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BACKGROUND: Different types of interventions have been assessed for the prevention of adverse events. However, determining which patient-safety practice is most effective can be challenging when there is no systematised evidence synthesis. An overview following the best methodological standards can provide the best reliable integrative evidence. OBJECTIVES: The objective of this study was to provide an overview of effectiveness nonpharmacological interventions aimed at preventing adverse events in the intensive care unit. METHODS: A review of systematic reviews (SRs) was conducted according to the Cochrane Handbook and PRISMA recommendations. PubMed, CINAHL, and Cochrane Library were searched for SRs published until March 2022. Two reviewers independently assessed the study's quality, using AMSTAR-2, and extracted data on intervention characteristics and effect on prevention of adverse events. RESULTS: Thirty-seven SRs were included, and 27 nonpharmacological interventions were identified to prevent 11 adverse events. Most of the reviews had critically low methodological quality. Among all the identified interventions, subglottic secretion drainage, semirecumbent position, and kinetic bed therapy were effective in preventing ventilator-associated pneumonia; the use of earplugs, early mobilisation, family participation, and music in reducing delirium; physical rehabilitation in improving muscle strength; use of respiratory support in preventing reintubation; the use of a computerised physician order entry system in reducing risk of medication errors; and the use of heated water humidifier was effective in reducing artificial airway occlusion. CONCLUSIONS: Some nonpharmacological interventions reduced adverse events in the intensive care setting. These findings should be interpreted carefully due to the low methodological quality. SRs on preventing adverse events in the intensive care unit should adhere to quality assessment tools so that best evidence can be used in decision-making.
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Cuidados Críticos , Unidades de Terapia Intensiva , Humanos , Unidades de Terapia Intensiva/normas , Revisões Sistemáticas como AssuntoRESUMO
BACKGROUND: The need to reduce healthcare practices that provide no value has led to the development of initiatives that generate and publish recommendations to improve the appropriateness of clinical practice by identifying potentially inappropriate services, making recommendations, and proposing improvements. DianaHealth (www.dianahealth.com) identifies, classifies, and publishes recommendations from numerous scientific societies. The purpose of this study was to determine the awareness and perceived usefulness and applicability of published recommendations on low-value diagnostic measures, as judged by physicians who are recognised clinical leaders in their respective centres. METHODS: We designed a questionnaire on the diagnostic recommendations considered relevant for each medical specialty and made it available, until September 2016, on DianaHealth. The survey was administered online to clinical leaders from 25 Spanish healthcare centres (hospitals and primary care centres). RESULTS: A total of 413 (40.0%) physicians from 34 different specialties participated. The participation rate varied between centres (range 21.1%-100.0%) and specialties (range 12.5%-78.9%). Do Not Do (57.1%) was the most widely-known initiative. Most participants (82.6%; IQR 77.9%-94.9%) stated that they knew at least one of the 12 initiatives that identify non-recommended practices, and on average they were aware of four initiatives (range 1-12). The initiatives were perceived useful by 82.4% (IQR 73.3%-90.4%), and perceived applicable by 75.6% (IQR 67.4%-86.8%). A total of 531 recommendations were assessed. Sixty-three percent (IQR 53.6%-77.5%) of participants reported they were aware of the recommendations for their corresponding specialty. A total of 84.5% (IQR 75.0%-90.0%) stated they agreed with the recommendations and 84.5% (IQR 75.0%-90.0%) considered them useful. Among those who agreed with their respective recommendations, a median of 51.5% (IQR 41.4%-60.9%) perceived the guidelines as being fully implemented, 40.1% (IQR 31.9%-46.8%) considered them partially implemented, and 7.1% (IQR 3.7%-12.9%), not implemented. CONCLUSIONS: Clinical leaders' awareness of initiatives that generate and publish recommendations to improve clinical appropriateness remains low, although they did consider them useful. In general, participants were familiar with their speciality-specific diagnostic recommendations, agreed with them, and perceived them as useful and implemented in their centres. More needs to be done to raise awareness among professionals who do not know of or apply these recommendations.
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Técnicas e Procedimentos Diagnósticos , Conhecimentos, Atitudes e Prática em Saúde , Médicos/psicologia , Guias de Prática Clínica como Assunto , Estudos Transversais , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Liderança , Espanha , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Complications arising from airway management represent an important cause of morbidity and mortality. Clinical practice guidelines (CPGs) are systematically created documents that summarise knowledge and assist the delivery of high-quality medical care by identifying evidence that supports best clinical care. OBJECTIVE: Using the Appraisal of Guidelines for Research & Evaluation II instrument, we aimed to evaluate the methodological rigour and transparency of unanticipated difficult airway management CPGs in adults. DESIGN: Using PUBMED without language restrictions, we identified eligible CPGs between 1 January 1996 and 30 June 2019. All versions of a CPG were included as independent guidelines to assess improvements over time or the methodological limitations of each version. CPGs-related obstetrics or paediatrics or the management extubation in cases of difficult airway were excluded. RESULTS: Fourteen CPGs were included. Of the six domains suggested by the Appraisal of Guidelines for Research & Evaluation II instrument, 'applicability' had the lowest score (23%) and 'scope and objectives' had the highest score (88%). The remaining domains (stakeholder involvement, editorial independence, rigour of development and clarity of presentation) had scores ranging between 56 and 81%. Overall, the highest scored CPG was the Difficult Airway Society 2015. CONCLUSION: Future updates of CPGs for difficult airway management in adults and severely ill patients should consider more emphasis on the applicability of their recommendations to real clinical practice.
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Manuseio das Vias Aéreas , Qualidade da Assistência à Saúde , Adulto , Criança , HumanosRESUMO
BACKGROUND: There is paucity in the level of knowledge on the actual insurer expenses associated with patients suffering with dementia in the developing world. Less is known about direct costs by severity and how costs vary because of the presence of other comorbidities. METHODS: Using claims data from an insurer for three years, we identified patients with AD with an algorithm that takes advantage of information on age, primary diagnosis, and services and drugs provided. RESULTS: Distribution by dementia stage was as follows: mild 21%, moderate 53%, severe 17%, and undetermined 9%. Expenses paid for all causes by the insurer were at least double than estimated in the literature and were increasing annually at rates higher than 30%. Also, 92% of patients have at least another chronic condition. CONCLUSIONS: Worldwide costs of dementia estimates maybe underestimating the actual costs to health systems in the developing world.
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Doença de Alzheimer/economia , Custos de Medicamentos/estatística & dados numéricos , Custos de Cuidados de Saúde/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Doença de Alzheimer/tratamento farmacológico , Colômbia , Comorbidade , Efeitos Psicossociais da Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fármacos Neuroprotetores/uso terapêutico , Análise de Regressão , Índice de Gravidade de DoençaRESUMO
BACKGROUND: Hemophagocytic lymphohistiocytosis (HLH) is characterized by uncontrolled activation of inflammatory cells and an exaggerated release of cytokines. It can be triggered by different factors, including viruses, such as dengue. The objective of this study was to characterize the clinical and laboratory profiles of children with severe dengue and HLH, and to identify the risk factors for this clinical complication. METHODS: An analytical study was conducted in children with severe dengue who were treated in an intensive care unit between January 2019 and March 2020. Clinical and laboratory factors were compared between patients with and without HLH. RESULTS: HLH represented 13.4% (15/112) of children with severe dengue. Patients with HLH had a long-lasting fever (10.1 vs. 5.8 days; P = 0.012), low hemoglobin levels (7.6 vs. 10.8 g/dL; P = 0.000) and high aspartate aminotransferase values (4443 vs. 1061 U/L; P = 0.002), alanine transaminase (1433 vs. 487 U/L; P = 0.004), partial thromboplastin time (80.6 vs. 51.8 seconds; P = 0.010), prothrombin time (23.5 vs. 19.6 seconds; P = 0.024), triglycerides (333.7 vs. 223.2 mg/dL; P = 0.005), lactate dehydrogenase (4209 vs. 1947 U/L; P = 0.006), soluble CD25 (3488 vs. 1026 pg/mL; P = 0.014), and presented with higher frequency of myocarditis (66.7% vs. 38.3%; P = 0.048), hepatitis (5.3% vs. 1.3%; P = 0.014), bacterial coinfection (73.3% vs. 26.7%; P = 0.010) and fatal outcome (26% vs. 5%; P = 0.037). CONCLUSIONS: HLH is a serious life-threatening clinical complication of dengue virus infection that must be considered, particularly during outbreaks.
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Linfo-Histiocitose Hemofagocítica , Dengue Grave , Humanos , Criança , Dengue Grave/complicações , Dengue Grave/epidemiologia , Linfo-Histiocitose Hemofagocítica/epidemiologia , Linfo-Histiocitose Hemofagocítica/tratamento farmacológico , Colômbia/epidemiologia , Estudos Retrospectivos , Surtos de DoençasRESUMO
BACKGROUND: We evaluated a strategy to shorten the time from admission to surgery in patients with proximal femur fractures on chronic antiplatelet therapy. We reported a 12-month follow-up on complications and quality of life (QoL). METHODS: Multicentre, open-label, randomized, parallel clinical trial. Patients were randomized to either early platelet function-guided surgery (experimental group) or delayed surgery (control group). Medical and surgical complications and QoL (EQ-5D-5L questionnaire) were assessed during the hospital stay, and after hospital discharge at 30 days, and 6 and 12 months. RESULTS: From 156 randomized patients, 143 patients underwent surgery. The mean age was 85.5 (7.8) years and 68.0% were female. After hospital discharge, 5.7% of patients had surgical wound complications and 55.9% had medical complications, with 42.7% having serious adverse events. QoL improved significantly after surgery, with the best scores at the six-month follow-up. The overall mortality was 32.2%. There were no differences between early and delayed surgery groups in any assessed outcomes. CONCLUSION: It seems safe to reduce the time of surgery under neuraxial anaesthesia in patients with hip fractures on chronic antiplatelet therapy by platelet function testing. QoL in particular improves in the first six months after surgery.
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This study aimed to establish factors associated with delayed surgery in patients with proximal femoral fracture and to assess patients' health-related quality of life (HRQoL) after surgery including all-cause 6-months mortality. This was a single-center, observational, prospective cohort study that included patients with a proximal femur fracture. We described patients' HRQoL measured by EuroQoL (EQ-5D-5L and EQ-VAS) questionnaire and perioperative complications (including mortality) 6 months after surgery. We included 163 patients with a mean age of 80.5 years, the majority were women and 76.1% reported falling from their own height. The mean time between hospital admission and surgery was 8.3 days (SD 4.9 days) and the mean hospital stay was 13.5 days (SD 10.4 days). After adjustment, the principal factor associated with delayed surgery was adjournment in surgery authorization (3.7 days). EQ-5D-5L index values and the VAS score at 1 month after surgery were 0.489 and 61.1, at 3 months were 0.613 and 65.8, and at 6 months 0.662 and 66.7 respectively. Mortality at 6 months of follow-up was 11% (18 patients). In conclusion, administrative authorization was the strongest associated factor with delayed time from hospital admission to surgery. HRQoL of patients with a proximal femoral fracture improved 6 months after surgery.Trial registration: NCT04217642.
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Fraturas Proximais do Fêmur , Humanos , Feminino , Masculino , Idoso de 80 Anos ou mais , Estudos Prospectivos , Qualidade de Vida , Acidentes por Quedas , HospitalizaçãoRESUMO
Hemostasis is crucial for reducing bleeding during surgical procedures. The points-of-care based on the platelet function test could be useful to minimize the complications related to chronic antiplatelet therapy during surgery. The present study is aimed at comparing two point-of-care platelet function devices-Platelet Function Analyzer PFA-100® (Siemens Canada, Mississauga, ON, Canada) and Plateletworks®(Helena Laboratories, Beaumont, TX, USA). Our objective is to evaluate if they provide comparable and useful information to manage anti-aggregate patients before surgery. We included patients with a femoral fracture receiving chronic antiplatelet therapy and a median age of 89 years (range from 70 to 98). A platelet function evaluation was performed on all patients before surgery using both devices-Plateletworks® and PFA-100®. The correlation between Plateletworks® and PFA-100® was performed using Cohen's Kappa coefficient. Twenty consecutive patients participated in the trial; 16 patients were under treatment with 75 mg/day of clopidogrel, three with >300 mg/day of acetylsalicylic acid (ASA), and only one was in treatment with both antiplatelet agents. Cohen's Kappa coefficient was 0.327 comparing PFA-100®-ADP (adenosine diphosphate) and Plateletworks® and, 0.200 comparing PFA-100®-EPI (epinephrine) and Plateletworks®. In conclusion, we found a weak concordance comparing PFA-100® and Plateletworks®. This could partially be due to the advanced age of the included patients. However, given the limited sample size, more studies are necessary to confirm these results.
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BACKGROUND: Patients with proximal femur fracture on antiplatelet treatment benefit from early surgery. Our goal was to perform early surgery under neuraxial anaesthesia when indicated by the platelet function test. METHODS: We conducted a multicentre randomised open-label parallel clinical trial. Patients were randomised to either early platelet function-guided surgery (experimental group) or delayed surgery (control group). Early surgery was programmed when the functional platelet count (as measured by Plateletworks) was >80 × 109/L. The primary outcome was the emergency admission-to-surgery interval. Secondary outcomes were platelet function, postoperative bleeding, medical and surgical complications, and mortality. RESULTS: A total of 156 patients were randomised, with 78 in each group, with a mean (SD) age of 85.96 (7.9) years, and 67.8% being female. The median (IQR) time to surgery was 2.3 (1.5-3.7) days for the experimental group and 4.9 (4.4-5.6) days for the control group. One-third of patients did not achieve the threshold functional platelet count on the first day of admission, requiring more than one test. There was no difference in clinical outcomes between groups. CONCLUSIONS: A strategy individualised according to the platelet function test shortens the time to proximal femur fracture surgery under neuraxial anaesthesia in patients on chronic antiplatelet treatment. Better powered randomised clinical trials are needed to further evaluate the clinical impact and safety of this strategy.
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BACKGROUND: The applicability of clinical practice guidelines (CPGs) on treatments for oral cancer remains unknown since there are no systematic assessments of their quality. Thus, the objective of this study is to identify and assess the quality of them. METHODS: We conducted a systematic search to identify CPGs that provided recommendations on treatments for oral cancer. The quality of each included CPG was determined using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument, by four appraisers independently. The inter-appraisers agreement was assessed. RESULTS: Twelve CPGs met the eligibility criteria. Overall agreement among appraisers was very good (ICC: 0.865; 95% CI: 0.835-0.889). The mean scores for each AGREE domain were the following: "scope and purpose" 88.4%±12.4%; "stakeholder involvement" 60.4%±25%; "rigor of development" 60.9%±25.3%; "clarity of presentation" 76.5%±19.8%; "applicability" 32.2%±30.7%; and "editorial independence" 61.6%±35.5%. Three CPGs were rated as "recommended"; six as "recommended with modifications"; and three as "not recommended". CONCLUSIONS: Overall, the quality of CPGs on treatments for oral cancer is suboptimal. These findings highlight the need to improve CPG development processes and their applicability in this field. Thus, increased efforts are required to enable the development of high-quality evidence-based CPGs for oral cancer.
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Oncologia/métodos , Oncologia/normas , Neoplasias Bucais/terapia , Guias de Prática Clínica como Assunto/normas , Carcinoma de Células Escamosas/terapia , Neoplasias de Cabeça e Pescoço/terapia , Humanos , Garantia da Qualidade dos Cuidados de Saúde , Carcinoma de Células Escamosas de Cabeça e PescoçoRESUMO
Introducción. El tejido mamario accesorio es una anomalía congénita que se presenta en el 2-6 % de la población femenina. En este tejido se pueden desarrollar las mismas patologías que en la mama normal. El manejo curativo es la resección quirúrgica. El objetivo de este estudio fue comparar los resultados de la técnica de resección vía abierta de tejido mamario accesorio con dren vs sin dren. Métodos. Se realizó un estudio observacional tipo cohorte retrospectivo, teniendo en cuenta dos grupos de pacientes con tejido mamario accesorio: a uno de ellos se les realizó resección quirúrgica mediante técnica abierta con dren y al otro grupo sin dren. Además, se incluyó un brazo prospectivo donde se evaluó la calidad de vida y la satisfacción de las pacientes con el resultado posoperatorio mediante el uso de la herramienta Breast-Q. Resultados. Se recolectó la información de 82 pacientes, la mayoría mujeres; 22 se intervinieron con técnica con dren y 60 con técnica sin dren. 13,6 % de los pacientes presentaron complicaciones tempranas, siendo la infección de sitio operatorio la más frecuente (36,4 %). En general, las complicaciones fueron más comunes en el grupo con dren (40,9 % vs 3,4 %), con una diferencia estadísticamente significativa (p=0,000). La calidad de vida fue similar en ambos grupos. Conclusiones. Los pacientes a quienes se les realizó resección de mama supernumeraria y se dejó un sistema de drenaje en el lecho de disección presentaron más complicaciones posoperatorias que las pacientes a quienes no se les dejó dren
Introduction. Accessory breast tissue is a congenital anomaly that occurs in 2-6% of the female population. It can develop the same pathologies that in the normal breast. The curative management of this pathology is surgical resection. The objective of this study was to compare the results of the accessory breast tissue open resection technique with a drain vs without a drain. Methods. An observational retrospective cohort study was conducted considering two groups of patients with accessory breast tissue: one of them underwent surgical resection using an open technique with a drain and the other group without a drain. In addition, a prospective arm where the quality of life and satisfaction of the patients with the postoperative result was evaluated by the Breast-Q tool. Results. Eighty-two patients were included, most of them women; 22 were operated with open technique with drain and 60 without drain. 13.6% of patients presented early complications, with surgical site infection being the most frequent (36.4%) and, in general, complications were more common in the group with drain (40.9% vs 3.4%) with a statistically significant difference (p=0.000). Quality of life was similar in both groups.Conclusions. Patients who undergo supernumerary breast resection and leaving drainage in the dissection bed present more postoperative complications compared to those without drain
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Humanos , Complicações Pós-Operatórias , Doenças Mamárias , Drenagem , Cirurgia Geral , Mama , CoristomaRESUMO
Introducción. El tratamiento oncológico perioperatorio en pacientes con cáncer gástrico localmente avanzado está indicado; aun así, no siempre es posible. El objetivo de este estudio fue evaluar la supervivencia de los pacientes según la administración de quimioterapia perioperatoria. Métodos. Estudio observacional, tipo cohorte ambispectivo, incluyendo pacientes con cáncer gástrico localmente avanzado quienes recibieron o no quimioterapia perioperatoria. Resultados. Se incluyeron 33 pacientes, 90,9 % pertenecían al régimen subsidiado de salud y el 78,8 % en estadio T4. El grupo que recibió quimioterapia perioperatoria, que solo tuvo 5 pacientes (15,1 %), presentó mayor supervivencia global a 2 años (100 %), seguido del grupo de quimioterapia postoperatoria (58,8 %) y del grupo sin quimioterapia, que alcanzó una supervivencia global a 2 años de 54,5 %. Discusión. La supervivencia global fue mayor en el grupo de quimioterapia perioperatoria, consonante a lo descrito a nivel internacional, aunque los pacientes se encontraban en un estadío localmente más avanzado, la mayoría con T4 y N+ según AJCC VIII edición. Conclusiones. El estadío clínico es un factor pronóstico importante y, en nuestro medio, la mayoría de los pacientes consultan en estadíos localmente más avanzados. A eso se suman las dificultades en el acceso a la atención en salud. Aun así, la quimioterapia perioperatoria mostró una supervivencia mayor en pacientes con cáncer gástrico localmente avanzado
Introduction. Perioperative cancer treatment in patients with locally advanced gastric cancer is indicated; even so, it is not always possible. The objective was to evaluate survival according to time and receipt of perioperative chemotherapy. Methods. Observational study, ambispective cohort type, including patients with locally advanced gastric cancer who received or did not receive perioperative chemotherapy. Results. Thirty-three patients were included, 90.9% belonged to the subsidized regimen and 78.8% with TNM T4. The perioperative chemotherapy group, which only had five patients (15.1%), had a higher overall survival at 2 years (100%), followed by the postoperative chemotherapy group and by the group without chemotherapy, with an overall survival at 2 years of 58.8% and 54.5%, respectively. Discussion. Overall survival was higher in the perioperative chemotherapy group, consistent with what has been described internationally, although the patients were in a more advanced stage, most being with T4 and N+ according to the AJCC VIII edition. Conclusions. The clinical stage is an important prognostic factor and in our environment, most patients consult in more advanced stages, coupled with difficulties in accessing health care. Even so, perioperative chemotherapy showed a longer survival in patients with locally advanced gastric cancer, the data should not be extrapolated since the number of patients in each group is significantly different
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Humanos , Neoplasias Gástricas , Análise de Sobrevida , Prognóstico , Mortalidade , Quimioterapia AdjuvanteRESUMO
Introducción. Durante el desarrollo embrionario normal, se espera que el denominado uraco o ligamento umbilical mediano se oblitere a las 32 semanas de gestación. Ante una obliteración incompleta surgen las diferentes anomalías, siendo las más frecuentes el quiste y la fístula urinaria umbilical. El objetivo de este artículo fue presentar el caso de una paciente joven, sin comorbilidades, con quiste de uraco. Caso clínico. Mujer indígena de 19 años que consultó por dolor leve en hipogastrio, asociado a síntomas urinarios y distensión abdominal. Se sospechó en primera instancia cólico renal, pero ante hallazgos ecográficos de masa infraumbilical y reactantes de fase aguda elevados, la impresión diagnóstica cambió a sepsis secundaria a absceso intraabdominal. Posterior a tomografía y cistoscopía con calibración uretral se identificó pequeño divertículo en cúpula vesical, que sugirió el diagnóstico de uraco persistente, por lo que la paciente fue llevada a intervención quirúrgica para su resección, con evolución favorable. Discusión. El quiste de uraco es una anormalidad infrecuente, en su mayoría asintomática y generalmente de hallazgo incidental en la población anciana, por lo que se requiere de imágenes y manejo multidisciplinar para su correcto diagnóstico y abordaje. Conclusión. Son pocos los casos de uraco persistente reportados, y mucho menos en el sexo femenino. Dada la posibilidad de complicaciones tardías es importante el seguimiento para su manejo. Este caso se ha controlado de manera ambulatoria por 2 años
Introduction. During normal embryonic development, it is expected that the so-called urachus or median umbilical ligament will be obliterated at 32 weeks of gestation. In the face of incomplete obliteration, the different anomalies of the urachus arise. The most frequent anomaly of the urachus is the cyst followed by the umbilical urinary fistula. The objective of this article was to present the case of a young patient without comorbidities with urachal cyst. Clinical case. A 19-year-old indigenous woman consulted for mild hypogastric pain associated with urinary symptoms and abdominal distension. Renal colic was suspected at first, but due to ultrasound findings of an infraumbilical mass and high acute phase reactants, the diagnostic impression changed to sepsis secondary to an intra-abdominal abscess. After tomography and cystoscopy with urethral calibration, a small diverticulum was identified in the bladder dome, suggesting a diagnosis of persistent urachus, for which the patient was taken to surgery for its resection, with favorable evolution. Discussion. The urachal cyst is a rare abnormality, mostly asymptomatic and usually incidental finding in the elderly population. Imaging and multidisciplinary management are required for its correct diagnosis and approach. Conclusion. There are few reported cases of persistent urachus and much less in females. Given the possibility of late complications, follow-up is important for its management, in this case we have carried out control for 2 years
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Humanos , Anormalidades Congênitas , Úraco , Cisto do Úraco , Dor Abdominal , Abscesso Abdominal , CistoscopiaRESUMO
Resumen La polimiositis es una miopatía autoinmune que causa cada año a nivel mundial 4 casos por cada millón de habitantes, es de diagnóstico clínico y necesita tratamiento rápido y agresivo porque puede llevar a desenlaces fatales. Esta patología es infrecuente en hombres con una proporción mujer/hombre de 2.5:1, por lo que el objetivo del artículo fue describir y comparar con la literatura el caso de un paciente masculino con polimiositis quien debutó con debilidad muscular y dolor poliarticular de 20 días de evolución, con valores de creatina quinasa de 24000 UI/L, asociado a pérdida de peso y respondiendo adecuadamente al tratamiento médico brindado en el momento. Después de 3 años asintomático, sufrió una agudización que fue manejada con medicamentos de primera línea, pero sin mejoría, por lo que requirió metilprednisolona oral a altas dosis e inmunomoduladores. En ningún momento presentó compromiso de órganos vitales, actualmente es sintomático y se encuentra en manejo médico. MÉD.UIS.2022;35(1):49-56.
Abstract Polymyositis is an autoimmune myopathy and each year it causes 4 cases per million in the worldwide population, it is clinically diagnosed and needs rapid and aggressive treatment because it can lead to fatal outcomes. This pathology is infrequent in men, with a proportion women/men 2.5:1, the objective of the article was to describe and compare with the literature the case of a male patient with polymyositis, who presented with muscle weakness and polyarticular pain of 20 days of evolution, with Creatine kinase values of 24,000 IU/L, associated with weight loss, and responding adequately to the medical treatment provided at the time. After 3 years asymptomatic, he suffered an acute phase that was managed with first-line medications but without improvement, for which he required oral methylprednisolone at high doses and inmunomodulators. At no time did he present vital organ involvement, he is currently symptomatic and is under medical management. MÉD.UIS.2022;35(1):49-56.
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Humanos , Pessoa de Meia-Idade , Polimiosite , Reumatologia , Doenças Autoimunes , Debilidade Muscular , Creatina QuinaseRESUMO
Resumen Introducción: con la actualización de las guías de la American Society for Gastrointestinal Endoscopy (ASGE) 2019, los criterios para los pacientes con sospecha de coledocolitiasis se volvieron más estrictos a la hora de elegir quienes deben ser llevados directamente a colangiopancreatografía retrógrada endoscópica (CPRE). El objetivo de este estudio fue comparar a los pacientes llevados directamente a CPRE según las guías ASGE de 2010 frente a la guía de 2019. Métodos: estudio retrospectivo de las CPRE realizadas entre enero de 2016 y diciembre de 2018 que evaluó el rendimiento diagnóstico de las variables paraclínicas y ecográficas de forma individual y en conjunto para comparar su sensibilidad, especificidad, valores predictivos y precisión de la probabilidad alta según guías de 2019 y de 2010 respecto a la presencia de cálculos en las CPRE. Resultados: 386 pacientes se llevaron a CPRE por sospecha de coledocolitiasis, 84,5% fueron procedimientos terapéuticos. El grupo de probabilidad alta presentó mayor tasa de CPRE terapéutico: 89,3% según las guías de 2019 frente a las de 2010 con 86,3% (p < 0,001). La sensibilidad y especificidad de la probabilidad alta según las guías de 2010 fueron del 86,8% y 25,0%, respectivamente, con un valor predictivo positivo (VPP) del 86,3% y una precisión del 77,2%. La probabilidad alta según las guías de 2019 mostró una menor sensibilidad (74%), pero mayor especificidad (51,7%), un VPP del 89,3% y una precisión del 70,7%. Conclusiones: la implementación de las guías ASGE 2019 sobre las indicaciones para la realización de la CPRE debe considerarse teniendo en cuenta los recursos de los centros hospitalarios, sobre todo en países de bajos y medianos ingresos. Las guías ASGE 2010 presentan una buena sensibilidad y precisión para orientar la realización de la CPRE.
Abstract Introduction: With the update of the American Society for Gastrointestinal Endoscopy (ASGE) 2019 guidelines, the criteria for patients with suspected choledocholithiasis became stricter when choosing who should be taken directly to endoscopic retrograde cholangiopancreatography (ERCP). This study aimed to compare patients taken directly to ERCP according to the 2010 vs. 2019 ASGE guidelines versus the 2019 guide. Materials and methods: A retrospective study of ERCPs performed between January 2016 and December 2018 evaluated the diagnostic performance of paraclinical and ultrasound variables individually and collectively to compare their sensitivity, specificity, predictive values, and high probability precision according to 2019 and 2010 guidelines regarding the presence of stones in ERCPs. Results: 386 patients underwent ERCP due to suspicion of choledocholithiasis; 84.5% were therapeutic procedures. The high probability group had a higher rate of therapeutic ERCP: 89.3% according to the 2019 guidelines compared to those of 2010 with 86.3% (p < 0.001). The sensitivity and specificity of high probability according to the 2010 guidelines were 86.8% and 25.0%, respectively, with a positive predictive value (PPV) of 86.3% and an accuracy of 77.2%. According to the 2019 guidelines, high probability showed lower sensitivity (74%) but higher specificity (51.7%), a PPV of 89.3%, and an accuracy of 70.7%. Conclusions: The implementation of the ASGE 2019 guidelines on the indications for ERCP should consider the resources of hospitals, especially in low- and middle-income countries. The ASGE 2010 guidelines show good sensitivity and precision to guide the performance of ERCP.
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Abstract Hip fracture is one of the major public healthcare problems in elderly patients around the world, mainly because of the risk of falls and osteoporosis which are typical during this stage of life, and may be the cause for up to 36% of deaths among those affected. Its management in principle is surgical and the best results are achieved with patients undergoing surgery during the first 24 to 72 hours after the fracture. Any delays in surgery are mostly associated with decompensated personal pathological factors, delays in perioperative assessment, or in presurgical complementary tests; sometimes, the delays are the result of administrative formalities of the healthcare providers. These determining factors may affect both morbidity and mortality, and contribute to functional decline, disability, and reduced quality of life of these patients. A third party intervention is then necessary to improve the preventable factors that delay the osteosynthesis in these types of fractures, in addition to ensuring education, infrastructure, inputs, skilled human resources, and prompt referral of patients from the first level of care. Investigating this scenario and assessing the quality of life impact on these patients should be a priority.
Resumen La fractura de cadera representa uno de los problemas de salud pública más grandes en los pacientes ancianos en todo el mundo, principalmente, por el riesgo de caídas y la osteoporosis típicos en esta etapa de la vida, que puede causar la muerte de hasta el 36 % de los afectados; su manejo es en principio quirúrgico y los mejores resultados se presentan cuando se interviene en las primeras 24 a 72 horas después de la fractura. El retraso en la corrección quirúrgica está asociado principalmente a factores patológicos personales no compensados, demora en la valoración perioperatoria o en los estudios complementarios prequirúrgicos, o por trámites administrativos de las empresas prestadoras de servicios de salud. Estos determinantes pueden afectar la morbimortalidad y contribuir a un deterioro funcional, incapacidad y pérdida de la calidad de vida de estos pacientes. Se hace necesaria una intervención por parte de terceros para mejorar los factores prevenibles que retrasan la osteosíntesis de este tipo de fracturas; además, asegurar educación, infraestructura, insumos, talento humano capacitado y remisión rápida de pacientes desde el primer nivel de atención. Investigar en este escenario y evaluar los efectos en la calidad de vida de estos pacientes debería ser una prioridad.
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Humanos , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Operatórios/métodos , Tempo para o Tratamento , Fraturas do Quadril , Qualidade de Vida , Mortalidade , Fraturas Ósseas , Fraturas por Osteoporose , Complicações IntraoperatóriasRESUMO
OBJECTIVE: To determine the independent contribution of prognostic factors to length of hospital stay of minor and moderate burn victims at the Hospital Universitario San José (HUSJ), Popayán, Colombia, 2000-2010. METHODS: This was a retrospective cohort study of minor and moderate burn victims admitted between 2000 and 2010, at the burn unit (HUSJ). This is a further analysis of a same cohort previously published in Burns. The following variables were recorded and analyzed: age, gender, origin, depth and extent of burn, causal agent, length of hospital stay and mortality. The main outcome under study was length of stay. Survival analysis was done to explore the association of covariates and length of hospital stay and Cox regression model to adjust the effect of covariates in the outcome. RESULTS: During the study period 2000-2010, 842 of 921 (91.5%) patients treated at the Burn Unit of HUSJ that had complete data were included. There were 520 (61.8%) males and 322 (38.2%) females with a male to female ratio of 1.6:1. Their median age was 9 years (IQR 3-28). The median of percent total body surface area burned (TBSA) was 12% (IQR 7-21) and the most common degree of burn was 2nd degree with 58% (488 patients). There were 12 deaths (censored data) and 830 patients were discharged alive. After multivariate adjustment, significant associations with length of hospital stay remained for age group, burn degree and extension of the burn. The strongest relationship found was for burn degree (2nd degree superficial vs. 3rd degree hazard ratio=2.66 CI 95% [2.13-3.33]). CONCLUSIONS: In patients admitted with mild and moderate burns at HUSJ, the main predictors of length of stay were age, burn degree and extension of the burn.
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Superfície Corporal , Queimaduras/patologia , Tempo de Internação/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Unidades de Queimados , Criança , Pré-Escolar , Estudos de Coortes , Colômbia , Feminino , Humanos , Masculino , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Índices de Gravidade do Trauma , Adulto JovemRESUMO
RESUMEN Introducción: El paludismo es una parasitosis producida por protozoos del género Plasmodium que puede causar disfunción orgánica. A pesar del control y prevención, es un problema de salud pública que contribuye a la morbilidad y mortalidad, especialmente en países tropicales. Objetivo: Identificar factores predisponentes para la complicación del paludismo en el departamento del Cauca, Colombia. Métodos: Se desarrolló un estudio observacional tipo casos y controles no pareados en el departamento del Cauca durante 2016-2019 con pacientes notificados al Sistema Nacional de Vigilancia en Salud Pública. Se recolectaron 445 pacientes con paludismo, aquellos con alguna complicación fueron definidos como casos (n= 89) y a cada uno se asignaron 4 controles (n= 356). La información de los complicados se contrastó con la historia clínica. Resultados: De la población estudiada (n= 445), 281 fueron hombres (63,1%), la edad media fue 28,34 años y 397 eran originarios del departamento del Cauca (89,2%). Noveta y nueve requirieron hospitalización (22,2 %) y tres fallecieron (0,7 %). Sesenta y uno complicados fueron por P. falciparum (68,5%). Los casos importados (p= 0,000), etnia negra (p=0,000), tratamiento después de 3 días (p= 0,000), procedencia urbana (p= 0,025), régimen contributivo (p=0,026), P. vivax (p= 0,000) y presencia de gametocitos (p=0,000) se asociaron con complicaciones. Conclusiones: La ubicación geográfica, redes hospitalarias ineficientes, desconocimiento de la enfermedad, entre otros factores deben intervenirse. La falta de estudios sobre paludismo y sus complicaciones limitan tomar decisiones.
ABSTRACT Introduction: Malaria is a parasitic infection caused by protozoa of the genus Plasmodium. This condition may lead to organ dysfunction. Despite the actions implemented to control and prevent malaria, it continues to be a public health problem contributing to morbidity and mortality, mainly in tropical countries. Objective: Identify the predisposing factors for complicated malaria in Cauca Department, Colombia. Methods: An observational non-paired case-control study was conducted in Cauca Department in the period 2016-2019. The study sample was 445 patients notified to the National Public Health Surveillance System. Patients with complications were defined as cases (n= 89). Each case was assigned four controls (n= 356). Information about complicated cases was contrasted with the medical records. Results: Of the total population studied (n= 445), 281 were men (63.1%) and 397 were from Cauca Department (89.2%). Mean age was 28.34 years. Ninety-nine patients required hospitalization (22.2%) and three died (0.7%). Sixty-one of the complicated patients were infected by P. falciparum (68.5%). The following factors were associated to complications: imported cases (p= 0.000), black ethnic group (p=0.000), treatment after three days (p= 0.000), urban area of residence (p= 0.025), contributory regime (p=0.026), P. vivax (p= 0.000) and presence of gametocytes (p=0.000). Conclusions: Actions should be implemented concerning geographic location, inefficient hospital networks and insufficient knowledge about the disease, among other factors. Lack of studies about malaria and its complications limit decision making.
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Introducción. La hipocalcemia posterior a tiroidectomía total es una complicación frecuente en la cirugía de tiroides. La hormona paratiroidea ha demostrado ser un predictor confiable para detectar los pacientes con alto riesgo de hipocalcemia significativa y la consecuente necesidad de administrar suplemento de calcio. El objetivo de este estudio fue determinar el tiempo óptimo de medición de la paratohormona para dicho fin. Métodos. Estudio prospectivo realizado en dos instituciones de nivel III en Popayán, Colombia, entre abril de 2016 y febrero de 2018, en el cual se midieron niveles de paratohormona prequirúrgico, a las 0, 2, 4 y 12 horas del postoperatorio, y se compararon con los valores obtenidos a los 3 meses de seguimiento en pacientes sometidos a tiroidectomía total. Se consideró como grupos de riesgo y con necesidad de suplemento de calcio un valor de paratohormona menor de 10 pg/ml o una disminución mayor del 80 % con respecto al valor prequirúrgico. Resultados. Se incluyeron 34 pacientes intervenidos. Tomando como umbral un valor menor de 10 pg/ml, la medición de paratohormona a las 4 horas fue sensible y específica (60 y 93,1 % respectivamente). Para una disminución mayor del 80 % con respecto al valor prequirúrgico, la sensibilidad fue del 60 % y la especificidad del 96,5 %, presentando un valor predictivo positivo de 75 % y negativo del 93,3 %, con una p < 0,001. Discusión. Una disminución mayor del 80 % del valor de paratohormona prequirúrgico medida a las 4 horas después de la tiroidectomía total permite identificar aquellos pacientes con alto riesgo de hipocalcemia significativa, que requieren administración temprana de suplementos de calcio, comparado con la determinación de la disminución a las 0, 2 y 12 horas postoperatorias
Introduction.Hypocalcemia after total thyroidectomy is a common complication in thyroid surgery.Parathyroid hormone has been shown to be a reliable predictor for detectingpatients with at high risk ofsignificant hypocalcemia and the consequent need for calcium supplementation. The objective of this study was to determine the optimal time for measuring parathormone for this purpose.Methods.Prospective study carried out in two level 3 institutions in Popayán, Colombia, between April 2016 and February 2018, in which levels of preoperative parathormone were measured at 0, 2, 4 and 12 hours postoperatively, and compared with the values obtained at 3 months of follow-up in patients undergoing total thyroidectomy. A parathormone value less than 10 pg/ml or a decrease greater than 80% with respect to the pre-surgical value was considered as risk groups and in need of calcium supplementation.Results. Thirty-four operated patients were included. Taking as a threshold a value of less than 10 pg/ml, the measurement of parathormone at 4 hours was sensitive and specific (60% and 93.1%, respectively). For a decrease greater than 80% with respect to the presurgical value, the sensitivity was 60% and the specificity was 96.5%, presenting a positive predictive value of 75% and a negative predictive value of 93.3% (p <0.001).Discussion.A decrease of more than 80% in the preoperative parathyroid hormone value measured at 4 hours after total thyroidectomy allows the identification of those patients at high risk of significant hypocalcaemia, who require early administration of calcium supplements, compared with the determination of the decrease at 0, 2 and 12 hours postoperatively
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Humanos , Hormônio Paratireóideo , Tireoidectomia , Hormônios e Agentes Reguladores de Cálcio , HipocalcemiaRESUMO
Introducción. El abdomen abierto es un recurso útil para el tratamiento de pacientes con patología abdominal compleja, con potencial de complicaciones. El objetivo de este estudio fue adaptar la guía de World Society of Emer-gency Surgery (WSES) 2018, en un hospital de nivel III de atención de la ciudad de Popayán, Colombia, y comparar los resultados obtenidos con los previos a su implementación. Métodos. Estudio cuasi-experimental en dos mediciones de pacientes con abdomen abierto y estancia en cuidado crítico, durante los meses de abril a octubre de los años 2018 y 2019, antes y después de la adaptación con el personal asistencial de la guía de práctica clínica WSES 2018. Se utilizó estadística descriptiva, prueba de Chi cuadrado y se empleó el software SPSS V.25. Resultados. Se incluyeron 99 pacientes críticos, con una edad media de 53,2 años, con indicación de abdomen abierto por etiología traumática en el 28,3 %, infecciosa no traumática en el 32,3 % y no traumática ni infecciosa en el 37,4 %. La mortalidad global fue de 25,3 %, de los cuales, un 68 % se debieron a causas ajenas a la patología abdominal. Las complicaciones postoperatorias se presentaron en 10 pacientes con infección de sitio operatorio y 9 pacientes con fístula enterocutánea. El uso del doble Viaflex se implementó en un 63,6 %, logrando un cierre de la pared abdominal en el 79,8 % de los casos (p=0,038). Conclusión. El abdomen abierto requiere de un abordaje multidisciplinar. El uso de doble Viaflex es una herramienta simple y efectiva. La implementación de la guía disminuyó el porcentaje de mortalidad, los días de abdomen abierto y la estancia en cuidados intensivos.
Introduction. The open abdomen is a useful resource for the treatment of patients with complex abdominal pathology, with the potential for complications. The aim of this study was to adapt the World Society of Emergency Surgery (WJES) 2018 guidelines, in a tertiary level hospital and compare the results obtained with those prior to its implementation. Methods. Experimental study in two measurements of patients with open abdomen and stay in critical care, during the months of April to October in 2018 and 2019, before and after the adaptation with the healthcare personnel of the WSES 2018 clinical practice guide. Descriptive statistics, Chi square test and SPSS V.25 software were used. Results. Ninety-nine critically ill patients were included, with a mean age of 53.2 years, with an indication of open abdomen due to traumatic etiology in 28.3%, infectious non-traumatic in 32.3%, and non-traumatic or infectious in 37.4 %. Overall mortality was 25.3%, of which 68% were due to causes other than abdominal pathology. Post-operative complications occurred in 10 patients with surgical site infection and 9 patients with enterocutaneous fistula. The use of the double Viaflex was implemented in 63.6%, achieving a closure of the abdominal wall in 79.8% (p=0.038) of the cases.Conclusion. The open abdomen requires a multidisciplinary approach. The use of double Viaflex is a simple and effective tool. The implementation of the guide decreased the percentage of mortality, the days of open abdomen and the stay in intensive care unit.