RESUMO
Chronic kidney disease (CKD) is associated with substantial cardiovascular morbidity and mortality. This is mediated by the high prevalence of traditional cardiovascular risk factors in patients with CKD such as arterial hypertension and diabetes mellitus, but also by the presence of CKD-specific so-called nontraditional cardiovascular risk factors such as vascular calcification, uremic toxins, uremic dyslipidemia as well as inflammation and oxidative stress. Therefore, the primary and secondary prevention of cardiovascular disease represents an integral part of nephrology. This entails optimal control of blood pressure and diabetes, therapy of the uremic dyslipidemia as well as lifestyle-modifying factors such as weight reduction and smoking cessation.
Assuntos
Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/prevenção & controle , Dislipidemias/epidemiologia , Insuficiência Renal Crônica/complicações , Toxinas Biológicas/sangue , Uremia/complicações , Pressão Sanguínea/fisiologia , Cálcio/metabolismo , Doenças Cardiovasculares/etiologia , Diabetes Mellitus/epidemiologia , Dislipidemias/etiologia , Humanos , Hipertensão/epidemiologia , Hipertensão/etiologia , Hipertensão/prevenção & controle , Inflamação/complicações , Estresse Oxidativo , Fatores de Risco , Uremia/epidemiologia , Uremia/metabolismo , Calcificação Vascular/complicações , Calcificação Vascular/epidemiologia , Rigidez VascularRESUMO
Working in anesthesiology is characterized by a complex environment in which effective teamwork with different disciplines as well as other professions (e.â¯g. nursing staff and surgical assistants) is crucial. Clinical risk management includes all steps to prevent incidents and patient harm. An example for this is simulation training based on crisis resource management (CRM). This training course focuses on teaching non-medical skills using simulation manikins in order to enable employees to maintain patient safety under the adverse, ever-changing and unfamiliar conditions of a medical emergency. In detail, this involves skills, such as situation awareness, teamwork, decision making, task management and communication, whereby all elements must be taken equally into account to be effective in terms of CRM. A sustainable training aims to build up, promote and permanently establish a mindset within the team. Positive effects of these could be demonstrated for long-term training that addressed the entire patient care team and that was implemented along with various other patient safety measures. In addition, other positive aspects of simulation training, such as stronger employee retention or more effective task management in critical situations are described; however, hospitals are often found to have difficulties in financing these training sessions. This article shows possible health economic considerations in the discussion about financing CRM-based simulation training. Cost-benefit and cost-effectiveness analyses are difficult to perform. They require an individual planning. Regardless of this, simulation training enables participants to experience (simulation) and reflect their own actions in critical situations (debriefing). With the help of specially trained CRM instructors, deviations from expected behavior can be detected. This non-conformity can be used as a starting point for the establishment and further development of patient safety by a structural analysis of possible failures within the system. The decision to finance CRM-based simulation training remains a fundamental decision of the management of the respective hospital. In the near future, pressure from liability insurers to prevent incidents might increase. The inclusion of CRM-based simulation training as an integral component of clinical risk management could provide key benefits in contract negotiation.
Assuntos
Gestão de Riscos/economia , Gestão de Riscos/organização & administração , Treinamento por Simulação , Anestesiologia , Educação Médica Continuada , Humanos , Equipe de Assistência ao Paciente/organização & administração , Segurança do PacienteRESUMO
BACKROUND: Each year 16-17 million determinations of high-density lipoprotein cholesterol (HDL-C) are conducted and interpreted in Germany. Recently acquired data have led to a fundamental reassessment of the clinical significance of HDL-C. METHOD: This review article is based on a selective literature search. RESULTS: Low HDLC levels usually indicate an increased cardiovascular risk, particularly in primary prevention but the epidemiological relationship between HDLC and the risk is complex. The HDL plays a role in the back transport and excretion of cholesterol; however, the biological functions of HDL are dependent on the protein and lipid composition, which is not reflected by the HDLC concentration. If the composition of HDL is pathologically altered it can also exert negative vascular effects. CONCLUSION: Compared with low-density lipoprotein cholesterol (LDL-C), HDLC is of secondary importance for cardiovascular risk stratification and the calculation of the LDL-C:HDLC ratio is not useful for all patients. Low HDLC levels should prompt a search for additional metabolic and inflammatory pathologies. An increase in HDLC through lifestyle changes (e.g. smoking cessation and physical exercise) has positive effects and is recommended; however, HDLC is currently not a valid target for drug therapy.
Assuntos
Doenças Cardiovasculares/sangue , Doenças Cardiovasculares/mortalidade , HDL-Colesterol/sangue , LDL-Colesterol/sangue , Biomarcadores/sangue , Doenças Cardiovasculares/diagnóstico , Medicina Baseada em Evidências , Humanos , Prevalência , Reprodutibilidade dos Testes , Fatores de Risco , Sensibilidade e EspecificidadeRESUMO
RATIONALE: Alterations of acid-base metabolism are an important outcome predictor in acute exacerbations of COPD, whereas sufficient metabolic compensation and adequate renal function are associated with decreased mortality. In stable COPD there is, however, only limited information on the combined role of acid-base balance, blood gases, renal and respiratory function on exacerbation risk grading. METHODS: We used baseline data of the COPD cohort COSYCONET, applying linear and logistic regression analyses, the results of which were implemented into a comprehensive structural equation model. As most informative parameters it comprised the estimated glomerular filtration rate (eGFR), lung function defined via forced expiratory volume in 1â¯s (FEV1), intrathoracic gas volume (ITGV) and (diffusing capacity for carbon monoxide (DLCO), moreover arterial oxygen content (CaO2), partial pressure of oxygen (PaCO2), base exess (BE) and exacerbation risk according to GOLD criteria. All measures were adjusted for age, gender, body-mass index, the current smoking status and pack years. RESULTS: 1506 patients with stable COPD (GOLD grade 1-4; mean age 64.5⯱â¯8.1â¯y; mean FEV1 54⯱â¯18 %predicted, mean eGFR 82.3⯱â¯16.9â¯mL/min/1.73â¯m2) were included. BE was linked to eGFR, lung function and PaCO2 and played a role as indirect predictor of exacerbation risk via these measures; moreover, eGFR was directly linked to exacerbation risk. These associations remained significant after taking into account medication (diuretics, oral and inhaled corticosteroids), whereby corticosteroids had effects on exacerbation risk and lung function, diuretics on eGFR, BE and lung function. CONCLUSION: Even in stable COPD acid-base metabolism plays a key integrative role in COPD risk assessment despite rather small deviations from normality. It partially mediates the effects of impairments in kidney function, which are also directly linked to exacerbation risk.
Assuntos
Desequilíbrio Ácido-Base/complicações , Doença Pulmonar Obstrutiva Crônica/sangue , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Desequilíbrio Ácido-Base/metabolismo , Idoso , Gasometria , Monóxido de Carbono/metabolismo , Estudos de Coortes , Comorbidade , Estudos Transversais , Progressão da Doença , Feminino , Volume Expiratório Forçado , Taxa de Filtração Glomerular/fisiologia , Humanos , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Pressão Parcial , Capacidade de Difusão Pulmonar/fisiologia , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Testes de Função Respiratória , Medição de Risco/métodosRESUMO
Genetic polymorphisms in plasminogen activator inhibitor-1 gene-675 4G/5G (PAI-1 4G/5G) are claimed to contribute to an increased risk of venous thromboembolism. Inherited thrombophilia, on the other hand, is associated with the occurrence of spontaneous abortions. The objective of this study was, to explore the significance of genetic polymorphisms of PAI-1 4G/5G with particular emphasis on 4G alleles in pregnant women suffering from venous thromboembolism or early spontaneous abortion, respectively. Therefore genetic PAI-1 4G/5G polymorphisms were studied in 108 pregnant females suffering from venous thromboembolism (n=69) or from spontaneous abortion (<20 week, n=39), respectively. Healthy volunteers (n=238) were taken as controls. The frequencies of 4G alleles (4G/4G or 4G/5G genotypes) of PAI-1 were significantly higher in venous thromboembolism (OR: 3.40, p=0.0088) and slightly higher, but not significantly, in abortions (RR: 2.33; p=0.1162) compared to controls. The incidence of 4G-carriers in females with abortion was 0.68 (-32%) compared to women suffering from venous thromboembolism alone. We conclude from these data, that the occurrence of PAI-1 4G/4G or 4G/5G genotypes, respectively, is clinically significant for the pathogenesis of venous thromboembolism in pregnancy but not for early abortion.
Assuntos
Aborto Espontâneo/genética , Inibidor 1 de Ativador de Plasminogênio/genética , Polimorfismo Genético , Complicações Cardiovasculares na Gravidez/genética , Tromboembolia Venosa/genética , Adolescente , Adulto , Alelos , Feminino , Frequência do Gene , Genótipo , Humanos , Gravidez , Fatores de Risco , Trombofilia/genéticaRESUMO
PURPOSE: A retrospective analysis of 74 patients with pure seminoma, treated at the University of Florida between 1964 and 1989, was undertaken. METHODS AND MATERIALS: All patients received megavoltage irradiation, with chemotherapy reserved for salvage. At 10 years, the probability of relapse-free survival was 91% for Stage I, 93% for Stage IIA, 83% for Stage IIB, and 75% for Stage III patients. RESULTS: There were seven recurrences, none of which occurred in irradiated areas. Only two of seven patients (29%) with recurrence were salvaged. CONCLUSION: A literature review revealed an increasing rate of mediastinal or supraclavicular recurrence, correlating with the size of the subdiaphragmatic disease, in Stage II patients who did not receive elective mediastinal irradiation. Recommendations are made regarding the role of elective mediastinal irradiation for Stage II disease. We conclude that patients with Stage I or II seminoma can have high cure rates when treated with radiotherapy alone. Patients with Stage III seminoma should be treated initially with cisplatin-based chemotherapy.
Assuntos
Seminoma/radioterapia , Neoplasias Testiculares/radioterapia , Adulto , Idoso , Intervalo Livre de Doença , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Radioterapia/efeitos adversos , Estudos Retrospectivos , Seminoma/patologia , Seminoma/secundário , Neoplasias Testiculares/patologia , Falha de TratamentoRESUMO
PURPOSE: Whereas there are many reports regarding treatment of early vocal cord cancer with cobalt 60 or 2-4-MV X-rays, there are still few reports on the results of treatment with 6-MV X-rays. Theoretically, 6-MV X-rays result in greater underdosage of tumor at the air-tissue interface and at the anterior commissure. This paper analyzes the results of irradiation of early and moderately advanced squamous cell carcinoma of the true vocal cord treated exclusively with 6-MV X-rays in a community hospital. The literature pertinent to the issue is reviewed. METHODS AND MATERIALS: Eighty-three patients with Tis, T1, T2, or T3 squamous cell carcinoma of the true vocal cord were treated with curative intent at Bethesda Memorial Hospital in Boynton Beach, Florida between April 1986 and April 1998. The dose schedules most commonly used were 63 Gy in 28 fractions (2.25 Gy per fraction once a day) for T1 tumors or 74.40 Gy in 62 fractions (1.2 Gy per fraction twice a day) for T2 and T3 tumors. All patients have minimum 2-year follow-up; 63 (76%) have 5-year minimum follow-up. RESULTS: Local control was achieved in 6 of 6 Tis, 53 of 54 (98%) T1, 8 of 8 T2, and 6 of 6 T3 lesions. No complications were encountered. CONCLUSIONS: A recent literature review indicates that the treatment of early vocal cord cancer with 6-MV X-rays remains controversial. The dose schedules used in the present paper produced a high rate of local control, a finding that is consistent with reports of other investigators who used dose schedules similar to those used in the present series. However, several other investigators have reported significantly lower rates of local control for T1 or T2 glottic cancer treated with 6-MV X-rays when compared to results obtained with cobalt 60 or 4 MV at their own institution. The latter institutions used lower total doses and/or lower dose per fraction than those institutions reporting high rates of local control with 6 MV. Data from the literature, as well as our own data, are consistent with the following hypotheses: (1) the lower rates of local control reported by several institutions when using 6 MV compared with cobalt or 2-4 MV, using the same radiation dose schedules for each beam energy, indicate that underdosage of mucosal surfaces in the laryngeal air cavity may be a clinically important phenomenon, and (2) time-dose factors, although certainly important for lower energy beams, may be even more important when using 6 MV.
Assuntos
Carcinoma de Células Escamosas/radioterapia , Neoplasias Laríngeas/radioterapia , Prega Vocal , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/secundário , Feminino , Humanos , Neoplasias Laríngeas/patologia , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Estadiamento de NeoplasiasRESUMO
The management of squamous cell carcinoma of the anal canal is controversial. Treatment currently varies from abdominoperineal resection to combined radiotherapy and chemotherapy. Our aim is to review the management of this disease and present our current treatment policies. Twenty-six patients treated at the University of Florida with surgery and adjuvant radiotherapy are compared with 12 patients treated with radiotherapy alone. The pertinent literature is reviewed to determine the role of primary surgery, the efficacy of adjuvant chemotherapy, and the optimal chemotherapy schedule. The preferred management of anal canal cancer is radiotherapy; abdominoperineal resection should be reserved for salvage after local recurrence and for patients with faecal incontinence caused by the destruction of the sphincter muscle. Adjuvant chemotherapy is probably indicated for patients with lesions that are stage T2 or larger. The optimal chemotherapy regimen consists of 5-fluorouracil and mitomycin. Preliminary data suggest that cisplatin may be substituted for mitomycin with equivalent efficacy and less toxicity.
Assuntos
Neoplasias do Ânus/terapia , Carcinoma de Células Escamosas/terapia , Terapia Combinada , HumanosRESUMO
They can shave a full day off the average hospital stay. At one facility, they lopped 20 percent off inpatient costs. ¿That's a slam dunk for us,¿ says one of the new class of doctors known as hospitalists.
Assuntos
Hospitalização/tendências , Corpo Clínico Hospitalar/tendências , Medicina/organização & administração , Relações Médico-Paciente , Especialização , Administração de Caso , Continuidade da Assistência ao Paciente/organização & administração , Redução de Custos , Eficiência Organizacional , Relações Interprofissionais , Programas de Assistência Gerenciada , Medicina/tendências , Admissão e Escalonamento de Pessoal/tendências , Médicos de Família , Estados UnidosRESUMO
When it comes to breast cancer screening, science takes a backseat to the politics of fear. In fact, researchers can't even decide whether to recommend routine screenings for women in their 40s.
Assuntos
Política de Saúde/legislação & jurisprudência , Mamografia/normas , Política , Adulto , Neoplasias da Mama/diagnóstico por imagem , Conferências para Desenvolvimento de Consenso de NIH como Assunto , Feminino , Sistemas Pré-Pagos de Saúde/normas , Humanos , Cobertura do Seguro/legislação & jurisprudência , Pessoa de Meia-Idade , Formulação de Políticas , Fatores de Risco , Avaliação da Tecnologia Biomédica , Estados UnidosRESUMO
Pioneering CEOs are backing ideals with their own money: They're linking bonuses to how well they improve community health. The day may be near when CEO pay hinges on meeting community health needs.
Assuntos
Diretores de Hospitais/economia , Planejamento em Saúde Comunitária/normas , Avaliação de Desempenho Profissional/métodos , Planos para Motivação de Pessoal , Avaliação de Desempenho Profissional/economia , Conselho Diretor , Nível de Saúde , Salários e Benefícios , Responsabilidade Social , Estados UnidosRESUMO
The no. 2 rehab provider took a dose of its own medicine--therapy that boosted productivity, slashed costs, and pushed the company into new markets. Now a consensus of analysts sees growth soaring by 20 percent a year.
Assuntos
Marketing de Serviços de Saúde/tendências , Centros de Reabilitação/organização & administração , Instituições de Assistência Ambulatorial , Administração Financeira/estatística & dados numéricos , Reestruturação Hospitalar , Humanos , Renda/estatística & dados numéricos , Terapia Ocupacional , Pacientes Ambulatoriais , Pennsylvania , Centros de Reabilitação/economia , Estados UnidosRESUMO
If family and friends were paid for their care of the chronically ill, the U.S. health care tab would take a $194 billion hit--exceeding home health spending. What do they get for giving so much? Harm to their own health.
Assuntos
Cuidadores/psicologia , Efeitos Psicossociais da Doença , Assistência Domiciliar/psicologia , Saúde da Família , Feminino , Humanos , Relações Profissional-Família , Estresse Psicológico/prevenção & controle , Estados UnidosRESUMO
"A healthy community isn't defined just by its rates of infection or inoculation," says Lawrence White Jr., CEO of St. Patrick Hospital, a winner of this year's NOVA Awards. Working with a wide array of community and health care organizations, the five winning hospitals have tackled knotty community problems--even ones not directly related to health care--in ways that reach beyond their traditional turf.
Assuntos
Distinções e Prêmios , Planejamento em Saúde Comunitária/normas , Administração Hospitalar/normas , Arkansas , Serviços de Saúde Comunitária/normas , Relações Comunidade-Instituição/normas , Kansas , Montana , Ohio , Estados Unidos , WashingtonRESUMO
No hospital creates a healthier community all by itself. But it can give its neighbors a jump start. As the winners of this year's NOVA Awards show, the result is a better life for the most vulnerable--the sickest, the poorest, the youngest, the oldest. And by tackling problems beyond their traditional turf, NOVA winners earn raves for leadership.
Assuntos
Distinções e Prêmios , Planejamento em Saúde Comunitária/normas , Relações Comunidade-Instituição , Hospitais Comunitários/normas , Área Programática de Saúde , Estados UnidosRESUMO
The disabled poor worry whether managed care will bring them into the medical mainstream or cast them adrift. That's why state Medicaid programs are approaching the task gingerly--if at all.
Assuntos
Pessoas com Deficiência , Programas de Assistência Gerenciada/normas , Medicaid/normas , Pobreza , Gastos em Saúde/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde , Humanos , Programas de Assistência Gerenciada/economia , Medicaid/organização & administração , Medicaid/estatística & dados numéricos , Planos Governamentais de Saúde , Estados UnidosRESUMO
Social ills lead to physical ones, and sometimes it's up to hospitals to help communities turn things around. From a quiet town in southwest Georgia to the hustle and bustle of Seattle, this year's NOVA recipients are adept at promoting their vision of a healthier, safer society.