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1.
Orthop Clin North Am ; 51(2): 235-239, 2020 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-32138861

RESUMEN

To determine if orthopedic surgeons are more efficient than nonsurgical providers at care of operative injuries in walk-in clinics, patients in a walk-in clinic for evaluation of acute injury who subsequently had surgical treatment of isolated distal radial fracture were compared based on whether the initial visit was with a surgical or nonsurgical provider. Initial evaluation in a walk-in orthopedic clinic setting versus a conventional hand surgeon's clinic was associated with longer delay between initial evaluation and surgical treatment, but this difference may not be significant. Evaluation by a nonsurgical provider was not associated with increased duration to definitive treatment.


Asunto(s)
Fracturas del Radio/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Atención Ambulatoria , Instituciones de Atención Ambulatoria , Femenino , Fijación Interna de Fracturas , Curación de Fractura , Humanos , Masculino , Persona de Mediana Edad , Fracturas del Radio/terapia , Tiempo de Tratamiento , Adulto Joven
2.
Rev Bras Epidemiol ; 23: e200020, 2020.
Artículo en Portugués, Inglés | MEDLINE | ID: mdl-32159630

RESUMEN

INTRODUCTION: Linkage is a critical step in the ongoing care of human immunodeficiency virus (HIV/aids) infection and is essential for providing access to antiretroviral therapy, as well as comprehensive care. METHODOLOGY: Cross-sectional study on people living with HIV (PLHIV), aged ≥ 18 years old, linked between January and December 2015, in a referral service for outpatient and hospital care specialized in HIV/AIDS in Belo Horizonte, Minas Gerais. Linkage time was defined as the time from diagnosis to service linkage. Timely care linkage was considered when this time was ≤ 90 days. Data were collected through clinical records. A logistic regression analysis with a confidence interval of 95% (95%CI) was performed. RESULTS: Among 208 patients, most of them were males (77.8%) with a mean age of 39 years. About 45% presented AIDS-defining conditions at the moment of linkage. Linkage time presented a mean of 138 ± 397 days. And timely linkage occurred for 76.9% of the patients. The variables associated with timely care linkage were: age ≥ 48 years (odds ratio - OR = 8.50; 95%CI 1.53 - 47.28), currently working (OR = 3.69; 95%CI 1.33 - 10.25) at the time of linkage, and present CD4+ T lymphocyte count (CD4+ T) ≤ 200 cells/mm3 at the time of HIV diagnosis (OR = 4.84; 95%CI 1.54 - 15.18). There was an important proportion of timely care linkage among PLHIV, but with late diagnosis. CONCLUSION: Interventions should be targeted at younger people with higher CD4+ T lymphocyte counts, in order to better provide continuous HIV care.


Asunto(s)
Fármacos Anti-VIH/uso terapéutico , Continuidad de la Atención al Paciente/estadística & datos numéricos , Infecciones por VIH/tratamiento farmacológico , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Servicios de Salud/estadística & datos numéricos , Derivación y Consulta/estadística & datos numéricos , Tiempo de Tratamiento/estadística & datos numéricos , Adolescente , Adulto , Terapia Antirretroviral Altamente Activa , Brasil/epidemiología , Recuento de Linfocito CD4 , Estudios Transversales , Diagnóstico Tardío , Femenino , Infecciones por VIH/diagnóstico , Infecciones por VIH/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Factores de Tiempo , Adulto Joven
3.
Orv Hetil ; 161(12): 458-467, 2020 Mar.
Artículo en Húngaro | MEDLINE | ID: mdl-32172587

RESUMEN

Introduction and aim: The authors analyse emergency care data for 6878 patients treated for acute myocardial infarction (AMI) using data from the Hungarian Myocardial Infarction Registry (HUMIR) and the National Ambulance Service (NAS). Method: Patients received treatment between 01/01/2017 and 31/12/2018, and all patients underwent percutaneous coronary intervention (PCI): 47.5% of patients had ST-elevation myocardial infarction (STEMI) and 3614 patients (52.5%) had non-ST-elevation myocardial infarction. The time between the beginning of the complaint and notification of NAS was regarded as the patient delay (PD). The time from the notification of NAS until arrival on the scene (M1), that of the on-site care (M2) and of the transport from the scene to the hospital (M3) were recorded. In-hospital care was evaluated from admission until opening the vessel ("door to balloon time"). The results were also broken down by counties. The median values and the quartiles (Q1, Q3) were given when the time was reported. Results: Patient delay in both types of infarction was unfavourably long: 101 minutes for STEMI and 687 minutes for NSTEMI. Immediate ambulance action was recorded in 58.7% for STEMI patients and 43.7% for NSTEMI patients. In both types of myocardial infarction, the median M1 time was 13 minutes, on-site care (M2) was 23 minutes, and M3 time was 30 minutes. In patients treated for STEMI, the time from hospital admission until opening the infarct-related artery was 37 minutes, and the total ischemic time was 243 minutes. In 9.5% of STEMI patients, the infarct-related artery was opened within 2 hours, in 49.1% within 4 hours, and in 88.1% within 12 hours. Significant differences were found between the counties for each of the periods examined. Conclusions: The PD is currently the biggest problem in providing optimal care timely for myocardial infarction patients. There are significant regional differences in rescue times, and further analysis is needed to investigate the causes. Orv Hetil. 2020; 161(12): 458-467.


Asunto(s)
Servicios Médicos de Urgencia/estadística & datos numéricos , Infarto del Miocardio/cirugía , Transferencia de Pacientes/métodos , Intervención Coronaria Percutánea , Tiempo de Tratamiento/estadística & datos numéricos , Humanos , Hungría , Infarto del Miocardio/diagnóstico , Factores de Tiempo , Resultado del Tratamiento
4.
Medicine (Baltimore) ; 99(11): e19446, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32176076

RESUMEN

Clinical manifestations of sepsis differ between patients with and without diabetes mellitus (DM), and these differences could influence the clinical behaviors of medical staff. Therefore, we aimed to investigate whether pre-existing DM was associated with the time to antibiotics or sepsis care protocols.This was a retrospective cohort study.It conducted at 53 intensive care units (ICUs) in Japan.Consecutive adult patients with severe sepsis admitted directly to ICUs form emergency departments from January 2016 to March 2017 were included.The primary outcome was time to antibiotics.Of the 619 eligible patients, 142 had DM and 477 did not have DM. The median times (interquartile ranges) to antibiotics in patients with and without DM were 103 minutes (60-180 minutes) and 86 minutes (45-155 minutes), respectively (P = .05). There were no significant differences in the rates of compliance with sepsis protocols or with patient-centred outcomes such as in-hospital mortality. The mortality rates of patients with and without DM were 23.9% and 21.6%, respectively (P = .55). Comparing patients with and without DM, the gamma generalized linear model-adjusted relative difference indicated that patients with DM had a delay to starting antibiotics of 26.5% (95% confidence intervals (95%CI): 4.6-52.8, P = .02). The gamma generalized linear model-adjusted relative difference with multiple imputation for missing data of sequential organ failure assessment was 19.9% (95%CI: 1.0-42.3, P = .04). The linear regression model-adjusted beta coefficient indicated that patients with DM had a delay to starting antibiotics of 29.2 minutes (95%CI: 6.8-51.7, P = .01). Logistic regression modelling showed that pre-existing DM was not associated with in-hospital mortality (odds ratio, 1.26; 95%CI: 0.72-2.19, P = .42).Pre-existing DM was associated with delayed antibiotic administration among patients with severe sepsis or septic shock; however, patient-centred outcomes and compliance with sepsis care protocols were comparable.


Asunto(s)
Antibacterianos/uso terapéutico , Diabetes Mellitus/epidemiología , Servicio de Urgencia en Hospital , Sepsis/tratamiento farmacológico , Tiempo de Tratamiento , Anciano , Anciano de 80 o más Años , Femenino , Mortalidad Hospitalaria , Humanos , Japón/epidemiología , Masculino , Estudios Retrospectivos , Sepsis/mortalidad
5.
West J Emerg Med ; 21(2): 404-410, 2020 Feb 25.
Artículo en Inglés | MEDLINE | ID: mdl-32191198

RESUMEN

INTRODUCTION: Shortening emergency department (ED) visit time can reduce ED crowding, morbidity and mortality, and improve patient satisfaction. Point-of-care testing (POCT) has the potential to decrease laboratory turnaround time, possibly leading to shorter time to decision-making and ED length of stay (LOS). We aimed to determine whether the implementation of POCT could reduce time to decision-making and ED LOS. METHODS: We conducted a randomized control trial at the Urgency Room of Siriraj Hospital in Bangkok, Thailand. Patients triaged as level 3 or 4 were randomized to either the POCT or central laboratory testing (CLT) group. Primary outcomes were time to decision-making and ED LOS, which we compared using Mann-Whitney-Wilcoxon test. RESULTS: We enrolled a total of 248 patients: 124 in the POCT and 124 in the CLT group. The median time from arrival to decision was significantly shorter in the POCT group (106.5 minutes (interquartile [IQR] 78.3-140) vs 204.5 minutes (IQR 165-244), p <0.001). The median ED LOS of the POCT group was also shorter (240 minutes (IQR 161.3-410) vs 395.5 minutes (IQR 278.5-641.3), p <0.001). CONCLUSION: Using a point-of-care testing system could decrease time to decision-making and ED LOS, which could in turn reduce ED crowding.


Asunto(s)
Toma de Decisiones , Servicio de Urgencia en Hospital , Satisfacción del Paciente , Pruebas en el Punto de Atención , Tiempo de Tratamiento , Aglomeración , Femenino , Hospitales , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Sistemas de Atención de Punto , Tailandia , Factores de Tiempo , Triaje
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.
Isr Med Assoc J ; 22(2): 83-88, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-32043324

RESUMEN

BACKGROUND: Rapid and selective bromelain-based enzymatic debridement provides a non-surgical alternative for the eschar removal in deep burns, which allows for early debridement of large surface areas, accurate evaluation of burn and wound depth, and the need for skin grafting. OBJECTIVES: To evaluate the efficacy of application of a bromelain-based selective enzymatic debridement (Nexobrid®) beyond the manufacturer's guidelines for use in burns > 48 hours as well as chemical, electrical, and pediatric burns, and chronic wounds. METHODS: This retrospective review included records collected between January 2017 and April 2019, from male and female patients aged 8 months to 99 years with deep burns or wounds treated with bromelain-based selective enzymatic debridement. RESULTS: Of the 33 patients who received the bromelain-based selective enzymatic debridement agent beyond the manufacturer's guidelines, 25 (76%) were observed to have successful debridement of the eschar, 8 (24%) were observed to have little effect on the burn eschar. Sixteen required further surgery after debridement. Clinical data on the use of bromelain-based selective enzymatic debridement agents are limited, but these results suggest the capacity to effectively debride burns > 48 hours (late presentation burns), use for pediatrics and for chemical and electrical burns, and apply to hard to heal full thickness chronic wounds. CONCLUSIONS: Bromelain-based selective enzymatic debridement was found to be an effective treatment modality beyond the recommended guidelines including late presentation burns and chronic wounds. This debridement method warrants further consideration when making clinical decisions concerning burn and wound care.


Asunto(s)
Bromelaínas/administración & dosificación , Quemaduras , Terapia Enzimática/métodos , Cicatrización de Heridas/efectos de los fármacos , Heridas y Traumatismos , Administración Tópica , Adulto , Quemaduras/diagnóstico , Quemaduras/terapia , Monitoreo de Drogas/métodos , Femenino , Humanos , Masculino , Estudios Retrospectivos , Tiempo de Tratamiento , Índices de Gravedad del Trauma , Resultado del Tratamiento , Heridas y Traumatismos/diagnóstico , Heridas y Traumatismos/terapia
8.
Lancet ; 395(10225): 698-708, 2020 02 29.
Artículo en Inglés | MEDLINE | ID: mdl-32050090

RESUMEN

BACKGROUND: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. METHODS: HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896). FINDINGS: Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4-9) in the accelerated-surgery group and 24 h (10-42) in the standard-care group (p<0·0001). 140 (9%) patients assigned to accelerated surgery and 154 (10%) assigned to standard care died, with a hazard ratio (HR) of 0·91 (95% CI 0·72 to 1·14) and absolute risk reduction (ARR) of 1% (-1 to 3; p=0·40). Major complications occurred in 321 (22%) patients assigned to accelerated surgery and 331 (22%) assigned to standard care, with an HR of 0·97 (0·83 to 1·13) and an ARR of 1% (-2 to 4; p=0·71). INTERPRETATION: Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared with standard care. FUNDING: Canadian Institutes of Health Research.


Asunto(s)
Artroplastia de Reemplazo de Cadera/métodos , Intervención Médica Temprana/métodos , Fijación Interna de Fracturas/métodos , Hemiartroplastia/métodos , Fracturas de Cadera/cirugía , Complicaciones Posoperatorias/epidemiología , Tiempo de Tratamiento/estadística & datos numéricos , Actividades Cotidianas , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/mortalidad , Comorbilidad , Delirio/epidemiología , Demencia/epidemiología , Diabetes Mellitus/epidemiología , Femenino , Fracturas del Cuello Femoral/epidemiología , Fracturas del Cuello Femoral/cirugía , Fracturas de Cadera/epidemiología , Humanos , Internacionalidad , Masculino , Persona de Mediana Edad , Mortalidad , Isquemia Miocárdica/epidemiología , Casas de Salud , Reducción Abierta/métodos , Hemorragia Posoperatoria/epidemiología , Modelos de Riesgos Proporcionales , Características de la Residencia/estadística & datos numéricos , Sepsis/epidemiología , Resultado del Tratamiento
9.
Emergencias (Sant Vicenç dels Horts) ; 32(1): 33-39, feb. 2020. tab, graf
Artículo en Español | IBECS | ID: ibc-185851

RESUMEN

Objetivo. Identificar los factores asociados con una respuesta inicial inmediata a los síntomas en los pacientes que han padecido un ictus isquémico. Método. Estudio observacional transversal en el que se incluyeron a todos los pacientes con ictus isquémico ingresados de forma consecutiva en el Hospital Universitario de Burgos (España) durante 1 año. Se recogieron parámetros sociodemográficos, clínicos, conductuales, cognitivos y contextuales, y se estudió su posible relación con el tiempo de reacción del paciente (TR) mediante análisis univariante y multivariante. Resultados. Se incluyeron 425 pacientes (mediana del TR de 140 minutos). El TR supuso un 72,6% del tiempo prehospitalario total (TPH), con una respuesta inmediata si el paciente se encontraba acompañado (OR 9,57; IC95% 3,89-23,52), si los síntomas se iniciaban durante el día (OR 8,77; 3,40-22,63), si el paciente sabía cómo actuar ante un posible ictus (OR 3,84; 2,77-7,09), si el primer contacto médico era con el servicio de emergencias médicas (SEM) (OR 3,03; 1,62-5,68), si el paciente percibía la situación como grave o muy grave (OR 2,38; 1,17-4,83) o si el ictus ocurría en el ámbito urbano (OR 2,17; 1,16-4,06). Conclusión. El intervalo de tiempo entre el inicio de los síntomas y la respuesta inicial del paciente se relaciona con factores conductuales, cognitivos y contextuales, los cuales deberían ser considerados en la planificación de futuras campañas educacionales


Objective. To identify factors related to a rapid response to the onset of symptoms and a call for help for patients with ischemic stroke. Methods. Observational cross-sectional study of all patients with ischemic stroke admitted consecutively to Hospital Universitario de Burgos in Spain during 1 year. We collected sociodemographic, clinical, behavioral, cognitive, and contextual data for all patients and applied uni- and multivariate analysis to explore possible associations with the patient's response time. Results. A total of 425 patients were included. The mean patient response time was 140.00 minutes. Patient delay accounted for 72.6% of the total prehospital response time. Factors associated with a rapid call for help were the presence of an accompanying person (OR, 9.57; 95% CI, 3.89-23.52), daytime onset of symptoms (OR, 8.77; 3.40-22.63), patient knowledge of how to act in case of stroke symptoms (OR, 3.84; 2.77-7.09), first medical contact through the public health system's emergency medical service (OR, 3.03; 1.62-5.68), patient perception of symptoms as severe or very severe (OR, 2.38; 1.17-4.83), and stroke onset in an urban area (OR, 2.17; 1.16-4.06). Conclusions. The patient's response time between onset of symptoms is related to behavioral, cognitive and contextual factors that should be taken into account when planning future patient education campaigns


Asunto(s)
Humanos , Masculino , Femenino , Anciano , Accidente Cerebrovascular/epidemiología , Isquemia Encefálica/complicaciones , Factores de Tiempo , Tiempo de Tratamiento , Estudios Transversales , Análisis Multivariante , Atención Prehospitalaria/estadística & datos numéricos , Conducta de Búsqueda de Ayuda
10.
Bone Joint J ; 102-B(1): 33-41, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31888365

RESUMEN

AIMS: The aim of this study was to explore whether time to surgery affects functional outcome in displaced proximal humeral fractures. METHODS: A total of 250 patients presenting within three weeks of sustaining a displaced proximal humeral fracture involving the surgical neck were recruited at 32 acute NHS hospitals in the United Kingdom between September 2008 and April 2011. Of the 125 participants, 109 received surgery (fracture fixation or humeral head replacement) as per randomization. Data were included for 101 and 67 participants at six-month and five-year follow-up, respectively. Oxford Shoulder Scores (OSS) collected at six, 12, and 24 months and at three, four, and five years following randomization was plotted against time to surgery. Long-term recovery was explored by plotting six-month scores against five-year scores and agreement was illustrated with a Bland-Altman plot. RESULTS: The mean time from initial trauma to surgery was 10.5 days (1 to 33). Earlier surgical intervention did not improve OSS throughout follow-up, nor when stratified by participant age (< 65 years vs ≥ 65 years) and fracture severity (one- and two-part vs three- and four-part fractures). Participants managed later than reported international averages (three days in the United States and Germany, eight days in the United Kingdom) did not have worse outcomes. At five-year follow-up, 50 participants (76%) had the same or improved OSS compared with six months (six-month mean OSS 35.8 (SD 10.0); five-year mean OSS 40.1 (SD 9.1); r = 0.613). A Bland-Altman plot demonstrated a positive mean difference (3.3 OSS points (SD 7.92)) with wide 95% limits of agreement (-12.2 and 18.8 points). CONCLUSION: Timing of surgery did not affect OSS at any stage of follow-up, irrespective of age or fracture type. Most participants had maximum functional outcome at six months that was maintained at five years. These findings may help guide providers of trauma services on surgical prioritization. Cite this article: Bone Joint J 2020;102-B(1):33-41.


Asunto(s)
Fracturas del Hombro/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Cadera/estadística & datos numéricos , Femenino , Estudios de Seguimiento , Fijación de Fractura/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Medición de Resultados Informados por el Paciente , Tiempo de Tratamiento
11.
Oncology ; 98(3): 168-173, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-31918425

RESUMEN

BACKGROUND: There is a paucity of literature examining the impact of timing of surgery after neoadjuvant chemotherapy. OBJECTIVE: This study aimed to analyze the impact of the time taken to initiate surgical treatment following completion of neoadjuvant chemotherapy on patients' outcomes by evaluating their pathological response, overall survival (OS), and disease-free survival (DFS). METHODS: This is a retrospective review of 611 patients diagnosed with stage II and III breast cancer that received neoadjuvant chemotherapy and surgery between January 2004 and December 2014. The data was collected from a prospectively gathered registry. The patients were stratified into three cohorts according to the time of surgery after neoadjuvant chemotherapy: <4 weeks, 4-7 weeks, or ≥8 weeks. Outcomes were assessed using Kaplan-Meier curves, and the variables were compared using log-rank statistics. RESULTS: The 5-year OS rate was 89.6% and the 5-year DFS rate was 74%. OS and DFS were not significantly different when stratified according to timing of surgery; however, the trends of OS and DFS were poor when surgery was delayed for ≥8 weeks. Median OS and median DFS have not yet been reached. Of the 17% of patients that had surgery after ≥8 weeks, 12.9% had pathological complete response (pCR), while among those that received surgery 4-7 weeks and <4 weeks after neoadjuvant chemotherapy, 26% and 21% had pCR, respectively (p = 0.02). ER+/HER-2+ patients had a statistically significant decrease in pCR if surgery was performed after ≥8 weeks. CONCLUSION: Our patients showed improved pCR if surgery was performed within 8 weeks, especially for ER+/HER-2+ patients. All patients had better OS and DFS trends if surgery was performed between 4 and 7 weeks after neoadjuvant chemotherapy.


Asunto(s)
Neoplasias de la Mama/terapia , Mastectomía , Terapia Neoadyuvante , Tiempo de Tratamiento , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/mortalidad , Neoplasias de la Mama/patología , Quimioterapia Adyuvante , Progresión de la Enfermedad , Supervivencia sin Enfermedad , Femenino , Humanos , Mastectomía/efectos adversos , Mastectomía/mortalidad , Persona de Mediana Edad , Terapia Neoadyuvante/efectos adversos , Terapia Neoadyuvante/mortalidad , Estadificación de Neoplasias , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Adulto Joven
12.
J Surg Oncol ; 121(3): 486-493, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-31919862

RESUMEN

BACKGROUND: Chemotherapy improves outcomes in patients with resectable gastric cancer. Minimally invasive gastrectomy (MIS) rates are increasing, though the impact of MIS on postoperative chemotherapy remains uncertain. This study examines the impact of MIS vs open gastrectomy (OG) on utilization of adjuvant chemotherapy for high-risk gastric cancer. METHODS: Patients in the National Cancer Database who underwent resection for high-risk gastric adenocarcinoma between 2010 and 2015 were included. Patients were stratified by surgical approach (MIS vs OG) and analyzed using multivariable regression modeling. Primary endpoints were utilization of and time to initiation of adjuvant chemotherapy. RESULTS: Overall, 23 071 patients were included; 16 595 (71.9%) underwent OG and 6476 (28.1%) underwent MIS. After adjusting for patient and tumor characteristics, MIS was not associated with increased use of adjuvant chemotherapy (odds ratio [OR]: 1.027, 95% confidence interval [CI]: 0.95 to 1.11, P = .50), and time to initiation of chemotherapy was similar (-2% change, 95% CI: -5% to +1%, P = .27). MIS was associated with shorter hospital stays (-1 day). Thirty-day readmission rates, 90-day mortality, and overall survival were similar between groups. CONCLUSIONS: In this study, while MIS for gastric adenocarcinoma was associated with shorter hospital stays and comparable survival, it was not associated with improved utilization or time to initiation of adjuvant chemotherapy.


Asunto(s)
Adenocarcinoma/mortalidad , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Quimioterapia Adyuvante/mortalidad , Gastrectomía/mortalidad , Procedimientos Quirúrgicos Mínimamente Invasivos/mortalidad , Neoplasias Gástricas/mortalidad , Adenocarcinoma/tratamiento farmacológico , Adenocarcinoma/patología , Adenocarcinoma/cirugía , Anciano , Femenino , Estudios de Seguimiento , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Neoplasias Gástricas/tratamiento farmacológico , Neoplasias Gástricas/patología , Neoplasias Gástricas/cirugía , Tasa de Supervivencia , Factores de Tiempo , Tiempo de Tratamiento
14.
Eur J Endocrinol ; 182(3): 285-292, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-31917681

RESUMEN

Objective: To examine all-cause mortality rates in patients with acromegaly on pegvisomant and identify pertinent risk factors, including insulin-like growth factor I (IGF-I). Design: Retrospective cohort analysis of data from ACROSTUDY (global surveillance study of patients with acromegaly treated with pegvisomant). Methods: Kaplan-Meier analyses and Cox regression techniques were used to examine survival rates. Standardized mortality ratios (SMR) with reference to general population (WHO GBD 2016) were estimated. Multiplicative multiple Poisson regression models were used to characterize the association between SMR, IGF-I, and other risk factors associated with mortality risk. Results: The study consisted of 2077 subjects who were followed for a median interval of 4.1 years, contributing to 8957 patient-years. Higher on-treatment IGF-I (P = 0.0035), older attained age (P < 0.0001), and longer duration of acromegaly (>10 years) before starting pegvisomant (P = 0.05) were associated with higher mortality rates. In reference to general population rates, higher SMR (1.10, 1.42, and 2.62, at attained age 55 years) were observed with higher serum IGF-I category (SMR trend: 1.44 (44%)/per fold level of IGF-I/ULN (95% CI: 1.10, 1.87), P = 0.0075). SMR increased per year of younger attained age (1.04 (1.02-1.04), P < 0.0001) and were higher for longer disease duration (>10 years) before starting pegvisomant (1.57 (1.02, 2.43), P = 0.042). Serum IGF-I levels within the normal range during pegvisomant therapy were associated with all-cause mortality rates that were indistinguishable from the general population. Conclusions: Higher on-treatment IGF-I, older attained age, and longer duration of acromegaly before starting pegvisomant are associated with higher all-cause mortality rates. Younger patients with uncontrolled acromegaly have higher excess all-cause mortality rates in comparison with older patients.


Asunto(s)
Acromegalia/tratamiento farmacológico , Hormona de Crecimiento Humana/análogos & derivados , Mortalidad , Receptores de Somatotropina/antagonistas & inhibidores , Acromegalia/metabolismo , Adulto , Factores de Edad , Anciano , Causas de Muerte , Estudios de Cohortes , Femenino , Hormona de Crecimiento Humana/uso terapéutico , Humanos , Factor I del Crecimiento Similar a la Insulina/metabolismo , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Tiempo de Tratamiento
15.
Bone Joint J ; 102-B(1): 72-81, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31888363

RESUMEN

AIMS: The early mortality in patients with hip fractures from bony metastases is unknown. The objectives of this study were to quantify 30- and 90-day mortality in patients with proximal femoral metastases, and to create a mortality prediction tool based on biomarkers associated with early death. METHODS: This was a retrospective cohort study of consecutive patients referred to the orthopaedic department at a UK trauma centre with a proximal femoral metastasis (PFM) over a seven-year period (2010 to 2016). The study group were compared to a matched control group of non-metastatic hip fractures. Minimum follow-up was one year. RESULTS: There was a 90-day mortality of 46% in patients with metastatic hip fractures versus 12% in controls (89/195 and 24/192, respectively; p < 0.001). Mean time to surgery was longer in symptomatic metastases versus complete fractures (9.5 days (SD 19.8) and 3.4 days (SD 11.4), respectively; p < 0.05). Albumin, urea, and corrected calcium were all independent predictors of early mortality and were used to generate a simple tool for predicting 90-day mortality, titled the Metastatic Early Prognostic (MEP) score. An MEP score of 0 was associated with the lowest risk of death at 30 days (14%, 3/21), 90 days (19%, 4/21), and one year (62%, 13/21). MEP scores of 3/4 were associated with the highest risk of death at 30 days (56%, 5/9), 90 days (100%, 9/9), and one year (100%, 9/9). Neither age nor primary cancer diagnosis was an independent predictor of mortality at 30 and 90 days. CONCLUSION: This score could be used to predict early mortality and guide perioperative counselling. The delay to surgery identifies a potential window to intervene and correct these abnormalities with the aim of improving survival. Cite this article: Bone Joint J. 2020;102-B(1):72-81.


Asunto(s)
Neoplasias Femorales/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores de Tumor/metabolismo , Estudios de Casos y Controles , Femenino , Neoplasias Femorales/secundario , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Escocia/epidemiología , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Tiempo de Tratamiento
16.
Zhonghua Yu Fang Yi Xue Za Zhi ; 54(1): 69-75, 2020 Jan 06.
Artículo en Chino | MEDLINE | ID: mdl-31914572

RESUMEN

Objective: To understand the consciousness of the cancer early treatment and its demographic and socioeconomic factors. Methods: A cross-sectional survey was conducted in 16 provinces covered by the Cancer Screening Program in Urban China (CanSPUC) from 2015 to 2017. A total of 32 257 local residents aged ≥18 years old who could understand the investigation procedure were included in the study by using the cluster sampling method and convenient sampling method. All local residents were categorized into four groups, which contained 15 524 community residents, 8 016 cancer risk assessment/screening population, 2 289 cancer patients and 6 428 occupational population, respectively. The questionnaire collected personal information, the consciousness of the cancer early treatment and relevant factors. The Chi square test was used to compare the difference between the consciousness of the cancer early treatment and relevant factors among the four groups. The logistic regression model was used to analyze the influencing factors related to the consciousness of the cancer early treatment. Results: With the assumption of being diagnosed as precancer or cancer, 89.97% of community residents, 91.84% of cancer risk assessment/screening population, 93.00% of cancer patients and 91.52% of occupational population would accept active treatments (P<0.001). If the immediate family members were diagnosed as precancer or cancer, people who would encourage their family members to receive early treatment in the four groups accounted for 91.96%, 91.94%, 92.44% and 91.55%, respectively (P<0.001). The company employees, annual household income with 40 000 yuan and more and other three groups had a relatively better consciousness of the cancer early treatment (P<0.05). Male, widowed, unemployed and from the central and western regions had a relatively worse consciousness of the cancer early treatment (P<0.05). Conclusion: Residents in urban China participants had a good consciousness of the cancer early treatment. The marital status, occupation, annual household income and residential regions were major factors related to the consciousness of the cancer early treatment.


Asunto(s)
Conocimientos, Actitudes y Práctica en Salud , Neoplasias/terapia , Tiempo de Tratamiento/estadística & datos numéricos , Población Urbana , Adolescente , Adulto , China , Estudios Transversales , Femenino , Humanos , Masculino , Factores Socioeconómicos , Población Urbana/estadística & datos numéricos
17.
Dis Colon Rectum ; 63(2): 217-225, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31914114

RESUMEN

BACKGROUND: The true incidence of, and risk factors for, readmission for treatment failure after nonoperative management of acute diverticulitis remain poorly understood. OBJECTIVE: The purpose of this study was to describe the incidence and risk factors for readmission for treatment failure after nonoperative management of acute diverticulitis using a large national database. DESIGN: This was a retrospective cohort study. SETTINGS: A representative sample of admissions and discharges from hospitals in the United States captured in the National Readmissions Database were included. PATIENTS: Adult patients (age ≥18 y) admitted with a primary diagnostic of colonic diverticulitis between 2010 and 2015 and who were managed nonoperatively and discharged from hospital alive were included. INTERVENTIONS: Study intervention included nonoperative management, consisting of medical therapy with or without percutaneous drainage. MAIN OUTCOME MEASURES: Readmission for treatment failure (defined as a nonelective readmission for diverticulitis within 90 d of discharge), complicated treatment failure (defined as a treatment failure with complicated diverticulitis), and time-to-treatment failure were measured. RESULTS: In total, 201,384 patients were included. The overall incidence of readmission for treatment failure was 6.6%. Treatment failure was significantly higher among patients with an index episode of acute complicated diverticulitis compared with acute uncomplicated diverticulitis (12.5% vs 5.7%; p < 0.001). The median time-to-readmission for treatment failure was 21.0 days (range, 20.4-21.6 d), and 85% of all readmissions occurred within 60 days of discharge. On multiple logistic regression, factors independently associated with readmission for treatment failure were an index admission of complicated diverticulitis (OR = 2.06 (95% CI, 1.97-2.16)), disposition on discharge (against medical advice: OR = 1.92 (95% CI, 1.66-2.20); home health care arrangements: OR = 1.24 (95% CI, 1.16-1.33)), and immunosuppression (OR = 1.42 (95% CI, 1.28-1.57)), among others. Risk factors for a complicated treatment failure were also described, after an index episode of complicated and uncomplicated diverticulitis. LIMITATIONS: The study was limited by residual confounding from missing covariates and its observational study design. CONCLUSIONS: The incidence of readmission for treatment failure after an episode of diverticulitis managed nonoperatively is 6.6%, and an index episode of complicated diverticulitis is the strongest risk factor for treatment failure. See Video Abstract at http://links.lww.com/DCR/B92. REINGRESO POR FRACASO DEL TRATAMIENTO DESPUÉS DEL TRATAMIENTO NO QUIRÚRGICO DE LA DIVERTICULITIS AGUDA: UN ANÁLISIS DE LA BASE DE DATOS DE REINGRESOS A NIVEL NACIONAL: La verdadera incidencia y los factores de riesgo para el reingreso por fracaso del tratamiento después de manejo no quirúrgico de la diverticulitis aguda siguen siendo mal definidos.Definir la incidencia y los factores de riesgo de reingreso por fracaso del tratamiento no quirúrgico de la diverticulitis aguda utilizando una base de datos nacional.Estudio de cohorte retrospectivo.Una muestra representativa de ingresos y egresos de hospitales en los Estados Unidos capturados en la base de datos nacional de reingresos hospitalarios.Pacientes adultos (≥18 años) ingresados con un diagnóstico primario de diverticulitis colónica entre 2010-2015, y que fueron tratados de forma no operativa y dados de alta del hospital vivos.Manejo no quirúrgico, que consiste en terapia médica con o sin drenaje percutáneo.Reingreso por fracaso del tratamiento (definido como un reingreso no electivo por diverticulitis dentro de los 90 días despues de ser dados de alta), fracaso del tratamiento complicado (definido como un fracaso del tratamiento con diverticulitis complicada) y el tiempo hasta el tratamiento en casos fracasaados.201.384 pacientes incluidos en total. La incidencia global de reingreso por fracaso del tratamiento fue del 6,6%. El fracaso del tratamiento fue significativamente mayor entre los pacientes con un episodio índice de diverticulitis aguda complicada en comparación con la diverticulitis aguda no complicada (12.5% vs. 5.7%, p <0.001). La mediana del tiempo hasta el reingreso por fracaso del tratamiento fue de 21.0 (20.4 - 21.6) días, y el 85% de todos los reingresos ocurrieron dentro de los 60 días posteriores a ser dados de alta. En la regresión logística múltiple, los factores asociados independientemente con el reingreso por fracaso del tratamiento fueron un índice de admisión de diverticulitis complicada (OR 2.06, IC 95% 1.97-2.16), disposición (de alta en contra del consejo médico: OR 1.92, IC 95% 1.66-2.2; atención médica domiciliaria: OR 1.24, IC 95% 1.16-1.33) e inmunosupresión (OR 1.42, IC 95% 1.28-1.57), entre otros. Los factores de riesgo para un fracaso del tratamiento complicado también se describieron, respectivamente, después de un episodio índice de diverticulitis complicada y no complicada.Covariables faltantes y diseño de estudio observacional.La incidencia de reingreso por fracaso del tratamiento después de un episodio de diverticulitis manejado de forma no operativa es del 6,6%, y un episodio índice de diverticulitis complicada es el factor de riesgo más fuerte para el fracaso del tratamiento. Consulte Video Resumen en http://links.lww.com/DCR/B92. (Traducción-Dr. Adrian E. Ortega).


Asunto(s)
Diverticulitis/terapia , Manejo de Atención al Paciente/tendencias , Readmisión del Paciente/estadística & datos numéricos , Enfermedad Aguda , Anciano , Bases de Datos Factuales , Diverticulitis/epidemiología , Drenaje/métodos , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Tiempo de Tratamiento/estadística & datos numéricos , Insuficiencia del Tratamiento , Estados Unidos/epidemiología
18.
J Stroke Cerebrovasc Dis ; 29(1): 104477, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31699573

RESUMEN

BACKGROUND: A nationally recommended practice to accelerate thrombolytic therapy for acute ischemic stroke is to route emergency medical services (EMS)-transported stroke patients directly to the computed tomography (CT) scanner on arrival. We evaluated door-to-needle time with direct-to-CT routing versus emergency department (ED)-bed first routing. METHODS: This was a retrospective analysis from a large regionalized stroke system. Paramedics utilize the modified Los Angeles Prehospital Stroke Screen and transport acute stroke patients to Approved Stroke Centers. Individual stroke centers postarrival protocols vary, with some routing patients directly to CT. Stroke centers report treatment and outcomes to a registry, from which data were abstracted from May 2015 through April 2016. Adult patients transported by EMS and treated with thrombolytic therapy were included. The primary outcome was door-to-needle time. Secondary outcome was door-to-imaging time. RESULTS: EMS transported 6315 patients for suspected stroke and 789 (13%) were treated with thrombolysis at 41 stroke centers, 171 (22%) at hospitals with direct-to-CT routing and 618 (78%) at hospitals with ED-bed routing. Patient characteristics were similar between groups. Door-to-needle time was not different in the 2 groups, median 57 minutes (interquartile range [IQR] 44-76) for CT routing versus 54 minutes (IQR 40-74) for ED routing, median difference 3 (95% CI -1, 7), P == .2. Door-to-imaging time was shorter with CT routing compared to ED routing, median 13 minutes (IQR 8-21) and 16 minutes (IQR 10-24), respectively. CONCLUSIONS: In this regional stroke system, hospitals with protocols for routing EMS-transported stroke patients directly to CT did not have reduced door-to-needle compared to hospitals without such protocols.


Asunto(s)
Servicio de Urgencia en Hospital , Fibrinolíticos/administración & dosificación , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica , Tiempo de Tratamiento , Tomógrafos Computarizados por Rayos X , Tomografía Computarizada por Rayos X/instrumentación , Transporte de Pacientes , Administración Intravenosa , Anciano , Anciano de 80 o más Años , Vías Clínicas , Femenino , Humanos , Los Angeles , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Sistema de Registros , Estudios Retrospectivos , Factores de Tiempo
19.
J Stroke Cerebrovasc Dis ; 29(1): 104472, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31699574

RESUMEN

BACKGROUND: Endovascular mechanical revascularization has become the mainstay acute stroke management secondary to emergent large vessel occlusions. In patients who can benefit from mechanical revascularization, the ability to intervene in a timely manner directly correlates with improved outcomes. The field assessment for stroke triage (FAST-ED) prehospital triage tool, is one of many stroke severity scales designed to decrease time to diagnosis in the field and optimize patient triage to comprehensive stroke centers. It is however unclear what impact if any, this tool has on time to activation of hospital stroke intervention teams. We set out to assess the impact of the implementation of the FAST-ED triage tool on the activation of the stroke intervention team in a community stroke treatment practice. METHODS: We retrospectively reviewed institutional records for consecutive admissions with reported stroke alerts between March 2017 and September 2018, and selected patients who presented via Emergency Medical Services (EMS). The association between FAST-ED scores and impact on time to revascularization as well as the association between FAST-ED scores and the presence of emergent large vessel occlusion were analyzed. RESULTS: There was a statistically significant improvement in interventional team activation times in favor of the FAST-ED cohort, (P < .05). CONCLUSIONS: FAST-ED implementation demonstrates a statistically significant improvement on stroke team activation times for patients who are candidates for mechanical revascularization. Larger cohort analysis is needed to fully evaluate the magnitude of this effect.


Asunto(s)
Revascularización Cerebral , Servicios Médicos de Urgencia , Servicio de Urgencia en Hospital , Procedimientos Endovasculares , Accidente Cerebrovascular/terapia , Tiempo de Tratamiento , Transporte de Pacientes , Triaje , Anciano , Anciano de 80 o más Años , Revascularización Cerebral/efectos adversos , Revascularización Cerebral/métodos , Técnicas de Apoyo para la Decisión , Prestación Integrada de Atención de Salud , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Grupo de Atención al Paciente , Valor Predictivo de las Pruebas , Mejoramiento de la Calidad , Indicadores de Calidad de la Atención de Salud , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/fisiopatología , Factores de Tiempo , Resultado del Tratamiento
20.
J Stroke Cerebrovasc Dis ; 29(1): 104464, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31699576

RESUMEN

INTRODUCTION: Emergency departments play a key role in the diagnosis and treatment of transient ischemic attacks, but limited data are available about the early management of such patients in emergency wards. Therefore, we aimed to evaluate emergency physicians' management of transient ischemic attack and analyze variations factors. METHODS: A multicenter survey among emergency physicians of the Grand Est region network (Est-RESCUE) was conducted from January 28th to March 28th, 2019. Medical and administrative data were collected by the same network and the national directory of medical resources. RESULTS: Among 542 emergency physicians recipients, 78 answered (14%) and 71 were finally included, practicing in 25 public hospitals homogeneously distributed across the territory, including 3 university hospitals. A cerebral magnetic resonance imaging was obtained for 75%-100% of patients by 4.3% of responders, 36.4% of which were performed within more than 24 hours. A cardiac monitoring was prescribed in 75%-100% of cases by 32.4% of responders. A neurologic consultation was routinely requested by 84.6% of responders practicing in a university hospital and 36.8% of responders practicing in a community hospital (P = .02). Patients were hospitalized in a neurovascular unit in 75%-100% of cases by 17.4% of responders, which happened more likely in university hospitals (P < .001). CONCLUSIONS: Transient ischemic attack suffers from management disparities across territories, due to limited access to technical facilities and neurologic consultations. Therefore, international recommendations are too often not followed. Implementation of territorial neurovascular tracks may help to standardize the management of these patients.


Asunto(s)
Servicio de Urgencia en Hospital/tendencias , Disparidades en Atención de Salud/tendencias , Hospitales/tendencias , Ataque Isquémico Transitorio/terapia , Pautas de la Práctica en Medicina/tendencias , Tiempo de Tratamiento/tendencias , Adulto , Femenino , Francia , Encuestas de Atención de la Salud , Hospitalización/tendencias , Humanos , Ataque Isquémico Transitorio/diagnóstico , Ataque Isquémico Transitorio/fisiopatología , Masculino , Persona de Mediana Edad , Derivación y Consulta/tendencias , Factores de Tiempo , Resultado del Tratamiento
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