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BACKGROUND: The use of video laryngoscopes by novice physicians may improve first-pass success rates compared with direct laryngoscopy. OBJECTIVE: The aim of the present study was to assess whether time to intubation, number of laryngoscopy attempts, and first-pass success rate during laryngoscopy with the video laryngoscope or conventional Macintosh laryngoscope are affected by personal protective equipment (PPE) donning. METHODS: Seventy inexperienced physicians were randomly assigned to video laryngoscope or Macintosh groups and were instructed to perform intubation with both devices on a manikin, using PPE or a standard uniform. The primary outcomes were insertion time, number of laryngoscopy attempts, and first-pass success rates for each device with or without donning PPE. RESULTS: In the Macintosh group, significantly less time was needed for the first successful intubation without PPE vs. with PPE (12.17 ± 3.69 s vs. 24.07 ± 5.09 s, respectively; p < 0.0001). On the other hand, such difference was not observed in the video laryngoscope group (14.99 ± 3.01 s vs. 14.01 ± 3.35 s, respectively; p = 0.07). With PPE, the first-pass success rate was significantly higher in the video laryngoscope group [41 (58.6%) vs. 66 (94.3%), p < 0.001]. The use of the video laryngoscope resulted in a significant decrease in insertion time compared with the Macintosh blade (14.01 ± 3.35 s vs. 24.07 ± 5.09 s, respectively; p < 0.0001). CONCLUSION: First-pass success and insertion time with the video laryngoscope were not affected by PPE donning. However, both were negatively affected with the Macintosh laryngoscope.
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Laringoscópios , Médicos , Desenho de Equipamento , Humanos , Intubação Intratraqueal , Laringoscopia , Manequins , Equipamento de Proteção Individual , Gravação em VídeoRESUMO
BACKGROUND: Strict glycaemic control early in the treatment process has been shown to reduce the occurrence of micro- and macro- vascular complications of diabetes in the long-term. Thus, treatment guidelines advise early intensification of treatment to achieve glycaemic control goals. However, evidence in Greece suggests that, despite guideline recommendations, glycaemic control among patients with T2DM remains challenging. This study presents the demographic and clinical characteristics of patients with T2DM in Greece using data from an electronic registry designed specifically for this treatment category and investigates the factors that are independently associated with glycaemic control. METHODS: This is a multi-center, observational, cross-sectional study to investigate epidemiological and clinical factors affecting glycaemic control among patients with T2DM in Greece. Data was collected via a web-based disease registry, the Diabetes Registry, which operated from January 1st to December 31st, 2017. Five large specialized diabetes centers operating in Greek hospitals participated in the study. RESULTS: Data for 1141 patients were retrieved (aged 63.02 ± 12.65 years, 56.9% male). Glycaemic control (Hb1Ac < 7%) was not achieved in 57.1% of patients. Factors independently associated with poor glycaemic control were: family history of diabetes [OR: 1.53, 95% CI: 1.06-2.23], BMI score between 25 to 30 [OR: 2.08, 95% CI: 1.05-4.13] or over 30 [OR: 2.12, 95% CI 1.12-4.07], elevated LDL levels [OR: 1.53, 95% 1.06-2.21] and low HDL levels [OR: 2.12, 95% CI: 1.44-3.12]. Lastly, use of injectable antidiabetic agents (in monotherapy or in combination) was less likely to be associated with poor glycaemic control versus treatment with combination of oral and injectable agents [OR: 0.50, 95% CI: 0.24-1.01]. This association was found to be marginally statistically significant. CONCLUSION: Inadequate lipid control, family history of diabetes and presence of obesity (ΒΜΙ ≥ 30 kg/m2) were associated with poor glycaemic control among study sample, whereas use of injectable antidiabetic agents was less likely to be associated with poor glycaemic control. These findings indicate how complex optimal glycaemic control is, highlighting the need for tailored interventions in high-risk subpopulations with T2DM.
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Biomarcadores/análise , Diabetes Mellitus Tipo 2/tratamento farmacológico , Hiperglicemia/prevenção & controle , Hipoglicemia/prevenção & controle , Hipoglicemiantes/uso terapêutico , Glicemia/análise , Estudos Transversais , Feminino , Seguimentos , Hemoglobinas Glicadas/análise , Humanos , Hiperglicemia/patologia , Hipoglicemia/patologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Sistema de RegistrosRESUMO
PURPOSE: To investigate whether a lipid emulsion could counteract the hypotensive effects of amiodarone overdose after an acute intravenous administration and improve 4 h survival in an established model of swine cardiovascular research. METHODS: Twenty pigs were intubated and instrumented to measure aortic pressures and central venous pressures (CVP). After allowing the animals to stabilize for 60 minutes, amiodarone overdose (1 mg/kg/min) was initiated for a maximum of 20 minutes. Afterwards, the animals were randomized into 2 groups. Group A (n = 10) received 0.9% Normal Saline (NS) and Group B (n = 10) received 20% Intralipid® (ILE). A bolus dose of 2 ml/kg in over 2 min time was initially administered in both groups followed by a 45 min infusion (0.2 ml/kg/min) of either NS or ILE. RESULTS: All animals survived the overdose and all animals survived the monitoring period of 4 hours. Systolic aortic pressure (SpthAorta) (6.90 vs 14.10 mmHg, P = .006) and mean arterial pressure (MAP) (6.10 vs 14.90 mmHg, P = .001) were higher in the ILE group 2 min after the bolus ILE infusion. This difference was maintained for 15 min after ILE infusion for both SpthAorta (7.85 vs 13.15 mmHg, P = .044) and MAP (7.85 vs 13.15 mmHg, P = .042). Animals that received ILE had higher CVP (11.6 vs 15.7 mmHg, P = .046), an effect which was attenuated 2 and 4 hours post administration. Animals receiving ILE were more acidotic (7.21 vs 7.38, P = .048) in the monitoring period compared to animals receiving NS. CONCLUSIONS: Intralipid attenuated the hypotensive effects of amiodarone toxicity for a period of 15 minutes compared to animals receiving NS.
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Amiodarona/toxicidade , Pressão Sanguínea/efeitos dos fármacos , Overdose de Drogas/tratamento farmacológico , Fosfolipídeos/administração & dosagem , Óleo de Soja/administração & dosagem , Doença Aguda , Animais , Modelos Animais de Doenças , Relação Dose-Resposta a Droga , Emulsões/administração & dosagem , Emulsões Gordurosas Intravenosas/administração & dosagem , Feminino , Bloqueadores dos Canais de Sódio/toxicidade , SuínosRESUMO
OBJECTIVE: Cardiac arrest is a daunting medical emergency. The aim of the present study was to assess whether the combination of adrenaline and glucagon would improve initial resuscitation success, 48-hour survival, and neurologic outcome compared with adrenaline alone in a porcine model of ventricular fibrillation. METHODS: Ventricular fibrillation was induced in 20 healthy Landrace/Large White piglets, which were subsequently left untreated for 8 minutes. The animals were randomized to receive adrenaline alone (n = 10, group C) and adrenaline plus glucagon (n = 10, group G). All animals were resuscitated according to the 2010 European Resuscitation Council guidelines. Hemodynamic variables were measured before arrest, during arrest and resuscitation, and during the first 60 minutes after return of spontaneous circulation. Survival and a neurologic alertness score were measured at 48 hours after return of spontaneous circulation. RESULTS: Return of spontaneous circulation was achieved in 8 animals (80%) from group C and 10 animals (100%) from group G (P = .198). A significant gradual increase in coronary perfusion pressure and diastolic aortic pressure over time, which started 1 minute after the onset of cardiopulmonary resuscitation, was observed. Three animals (30%) from group C and 9 animals (90%) from group G survived after 48 hours (P = .006), whereas neurologic examination was significantly better in the animals of group G (P < .001). CONCLUSIONS: In this porcine model of prolonged ventricular fibrillation, the addition of glucagon to adrenaline improves hemodynamics during resuscitation and early postresuscitation period and may increase survival.
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Epinefrina/uso terapêutico , Glucagon/uso terapêutico , Hemodinâmica/efeitos dos fármacos , Fibrilação Ventricular/tratamento farmacológico , Animais , Pressão Sanguínea/efeitos dos fármacos , Reanimação Cardiopulmonar/métodos , Modelos Animais de Doenças , Quimioterapia Combinada , Epinefrina/administração & dosagem , Glucagon/administração & dosagem , Parada Cardíaca/tratamento farmacológico , Parada Cardíaca/fisiopatologia , Frequência Cardíaca/efeitos dos fármacos , Masculino , Suínos , Fibrilação Ventricular/fisiopatologiaRESUMO
OBJECTIVE: The objective was to evaluate whether passive leg raising during cardiopulmonary resuscitation in a porcine model of prolonged ventricular fibrillation improves hemodynamics, return of spontaneous circulation, 24-hour survival, and neurological outcome. METHODS: Ventricular fibrillation was induced in 20 healthy Landrace/Large White piglets, which were subsequently left untreated for 8 minutes. Ten animals were randomly assigned into the control group and were resuscitated according to the 2005 European Resuscitation Council guidelines, and 10 piglets were assigned into the passive leg raising group and were resuscitated with the legs passively raised at 45° with the aid of a special purpose-made metallic device. End points were either return of spontaneous circulation or asystole. RESULTS: Return of spontaneous circulation was observed in 6 and 9 animals from the control and the passive leg raising group, respectively (P = .121; odds ratio = 0.16; 95% confidence interval, 0.01-1.87). Just prior to the first defibrillation attempt, coronary perfusion pressure was significantly higher in the passive leg raising group (22.8 ± 9.5 vs 10.6 ± 6.5 mm Hg, P < .004); but no subsequent significant differences were observed. Although all animals that restored spontaneous circulation survived for 24 hours, neurologic alertness score was significantly better in the animals treated with passive leg raising (90 ± 10 vs 76.6 ± 12.1, P = .037). CONCLUSIONS: Passive leg raising during cardiopulmonary resuscitation significantly increased coronary perfusion pressure in the minute prior to the first shock. Return of spontaneous circulation and 24-hour survival rate were comparable between groups. However, the animals in the passive leg raising group exhibited significantly higher neurological scores.
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Reanimação Cardiopulmonar/métodos , Hipóxia Encefálica/prevenção & controle , Fibrilação Ventricular/terapia , Animais , Pressão Sanguínea , Modelos Animais de Doenças , Extremidades , Frequência Cardíaca , Hipóxia Encefálica/etiologia , Masculino , Posicionamento do Paciente , Suínos , Resultado do Tratamento , Fibrilação Ventricular/complicaçõesRESUMO
BACKGROUND: Mean circulatory filling pressure (Pmcf) provides information on stressed volume and is crucial for maintaining venous return. This study investigated the Pmcf and other determinants of venous return in dysrhythmic and asphyxial circulatory shock and arrest. METHODS: Twenty Landrace/Large-White piglets were allocated into two groups of 10 animals each. In the dysrhythmic group, ventricular fibrillation was induced with a 9 V cadmium battery, while in the asphyxia group, cardiac arrest was induced by stopping and disconnecting the ventilator and clamping the tracheal tube at the end of exhalation. Mean circulatory filling pressure was calculated using the equilibrium mean right atrial pressure at 5-7.5 s after the onset of cardiac arrest and then every 10 s until 1 min post-arrest. Successful resuscitation was defined as return of spontaneous circulation (ROSC) with a MAP of at least 60 mmHg for a minimum of 5 min. RESULTS: After the onset of asphyxia, a ΔPmca increase of 0.004 mmHg, 0.01 mmHg, and 1.26 mmHg was observed for each mmHg decrease in PaO2, each mmHg increase in PaCO2, and each unit decrease in pH, respectively. Mean Pmcf value in the ventricular fibrillation and asphyxia group was 14.81 ± 0.5 mmHg and 16.04 ± 0.6 mmHg (p < 0.001) and decreased by 0.031 mmHg and 0.013 mmHg (p < 0.001), respectively, for every additional second passing after the onset of cardiac arrest. With the exception of the 5-7.5 s time interval, post-cardiac arrest right atrial pressure was significantly higher in the asphyxia group. Mean circulatory filling pressure at 5 to 7.5 s after cardiac arrest predicted ROSC in both groups, with a cut-off value of 16 mmHg (AUC = 0.905, p < 0.001). CONCLUSION: Mean circulatory filling pressure was higher in hypoxic hypercapnic conditions and decreased at a lower rate after cardiac arrest compared to normoxemic and normocapnic state. A Pmcf cut-off point of 16 mmHg at 5-7.5 s after cardiac arrest can highly predict ROSC.
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AIMS: To determine the prevalence of Associated Autoimmune Diseases (AADs) in Latent Autoimmune Diabetes of Adults (LADA) versus autoimmune Type 1 Diabetes (T1D) and the role of glutamic-acid decarboxylase antibodies (GADA) and other factors. METHODS: Adults with autoimmune diabetes mellitus (DM) were recruited from the Diabetes Center of Nikaia-Piraeus Hospital. Demographic and clinical parameters were recorded and anti-pancreatic and organ-specific antibodies were measured. RESULTS: Of 160 patients, 33.75% had one AAD and 24.37% had two or more. Patients with LADA had higher overall prevalence of AADs, mainly autoimmune thyroiditis and gastritis. Celiac disease was present only in T1D. GADA positive patients had higher prevalence of AADs and multiple autoimmunity, especially thyroiditis and gastritis. Patients with LADA had higher rates of positive GADA or islet-cell antibodies (ICA). After controlling for LADA, GADA remained a significant predictor of AADs. Female gender and chronological age were also significant predictors of AADs. CONCLUSIONS: AADs were present in 58.13% of patients. Patients with LADA were more prone to a generalized autoimmune disorder than those with T1D. AADs development was significantly associated with female sex, older age and positive GADA, which proved an independent marker of associated autoimmunity.
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Autoanticorpos/imunologia , Autoimunidade/fisiologia , Diabetes Mellitus Tipo 1/complicações , Glutamato Descarboxilase/imunologia , Diabetes Autoimune Latente em Adultos/imunologia , Adulto , Diabetes Mellitus Tipo 1/patologia , Feminino , Humanos , MasculinoRESUMO
The baseline levels of various inflammatory mediators and their changes during anesthesia in swine are not known. The aim of this animal study was to measure the baseline values and kinetics of interleukin-6, procalcitonin, and tumor necrosis factor-alpha in healthy Landrace-Large White swine anesthetized with propofol-based total intravenous anesthesia. We included 8 healthy male pigs with an average weight of 19 ± 2 kg (aged 10-15 weeks) that were subjected to propofol-based total intravenous anesthesia for 8 hours. Complete blood count, serum chemistry, and serum levels of interleukin-6, procalcitonin, and tumor necrosis factor-alpha were analyzed, and serum levels were quantified hourly. Blood was also collected for bacterial culturing. Baseline values of interleukin-6 and procalcitonin were 18 pg/ml and 21 ng/ml, respectively, while tumor necrosis factor-alpha was not detectable during collection of baseline samples. A statistically significant difference was observed in interleukin-6 levels between time points (p < 0.0001). Procalcitonin increased with time, but there were no significant differences between time points (p = 0.152). Tumor necrosis factor-alpha increased until the 3rd hour of propofol-based total intravenous anesthesia, while after the 4th hour, it gradually decreased, reaching its baseline undetectable values by the 7th hour (p < 0.001). Our results can serve as the basis for further translational research.
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Anestesia Intravenosa/métodos , Interleucina-6/sangue , Pró-Calcitonina/sangue , Propofol/farmacologia , Fator de Necrose Tumoral alfa/sangue , Anestesia , Anestesia Geral , Anestésicos Inalatórios , Animais , Citocinas/sangue , Eletrocardiografia , Frequência Cardíaca , Hemodinâmica , Inflamação , Mediadores da Inflamação , Cinética , Masculino , Suínos , Fatores de Tempo , Pesquisa Translacional BiomédicaRESUMO
CONTEXT: Inhibitors of sodium-glucose cotransporters-2 have cardio- and renoprotective properties. However, the underlying mechanisms remain indeterminate. OBJECTIVE: To evaluate the effect of dapagliflozin on renal metabolism assessed by urine metabolome analysis in patients with type 2 diabetes. DESIGN: Prospective cohort study. SETTING: Outpatient diabetes clinic of a tertiary academic center. PATIENTS: Eighty patients with hemoglobin A1c > 7% on metformin monotherapy were prospectively enrolled. INTERVENTION: Fifty patients were treated with dapagliflozin for 3 months. To exclude that the changes observed in urine metabolome were merely the result of the improvement in glycemia, 30 patients treated with insulin degludec were used for comparison. MAIN OUTCOME MEASURE: Changes in urine metabolic profile before and after the administration of dapagliflozin and insulin degludec were assessed by proton-nuclear magnetic resonance spectroscopy. RESULTS: In multivariate analysis urine metabolome was significantly altered by dapagliflozin (R2Xâ =â 0.819, R2Yâ =â 0.627, Q2Yâ =â 0.362, and coefficient of variation analysis of variance, Pâ <â 0.001) but not insulin. After dapagliflozin, the urine concentrations of ketone bodies, lactate, branched chain amino acids (Pâ <â 0.001), betaine, myo-inositol (Pâ <â 0001), and N-methylhydantoin (Pâ <â 0.005) were significantly increased. Additionally, the urine levels of alanine, creatine, sarcosine, and citrate were also increased (Pâ <â 0001, Pâ <0.0001, and Pâ <0.0005, respectively) whereas anserine decreased (Pâ <â 0005). CONCLUSIONS: Dapagliflozin significantly affects urine metabolome in patients with type 2 diabetes in a glucose lowering-independent way. Most of the observed changes can be considered beneficial and may contribute to the renoprotective properties of dapagliflozin.
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Compostos Benzidrílicos/farmacologia , Diabetes Mellitus Tipo 2/urina , Glucosídeos/farmacologia , Metaboloma/efeitos dos fármacos , Idoso , Compostos Benzidrílicos/administração & dosagem , Glicemia/efeitos dos fármacos , Glicemia/metabolismo , Diabetes Mellitus Tipo 2/tratamento farmacológico , Diabetes Mellitus Tipo 2/metabolismo , Feminino , Glucosídeos/administração & dosagem , Hemoglobinas Glicadas/efeitos dos fármacos , Hemoglobinas Glicadas/metabolismo , Grécia , Humanos , Masculino , Metformina/administração & dosagem , Pessoa de Meia-Idade , Resultado do Tratamento , UrináliseRESUMO
Background Type 2 diabetes mellitus is a risk factor for lower extremity arterial disease. Cilostazol expresses antiplatelet, anti-inflammatory, and vasodilator actions and improves the claudication intermittent symptoms. We investigated the efficacy and safety of adjunctive cilostazol to clopidogrel-treated patients with type 2 diabetes mellitus exhibiting symptomatic lower extremity arterial disease, in the prevention of ischemic vascular events and improvement of the claudication intermittent symptoms. Methods and Results In a prospective 2-arm, multicenter, open-label, phase 4 trial, patients with type 2 diabetes mellitus with intermittent claudication receiving clopidogrel (75 mg/d) for at least 6 months, were randomly assigned in a 1:1 ratio, either to continue to clopidogrel monotherapy, without receiving placebo cilostazol (391 patients), or to additionally receive cilostazol, 100 mg twice/day (403 patients). The median duration of follow-up was 27 months. The primary efficacy end point, the composite of acute ischemic stroke/transient ischemic attack, acute myocardial infarction, and death from vascular causes, was significantly reduced in patients receiving adjunctive cilostazol compared with the clopidogrel monotherapy group (sex-adjusted hazard ratio [HR], 0.468; 95% CI, 0.252-0.870; P=0.016). Adjunctive cilostazol also significantly reduced the stroke/transient ischemic attack events (sex-adjusted HR, 0.38; 95% CI, 0.15-0.98; P=0.046) and improved the ankle-brachial index and pain-free walking distance values (P=0.001 for both comparisons). No significant difference in the bleeding events, as defined by Bleeding Academic Research Consortium criteria, was found between the 2 groups (sex-adjusted HR, 1.080; 95% CI, 0.579-2.015; P=0.809). Conclusions Adjunctive cilostazol to clopidogrel-treated patients with type 2 diabetes mellitus with symptomatic lower extremity arterial disease may lower the risk of ischemic events and improve intermittent claudication symptoms, without increasing the bleeding risk, compared with clopidogrel monotherapy. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02983214.
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Isquemia Encefálica , Cilostazol , Clopidogrel , Diabetes Mellitus Tipo 2/complicações , Claudicação Intermitente , Infarto do Miocárdio , Idoso , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etiologia , Isquemia Encefálica/mortalidade , Isquemia Encefálica/prevenção & controle , Cilostazol/administração & dosagem , Cilostazol/efeitos adversos , Clopidogrel/administração & dosagem , Clopidogrel/efeitos adversos , Monitoramento de Medicamentos/métodos , Quimioterapia Combinada/métodos , Feminino , Humanos , Claudicação Intermitente/complicações , Claudicação Intermitente/terapia , Extremidade Inferior/irrigação sanguínea , Extremidade Inferior/fisiopatologia , Masculino , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/prevenção & controle , Avaliação de Processos e Resultados em Cuidados de Saúde , Inibidores da Agregação Plaquetária/administração & dosagem , Inibidores da Agregação Plaquetária/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: Mean systemic filling pressure (Pmsf) is a quantitative measurement of a patient's volume status and represents the tone of the venous reservoir. The aim of this study was to estimate Pmsf after severe hemorrhagic shock and cardiac arrest in swine anesthetized with propofol-based total intravenous anesthesia, as well as to evaluate Pmsf's association with vasopressor-free resuscitation. METHODS: Ten healthy Landrace/Large-White piglets aged 10-12 weeks with average weight 20±1 kg were used in this study. The protocol was divided into four distinct phases: stabilization, hemorrhagic, cardiac arrest, and resuscitation phases. We measured Pmsf at 5-7.5 seconds after the onset of cardiac arrest and then every 10 seconds until 1 minute postcardiac arrest. During resuscitation, lactated Ringers was infused at a rate that aimed for a mean right atrial pressure of ≤4 mm Hg. No vasopressors were used. RESULTS: The mean volume of blood removed was 860±20 ml (blood loss, ~61%) and the bleeding time was 43.2±2 minutes while all animals developed pulseless electrical activity. Mean Pmsf was 4.09±1.22 mm Hg, and no significant differences in Pmsf were found until 1 minute postcardiac arrest (4.20±0.22 mm Hg at 5-7.5 seconds and 3.72±0.23 mm Hg at 55- 57.5 seconds; P=0.102). All animals achieved return of spontaneous circulation (ROSC), with mean time to ROSC being 6.1±1.7 minutes and mean administered volume being 394±20 ml. CONCLUSIONS: For the first time, Pmsf was estimated after severe hemorrhagic shock. In this study, Pmsf remained stable during the first minute post-arrest. All animals achieved ROSC with goal-directed fluid resuscitation and no vasopressors.
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AIMS: To estimate and compare the prescription costs for the management of patients with diabetes over a period of 20 years in Greece, based on real world data. METHODS: The records of outpatients with T2D, monitored at three diabetes centres, were examined in four cross-sections (1998, 2006, 2012, 2018). Prescribed medicines per patient, along with a set of clinical indicators were recorded. Annual costs of pharmaceutical treatment per patient were calculated by using each year's nominal retail prices, as well as by adjusting for 2018 price levels, in order to account for price differences over time. RESULTS: 4066 patients were included in the analysis. Prescription patterns indicate a quick uptake of the new classes of glucose-lowering drugs and a reduction in the proportional use of sulfonylurea and glitazone. Adjusting for 2018 prices, the average total annual prescription cost per patient was 381.54 Euros (s.d. 297.44) in 1998 and 1147.21 Euros (s.d. 814.39) in 2018. Glucose-lowering drug costs per patient increase from 1998 onwards, whereas the costs of antihypertensive, antiplatelet and lipid-lowering treatment declined gradually, especially after 2006. CONCLUSIONS: Per patient prescription costs for glucose-lowering drugs present a steep increase, in Greece over the last 20 years. Real-world evidence studies that compare this increase with the changes in patient outcomes are essential in order to examine whether a costs-vs-outcomes balance is optimal.
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Diabetes Mellitus Tipo 2/tratamento farmacológico , Custos de Medicamentos/tendências , Hipoglicemiantes/economia , Medicamentos sob Prescrição/economia , Compostos de Sulfonilureia/economia , Tiazolidinedionas/economia , Idoso , Custos e Análise de Custo , Estudos Transversais , Feminino , Grécia , Humanos , Hipoglicemiantes/uso terapêutico , Masculino , Pessoa de Meia-Idade , Medicamentos sob Prescrição/uso terapêutico , Compostos de Sulfonilureia/uso terapêutico , Tiazolidinedionas/uso terapêuticoRESUMO
BACKGROUND AND AIMS: Clinical audit is applied to optimize clinical practice and quality of healthcare services while controlling for money spent, critically in resource-deprived settings. This case study reports on the outcomes of a retrospective clinical audit on private hospitalizations, for which reimbursement had been pending by the Health Care Organization for Public Servants (OPAD) in Greece. This case study is the first effort by a social insurance organization in Greece to employ external clinical audit before settling contracted private healthcare charges. METHODS: One thousand two hundred hospitalization records were reviewed retrospectively and a fully anonymized clinical audit summary report created for each one of them by a team of clinical audit experts, proposing evidence-based cuts in pending charges where medical services were deemed clinically unnecessary. These audit reports were then collated and analysed to test trends in overcharges among hospitalized insureds per reason for hospitalization. RESULTS: The clinical audit report concluded that 17.4% of a total reimbursement claim of 12,387,702.18 should not be reimbursed, as it corresponded to unnecessary or not fully justifiable according to evidence-based, best practice, medical service provision. The majority of proposed cuts were related to charges for medical devices, which are borne directly by social insurance with no patient or private insurance co-payment. CONCLUSION: Clinical audit of hospital practice may be a key tool to optimize care provision, address supplier-induced demand and effectively manage costs for national health insurance, especially in circumstances of budgetary constraints, such as in austerity-stricken settings or developing national healthcare systems.
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BACKGROUND & AIMS: People on intensive insulin therapy usually calculate their premeal insulin dose based on the total amount of consumed carbohydrates. However, arguments have been expressed supporting that also the protein and fat content of the meals should be considered when estimating premeal insulin dose. We examined the effectiveness of the carbohydrate counting method after consumption of mixed meals, and we further explored the effects of added extra virgin olive oil in these mixed meals, in adults with type 1 diabetes. METHODS: Twenty adults (35.0 ± 8.9 years, BMI 27 ± 5 kg/m2) with diabetes duration 17 ± 11 years, on intensive insulin therapy with multiple injections, consumed 3 mixed meals (pasticcio, chicken with vegetables and baked giant beans), with and without the addition of 11 ml extra virgin olive oil (total of 6 meals), in random order, with the insulin dose determined by using the carbohydrate counting method. Capillary blood glucose was measured at premeal (baseline) and 30, 60, 90, 120, 150 and 180 min after meal consumption. At every visit, participants were assessed for anthropometric parameters and subjective stress. RESULTS: Participants had mean HbA1c 7.5 ± 1.2%, mean carbohydrate to insulin ratio 9:1 IU and stable body weight, waist circumference and subjective stress throughout the study. The mean glucose concentration, for all 6 meals, 120 min postprandially was within target (<180 mg/dl) in nearly 80% of the sample. Addition of olive oil produced sustained increased postprandial glucose concentrations only to pasticcio meal, although within target, and no significant differences were noticed for the grilled chicken with vegetables or the baked giant beans (legume) meals. CONCLUSIONS: The carbohydrate-counting method was effective for achieving postprandial glucose levels within target threshold up to 3 h postprandially. Moreover, adding small amounts of dietary fat (extra virgin olive oil) to low fat meals does not significantly alter the postprandial response within the first 3 h, whereas caused a sustained increase in postprandial blood glucose concentrations to the high energy density meal (i.e. the pasticcio meal).
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Glicemia , Diabetes Mellitus Tipo 1/sangue , Diabetes Mellitus Tipo 1/dietoterapia , Carboidratos da Dieta/administração & dosagem , Refeições , Adolescente , Adulto , Estudos Cross-Over , Gorduras na Dieta/administração & dosagem , Proteínas Alimentares/administração & dosagem , Feminino , Índice Glicêmico , Humanos , Insulina/sangue , Insulina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Azeite de Oliva/administração & dosagem , Período Pós-Prandial , Inquéritos e Questionários , Adulto JovemRESUMO
BACKGROUND AND PURPOSE: The available data regarding the association between metabolic syndrome (MS) or MS components and ischemic stroke in type 2 diabetics are limited and inconsistent. This study aimed to investigate these associations. METHODS: Five hundred ninety-nine consecutive type 2 diabetic patients (mean age 60.4+/-9.6 years, 54% men) were followed-up for 10.1 years (median period). Baseline clinical and laboratory characteristics and the occurrence of a first-ever ischemic stroke during follow-up were recorded. RESULTS: Seventy-eight patients developed a first-ever ischemic stroke. According to Cox proportional hazard model, waist circumference (hazard ratio, HR:1.006, 95% CI:1.002 to 1.010, P=0.003) and age (HR:1.061, 95% CI:1.002 to 1.125, P=0.04) were significant predictors. After incorporating various combinations of MS components in multivariate models, only age and waist circumference remained significant. CONCLUSIONS: MS per se at baseline or combinations of its components do not predict the development of ischemic stroke in type 2 diabetic patients. Waist circumference represents an independent prognostic factor and could be used as a clinical tool for stroke prevention in this population.
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Isquemia Encefálica/complicações , Diabetes Mellitus Tipo 2/complicações , Síndrome Metabólica/complicações , Acidente Vascular Cerebral/etiologia , Fatores Etários , Idoso , Antropometria , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Modelos de Riscos ProporcionaisRESUMO
AIM: To assess the usefulness of airway pressure as predictor of return of spontaneous circulation (ROSC), as well as to investigate the optimized ventilation compression strategy during cardiopulmonary resuscitation (CPR). METHODS: In this prospective observational study, 300 out-of-hospital cardiac arrest victims were intubated and resuscitated with the use of a ventilator. Mean airway pressure (mPaw) was measured at pre-defined phases of CPR. RESULTS: A significant difference in mPaw was observed between survivors and non-survivors after the onset of the third minute of CPR. An mPaw value of 42.5mbar during CPR had specificity and sensitivity of 0.788 and 0.804, respectively, for ROSC (AUC=0.668, p=0.047). During CPR, we found statistically significant differences in mPaw at phases zero (F=4.526, p=0.002), two (F=4.506, p=0.002), four (F=8.187, p<0.0001), five (F=2.871, p=0.024), and six (F=5.364, p<0.0001). CONCLUSION: Mean airway pressure was higher in survivors. A value of 42.5mbar was associated with ROSC.
Assuntos
Reanimação Cardiopulmonar/métodos , Parada Cardíaca Extra-Hospitalar , Respiração Artificial/métodos , Sistema Respiratório/fisiopatologia , Adulto , Idoso , Circulação Sanguínea , Feminino , Grécia/epidemiologia , Humanos , Masculino , Pressões Respiratórias Máximas , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/mortalidade , Parada Cardíaca Extra-Hospitalar/fisiopatologia , Parada Cardíaca Extra-Hospitalar/terapia , Avaliação de Resultados em Cuidados de Saúde , Análise de SobrevidaRESUMO
OBJECTIVES: The objective was to analyze the cardiac arrest rhythms presenting during asphyxial cardiac arrest (ACA). METHODS: Asphyxial cardiac arrest was induced in 30 Landrace large white piglets, aged 12 to 15 weeks and with a mean (±SD) weight of 20 (±2) kg. After the onset of cardiac arrest, the animals were left untreated for 4 minutes, after which cardiopulmonary resuscitation was commenced. Heart rhythms were monitored from the onset of asphyxia until return of spontaneous circulation or death. RESULTS: After endotracheal tube clamping and prior to cardiac arrest, normal sinus rhythm was noted in 14 animals, atrial fibrillation in two animals, Mobitz II atrioventricular block in 10 animals, and third-degree atrioventricular block in four animals. At the onset of cardiac arrest, seven animals had ventricular fibrillation (VF), two had asystole, and 21 had pulseless electrical activity (PEA). During the 4-minute period of untreated arrest, however, significant changes in the monitored rhythm were noted; at the end of the fourth minute, 19 animals had VF, two animals had asystole, and nine animals had PEA. CONCLUSIONS: The most common rhythm after 4 minutes of untreated ACA was VF, while in 57% of animals, PEA was spontaneously converted to VF during the cardiac arrest interval.
Assuntos
Asfixia/complicações , Fibrilação Atrial/fisiopatologia , Parada Cardíaca/fisiopatologia , Fibrilação Ventricular/fisiopatologia , Animais , Reanimação Cardiopulmonar/métodos , Modelos Animais de Doenças , Feminino , Parada Cardíaca/etiologia , Parada Cardíaca/terapia , Masculino , SuínosRESUMO
Cardiopulmonary resuscitation in patients with severe sepsis and septic shock is challenging and usually unsuccessful. The aim of the present study is to describe our swine model of cardiac arrest and resuscitation in severe sepsis and septic shock. In this prospective randomized animal study, 10 healthy female Landrace-Large White pigs with an average weight of 20 ± 1 kg (aged 19 - 21 weeks) were the study subjects. Septicemia was induced by an intravenous infusion of a bolus of 20-mL bacterial suspension in 2 min, followed by a continuous infusion during the rest of the experiment. After septic shock was confirmed, the animals were left untreated until cardiac arrest occurred. All animals developed pulseless electrical activity between the fifth and sixth hours of septicemia, whereas five (50%) of 10 animals were successfully resuscitated. Coronary perfusion pressure was statistically significantly different between surviving and nonsurviving animals. We found a statistically significant correlation between mean arterial pressure and unsuccessful resuscitation (P = 0.046), whereas there was no difference in end-tidal carbon dioxide (23.05 ± 1.73 vs. 23.56 ± 1.70; P = 0.735) between animals with return of spontaneous circulation and nonsurviving animals. During the 45-min postresuscitation monitoring, we noted a significant decrease in hemodynamic parameters, although oxygenation indices and lactate clearance were constantly increased (P = 0.001). This successful basic swine model was for the first time developed and may prove extremely useful in future studies on the periarrest period in severe sepsis and septic shock.
Assuntos
Reanimação Cardiopulmonar/métodos , Parada Cardíaca/etiologia , Parada Cardíaca/terapia , Sepse/complicações , Choque Séptico/complicações , Animais , Modelos Animais de Doenças , Feminino , Parada Cardíaca/fisiopatologia , Hemodinâmica , Oxigênio/sangue , Sepse/fisiopatologia , Choque Séptico/fisiopatologia , Sus scrofa , Fatores de TempoRESUMO
INTRODUCTION: Primary percutaneous coronary intervention (PPCI) is a key therapeutic method in the treatment of ST-elevation myocardial infarction (STEMI). We studied the characteristics and survival to discharge in STEMI patients who presented in a PPCI-capable hospital and a non-PPCI hospital. PATIENTS AND METHODS: This prospective observational study included 240 consecutive patients. One basic questionnaire was distributed along with an explanatory letter to the participants, who were followed until discharge from the hospital or death. RESULTS: Of the 240 patients, 234 (97.5%) survived to hospital discharge. Only 6 (5%) patients who were initially presented to a non-PPCI hospital died after inter-facility transfer. Also, 36 (92.3%) of the 39 patients with an intervening time of over 90 min were admitted initially in a non-PPCI hospital. Although there was a statistically significant correlation between the type of the hospital and the delay from the onset of symptoms to PPCI (P=0.001), such correlation was not found between the delay PPCI and the outcome of the patients (P>0.05). CONCLUSION: Patients with STEMI may be transferred to a non-PPCI hospital due to the lack of prehospital triage. However, prompt inter-facility transfer results in good outcome.