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1.
BMC Infect Dis ; 19(1): 769, 2019 Sep 03.
Artículo en Inglés | MEDLINE | ID: mdl-31481123

RESUMEN

BACKGROUND: Health-workers in developing countries rely on clinical algorithms, such as the Integrated Management of Childhood Illnesses (IMCI), for the management of patients, including diagnosis of serious bacterial infections (SBI). The diagnostic accuracy of IMCI in detecting children with SBI is unknown. Prediction rules and guidelines for SBI from well-resourced countries at outpatient level may help to improve current guidelines; however, their diagnostic performance has not been evaluated in resource-limited countries, where clinical conditions, access to care, and diagnostic capacity differ. The aim of this study was to estimate the diagnostic accuracy of existing prediction rules and clinical guidelines in identifying children with SBI in a cohort of febrile children attending outpatient health facilities in Tanzania. METHODS: Structured literature review to identify available prediction rules and guidelines aimed at detecting SBI and retrospective, external validation on a dataset containing 1005 febrile Tanzanian children with acute infections. The reference standard, SBI, was established based on rigorous clinical and microbiological criteria. RESULTS: Four prediction rules and five guidelines, including IMCI, could be validated. All examined rules and guidelines had insufficient diagnostic accuracy for ruling-in or ruling-out SBI with positive and negative likelihood ratios ranging from 1.04-1.87 to 0.47-0.92, respectively. IMCI had a sensitivity of 36.7% (95% CI 29.4-44.6%) at a specificity of 70.3% (67.1-73.4%). Rules that use a combination of clinical and laboratory testing had better performance compared to rules and guidelines using only clinical and or laboratory elements. CONCLUSIONS: Currently applied guidelines for managing children with febrile illness have insufficient diagnostic accuracy in detecting children with SBI. Revised clinical algorithms including simple point-of-care tests with improved accuracy for detecting SBI targeting in tropical resource-poor settings are needed. They should undergo careful external validation against clinical outcome before implementation, given the inherent limitations of gold standards for SBI.


Asunto(s)
Infecciones Bacterianas/diagnóstico , Fiebre/diagnóstico , Técnicas Microbiológicas/normas , Pruebas en el Punto de Atención/normas , Guías de Práctica Clínica como Asunto , Edad de Inicio , Algoritmos , Infecciones Bacterianas/epidemiología , Infecciones Bacterianas/microbiología , Niño , Preescolar , Femenino , Fiebre/microbiología , Humanos , Lactante , Masculino , Técnicas Microbiológicas/métodos , Técnicas Microbiológicas/estadística & datos numéricos , Pruebas en el Punto de Atención/estadística & datos numéricos , Guías de Práctica Clínica como Asunto/normas , Valor Predictivo de las Pruebas , Pronóstico , Reproducibilidad de los Resultados , Estudios Retrospectivos , Sensibilidad y Especificidad , Tanzanía/epidemiología
2.
Gac Med Mex ; 155(4): 428-435, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31486801

RESUMEN

Neuropathic pain is an entity that causes patient disability and its diagnosis and treatment is a challenge for physicians. In a significant percentage of patients with neuropathic pain, it is restricted to one dermatome or to a particular region of the body; in this case, it is referred to as localized neuropathic pain. There are no Mexican clinical guidelines proposing recommendations for the diagnosis and treatment of localized neuropathic pain in our population. This article presents the recommendations of a multidisciplinary consensus of specialists from different areas involved in the diagnosis and treatment of this type of patients.

3.
Prosthes. Esthet. Sci ; 8(31): 69-78, abr./mai./jun. 2019.
Artículo en Portugués | BBO - Odontología | ID: biblio-1016240

RESUMEN

Com a evolução da odontologia digital, muitos programas de planejamento virtual, scanners intraorais e métodos CAD-CAM têm sido desenvolvidos com o intuito de auxiliar o desenvolvimento e a confecção de guias cirúrgicos prototipados, tanto para a implantodontia quanto para a periodontia, visando permitir que as terapias de reabilitação dental sejam realizadas com maior segurança e previsibilidade. Uma reabilitação estética de sucesso dos pacientes com excesso de exibição gengival e coroas clínicas curtas requer uma abordagem interdisciplinar e sintonia entre o periodontista e o protesista, pois devolver simetria gengival e harmonia ao sorriso é uma tarefa árdua e minuciosa. Dessa forma, o objetivo deste trabalho é relatar um caso clínico de aumento de coroa, utilizando o fluxo de trabalho digital com o uso do guia duplo periodontal. (AU).


The evolution of digital dentistry, many virtual planning programs, intraoral scanners and CAD-CAM methods have been developed with the purpose of assisting the development and production of prototyped surgical guides for both implantology and periodontics, in order to allow that dental rehabilitation therapies are performed with greater safety and predictability. Successful aesthetic rehabilitation of patients with excessive gingival display and short clinical crowns requires an interdisciplinary approach and attunement between the periodontist and the prosthodontist, as returning gingival symmetry and harmony to the smile is an arduous and meticulous task. Thus, the objective of this work is to report a clinical case of Crow increase, using digital workflow with Double periodontal guide.


Asunto(s)
Humanos , Masculino , Adulto , Tecnología Odontológica , Cirugía Asistida por Computador , Informática Odontológica , Estética Dental
4.
Salud Publica Mex ; 61(3): 359-414, 2019.
Artículo en Español | MEDLINE | ID: mdl-31276353

RESUMEN

OBJECTIVE: Lung cancer is one the leading causes of mortality worldwide. Symptomatic manifestations of the disease generally occur in the advanced-stage setting, and therefore an important number of patients have advanced or metastatic disease by the time they are diagnosed. This situation contributes to a poor prognosis in the treatment of lung cancer. Evidencebased clinical recommendations are of great value to support decision-making for daily practice, and thus improving health care quality and patient outcomes. MATERIALS AND METHODS: This document was an initiative of the Mexican Society of Oncology (SMEO) in collaboration with Mexican Center of Clinical Excellence (Cenetec) according to Interna- tional Standards. Such standards included those described by the IOM, NICE, SIGN and GI-N. An interdisciplinary Guideline Development Group (GDG) was put together which included medical oncologists, surgical oncologistsc, radiation therapists, and methodologists with expertise in critical appraisal, sys- tematic reviews and clinical practice guidelines development. RESULTS: 62 clinical questions were agreed among members of the GDG. With the evidence identified from systematic reviews, the GDG developed clinical recommendations using a Modified Delphi Panel technique. Patients' representatives validated them. CONCLUSIONS: These Clinical Practice Guideline aims to support the shared decision-making process for patients with different stages of non-small cell lung cancer. Our goal is to improve health-care quality on these patients.

6.
High Blood Press Cardiovasc Prev ; 26(4): 273-281, 2019 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-31297720

RESUMEN

Syncope is a temporary loss of consciousness due to transient global cerebral hypoperfusion. Reflex syncope is the most frequent, representing 21% of all types of syncopal events, and includes: (a) the vasovagal syncope (classical type); (b) the situational syncope; (c) the carotid sinus syncope and (d) non-classical forms. An accurate anamnesis and physical examination are fundamental for the diagnosis. Although limited evidence is available regarding the efficacy of some treatments, a number of these can be successfully used in the clinical practice. It is, however, important to personalize the therapeutic approach in order to achieve an efficient reduction or suppression of syncopal episodes. Patients should be reassured about the benignity of these events and the possibility of reducing their frequency over time. They should be also educated on how to recognize and abort incoming syncopal episodes. Patients may be advised to increase their introit in water and salt, as well as to reduce vasoactive medications, if no contraindications exist. Orthostatic training may be beneficial but only in very motivated young patients capable of strictly adhering to the exercise plan. So far, any proposed pharmacological treatment has demonstrated very limited efficacy and, therefore, it should be tried in case of failure of non-pharmacological approaches. Pacemaker implantation is clearly indicated in patients with documented cardioinhibitory syncope in the absence of a vasodepressor component, which can compromise their quality of life. Despite the American and European guidelines for the treatment of syncope are similar, still some differences can be denoted. Aim of this study is to evaluate the management of patients with recurrent syncopal episodes focusing on pharmacological and non-pharmacological approaches.


Asunto(s)
Circulación Cerebrovascular , Estado de Conciencia , Síncope Vasovagal/terapia , Presión Sanguínea , Toma de Decisiones Clínicas , Humanos , Guías de Práctica Clínica como Asunto , Recurrencia , Factores de Riesgo , Síncope Vasovagal/diagnóstico , Síncope Vasovagal/etiología , Síncope Vasovagal/fisiopatología , Resultado del Tratamiento
7.
Stud Health Technol Inform ; 262: 7-10, 2019 Jul 04.
Artículo en Inglés | MEDLINE | ID: mdl-31349252

RESUMEN

Execution of multiple computer-interpretable guidelines (CIGs), enables the creation of patient-centered care plans for multimorbidity, which can be monitored by clinical decision support systems. This paper introduces an execution framework to manage multiple, concurrently implemented CIGs, also discussing the approaches used such as constraint satisfaction.


Asunto(s)
Toma de Decisiones Asistida por Computador , Sistemas de Apoyo a Decisiones Clínicas , Guías de Práctica Clínica como Asunto , Computadores , Humanos
8.
Rev Clin Esp ; 2019 Jul 04.
Artículo en Inglés, Español | MEDLINE | ID: mdl-31280888

RESUMEN

The epidemiological association of cholesterol associated with low density lipoproteins (LDL-c) levels and the development of atherosclerotic vascular disease has been ratified by mendelian randomization studies. Paradoxically, the success of statins led to the underestimation of other lipid-lowering therapies and even the measurement of LDL-c. Recent studies show that the reduction of LDL-c to extraordinarily low levels through absorption inhibition, and, in a particularly intensive manner, with monoclonal antibodies against pro-protein convertase subtilisine Kesine 9 (PCSK9) continues to offer cardiovascular protection. However, the high cost and limited experience with PCSK-9 inhibitors advised a prudent use of them. An appropriate selection of patients most likely to benefit from treatment with PCSK9 inhibitors emerges as the basis for a consensus of international guidelines: the combination of a high absolute vascular risk and a greater expected benefit by the starting LDL-c levels.

9.
J Stroke Cerebrovasc Dis ; 28(9): 2488-2495, 2019 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-31277995

RESUMEN

BACKGROUND AND OBJECTIVE: Current standard practice guidelines recommend ICU admission for ischemic stroke patients treated with intravenous tissue plasminogen activator (IV-tPA). More recently, the trend in stroke care is to broaden eligibility for IV thrombolysis. Two examples are a more liberal inclusion criteria known as SMART criteria (sIV-tPA), and the transfer of patients to comprehensive stroke centers (CSC). The present study characterizes ICU interventions in these patients. Understanding which stroke patients that require ICU-level care may allow for placement of patients in the appropriate level of care at hospital admission. METHODS: We performed a retrospective review of consecutive transfer and nontransfer sIV-tPA-treated patients admitted to the ICU at a CSC. We evaluated the frequency, timing, and nature of ICU interventions. RESULTS: Three hundred and thirty one patients were treated with sIV-tPA and 42% required ICU interventions during ICU admission. Of patients requiring ICU interventions, 98% had an ICU intervention performed in triage, prior to admission. National Institute of Health Stroke Scale score only had a moderate association to requirement of ICU interventions. Neither transferring patients to a CSC nor the number of standard IV-tPA contraindications increased ICU interventions. CONCLUSIONS: Liberalized IV-tPA administration did not increase ICU interventions. Nearly all patients that required ICU interventions declared this need in triage, prior to ICU admission. This timing of ICU intervention use during triage is highly sensitive for whether a patient will require ongoing ICU-level care during hospital admission. Identifying ICU intervention use in triage may allow for more effective placement of post-IV-tPA patients in the appropriate inpatient care setting, leading to better utilization of scarce ICU resources.


Asunto(s)
Isquemia Encefálica/tratamiento farmacológico , Fibrinolíticos/administración & dosificación , Unidades de Cuidados Intensivos , Admisión del Paciente , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica/métodos , Activador de Tejido Plasminógeno/administración & dosificación , Triaje , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico , Toma de Decisiones Clínicas , Bases de Datos Factuales , Femenino , Fibrinolíticos/efectos adversos , Humanos , Infusiones Intravenosas , Unidades de Cuidados Intensivos/normas , Masculino , Persona de Mediana Edad , Admisión del Paciente/normas , Selección de Paciente , Transferencia de Pacientes , Guías de Práctica Clínica como Asunto , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Accidente Cerebrovascular/diagnóstico , Terapia Trombolítica/efectos adversos , Terapia Trombolítica/normas , Factores de Tiempo , Activador de Tejido Plasminógeno/efectos adversos , Resultado del Tratamiento , Triaje/normas
10.
Anaesthesia ; 74(10): 1298-1304, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31292953

RESUMEN

Effective peri-operative pain management is a prerequisite for optimal recovery after surgery. Despite published evidence-based guidelines from several professional groups, postoperative pain management remains inadequate. The procedure-specific pain management (PROSPECT) collaboration consists of anaesthetists and surgeons with broad international representation that provide healthcare professionals with practical and evidence-based recommendations formulated in a way that facilitates clinical decision-making across all stages of the peri-operative period on a procedure-specific basis. The aim of this manuscript is to provide a detailed description of the current PROSPECT methodology with the intention of providing the rigour and transparency in which procedure-specific pain management recommendations are developed. The high methodological standards of the recommendations should improve the quality of clinical practice.


Asunto(s)
Medicina Basada en la Evidencia/métodos , Manejo del Dolor/métodos , Dolor Postoperatorio/terapia , Atención Perioperativa/métodos , Anestesiólogos , Toma de Decisiones Clínicas , Técnica Delfos , Guías como Asunto , Humanos , Dimensión del Dolor , Cirujanos
11.
ABC., imagem cardiovasc ; 32(3): 157-197, jul.-set. 2019. ilus, tab
Artículo en Portugués | LILACS, Sec. Est. Saúde SP, SESSP-IDPCPROD, Sec. Est. Saúde SP | ID: biblio-1006549
12.
BMC Health Serv Res ; 19(1): 474, 2019 Jul 10.
Artículo en Inglés | MEDLINE | ID: mdl-31291959

RESUMEN

BACKGROUND: Despite the high burden of pneumococcal disease, pneumococcal vaccine coverage continues to fall short of Healthy People 2020 goals. A quasi-experimental design was used to investigate the impact of pneumococcal-specific best-practice alerts (BPAs) with and without workflow redesign compared to health maintenance notifications only, on pneumococcal vaccination rates in at-risk and high-risk adults, and on series completion in immunocompetent adults aged 65+ years. METHODS: This retrospective study used electronic health record and administrative data to identify pneumococcal vaccinations using cross sectional and historical cohorts of adults age 19+ years from 2013 to 2017 who attended clinics associated with the University of Utah Health. Difference-in-differences (DD) analyses was used to assess the impact of interventions across three observation periods (Baseline, Interim, and Follow Up). Adherence to the 2-dose vaccination schedule in older adults was measured through a longitudinal analysis. RESULTS: In DD analyses, implementing both workflow redesign and the BPA raised the vaccination rate by 8 percentage points (pp) (P < 0.001) and implementing the BPA only raised the rate by 7 pp. (P < 0.001) among at-risk adults age 19-64 years, relative to implementing health maintenance notifications (i.e., usual care) only in comparison clinics. In high-risk adults age 19-64 years, the BPA with or without workflow redesign did not significantly affect vaccination rates from baseline to follow up relative to health maintenance notifications. Per DD analyses, the effect of the BPA was mixed in immunocompetent and immunocompromised adults age 65+ years. However, immunocompetent older adults attending a clinic that implemented the BPA plus health maintenance notifications and workflow redesign (all 3 interventions) had 1.94 times higher odds (Odds ratio (OR) 1.94; P = 0.0003, 95% CI 1.24, 3.01) to receive the second pneumococcal dose than patients attending a usual practice clinic (i.e., no intervention). CONCLUSIONS: A pneumococcal BPA tool that reflects current guidelines implemented with and without workflow redesign improved vaccination rates for at-risk adults age 19-64 years and increased the likelihood of adults aged 65+ to complete the recommended 2-dose series. However, in other adult patient groups, the BPA was not consistently associated with improvements in pneumococcal vaccination rates.


Asunto(s)
Vacunas Neumococicas/administración & dosificación , Guías de Práctica Clínica como Asunto , Atención Primaria de Salud , Sistemas Recordatorios , Vacunación/estadística & datos numéricos , Adulto , Anciano , Estudios Transversales , Registros Electrónicos de Salud , Femenino , Investigación sobre Servicios de Salud , Humanos , Esquemas de Inmunización , Masculino , Persona de Mediana Edad , Infecciones Neumocócicas/prevención & control , Estudios Retrospectivos , Medición de Riesgo , Adulto Joven
13.
Int. j. cardiovasc. sci. (Impr.) ; 32(3): 302-309, May-June 2019. tab, ilus
Artículo en Inglés | LILACS | ID: biblio-1002221

RESUMEN

This paper is about the Guideline for Ventilation / Perfusion Scintigraphy. It has been developed by the Brazilian Society of Nuclear Medicine to be a best practices guide used in Nuclear Medicine. Its function is to be an educational tool to help the Nuclear Medicine Services in Brazil to guarantee a quality care to the patients


Asunto(s)
Humanos , Masculino , Femenino , Relación Ventilacion-Perfusión , Guías como Asunto/normas , Arteria Pulmonar/patología , Embolia Pulmonar/complicaciones , Embolia Pulmonar/diagnóstico por imagen , Diagnóstico por Imagen/métodos , Cintigrafía/métodos , Medicina Nuclear/normas
14.
Gastroenterol Hepatol ; 42(7): 423-428, 2019.
Artículo en Inglés, Español | MEDLINE | ID: mdl-31155427

RESUMEN

INTRODUCCIóN: Adherence to guidelines on the periendoscopic management of antiplatelet therapy (APT) has not been analyzed in detail. Our aim was to assess adherence to guidelines in patients referred to our Endoscopy Unit on a case-by-case basis, describing in detail the detected deviations and identifying areas of improvement. PATIENTS AND METHODS: Cross-sectional study of outpatients consecutively scheduled for an unsedated upper or lower gastrointestinal endoscopy between January and June 2015. Patients on anticoagulant therapy were excluded. RESULTS: 675 patients were evaluated, including 91 (13.5%) patients on APT [upper GI endoscopy 25 (27.5%), lower GI endoscopy 66 (72.5%)]. Contrary to the clinical guidelines, aspirin was discontinued in 25 of the 77 patients previously prescribed the drug (32.5%) but this modification was patient's own decision in 11 cases. Most of the apparent deviations in the management of clopidogrel and dual antiplatelet therapy (DAPT) were not true non-adherence cases. The Primary Care physician modified an APT prescribed by another physician in 8 of 9 cases (88.9%), always in cases with aspirin. No relationship was found between the endoscopic procedure's predicted risk of bleeding or the patient's thrombotic risk and modification of therapy. DISCUSSION: In many patients, the peri-procedural management of APT goes against current guidelines, but some of these inconsistencies cannot be considered true deviations from practice. Identified areas for improvement are increasing patient awareness about APT, disseminating the guidelines in Primary Care, and underscoring the significance of thrombotic risk related to APT withdrawal.

16.
Lakartidningen ; 1162019 May 15.
Artículo en Sueco | MEDLINE | ID: mdl-31192408

RESUMEN

Idiopathic intracranial hypertension (IIH) is a disorder affecting both the pediatric and adult population. Investigations and treatments may differ considerably. There are no evidence-based guidelines for treatment. During a national multidisciplinary meeting in Stockholm January 2018 IIH experts from several Swedish regions met to discuss how to manage this patient group. These guidelines are based on this meeting and a review of current medical knowledge. To summarize: All patients should be investigated and treated for underlying factors that could be the cause of high intracranial pressure (ICP) (such as obesity, secondary causes such as intracranial tumors or other factors reported to affect ICP). When treating IIH the preservation of vision is crucial. Follow-up depends on visual status. In case of acute risk of visual impairment prompt surgical intervention must be considered. Symptomatic treatment of headache is recommended.


Asunto(s)
Guías de Práctica Clínica como Asunto , Seudotumor Cerebral , Acetazolamida/administración & dosificación , Acetazolamida/uso terapéutico , Cirugía Bariátrica , Inhibidores de Anhidrasa Carbónica/administración & dosificación , Inhibidores de Anhidrasa Carbónica/uso terapéutico , Consenso , Vías Clínicas , Diagnóstico Diferencial , Femenino , Cefalea/etiología , Humanos , Obesidad/complicaciones , Obesidad/cirugía , Embarazo , Seudotumor Cerebral/complicaciones , Seudotumor Cerebral/diagnóstico , Seudotumor Cerebral/tratamiento farmacológico , Seudotumor Cerebral/cirugía , Factores de Riesgo , Stents , Suecia , Derivación Ventriculoperitoneal
17.
Arch Esp Urol ; 72(5): 483-499, 2019 Jun.
Artículo en Español | MEDLINE | ID: mdl-31223126

RESUMEN

OBJECTIVES: The purpose of this document is to establish practical recommendations on neurogenic bladder (NB) management based on scientific evidence and medical and nursing perspective in Spinal Cord Injury (SCI) Units as a first multidisciplinary consensual approach in Spain. METHODS: This paper reports results from the first modified Delphi consensus building exercise on this procedure. A committee of recognised opinion-leaders in rehabilitation and urology with special interest in NB was constituted. A working group formed by rehabilitation doctors, urologists and nursing staff of SCI and Neurorehabilitation Units of a number of Spanish hospitals and specialised centres associated with the panel of NB experts have prepared this document. RESULTS: This review provided an overview of the main aspects described by the different clinical guidelines already available and highlighted the need to focus on recommendations in special priority situations in which there was no consensus. In view of the considerable impact this condition has on quality of life, patients should be offered help to better understand the disorder and they should be taught how to use the treatment techniques to obtain satisfactory results and promote their autonomy. CONCLUSIONS: This article presents a version of guidelines for patients with NB. The guidelines define the clinical profile of patients to provide the best evidence- based care and also an overview of the current drug and surgical treatments of NB.


Asunto(s)
Vejiga Urinaria Neurogénica , Consenso , Humanos , Calidad de Vida , España , Vejiga Urinaria Neurogénica/diagnóstico , Vejiga Urinaria Neurogénica/terapia
19.
Lakartidningen ; 1162019 Feb 19.
Artículo en Sueco | MEDLINE | ID: mdl-31192373

RESUMEN

Syncope is the chief complaint in 1-2 percent of emergency department visits. Syncope belongs to the broader category transient loss of consciousness (TLOC), defined as a short loss of consciousness with loss of awareness and responsiveness, and with subsequent amnesia for the event. Syncope is defined as TLOC due to cerebral hypoperfusion, with rapid onset and spontaneous complete recovery. The main categories of syncope are reflex syncope, orthostatic hypotension, and cardiac syncope. The 2018 guidelines by the European Society of Cardiology emphasizes the process of risk stratification in the initial management of suspected syncope. Risk stratification serves to separate the patients with likely orthostatic and reflex syncope with good prognosis from the patients with likely cardiac syncope and high short-term risk of an adverse outcome. It determines the appropriate next level of care. Further evaluation should be based on clinical suspicion and frequency of symptoms.


Asunto(s)
Síncope/diagnóstico , Cardiología , Vías Clínicas , Diagnóstico Diferencial , Manejo de la Enfermedad , Europa (Continente) , Humanos , Hipotensión Ortostática/diagnóstico , Hipotensión Ortostática/etiología , Hipotensión Ortostática/terapia , Guías de Práctica Clínica como Asunto , Medición de Riesgo , Sociedades Médicas , Síncope/etiología , Síncope/terapia , Síncope Vasovagal/diagnóstico , Síncope Vasovagal/etiología , Síncope Vasovagal/terapia
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