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3.
Med Clin North Am ; 104(2): 199-211, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32035564

RESUMEN

This article summarizes stroke rehabilitation, with a particular focus on rehabilitation from acute diagnosis to chronic impairments of stroke. The emphasis is on both pharmacologic and nonpharmacologic intervention and interdisciplinary collaboration.


Asunto(s)
Comunicación Interdisciplinaria , Manejo de Atención al Paciente/métodos , Rehabilitación de Accidente Cerebrovascular/métodos , Humanos
4.
Med Clin North Am ; 104(2): 213-238, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32035565

RESUMEN

Traumatic brain injury (TBI) is an acquired insult to the brain from an external mechanical force that may result in temporary or permanent impairment. The goal of this article is to provide a general review of the epidemiology, pathophysiology and medical management of adult patients with TBI for providers practicing outside the field of physical medicine and rehabilitation. The medical and rehabilitation management of moderate to severe TBI is the focus of this article, with a brief discussion of the management of mild injuries.


Asunto(s)
Lesiones Traumáticas del Encéfalo , Manejo de Atención al Paciente/métodos , Lesiones Traumáticas del Encéfalo/epidemiología , Lesiones Traumáticas del Encéfalo/fisiopatología , Lesiones Traumáticas del Encéfalo/terapia , Humanos , Pronóstico , Resultado del Tratamiento
5.
Med Clin North Am ; 104(2): 263-278, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32035568

RESUMEN

Individuals with spinal cord injuries or disorders (SCI/D), whether of traumatic or nontraumatic cause, require multidisciplinary management by their care team to achieve optimal health outcomes. SCI/D is relatively rare in the general population and primary care providers (PCPs) may not have extensive experience managing people with these disorders. Spinal cord injuries, impair the body's autonomic and biomechanical performance by interrupting the communications to and from major bodily systems. This article provides a framework to help PCPs understand how these changes impact their patient's physiologic function and subsequent risks for health complications with guidance for initial treatment approaches.


Asunto(s)
Manejo de Atención al Paciente/métodos , Traumatismos de la Médula Espinal , Enfermedad Crónica , Humanos , Grupo de Atención al Paciente/organización & administración , Traumatismos de la Médula Espinal/fisiopatología , Traumatismos de la Médula Espinal/terapia
6.
Med Clin North Am ; 104(2): 279-292, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32035569

RESUMEN

Neck pain is the fourth leading cause of disability. Acute neck pain largely resolves within 2 months. History and physical examination play a key role in ruling out some of the more serious causes for neck pain. The evidence for pharmacologic interventions for acute and chronic musculoskeletal neck pain is limited. Lower back pain is the leading cause of disability and productivity loss. Consultation with a physical medicine and rehabilitation spine specialist within 48 hours for acute pain and within 10 days for all patients with lower back pain may significantly decrease rate of surgical interventions and increase patient satisfaction.


Asunto(s)
Dolor de la Región Lumbar , Dolor de Cuello , Manejo de Atención al Paciente/métodos , Humanos , Dolor de la Región Lumbar/diagnóstico , Dolor de la Región Lumbar/terapia , Dolor de Cuello/diagnóstico , Dolor de Cuello/terapia , Pronóstico , Tiempo de Tratamiento
7.
Med Clin North Am ; 104(2): 293-311, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32035570

RESUMEN

Osteoarthritis (OA) is a worldwide endemic and debilitating disease. Previously thought to simply be damaged from "wear and tear," OA is now understood to be a complex interaction of local and systemic factors. This article reviews the pathology, symptoms, diagnosis, and various conservative, surgical, and novel treatments of OA.


Asunto(s)
Osteoartritis , Manejo de Atención al Paciente/métodos , Humanos , Osteoartritis/diagnóstico , Osteoartritis/fisiopatología , Osteoartritis/terapia
8.
Med Clin North Am ; 104(2): 313-325, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32035571

RESUMEN

Each year increasing numbers of people participate in a wider variety of athletic endeavors. Unlike previous generations, many patients remain in these activities later into their lives, some well beyond retirement. As the population ages and their activities continue, they are subject to injury of various forms affecting all aspects of their bodies.


Asunto(s)
Traumatismos en Atletas , Actividades Recreativas , Manejo de Atención al Paciente/métodos , Traumatismos en Atletas/clasificación , Traumatismos en Atletas/etiología , Traumatismos en Atletas/prevención & control , Traumatismos en Atletas/terapia , Conductas de Riesgo para la Salud/fisiología , Humanos , Conducta Sedentaria , Factores de Tiempo
9.
Isr Med Assoc J ; 22(2): 111-115, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-32043329

RESUMEN

BACKGROUND: Despite advances in therapeutic modalities, especially with biologic treatments, the number of hospitalizations due to complications for Crohn's disease did not decrease. We examined the prevalence and possible predictive factors of hospitalizations in Crohn's disease. A systematic literature search was conducted until 31 October 2018. Relevant studies were screened according to established protocol. Retrospective cohort studies describing hospitalizations of Crohn's disease patients were included. Meta-analysis was performed by using comprehensive meta-analysis software. Pooled odds ratios (ORs) and 95% confidence intervals (95%CIs) were calculated for the number of patients hospitalized. Twelve studies published before 31 March 2018 fulfilled the inclusion criteria and were comprised of 23 data-sets and included 4421 patients from six countries. A funnel plot demonstrates a moderate publication bias. We reported the event rates for the number of patients hospitalized, in a follow-up survey of 20,987 patient-years, and for the patients who underwent surgery in a follow-up of 5061 patient-years, with ORs of 0.233 with 95%CI 0.227-0.239, and 0.124 with 95%CI 0.114-0.135 (P < 0.001), respectively. Thus, when collecting the data from 12 cohort studies we found that hospitalization takes place in 23.3% of the patients, and operation in 12.4% along their disease duration. Patients with Crohn's disease may be hospitalized due to exacerbation of their inflammatory disease, because of non-inflammatory disease (such as fistula or stricture), or due to medical complications. The goal of therapy should be to keep the Crohn's disease patients in their natural environment and out of the hospital and to prevent surgery as much as possible.


Asunto(s)
Enfermedad de Crohn/terapia , Hospitalización/estadística & datos numéricos , Humanos , Manejo de Atención al Paciente/métodos , Estudios Retrospectivos
10.
J Clin Psychiatry ; 81(2)2020 Jan 28.
Artículo en Inglés | MEDLINE | ID: mdl-31995679

RESUMEN

Valbenazine and deutetrabenazine are FDA-approved as treatment for tardive dyskinesia (TD). Both medications are vesicular monoamine transporter type 2 (VMAT2) inhibitors, and both are effective for reducing TD symptoms. Clinicians need to be aware of the adverse effects of valbenazine and deutetrabenazine, as well as other key differences between the two, in order to individualize treatment. Using the Abnormal Involuntary Movement Scale assists clinicians in assessing progress for each patient. Treating TD effectively with these new medications will reduce the burden of the condition for patients.


Asunto(s)
Examen Neurológico/métodos , Discinesia Tardía , Tetrabenazina/análogos & derivados , Valina/análogos & derivados , Proteínas de Transporte Vesicular de Monoaminas/antagonistas & inhibidores , Monitoreo de Drogas/métodos , Humanos , Administración del Tratamiento Farmacológico , Moduladores del Transporte de Membrana/administración & dosificación , Moduladores del Transporte de Membrana/efectos adversos , Manejo de Atención al Paciente/métodos , Manejo de Atención al Paciente/normas , Psiquiatría/educación , Discinesia Tardía/inducido químicamente , Discinesia Tardía/diagnóstico , Discinesia Tardía/tratamiento farmacológico , Tetrabenazina/administración & dosificación , Tetrabenazina/efectos adversos , Resultado del Tratamiento , Valina/administración & dosificación , Valina/efectos adversos
11.
Mayo Clin Proc ; 95(1): 136-156, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31902409

RESUMEN

Globally, cardiovascular disease remains a major cause of adverse outcomes in young individuals, unlike its decline in other age groups. This group is not well studied and has a unique risk profile with less traditional cardiovascular risk factors compared with older populations. Plaque rupture still remains the most common etiology of myocardial infarction, but unique syndromes such as plaque erosion, coronary microvascular dysfunction, spontaneous coronary artery dissection, and coronary spasm related to drug use are more prevalent in this age group. Such diversity of diagnosis and presentation, along with therapeutic implications, underscore the need to study the profile of myocardial infarction in young persons. We searched PubMed for articles published from 1980 to 218 using the terms acute myocardial infarction, young, plaque rupture, plaque erosion, spontaneous coronary artery dissection (SCAD), coronary vasospasm, variant or Prinzmetal angina, drug-induced myocardial infarction, myocarditis, coronary embolism, microvascular dysfunction, MINOCA, and myocardial infarction in pregnancy and reviewed all the published studies. With the data from this search, we aim to inform readers of the prevalence, risk factors, presentation, and management of acute myocardial infarction in young patients and elaborate on special subgroups with diagnostic and therapeutic challenges. We also outline a parsimonious method designed to simplify management of these complex patients.


Asunto(s)
Infarto del Miocardio , Manejo de Atención al Paciente/métodos , Adulto , Edad de Inicio , Causalidad , Humanos , Infarto del Miocardio/epidemiología , Infarto del Miocardio/etiología , Infarto del Miocardio/terapia , Pronóstico , Factores de Riesgo
13.
N Engl J Med ; 382(2): 152-162, 2020 01 09.
Artículo en Inglés | MEDLINE | ID: mdl-31914242

RESUMEN

BACKGROUND: There is widespread interest in programs aiming to reduce spending and improve health care quality among "superutilizers," patients with very high use of health care services. The "hotspotting" program created by the Camden Coalition of Healthcare Providers (hereafter, the Coalition) has received national attention as a promising superutilizer intervention and has been expanded to cities around the country. In the months after hospital discharge, a team of nurses, social workers, and community health workers visits enrolled patients to coordinate outpatient care and link them with social services. METHODS: We randomly assigned 800 hospitalized patients with medically and socially complex conditions, all with at least one additional hospitalization in the preceding 6 months, to the Coalition's care-transition program or to usual care. The primary outcome was hospital readmission within 180 days after discharge. RESULTS: The 180-day readmission rate was 62.3% in the intervention group and 61.7% in the control group. The adjusted between-group difference was not significant (0.82 percentage points; 95% confidence interval, -5.97 to 7.61). In contrast, a comparison of the intervention-group admissions during the 6 months before and after enrollment misleadingly suggested a 38-percentage-point decline in admissions related to the intervention because the comparison did not account for the similar decline in the control group. CONCLUSIONS: In this randomized, controlled trial involving patients with very high use of health care services, readmission rates were not lower among patients randomly assigned to the Coalition's program than among those who received usual care. (Funded by the National Institute on Aging and others; ClinicalTrials.gov number, NCT02090426; American Economic Association registry number, AEARCTR-0000329.).


Asunto(s)
Enfermedad Crónica/terapia , Hospitalización/estadística & datos numéricos , Manejo de Atención al Paciente/métodos , Readmisión del Paciente/estadística & datos numéricos , Adulto , Anciano , Atención Ambulatoria/estadística & datos numéricos , Costos de la Atención en Salud , Visita Domiciliaria , Humanos , Modelos Lineales , Persona de Mediana Edad , New Jersey , Manejo de Atención al Paciente/organización & administración , Resumen del Alta del Paciente , Estudios Prospectivos , Factores Socioeconómicos , Estados Unidos
14.
BMJ ; 368: l6968, 2020 01 29.
Artículo en Inglés | MEDLINE | ID: mdl-31996352

RESUMEN

OBJECTIVE: To examine the distribution and patterns of opioid prescribing in the United States. DESIGN: Retrospective, observational study. SETTING: National private insurer covering all 50 US states and Washington DC. PARTICIPANTS: An annual average of 669 495 providers prescribing 8.9 million opioid prescriptions to 3.9 million patients from 2003 through 2017. MAIN OUTCOME MEASURES: Standardized doses of opioids in morphine milligram equivalents (MMEs) and number of opioid prescriptions. RESULTS: In 2017, the top 1% of providers accounted for 49% of all opioid doses and 27% of all opioid prescriptions. In absolute terms, the top 1% of providers prescribed an average of 748 000 MMEs-nearly 1000 times more than the middle 1%. At least half of all providers in the top 1% in one year were also in the top 1% in adjacent years. More than two fifths of all prescriptions written by the top 1% of providers were for more than 50 MMEs a day and over four fifths were for longer than seven days. In contrast, prescriptions written by the bottom 99% of providers were below these thresholds, with 86% of prescriptions for less than 50 MMEs a day and 71% for fewer than seven days. Providers prescribing high amounts of opioids and patients receiving high amounts of opioids persisted over time, with over half of both appearing in adjacent years. CONCLUSIONS: Most prescriptions written by the majority of providers are under the recommended thresholds, suggesting that most US providers are careful in their prescribing. Interventions focusing on this group of providers are unlikely to effect beneficial change and could induce unnecessary burden. A large proportion of providers have established relationships with their patients over multiple years. Interventions to reduce inappropriate opioid prescribing should be focused on improving patient care, management of patients with complex pain, and reducing comorbidities rather than seeking to enforce a threshold for prescribing.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Prescripción Inadecuada/prevención & control , Manejo de Atención al Paciente/normas , Médicos , Pautas de la Práctica en Medicina , Adulto , Prescripciones de Medicamentos/normas , Prescripciones de Medicamentos/estadística & datos numéricos , Femenino , Humanos , Revisión de Utilización de Seguros/estadística & datos numéricos , Masculino , Médicos/clasificación , Médicos/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Pautas de la Práctica en Medicina/tendencias , Medicamentos bajo Prescripción/uso terapéutico , Mejoramiento de la Calidad , Estudios Retrospectivos , Estados Unidos/epidemiología
15.
BJOG ; 127(3): 416-423, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31677228

RESUMEN

OBJECTIVE: To develop a sepsis care bundle for the initial management of maternal sepsis in low resource settings. DESIGN: Modified Delphi process. SETTING: Participants from 34 countries. POPULATION: Healthcare practitioners working in low resource settings (n = 143; 34 countries), members of an expert panel (n = 11) and consultation with the World Health Organization Global Maternal and Neonatal Sepsis Initiative technical working group. METHODS: We reviewed the literature to identify all potential interventions and practices around the initial management of sepsis that could be bundled together. A modified Delphi process, using an online questionnaire and in-person meetings, was then undertaken to gain consensus on bundle items. Participants ranked potential bundle items in terms of perceived importance and feasibility, considering their use in both hospitals and health centres. Findings from the healthcare practitioners were then triangulated with those of the experts. MAIN OUTCOME MEASURE: Consensus on bundle items. RESULTS: Consensus was reached after three consultation rounds, with the same items deemed most important and feasible by both the healthcare practitioners and expert panel. Final bundle items selected were: (1) Fluids, (2) Antibiotics, (3) Source identification and control, (4) Transfer (to appropriate higher-level care) and (5) Monitoring (of both mother and neonate as appropriate). The bundle was given the acronym 'FAST-M'. CONCLUSION: A clinically relevant maternal sepsis bundle for low resource settings has been developed by international consensus. TWEETABLE ABSTRACT: A maternal sepsis bundle for low resource settings has been developed by international consensus.


Asunto(s)
Paquetes de Atención al Paciente/métodos , Manejo de Atención al Paciente , Complicaciones Infecciosas del Embarazo , Consenso , Técnica Delfos , Femenino , Humanos , Recién Nacido , Cooperación Internacional , Área sin Atención Médica , Manejo de Atención al Paciente/métodos , Manejo de Atención al Paciente/organización & administración , Embarazo , Complicaciones Infecciosas del Embarazo/diagnóstico , Complicaciones Infecciosas del Embarazo/terapia , Organización Mundial de la Salud
16.
Cancer Treat Rev ; 82: 101929, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31770695

RESUMEN

Autologous stem cell transplantation (ASCT) has been the mainstay of multiple myeloma (MM) treatment for approximately 30 years. Although the continuous introduction of novel agents in the armamentarium against MM has questioned its value, ASCT remains a backbone treatment for fit MM patients. However, there is no unanimous approach for several aspects including the positioning of ASCT in the therapeutic algorithm either upfront or following the first relapse, the need for single or tandem ASCT, as well as the role of ASCT as salvage therapy. Furthermore, the anti-CD38 monoclonal antibodies along with the next generation proteasome inhibitors and immunomodulatory drugs provide a platform for optimizing the induction and consolidation/maintenance regimens. In this review, we present current data pertaining to all aspects of ASCT in MM, whereas we highlight the open issues that should be addressed in the design of future clinical trials in the field.


Asunto(s)
Mieloma Múltiple/terapia , Manejo de Atención al Paciente , Trasplante de Células Madre/métodos , Antineoplásicos Inmunológicos/farmacología , Humanos , Manejo de Atención al Paciente/métodos , Manejo de Atención al Paciente/normas , Inhibidores de Proteasoma/farmacología , Trasplante Autólogo
17.
Thorac Surg Clin ; 30(1): 15-24, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31761280

RESUMEN

Nonintubated video-assisted thoracoscopic surgery for the treatment of primary and secondary pneumothorax was first reported in 1997 by Nezu. However, studies on this technique are few. Research in the past 20 years has focused on the perioperative outcomes, including the surgical duration, length of hospital stay, and postoperative morbidity and respiratory complication rates, which appear to be better than those of surgery under intubated general anesthesia. This study provides information pertaining to the physiologic, surgical, and anesthetic aspects and describes the potential benefits of nonintubated thoracoscopic surgery for the management of primary and secondary spontaneous pneumothorax.


Asunto(s)
Manejo de Atención al Paciente/métodos , Neumotórax/cirugía , Complicaciones Posoperatorias , Cirugía Torácica Asistida por Video , Anestesia General/métodos , Humanos , Neumotórax/etiología , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/prevención & control , Cirugía Torácica Asistida por Video/efectos adversos , Cirugía Torácica Asistida por Video/métodos
18.
Thorac Surg Clin ; 30(1): 25-32, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31761281

RESUMEN

Video-assisted thoracic surgery has considerably improved the care of the thoracic surgical patient. Patients are able to leave the hospital sooner and experience less pain with equal oncologic outcomes when compared with open surgery. Nonintubated thoracic surgery has more recently been applied in the management of both benign and malignant pleural effusions. This article provides the general thoracic surgeon a detailed description on how to manage pleural effusions using video-assisted thoracoscopic surgery in a nonintubated patient. Surgical techniques and pearls are also presented.


Asunto(s)
Manejo de Atención al Paciente/métodos , Derrame Pleural , Cirugía Torácica Asistida por Video/métodos , Humanos , Derrame Pleural/etiología , Derrame Pleural/cirugía
19.
Thorac Surg Clin ; 30(1): 33-39, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31761282

RESUMEN

Chest infection is a health care problem in many regions of the world, and pleural empyema is the most common type of surgical chest infection. In the past decennium, the introduction of nonintubated surgery and uniportal video-assisted thoracic surgery changed considerably surgical treatment of pleural empyema. Although the advantages seem evident, the need for randomized controlled trials is necessary to confirm the usefulness. Moreover, in the future, an education and training program for thoracic surgeons and anesthesiologists would allow increasing the number of awake surgical options in caring for patients with stages II to III empyema.


Asunto(s)
Empiema Pleural/cirugía , Absceso Pulmonar/cirugía , Manejo de Atención al Paciente/métodos , Cirugía Torácica Asistida por Video/métodos , Humanos , Resultado del Tratamiento
20.
Semin Oncol ; 46(4-5): 308-313, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31711680

RESUMEN

Cancer clinical trials represent an important option for patients with a diagnosis of cancer and the clinician-investigators involved in their care who seek options for their disease. For all who are impacted by cancer, these studies offer opportunities for greater learning. Conducting these important studies involves several challenges, including recruiting eligible participants. To address barriers that arise over the course of these activities, the Department of Veterans Affairs (VA) and National Cancer Institute (NCI) have partnered to increase Veteran participation in oncology clinical trials. This initiative, the NCI And VA Interagency Group to Accelerate Trials Enrollment, or NAVIGATE, is focused on addressing recruitment across the VA healthcare system and finding systematic solutions related to activating, recruiting for and conducting oncology clinical trials at VA Medical Centers. Additional goals include (1) establishing a sustainable network that can serve as a model for other VA sites interested in doing cancer clinical trials, (2) recruitment of minority patients, and (3) developing best practices and policies that can be deployed across the VA healthcare system. In this manuscript, we describe the scope, organization, activities, and future directions of NAVIGATE while also highlighting key needs for successfully conducting cancer clinical trials within the VA system. This partnership between 2 large federal agencies with a shared commitment to improving cancer care may provide lessons to others who are also dedicated to helping those affected by the disease.


Asunto(s)
Ensayos Clínicos como Asunto/organización & administración , Oncología Médica/organización & administración , Manejo de Atención al Paciente/organización & administración , Humanos , Oncología Médica/métodos , Oncología Médica/normas , National Cancer Institute (U.S.) , Atención al Paciente , Mejoramiento de la Calidad , Estados Unidos , United States Department of Veterans Affairs
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