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1.
J Occup Environ Hyg ; 21(6): 379-388, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38652919

RESUMO

Residents of long-term care facilities are particularly vulnerable to communicable diseases. Low-cost interventions to increase air exchange rates (AERs) may be useful in reducing the transmission of airborne communicable diseases between long-term care residents and staff. In this study, carbon dioxide gas was used as a tracer to evaluate the AER associated with the implementation of low-cost ventilation interventions. Under baseline conditions with the room's door closed, the mean AER was 0.67 ACH; while baseline conditions with the door open had a significantly higher mean AER of 3.87 ACH (p < 0.001). Subsequently opening a window with the door open increased mean AER by 1.49 ACH (p = 0.012) and adding a fan in the window further increased mean AER by 1.87 ACH (p < 0.001). Regression analyses indicated that the flow rate of air entering through the window, both passively and through the use of a fan, was significantly associated with an increase in AER (p < 0.001). These results indicate that low-cost interventions that pull outside air into resident rooms were effective in improving the air exchange rates in these facilities. While implementation of these interventions is dependent on facility rules and isolation requirements of residents with airborne communicable diseases, these interventions remain viable options for long-term care facilities to improve resident room ventilation without requiring costly ventilation system upgrades.


Assuntos
Assistência de Longa Duração , Ventilação , Ventilação/métodos , Humanos , Assistência de Longa Duração/economia , Poluição do Ar em Ambientes Fechados/prevenção & controle , Casas de Saúde , Dióxido de Carbono/análise
2.
Tob Control ; 2023 Feb 23.
Artigo em Inglês | MEDLINE | ID: mdl-36822833

RESUMO

INTRODUCTION: Despite progress in adoption of smoke-free policies, smoking in casinos is allowed in some US states, including Nevada. In 2020, for the first time, a resort-style casino in Las Vegas prohibited smoking voluntarily. This study is the first to assess air quality in this casino and compare results with similar casinos that allow smoking. METHODS: A real-time personal aerosol monitor evaluated particulate matter with a diameter <2.5 µm (PM2.5), a surrogate for secondhand smoke (SHS). PM2.5 was measured at eight Las Vegas casinos, including the smoke-free casino. Each casino was visited twice, and PM2.5 was assessed in smoking-permitted gaming areas and areas where smoking is otherwise prohibited. RESULTS: Average PM2.5 levels were significantly higher in casinos that allow smoking, for both casino gaming areas and areas where smoking is otherwise prohibited (p<0.05). Mean PM2.5 in gaming areas was 164.9 µg/m3 in casinos that allow smoking and 30.5 µg/m3 in the smoke-free casino. Mean PM2.5 in areas where smoking is otherwise prohibited was 83.2 µg/m3 in casinos which allowed smoking in gaming areas, and 48.1 µg/m3 in the smoke-free casino. CONCLUSION: Despite robust evidence about the harms of SHS, tens of thousands of casino employees and tens of millions of tourists are exposed to high levels of SHS in Las Vegas casinos annually, with PM2.5 levels 5.4 times higher in gaming areas when compared with a smoke-free casino. The only way to protect people from SHS exposure is to prohibit smoking in all indoor areas.

3.
J Occup Environ Hyg ; 20(7): 268-278, 2023 07.
Artigo em Inglês | MEDLINE | ID: mdl-37146269

RESUMO

Cannabis cultivation and processing is becoming an important industry in the United States and Canada. The industry employs over 400,000 workers in the United States and is growing rapidly. Both natural sunlight and artificial lamp-generated radiation are commonly used to grow cannabis plants. These optical sources can contain both visible and ultraviolet radiation (UVR) wavelengths, and overexposure to UVR is associated with negative health effects. The severity of these adverse health effects is governed by the specific wavelengths and exposed dose of UVR, yet worker exposure to UVR within cannabis-growing facilities has not been studied. In this study, worker exposure to UVR was assessed at five cannabis production facilities in Washington State, including indoor, outdoor, and shade house facilities. Lamp emission testing was performed at each facility and worker UVR exposures were measured for 87 work shifts. Observations of worker activities and use of personal protective equipment in association with UVR exposure measurements were recorded. For lamp emission measurements, at 3 feet from the center of the lamp, the average irradiances were 4.09 × 10-4, 6.95 × 10-8, 6.76 × 10-9, 3.96 × 10-9, and 1.98 × 10-9 effective W/cm2 for germicidal lamps, metal halide lamps, high-pressure sodium lamps, fluorescent lamps, and light emitting diodes, respectively. The average measured UVR exposure was 2.91 × 10-3 effective J/cm2 (range: 1.54 × 10-6, 1.57 × 10-2 effective J/cm2). Thirty percent of the work shifts monitored exceeded the American Conference for Governmental Industrial Hygienists (ACGIH®) threshold limit value (TLV®) of 0.003 effective J/cm2. Exposures were highest for workers who spent all or part of the work shift outdoors, and solar radiation was the primary source of worker UVR exposure for most of the work shifts that exceeded the TLVs. Outdoor workers can reduce UVR exposure by applying sunscreen and wearing appropriate personal protective equipment. Although the artificial lighting used in the cannabis production facilities included in this study did not contribute substantially to the measured UV exposures, in many cases the lamp emissions would generate theoretical exposures at 3 feet from the center of the lamp that would exceed the TLV. Therefore, employers should choose low UVR emitting lamps for indoor grow operations and should use engineering controls (e.g., door-interlocks to de-energize lamps) to prevent worker exposure to UVR from germicidal lamps.


Assuntos
Cannabis , Exposição Ocupacional , Humanos , Raios Ultravioleta/efeitos adversos , Luz Solar , Indústrias , Canadá , Exposição Ocupacional/prevenção & controle , Exposição Ocupacional/análise
4.
Sensors (Basel) ; 22(22)2022 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-36433426

RESUMO

Available wearable dosimeters suffer from spectral mismatch during the measurement of broadband UV and visible radiation in environments that receive radiation from multiple sources emitting differing spectra. We observed this type of multi-spectra environment in all five Washington State cannabis farms visited during a field study investigating worker exposure to ultraviolet radiation in 2018. Spectroradiometers do not suffer from spectral mismatch in these environments, however, an extensive literature review conducted at the time of writing did not identify any spectroradiometers that were directly deployable as wearable dosimetry devices. To close this research gap, we developed a microcontroller system and platform that allows for researchers to mount and deploy the Ocean Insight Flame-S Spectroradiometer as a wearable device for measurement of UV and visible wavelengths (300 to 700 nm). The platform validation consisted of comparing measurements taken under platform control with measurements taken with the spectrometer controlled by a personal computer running the software provided by the spectroradiometer manufacturer. Three Mann-Whitney U-Tests (two-tailed, 95% CI), one for each intensity condition, compared the central tendency between the total spectral power (TSP), the integral of a spectrum measurement, measured under both control schemas. An additional analysis of per pixel agreement and overall platform stability was performed. The three Mann-Whitney tests returned no significant difference between the set of TSPs for each filter condition. These results suggest that the spectroradiometer takes measurements of equivalent accuracy under both control schemas, and can be deployed as a wearable device for the measurement of wavelength resolved UV and visible radiation.


Assuntos
Raios Ultravioleta , Dispositivos Eletrônicos Vestíveis , Radiometria , Luz , Dosímetros de Radiação
5.
J Occup Environ Hyg ; 19(9): 524-537, 2022 09.
Artigo em Inglês | MEDLINE | ID: mdl-35816423

RESUMO

The emergence of COVID-19 and its corresponding public health burden has prompted industries to rapidly implement traditional and novel control strategies to mitigate the likelihood of SARS-CoV-2 transmission, generating a surge of interest and application of ultraviolet germicidal irradiation (UVGI) sources as disinfection systems. With this increased attention the need to evaluate the efficacy and safety of these types of devices is paramount. A field study of the early implementation of UVGI devices was conducted at the Space Needle located in Seattle, Washington. Six devices were evaluated, including four low-pressure (LP) mercury-vapor lamp devices for air and surface sanitation not designed for human exposure and two krypton chloride (KrCl*) excimer lamp devices to be operated on and around humans. Emission spectra and ultraviolet (UV) irradiance at different locations from the UV devices were measured and germicidal effectiveness against SARS-CoV-2 was estimated. The human safety of KrCl* excimer devices was also evaluated based on measured irradiance and estimated exposure durations. Our results show all LP devices emitted UV radiation primarily at 254 nm as expected. Both KrCl* excimers emitted far UVC irradiation at 222 nm as advertised but also emitted at longer, more hazardous wavelengths (228 to 262 nm). All LP devices emitted strong UVC irradiance, which was estimated to achieve three log reduction of SARS-CoV-2 within 10 sec of exposure at reasonable working distances. KrCl* excimers, however, emitted much lower irradiance than needed for effective disinfection of SARS-CoV-2 (>90% inactivation) within the typical exposure times. UV fluence from KrCl* excimer devices for employees was below the American Conference of Governmental Industrial Hygienists (ACGIH) Threshold Limit Values (TLVs) under the reported device usage and work shifts. However, photosensitive individuals, human susceptibility, or exposure to multiple UV sources throughout a worker's day, were not accounted for in this study. Caution should be used when determining the acceptability of UV exposure to workers in this occupational setting and future work should focus on UVGI sources in public settings.


Assuntos
COVID-19 , SARS-CoV-2 , COVID-19/epidemiologia , COVID-19/prevenção & controle , Desinfecção/métodos , Humanos , Saúde Pública , Raios Ultravioleta
6.
Catheter Cardiovasc Interv ; 98(3): 607-612, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-33817969

RESUMO

BACKGROUND: Urgent transcatheter aortic valve implantation (TAVI) is a feasible option for aortic stenosis (AS) patients with decompensated heart failure (HF) and cardiogenic shock (CS) as compared to the more traditional urgent balloon aortic valvuloplasty (BAV). OBJECTIVES: We conducted a retrospective analysis to compare risk and cause of readmission in these two high-risk groups. METHODS: Nationwide Readmission Database (NRD) 2011-2014 was retrospectively analyzed to identify patients with AS having either urgent TAVI or urgent BAV using appropriate ICD-9 codes. Propensity scores were used to match patients with urgent TAVI as compared to patients with urgent BAV. Statistical analysis was performed using the Stata 15.1 software. RESULTS: We identified a weighted sample of 6,670 patients with urgent BAV and 6,964 patients with urgent TAVI. The all-cause 30- and 90-day readmission was lower in the urgent TAVI group compared to urgent BAV (15.4 vs. 22.5%, (aHR): 0.92 [0.90-0.95] p < .001). 30-day readmission due to CV cause and HF was also lower in the urgent TAVI group (aHR, 0.93: p < .001 and aHR, 0.98: p = .040, respectively). The 30-day gastrointestinal (GI) bleed readmission rate was three times higher in urgent TAVI group (aHR, 3.00:95% CI (1.23-7.33), p = .016), but was not statistically significant at 90-days. Cardiac causes of readmission were the predominant cause of readmission in both groups, but more pronounced in urgent BAV group (60.3 vs. 40.5%, p < .001). CONCLUSION: Urgent TAVI appears beneficial in patients with AS and decompensated HF or CS driven by roughly 10 and 25% reductions in overall readmissions at 30 and 90 days, and marked reductions in reintervention, although offset partially by higher risk of readmission due to GI bleeding at 30 days.


Assuntos
Estenose da Valva Aórtica , Valvuloplastia com Balão , Insuficiência Cardíaca , Substituição da Valva Aórtica Transcateter , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Valvuloplastia com Balão/efeitos adversos , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/terapia , Humanos , Readmissão do Paciente , Estudos Retrospectivos , Fatores de Risco , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/etiologia , Choque Cardiogênico/terapia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do Tratamento
7.
Clin Exp Rheumatol ; 39 Suppl 130(3): 115-119, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33938797

RESUMO

OBJECTIVES: Medications have only small to moderate effects on symptoms in fibromyalgia (FM). Cannabinoids, including medical cannabis (MC) may have potential to fill this gap. Since recreational legalisation of cannabis in Canada, patients have easier access and may be self-medicating with cannabis. We have examined the prevalence and characteristics of MC use in FM patients. METHODS: During a two-month period (June-August 2019), consecutive attending rheumatology patients participated in an onsite survey comprising 2 questionnaires: 1) demographic and disease information completed by the rheumatologist, 2) patient anonymous questionnaire of health status, cannabis use (recreational and/or medicinal) and characteristics of use. RESULTS: In a cohort of 1000 rheumatology attendees, 117 (11.7%) were diagnosed with FM. Ever use of MC was reported by 28 (23.9%; 95%CI: 16.5%-32.7%) FM patients compared to 98 (11.1%; 95%CI: 9.1%-13.4%) non-FM patients. Among FM ever users, 17 (61%) patients continued use of MC. FM ever users vs. FM nonusers tended to be younger, 53 vs. 58 years (p=0.072), were more likely unemployed or disabled 39% vs. 17% (p=0.019) and used more medication types (p=0.013) but did not differ in symptom severity parameters. Cigarette smoking and recreational cannabis were more common in ever users. Global symptom relief on a VAS (1-10) was 7.0±2.3. CONCLUSIONS: FM patients have commonly used MC, with more than half continuing use. Reported symptom relief was substantial. Cigarette smoking and recreational cannabis use may play a facilitatory role in MC use in FM. Adjunctive MC may be a treatment consideration for some FM patients.


Assuntos
Cannabis , Fibromialgia , Maconha Medicinal , Canadá/epidemiologia , Cannabis/efeitos adversos , Estudos Transversais , Fibromialgia/epidemiologia , Humanos , Maconha Medicinal/uso terapêutico
8.
Circ Res ; 120(2): 324-331, 2017 Jan 20.
Artigo em Inglês | MEDLINE | ID: mdl-27821724

RESUMO

RATIONALE: Despite direct immediate intervention and therapy, ST-segment-elevation myocardial infarction (STEMI) victims remain at risk for infarct expansion, heart failure, reinfarction, repeat revascularization, and death. OBJECTIVE: To evaluate the safety and bioactivity of autologous CD34+ cell (CLBS10) intracoronary infusion in patients with left ventricular dysfunction post STEMI. METHODS AND RESULTS: Patients who underwent successful stenting for STEMI and had left ventricular dysfunction (ejection fraction≤48%) ≥4 days poststent were eligible for enrollment. Subjects (N=161) underwent mini bone marrow harvest and were randomized 1:1 to receive (1) autologous CD34+ cells (minimum 10 mol/L±20% cells; N=78) or (2) diluent alone (N=83), via intracoronary infusion. The primary safety end point was adverse events, serious adverse events, and major adverse cardiac event. The primary efficacy end point was change in resting myocardial perfusion over 6 months. No differences in myocardial perfusion or adverse events were observed between the control and treatment groups, although increased perfusion was observed within each group from baseline to 6 months (P<0.001). In secondary analyses, when adjusted for time of ischemia, a consistently favorable cell dose-dependent effect was observed in the change in left ventricular ejection fraction and infarct size, and the duration of time subjects was alive and out of hospital (P=0.05). At 1 year, 3.6% (N=3) and 0% deaths were observed in the control and treatment group, respectively. CONCLUSIONS: This PreSERVE-AMI (Phase 2, randomized, double-blind, placebo-controlled trial) represents the largest study of cell-based therapy for STEMI completed in the United States and provides evidence supporting safety and potential efficacy in patients with left ventricular dysfunction post STEMI who are at risk for death and major morbidity. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01495364.


Assuntos
Antígenos CD34/administração & dosagem , Transplante de Medula Óssea/métodos , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/terapia , Idoso , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/efeitos dos fármacos , Método Duplo-Cego , Feminino , Humanos , Infusões Intra-Arteriais/métodos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Transplante Autólogo/métodos , Resultado do Tratamento , Disfunção Ventricular Esquerda/etiologia
9.
Catheter Cardiovasc Interv ; 92(3): E168-E171, 2018 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-28303686

RESUMO

Acute afterload mismatch after surgery for mitral regurgitation (MR) with transient left ventricular dysfunction is well known, but not described after transcatheter mitral valve repair with MitraClip, except in functional MR and cardiomyopathy. MitraClip to manage acute severe MR and cardiogenic shock has also been rarely reported. We report here a 77-year-old female who presented with acute severe degenerative MR from a flail posterior leaflet, with cardiogenic shock requiring intra-aortic balloon pump support. She was medically stabilized and underwent successful MitraClip repair with mild residual MR, but developed acute afterload mismatch and severe left ventricular dysfunction and shock 24 hr after her procedure. Patient was medically managed with intra-aortic balloon pump and inotropic support. She subsequently fully recovered with normal ventricular function and was discharged after 14 days. Patient remained asymptomatic in NYHA I functional class 9 months after MitraClip repair, with mild residual MR and normal ventricular function. MitraClip repair in patients with acute severe degenerative MR and cardiogenic shock is a less invasive and potentially safer alternative to open surgery, but acute afterload mismatch may occur and requires prompt diagnosis and management for a successful outcome. © 2017 Wiley Periodicals, Inc.


Assuntos
Implante de Prótese de Valva Cardíaca/instrumentação , Hemodinâmica , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Choque Cardiogênico/fisiopatologia , Disfunção Ventricular Esquerda/fisiopatologia , Função Ventricular Esquerda , Idoso , Ecocardiografia Doppler em Cores , Ecocardiografia Transesofagiana , Feminino , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Balão Intra-Aórtico , Valva Mitral/diagnóstico por imagem , Valva Mitral/fisiopatologia , Insuficiência da Valva Mitral/complicações , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/fisiopatologia , Desenho de Prótese , Recuperação de Função Fisiológica , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/etiologia , Choque Cardiogênico/terapia , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/etiologia , Disfunção Ventricular Esquerda/terapia
10.
J Interv Cardiol ; 31(6): 907-915, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30168203

RESUMO

OBJECTIVES: We report our multicenter experience on continuous hemodynamic monitoring using exclusively the steerable guide catheter (SGC) during MitraClip repair. BACKGROUND: Left atrial pressure (LAP) and V-wave are useful to evaluate MitraClip repair but no simple method of continuous monitoring exists. METHODS: From 11/2016 to 8/2017, 74 patients from four centers with symptomatic moderate-severe to severe mitral regurgitation (MR), underwent MitraClip NT repair with continuous hemodynamic monitoring via the SGC. Real-time LAP/V-wave changes were compared with transesophageal echocardiography (TEE). When mitral stenosis was suspected, transmitral gradients were verified by invasive hemodynamics. Clinical and echocardiographic outcomes were determined. RESULTS: Mean age was 78 ± 10 years and STS score 9.1 ± 11.0%. Pathology included leaflet prolapse/flail (45%), restriction (35%), and mixed (20%). Number of clips averaged 1.7 ± 0.7 per case. There was a significant reduction in LAP (21 ± 10 to 15 ± 7 mmHg, P < 0.0001) and V-wave(37 ± 19 to 24 ± 10 mmHg, P < 0.0001) post MitraClip, but the decrease was less in patients with atrial fibrillation (P < 0.05). Transmitral gradient significantly increased from 2.0 ± 1.2 to 4.0 ± 1.7 mmHg (P < 0.0001). Paradoxical increases in LAP and V-wave despite MR reduction were observed in three cases requiring MitraClip repositioning or retrieval to avoid stenosis. Follow-up averaged 5.0 ± 2.9 months and was 100% complete. KCCQ improvement was significant and MR reduction to <1+ was 67% and <2+ was 93% at 30 days. CONCLUSIONS: Continuous hemodynamic monitoring using the SGC complements TEE to assess and optimize MitraClip repair in real-time. Further validation is necessary but this feature may be part of future MitraClip and other transcatheter mitral repair systems.


Assuntos
Cateterismo Cardíaco/métodos , Monitorização Hemodinâmica/métodos , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Cateteres Cardíacos , Ecocardiografia Transesofagiana/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/fisiopatologia , Sistema de Registros , Estudos Retrospectivos , Instrumentos Cirúrgicos/efeitos adversos , Resultado do Tratamento
11.
Aust N Z J Psychiatry ; 52(5): 435-445, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29103308

RESUMO

OBJECTIVE: Parenthood is central to the personal and social identity of many people. For individuals with psychotic disorders, parenthood is often associated with formidable challenges. We aimed to identify predictors of adequate parenting among parents with psychotic disorders. METHODS: Data pertaining to 234 parents with psychotic disorders living with dependent children were extracted from a population-based prevalence study, the 2010 second Australian national survey of psychosis, and analysed using confirmatory factor analysis. Parenting outcome was defined as quality of care of children, based on participant report and interviewer enquiry/exploration, and included level of participation, interest and competence in childcare during the last 12 months. RESULTS: Five hypothesis-driven latent variables were constructed and labelled psychosocial support, illness severity, substance abuse/dependence, adaptive functioning and parenting role. Importantly, 75% of participants were not identified to have any dysfunction in the quality of care provided to their child(ren). Severity of illness and adaptive functioning were reliably associated with quality of childcare. Psychosocial support, substance abuse/dependence and parenting role had an indirect relationship to the outcome variable via their association with either severity of illness and/or adaptive functioning. CONCLUSION: The majority of parents in the current sample provided adequate parenting. However, greater symptom severity and poorer adaptive functioning ultimately leave parents with significant difficulties and in need of assistance to manage their parenting obligations. As symptoms and functioning can change episodically for people with psychotic illness, provision of targeted and flexible support that can deliver temporary assistance during times of need is necessary. This would maximise the quality of care provided to vulnerable children, with potential long-term benefits.


Assuntos
Adaptação Psicológica , Educação Infantil , Filho de Pais com Deficiência , Poder Familiar , Pais , Transtornos Psicóticos , Índice de Gravidade de Doença , Adulto , Austrália , Criança , Análise Fatorial , Feminino , Inquéritos Epidemiológicos , Humanos , Masculino , Pessoa de Meia-Idade , Apoio Social , Adulto Jovem
12.
Aust N Z J Psychiatry ; 51(2): 124-140, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27913580

RESUMO

OBJECTIVE: The objective is to summarise recent findings from the 2010 Australian Survey of High Impact Psychosis (SHIP) and examine their implications for future policy and planning to improve mental health, physical health and other circumstances of people with a psychotic disorder. METHODS: Survey of High Impact Psychosis collected nationally representative data on 1825 people with psychotic illness. Over 60 papers have been published covering key challenges reported by participants: financial problems, loneliness and social isolation, unemployment, poor physical health, uncontrolled symptoms of mental illness, and lack of stable, suitable housing. Findings are summarised under the rubric of participant-ranked top challenges. RESULTS: The main income source for the majority (85%) of participants was a government benefit. Only one-third was employed, and the most appropriate employment services for this group were under-utilised. High rates of loneliness and social isolation impacted mental and physical health. The rate of cardiometabolic disease was well above the general population rate, and associated risk factors were present from a very young age. Childhood abuse (30.6%), adult violent victimisation (16.4%) and alcohol and substance abuse/dependence (lifetime rates of 50.5% and 54.5%, respectively) complicated the clinical profile. Treatment with medication was suboptimal, with physical health conditions undertreated, a high rate of psychotropic polypharmacy and underutilisation of clozapine in chronic persistent psychotic illness. Only 38.6% received evidence-based psychosocial therapies. In the previous year, 27.4% had changed housing and 12.8% had been homeless, on average for 155 days. CONCLUSION: Money, social engagement and employment are the most important challenges for people with psychotic illness, as well as good physical and mental health. An integrated approach to recovery is needed to optimise service delivery and augment evidence-based clinical practice with measures to improve physical health and social circumstances. Meeting these challenges has the potential to reduce costs to government and society, as well as promote recovery.


Assuntos
Vítimas de Crime/estatística & dados numéricos , Emprego/estatística & dados numéricos , Nível de Saúde , Transtornos Psicóticos/epidemiologia , Isolamento Social , Austrália/epidemiologia , Inquéritos Epidemiológicos , Humanos
13.
Catheter Cardiovasc Interv ; 88(1): 135-43, 2016 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-26603266

RESUMO

OBJECTIVE: This study evaluates the feasibility and safety of a balloon-expandable, re-collapsible sheath for TAVR patients, including those with small iliofemoral access (≤5.0 mm). BACKGROUND: The recommended iliofemoral diameter for the CoreValve TAVR system is ≥6.0 mm, but the lowest limit has not been determined. METHODS: Of 322 consecutive patients who underwent TAVR from 1/2014 to 8/2015 at two institutions, 64 underwent transfemoral CoreValve implantation, using an 11/19-French balloon-expandable, re-collapsible sheath, which has a 4.45 mm outer diameter (OD) on arterial entry, expands to 7.67 mm, then re-collapses upon removal. Valve sizing and vascular access were determined by computed tomography, and outcomes were assessed using the Valve Academic Research Consortium 2 (VARC-2) definitions. RESULTS: Thirteen of 64 patients had a minimal iliofemoral artery luminal diameter (MLD) of ≤5.0 mm (mean 4.38+/-0.59 mm, range 3.1-5.0 mm), with vessel calcification ≤90° to 360° and tortuosity <45° to >90°. At the MLD point, the sheath-to-artery ratios, based on the fully expanded 7.67 mm OD, ranged 1.53-2.47, higher than previously reported ratios that risk vascular complications. Major comorbidities included chronic renal failure, severe chronic obstructive pulmonary disease, extreme thrombocytopenia, cirrhosis, prior cardiac surgery, poor ventricular function, and frailty. All 64 patients had TAVR with IV sedation and local anesthesia, with 0% sheath malfunction, 0% vascular complications, and 0% bleeding in-hospital and at 30 days per VARC-2 definitions. CONCLUSIONS: TAVR using a balloon-expandable, re-collapsible sheath is safe, including in small iliofemoral access ≤5.0 mm, thus considerably expanding the population suitable for transfemoral approach. © 2015 Wiley Periodicals, Inc.


Assuntos
Estenose da Valva Aórtica/terapia , Valva Aórtica , Bioprótese , Cateterismo Cardíaco/instrumentação , Cateterismo Periférico/instrumentação , Artéria Femoral , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Dispositivos de Acesso Vascular , Doenças Vasculares/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/diagnóstico por imagem , Cateterismo Cardíaco/efeitos adversos , Cateterismo Periférico/efeitos adversos , Angiografia por Tomografia Computadorizada , Estudos de Viabilidade , Feminino , Artéria Femoral/diagnóstico por imagem , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada Multidetectores , New York , Desenho de Prótese , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Texas , Resultado do Tratamento , Doenças Vasculares/etiologia
14.
15.
Acad Psychiatry ; 39(2): 174-80, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25398264

RESUMO

OBJECTIVE: This research sought to gain insight into the processes used by clinicians to discuss a schizophrenia diagnosis with patients/families, with the aim of informing the development of a communications skills training program. METHODS: A generic qualitative methodological approach was used. Sixteen mental health clinicians were recruited. Semi-structured individual interviews were used to explore their perceptions and experiences communicating a schizophrenia diagnosis. Interviews were recorded, transcribed, and thematic analysis undertaken. RESULTS: There were five key themes relating to the process of communication about a diagnosis of schizophrenia: (1) orientation to patient care, (2) planning of communication, (3) the impact of team leadership and inter/intra-professional functioning on communication tasks, (4) the roles of different clinicians in communicating about diagnosis and treatment, and (5) time and resource deficiencies. Despite expressing care and concern for vulnerable patients and embracing the concept of multidisciplinary teams, communicating diagnostic information to patients and families was generally unplanned for, with little consistency regarding leadership approaches, or how the team communicated diagnostic information to the patient and family. This contributed to tensions between different team members. CONCLUSION: The findings demonstrated a number of issues compromising good communication around a schizophrenia diagnosis, both in terms of clinician skill and clinical context, and support the importance of education and training for all members of the multidisciplinary team about their role in the communication process.


Assuntos
Internato e Residência , Liderança , Equipe de Assistência ao Paciente/organização & administração , Relações Médico-Paciente , Relações Profissional-Família , Prognóstico , Psiquiatria/educação , Esquizofrenia/diagnóstico , Adulto , Competência Clínica/normas , Barreiras de Comunicação , Educação/métodos , Feminino , Humanos , Internato e Residência/métodos , Internato e Residência/normas , Masculino , Avaliação das Necessidades , Pesquisa Qualitativa
16.
Australas Psychiatry ; 23(4): 429-31, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26104774

RESUMO

OBJECTIVE: Mental health clinicians can experience problems communicating distressing diagnostic information to patients and their families, especially about severe mental illnesses such as schizophrenia. Evidence suggests that interpersonal communication skills can be effectively taught, as has been demonstrated in the specialty of oncology. However, very little literature exists with respect to interpersonal communication skills training for psychiatry. This paper provides an overview of the communication skills training literature. CONCLUSIONS: The report reveals significant gaps exist and highlights the need for advanced communication skills training for mental health clinicians, particularly about communicating a diagnosis and/or prognosis of schizophrenia. A new communication skills training framework for psychiatry is described, based on that used in oncology as a model. This model promotes applied skills and processes that are easily adapted for use in psychiatry, providing an effective platform for the development of similar training programs for psychiatric clinical practice.


Assuntos
Comunicação , Currículo , Relações Médico-Paciente , Psiquiatria/educação , Humanos , Avaliação de Programas e Projetos de Saúde , Esquizofrenia/diagnóstico
17.
Cardiology ; 129(3): 137-43, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25277292

RESUMO

OBJECTIVES: Patients with profound cardiovascular compromise have poor prognosis despite inotropic and intra-aortic balloon pump (IABP) support. Peripheral venoarterial extracorporeal membrane oxygenation (V-A ECMO) offers these patients temporary support as a bridge to various options including the 'bridge to recovery'. METHODS: We studied the outcomes of 135 patients who underwent peripheral V-A ECMO and concomitant IABP implantation in our hospital from 2007 to 2012 for various clinical indications. The ECMO circuit consisted of a centrifugal pump and an oxygenator. RESULTS: V-A ECMO was implanted in the cardiac catheterization laboratory in 51 patients (37.8%), at the bedside in 5 (3.7%) and in the operating room in 79 (58.5%). Mean duration of support was 8.5 ± 7.1 days. Median length of stay was 28 days (interquartile range 14-62). Complications included bleeding at the access site in 14.1%, stroke in 11.1% and vascular complications requiring intervention in 16.3%. Overall inhospital survival was 57.8% with outcomes including heart transplantation (3%), implantable left ventricular assist device (8.1% as bridge to transplantation and 6.7% as destination therapy), surgery (7.4%) and myocardial recovery (40.7%). Prior IABP use and axillary cannulation were independent predictors of reduced inhospital mortality, stroke or vascular injury. CONCLUSIONS: Peripheral V-A ECMO with IABP is an effective therapy for patients with severely compromised cardiovascular function. It offers reasonable survival and a spectrum of definitive options from 'bridge to recovery' to heart transplantation for the management of this critically ill population.


Assuntos
Cardiomiopatias/terapia , Oxigenação por Membrana Extracorpórea , Coração Auxiliar , Balão Intra-Aórtico , Adulto , Idoso , Índice de Massa Corporal , Cardiomiopatias/mortalidade , Cuidados Críticos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Feminino , Transplante de Coração/métodos , Mortalidade Hospitalar , Humanos , Pacientes Internados , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Resultado do Tratamento , Estados Unidos
18.
Soc Psychiatry Psychiatr Epidemiol ; 49(11): 1729-37, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-24789454

RESUMO

PURPOSE: Registers derived from administrative datasets are valuable tools in psychosis research, but diagnostic accuracy can be problematic. We sought to compare the relative performance of four methods for assigning a single diagnosis from longitudinal administrative clinical records when compared with reference diagnoses. METHODS: Diagnoses recorded in inpatient and community mental health records were compared to research diagnoses of psychotic disorders obtained from semi-structured clinical interviews for 289 persons. Diagnoses were derived from administrative datasets using four algorithms; 'At least one' diagnosis, 'Last' or most recent diagnosis, 'Modal' or most frequently occurring diagnosis, and 'Hierarchy' in which a diagnostic hierarchy was applied. Agreements between algorithm-based and reference diagnoses for overall presence/absence of psychosis and for specific diagnoses of schizophrenia, schizoaffective disorder, and affective psychosis were examined using estimated prevalence rates, overall agreement, ROC analysis, and kappa statistics. RESULTS: For the presence/absence of psychosis, the most sensitive and least specific algorithm ('At least one' diagnosis) performed best. For schizophrenia, 'Modal' and 'Last' diagnoses had greatest agreement with reference diagnosis. For affective psychosis, 'Hierarchy' diagnosis performed best. Agreement between clinical and reference diagnoses was no better than chance for diagnoses of schizoaffective disorder. Overall agreement between administrative and reference diagnoses was modest, but may have been limited by the use of participants who had been screened for likely psychosis prior to assessment. CONCLUSION: The choice of algorithm for extracting a psychosis diagnosis from administrative datasets may have a substantial impact on the accuracy of the diagnoses derived. An 'Any diagnosis' algorithm provides a sensitive measure for the presence of any psychosis, while 'Last diagnosis' is more accurate for specific diagnosis of schizophrenia and a hierarchical diagnosis is more accurate for affective psychosis.


Assuntos
Transtornos Psicóticos Afetivos/diagnóstico , Algoritmos , Prontuários Médicos , Transtornos Psicóticos/diagnóstico , Esquizofrenia/diagnóstico , Adolescente , Adulto , Transtornos Psicóticos Afetivos/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Probabilidade , Escalas de Graduação Psiquiátrica/estatística & dados numéricos , Transtornos Psicóticos/epidemiologia , Esquizofrenia/epidemiologia , Adulto Jovem
19.
Australas Psychiatry ; 22(1): 32-40, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24288380

RESUMO

OBJECTIVE: A tool for psychiatric case formulation known as pattern-based formulation (PBF) has been recently introduced. This paper presents an application of this methodology in formulating and managing complex clinical cases. METHOD: The symptomatology of the clinical presentation has been parsed into individual clinical phenomena and interpreted by selecting explanatory models. RESULTS: The clinical presentation demonstrates how PBF has been used as a clinical tool to guide clinicians' thinking, that takes a structured approach to manage multiple issues using a broad range of management strategies. In doing so, the paper also introduces a number of patterns related to the observed clinical phenomena that can be re-used as explanatory models when formulating other clinical cases. CONCLUSION: It is expected that this paper will assist clinicians, and particularly trainees, to better understand PBF methodology and apply it to improve their formulation skills.


Assuntos
Transtornos Mentais/diagnóstico , Transtornos Mentais/psicologia , Psiquiatria/métodos , Ira , Antidepressivos/intoxicação , Ansiedade/etiologia , Ansiedade/psicologia , Bullying/psicologia , Transtorno Depressivo/etiologia , Transtorno Depressivo/psicologia , Overdose de Drogas , Resistência a Medicamentos , Eletroconvulsoterapia , Feminino , Culpa , Humanos , Relações Interpessoais , Mães , Assédio Sexual/psicologia , Vergonha , Transtornos de Estresse Pós-Traumáticos/psicologia , Transtornos de Estresse Pós-Traumáticos/terapia , Tentativa de Suicídio , Adulto Jovem
20.
Oncologist ; 18(4): 460-6, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23576486

RESUMO

On November 7, 2011, the U.S. Food and Drug Administration approved cetuximab in combination with cisplatin or carboplatin and 5-fluorouracil for the first-line treatment of patients with recurrent locoregional or metastatic squamous cell head and neck cancer. Approval was based on a randomized study of 442 patients conducted outside the U.S. Cisplatin (100 mg/m2 intravenously) or carboplatin (area under the curve 5 intravenously) on day 1 with 5-fluorouracil (1,000 mg/m2/day continuous intravenous infusion days 1-4) were administered every 3 weeks. Cetuximab, 400 mg/m2 intravenously, was administered initially followed by cetuximab, 250 mg/m2 intravenously weekly. After completion of six planned treatment courses, cetuximab patients without progression continued cetuximab 250 mg/m2 weekly. The study used European Union (EU)-approved cetuximab rather than U.S.-approved cetuximab. U.S.-approved cetuximab provides approximately 28% higher exposure relative to EU-approved cetuximab in a pharmacokinetic comparability study in monkeys. Overall survival, the primary efficacy endpoint, was significantly improved in cetuximab-treated patients (hazard ratio [HR]: 0.80; 95% confidence interval [CI]: 0.64-0.98; p = .034, stratified log-rank test). Median survival times were 10.1 and 7.4 months, respectively. Progression-free survival (PFS) was also significantly improved in patients receiving cetuximab (HR: 0.57; 95% CI: 0.46-0.72; p < .0001). Median PFS times were 5.5 and 3.3 months, respectively. Response rates were 35.6% and 19.5% (odds ratio: 2.33; 95% CI: 1.50-3.60; p = .0001). Adverse reactions (≥25%) from cetuximab plus chemotherapy treatment included nausea, anemia, vomiting, neutropenia, rash, asthenia, diarrhea, and anorexia. Conjunctivitis occurred in 10% of cetuximab patients. Other adverse reactions, sometimes severe, included infusion reactions, hypomagnesemia, hypocalcemia, and hypokalemia.


Assuntos
Anticorpos Monoclonais Humanizados/administração & dosagem , Carcinoma de Células Escamosas/tratamento farmacológico , Cisplatino/administração & dosagem , Fluoruracila/administração & dosagem , Neoplasias de Cabeça e Pescoço/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Cetuximab , Intervalo Livre de Doença , Aprovação de Drogas , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , União Europeia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Metástase Neoplásica/tratamento farmacológico , Metástase Neoplásica/patologia , Recidiva Local de Neoplasia/tratamento farmacológico , Recidiva Local de Neoplasia/patologia , Carcinoma de Células Escamosas de Cabeça e Pescoço
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