RESUMO
OBJECTIVES: COVID19 pandemic has forced physicians from different specialties to assist cases overload. Our aim is to assess gastroenterologist's assistance in COVID-19 by assessing mortality, ICU admission, and length of stay, and seek for risk factors for in-hospital mortality and longer hospital stay. METHODS: A total of 41 COVID-19 patients assisted by gastroenterologist (GI cohort) and 137 assisted by pulmonologist, internal medicine practitioners, and infectious disease specialists (COVID expert cohort) during October-November 2020 were prospectively collected. Clinical, demographic, imaging, and laboratory markers were collected and compared between both cohorts. Bivariate analysis and logistic regression were performed to search for risk factors of mortality and longer hospital stays. RESULTS: A total of 27 patients died (15.1%), 11 were admitted to ICU (6.1%). There were no differences between cohorts in mortality (14.6% vs 15.4%;p = 0.90), ICU admission (12.1% vs 4%;p = 0.13), and length of stay (6.67 ± 4 vs 7.15 ± 4.5 days; p = 0.58). PaO2/FiO2 on admission (OR 0.991;CI95% 0.984-0.998) and age > 70 (OR 17.54;CI95% 3.93-78.22) were independently related to mortality. Age > 70, history of malignancy, diabetes, and cardiovascular disease were related to longer hospital stays (p < 0.001, p = 0.03, p = 0.04, p = 0.02 respectively). CONCLUSIONS: COVID-19 assistance was similar between gastroenterologist and COVID experts when assessing mortality, ICU admission, and length of stay. Age>70 and decreased PaO2/FiO2 on admission were independent risk factors of mortality. Age and several comorbidities were related to longer hospital stay.
Assuntos
COVID-19 , Prova Pericial , Gastroenterologistas/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Fatores Etários , Idoso , COVID-19/diagnóstico , COVID-19/mortalidade , COVID-19/fisiopatologia , Comorbidade , Prova Pericial/métodos , Prova Pericial/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Humanos , Comunicação Interdisciplinar , Masculino , Prognóstico , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , Fatores de Risco , SARS-CoV-2/isolamento & purificação , Espanha/epidemiologiaRESUMO
BACKGROUND: Globally, chronic hepatitis B (CHB) is a major public health concern. Timely and effective management can prevent disease progression to cirrhosis and reduce the risk of hepatocellular carcinoma (HCC). Currently, there is no consensus on the clinical management of CHB in East Asia. AIM: To establish an East Asia expert opinion on treatment initiation for CHB based on alanine aminotransferase (ALT) level, hepatitis B virus (HBV) deoxyribonucleic acid (DNA) level, cirrhosis and HCC risk scores. METHODS: A meeting was held online with a panel of 10 experts from East Asia to discuss ALT, HBV DNA, cirrhosis and HCC risk scores. Indications for CHB treatment in the latest international guidelines were reviewed. Consensus was summarised to provide recommendations on the initiation of treatment for CHB. RESULTS: Anti-viral therapy is recommended for CHB patients with (a) HBV DNA ≥ 2000 IU/mL and ALT ≥ 1× upper limit of normal (ULN); (b) HBV DNA ≥ 2000 IU/mL, ALT < 1× ULN and ≥ F2 fibrosis and/or ≥ A2 necroinflammation occurs; (c) cirrhosis and detectable HBV DNA; or (d) HBV DNA ≥ 2000 IU/mL, ALT < 1× ULN and a family history of cirrhosis or HCC, extrahepatic manifestations or age > 40 years. Patients with cirrhosis and/or HCC should be treated regardless of ALT levels if HBV DNA level is detectable. Initiating anti-viral therapy or close monitoring at 3-month intervals is recommended for CHB patients with at least two HCC risk factors. CONCLUSIONS: These expert recommendations will contribute to a new standard of daily clinical practice in East Asia.
Assuntos
Prova Pericial , Hepatite B Crônica/terapia , Guias de Prática Clínica como Assunto , Carcinoma Hepatocelular/epidemiologia , Carcinoma Hepatocelular/etiologia , Carcinoma Hepatocelular/prevenção & controle , Congressos como Assunto , Progressão da Doença , Prova Pericial/estatística & dados numéricos , Ásia Oriental/epidemiologia , Vírus da Hepatite B/fisiologia , Hepatite B Crônica/complicações , Hepatite B Crônica/tratamento farmacológico , Hepatite B Crônica/epidemiologia , Humanos , Cirrose Hepática/complicações , Cirrose Hepática/epidemiologia , Cirrose Hepática/prevenção & controle , Cirrose Hepática/virologia , Neoplasias Hepáticas/epidemiologia , Neoplasias Hepáticas/etiologia , Neoplasias Hepáticas/prevenção & controle , Guias de Prática Clínica como Assunto/normas , Fatores de RiscoRESUMO
Life expectancy is increasing and so is the prevalence of age-related non-communicable diseases (NCDs). Consequently, older people and patients present with multi-morbidities and more complex needs, putting significant pressure on healthcare systems. Effective nutrition interventions could be an important tool to address patient needs, improve clinical outcomes and reduce healthcare costs. Inflammation plays a central role in NCDs, so targeting it is relevant to disease prevention and treatment. The long-chain omega-3 polyunsaturated fatty acids (omega-3 LCPUFAs) docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) are known to reduce inflammation and promote its resolution, suggesting a beneficial role in various therapeutic areas. An expert group reviewed the data on omega-3 LCPUFAs in specific patient populations and medical conditions. Evidence for benefits in cognitive health, age- and disease-related decline in muscle mass, cancer treatment, surgical patients and critical illness was identified. Use of DHA and EPA in some conditions is already included in some relevant guidelines. However, it is important to note that data on the effects of omega-3 LCPUFAs are still inconsistent in many areas (e.g., cognitive decline) due to a range of factors that vary amongst the trials performed to date; these factors include dose, timing and duration; baseline omega-3 LCPUFA status; and intake of other nutrients. Well-designed intervention studies are required to optimize the effects of DHA and EPA in specific patient populations and to develop more personalized strategies for their use.
Assuntos
Envelhecimento/fisiologia , Suplementos Nutricionais , Ácidos Docosa-Hexaenoicos/farmacologia , Ácido Eicosapentaenoico/farmacologia , Prova Pericial/estatística & dados numéricos , Fenômenos Fisiológicos da Nutrição/fisiologia , Idoso , Idoso de 80 Anos ou mais , Envelhecimento/efeitos dos fármacos , Ácidos Graxos Ômega-3/farmacologia , Humanos , Inflamação/prevenção & controle , Fenômenos Fisiológicos da Nutrição/efeitos dos fármacosRESUMO
BACKGROUND: There is limited data on the risk of perioperative myocardial infarctions (MIs) in patients with a recent MI who undergo dermatologic surgeries. OBJECTIVE: Present the recommendations of dermatologic surgeons and cardiologists to determine the safety of dermatologic surgeries after a recent MI. METHODS: An electronic survey was distributed to Mohs surgeons and cardiologists to infer the risk of major adverse cardiac events (MACE) inherent to dermatologic surgery and determine timing of dermatologic surgery in patients with a recent MI. RESULTS: One hundred twenty Mohs surgeons and 30 cardiologists were surveyed. Ninety-seven percent of cardiologists and 87% of Mohs surgeons deemed cutaneous excisions and Mohs micrographic surgery as low-risk procedures with less than one-percent chance of MACE. Seventy-seven percent of cardiologists and 46% of Mohs surgeons stated dermatologic surgery should either not be delayed or be delayed up to 1 month after an MI. Responses between cardiologists and Mohs surgeons did not significantly differ. CONCLUSION: A preponderance of surveyed experts believe that most dermatologic surgeries may be safely performed in patients with a history of an MI within 1 month. The decision to implement urgent dermatologic surgery in patients with a recent MI should account for all clinically significant factors.
Assuntos
Tomada de Decisão Clínica , Cirurgia de Mohs/efeitos adversos , Infarto do Miocárdio/complicações , Complicações Pós-Operatórias/prevenção & controle , Tempo para o Tratamento/normas , Cardiologistas/estatística & dados numéricos , Dermatologia/estatística & dados numéricos , Prova Pericial/estatística & dados numéricos , Humanos , Cirurgia de Mohs/normas , Infarto do Miocárdio/prevenção & controle , Complicações Pós-Operatórias/etiologia , Guias de Prática Clínica como Assunto , Recidiva , Cirurgiões/estatística & dados numéricos , Inquéritos e Questionários/estatística & dados numéricos , Fatores de Tempo , Tempo para o Tratamento/estatística & dados numéricosRESUMO
BACKGROUND: Building tools to support personalized medicine needs to model medical decision-making. For this purpose, both expert and real world data provide a rich source of information. Currently, machine learning techniques are developing to select relevant variables for decision-making. Rather than using data-driven analysis alone, eliciting prior information from physicians related to their medical decision-making processes can be useful in variable selection. Our framework is electronic health records data on repeated dose adjustment of Irinotecan for the treatment of metastatic colorectal cancer. We propose a method that incorporates elicited expert weights associated with variables involved in dose reduction decisions into the Stochastic Search Variable Selection (SSVS), a Bayesian variable selection method, by using a power prior. METHODS: Clinician experts were first asked to provide numerical clinical relevance weights to express their beliefs about the importance of each variable in their medical decision making. Then, we modeled the link between repeated dose reduction, patient characteristics, and toxicities by assuming a logistic mixed-effects model. Simulated data were generated based on the elicited weights and combined with the observed dose reduction data via a power prior. We compared the Bayesian power prior-based SSVS performance to the usual SSVS in our case study, including a sensitivity analysis using the power prior parameter. RESULTS: The selected variables differ when using only expert knowledge, only the usual SSVS, or combining both. Our method enables one to select rare variables that may be missed using only the observed data and to discard variables that appear to be relevant based on the data but not relevant from the expert perspective. CONCLUSION: We introduce an innovative Bayesian variable selection method that adaptively combines elicited expert information and real world data. The method selects a set of variables relevant to model medical decision process.
Assuntos
Neoplasias do Colo/tratamento farmacológico , Prova Pericial/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Teorema de Bayes , Tomada de Decisão Clínica , Relação Dose-Resposta a Droga , Registros Eletrônicos de Saúde , Feminino , Humanos , Irinotecano/administração & dosagem , Modelos Logísticos , Masculino , Metástase Neoplásica/tratamento farmacológico , Medicina de Precisão , Projetos de Pesquisa , Inibidores da Topoisomerase I/administração & dosagemRESUMO
BACKGROUND: Long-term clinical outcomes are necessary to assess the cost-effectiveness of new treatments over a lifetime horizon. Without long-term clinical trial data, current practice to extrapolate survival beyond the trial period involves fitting alternative parametric models to the observed survival. Choosing the most appropriate model is based on how well each model fits to the observed data. Supplementing trial data with feedback from experts may improve the plausibility of survival extrapolations. We demonstrate the feasibility of formally integrating long-term survival estimates from experts with empirical clinical trial data to provide more credible extrapolated survival curves. METHODS: The case study involved relapsed or refractory B-cell pediatric and young adult acute lymphoblastic leukemia (r/r pALL) regarding long-term survival for tisagenlecleucel (chimeric antigen receptor T-cell [CAR-T]) with evidence from the phase II ELIANA trial. Seven pediatric oncologists and hematologists experienced with CAR-T therapies were recruited. Relevant evidence regarding r/r pALL and tisagenlecleucel provided a common basis for expert judgments. Survival rates and related uncertainty at 2, 3, 4, and 5 years were elicited from experts using a web-based application adapted from Sheffield Elicitation Framework. Estimates from each expert were combined with observed data using time-to-event parametric models that accounted for experts' uncertainty, producing an overall distribution of survival over time. These results were validated based on longer term follow-up (median duration 24.2 months) from ELIANA following the elicitation. RESULTS: Extrapolated survival curves based on ELIANA trial without expert information were highly uncertain, differing substantially depending on the model choice. Survival estimates between 2 to 5 years from individual experts varied with a fair amount of uncertainty. However, incorporating expert estimates improved the precision in the extrapolated survival curves. Predictions from a Gompertz model, which experts believed was most appropriate, suggested that more than half of the ELIANA patients treated with tisagenlecleucel will survive up to 5 years. Expert estimates at 24 months were validated by longer follow-up. CONCLUSIONS: This study provides an example of how expert opinion can be elicited and synthesized with observed survival data using a transparent and formal procedure, capturing expert uncertainty, and ensuring projected long-term survival is clinically plausible.
Assuntos
Ensaios Clínicos como Assunto/estatística & dados numéricos , Prova Pericial/estatística & dados numéricos , Imunoterapia Adotiva/métodos , Leucemia-Linfoma Linfoblástico de Células Precursoras/terapia , Adolescente , Criança , Pré-Escolar , Resistencia a Medicamentos Antineoplásicos , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Masculino , Recidiva Local de Neoplasia , Adulto JovemRESUMO
INTRODUCTION: Hospital inpatient stays are reimbursed on the basis of German diagnosis-related groups (G-DRG). The G-DRG classification system is based on complex coding guidelines. The Medical Review Board of the Statutory Health Insurance Funds (MDK) examines the encoding by hospitals and delivers individual expertises on behalf of the German statutory health insurance companies in cases in which irregularities are suspected. A study was conducted on the inter-rater reliability of the MDK expertises regarding the scope of the assessment. METHODS: A representative sample of 212 MDK expertises was taken from a selected pool of 1 392 MDK expertises in May 2013. This representative sample underwent a double-examination by 2 independent MDK experts using a special software based on the 3MTM G-DRG Grouper 2013 of 3M Medica, Germany. The following items encoded by the hospitals were examined: DRG, principal diagnosis, secondary diagnoses, procedures and additional payments. It was analysed whether the results of MDK expertises were consistent, reliable and correct. RESULTS: 202 expertises were eligible for evaluation, containing a total of 254 questions regarding one or more of the 5 items encoded by hospitals. The double-examination by 2 independent MDK experts showed matching results in 187 questions (73.6%) meaning they had been examined consistently and correctly. 59 questions (23.2%) did not show matching results, nevertheless they had been examined correctly regarding the scope of the assessment. None of the principal diagnoses was significantly affected by inconsistent or wrong judgment. CONCLUSION: A representative sample of MDK expertises examining the DRG encoding by hospitals showed a very high percentage of correct examination by the MDK experts. Identical MDK expertises cannot be achieved in all cases due to the scope of the assessment. Further improvement and simplification of codes and coding guidelines are required to reduce the scope of assessment with regard to correct DRG encoding and its examination.
Assuntos
Grupos Diagnósticos Relacionados/estatística & dados numéricos , Prova Pericial/estatística & dados numéricos , Prova Pericial/normas , Programas Nacionais de Saúde/estatística & dados numéricos , Competência Profissional/estatística & dados numéricos , Garantia da Qualidade dos Cuidados de Saúde/estatística & dados numéricos , Grupos Diagnósticos Relacionados/normas , Prova Pericial/legislação & jurisprudência , Honorários e Preços , Alemanha , Hospitalização/estatística & dados numéricos , Programas Nacionais de Saúde/normas , Garantia da Qualidade dos Cuidados de Saúde/normas , Métodos de Controle de Pagamentos/normas , Métodos de Controle de Pagamentos/estatística & dados numéricosAssuntos
Prova Pericial/legislação & jurisprudência , Prova Pericial/estatística & dados numéricos , Imperícia/legislação & jurisprudência , Imperícia/estatística & dados numéricos , Programas Nacionais de Saúde/legislação & jurisprudência , Programas Nacionais de Saúde/estatística & dados numéricos , Estudos Transversais , Alemanha , Humanos , Revisão da Utilização de Recursos de Saúde/estatística & dados numéricosRESUMO
The present study investigated health professionals' opinions about important questions that should be discussed with patients who may require post-prostatectomy radiotherapy. A 74-question survey was conducted among radiation oncologists, urologists, nurses, and radiation therapists involved in the care of prostate cancer patients. Survey questions covered six domains: understanding my situation and prostate cancer diagnosis, making a decision, radiotherapy: procedures involved, potential benefits, side effects, and my support network during radiation treatment. Respondents rated the importance of addressing these questions as either essential, important, no opinion, or avoid with a hypothetical post-prostatectomy case. The majority of questions were rated as either essential or important. There was disagreement between professions on essential questions, mostly between nurses and urologists in the side-effects domain. There was agreement between all professions regarding which questions should be avoided.
Assuntos
Tomada de Decisões , Prova Pericial/estatística & dados numéricos , Equipe de Assistência ao Paciente/normas , Educação de Pacientes como Assunto , Padrões de Prática Médica , Neoplasias da Próstata/radioterapia , Radioterapia/estatística & dados numéricos , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Período Pós-Operatório , Prognóstico , Prostatectomia , Neoplasias da Próstata/psicologia , Neoplasias da Próstata/cirurgia , Especialização , Inquéritos e QuestionáriosRESUMO
The increasing use of high-resolution computed tomography in formerly asbestos-exposed workers requires valid diagnostic criteria for the findings which have to be reported as suspicious for being asbestos-related in surveillance programmes and for the assessment of causal relationships between former asbestos exposure and findings in computed tomography. The present article gives examples for asbestos-related findings in HR-CT and discusses the specificity of parenchymal and pleural changes due to asbestos fibres.
Assuntos
Amianto/análise , Asbestose/diagnóstico , Asbestose/epidemiologia , Prova Pericial/estatística & dados numéricos , Pulmão/diagnóstico por imagem , Vigilância da População/métodos , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Causalidade , Alemanha/epidemiologia , Humanos , Programas de Rastreamento/métodos , Programas de Rastreamento/estatística & dados numéricos , Medição de Risco/métodos , Fatores de RiscoAssuntos
Assistência Odontológica Integral/estatística & dados numéricos , Assistência Odontológica/legislação & jurisprudência , Assistência Odontológica/estatística & dados numéricos , Prova Pericial/estatística & dados numéricos , Erros Médicos/legislação & jurisprudência , Erros Médicos/estatística & dados numéricos , Satisfação do Paciente/estatística & dados numéricos , Assistência Odontológica Integral/legislação & jurisprudência , Assistência Odontológica Integral/normas , Assistência Odontológica/normas , Humanos , Polônia/epidemiologia , Estudos RetrospectivosRESUMO
La medicina basada en la evidencia constituye la herramienta más poderosa para una adecuada atención de nuestros pacientes. También lo es cuando queremos enseñar a nuestros alumnos o cuando queremos explicarle el padecimiento al paciente o a sus familiares. La evidencia está dada por los estudios al respecto y de ellos el ensayo clínico controlado es el más poderoso y mejor no siempre disponible. Se presentan los fundamentos de la medicina basada en la evidencia y los diferentes tipos de estudios que la avalan y su respectiva jerarquía