RESUMO
The emergence of the COVID-19 pandemic necessitated rapid expansion of telehealth as part of healthcare delivery. This study compared HIV-related no-shows by visit type (in-person; video; telephone) during the COVID-19 pandemic (April 2020-September 2021) from the Data for Care Alabama project. Using all primary care provider visits, each visit's outcome was categorized as no-show or arrived. A logistic regression model using generalized estimating equations accounting for repeat measures in individuals and within sites calculated odds ratios (OR) and their accompanying 95% confidence interval (CI) for no-shows by visit modality. The multivariable models adjusted for sociodemographic factors. In-person versus telephone visits [OR (95% CI) 1.64 (1.48-1.82)] and in-person versus video visits [OR (95% CI) 1.53 (1.25-1.85)] had higher odds of being a no-show. In-person versus telephone and video no-shows were significantly higher. This may suggest success of telehealth visits as a method for HIV care delivery even beyond COVID-19.
Assuntos
COVID-19 , Infecções por HIV , Telemedicina , Humanos , COVID-19/epidemiologia , Pandemias , Estudos Retrospectivos , Infecções por HIV/epidemiologia , Alabama/epidemiologiaRESUMO
We compared retention in care outcomes between a pre-COVID-19 (Apr19-Mar20) and an early-COVID-19 (Apr20-Mar21) period to determine whether the pandemic had a significant impact on these outcomes and assessed the role of patient sociodemographics in both periods in individuals enrolled in the Data for Care Alabama project (n = 6461). Using scheduled HIV primary care provider visits, we calculated a kept-visit measure and a missed-visit measure and compared them among the pre-COVID-19 and early-COVID-19 periods. We used logistic regression models to calculated odds ratios (OR) and accompanying 95% confidence intervals (CI). Overall, individuals had lowers odds of high visit constancy [OR (95% CI): 0.85 (0.79, 0.92)] and higher odds of no-shows [OR (95% CI): 1.27 (1.19, 1.35)] during the early-COVID-19 period. Compared to white patients, Black patients were more likely to miss an appointment and transgender people versus cisgender women had lower visit constancy in the early-COVID-19 period.
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COVID-19 , Infecções por HIV , Cooperação do Paciente , Feminino , Humanos , Alabama/epidemiologia , COVID-19/epidemiologia , Infecções por HIV/epidemiologia , Atenção Primária à Saúde , Negro ou Afro-Americano , Minorias Sexuais e de GêneroRESUMO
This systematic review and meta-analysis aimed to evaluate the comparative outcomes of laparoscopic sleeve gastrectomy with omentopexy (LSGO) versus conventional laparoscopic sleeve gastrectomy (LSG) for obesity treatment. A systematic online search was conducted using the available online databases, and Revman software was used for data analysis. Twenty-two eligible comparative studies were included (n = 9,321). LSGO showed a significantly lower rate of gastric leak (P = 0.0001), staple line bleeding (P = 0.00001), and gastric torsion (P = 0.002) in comparison to the LSG group. Operative time was significantly shorter in the LSG group (P = 0.00001); however, the length of hospital stay was in favour of the LSGO (P = 0.00001). Compared to LSG without omentopexy, LSG with omentopexy provides a significantly lower rate of postoperative complications and shorter LOS at the expense of operative time.
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Laparoscopia , Obesidade Mórbida , Humanos , Obesidade Mórbida/cirurgia , Gastrectomia , Complicações Pós-Operatórias/cirurgia , Estômago , Resultado do TratamentoRESUMO
The optimal timing for percutaneous cholecystostomy (PCT) in patients with acute biliary sepsis, who are high-risk for cholecystectomy, requires further investigation. We aimed to study local factors influencing the timing to PCT placement, and investigate patient outcomes in early (≤ 48 h) vs. delayed PCT over a six-year period. A retrospective observational study investigating patients who required a PCT at a single hospital in the UK between January 2014 and December 2019. Placement of a PCT was at the discretion of the on-call surgical consultant according to their own personal experience and not based on a standard local protocol. Clinical outcomes, hospital statistics and details of any subsequent bridging surgery were analysed using multivariate logistic regression models adjusting for age, sex, Charlson Comorbidity Index (CCI) and American Society of Anaesthesiologists (ASA) grade. There were 72 patients with 35/72 (48.6%) classed as TG18 AC grade 3; 26/72 (36.1%) had an early PCT placed and 46/72 (63.9%) delayed. Median age was 76 (65-83) years, 52.8% were female, and 51.4% were classed ASA ≥ 3 with 94.0% scoring CCI > 2. Trial on antibiotic therapy was the primary reason for delayed PCT. In adjusted models, early PCT was associated with a shorter length in hospital stay (OR 3.02, p = 0.044), successful definitive treatment (OR 6.26, p = 0.009); and reduced likelihood for catheter dislodgment (OR 0.12, p = 0.004) with fewer patients bridging to later emergency open surgery (OR 0.19, p = 0.024). Clinical outcomes may be superior in urgent or early PCT for high anaesthetic-risk patients following acute biliary sepsis.
Assuntos
Anestésicos , Colecistite Aguda , Colecistostomia , Sepse , Humanos , Feminino , Idoso , Masculino , Colecistostomia/efeitos adversos , Colecistostomia/métodos , Colecistite Aguda/cirurgia , Colecistite Aguda/etiologia , Resultado do Tratamento , Estudos Retrospectivos , Sepse/etiologiaRESUMO
INTRODUCTION: Ending the HIV Epidemic initiatives provide a unique opportunity to use implementation scientific methods to guide implementation of evidence-based practices and evaluate their effectiveness in real-word settings to improve HIV inequities. This report demonstrates our use of Implementation Mapping (IM) to engage participating county health departments, AIDS services organizations, and community-based organizations in the development of a data dashboard to track the PrEP care continuum for the state of Alabama, an Ending the HIV Epidemic hotspot. METHODS: Our project is guided by an overarching Implementation Research Logic Model and by the tenets of IM, a 5-step approach to support researchers and community partners in the systematic selection, development, and/or tailoring of implementation strategies to increase program adoption, implementation, and sustainability. RESULTS: Step 1, the needs assessment, established baseline data elements for a PrEP care continuum for participating community-based organizations, AIDS services organizations, and the state health department as well as investigated their desire for data visualization and willingness to share data to inform initiatives to improve PrEP access. Step 2 identified adaptability, relative advantage, and complexity as determinants of intervention adoption. Based on findings from steps 1 and 2, the investigators and community partners determined to move forward with development of a data dashboard. Step 3 identified the following implementation strategies to support a dashboard, including development of educational materials, synchronous and asynchronous training, technical assistance, and improved record systems. DISCUSSION: Using IM supports community-engaged researchers in designing strategies to end the epidemic that are context-specific and more impactful in real-word settings.
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Síndrome da Imunodeficiência Adquirida , Infecções por HIV , Profilaxia Pré-Exposição , Alabama , Continuidade da Assistência ao Paciente , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Humanos , Profilaxia Pré-Exposição/métodosRESUMO
PURPOSE: The authors investigated prostacyclin (PGI2) and thromboxane (TX) productions in peripheral venous blood after lower limb revascularization by percutaneous transluminal angioplasty (PTA) versus diagnostic angiography. The purpose of this study was to investigate PGI2/TX imbalance after PTA. This imbalance is of pathophysiologic importance and it is a potential sign of platelet function alteration. MATERIALS AND METHODS: Twenty-five patients requiring PTA were compared with 20 patients undergoing angiography alone from April 2004-December 2005 from a single vascular unit. Patient age range was 42-90 years, and the majority of patients were men. Prostaglandin F2-alpha (PGF2-alpha) and thromboxane B2 (TXB2) were measured sequentially (preprocedure, at 1 hour, and 24 hours after procedure). Differences between postprocedure and preprocedure level were compared statistically between angiography and PTA. RESULTS: Baseline demographics were distributed equally between the two groups except presence of critical ischemia and ankle brachial pressure index, which were two significant confounders. TXB2 was significantly higher after PTA at 1 hour and 24 hours after PTA (P = .005 and P = .014 respectively), PGF2-alpha was significantly higher 24 hours after PTA only (P = .018) (Mann-Whitney U test). CONCLUSIONS: PGI2/TX balance homeostasis is of significant pathophysiologic importance. The authors found that PTA results in significant PGI2/TX imbalance and shifts more toward increased TX production. This finding is partly suggestive of significant platelet activation. This imbalance in PGI2/TX level may have implications for future failure of PTA. Future research in reducing this platelet activation is recommended.
Assuntos
Angioplastia , Plaquetas/metabolismo , Artéria Femoral , Artéria Ilíaca , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/terapia , Prostaglandinas I/sangue , Radiografia Intervencionista , Tromboxanos/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Angioplastia/efeitos adversos , Índice Tornozelo-Braço , Biomarcadores/sangue , Constrição Patológica , Dinoprosta/sangue , Inglaterra , Epoprostenol/sangue , Feminino , Artéria Femoral/diagnóstico por imagem , Humanos , Artéria Ilíaca/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/sangue , Doença Arterial Periférica/diagnóstico por imagem , Ativação Plaquetária , Radiografia Intervencionista/efeitos adversos , Tromboxano A2/sangue , Tromboxano B2/sangue , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Percutaneous transluminal angioplasty (PTA) of a lower limb arterial segment is a well-established treatment for suitable lesions for critical or noncritical lower limb ischemia. Our aim was to define the inflammatory response after PTA by measuring inflammatory markers. METHODS: Twenty-five patients having PTA were compared with 20 patients having angiography alone. Interleukin-6 (IL-6), IL-8, IL-10, and tumor necrosis factor-alpha (TNF-alpha) were measured sequentially. The difference between postprocedure and preprocedure baseline levels were compared statistically between angiography alone and PTA. Patients were followed up to 1 year after the procedure, and the failure rate of PTA was noted. RESULTS: IL-6 and TNF-alpha were significantly higher in PTA patients at 1 hr after PTA (p < 0.05), and the IL-6 level only was significantly higher at 24 hr post-PTA (p < 0.05) compared to angiography alone (Mann-Whitney test). IL-8 and IL-10 levels did not differ significantly in the PTA group. At 1 year after the procedure, 45% of PTAs had failed. There was no statistically significant correlation between failed PTA and inflammatory response. CONCLUSION: PTA appears to cause a significant inflammatory response compared to angiography alone. This demonstrates a systemic manifestation of localized ischemia/reperfusion injury. Further investigation of the inflammatory response due to ischemia/reperfusion injury and its correlation with restenosis is recommended.
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Angioplastia com Balão/efeitos adversos , Arteriopatias Oclusivas/terapia , Mediadores da Inflamação/sangue , Isquemia/terapia , Extremidade Inferior/irrigação sanguínea , Síndrome de Resposta Inflamatória Sistêmica/etiologia , Idoso , Arteriopatias Oclusivas/sangue , Arteriopatias Oclusivas/complicações , Arteriopatias Oclusivas/diagnóstico por imagem , Biomarcadores/sangue , Estudos de Casos e Controles , Feminino , Humanos , Interleucina-10/sangue , Interleucina-6/sangue , Interleucina-8/sangue , Isquemia/sangue , Isquemia/diagnóstico por imagem , Isquemia/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Radiografia , Recidiva , Síndrome de Resposta Inflamatória Sistêmica/sangue , Fatores de Tempo , Falha de Tratamento , Fator de Necrose Tumoral alfa/sangueRESUMO
BACKGROUND: Multidisciplinary team (MDT) meetings are widely recommended in the management of bariatric surgery patients; however, there is limited evidence for their effectiveness. The aims of this study were to evaluate the decision-making process of a single-day bariatric MDT clinic and secondly to evaluate whether these MDT decisions were implemented. METHODS: This was a retrospective observational study analysing MDT treatment decisions from February 2012 to June 2013 using an MDT proforma. The decision-making process of the MDT meeting was investigated by assessing the alterations in management plan between the surgeon and the rest of the MDT. Adherence to MDT decisions was also assessed. RESULTS: Decisions regarding 200 consecutive patients were analyzed. There was MDT agreement for 55%, and patients were listed for surgery on the day of the MDT. There was MDT disagreement regarding 45%, with conflicting opinions expressed by surgeons in 33/200 (17%), anaesthetists in 60/200 (30%) and dieticians in 65/200 (33%). The MDT plan was instigated in 78% and the most common reason for failure was patients failing to attend for further assessment. By the end of the study, 85% of patients underwent bariatric surgery, 11.5% declined further input, 2.5% chose further weight loss and 1% were removed from waiting list. CONCLUSION: Use of a single-day MDT clinic format resulted in a change in plan for a significant number of patients. This can be interpreted as improved quality of care for these patients, and we conclude the MDT approach is valuable.
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Cirurgia Bariátrica , Obesidade Mórbida/cirurgia , Equipe de Assistência ao Paciente/organização & administração , Adulto , Tomada de Decisão Clínica/métodos , Prestação Integrada de Cuidados de Saúde/organização & administração , Inglaterra , Feminino , Pesquisa sobre Serviços de Saúde/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Redução de Peso , Adulto JovemRESUMO
BACKGROUND: The Alabama Quality Management Group (AQMG), a consortium of 9 Ryan White-funded part C and D clinics, distributed statewide was established in 2006 under the guidance from the Health and Resources Services Administration with a clinical quality improvement (CQI) focus. METHODS: We describe the origins and evolution of the AQMG, including requisite shifts from aggregate clinic-wide to de-identified individual-level data reporting for implementation of the Data for Care (D4C-AL) Alabama program. The D4C-AL strategy uses a clinic-wide risk stratification of all patients based on missed clinic visits in the previous 12 months. Intermediate (1-2 missed visits) and high-risk patients (>3 missed visits) receive the evidence-informed Retention through Enhanced Personal Contact intervention. We report on a pilot of the D4CAL program in 4 of 33 primary HIV care clinics at the UAB 1917 Clinic. RESULTS: Among 3859 patients seen between April 2018 and February 2019, the missed visit rate was not significantly different between the D4C-1917 (19.2%) and non-D4C clinics (20.5%) in a preintervention period (May 2017-April 2018). However, a significantly lower missed visit rate was observed in the D4C-1917 vs. non-D4C-1917 clinics during the intervention period (April 2018-February 2019, P = 0.049). CONCLUSIONS: The AQMG has been transformed into a health service research and implementation science platform, building on a shared vision, mission, data reporting, and quality improvement focus. Moreover, CQI may be viewed as an implementation strategy that seeks to enhance uptake and sustained use of effective interventions with D4C-AL representing a prototype for future initiatives embedded within extant quality improvement consortia.
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Agregação de Dados , Infecções por HIV/prevenção & controle , Pesquisa sobre Serviços de Saúde/organização & administração , Melhoria de Qualidade/organização & administração , Retenção nos Cuidados/organização & administração , Medição de Risco/métodos , Adulto , Idoso , Alabama , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estados UnidosRESUMO
The objective of this paper was to evaluate whether delaying surgery following long-course chemoradiotherapy for rectal cancer correlates with pathologic complete response. Pre-operative chemoradiotherapy (CRT) is standard practice in the UK for the management of locally advanced rectal cancer. Optimal timing of surgery following CRT is still not clearly defined. All patients with a diagnosis of rectal cancer who had undergone long-course CRT prior to surgery between January 2008 and December 2011 were included. Statistical analysis was performed using Stata 11. Fifty-nine patients received long-course CRT prior to surgery in the selected period. Twenty-seven percent (16/59) of patients showed a complete histopathologic response and 59.3% (35/59) of patients had tumor down-staging from radiologically-assessed node positive to histologically-proven node negative disease. There was no statistically significant delay to surgery after completion of CRT in the 16 patients with complete response (CR) compared with the rest of the group [IR: incomplete response; CR group median: 74.5 days (IQR: 70-87.5) and IR group median: 72 days (IQR: 57-83), P = 0.470]. Although no statistically significant predictors of either complete response or tumor nodal status down-staging were identified in logistic regression analyses, a trend toward complete response was seen with longer delay to surgery following completion of long-course CRT.
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Quimiorradioterapia , Neoplasias Retais/terapia , Administração Oral , Idoso , Antimetabólitos Antineoplásicos/administração & dosagem , Antimetabólitos Antineoplásicos/uso terapêutico , Capecitabina/administração & dosagem , Capecitabina/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Estudos Prospectivos , Neoplasias Retais/cirurgia , Fatores de Tempo , Resultado do TratamentoRESUMO
Streptococcus equi is a common equine infectious disease, but transmission to man is rare and confined to those who commonly come into close contact with horses. Similarly, prosthetic stent graft infection is a rare complication of endovascular aortic aneurysm repair. We describe the first reported case of aortic stent graft with S. equi occurring in a professional racehorse trainer. Clinical presentation, investigations, imaging and management of this case are described. In conclusion, clinicians should consider infection with rare organisms in patients with prosthetic implants who regularly come into contact with horses and other ruminants.
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Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Infecções Relacionadas à Prótese/microbiologia , Infecções Estreptocócicas/microbiologia , Streptococcus equi/isolamento & purificação , Idoso , Animais , Antibacterianos/uso terapêutico , Aortografia/métodos , Implante de Prótese Vascular/instrumentação , Remoção de Dispositivo , Procedimentos Endovasculares/instrumentação , Cavalos , Humanos , Masculino , Imagem Multimodal , Tomografia por Emissão de Pósitrons , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/terapia , Infecções Relacionadas à Prótese/transmissão , Reoperação , Infecções Estreptocócicas/diagnóstico , Infecções Estreptocócicas/terapia , Infecções Estreptocócicas/transmissão , Tomografia Computadorizada por Raios X , Resultado do Tratamento , ZoonosesRESUMO
PURPOSE: To evaluate the midterm feasibility, efficacy and safety of internal iliac artery branch grafts for endovascular repair of aortoiliac, common iliac, and internal iliac artery aneurysms. METHODS: Between December 2006 and September 2008, 8 patients underwent elective endovascular repair of aortoiliac, common iliac, and internal iliac artery aneurysms. Computed tomography aortography (CTA) was used to detect postoperative endoleak, stent migration, branch patency, and aneurysm sac expansion. RESULTS: All stent grafts were correctly implanted. However, intraoperative branch occlusion occurred in 2 of 8 cases. Both occlusions have been managed conservatively, with only 1 patient suffering detrimental symptoms. One endoleak was found. Median follow up by CT was 402 days (range 77 to 718 days). No patients died. CONCLUSIONS: Midterm results are encouraging for endovascular branch grafts to include the internal iliac artery. However, patient selection is of great importance and our series illustrates the value of caution and multidisciplinary teamwork.
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Implante de Prótese Vascular/instrumentação , Prótese Vascular , Aneurisma Ilíaco/cirurgia , Artéria Ilíaca/cirurgia , Stents , Idoso , Implante de Prótese Vascular/efeitos adversos , Procedimentos Cirúrgicos Eletivos , Estudos de Viabilidade , Migração de Corpo Estranho/etiologia , Humanos , Aneurisma Ilíaco/diagnóstico , Aneurisma Ilíaco/fisiopatologia , Artéria Ilíaca/diagnóstico por imagem , Artéria Ilíaca/fisiopatologia , Desenho de Prótese , Falha de Prótese , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Ultrassonografia Doppler Dupla , Grau de Desobstrução VascularRESUMO
INTRODUCTION: The safety and feasibility of laparoscopic liver resections have recently been confirmed. This has encouraged laparoscopic surgeons to widen the indications and push the boundaries in laparoscopic liver resections. However, a complete laparoscopic two-stage liver resection has not been reported previously. AIM: The aim of this work was to assess the feasibility and safety of the two-stage laparoscopic liver resection for metastatic disease. METHODS: The two-stage laparoscopic liver resection was safely performed in a 58-year-old man with colorectal liver metastasis (one in segment 2/3 and one in the right lobe). A left lateral sectionectomy was first performed, followed by right portal vein embolization 1 week later, and a nonanatomic resection of the right liver was performed after 6 weeks. CONCLUSIONS: Laparoscopic liver surgery is gaining popularity and major procedures can now be performed in centers with wide experience. The laparoscopic approach should always be considered for left lateral sectionectomy, and in selected cases, a complete laparoscopic two-stage resection can safely be performed.
Assuntos
Hepatectomia/métodos , Laparoscopia , Neoplasias Hepáticas/cirurgia , Estudos de Viabilidade , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
This report presents a case illustrating the complications of Kasabach-Merritt syndrome in a 22-year-old man. The patient presented with acute abdominal pain and profound anaemia; a CT scan revealed intraperitoneal bleeding from spontaneous splenic rupture. The patient underwent initial emergency laparotomy and splenectomy, with a subsequent further laparotomy to control haemorrhage. Blood products requirements were extensive: 28 units red blood cells, 14 units fresh frozen plasma, 10 units platelets, 10 units cryoprecipitate and 2× Novo VII. He was then transferred to a nearby tertiary care unit for further management to control his coagulaopathy and he made a full recovery after 4 weeks.