosas/diagnóstico , Carcinoma de Células Escamosas/terapia , Humanos , Neoplasias de la Boca/diagnóstico , Neoplasias de la Boca/terapia , Carcinoma de Células Escamosas de Cabeza y CuelloRESUMEN
BACKGROUND: Larynx cancer is a common site for tumors of the upper aerodigestive tract. In cases with a clinically negative neck, the indications for an elective neck treatment are still debated. The objective is to define the prevalence of occult metastasis based on the subsite of the primary tumor, T classification and neck node levels involved. METHODS: All studies included provided the rate of occult metastases in cN0 larynx squamous cell carcinoma patients. The main outcome was the incidence of occult metastasis. The pooled incidence was calculated with random effects analysis. RESULTS: 36 studies with 3803 patients fulfilled the criteria. The incidence of lymph node metastases for supraglottic and glottic tumors was 19.9% (95% CI 16.4-23.4) and 8.0% (95% CI 2.7-13.3), respectively. The incidence of occult metastasis for level I, level IV and level V was 2.4% (95% CI 0-6.1%), 2.0% (95% CI 0.9-3.1) and 0.4% (95% CI 0-1.0%), respectively. For all tumors, the incidence for sublevel IIB was 0.5% (95% CI 0-1.3). CONCLUSIONS: The incidence of occult lymph node metastasis is higher in supraglottic and T3-4 tumors. Level I and V and sublevel IIB should not be routinely included in the elective neck treatment of cN0 laryngeal cancer and, in addition, level IV should not be routinely included in cases of supraglottic tumors.
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Introduction: Management of clinically negative neck (cN0) in patients with parotid gland cancer is controversial. Treatment options can include observation, elective neck dissection or elective radiotherapy. Areas covered: We addressed the treatment options for cN0 patients with parotid gland cancer. A literature review was undertaken to determine the optimal management of this group of patients. Expert opinion: Patients with parotid carcinoma and clinically negative neck have various options for their management. The analysis of tumor stage, histology and grade is essential to better define patients at risk for occult lymph node metastasis. These patients can be managed by surgery, radiotherapy or their combination, depending on the presence of risk factors, the moment at which such risk factors are detected, patient-related clinical conditions, medical provider expertise and institutional facilities.
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Disección del Cuello/métodos , Neoplasias de la Parótida/terapia , Medicina Basada en la Evidencia , Humanos , Metástasis Linfática , Estadificación de Neoplasias , Neoplasias de la Parótida/patología , Factores de RiesgoRESUMEN
Progesterone elevation (PE) during the late follicular phase of controlled ovarian stimulation in fresh embryo transfer in vitro fertilization (IVF)/intracytoplasmic sperm injection cycles has been claimed to be associated with decreased pregnancy rates. However, the evidence is not unequivocal, and clinicians still have questions about the clinical validity of measuring P levels during the follicular phase of stimulated cycles. We reviewed the existing literature aimed at answering four relevant clinical questions, namely (i) Is gonadotropin type associated with PE during the follicular phase of stimulated cycles? (ii) Is PE on the day of human chorionic gonadotropin (hCG) associated with negative fresh embryo transfer IVF/intracytoplasmic sperm injection (ICSI) cycles outcomes in all patient subgroups? (iii) Which P thresholds are best to identify patients at risk of implantation failure due to PE in a fresh embryo transfer? and (iv) Should a freeze all policy be adopted in all the cycles with PE on the day of hCG? The existing evidence indicates that late follicular phase progesterone rise in gonadotropin releasing analog cycles is mainly caused by the supraphysiological stimulation of granulosa cells with exogenous follicle-stimulating hormone. Yet, the type of gonadotropin used for stimulation seems to play no significant role on progesterone levels at the end of stimulation. Furthermore, PE is not a universal phenomenon with evidence indicating that its detrimental consequences on pregnancy outcomes do not affect all patient populations equally. Patients with high ovarian response to control ovarian stimulation are more prone to exhibit PE at the late follicular phase. However, in studies showing an overall detrimental effect of PE on pregnancy rates, the adverse effect of PE on endometrial receptivity seems to be offset, at least in part, by the availability of good quality embryo for transfer in women with a high ovarian response. Given the limitations of the currently available assays to measure progesterone at low ranges, caution should be applied to adopt specific cutoff values above which the effect of progesterone rise could be considered detrimental and to recommend "freeze-all" based solely on pre-defined cutoff points.
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BACKGROUND: Age is a critical factor in outcome for patients with well-differentiated thyroid cancer. Currently, age 45 years is used as a cutoff in staging, although there is increasing evidence to suggest this may be too low. The aim of this study was to assess the potential for changing the cut point for the American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) staging system from 45 years to 55 years based on a combined international patient cohort supplied by individual institutions. METHODS: A total of 9484 patients were included from 10 institutions. Tumor (T), nodes (N), and metastasis (M) data and age were provided for each patient. The group was stratified by AJCC/UICC stage using age 45 years and age 55 years as cutoffs. The Kaplan-Meier method was used to calculate outcomes for disease-specific survival (DSS). Concordance probability estimates (CPE) were calculated to compare the degree of concordance for each model. RESULTS: Using age 45 years as a cutoff, 10-year DSS rates for stage I-IV were 99.7%, 97.3%, 96.6%, and 76.3%, respectively. Using age 55 years as a cutoff, 10-year DSS rates for stage I-IV were 99.5%, 94.7%, 94.1%, and 67.6%, respectively. The change resulted in 12% of patients being downstaged, and the downstaged group had a 10-year DSS of 97.6%. The change resulted in an increase in CPE from 0.90 to 0.92. CONCLUSIONS: A change in the cutoff age in the current AJCC/UICC staging system from 45 years to 55 years would lead to a downstaging of 12% of patients, and would improve the statistical validity of the model. Such a change would be clinically relevant for thousands of patients worldwide by preventing overstaging of patients with low-risk disease while providing a more realistic estimate of prognosis for those who remain high risk.
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Diferenciación Celular , Técnicas de Apoyo para la Decisión , Estadificación de Neoplasias/métodos , Neoplasias de la Tiroides/patología , Factores de Edad , Brasil , Supervivencia sin Enfermedad , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Nueva Gales del Sur , América del Norte , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Neoplasias de la Tiroides/mortalidad , Neoplasias de la Tiroides/terapia , Resultado del TratamientoRESUMEN
BACKGROUND: We hypothesized that pathological N1 (pN1) and N2a (pN2a) nodal disease portend a similar prognosis in patients with oral cancer. METHODS: An international multicenter study of 739 oral squamous cell carcinoma (SCC) patients with pN1 or pN2a stage disease was conducted. Multivariable analyses were performed using Cox proportional hazard models to compare locoregional failure, disease-specific survival (DSS), and overall survival (OS). Institutional heterogeneity was assessed using 2-stage random effects meta-analysis techniques. RESULTS: Univariate analysis revealed no difference in locoregional failure (p = .184), DSS (p = .761), or OS (p = .475). Similar results were obtained in adjusted multivariable models and no evidence of institutional heterogeneity was demonstrated. CONCLUSION: The prognosis of pN2a and pN1 disease is similar in oral SCC suggesting these categories could be combined in future revisions of the nodal staging system to enhance prognostic accuracy. However, these results may reflect more aggressive treatment of N2a disease; hence, we caution against using these data to deintensify treatment.
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Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/cirugía , Neoplasias de la Boca/patología , Neoplasias de la Boca/cirugía , Recurrencia Local de Neoplasia/patología , Recurrencia Local de Neoplasia/cirugía , Anciano , Australia , Brasil , Carcinoma de Células Escamosas/mortalidad , Femenino , Estudios de Seguimiento , Alemania , Humanos , India , Israel , Italia , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Neoplasias de la Boca/mortalidad , Recurrencia Local de Neoplasia/mortalidad , Estadificación de Neoplasias , Pronóstico , Taiwán , Estados UnidosRESUMEN
OBJECTIVES/HYPOTHESIS: To identify the association between surgeon/hospital volume with outcomes in surgical treatment for obstructive sleep apnea (OSA) in a nationally representative sample. We hypothesized that surgeons/hospitals with lower patient volumes would have: higher mortality rates, longer hospital length of stay (LOS), and higher postoperative complication rates and hospitalization charges. STUDY DESIGN: Secondary data analysis of the 2007 Nationwide Inpatient Sample database. METHODS: We selected 24,298 adults undergoing OSA surgery. The data analysis included trend test, regression, and multivariate models that were adjusted by demographic and clinical variables. RESULTS: The patients were mostly White (76.43%), male (78.26%), with a mean age of 46 years. Patients treated by surgeons with low volume of procedures (1 procedure/year) had significantly higher mortality rate (odds ratio [OR] 3.05; confidence interval [CI], 1.96-4.77), longer average LOS (increased until 8.16 hours), and higher hospitalization charges (increased up to $1701.75) versus medium- and high-volume surgeons (2-4 procedures/year; greater than/or equal to 5 procedures/year, respectively). Patients treated at hospitals with low volume of procedures (0-5/year) had significantly higher occurrence of oxygen desaturation (OR, 2.12; CI, 1.50-2.99), longer LOS (increased until almost 2 hours) and higher hospitalization charges (at least $951.50 more expensive) versus patients treated at high-volume hospitals (greater than/or equal to 18 procedures/year). CONCLUSION: Our investigation validates the hypothesis that lower volume standards (surgeon/hospital) are associated with increase of LOS following surgery to treat OSA, as well as lower surgeon volume associated with increase of mortality and hospitalization charges and lower hospital volume with occurrence of oxygen desaturation as postoperative complication.
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Hospitalización/estadística & datos numéricos , Procedimientos Quirúrgicos Otorrinolaringológicos/estadística & datos numéricos , Apnea Obstructiva del Sueño/cirugía , Femenino , Mortalidad Hospitalaria , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Resultado del TratamientoRESUMEN
IMPORTANCE: After surgical resection for oral cavity squamous cell carcinoma, adjuvant radiotherapy may be recommended for patients at higher risk for locoregional recurrence, but it can be difficult to predict whether a particular patient will benefit. OBJECTIVE: To construct a model to predict which patients with oral cavity squamous cell carcinoma would benefit from adjuvant radiotherapy. DESIGN AND SETTING: We constructed several types of survival models using a set of 979 patients with oral cavity squamous cell carcinoma. Covariates were age, sex, tobacco use, stage, grade, margins, and subsite. The best performing model was externally validated on a set of 431 patients. PARTICIPANTS: The model was based on a set of 979 patients with oral cavity squamous cell carcinoma, including 563 from Memorial Sloan Kettering Cancer Center, New York, New York, and 416 from the Hospital AC Camargo, São Paulo, Brazil. The validation set consisted of 431 patients from Princess Margaret Hospital, Toronto, Ontario, Canada. MAIN OUTCOME AND MEASURE: The primary outcome measure of interest was locoregional recurrence-free survival. RESULTS: The lognormal model showed the best performance per the Akaike information criterion. An online nomogram was built from this model that estimates locoregional failure-free survival with and without postoperative radiotherapy. CONCLUSIONS AND RELEVANCE: A web-based nomogram can be used as a decision aid for adjuvant treatment decisions for patients with oral cavity squamous cell carcinoma.
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Carcinoma de Células Escamosas/radioterapia , Neoplasias de la Boca/radioterapia , Nomogramas , Radioterapia Adyuvante , Brasil/epidemiología , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/cirugía , Interpretación Estadística de Datos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neoplasias de la Boca/patología , Neoplasias de la Boca/cirugía , Clasificación del Tumor , Recurrencia Local de Neoplasia , Estadificación de Neoplasias , New York/epidemiología , Ontario/epidemiología , Valor Predictivo de las Pruebas , Factores de Riesgo , Fumar/epidemiología , Tasa de SupervivenciaRESUMEN
Se describe una creciente incidencia de carcinoma de tiroides en todo el mundo, pero la mayor parte de estos casos corresponde a cánceres de bajo riesgo. Se necesita comprender con precisión la patología tumoral y su comportamiento biológico, para aprovechar estos parámetros en una terapia rentable con utilización adecuada de recursos. La apreciación de la importancia y el significado de los factores pronósticos y la estratificación por grupos de riesgo es esencial para el enfoque actual del carcinoma tiroideo. Se requiere discreción para la selección del tratamiento quirúrgico y la indicación de terapias adyuvantes, así como para las estrategias de vigilancia (AU)
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Neoplasias de la Tiroides/complicaciones , Neoplasias de la Tiroides/diagnóstico , Neoplasias de la Tiroides/rehabilitación , Neoplasias de la Tiroides/terapia , Ganglios/anomalías , Metástasis de la Neoplasia/prevención & controlRESUMEN
Se describe una creciente incidencia de carcinoma de tiroides en todo el mundo, pero la mayor parte de estos casos corresponde a cánceres de bajo riesgo. Se necesita comprender con precisión la patología tumoral y su comportamiento biológico, para aprovechar estos parámetros en una terapia rentable con utilización adecuada de recursos. La apreciación de la importancia y el significado de los factores pronósticos y la estratificación por grupos de riesgo es esencial para el enfoque actual del carcinoma tiroideo. Se requiere discreción para la selección del tratamiento quirúrgico y la indicación de terapias adyuvantes, así como para las estrategias de vigilancia
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Ganglios/anomalías , Metástasis de la Neoplasia/prevención & control , Neoplasias de la Tiroides/complicaciones , Neoplasias de la Tiroides/diagnóstico , Neoplasias de la Tiroides/rehabilitación , Neoplasias de la Tiroides/terapiaRESUMEN
BACKGROUND: With the exponential expansion of clinical trials conducted in (Brazil, Russia, India, and China) and VISTA (Vietnam, Indonesia, South Africa, Turkey, and Argentina) countries, corresponding gains in cost and enrolment efficiency quickly outpace the consonant metrics in traditional countries in North America and European Union. However, questions still remain regarding the quality of data being collected in these countries. We used ethnographic, mapping and computer simulation studies to identify/address areas of threat to near miss events for data quality in two cancer trial sites in Brazil. METHODOLOGY/PRINCIPAL FINDINGS: Two sites in Sao Paolo and Rio Janeiro were evaluated using ethnographic observations of workflow during subject enrolment and data collection. Emerging themes related to threats to near miss events for data quality were derived from observations. They were then transformed into workflows using UML-AD and modeled using System Dynamics. 139 tasks were observed and mapped through the ethnographic study. The UML-AD detected four major activities in the workflow evaluation of potential research subjects prior to signature of informed consent, visit to obtain subjectÌs informed consent, regular data collection sessions following study protocol and closure of study protocol for a given project. Field observations pointed to three major emerging themes: (a) lack of standardized process for data registration at source document, (b) multiplicity of data repositories and (c) scarcity of decision support systems at the point of research intervention. Simulation with policy model demonstrates a reduction of the rework problem. CONCLUSIONS/SIGNIFICANCE: Patterns of threats to data quality at the two sites were similar to the threats reported in the literature for American sites. The clinical trial site managers need to reorganize staff workflow by using information technology more efficiently, establish new standard procedures and manage professionals to reduce near miss events and save time/cost. Clinical trial sponsors should improve relevant support systems.
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Antropología Cultural/métodos , Ensayos Clínicos como Asunto , Simulación por Computador , Proyectos de Investigación , Flujo de Trabajo , Investigación Biomédica/organización & administración , Brasil , Política de Salud , Humanos , Modelos Teóricos , Terminología como AsuntoRESUMEN
BACKGROUND: Roux-en-Y gastric bypass (RYGB) surgery is the gold standard surgical treatment for obesity. However, unintended nutritional deficiencies following this surgery are common, including changes in bone metabolism. We assessed changes in bone mineral density (BMD), nutritional compounds, and bone resorption markers before and 1 year following RYGB surgery. METHODS: Our study included 22 female patients with class II/III obesity. A clinical questionnaire, a 24-h recall, blood and urine samples, and dual-energy X-ray absorptiometry were provided. RESULTS: Mean age was 37.2 ± 9.6 years; 86 % were Caucasian and 77.2 % were premenopausal. Mean preoperative body mass index was 44.4 ± 5.0 and 27.5 ± 4.5 kg/m(2) at 1-year follow-up (p < 0.001). 25-OH-vitamin D-levels were similar in both periods [11.7 (9.7-18.0) vs. 15.7 (10.2-2.7) pg/dL, p = 0.327]. Serum N-telopeptide (16.3 ± 3.4 vs. 38.2 ± 7.0 nM BCE, p < 0.001) and parathyroid hormone (45.4 ± 16.7 vs. 62.7 ± 28.9 pg/mL, p = 0.026) increased after RYGB surgery, reflecting bone resorption. BMD decreased after RYGB surgery in the lumbar spine (1.13 ± 0.11 vs. 1.04 ± 0.09 g/cm(2), p = 0.001), femoral neck (1.03 ± 0.15 vs. 0.94 ± 0.16 g/cm(2), p = 0.001), and total femur (1.07 ± 0.11 vs. 0.97 ± 0.15 g/cm(2), p = 0.003). CONCLUSIONS: Decreased BMD in the lumbar spine, femoral neck, and total femur is detectable in women 1 year after RYGB surgery. Calcium malabsorption, caused by vitamin D deficiency and increased bone resorption, is partially responsible for these outcomes and should be targeted in future clinical trials.
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Densidad Ósea , Resorción Ósea/metabolismo , Fémur/metabolismo , Vértebras Lumbares/metabolismo , Obesidad Mórbida/metabolismo , Deficiencia de Vitamina D/metabolismo , Absorciometría de Fotón , Adulto , Índice de Masa Corporal , Resorción Ósea/diagnóstico por imagen , Brasil , Calcio de la Dieta/metabolismo , Femenino , Fémur/diagnóstico por imagen , Estudios de Seguimiento , Derivación Gástrica/efectos adversos , Derivación Gástrica/métodos , Humanos , Vértebras Lumbares/diagnóstico por imagen , Obesidad Mórbida/diagnóstico por imagen , Obesidad Mórbida/cirugía , Premenopausia , Estudios Prospectivos , Encuestas y Cuestionarios , Pérdida de PesoRESUMEN
Despite the importance of delivering evidence-based health care, orthopedic surgeons have directed fewer efforts towards the generation of such evidence. Even when present, published evidence lacks methodological rigor and is known to be inaccurate. One of the main reasons for the lack of generation of quality evidence, and the low involvement in research among orthopedic surgeons, is the lack of structured research coaching environments where they can learn concepts and hone their research skills. There is a palpable need for a pragmatic and outcome-oriented approach that can equip orthopedic surgeons with effective ways of communicating their research in writing. We describe a pragmatic research coaching program, designed and developed by the Research on Research group, which aims to build a global network of orthopedic researchers trained in streamlined and standardized research methods. We also provide a brief overview of the course principles and tools, and the platforms used in this program.
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HYPOTHESIS: Race and insurance status are independent predictors of the choice between total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) of the shoulder joint. BACKGROUND: Current literature shows that ethnic and socioeconomic status may influence access to health care. However, no study has demonstrated whether insurance status and race are independent predictors that patients with glenohumeral osteoarthritis will undergo TSA. MATERIALS AND METHODS: Patients with primary International Classification of Diseases, 9th revision, Clinical Modification, procedure codes for TSA and HA were selected from the 1988 to 2007 United States Nationwide Inpatient Sample. Primary predictors were race (Caucasian, African American, Hispanic, other) and insurance status (private, Medicare, Medicaid, other). Multiple logistic regressions were used to determine whether insurance status and race were associated with the choice of procedure for patients presenting with glenohumeral osteoarthritis. RESULTS: The study included data for 3529 patients, of whom 2369 underwent TSA (67.1%) and the remaining 1160 (32.9%) underwent HA. Of patients treated using TSA, 29% were privately insured, 63.2% had Medicare, and 2.5% had Medicaid (P < .001), and 62.1% were Caucasian, 2.5% were African American, 2.46% were Hispanic, and 30.9% had other ethnicities (P < .001). DISCUSSION: Multiple logistic regression analysis found that privately insured patients and Medicare patients did not show statistically different odds of having TSA compared with patients within the Medicaid (reference category) or "other payment" categories, after adjustment for a variety of potential confounders. Caucasian patients also did not show statistically different chances of undergoing TSA compared with African Americans. CONCLUSIONS: We were unable to support statistical evidence that race and insurance status are independent factors associated with the choice of the surgical procedure in patients with glenohumeral osteoarthritis.
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Artroplastia de Reemplazo/economía , Etnicidad , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Cobertura del Seguro , Osteoartritis/economía , Articulación del Hombro/cirugía , Artroplastia de Reemplazo/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Osteoartritis/etnología , Osteoartritis/cirugía , Estudios Retrospectivos , Clase Social , Estados Unidos/epidemiologíaRESUMEN
Apesar da importância de praticar o atendimento de saúde baseado em evidências, os cirurgiões ortopedistas têm direcionado poucos esforços para gerar essas evidências. Mesmo quando presente, a evidência publicada é falha quanto ao rigor metodológico e sabe-se que é imprecisa. Um dos principais motivos para a falta de geração de evidências de qualidade é o baixo envolvimento dos cirurgiões ortopedistas na pesquisa e a falta de ambientes de treinamento estruturados em pesquisa, onde eles possam aprender conceitos, assim como aprimorar suas habilidades em pesquisa. Existe a necessidade de uma abordagem objetiva que possa equipar os cirurgiões ortopedistas com métodos eficientes para transitarem da pesquisa para a escrita. Descrevemos um programa pragmático de treinamento em pesquisa, planejado e desenvolvido pelo grupo de Pesquisa sobre Pesquisa, que visa montar uma rede global de pesquisadores ortopedistas treinados em métodos de pesquisa funcionais e padronizados. Também fornecemos um rápido panorama sobre os princípios do curso e suas ferramentas, assim como plataformas usadas nesse programa.
Despite the importance of delivering evidence-based health care, orthopedic surgeons have directed fewer efforts towards the generation of such evidence. Even when present, published evidence lacks methodological rigor and is known to be inaccurate. One of the main reasons for the lack of generation of quality evidence, and the low involvement in research among orthopedic surgeons, is the lack of structured research coaching environments where they can learn concepts and hone their research skills. There is a palpable need for a pragmatic and outcome-oriented approach that can equip orthopedic surgeons with effective ways of communicating their research in writing. We describe a pragmatic research coaching program, designed and developed by the Research on Research group, which aims to build a global network of orthopedic researchers trained in streamlined and standardized research methods. We also provide a brief overview of the course principles and tools, and the platforms used in this program.
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Humanos , Masculino , Femenino , Medicina Basada en la Evidencia , Metodología como un Tema , Ortopedia , InvestigaciónRESUMEN
BACKGROUND: With the global expansion of clinical trials and the expectations of the rise of the emerging economies known as BRICs (Brazil, Russia, India and China), the understanding of factors that affect the willingness to participate in clinical trials of patients from those countries assumes a central role in the future of health research. METHODS: We conducted a systematic review and meta-analysis (SRMA) of willingness to participate in clinical trials among Brazilian patients and then we compared it with Indian patients (with results of another SRMA previously conducted by our group) through a system dynamics model. RESULTS: Five studies were included in the SRMA of Brazilian patients. Our main findings are 1) the major motivation for Brazilian patients to participate in clinical trials is altruism, 2) monetary reimbursement is the least important factor motivating Brazilian patients, 3) the major barrier for Brazilian patients to not participate in clinical trials is the fear of side effects, and 4) Brazilian patients are more likely willing to participate in clinical trials than Indians. CONCLUSION: Our study provides important insights for investigators and sponsors for planning trials in Brazil (and India) in the future. Ignoring these results may lead to unnecessary fund/time spending. More studies are needed to validate our results and for better understanding of this poorly studied theme.