RESUMO
PURPOSE: Mortality in burn intensive care unit (ICU) has been decreasing and treatment appears to be changing. The aims of this study: (1) examine outcome in burn patients, (2) examine changes in ICU indication and (3) explore the influence of a changing case-mix. METHODS: Retrospective study in patients admitted to ICU (1987-2016). Four groups were specified: major burns (≥15% TBSA), inhalation injury with small injury (<15% TBSA, inhalation injury), watchful waiting (<15% TBSA, without inhalation injury), tender loving care (patients withheld from treatment). Logistic regression was performed to evaluate the relation between case-mix and outcome. RESULTS: Overall mortality decreased to 7%. Mortality of major burns decreased by 15%. The major burn group decreased by 36%. The inhalation injury and watchful waiting group increased by 9% and 21%. The percentage of ventilated patients increased by 14% in the major burn group. 40% of patients were ventilated in the watchful waiting group. CONCLUSIONS: After correction for case-mix, survival improved, mainly in the major burn group. Case-mix shifted towards inhalation injury and watchful waiting. Growth of the watchful waiting group is not necessarily harmful. However, the increase of mechanical ventilation could be. We suggest raising awareness for risks and consequences of mechanical ventilation.
Assuntos
Queimaduras/mortalidade , Cuidados Críticos/tendências , Grupos Diagnósticos Relacionados/tendências , Taxa de Sobrevida/tendências , Adulto , Idoso , Idoso de 80 Anos ou mais , Superfície Corporal , Unidades de Queimados , Queimaduras/patologia , Queimaduras/terapia , Queimaduras por Inalação/mortalidade , Queimaduras por Inalação/terapia , Feminino , Humanos , Tempo de Internação/tendências , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Países Baixos , Cuidados Paliativos/tendências , Respiração Artificial/tendências , Estudos Retrospectivos , Risco Ajustado , Conduta Expectante/tendências , Suspensão de Tratamento/tendências , Adulto JovemRESUMO
In An NHS Trust and others v Y and another, the Supreme Court was asked to address the question of whether a court order must always be obtained before clinically assisted nutrition and hydration (CANH), which is keeping alive a person with a prolonged disorder of consciousness (PDOC). This case note explores the Court's decision to dispense with the need for such a court order and analyses that important change in approach from the perspective of the right to life protected in Article 2 European Convention on Human Rights (ECHR) as well as in the broader context of end of life decision-making.
Assuntos
Cuidados para Prolongar a Vida/legislação & jurisprudência , Programas Nacionais de Saúde/legislação & jurisprudência , Apoio Nutricional , Suspensão de Tratamento/legislação & jurisprudência , Transtornos da Consciência/classificação , Humanos , Jurisprudência , Programas Nacionais de Saúde/tendências , Assistência Centrada no Paciente/ética , Assistência Centrada no Paciente/legislação & jurisprudência , Assistência Centrada no Paciente/tendências , Assistência Terminal/ética , Assistência Terminal/legislação & jurisprudência , Assistência Terminal/tendências , Reino Unido , Valor da Vida , Suspensão de Tratamento/tendênciasRESUMO
The authors compared the effectiveness of thiazide diuretic (TD), angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), and calcium channel blocker (CCB) monotherapies for the treatment of nondiabetic hypertension using MarketScan Databases 2010-2014. Multivariable Cox regression models assessed whether the addition of a new antihypertensive drug, treatment discontinuation, or switch and major cardiovascular or cerebrovascular events varied across groups. A total of 565 009 patients started monotherapy with ACEIs (43.6%), CCBs (23.6%), TDs (18.8%), or ARBs (14.0%). Patients who took TDs had a higher risk for either drug addition or discontinuation than patients who took ACEIs (hazard ratio [HR], 0.69 [95% CI, 0.68-0.70] vs HR, 0.81 [95% CI, 0.80-0.81]), ARBs (HR, 0.67 [95% CI, 0.66-0.68] vs HR, 0.66 [95% CI, 0.65-0.67]), and CCBs (HR, 0.85 [95% CI, 0.84-0.87] vs HR, 0.94 [95% CI, 0.93-0.95]). Conversely, patients who took TDs experienced a lower risk of clinical events compared with patients who took ACEIs (HR, 1.24 [95% CI, 1.15-1.33]), ARBs (HR, 1.28 [95% CI, 1.18-1.39]), and CCBs (HR, 1.35 [95% CI, 1.25-1.46]). Our results provide a strong rationale for choosing TDs as first-line monotherapy for the control of hypertension.
Assuntos
Antagonistas de Receptores de Angiotensina/farmacologia , Inibidores da Enzima Conversora de Angiotensina/farmacologia , Anti-Hipertensivos/farmacologia , Bloqueadores dos Canais de Cálcio/farmacologia , Hipertensão/tratamento farmacológico , Inibidores de Simportadores de Cloreto de Sódio/farmacologia , Antagonistas de Receptores de Angiotensina/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Anti-Hipertensivos/efeitos adversos , Pressão Sanguínea/efeitos dos fármacos , Bloqueadores dos Canais de Cálcio/efeitos adversos , Doenças Cardiovasculares/induzido quimicamente , Doenças Cardiovasculares/complicações , Doenças Cardiovasculares/epidemiologia , Transtornos Cerebrovasculares/induzido quimicamente , Transtornos Cerebrovasculares/complicações , Transtornos Cerebrovasculares/epidemiologia , Tomada de Decisão Clínica , Ensaios Clínicos como Assunto , Bases de Dados Factuais , Feminino , Humanos , Hipertensão/economia , Hipertensão/epidemiologia , Masculino , Pessoa de Meia-Idade , Projetos de Pesquisa , Estudos Retrospectivos , Inibidores de Simportadores de Cloreto de Sódio/efeitos adversos , Inibidores de Simportadores de Cloreto de Sódio/economia , Resultado do Tratamento , Estados Unidos/epidemiologia , Suspensão de Tratamento/estatística & dados numéricos , Suspensão de Tratamento/tendênciasRESUMO
The objective was to assess the cost of Medication Overuse Headache (MOH) at the time-point of withdrawal treatment. We implemented a protocol in which both direct and indirect cost were directly gathered from patients and referred to the previous three months. Direct costs were calculated by medications for acute treatment and prophylaxis, diagnostic procedures, visits, complementary treatments, informal care. Indirect costs were referred to missed workdays and workdays with reduced productivity: we asked patients to refer their salaries and to rate the overall level of performance in days worked with reduced productivity, and we calculated indirect costs on this basis. A total of 135 patients were enrolled: direct costs were around 415/month; indirect costs were 530/month, and were mostly due to presenteeism (350, 66.3%) rather than to absenteeism (160, 33.7%). Our data showed higher cost than those of a previous study: this is likely due to a different approach to cost definition, to the inclusion of direct non-medical cost, and of non-pharmacological treatments.
Assuntos
Efeitos Psicossociais da Doença , Transtornos da Cefaleia Secundários/economia , Transtornos da Cefaleia Secundários/terapia , Estatística como Assunto/economia , Suspensão de Tratamento/economia , Adulto , Feminino , Transtornos da Cefaleia Secundários/epidemiologia , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estatística como Assunto/tendências , Fatores de Tempo , Suspensão de Tratamento/tendênciasAssuntos
Aborto Induzido/ética , Benzimidazóis/farmacologia , Ética Médica , Medicina Baseada em Evidências/ética , Medicalização , Disfunções Sexuais Psicogênicas/tratamento farmacológico , Suspensão de Tratamento/estatística & dados numéricos , Benzimidazóis/uso terapêutico , Aprovação de Drogas , Indústria Farmacêutica/ética , Feminino , Política de Saúde/legislação & jurisprudência , Humanos , Recém-Nascido , Legislação Médica/tendências , Libido/efeitos dos fármacos , Masculino , Medicalização/ética , Medicalização/tendências , Países Baixos , Gravidez , Segundo Trimestre da Gravidez , Ultrassonografia Pré-Natal/ética , Estados Unidos , United States Food and Drug Administration , Suspensão de Tratamento/ética , Suspensão de Tratamento/tendênciasRESUMO
OBJECTIVE: Limitation of life-sustaining treatment (LLST) is a recommended practice in certain circumstances. Limitation practices are varied, and their application differs from one center to another. The present study evaluates the current situation of LLST practices in patients with prolonged admission to the ICU who suffer worsening of their condition. DESIGN: A prospective, observational cohort study was carried out. SETTING: Seventy-five Spanish ICUs. PATIENTS: A total of 589 patients suffering 777 complications or adverse events with organ function impairment after day 7 of admission, during a three-month recruitment period. MAIN VARIABLES OF INTEREST: The timing of limitation, the subject proposing LLST, the degree of agreement within the team, the influence of LLST upon the doctor-patient-family relationship, and the way in which LLST is implemented. RESULTS: LLST was proposed in 34.3% of the patients presenting prolonged admission to the ICU with severe complications. The incidence was higher in patients with moderate to severe lung disease, cancer, immunosuppressive treatment or dependence for basic activities of daily living. LLST was finally implemented in 97% of the cases in which it was proposed. The decision within the medical team was unanimous in 87.9% of the cases. The doctor-patient-family relationship usually does not change or even improves in this situation. CONCLUSION: LLST in ICUs is usually carried out under unanimous decision of the medical team, is performed more frequently in patients with severe comorbidity, and usually does not have a negative impact upon the relationship with the patients and their families.
Assuntos
Cuidados Críticos/estatística & dados numéricos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Suspensão de Tratamento/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Cuidados Críticos/ética , Cuidados Críticos/tendências , Tomada de Decisões , Grupos Diagnósticos Relacionados , Progressão da Doença , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Relações Interprofissionais , Cuidados para Prolongar a Vida/ética , Cuidados para Prolongar a Vida/tendências , Masculino , Futilidade Médica , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente , Relações Profissional-Família , Estudos Prospectivos , Espanha , Suspensão de Tratamento/ética , Suspensão de Tratamento/tendênciasRESUMO
Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by inflammation and joint destruction that causes significant morbidity and mortality. However, the combined use of methotrexate (MTX), a synthetic disease-modifying anti-rheumatic drug (sDMARD) and biological DMARDs (bDMARDs) has revolutionized treatment of RA and clinical remission or low disease activity (LDA) are now realistic targets, achieved by a large proportion of RA patients. We are now in a position to evaluate if it is possible to maintain remission or LDA while at the same time reducing the burden of treatment on the patient and healthcare system. Data are emerging from large, well-conducted studies designed to answer this question, shedding light on which patient populations and treatment algorithms can survive treatment discontinuation or tapering with low risk of disease flare. For early RA, approximately half of early RA patients could discontinue TNF-targeted bDMARDs without clinical flare and functional impairment after obtaining clinical remission by bDMARDs with MTX. In contrast, for established RA, fewer patients sustained remission or LDA after the discontinuation of bDMARDs and "deep remission" at the discontinuation was a key factor to maintain the treatment holiday of bDMARDs. Thus, this article provides a brief outline on withdrawing or tapering bDMARDs once patients have achieved remission or LDA in RA.
Assuntos
Antirreumáticos/farmacologia , Artrite Reumatoide , Indução de Remissão/métodos , Suspensão de Tratamento/tendências , Artrite Reumatoide/tratamento farmacológico , Artrite Reumatoide/fisiopatologia , Humanos , Imunossupressores/farmacologia , Conduta do Tratamento Medicamentoso/tendências , Metotrexato/farmacologia , Gravidade do PacienteRESUMO
Low statin adherence and discontinuation of statins are common in patients with coronary heart disease. We hypothesized that low antihypertensive medication adherence would be associated with future statin discontinuation and low adherence in patients initiating statins. Using a 5% national sample of Medicare beneficiaries, we conducted a cohort study of Medicare beneficiaries initiating statins after hospitalization for acute myocardial infarction or coronary revascularization in 2007, 2008, and 2009. Antihypertensive medication adherence, defined using the average proportion of days covered across 5 classes during the 365 days before hospitalization, was categorized as ≥80% (high), 50% to <80% (medium), and <50% (low). Statin discontinuation was defined as failure to refill a statin within 365 days of hospital discharge, and low adherence was defined as proportion of days covered for statins <80%. In 2,695 Medicare beneficiaries who initiated statins after hospital discharge, 6.0%, 8.4%, and 14.5% with high, medium, and low antihypertensive medication adherence discontinued statins. After multivariable adjustment, the risk ratios (95% confidence interval) for statin discontinuation were 1.38 (0.98 to 1.95) and 2.41 (1.51 to 3.87) for beneficiaries with medium and low versus high antihypertensive medication adherence, respectively. In beneficiaries who did not discontinue statins, 36.2% had low statin adherence. Compared with high adherence, medium and low antihypertensive medication adherences were associated with multivariable adjusted risk ratios (95% confidence interval) for low statin adherence of 1.33 (1.14 to 1.55) and 1.62 (1.25 to 2.10), respectively. In conclusion, low antihypertensive medication adherence before initiating statins is associated with future statin discontinuation and low statin adherence.
Assuntos
Anti-Hipertensivos/uso terapêutico , Doença da Artéria Coronariana/tratamento farmacológico , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Hipertensão/tratamento farmacológico , Cooperação do Paciente/estatística & dados numéricos , Suspensão de Tratamento/tendências , Idoso , Idoso de 80 Anos ou mais , Doença da Artéria Coronariana/complicações , Quimioterapia Combinada , Seguimentos , Hospitalização , Humanos , Hipertensão/complicações , Masculino , Medicare/estatística & dados numéricos , Prognóstico , Estudos Retrospectivos , Estados UnidosRESUMO
Contrary to the widespread concern about over-treatment at the end of life, today, patient preferences for palliative care at the end of life are frequently respected. However, ethically challenging situations in the current healthcare climate are, instead, situations in which a competent patient requests active treatment with the goal of life-prolongation while the physician suggests best supportive care only. The argument of futility has often been used to justify unilateral decisions made by physicians to withhold or withdraw life-sustaining treatment. However, we argue that neither the concept of futility nor that of patient autonomy alone is apt for resolving situations in which physicians are confronted with patients' requests for active treatment. Instead, we integrate the relevant arguments that have been put forward in the academic discussion about 'futile' treatment into an ethical algorithm with five guiding questions: (1) Is there a chance that medical intervention will be effective in achieving the patient's treatment goal? (2) How does the physician evaluate the expected benefit and the potential harm of the treatment? (3) Does the patient understand his or her medical situation? (4) Does the patient prefer receiving treatment after evaluating the benefit-harm ratio and the costs? (5) Does the treatment require many resources? This algorithm shall facilitate approaching patients' requests for treatments deemed futile by the physician in a systematic way, and responding to these requests in an ethically appropriate manner. It thereby adds substantive considerations to the current procedural approaches of conflict resolution in order to improve decision making among physicians, patients and families.