RESUMO
BACKGROUND: The shock index pediatric age-adjusted (SIPA) predicts the need for increased resources and mortality among pediatric trauma patients without incorporating neurological status. A new scoring tool, rSIG, which is the reverse shock index (rSI) multiplied by the Glasgow Coma Scale (GCS), has been proven superior at predicting outcomes in adult trauma patients and mortality in pediatric patients compared with traditional scoring systems. We sought to compare the accuracy of rSIG to Shock Index (SI) and SIPA in predicting the need for early interventions in civilian pediatric trauma patients. METHODS: Patients (aged 1-18 years) in the 2014 to 2018 Pediatric Trauma Quality Improvement Program database with complete heart rate, systolic blood pressure, and total GCS were included. Optimal cut points of rSIG were calculated for predicting blood transfusion within 4 hours, intubation, intracranial pressure monitoring, and intensive care unit admission. From the optimal thresholds, sensitivity, specificity, and area under the curve were calculated from receiver operating characteristics analyses to predict each outcome and compared with SI and SIPA. RESULTS: A total of 604,931 patients with a mean age of 11.1 years old were included. A minority of patients had a penetrating injury mechanism (5.6%) and the mean Injury Severity Score was 7.6. The mean SI and rSIG scores were 0.85 and 18.6, respectively. Reverse shock index multiplied by Glasgow Coma Scale performed better than SI and SIPA at predicting early trauma outcomes for the overall population, regardless of age. CONCLUSION: Reverse shock index multiplied by Glasgow Coma Scale outperformed SI and SIPA in the early identification of traumatically injured children at risk for early interventions, such as blood transfusion within 4 hours, intubation, intracranial pressure monitoring, and intensive care unit admission. Reverse shock index multiplied by Glasgow Coma Scale adds neurological status in initial patient assessment and may be used as a bedside triage tool to rapidly identify pediatric patients who will likely require early intervention and higher levels of care. LEVEL OF EVIDENCE: Prognostic, level III.
Assuntos
Intervenção Médica Precoce , Escala de Coma de Glasgow , Risco Ajustado , Choque , Ferimentos e Lesões , Pressão Sanguínea , Transfusão de Sangue/métodos , Transfusão de Sangue/estatística & dados numéricos , Criança , Diagnóstico Precoce , Intervenção Médica Precoce/métodos , Intervenção Médica Precoce/normas , Feminino , Frequência Cardíaca , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva/estatística & dados numéricos , Pressão Intracraniana , Masculino , Medicina de Emergência Pediátrica/métodos , Medicina de Emergência Pediátrica/normas , Projetos de Pesquisa , Risco Ajustado/métodos , Risco Ajustado/normas , Choque/diagnóstico , Choque/etiologia , Choque/terapia , Ferimentos e Lesões/complicações , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/fisiopatologiaRESUMO
OBJECTIVES: To evaluate the association between low left ventricular ejection fraction (LVEF), complication rescue, and long-term survival after isolated coronary artery bypass grafting. METHODS: National cohort study of patients who underwent isolated coronary artery bypass grafting (2000-2016) using Veterans Affairs Surgical Quality Improvement Program data. Left ventricular ejection fraction was categorized as ≥35% (n = 55,877), 25%-34% (n = 3893), or <25% (n = 1707). Patients were also categorized as having had no complications, 1 complication, or more than 1 complication. The association between LVEF, complication rescue, and risk of death was evaluated with multivariable Cox regression. RESULTS: Among 61,477 patients, 6586 (10.7%) had a perioperative complication and 2056 (3.3%) had multiple complications. Relative to LVEF ≥35%, decreasing ejection fraction was associated with greater odds of complications (25%-34%, odds ratio, 1.30 [1.18-1.42]; <25%, odds ratio, 1.65 [1.43-1.92]). There was a dose-response relationship between decreasing LVEF and overall risk of death (≥35% [ref]; 25%-35%, hazard ratio, 1.46 [1.37-1.55]; <25%, hazard ratio, 1.68 [1.58-1.79]). Among patients who were rescued from complications, there were decreases in 10-year survival, regardless of LVEF. Among those rescued after multiple complications, LVEF was no longer associated with risk of death. CONCLUSIONS: While decreasing LVEF is associated with post-coronary artery bypass grafting complications, patients rescued from complications have worse long-term survival, regardless of left ventricular function. Prevention and timely treatment of complications should remain a focus of quality improvement initiatives, and future work is needed to mitigate their long-term detrimental impact on survival.
Assuntos
Ponte de Artéria Coronária , Doença da Artéria Coronariana , Efeitos Adversos de Longa Duração , Complicações Pós-Operatórias , Disfunção Ventricular Esquerda , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/cirurgia , Intervenção Médica Precoce/normas , Feminino , Humanos , Efeitos Adversos de Longa Duração/diagnóstico , Efeitos Adversos de Longa Duração/mortalidade , Efeitos Adversos de Longa Duração/fisiopatologia , Efeitos Adversos de Longa Duração/prevenção & controle , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/terapia , Serviços Preventivos de Saúde , Melhoria de Qualidade , Medição de Risco , Volume Sistólico , Análise de Sobrevida , Tempo para o Tratamento/normas , Estados Unidos , United States Department of Veterans Affairs , Disfunção Ventricular Esquerda/complicações , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/fisiopatologia , Disfunção Ventricular Esquerda/terapiaAssuntos
Intervenção Médica Precoce , Escore de Alerta Precoce , Serviços Médicos de Emergência , Medição de Risco/métodos , Sepse , Procedimentos Clínicos/normas , Erros de Diagnóstico/prevenção & controle , Diagnóstico Precoce , Intervenção Médica Precoce/métodos , Intervenção Médica Precoce/normas , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/organização & administração , Humanos , Guias de Prática Clínica como Assunto , Sepse/diagnóstico , Sepse/terapia , Medicina Estatal/normas , Tempo para o Tratamento , Reino UnidoRESUMO
BACKGROUND: More than 3 million cardiovascular implantable electronic devices (CIEDs) are implanted annually. There are minimal data regarding the timing of diagnosis of acute complications after implantation. It remains unclear whether patients can be safely discharged less than 24 hours postimplantation. OBJECTIVE: The purpose of this study was to determine the precise timing of acute complication diagnosis after CIED implantation and optimal timing for same-day discharge. METHODS: A retrospective cohort analysis of adults 18 years or older who underwent CIED implantation at a large urban quaternary care medical center between June 1, 2015, and March 30, 2020, was performed. Standard of care included overnight observation and chest radiography 6 and 24 hours postprocedure. Medical records were reviewed for the timing of diagnosis of acute complications. Acute complications included pneumothorax, hemothorax, pericardial effusion, lead dislodgment, and implant site hematoma requiring surgical intervention. RESULTS: A total of 2421 patients underwent implantation. Pericardial effusion or cardiac tamponade was diagnosed in 13 patients (0.53%), pneumothorax or hemothorax in 19 patients (0.78%), lead dislodgment in 11 patients (0.45%), and hematomas requiring surgical intervention in 5 patients (0.2%). Of the 48 acute complications, 43 (90%) occurred either within 6 hours or more than 24 hours after the procedure. Only 3 acute complications identified between 6 and 24 hours required intervention during the index hospitalization (0.12% of all cases). CONCLUSION: Most acute complications are diagnosed either within the first 6 hours or more than 24 hours after implantation. With rare exception, patients can be considered for discharge after 6 hours of appropriate monitoring.
Assuntos
Tamponamento Cardíaco , Desfibriladores Implantáveis/efeitos adversos , Intervenção Médica Precoce , Hematoma , Hemotórax , Marca-Passo Artificial/efeitos adversos , Complicações Pós-Operatórias , Implantação de Prótese , Idoso , Terapia de Ressincronização Cardíaca/efeitos adversos , Terapia de Ressincronização Cardíaca/métodos , Tamponamento Cardíaco/epidemiologia , Tamponamento Cardíaco/terapia , Unidades de Observação Clínica/estatística & dados numéricos , Diagnóstico Precoce , Intervenção Médica Precoce/métodos , Intervenção Médica Precoce/normas , Intervenção Médica Precoce/estatística & dados numéricos , Feminino , Hematoma/epidemiologia , Hematoma/terapia , Hemotórax/epidemiologia , Hemotórax/terapia , Humanos , Masculino , Complicações Pós-Operatórias/classificação , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Implantação de Prótese/efeitos adversos , Implantação de Prótese/instrumentação , Implantação de Prótese/métodos , Radiografia Torácica/métodos , Estudos Retrospectivos , Padrão de Cuidado , Tempo para o Tratamento/organização & administraçãoRESUMO
Emergency medical services (EMS) activation is an integral component in managing individuals with myocardial infarction (MI). EMS play a crucial role in early MI symptom recognition, prompt transport to percutaneous coronary intervention centres and timely administration of management. The objective of this study was to examine sex differences in prehospital EMS care of patients hospitalized with Ml using data from a retrospective population-based cohort study of linked health administrative data for people with a hospital diagnosis of MI in Australia (2001-18).
Assuntos
Despacho de Emergência Médica , Serviços Médicos de Emergência , Infarto do Miocárdio , Intervenção Coronária Percutânea , Fatores Sexuais , Tempo para o Tratamento/normas , Idoso , Ambulâncias/estatística & dados numéricos , Austrália/epidemiologia , Estudos de Coortes , Intervenção Médica Precoce/normas , Intervenção Médica Precoce/estatística & dados numéricos , Despacho de Emergência Médica/métodos , Despacho de Emergência Médica/normas , Despacho de Emergência Médica/estatística & dados numéricos , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/normas , Serviços Médicos de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea/métodos , Intervenção Coronária Percutânea/estatística & dados numéricos , Melhoria de Qualidade/organização & administração , Estudos Retrospectivos , Dados de Saúde Coletados Rotineiramente , Tempo para o Tratamento/organização & administraçãoRESUMO
INTRODUCTION: Tubercular bacterial meningitis continues to be an important cause of morbidity (especially neurologic handicap) in children from resource-poor countries. The present study was planned to assess the clinical and radiological presentation in cases of tubercular meningitis as well as to study the factors associated with mortality. METHODOLOGY: This study was done over a period of 12 months on children between 5 years and 13 years with suspected TBM. Staging of tubercular meningitis was done according to RNTCP Pediatric TB guideline 2019. RESULT: The study was conducted on a total of 47 pediatric patients with TBM. Mean age of children in present study was 8.77 ± 2.5 years. Our study documented male preponderance for TBM. Severe thinness was observed in 38.3% patients with TBM. Only 59.6% patients were immunized against tuberculosis and history of contact was documented in 40.5% patients. Maximum children belonged to stage I of TBM (59.6%) followed by stage III and stage II in 34% and 6.4% patients respectively. Montoux test positivity was observed in 14.9% patients only. CSF CBNAAT was positive in 6.4% patients. The most common finding was meningeal enhancement seen in 27.7% of patients followed by tuberculomas in 10.6%.Chest X ray was abnormal in 44.7% patients. In present study mortality was observed in 11 (23.4%) cases. Out of various risk factors, mortality was significantly associated with nutritional status and stage of TBM (p < 0.01). CONCLUSION: TBM is associated with high morbidity and mortality in children especially in India where Burden of TB is high. Our study emphasized on the risk factors associated with mortality in children with TBM and need for early diagnosis and appropriate treatment.
Assuntos
Mycobacterium tuberculosis/isolamento & purificação , Doenças do Sistema Nervoso , Estado Nutricional , Radiografia Torácica/métodos , Tuberculose Meníngea , Criança , Intervenção Médica Precoce/normas , Feminino , Necessidades e Demandas de Serviços de Saúde , Humanos , Índia/epidemiologia , Masculino , Doenças do Sistema Nervoso/diagnóstico , Doenças do Sistema Nervoso/etiologia , Gravidade do Paciente , Prognóstico , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , Tuberculose Meníngea/complicações , Tuberculose Meníngea/diagnóstico por imagem , Tuberculose Meníngea/mortalidade , Tuberculose Meníngea/fisiopatologiaRESUMO
BACKGROUND: Ninety-four percent of all maternal deaths occur in low- and middle-income countries, and the majority are preventable. Access to quality Obstetric ultrasound can identify some complications leading to maternal and neonatal/perinatal mortality or morbidity and may allow timely referral to higher-resource centers. However, there are significant global inequalities in access to imaging and many challenges to deploying ultrasound to rural areas. In this study, we tested a novel, innovative Obstetric telediagnostic ultrasound system in which the imaging acquisitions are obtained by an operator without prior ultrasound experience using simple scan protocols based only on external body landmarks and uploaded using low-bandwidth internet for asynchronous remote interpretation by an off-site specialist. METHODS: This is a single-center pilot study. A nurse and care technician underwent 8 h of training on the telediagnostic system. Subsequently, 126 patients (68 second trimester and 58 third trimester) were recruited at a health center in Lima, Peru and scanned by these ultrasound-naïve operators. The imaging acquisitions were uploaded by the telemedicine platform and interpreted remotely in the United States. Comparison of telediagnostic imaging was made to a concurrently performed standard of care ultrasound obtained and interpreted by an experienced attending radiologist. Cohen's Kappa was used to test agreement between categorical variables. Intraclass correlation and Bland-Altman plots were used to test agreement between continuous variables. RESULTS: Obstetric ultrasound telediagnosis showed excellent agreement with standard of care ultrasound allowing the identification of number of fetuses (100% agreement), fetal presentation (95.8% agreement, κ =0.78 (p < 0.0001)), placental location (85.6% agreement, κ =0.74 (p < 0.0001)), and assessment of normal/abnormal amniotic fluid volume (99.2% agreement) with sensitivity and specificity > 95% for all variables. Intraclass correlation was good or excellent for all fetal biometric measurements (0.81-0.95). The majority (88.5%) of second trimester ultrasound exam biometry measurements produced dating within 14 days of standard of care ultrasound. CONCLUSION: This Obstetric ultrasound telediagnostic system is a promising means to increase access to diagnostic Obstetric ultrasound in low-resource settings. The telediagnostic system demonstrated excellent agreement with standard of care ultrasound. Fetal biometric measurements were acceptable for use in the detection of gross discrepancies in fetal size requiring further follow up.
Assuntos
Assistência Perinatal , Consulta Remota/métodos , Desenvolvimento de Pessoal , Telemedicina/métodos , Ultrassonografia Pré-Natal , Diagnóstico Precoce , Intervenção Médica Precoce/normas , Feminino , Humanos , Obstetrícia/educação , Assistência Perinatal/métodos , Assistência Perinatal/normas , Peru/epidemiologia , Testes Imediatos/organização & administração , Gravidez , Trimestres da Gravidez , Melhoria de Qualidade/organização & administração , Serviços de Saúde Rural/normas , Serviços de Saúde Rural/tendências , Enfermagem Rural/métodos , Desenvolvimento de Pessoal/métodos , Desenvolvimento de Pessoal/organização & administração , Ultrassonografia Pré-Natal/métodos , Ultrassonografia Pré-Natal/normasRESUMO
INTRODUCTION: Firearm-related spinal cord injuries are commonly missed in the initial assessment as they are often obscured by concomitant injuries and emergent trauma management. These injuries, however, have a significant health and financial impact. The objective of this study was to examine firearm-related spinal cord injuries and identify predictors of presence of such injuries in adult trauma patients. METHODS: This retrospective cohort study examined adult trauma patients (≥16 years) with injuries from firearms included in the 2015 United States National Trauma Data Bank. We performed descriptive and bivariate analyses and compared two groups: patients with no spinal cord injury (SCI) or vertebral column injury (VCI); and patients with SCI and/or VCI. Predictors of SCI and/or VCI in patients with firearm-related injuries were identified using a multivariate logistic regression analysis. RESULTS: There were 34,898 patients who sustained a firearm-induced injury. SCI and/or VCI were present in 2768 (7.9%) patients. Patients with SCI and/or VCI had more frequently severe injuries, higher Injury Severity Score (ISS), lower mean systolic blood pressure, and lower Glasgow Coma Scale (GCS). The mortality rate was not significantly different between the two groups (14.7%, N = 407 in SCI and/or VCI vs 15.0%, N = 4,811 in no SCI or VCI group). Significant general positive predictors of presence of SCI and/or VCI were as follows: university hospital; assault; public or unspecified location of injury; drug use; air medical transport; and Medicaid coverage. Significant clinical positive predictors included fractures, torso injuries, blood vessel or internal organ injuries, open wounds, mild (13-15) and moderate GCS scores (9 - 12), and ISS ≥ 16. CONCLUSION: Firearm-induced SCI and/or VCI injuries have a high burden on affected victims. The identified predictors for the presence of SCI and/or VCI injuries can help with early detection, avoiding management delays, and improving outcomes. Further studies defining the impact of each predictor are needed.
Assuntos
Intervenção Médica Precoce , Armas de Fogo , Traumatismo Múltiplo , Traumatismos da Medula Espinal , Ferimentos por Arma de Fogo , Adulto , Intervenção Médica Precoce/métodos , Intervenção Médica Precoce/normas , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Medicaid/estatística & dados numéricos , Traumatismo Múltiplo/diagnóstico , Traumatismo Múltiplo/epidemiologia , Traumatismo Múltiplo/etiologia , Prognóstico , Estudos Retrospectivos , Traumatismos da Medula Espinal/diagnóstico , Traumatismos da Medula Espinal/epidemiologia , Traumatismos da Medula Espinal/etiologia , Estados Unidos/epidemiologia , Ferimentos por Arma de Fogo/complicações , Ferimentos por Arma de Fogo/epidemiologiaRESUMO
BACKGROUND: Many countries have adopted a mandatory routine pulse oximetry screening of newborn infants to identify babies with otherwise asymptomatic critical congenital heart disease (CCHD). OBJECTIVES: To describe the current status of pulse oximetry CCHD screening in Israel, with a special emphasis on the experience of the Shaare Zedek Medical Center. METHODS: We review the difficulties of the Israeli Medical system with adopting the SaO2 screening, and the preliminary results of the screening at the Shaare Zedek Medical Center, both in terms of protocol compliance and CCHD detection. RESULTS: Large scale protocol cannot be implemented in one day, and regular quality assessment programs must take place in order to improve protocol compliance and identify the reasons for protocol failures. CONCLUSIONS: Quality control reviews should be conducted soon after implementation of the screening to allow for prompt diagnosis and quick resolution.
Assuntos
Diagnóstico Precoce , Cardiopatias Congênitas , Triagem Neonatal , Oximetria/métodos , Intervenção Médica Precoce/normas , Necessidades e Demandas de Serviços de Saúde , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/epidemiologia , Humanos , Recém-Nascido , Israel , Triagem Neonatal/métodos , Triagem Neonatal/organização & administração , Triagem Neonatal/normas , Triagem Neonatal/tendências , Qualidade da Assistência à Saúde/organização & administraçãoRESUMO
BACKGROUND: Neonatal lupus erythematosus is an autoimmune disease acquired during fetal life as a result of transplacental passage of maternal anti-Sjögren's-syndrome-related antigen A (anti-SSA/Ro), anti-Sjögren's-syndrome-related antigen B (anti-SSB/La) or anti-U1 ribonucleoprotein (anti-U1-RNP) antinuclear autoantibodies. CONTENTS: Clinical manifestations include skin lesions, congenital heart block, hepatobiliary involvement and cytopenias. Most of the disorders disappear spontaneously after clearance of maternal antibodies. Cardiac symptoms, however, are not self-resolving and often pacemaker implantation is required. Diagnosis is based on clinical presentation and the presence of typical antibodies in the mother's or infant's serum. OUTLOOK: Neonatal lupus erythematosus may develop in children born to anti-SSA/Ro or anti-SSB/La women with various systemic connective tissue diseases. However, in half of the cases, the mother is asymptomatic, which may delay the diagnosis and have negative impact on the child's prognosis. Testing for antinuclear antibodies should be considered in every pregnant woman since early treatment with hydroxychloroquine or intravenous immunoglobulin (IVIG) has proven to be effective in preventing congenital heart block.
Assuntos
Doenças Autoimunes , Intervenção Médica Precoce , Bloqueio Cardíaco/congênito , Lúpus Eritematoso Sistêmico/congênito , Complicações na Gravidez , Doenças Autoimunes/imunologia , Doenças Autoimunes/terapia , Diagnóstico Precoce , Intervenção Médica Precoce/métodos , Intervenção Médica Precoce/normas , Feminino , Bloqueio Cardíaco/etiologia , Bloqueio Cardíaco/prevenção & controle , Humanos , Recém-Nascido , Lúpus Eritematoso Sistêmico/complicações , Lúpus Eritematoso Sistêmico/diagnóstico , Lúpus Eritematoso Sistêmico/imunologia , Lúpus Eritematoso Sistêmico/terapia , Guias de Prática Clínica como Assunto , Gravidez , Complicações na Gravidez/imunologia , Complicações na Gravidez/terapiaAssuntos
Assistência Ambulatorial , COVID-19/complicações , Equipe de Assistência ao Paciente/organização & administração , Cuidados Semi-Intensivos , Assistência Ambulatorial/métodos , Assistência Ambulatorial/organização & administração , COVID-19/epidemiologia , COVID-19/terapia , Diagnóstico Precoce , Intervenção Médica Precoce/normas , Intervenção Médica Precoce/provisão & distribuição , Hospitalização/estatística & dados numéricos , Humanos , Modelos Organizacionais , Alocação de Recursos , SARS-CoV-2 , Cuidados Semi-Intensivos/métodos , Cuidados Semi-Intensivos/organização & administração , Sobreviventes , Estados Unidos/epidemiologia , Populações VulneráveisAssuntos
Intervenção Médica Precoce/normas , Perda Auditiva/diagnóstico , Testes Auditivos/normas , Fala/fisiologia , Audiologistas/ética , Criança , Pré-Escolar , Implantes Cocleares/efeitos adversos , Implantes Cocleares/estatística & dados numéricos , Diagnóstico Precoce , Intervenção Médica Precoce/estatística & dados numéricos , Fidelidade a Diretrizes , Perda Auditiva/congênito , Perda Auditiva/epidemiologia , Perda Auditiva/cirurgia , Testes Auditivos/estatística & dados numéricos , Humanos , Incidência , Lactente , Recém-Nascido , Triagem Neonatal/normas , Otorrinolaringologistas/ética , Avaliação de Resultados em Cuidados de SaúdeAssuntos
Dor no Peito , Diagnóstico Tardio/prevenção & controle , Infarto do Miocárdio , Educação de Pacientes como Assunto/métodos , Tempo para o Tratamento/normas , Troponina I/sangue , Adulto , Biomarcadores/sangue , Dor no Peito/sangue , Dor no Peito/diagnóstico , Dor no Peito/etiologia , Dor no Peito/psicologia , Intervenção Médica Precoce/métodos , Intervenção Médica Precoce/normas , Europa (Continente)/epidemiologia , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Comportamento de Busca de Ajuda , Humanos , Masculino , Anamnese/métodos , Infarto do Miocárdio/sangue , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/fisiopatologia , Infarto do Miocárdio/psicologia , Revascularização Miocárdica/métodos , Revascularização Miocárdica/estatística & dados numéricosRESUMO
AIM: To describe the development of an intervention-specific fidelity measure and its utilization and to determine whether the newly developed Sitting Together and Reaching to Play (START-Play) intervention was implemented as intended. Also, to quantify differences between START-Play and usual early intervention (uEI) services. METHOD: A fidelity measure for the START-Play intervention was developed for children with neuromotor disorders by: (1) identifying key intervention components, (2) establishing a measurement coding system, and (3) testing the reliability of instrument scores. After establishing acceptable interrater reliability, 103 intervention videos from the START-Play randomized controlled trial were coded and compared between the START-Play and uEI groups to measure five dimensions of START-Play fidelity, including adherence, dosage, quality of intervention, participant responsiveness, and program differentiation. RESULTS: Fifteen fidelity variables out of 17 had good to excellent interrater reliability evidence with intraclass correlation coefficients (ICCs) ranging from 0.77 to 0.95. The START-Play therapists met the criteria for acceptable fidelity of the intervention (rates of START-Play key component use ≥0.8; quality ratings ≥3 [on a scale of 1-4]). The START-Play and uEI groups differed significantly in rates of START-Play key component use and quality ratings. INTERPRETATION: The START-Play fidelity measure successfully quantified key components of the START-Play intervention, serving to differentiate START-Play from uEI.
Assuntos
Intervenção Educacional Precoce/normas , Intervenção Médica Precoce/normas , Transtornos das Habilidades Motoras/reabilitação , Reabilitação Neurológica/normas , Avaliação de Processos em Cuidados de Saúde/normas , Desenvolvimento de Programas , Psicometria/normas , Criança , Humanos , Reabilitação Neurológica/métodos , Psicometria/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Reprodutibilidade dos TestesRESUMO
BACKGROUND: Cholera epidemics continue to challenge disease control, particularly in fragile and conflict-affected states. Rapid detection and response to small cholera clusters is key for efficient control before an epidemic propagates. To understand the capacity for early response in fragile states, we investigated delays in outbreak detection, investigation, response, and laboratory confirmation, and we estimated epidemic sizes. We assessed predictors of delays, and annual changes in response time. METHODS: We compiled a list of cholera outbreaks in fragile and conflict-affected states from 2008 to 2019. We searched for peer-reviewed articles and epidemiological reports. We evaluated delays from the dates of symptom onset of the primary case, and the earliest dates of outbreak detection, investigation, response, and confirmation. Information on how the outbreak was alerted was summarized. A branching process model was used to estimate epidemic size at each delay. Regression models were used to investigate the association between predictors and delays to response. RESULTS: Seventy-six outbreaks from 34 countries were included. Median delays spanned 1-2 weeks: from symptom onset of the primary case to presentation at the health facility (5 days, IQR 5-5), detection (5 days, IQR 5-6), investigation (7 days, IQR 5.8-13.3), response (10 days, IQR 7-18), and confirmation (11 days, IQR 7-16). In the model simulation, the median delay to response (10 days) with 3 seed cases led to a median epidemic size of 12 cases (upper range, 47) and 8% of outbreaks ≥ 20 cases (increasing to 32% with a 30-day delay to response). Increased outbreak size at detection (10 seed cases) and a 10-day median delay to response resulted in an epidemic size of 34 cases (upper range 67 cases) and < 1% of outbreaks < 20 cases. We estimated an annual global decrease in delay to response of 5.2% (95% CI 0.5-9.6, p = 0.03). Outbreaks signaled by immediate alerts were associated with a reduction in delay to response of 39.3% (95% CI 5.7-61.0, p = 0.03). CONCLUSIONS: From 2008 to 2019, median delays from symptom onset of the primary case to case presentation and to response were 5 days and 10 days, respectively. Our model simulations suggest that depending on the outbreak size (3 versus 10 seed cases), in 8 to 99% of scenarios, a 10-day delay to response would result in large clusters that would be difficult to contain. Improving the delay to response involves rethinking the integration at local levels of event-based detection, rapid diagnostic testing for cluster validation, and integrated alert, investigation, and response.
Assuntos
Cólera/diagnóstico , Cólera/epidemiologia , Países em Desenvolvimento/estatística & dados numéricos , Diagnóstico Precoce , Epidemias , Controle de Infecções/métodos , Conflitos Armados/estatística & dados numéricos , Cólera/prevenção & controle , Cólera/terapia , Simulação por Computador , Diagnóstico Tardio/estatística & dados numéricos , Surtos de Doenças/história , Surtos de Doenças/prevenção & controle , Surtos de Doenças/estatística & dados numéricos , Intervenção Médica Precoce/métodos , Intervenção Médica Precoce/normas , Epidemias/história , Epidemias/prevenção & controle , Epidemias/estatística & dados numéricos , História do Século XX , História do Século XXI , Humanos , Controle de Infecções/organização & administração , Controle de Infecções/normas , Modelos Estatísticos , Vigilância da População/métodos , Tempo de Reação , Refugiados/estatística & dados numéricos , Tempo para o Tratamento/estatística & dados numéricos , Populações Vulneráveis/estatística & dados numéricosRESUMO
Over the past 25 years, in the field of psychosis there is an increased interest in early detection of symptoms and treatment provision for people who are either at Ultra High Risk (UHR) of developing psychosis or with First Episode Psychosis (FEP). Extensive research has proved, that by engaging quickly into treatment and addressing the needs of each case individually, clinical outcomes could be improved substantially. The above evidence-based argument has resulted in the establishment of specialized Early Intervention in Psychosis (EIP) services worldwide. Eginition University Hospital (EUH) in Athens has been providing care for Early Psychosis through a specialized outpatient EIP service since 2012, which receives all early psychosis cases. Initially clinical focus was mainly directed towards UHR cases, since EUH had long been providing standard care for FEP. However, over the last 4 years, the EIP Unit has evolved incrementally into a network of directly linked services, involving the EIP outpatient service, an Inpatient Unit for prompt hospitalization and a Day Clinic for partial hospitalization, to address acute treatment, follow-up and recovery/relapse prevention phases. Diagnostic evaluation is made through specialized instruments along with the typical psychiatric interview. The therapeutic approach follows the international guidelines for EIP, namely symptom-based and phase-specific treatment, which includes supportive counselling, coping strategies and psychoeducation both for subjects and family members, as well as pharmacotherapy when needed and preferably in low doses. Regarding our results, in the first 3 years (3/2012-3/2015) the EIP unit received 26 (60%) UHR subjects and 17 (40%) FEP patients. Over the last 4 years (3/2015-3/2019) the referrals rose to 167 with 35 (21%) UHR and 132 (79%) FEP cases. All of the UHR subjects were from the outset followed by the specialized outpatient EIP service for up to 3 years. As to the FEP patients, seventy-seven (60%) were acutely hospitalized for less than a month, and 10 (8%) attended the Day Clinic for 6 - 12 months, before being referred to the outpatient service. Concluding, the development of the EIP network of specialized services has cohesively enabled a broader therapeutic framework, shifting the clinical focus towards FEP, although UHR subjects are still being assessed systematically. However, there is still considerable work to be done, in order to enhance the full potential of all units and promote the interconnection with potential community settings.
Assuntos
Assistência Ambulatorial/métodos , Redes Comunitárias/organização & administração , Intervenção Médica Precoce , Serviços de Saúde Mental , Transtornos Psicóticos , Adolescente , Adulto , Diagnóstico Precoce , Intervenção Médica Precoce/organização & administração , Intervenção Médica Precoce/normas , Feminino , Grécia/epidemiologia , Hospitais Psiquiátricos/estatística & dados numéricos , Humanos , Masculino , Recuperação da Saúde Mental , Serviços de Saúde Mental/organização & administração , Serviços de Saúde Mental/estatística & dados numéricos , Prognóstico , Técnicas Psicológicas , Processos Psicoterapêuticos , Transtornos Psicóticos/diagnóstico , Transtornos Psicóticos/psicologia , Transtornos Psicóticos/terapia , Tempo para o Tratamento/normasRESUMO
The duration and lifetime pattern of hypertension is related to risk of stroke and dementia. In turn, cerebral small vessel disease (CSVD) is the most frequent form of cerebrovascular disease underlying dementia and stroke. Thus, study of the relation of mid to late life hypertension trends with CSVD late in life will help understand hypertension's role and inform preventive efforts of CSVD consequences. We studied 1686 Framingham Heart Study Offspring cohort participants free of stroke and dementia, who were examined in mid and late life, and had available brain magnetic resonance imaging during late life. We related hypertension trends between mid and late life (normotension-normotension N-N, normotension-hypertension N-H, hypertension-hypertension H-H) to cerebral microbleeds and covert brain infarcts (CBI), overall and stratified by brain topography. We used multivariable logistic regression analyses to calculate odds ratio and 95% CIs for CSVD measures. The prevalence of CSVD in late life was 8% for cerebral microbleeds and 13% for covert brain infarcts and increased with longer hypertension exposure across all brain regions. Compared with the trend pattern of N-N, both N-H and H-H trends had higher odds of mixed cerebral microbleeds (2.71 [1.08-6.80], and 3.44 [1.39-8.60], respectively); H-H also had higher odds of any cerebral microbleeds or covert brain infarcts (1.54 [1.12-2.20]), and any covert brain infarcts (1.55 [1.08-2.20]). The burden of CSVD also increased with longer hypertension exposure. Our results highlight hypertension having a major role in subclinical CSVD, across subtypes and brain regions, and call attention to improve recognition and treatment of hypertension early in life.
Assuntos
Encéfalo , Doenças de Pequenos Vasos Cerebrais , Demência , Hipertensão , Acidente Vascular Cerebral , Idoso , Doenças Assintomáticas/epidemiologia , Encéfalo/diagnóstico por imagem , Encéfalo/patologia , Doenças de Pequenos Vasos Cerebrais/diagnóstico , Doenças de Pequenos Vasos Cerebrais/epidemiologia , Demência/diagnóstico , Demência/epidemiologia , Intervenção Médica Precoce/normas , Feminino , Humanos , Hipertensão/diagnóstico , Hipertensão/epidemiologia , Hipertensão/fisiopatologia , Hipertensão/terapia , Estudos Longitudinais , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Prevalência , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologiaRESUMO
BACKGROUND: Specialized early intervention programs for individuals experiencing a first episode of psychosis prioritize service engagement, generally operationalized as attendance, treatment completion, therapeutic alliance, and treatment adherence. However, there are critical theoretical and methodological gaps in understanding how service users experience and define their engagement with the service. OBJECTIVES: This study aimed to explore how current and former service users define their engagement with a specialized early intervention program. DESIGN: A qualitative descriptive approach was used to explore service users' decisions to use, remain involved with, and/or leave early intervention services. SETTING: This study took place in an early intervention service for psychosis in Montreal, Canada. PARTICIPANTS: Twenty-four participants who had experienced a first episode of psychosis and had been engaged in the service to varying degrees (fully engaged, partially engaged, disengaged) took part in in-depth interviews. METHODS: In-depth interviews were employed to collect rich insights into participants' experiences and perceptions. The interviews were transcribed and analysed using thematic analysis, beginning with an inductive approach and completing the analysis using a theoretical approach. During the analysis, our original notions of engagement and disengagement were challenged by theorizing engagement in terms of agency and structure. Researchers engaged in reflexive practices to maintain and promote research rigor and trustworthiness. RESULTS: Participants' narratives were thematically analyzed and organized into three themes: fluidity and temporality of engagement and disengagement; engagement as an ongoing negotiation; and critical structures and agency. Participants described engagement in a variety of ways, some of which were broader than service use and focused on self-care and commitment to recovery. These conceptions were subject to change as the individuals' perceptions of their needs changed. As needs changed, individuals also negotiated and renegotiated their care needs with themselves and with their treatment team. These exercises of agency were constrained by key structures: the treatment team, family and friends, and societal conceptions of mental health. CONCLUSIONS: Our study findings argue for an expanded definition of engagement which prioritizes individuals' experience and acknowledges the steps towards recovery that they may make outside of the purview of the service. It also underlines the importance of a treatment structure which aligns with individuals' needs for both support and autonomy.
Assuntos
Intervenção Médica Precoce/métodos , Autonomia Pessoal , Transtornos Psicóticos/terapia , Fatores de Tempo , Adulto , Intervenção Médica Precoce/normas , Intervenção Médica Precoce/estatística & dados numéricos , Feminino , Humanos , Entrevistas como Assunto/métodos , Masculino , Transtornos Psicóticos/psicologia , Pesquisa Qualitativa , QuebequeAssuntos
Glicemia/metabolismo , Infecções por Coronavirus/terapia , Diabetes Mellitus Tipo 2/terapia , Hospitalização , Insulina/administração & dosagem , Peptidil Dipeptidase A/fisiologia , Pneumonia Viral/terapia , Enzima de Conversão de Angiotensina 2 , Animais , Glicemia/efeitos dos fármacos , COVID-19 , Infecções por Coronavirus/sangue , Infecções por Coronavirus/complicações , Infecções por Coronavirus/epidemiologia , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/epidemiologia , Esquema de Medicação , Intervenção Médica Precoce/métodos , Intervenção Médica Precoce/normas , Hemoglobinas Glicadas/efeitos dos fármacos , Hemoglobinas Glicadas/metabolismo , Humanos , Hipoglicemiantes/administração & dosagem , Camundongos , Camundongos Knockout , Pandemias , Peptidil Dipeptidase A/uso terapêutico , Peptidil Dipeptidase A/urina , Pneumonia Viral/sangue , Pneumonia Viral/complicações , Pneumonia Viral/epidemiologia , Proteínas Recombinantes/uso terapêutico , Fatores de TempoRESUMO
OBJECTIVE: To investigate the effect of determining the drug type and level on emergency management in patients presenting with intoxication, and to identify the factors behind associated mortality. METHODS: The retrospective, observational, cross-sectional and single centre study was conducted at a large tertiary care teaching hospital in Istanbul, Turkey, between September and November 2016 using the hospital's toxicology registry. Data was extracted for patients who had presented to the emergency department from January 1, 2011, to February 28, 2013, and were found to have toxic doses of single active ingredients in the plasma. The patients were evaluated in terms of age, gender, demographic characteristics, time from ingestion to presentation, reason for drug ingestion, type of drug ingested, time elapsed before the emergency service was called, treatment given, drug level, hospitalisation and mortality. Data was analysed using SPSS 11.5. RESULTS: Of the 224 patients, 145(64.8%) were women. The overall mean age was 30.8±15.4 years. Drug ingestion was more common in women aged 18-30 years (p<0.0001). Besides, 215(96%) patients had ingested drugs with the intent to commit suicide. The minimum education level of 163(72.8%) patients was high school. The most frequently ingested drug was paracetamol 90(40.2%). Overall mortality was 4(1.8%) and all of them were brought to the emergency department after a delay of more than five hours (p<0.0001). CONCLUSIONS: Drug type and quantity were found to be of great importance in taking timely decisions while attending to patients with intoxication in an emergency setting. Delay in presentation was associated with mortality..