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2.
Ann R Coll Surg Engl ; 103(2): 120-129, 2021 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-33559556

RESUMEN

INTRODUCTION: Recent consensus guidelines suggest that the laparoscopic approach may be a useful, safe and feasible approach in emergency general surgery. Despite this, the UK National Emergency Laparotomy Audit (NELA) suggests the rate of laparoscopy is low (9% fully laparoscopic) and slow to increase over time. A European survey found uptake to be variable. This UK survey was therefore undertaken to establish current UK practice and to determine factors affecting implementation. MATERIALS AND METHODS: A questionnaire survey of currently practising UK consultant general surgeons was carried out by the North West Surgical Research Collaborative, using a secure web-based database maintained by the North West Surgical Trials Centre. RESULTS: A total of 151 completed questionnaires were returned from 22 UK centres; 18% of respondents were unaware that laparoscopic cases should be reported to NELA. Appendicectomy (97%) and cholecystectomy (87%) were routinely performed laparoscopically. Laparoscopy was infrequently used in perforation, ischaemia or obstructed hernias. There appears to be equipoise regarding laparoscopic compared with open surgery in small-bowel obstruction among all subspecialty emergency general surgeons, in perforated peptic ulcer among upper gastrointestinal surgeons and in Hinchey III diverticulitis among colorectal surgeons. CONCLUSION: Uptake of laparoscopy in UK emergency general surgery is influenced by surgeon preference, subspecialty, patient and operative factors. Further research into outcomes may help to identify areas of greatest potential benefit. The rate of laparoscopy reported by NELA may be an underestimate due to the 18% of surgeons unaware that laparoscopic cases should be reported, which may affect the validity of analyses performed from this dataset.


Asunto(s)
Tratamiento de Urgencia/estadística & datos numéricos , Laparoscopía/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Consenso , Consultores/estadística & datos numéricos , Tratamiento de Urgencia/normas , Humanos , Laparoscopía/normas , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/normas , Cirujanos/estadística & datos numéricos , Encuestas y Cuestionarios/estadística & datos numéricos , Reino Unido
3.
BMJ ; 372: n107, 2021 02 10.
Artículo en Inglés | MEDLINE | ID: mdl-33568349

RESUMEN

OBJECTIVE: To examine the association between the use of macrolide antibiotics in pregnancy and the risk of major birth defects. DESIGN: Nationwide, register based cohort study. SETTING: Denmark, 1997-2016. PARTICIPANTS: Of 1 192 539 live birth pregnancies, pregnancies during which macrolides had been used (13 019) were compared with those during which penicillin (that is, phenoxymethylpenicillin) had been used (matched in a 1:1 ratio on propensity scores). Other comparative groups were pregnancies when macrolides had been used recently but before pregnancy (matched 1:1) and pregnancies where no antibiotics had been used (matched 1:4). MAIN OUTCOME MEASURES: Association with an outcome of any major birth defect and specific subgroups of birth defects were assessed by relative risk ratios and absolute risk differences. RESULTS: In matched comparisons, 457 infants were born with major birth defects to women who had used macrolides during pregnancy (35.1 per 1000 pregnancies) compared with 481 infants (37.0 per 1000 pregnancies) to women who had used penicillin (relative risk ratio 0.95; 95% confidence interval 0.84 to 1.08), corresponding to an absolute risk difference of -1.8 (95% confidence interval -6.4 to 2.7) per 1000 pregnancies. The risk of major birth defects was not significantly increased for women who had used macrolides during pregnancy compared with those who had used macrolides recently but before becoming pregnant (relative risk ratio 1.00 (95% confidence interval 0.88 to 1.14); absolute risk difference -0.1 (95% confidence interval -4.8 to 4.7) per 1000 pregnancies) or compared with women who did not use any antibiotics (1.05 (0.95 to 1.17); 1.8 (-1.7 to 5.3) per 1000 pregnancies). For all three comparative group analyses and in the analyses of use of individual macrolides, no significant increased risk of specific subgroups of birth defects associated with the use of macrolides was found. CONCLUSIONS: In this nationwide cohort study, the use of macrolide antibiotics in pregnancy was not associated with an increased risk of major birth defects. Analyses of the associated risk of 12 specific subgroups of birth defects with the use of macrolides in pregnancy were not significant.


Asunto(s)
Anomalías Inducidas por Medicamentos/epidemiología , Antibacterianos/uso terapéutico , Macrólidos/uso terapéutico , Penicilina V/uso terapéutico , Adulto , Estudios de Casos y Controles , Estudios de Cohortes , Femenino , Edad Gestacional , Humanos , Recién Nacido , Pautas de la Práctica en Medicina/estadística & datos numéricos , Embarazo , Puntaje de Propensión , Sistema de Registros
4.
BMJ ; 372: n102, 2021 02 10.
Artículo en Inglés | MEDLINE | ID: mdl-33568363

RESUMEN

OBJECTIVE: To evaluate the risk of first trimester exposure to prescription opioids for major congenital malformations, previously reported to be associated with such exposure. DESIGN: Population based cohort study. SETTING: Nationwide sample of publicly and commercially insured pregnant women linked to their liveborn infants, nested in the Medicaid Analytic eXtract (MAX, 2000-14) and the MarketScan Research Database (MarketScan, 2003-15). PARTICIPANTS: 1 602 580 publicly insured (MAX) and 1 177 676 commercially insured (MarketScan) pregnant women with eligibility from at least three months before pregnancy to one month after delivery; infants with eligibility for at least three months after birth. INTERVENTIONS: Use of prescription opioids was ascertained by requiring two or more dispensations of any opioid during the first trimester. MAIN OUTCOMES MEASURES: Major malformations overall, cardiac malformations overall, ventricular septal defect, secundum atrial septal defect/patent foramen ovale, neural tube defect, clubfoot, and oral cleft, defined based on validated algorithms. Propensity score stratification was used to adjust for potential confounders and/or proxies for confounders. Estimates from each database were combined using meta-analysis. RESULTS: 70 447 (4.4%) of 1 602 580 publicly insured and 12 454 (1.1%) of 1 177 676 commercially insured pregnant women had two or more dispensations of an opioid during the first trimester. Absolute risk of malformations overall was 41.0 (95% confidence interval 39.5 to 42.5) per 1000 pregnancies exposed to opioids versus 32.0 (31.7 to 32.3) per 1000 unexposed pregnancies in the MAX cohort, and 42.6 (39.0 to 46.1) and 37.3 (37.0 to 37.7) per 1000, respectively, in the MarketScan cohort. Pooled unadjusted relative risk estimates were raised for all outcomes but shifted substantially toward the null after adjustment; for malformations overall (relative risk 1.06, 95% confidence interval 1.02 to 1.10), cardiovascular malformations (1.09, 1.00 to 1.18), ventricular septal defect (1.07, 0.95 to 1.21), atrial septal defect/patent foramen ovale (1.04, 0.88 to 1.24), neural tube defect (0.82, 0.53 to 1.27), and clubfoot (1.06, 0.88 to 1.28). The relative risk for oral clefts remained raised after adjustment (1.21, 0.98 to 1.50), with a higher risk of cleft palate (1.62, 1.23 to 2.14). CONCLUSIONS: Prescription opioids used in early pregnancy are not associated with a substantial increase in risk for most of the malformation types considered, although a small increase in the risk of oral clefts associated with their use is possible.


Asunto(s)
Anomalías Inducidas por Medicamentos/epidemiología , Analgésicos Opioides/efectos adversos , Complicaciones del Embarazo/tratamiento farmacológico , Anomalías Inducidas por Medicamentos/etiología , Adulto , Estudios de Casos y Controles , Estudios de Cohortes , Estudios Transversales , Bases de Datos Factuales , Femenino , Humanos , Recién Nacido , Manejo del Dolor/métodos , Manejo del Dolor/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Embarazo , Complicaciones del Embarazo/epidemiología , Primer Trimestre del Embarazo , Riesgo
5.
Respir Res ; 22(1): 50, 2021 Feb 12.
Artículo en Inglés | MEDLINE | ID: mdl-33579277

RESUMEN

The importance of vaccinations for COPD patients has been previously described. However, there is still a gap between guideline recommendations and the implementation of preventive care delivery for these patients. Specially, the rise of SARS-CoV-2 pandemic has made the significance of vaccination adherence more critical to address. Our study showed that referral to pulmonary clinic is associated with increased odds of receiving influenza (OR = 1.97, [95% CI 1.07, 3.65]) and pneumococcal vaccinations (PCV13 OR = 3.55, [1.47, 8.54]; PPSV23 OR = 4.92, [1.51, 16.02]). These data suggest that partnerships between primary care physicians and pulmonologists can potentially improve the vaccination rates for patients with COPD.


Asunto(s)
Pautas de la Práctica en Medicina , Atención Primaria de Salud , Enfermedad Pulmonar Obstructiva Crónica/terapia , Neumología , Derivación y Consulta , Vacunación , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Adhesión a Directriz , Humanos , Vacunas contra la Influenza/uso terapéutico , Masculino , Persona de Mediana Edad , Vacunas Neumococicas/uso terapéutico , Guías de Práctica Clínica como Asunto , Enfermedad Pulmonar Obstructiva Crónica/diagnóstico , Estudios Retrospectivos
6.
Clin Appl Thromb Hemost ; 27: 1076029620987900, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-33517715

RESUMEN

Patients with renal impairment require dose adjustments for direct oral anticoagulants (DOACs), though there is uncertainty regarding their use in severe chronic kidney disease. Inappropriately dosed DOACs may increase risk of ischemic events when under-dosed, or risk of bleeding when over-dosed. The purpose of this study was to describe DOAC selection, dosing strategies, and associated clinical outcomes in patients with moderate to severe renal impairment at our institution. This was a single-center retrospective analysis of adult outpatients with moderate to severe renal impairment (estimated creatinine clearance <50 mL/min, including need for hemodialysis) who were prescribed a DOAC by a cardiologist between June 1, 2015 and December 1, 2018. Outcomes evaluated included the percentage of patients who received appropriate and inappropriate DOAC dosing, prescriber reasons for inappropriate DOAC dosing if documented, and incidence of thrombotic and bleeding events. A total of 207 patients were included. Overall, 61 (29.5%) patients received inappropriate dosing, with 43 (70.5%) being under-dosed and 18 (29.5%) being over-dosed as compared to FDA-labeled dosing recommendations for atrial fibrillation or venous thromboembolism (VTE). By a median follow-up duration of 20 months, stroke occurred in 6 (3.3%) patients receiving DOACs for atrial fibrillation, and VTE occurred in 1 (4.3%) patient receiving a DOAC for VTE. International Society on Thrombosis and Haemostasis major or clinically relevant nonmajor bleeding occurred in 25 (12.1%) patients. Direct oral anticoagulants were frequently prescribed at off-label doses in patients with moderate to severe renal impairment, with a tendency toward under-dosing.


Asunto(s)
Fibrilación Atrial/tratamiento farmacológico , Inhibidores del Factor Xa/administración & dosificación , Enfermedades Renales/fisiopatología , Riñón/fisiopatología , Pautas de la Práctica en Medicina , Tromboembolia/prevención & control , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/complicaciones , Utilización de Medicamentos , Inhibidores del Factor Xa/efectos adversos , Femenino , Hemorragia/inducido químicamente , Humanos , Prescripción Inadecuada , Incidencia , Enfermedades Renales/complicaciones , Enfermedades Renales/terapia , Masculino , Uso Fuera de lo Indicado , Diálisis Renal , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Tromboembolia/etiología , Factores de Tiempo , Resultado del Tratamiento
8.
BMC Fam Pract ; 22(1): 31, 2021 02 03.
Artículo en Inglés | MEDLINE | ID: mdl-33535973

RESUMEN

BACKGROUND: Interprofessional primary care (IPC) teams provide comprehensive and coordinated care and are ideally equipped to support those populations most at risk of adverse health outcomes during the COVID-19 pandemic, including older adults, and patients with chronic physical and mental health conditions. There has been little focus on the experiences of healthcare teams and no studies have examined IPC practice during the early phase of the COVID-19 pandemic. The objective of the study was to describe the state of interprofessional health provider practice within IPC teams during the COVID-19 pandemic. METHODS: Observational cross-sectional design. A web-based survey was deployed to IPC providers working in team-based primary care clinics in the province of Ontario, Canada. The survey included 26 close-ended and six open-ended questions. Close-ended questions were analyzed using descriptive statistics. Content analysis was used to analyze the open-ended questions. RESULTS: 445 surveys were included in the final analysis. Service delivery shifted from in-person care (77% pre-COVID-19) to telephone (76.5% during the COVID-19 pandemic). Less than half of the respondents (40%) reported receiving any training for virtual delivery. Wait times to access team members were reported to have decreased. There has also been a shift in what IPC providers report as the most commonly seen conditions, with increases in visits related to mental health concerns, acute infections (including COVID-19), social isolation, and resource navigation. Respondents also reported a reduction in healthcare provision for multiple chronic conditions including diabetes, cardiovascular disease, and chronic pain. CONCLUSIONS: IPC teams are rapidly shifting their practice to supporting their patients during the pandemic. A surge in mental health issues has been seen and is expected to continue to increase in response to COVID-19. Understanding early experiences can help plan for future pandemic waves.


Asunto(s)
/epidemiología , Relaciones Interprofesionales , Atención Primaria de Salud/métodos , Estudios Transversales , Humanos , Trastornos Mentales/diagnóstico , Trastornos Mentales/epidemiología , Trastornos Mentales/terapia , Ontario/epidemiología , Grupo de Atención al Paciente/organización & administración , Grupo de Atención al Paciente/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Atención Primaria de Salud/estadística & datos numéricos , Encuestas y Cuestionarios
9.
J Foot Ankle Res ; 14(1): 11, 2021 Feb 03.
Artículo en Inglés | MEDLINE | ID: mdl-33536046

RESUMEN

BACKGROUND: On the 19th of January, 2020, the Chief Medical Officer of Australia issued a statement about a novel coronavirus, or SARS-CoV-2. Since this date, there have been variable jurisdictional responses, including lockdowns, and restrictions on podiatry practice. This study aimed to describe impacts of the SARS-CoV-2 pandemic on the podiatry profession in Australia. METHODS: This was a cross sectional study of Australian podiatrists using demographic data collected between 2017 and 2020, and pandemic-related question responses collected between 30th March and 31st August, 2020. Data were collected online and participants described their work settings, patient funding types, business decisions and impacts, and information sources used to guide practice decisions during this time-period. Inductive thematic analysis was used to analyse open-ended questions about their practice impact of SARS-CoV-2. RESULTS: There were 732 survey responses, with 465 Australian podiatrists or podiatric surgeons providing responses describing pandemic impact. From these responses, 223 (49% of 453) podiatrists reported no supply issues, or having adequate supplies for the foreseeable future with personal protective equipment (PPE) or consumables to support effective infection prevention and control. The most frequent responses about employment, or hours of work, impact were reported in the various categories of "business as usual" (n = 312, 67%). Participants described most frequently using the local state and territory Department of Health websites (n = 347, 75%), and the Australian Podiatry Association (n = 334, 72%) to make decisions about their business. Overarching themes which resounded through open-ended comments was that working through the pandemic was likened to a marathon, and not a sprint. Themes were: (i) commitment to do this, (ii) it's all in the plan, but not everything goes to plan, (iii) my support team must be part of getting through it, (iv) road blocks happen, and (v) nothing is easy, what's next? CONCLUSION: Podiatrists in Australia reported variable pandemic impact on their business decisions, PPE stores, and their valued sources of information. Podiatrists also described their "marathon" journey through the pandemic to date, with quotes describing their challenges and highlights. Describing these experiences should provide key learnings for future workforce challenges, should further restrictions come into place.


Asunto(s)
/prevención & control , Control de Infecciones/tendencias , Médicos/psicología , Podiatría/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Adulto , Anciano , Australia , Estudios Transversales , Femenino , Encuestas de Atención de la Salud , Humanos , Masculino , Persona de Mediana Edad , Médicos/estadística & datos numéricos
12.
BMC Infect Dis ; 21(1): 123, 2021 Jan 28.
Artículo en Inglés | MEDLINE | ID: mdl-33509114

RESUMEN

BACKGROUND: Xpert MTB/RIF (Xpert) has been recommended by WHO as the initial diagnostic test for TB and rifampicin-resistance detection. Existing evidence regarding its uptake is limited to public health systems and corresponding resource and infrastructure challenges. It cannot be readily extended to private providers, who treat more than half of India's TB cases and demonstrate complex diagnostic behavior. METHODS: We used routine program data collected from November 2014 to April 2017 from large-scale private sector engagement pilots in Mumbai and Patna. It included diagnostic vouchers issued to approximately 150,000 patients by about 1400 providers, aggregated to 18,890 provider-month observations. We constructed three metrics to capture provider behavior with regards to adoption of Xpert and studied their longitudinal variation: (i) Uptake (ordering of test), (ii) Utilization for TB diagnosis, and (iii) Non-adherence to negative results. We estimated multivariate linear regression models to assess heterogeneity in provider behavior based on providers' prior experience and Xpert testing volumes. RESULTS: Uptake of Xpert increased considerably in both Mumbai (from 36 to 60.4%) and Patna (from 12.2 to 45.1%). However, utilization of Xpert for TB diagnosis and non-adherence to negative Xpert results did not show systematic trends over time. In regression models, cumulative number of Xpert tests ordered was significantly associated with Xpert uptake in Patna and utilization for diagnosis in Mumbai (p-value< 0.01). Uptake of Xpert and its utilization for diagnosis was predicted to be higher in high-volume providers compared to low-volume providers and this gap was predicted to widen over time. CONCLUSIONS: Private sector engagement led to substantial increase in uptake of Xpert, especially among high-volume providers, but did not show strong evidence of Xpert results being integrated with TB diagnosis. Increasing availability and affordability of a technically superior diagnostic tool may not be sufficient to fundamentally change diagnosis and treatment of TB in the private sector. Behavioral interventions, specifically aimed at, integrating Xpert results into clinical decision making of private providers may be required to impact patient-level outcomes.


Asunto(s)
Técnicas de Diagnóstico Molecular/estadística & datos numéricos , Mycobacterium tuberculosis/aislamiento & purificación , Sector Privado/estadística & datos numéricos , Tuberculosis/diagnóstico , Antibióticos Antituberculosos/uso terapéutico , Farmacorresistencia Bacteriana/genética , Humanos , India/epidemiología , Mycobacterium tuberculosis/genética , Proyectos Piloto , Pautas de la Práctica en Medicina/estadística & datos numéricos , Rifampin/uso terapéutico , Tuberculosis/tratamiento farmacológico
14.
BMJ Open Respir Res ; 8(1)2021 01.
Artículo en Inglés | MEDLINE | ID: mdl-33414261

RESUMEN

INTRODUCTION: The COVID-19 pandemic has impacted specialty chronic obstructive pulmonary disease (COPD) care. We examined the degree to which care has moved to remote approaches, eliciting clinician and patient perspectives on what is appropriate for ongoing remote delivery. METHODS: Using an online research platform, we conducted a survey and consensus-building process involving clinicians and patients with COPD. RESULTS: Fifty-five clinicians and 19 patients responded. The majority of clinicians felt able to assess symptom severity (n=52, 95%), reinforce smoking cessation (n=46, 84%) and signpost to other healthcare resources (n=44, 80%). Patients reported that assessing COPD severity and starting new medications were being addressed through remote care. Forty-three and 31 respondents participated in the first and second consensus-building rounds, respectively. When asked to rate the appropriateness of using remote delivery for specific care activities, respondents reached consensus on 5 of 14 items: collecting information about COPD and overall health status (77%), providing COPD education and developing a self-management plan (74%), reinforcing smoking cessation (81%), deciding whether patients should seek in-person care (72%) and initiating a rescue pack (76%). CONCLUSION: Adoption of remote care delivery appears high, with many care activities partially or completely delivered remotely. Our work identifies strengths and limitations of remote care delivery.


Asunto(s)
Actitud del Personal de Salud , Educación del Paciente como Asunto , Pautas de la Práctica en Medicina , Enfermedad Pulmonar Obstructiva Crónica/terapia , Automanejo , Cese del Hábito de Fumar , Telemedicina/métodos , Adulto , Anciano , Actitud Frente a la Salud , Prestación de Atención de Salud/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Enfermeras y Enfermeros , Aceptación de la Atención de Salud , Fisioterapeutas , Médicos , Pautas de la Práctica en Enfermería , Enfermedad Pulmonar Obstructiva Crónica/fisiopatología , Índice de Severidad de la Enfermedad , Encuestas y Cuestionarios , Reino Unido
15.
BMC Infect Dis ; 21(1): 97, 2021 Jan 21.
Artículo en Inglés | MEDLINE | ID: mdl-33478430

RESUMEN

BACKGROUND: Inappropriate antibiotic use is linked to the spread of antimicrobial resistance worldwide, but there are limited systemic data on antibiotic utilization in low- and middle-income countries. The purpose of this study was to evaluate the prevalence and patterns of antibiotic prescription in an ambulatory care setting in Sri Lanka. METHODS: This cross-sectional survey was conducted at the Outpatient Department of a public tertiary medical center in Southern Province, Sri Lanka from February to April 2019. Among consecutive outpatients presenting for care, questionnaires were verbally administered to a systematic random sample to capture information about patient demographics, illness characteristics, and visit outcomes. Prescription data were obtained from the outpatient pharmacy's electronic prescribing system. RESULTS: Of 409 surveyed patients, 146 (35.7%) were prescribed an antibiotic. The most frequently prescribed agents were amoxicillin (41 patients, 28.1% of antibiotic recipients) and first-generation cephalosporins (38, 26.0%). Respiratory indications were the most common reason for antibiotic use, comprising 69 (47.3%) of all antibiotic prescriptions. Antibiotics were prescribed for 66.1% of patients presenting with cough and 78.8% of those presenting with rhinorrhea or nasal congestion. Among all antibiotic recipients, 6 (4.1%) underwent diagnostic studies. CONCLUSIONS: A high prevalence of antibiotic prescription was observed, in particular for treatment of respiratory conditions. These data support the need for improved antimicrobial stewardship in the Sri Lankan outpatient setting.


Asunto(s)
Atención Ambulatoria/estadística & datos numéricos , Antibacterianos/uso terapéutico , Prescripciones/estadística & datos numéricos , Enfermedades Respiratorias/tratamiento farmacológico , Adolescente , Adulto , Programas de Optimización del Uso de los Antimicrobianos , Niño , Estudios Transversales , Femenino , Encuestas de Atención de la Salud , Humanos , Masculino , Persona de Mediana Edad , Pacientes Ambulatorios , Pautas de la Práctica en Medicina , Prevalencia , Enfermedades Respiratorias/diagnóstico , Enfermedades Respiratorias/epidemiología , Sri Lanka/epidemiología , Centros de Atención Terciaria , Adulto Joven
16.
Ital J Pediatr ; 47(1): 10, 2021 Jan 15.
Artículo en Inglés | MEDLINE | ID: mdl-33451342

RESUMEN

Opioid-related mortality in adolescents is spreading in the US, with prescription opioids playing a crucial role in the development of addiction. We traced back to the process leading to the so called "opioid overflow", trying to identify any modifiable attitude.Since the late 1990s, pain was labelled as the "fifth vital sign" and its proper management was prompted, encouraging the use of opioids for any pain scored at a Numerical Rating Scale (NRS) of 7 or higher. This assumption has some remarkable limitations. NRS is a proxy of pain severity in children, and pain measurement should be strengthened by a more comprehensive pain evaluation. Moreover, while remaining a fundamental therapeutic right of patients suffering postoperative or chronic severe pain, opioids show no evidence of superiority respect to non-opioid regimens in the management of pain from several acute conditions.Italy, as other European countries, is often reluctant to the use of opioids, even when highly recommendable, missing the opportunity of properly treating those selected patients with severe pain. Both attitudes can be viewed as the result of an extreme simplification of the complex process of pain evaluation and treatment, by means of a 'one-size-fits-all' approach.This highlights the need for a systematic and patient-tailored attitude to children in pain, avoiding applying guidelines without question. Good clinical practice must rely on guidelines, which, however, as often based on partial and insufficient data, can be questioned by emerging new evidence, and should not substitute our rational thinking, and capability to understand each patient, avoiding excessive conformism.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Actitud del Personal de Salud , Trastornos Relacionados con Opioides/epidemiología , Dolor/tratamiento farmacológico , Rol del Médico , Pautas de la Práctica en Medicina , Adolescente , Niño , Humanos , Trastornos Relacionados con Opioides/prevención & control , Dolor/diagnóstico , Dimensión del Dolor
17.
Medicine (Baltimore) ; 100(1): e24176, 2021 Jan 08.
Artículo en Inglés | MEDLINE | ID: mdl-33429803

RESUMEN

ABSTRACT: Brazil has a high rate of cesarean sections (CS) that cannot be solely justified by women's clinical conditions; thus, other causes, for example, CS on maternal request and physicians' fear of litigation as possible influencing factors, cannot be overlooked.This study aimed to identify through a survey whether Brazilian gynecologists and obstetricians (GOs) perform defensive CS.In this cross-sectional, descriptive study, a questionnaire was administered. The target population comprised of GOs who were members of premier Brazilian professional associations of gynecology and obstetrics. A total of 403 GOs participated in the survey using an obstetrics questionnaire about litigation and defensive medicine (DM). Statistical analyses were performed on pairs of variables to determine the risk factors of performing CS due to concerns of complications during vaginal delivery and to avoid lawsuits.The mean age of the GOs was 47.7 years who were mostly female (58.3%) and having worked professionally in both public and private sectors (71.7%). Of all participants, 80.6% had been sued or knew an obstetrician who had been sued. The obstetricians who had been sued or who knew a colleague that had been sued exhibited a significantly higher likelihood of performing defensive CS than physicians who had not been sued or did not know physicians who had been sued. The perception of a higher risk of lawsuits against obstetricians influenced the practice of DM and led to a more than six-fold increase in CSs in specialists with this perception compared to specialists who did not believe the presence of an increased risk of litigation in obstetrics existed.The majority of Brazilian GOs perform defensive CS. It is important to consider DM as one of the causes of high CS rates in Brazil and include it in the development of public policies to reduce these CS rates.


Asunto(s)
Cesárea/estadística & datos numéricos , Medicina Defensiva/métodos , Adulto , Actitud del Personal de Salud , Brasil , Cesárea/normas , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pautas de la Práctica en Medicina/estadística & datos numéricos , Embarazo , Encuestas y Cuestionarios
18.
Medicine (Baltimore) ; 100(1): e24268, 2021 Jan 08.
Artículo en Inglés | MEDLINE | ID: mdl-33429837

RESUMEN

ABSTRACT: Query of Prescription Drug Monitoring Programs (PDMPs) is recommended before prescribing opioids by the US Centers for Disease Control and Prevention, to inform clinical practice and aid diversion prevention. Many states mandate prescriber PDMP use; however, little is known about PDMP perception of utility and use among Obstetricians-Gynecologists (OB/GYN), who are the primary provider for most women during pregnancy.This study examined OB/GYN perceptions and utilization of their state PDMP.Survey items were developed by expert consensus. A voluntary anonymous survey was emailed to a random sample of 5000 OB/GYNs (adjusted participants n = 1470, minus unread/refusals). Responses were stratified by state policy environment, where response frequency distributions were compared for OB/GYNs practicing in states with mandatory vs voluntary PDMP query.Adjusted response rate was 27% (n = 397). Most OB/GYNs (78%) were registered with their PDMP. The majority agreed that "…mandating physician use of the PDMP was a good idea" (51.4% mandatory state vs 58.3% voluntary state). Respondents in mandatory states reported that the primary purpose of the PDMP was "to allow the physician to verify medications that the patient is being prescribed" less frequently than those in voluntary states (38.3% vs 52.8%). Several report speaking with patients about controlled substance prescriptions after viewing PDMP reports (27.8% in mandatory vs 26.3% in voluntary states). In qualitative responses, reported frustration with PDMPs was evident.OB/GYNs are diverse in their perceptions regarding the utility and purpose of PDMPs. Tailored education is needed regarding clinical utility of PDMPs for OB/GYN practice.


Asunto(s)
Actitud del Personal de Salud , Ginecología , Obstetricia , Pautas de la Práctica en Medicina/estadística & datos numéricos , Programas de Monitoreo de Medicamentos Recetados , Estudios Transversales , Femenino , Humanos , Masculino , Encuestas y Cuestionarios , Estados Unidos
20.
Clin Appl Thromb Hemost ; 27: 1076029620975489, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-33443455

RESUMEN

Low molecular weight heparin (LMWH) is the standard of care for treating cancer-associated thrombosis (CAT), although new evidence for direct oral anticoagulants (DOACs) supports use in specific cancer populations. In this retrospective review at a specialty CAT clinic from 2016 to 2019, we report the use of anticoagulants (LMWH, DOACs, warfarin, anticoagulant class change) in the acute and chronic phases of CAT and compare use before/after publication of the Hokusai-VTE Cancer trial. Death, venous thromboembolism (VTE) recurrence and bleeding was also reported. Of the 221 included, median age was 69 years, with 57.5% having metastatic disease. In the acute phase, 80.1% were prescribed LMWH, 4.1% DOAC, and 14.5% had an anticoagulant class change (LMWH to DOAC; 78.1%). In the chronic phase, 35.8% were prescribed LMWH, 11.3% DOAC, and 42.9% had an anticoagulant class change (LMWH to DOAC; 90.1%). Use of DOACs in the acute and chronic phase prior to the Hokusai-VTE trial was 1.0% and 2.0%, respectively, and following publication was 6.8% and 19.6%. Death occurred for 22.6% patients, recurrent VTE in 7.2%, and bleeding in 5.0%. DOAC use is increasing with time; real-world data may help to guide optimization of the care of complex patients.


Asunto(s)
Anticoagulantes/uso terapéutico , Neoplasias/complicaciones , Trombosis/tratamiento farmacológico , Trombosis/etiología , Enfermedad Aguda , Administración Oral , Anciano , Alberta , Anticoagulantes/administración & dosificación , Enfermedad Crónica , Femenino , Heparina de Bajo-Peso-Molecular/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Pautas de la Práctica en Medicina , Estudios Retrospectivos , Tromboembolia Venosa/tratamiento farmacológico , Tromboembolia Venosa/etiología , Warfarina/uso terapéutico
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