Assuntos
Anticonvulsivantes , Lamotrigina , Topiramato , Ácido Valproico , Humanos , Lamotrigina/uso terapêutico , Lamotrigina/efeitos adversos , Topiramato/uso terapêutico , Topiramato/efeitos adversos , Ácido Valproico/uso terapêutico , Ácido Valproico/efeitos adversos , Anticonvulsivantes/uso terapêutico , Anticonvulsivantes/efeitos adversos , Feminino , Transtorno Autístico/tratamento farmacológico , Masculino , Criança , Frutose/análogos & derivados , Frutose/efeitos adversos , Frutose/uso terapêutico , Triazinas/uso terapêutico , Triazinas/efeitos adversos , Pré-EscolarAssuntos
Doença de Alzheimer , Anticorpos Monoclonais , Humanos , Doença de Alzheimer/tratamento farmacológico , Anticorpos Monoclonais/uso terapêutico , Anticorpos Monoclonais/efeitos adversos , Anticorpos Monoclonais Humanizados/uso terapêutico , Anticorpos Monoclonais Humanizados/efeitos adversosRESUMO
Background and Objectives: Quality improvement capacity is defined as ongoing commitment to sustained quality improvement (QI) and requires knowledge of QI methods and commitment to QI activities from practice leadership and staff. The aim of this project was to identify the major facilitators and barriers to developing quality improvement capacity in a teaching practice of a department of family medicine. Methods: We conducted an exploratory, sequential, mixed-methods study, inviting key informants to participate in qualitative interviews and then conducting a survey of faculty, resident physicians, and staff at a community residency teaching practice affiliated with an academic medical center in the Midwest United States. Results: Among 12 qualitative key informant interviewees, facilitators of QI capacity included a strong motivation to provide high-quality care and a desire to leverage team-based care in QI interventions. Barriers included competing clinical and educational priorities, lack of faculty expertise in quality and scholarship, and lack of infrastructure to turn QI into scholarship. The survey response rate was 75% (48 of 64 total team members). The most common motivation for participation in QI work was "making a difference" (41, 85%), while the biggest barriers were prioritization of patient care (25, 53%), and teaching (19, 40%). Conclusion: This mixed-methods study identified key barriers and facilitators to QI capacity, of which addressing competing priorities, improving QI training, and creating infrastructure for scholarship may improve QI capacity.
Assuntos
Infecções por Papillomavirus , Displasia do Colo do Útero , Neoplasias do Colo do Útero , Feminino , Humanos , Displasia do Colo do Útero/patologia , Neoplasias do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/patologia , Infecções por Papillomavirus/diagnóstico , Infecções por Papillomavirus/prevenção & controle , PapillomaviridaeRESUMO
Here are updated guidelines for prevention, testing, and treatment. Elimination of causative HPV continues to hold center stage in the global effort to curb disease.
Assuntos
Infecções por Papillomavirus , Neoplasias do Colo do Útero , Detecção Precoce de Câncer , Feminino , Humanos , Programas de Rastreamento , Infecções por Papillomavirus/diagnóstico , Infecções por Papillomavirus/prevenção & controle , Neoplasias do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/prevenção & controleRESUMO
POEMs (patient-oriented evidence that matters) are studies that address a relevant clinical question, demonstrate improved patient-oriented outcomes, and have the potential to change practice. For 20 years the authors of this article have reviewed more than 100 English language clinical journals monthly to identify POEMs in the medical literature relevant to primary care practice. This article identifies the POEMs in each of the last 20 years that were highest ranked for having recommended a major and persistent change in practice that year. They include POEMs that recommend a novel, effective intervention, a second group that recommends abandoning an ineffective practice, and a third group that recommends abandoning a potentially harmful practice. The top POEMs of the past 20 years illustrate the breadth of practice change in primary care and the need for family physicians to have a systematic approach to keeping up with the medical literature, such as that in POEMs, especially because many of these important articles did not appear in the primary care literature.
Assuntos
Pesquisa Biomédica/tendências , Medicina Baseada em Evidências/tendências , Medicina de Família e Comunidade/tendências , Médicos de Família/tendências , Atenção Primária à Saúde/tendências , Pesquisa Biomédica/história , Medicina Baseada em Evidências/história , Medicina de Família e Comunidade/história , História do Século XX , História do Século XXI , Humanos , Médicos de Família/história , Atenção Primária à Saúde/históriaRESUMO
Chronic pelvic pain in women is defined as persistent, noncyclic pain perceived to be in structures related to the pelvis and lasting more than six months. Often no specific etiology can be identified, and it can be conceptualized as a chronic regional pain syndrome or functional somatic pain syndrome. It is typically associated with other functional somatic pain syndromes (e.g., irritable bowel syndrome, nonspecific chronic fatigue syndrome) and mental health disorders (e.g., posttraumatic stress disorder, depression). Diagnosis is based on findings from the history and physical examination. Pelvic ultrasonography is indicated to rule out anatomic abnormalities. Referral for diagnostic evaluation of endometriosis by laparoscopy is usually indicated in severe cases. Curative treatment is elusive, and evidence-based therapies are limited. Patient engagement in a biopsychosocial approach is recommended, with treatment of any identifiable disease process such as endometriosis, interstitial cystitis/painful bladder syndrome, and comorbid depression. Potentially beneficial medications include depot medroxyprogesterone, gabapentin, nonsteroidal anti-inflammatory drugs, and gonadotropin-releasing hormone agonists with add-back hormone therapy. Pelvic floor physical therapy may be helpful. Behavioral therapy is an integral part of treatment. In select cases, neuromodulation of sacral nerves may be appropriate. Hysterectomy may be considered as a last resort if pain seems to be of uterine origin, although significant improvement occurs in only about one-half of cases. Chronic pelvic pain should be managed with a collaborative, patient-centered approach.
Assuntos
Manejo da Dor/métodos , Medição da Dor/métodos , Dor Pélvica , Dor Crônica , Feminino , Humanos , Dor Pélvica/diagnóstico , Dor Pélvica/etiologia , Dor Pélvica/terapiaRESUMO
BACKGROUND: Postpartum endometritis occurs when vaginal organisms invade the endometrial cavity during the labor process and cause infection. This is more common following cesarean birth. The condition warrants antibiotic treatment. OBJECTIVES: Systematically, to review treatment failure and other complications of different antibiotic regimens for postpartum endometritis. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2014) and reference lists of retrieved studies. SELECTION CRITERIA: We included randomized trials of different antibiotic regimens after cesarean birth or vaginal birth; no quasi-randomized trials were included. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS: The review includes a total of 42 trials, and 40 of these trials contributed data on 4240 participants.Regarding the primary outcomes, seven studies compared clindamycin plus an aminoglycoside versus penicillins and showed fewer treatment failures (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.46 to 0.90). There were more treatment failures in those treated with an aminoglycoside plus penicillin when compared to those treated with gentamycin/clindamycin (RR 2.57, 95% CI 1.48 to 4.46). There were more treatment failures (RR 1.66, 95% CI 1.01 to 2.74) and wound infections (RR 1.88, 95% CI 1.08 to 3.28) in those treated with second or third generation cephalosporins (excluding cephamycins) versus those treated with clindamycin plus gentamycin. In four studies comparing once-daily with thrice-daily dosing of gentamicin, there were fewer failures with once-daily dosing. There were more treatment failures (RR 1.94, 95% CI 1.38 to 2.72) and wound infections (RR 1.88, 95% CI 1.17 to 3.02) in those treated with a regimen with poor activity against penicillin-resistant anaerobic bacteria as compared to those treated with a regimen with good activity against penicillin-resistant anaerobic bacteria. There were no differences between groups with respect to severe complications and no trials reported any maternal deaths.Regarding the secondary outcomes, three studies that compared continued oral antibiotic therapy after intravenous therapy with no oral therapy, found no differences in recurrent endometritis or other outcomes. Four trials that compared clindamycin plus aminoglycoside versus cephalosporins identified fewer wound infections in those treated with clindamycin plus an aminoglycoside (RR 0.53, 95% CI 0.30 to 0.93). There were no differences between groups for the outcomes of allergic reactions. The overall risk of bias was unclear in the most of the studies. The quality of the evidence using GRADE comparing clindamycin and an aminoglycoside with another regimen (compared with cephalosporins or penicillins) was low to very low for therapeutic failure, severe complications, wound infection and allergic reaction. AUTHORS' CONCLUSIONS: The combination of clindamycin and gentamicin is appropriate for the treatment of endometritis. Regimens with good activity against penicillin-resistant anaerobic bacteria are better than those with poor activity against penicillin-resistant anaerobic bacteria. There is no evidence that any one regimen is associated with fewer side-effects. Following clinical improvement of uncomplicated endometritis which has been treated with intravenous therapy, the use of additional oral therapy has not been proven to be beneficial.
Assuntos
Antibacterianos/uso terapêutico , Endometrite/tratamento farmacológico , Infecção Puerperal/tratamento farmacológico , Aminoglicosídeos/uso terapêutico , Cefalosporinas/uso terapêutico , Clindamicina/uso terapêutico , Quimioterapia Combinada , Feminino , Gentamicinas/uso terapêutico , Humanos , Penicilinas/uso terapêutico , Período Pós-Parto , Ensaios Clínicos Controlados Aleatórios como Assunto , Falha de TratamentoRESUMO
Recent advances in our understanding of the pathophysiology of chronic fatigue and related disorders can help guide your response to this common complaint.