RESUMO
BACKGROUND: Older adults with multimorbidity represent a growing segment of the population. Metrics to assess quality, safety and effectiveness of care can support policy makers and healthcare providers in addressing patient needs. However, there is a lack of valid measures of quality of care for this population. In the MULTIqual project, 24 general practitioner (GP)-reported and 14 patient-reported quality indicators for the healthcare of older adults with multimorbidity were developed in Germany in a systematic approach. This study aimed to select, validate and pilot core sets of these indicators. METHODS: In a cross-sectional observational study, we collected data in general practices (n = 35) and patients aged 65 years and older with three or more chronic conditions (n = 346). One-dimensional core sets for both perspectives were selected by stepwise backward selection based on corrected item-total correlations. We established structural validity, discriminative capacity, feasibility and patient-professional agreement for the selected indicators. Multilevel multivariable linear regression models adjusted for random effects at practice level were calculated to examine construct validity. RESULTS: Twelve GP-reported and seven patient-reported indicators were selected, with item-total correlations ranging from 0.332 to 0.576. Fulfilment rates ranged from 24.6 to 89.0%. Between 0 and 12.7% of the values were missing. Seventeen indicators had agreement rates between patients and professionals of 24.1% to 75.9% and one had 90.7% positive and 5.1% negative agreement. Patients who were born abroad (- 1.04, 95% CI = - 2.00/ - 0.08, p = 0.033) and had higher health-related quality of life (- 1.37, 95% CI = - 2.39/ - 0.36, p = 0.008), fewer contacts with their GP (0.14, 95% CI = 0.04/0.23, p = 0.007) and lower willingness to use their GPs as coordinators of their care (0.13, 95% CI = 0.06/0.20, p < 0.001) were more likely to have lower GP-reported healthcare quality scores. Patients who had fewer GP contacts (0.12, 95% CI = 0.04/0.20, p = 0.002) and were less willing to use their GP to coordinate their care (0.16, 95% CI = 0.10/0.21, p < 0.001) were more likely to have lower patient-reported healthcare quality scores. CONCLUSIONS: The quality indicator core sets are the first brief measurement tools specifically designed to assess quality of care for patients with multimorbidity. The indicators can facilitate implementation of treatment standards and offer viable alternatives to the current practice of combining disease-related metrics with poor applicability to patients with multimorbidity.
Assuntos
Clínicos Gerais , Humanos , Idoso , Multimorbidade , Indicadores de Qualidade em Assistência à Saúde , Qualidade de Vida , Estudos Transversais , Atenção Primária à SaúdeRESUMO
BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been associated with significant morbidity and increased hospital length of stay (LOS). The authors report their experience after implementation of an enhanced recovery after surgery (ERAS) program for CRS-HIPEC. METHODS: Outcomes were analyzed before and after ERAS implementation. The components of ERAS included preoperative carbohydrate loading, goal-directed fluid management, multimodal pain management, minimization of narcotic use, avoidance of nasogastric tubes, and early mobilization and feeding. RESULTS: Of 168 procedures, 88 (52%) were in the pre-ERAS group and 80 (48%) were in the post-ERAS group. The two groups did not differ in terms of age, sex, comorbidities, peritoneal carcinomatosis index scores, completeness of cytoreduction, or operative time. The ERAS patients received fewer fluids intraoperatively (mean, 4.2 vs 6.4 L; p < 0.01). The mean LOS was 7.9 days post-ERAS compared with 10.0 days pre-ERAS (p = 0.015). Clavien-Dindo complications classified as grade ≥ 3 were lower after ERAS (23.7% vs 38.6%; p = 0.04). Moreover, the readmission rates remained the same (16.2% vs 13.6%; p = 0.635). CONCLUSIONS: Implementation of an ERAS program for patients undergoing CRS-HIPEC is feasible and not associated with an increase in overall major complications or readmissions. These data support incorporation of ERAS protocols for CRS-HIPEC procedures.
Assuntos
Recuperação Pós-Cirúrgica Melhorada , Hipertermia Induzida , Quimioterapia do Câncer por Perfusão Regional , Terapia Combinada , Procedimentos Cirúrgicos de Citorredução , Humanos , Quimioterapia Intraperitoneal Hipertérmica , Tempo de Internação , Complicações Pós-Operatórias , Período Pós-Operatório , Estudos RetrospectivosRESUMO
Advocates for the professionalization of clinical bioethics argue that bioethics professionals play an important role in contemporary medicine and patient care, especially when addressing complex ethical questions that arise in the delivery of reproductive medicine. For bioethics consultants to serve effectively, they need adequate training in the medical and ethical issues that patients and clinicians will face, and they need skills to facilitate effective dialog among all parties. Because clinical ethics consultation is a "high-stakes endeavor" that can acutely affect patient care, efforts are under way to ensure that bioethics consultants have the competence to provide such guidance. Yet to date, no studies have examined whether the training of bioethics consultants meets the needs of health care professionals who are on the front lines of such issues. In fact, limited information is available on the reproductive health issues that bioethics training programs address or the degree to which these programs meet the needs of patients confronting reproductive health decisions and their clinicians. It is therefore important to answer this key question: What are the primary ethical issues encountered in reproductive medicine that currently affect patient care? Equally important, are bioethics training programs prepared to address those issues? To begin to answer these questions, we conducted parallel surveys of directors of graduate bioethics training programs and obstetrician-gynecologists. The goal of this project is to lay the groundwork to establish a working partnership between bioethics educators and reproductive medicine practitioners to address the often troubling and frequently complex ethical issues in reproductive medicine.
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Bioética/educação , Educação Médica/organização & administração , Medicina Reprodutiva/ética , Adulto , Temas Bioéticos , Estudos Transversais , Tomada de Decisões , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
The computer revolution has had an enormous effect on all aspects of the practice of medicine, yet little thought has been given to the role of social media in identifying treatment choices for incompetent patients. We are currently living in the "Internet age" and many people have integrated social media into all aspects of their lives. As use becomes more prevalent, and as users age, social media are more likely to be viewed as a source of information regarding medical care preferences. This article explores the ethical and legal issues raised by the use of social media in surrogate decision making.
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Diretivas Antecipadas , Tomada de Decisões/ética , Competência Mental , Mídias Sociais , Consentimento do Representante Legal/ética , Comportamento de Escolha/ética , Humanos , Internet , Masculino , Pessoa de Meia-Idade , Fatores de TempoRESUMO
PURPOSE: Infants with deformational plagiocephaly (DP) have been shown to exhibit developmental delays relative to unaffected infants. Although the mechanisms accounting for these delays are unknown, one hypothesis focuses on underlying differences in brain development. In this study, we used MRI to examine brain volume and shape in infants with and without DP. METHODS: Participants included 20 infants with DP (mean age = 7.9 months, SD = 1.2; n = 12 male) and 21 controls (mean age = 7.9 months, SD = 1.3; n = 11 male). Measures included volumes of the total brain and cerebellum; midsagittal areas of the corpus callosum and cerebellar vermis; and linear distance measures used to quantify the shape of selected brain structures. We also evaluated the association between shape measures and developmental scores on the Bayley Scales of Infant and Toddler Development-III (BSID-III). RESULTS: Brain volume did not distinguish cases and controls (p = .214-.976). However, cases exhibited greater asymmetry and flattening of the posterior brain (p < .001-.002) and cerebellar vermis (p = .035), shortening of the corpus callosum (p = .012), and differences in the orientation of the corpus callosum (p = .005). Asymmetry and flattening of brain structures were associated with worse developmental outcomes on the BSID-III. CONCLUSIONS: Infants with DP show differences in brain shape, consistent with the skull deformity characteristic of this condition, and shape measures were associated with infant development. Longitudinal studies, beginning in the neonatal period, are needed to clarify whether developmental effects precede or follow brain deformation.
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Encéfalo/crescimento & desenvolvimento , Encéfalo/patologia , Deficiências do Desenvolvimento/patologia , Plagiocefalia não Sinostótica/patologia , Fatores Etários , Feminino , Humanos , Processamento de Imagem Assistida por Computador , Lactente , Imageamento por Ressonância Magnética , Masculino , Índice de Gravidade de DoençaRESUMO
It is unknown if simultaneous stimulation of the respiratory and locomotor muscle afferents via inspiratory loading (IL) and locomotor subsystolic cuff inflation (CUFF) influences the cardiovascular responses during exercise. We hypothesized that combined IL and CUFF (IL + CUFF) will result in greater increases in blood pressure (MAP) and systemic vascular resistance (SVR) than IL and CUFF alone during exercise. Eight adults (6 males/2 females) were enrolled and performed four 10-min bouts of constant-load cycling eliciting 40% maximal oxygen uptake on a single day. For each exercise bout, the first 5 min consisted of spontaneous breathing. The second 5 min consisted of voluntary hyperventilation (i.e., breathing frequency of 40 breaths/min) with IL (30% maximum inspiratory pressure), CUFF (80 mmHg), IL + CUFF, or no intervention (CTL) in randomized order. During exercise, cardiac output and MAP were determined via open-circuit acetylene wash-in and manual sphygmomanometry, respectively, and SVR was calculated. Across CTL, IL, CUFF, and IL + CUFF, MAP was greater with each condition (CTL: 97 ± 14; IL: 106 ± 13; CUFF: 114 ± 14; IL + CUFF: 119 ± 15 mmHg, all P < 0.02). Furthermore, SVR was greater with IL + CUFF compared with IL, CUFF, and CTL (CTL: 6.6 ± 1.1; IL: 7.5 ± 1.4; CUFF: 7.5 ± 1.3; IL + CUFF: 8.2 ± 1.4 mmHg·L-1·min-1, all P < 0.02). Cardiac output was not different across conditions (CTL: 15.2 ± 3.8; IL: 14.8 ± 3.7; CUFF: 15.6 ± 3.5; IL + CUFF: 14.7 ± 4.3 L/min, all P > 0.05). These data demonstrate that simultaneous stimulation of respiratory and locomotor muscle afferent feedback results in additive MAP and SVR responses than IL and CUFF alone during submaximal exercise. These findings have important clinical implications for populations with exaggerated locomotor and respiratory muscle reflex feedbacks.NEW & NOTEWORTHY Reflexes arising from the respiratory and locomotor muscles influence cardiovascular regulation during exercise. However, it is unclear how the respiratory and locomotor muscle reflexes interact when simultaneously stimulated. Herein, we demonstrate that stimulation of the respiratory and locomotor muscle reflexes yielded additive cardiovascular responses during submaximal exercise.
Assuntos
Sistema Cardiovascular , Músculos Respiratórios , Pressão Sanguínea , Exercício Físico , Feminino , Humanos , Masculino , Músculo Esquelético , Reflexo , Resistência VascularRESUMO
INTRODUCTION: It remains unclear if naturally occurring respiratory muscle (RM) work influences leg diffusive O2 transport during exercise in heart failure patients with reduced ejection fraction (HFrEF). In this retrospective study, we hypothesized that RM unloading during submaximal exercise will lead to increases in locomotor muscle O2 diffusion capacity (DM O2 ) contributing to the greater leg VO2 . METHODS: Ten HFrEF patients and 10 healthy control matched participants performed two submaximal exercise bouts (i.e., with and without RM unloading). During exercise, leg blood flow was measured via constant infusion thermodilution. Intrathoracic pressure was measured via esophageal balloon. Radial arterial and femoral venous blood gases were measured and used to calculate leg arterial and venous content (CaO2 and CvO2 , respectively), VO2 , O2 delivery, and DM O2 . RESULTS: From CTL to RM unloading, leg VO2 , O2 delivery, and DM O2 were not different in healthy participants during submaximal exercise (all, p > .15). In HFrEF, leg VO2 (CTL: 0.7 ± 0.3 vs. RM unloading: 1.0 ± 0.4 L/min, p < .01), leg O2 delivery (CTL: 0.9 ± 0.4 vs. RM unloading: 1.4 ± 0.5 L/min, p < .01), and leg DM O2 (CTL: 31.5 ± 11.4 vs. RM unloading: 49.7 ± 18.6 ml min-1 mmHg-1 ) increased from CTL to RM unloading during submaximal exercise (all, p < .01), whereas CaO2 -CvO2 was not different (p = .51). The degree of RM unloading (i.e., % decrease in esophageal pressure-time integral during inspiration) was related to the % increase in leg DM O2 with RM unloading (r = -.76, p = .01). CONCLUSION: Our data suggest RM unloading leads to increased leg VO2 due to greater convective and diffusive O2 transport during submaximal exercise in HFrEF patients.
Assuntos
Exercício Físico/fisiologia , Insuficiência Cardíaca/fisiopatologia , Perna (Membro)/irrigação sanguínea , Oxigênio/sangue , Músculos Respiratórios/fisiologia , Gasometria , Débito Cardíaco , Estudos de Casos e Controles , Insuficiência Cardíaca/sangue , Hemodinâmica , Humanos , Perna (Membro)/fisiologia , Pessoa de Meia-Idade , Consumo de Oxigênio/fisiologia , Fluxo Sanguíneo Regional/fisiologia , Estudos RetrospectivosRESUMO
AIMS: Patients with hypertrophic obstructive cardiomyopathy (HOCM) have impaired exercise capacity. The gold standard therapy for patients with HOCM is septal myectomy surgery; however, changes in maximum oxygen uptake (VO2peak) following myectomy are variable, with VO2peak decreasing in some patients. Therefore, we evaluated changes in VO2peak following surgical myectomy to determine clinical predictors of those exhibiting decreased VO2peak post-myectomy. METHODS: HOCM patients (N = 295) who performed symptom limited cardiopulmonary exercise testing prior to and following surgical myectomy were included for analysis. The VO2peak non-responder group (n = 128) was defined as <0% change in VO2peak from pre- to post-myectomy. Step-wise regression models using demographics, clinical, and physiologic characteristics were created to determine predictors of hypertrophic cardiomyopathy patients in the VO2peak non-responder group. RESULTS: Independent predictors of the VO2peak non-responder group included higher pre-myectomy VO2peak (% predicted), older age, women, history of dyslipidemia, lack of cardiac rehabilitation enrollment, and lower body mass index (all p < 0.03). Forty-three (14.6%) patients reached the primary end-point of all-cause mortality during a median follow up of 11.25 years (interquartile range 6.94 to 16.40). After adjustment for age, sex, beta-blocker use, coronary artery disease history, and body mass index, the VO2peak non-responder group had greater risk of death compared with the VO2peak responder group (adjusted hazard ratio: 1.77, 95% confidence interval: 1.06-3.34, p = 0.01). CONCLUSION: This large hypertrophic cardiomyopathy cohort demonstrated that demographic (i.e. female sex), lack of cardiac rehabilitation enrollment, and cardiovascular risk factors (i.e. history of dyslipidemia) are predictive of those patients that did not exhibit increases in VO2peak following septal myectomy surgery.
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Procedimentos Cirúrgicos Cardíacos/métodos , Cardiomiopatia Hipertrófica/cirurgia , Tolerância ao Exercício , Septos Cardíacos/cirurgia , Cardiomiopatia Hipertrófica/metabolismo , Cardiomiopatia Hipertrófica/fisiopatologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Consumo de Oxigênio/fisiologia , Prognóstico , Estudos Retrospectivos , Fatores de TempoRESUMO
Building on the knowledge generated by the long history of disease-oriented research, the next few decades will witness an explosion of biomedical enhancements to make people faster, stronger, smarter, less forgetful, happier, prettier, and live longer. Growing interest in pediatric enhancements is likely to stimulate the conduct of enhancement research involving children. However, guidelines for the protection of human subjects were developed for investigations of therapeutic modalities. To date, virtually no attention has been paid to whether these rules would be appropriate for investigations to establish the safety and efficacy of technologies intended for enhancement rather than therapeutic uses and, if not, whether ethically acceptable rules could be designed. This article discusses whether the current guidelines for pediatric research provide appropriate protections for pediatric subjects in enhancement research and considers what additional protections might be necessary.
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Melhoramento Biomédico/ética , Pesquisa Biomédica/ética , Pesquisa Biomédica/legislação & jurisprudência , Experimentação Humana não Terapêutica/ética , Experimentação Humana não Terapêutica/legislação & jurisprudência , Pediatria , Criança , Humanos , Estados UnidosRESUMO
In this review, we highlight the underlying mechanisms responsible for the sex differences in the exercise pressor reflex (EPR), and, importantly, the impact of sex hormones and menopausal status. The EPR is attenuated in premenopausal women compared with age-matched men. Specifically, activation of the metaboreflex (a component of the EPR) results in attenuated increases in blood pressure and sympathetic vasomotor outflow compared with age-matched men. In addition, premenopausal women exhibit less transduction of sympathetic outflow to the peripheral vasculature than men. In stark contrast, postmenopausal women exhibit an augmented EPR arising from exaggerated metaboreflex-induced autonomic and cardiovascular reflexes. We propose that metaboreflex-induced autonomic and cardiovascular changes associated with menopause majorly contribute to the elevated blood pressure response during dynamic exercise in postmenopausal women. In addition, we discuss the potential mechanisms by which sex hormones in premenopausal women may impact the EPR as well as metaboreflex.
Assuntos
Exercício Físico , Menopausa , Ciclo Menstrual , Reflexo , Fatores Sexuais , Sistema Nervoso Autônomo , Pressão Sanguínea , Sistema Cardiovascular , Feminino , Hormônios Esteroides Gonadais/fisiologia , Humanos , Masculino , Sistema Nervoso SimpáticoRESUMO
The protection of human subjects in biomedical research relies on two principal mechanisms: assessing and comparing the risks and potential benefits of proposed research, and obtaining potential subjects' informed consent. While these have been discussed extensively in the literature, no attention has been paid to whether the processes should be different when the objective of an experimental biomedical intervention is to improve individual appearance, performance, or capability ("enhancement research") rather than to prevent, cure, or mitigate disease ("health-oriented research"). This essay examines this question in order to ensure that subjects in biomedical enhancement research receive adequate protection.
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Melhoramento Biomédico/ética , Pesquisa Biomédica/ética , Consentimento Livre e Esclarecido/ética , Melhoramento Biomédico/normas , Pesquisa Biomédica/normas , Humanos , Consentimento Livre e Esclarecido/normasAssuntos
Acesso à Informação/legislação & jurisprudência , Registros Eletrônicos de Saúde/legislação & jurisprudência , Direitos do Paciente , Administração em Saúde Pública , Confidencialidade/legislação & jurisprudência , Humanos , Consentimento Livre e Esclarecido , Política Organizacional , Confiança , Estados UnidosRESUMO
This essay considers the potential role of bioethics in disaster response planning and preparedness. Bioethicists can make substantial contributions, by ensuring that decision-making and distribution of resources during crises is carried out in a fair and just manner, as well as by examining the assumptions upon which disaster planning are based. Bioethicists should also be aware of potential pitfalls of overly-hasty engagement with this new field.
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Temas Bioéticos , Bioética , Planejamento em Desastres , Bioética/tendências , Planejamento em Desastres/organização & administração , Planejamento em Desastres/normas , Análise Ética , Teoria Ética , Eticistas , Humanos , Estados UnidosAssuntos
Experimentação Humana/ética , Experimentação Humana/legislação & jurisprudência , Comitês de Ética em Pesquisa , Health Insurance Portability and Accountability Act , Humanos , National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division , Estados Unidos , United States Dept. of Health and Human Services , United States Food and Drug AdministrationAssuntos
Instituições de Caridade , Reforma dos Serviços de Saúde , Hospitais Filantrópicos/organização & administração , Cuidados de Saúde não Remunerados , Hospitais Filantrópicos/economia , Humanos , Organizações sem Fins Lucrativos/economia , Organizações sem Fins Lucrativos/organização & administração , Estados UnidosRESUMO
This study investigated associations between maternal and paternal emotion coaching and the self-regulation skills of kindergarten and first-grade children. Participants were 54 children categorized as either aggressive/rejected or low aggressive/popular by peer reports. Findings indicated a statistical trend for fathers of low aggressive/popular children to engage in more emotion coaching than fathers of aggressive/rejected children. Paternal emotion coaching accounted for significant variance in children's regulation of attention. Maternal emotion coaching moderated the relation between children's status and regulation of emotion. Findings suggest that interventions focused on parental emotion coaching may prove beneficial for increasing the self-regulation and attention skills of children with social and conduct problems.