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1.
Psychiatr Q ; 2020 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-32383134

RESUMO

Generalized Anxiety Disorder (GAD) from an official recognition as a residual category in DSM-III has come a long way to be appreciated as a common underlying anxiety pathway in the literature. Despite still being defined as extreme anxiety and worry upon performance and about one's health, GAD seems to be a general umbrella of anxiety, covering even social anxiety and panic disorder (PD) and even when not treated and chronic, leading to major depressive disorder (MDD). Along the line of some other similar studies and contentions, in the present study we sought to validate the hypothesis of GAD encompassing social anxiety as well as performance anxiety and its extension to PD and MDD. We also examined the onset of each diagnostic category of GAD, PD and MDD and their developmental course in our clinical sample. 113 patients with Generalized Anxiety Disorder (GAD) out of 295 referrals to our mood and anxiety clinic during the three months of May-July 2019, were identified and included in this research. We expanded the definition of GAD as per our clinical observation to include any situations triggering the anxiety including any performance and social situations and did not exclude if the anxiety led to panic attacks. The results of our study showed that an encompassing GAD (including performance and social anxiety) has an early onset, recognized partially in childhood, but mostly during adolescence. An untreated GAD was complicated with panic disorder and episodes of major depression, each with an onset later in life. GAD in our study was also found to be familial and genetic, while its post-morbid depression seemed to be more a reaction to a long-standing untreated anxiety. The findings of our study if replicated has research implication of better understanding the developmental course of mood disorders and hold the promise of more targeted treatments of anxiety, panic and depression in clinical practice.

2.
Liver Transpl ; 26(3): 379-389, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31872969

RESUMO

Alcohol relapse after liver transplantation (LT) in patients with alcohol-related liver disease (ALD) is a major challenge. Although its association with pretransplant psychosocial factors was extensively studied, the impacts of posttransplant courses on alcohol relapse have not been well investigated. The aim of this study is to analyze peritransplant factors associated with posttransplant alcohol relapse in patients with ALD. This study evaluated 190 adult LT patients with ALD from 2013 to 2019. Risk factors for alcohol relapse were analyzed, focusing on posttransplant chronic complications, which were classified as Clavien-Dindo classification 3a or higher that lasted over 30 days. The posttransplant alcohol relapse rate was 13.7% (26/190) with a median onset time of 18.6 months after transplant. Multivariate Cox regression analysis revealed that posttransplant chronic complications were an independent risk factor for posttransplant alcohol relapse (hazard ratio [HR], 5.40; P = 0.001), along with psychiatric comorbidity (HR, 3.93; P = 0.001), history of alcohol relapse before LT (HR, 3.00; P = 0.008), and an abstinence period <1.5 years (HR, 12.05; P = 0.001). A risk prediction model was created using 3 pretransplant risk factors (psychiatric comorbidity, alcohol relapse before LT, and abstinence period <1.5 years). This model clearly stratified the risk of alcohol relapse into high-, moderate-, and low-risk groups (P < 0.001). Of the 26 patients who relapsed, 11 (42.3%) continued drinking, of whom 3 died of severe alcoholic hepatitis, and 13 (50.0%) achieved sobriety (outcomes for 2 patients were unknown). In conclusion, posttransplant chronic complications increased the risk of alcohol relapse. Recognition of posttransplant chronic complications in conjunction with the risk stratification model by pretransplant psychosocial factors would help with the prediction of posttransplant alcohol relapse.

4.
Cancer Res ; 79(17): 4326-4330, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31481419

RESUMO

Hepatocellular carcinoma (HCC) has emerged as a major cause of cancer deaths globally. The landscape of systemic therapy has recently changed, with six additional systemic agents either approved or awaiting approval for advanced stage HCC. While these agents have the potential to improve outcomes, a survival increase of 2-5 months remains poor and falls short of what has been achieved in many other solid tumor types. The roles of genomics, underlying cirrhosis, and optimal use of treatment strategies that include radiation, liver transplantation, and surgery remain unanswered. Here, we discuss new treatment opportunities, controversies, and future directions in managing HCC.

5.
J Viral Hepat ; 26(11): 1293-1300, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31294521

RESUMO

Hepatitis C (HCV) is more common among patients with end-stage renal disease requiring haemodialysis compared to the general population. Thus, we aimed to assess trends in prevalence, health resource utilization and mortality among Medicare beneficiaries with HCV on haemodialysis. This is a retrospective study of outpatient and inpatient claims for Medicare beneficiaries receiving haemodialysis (2005-2016). A total of 291 663 subjects on haemodialysis were included (67.3 ± 15.2 years, 55% male, 55% white, 49% age-based eligibility). The prevalence of HCV in subjects on haemodialysis was stable and was significantly higher (mean 4.2% in 2005-2016, P = 0.50 for the trend) than in subjects not on haemodialysis (<1%). In multivariate analysis, liver cirrhosis (odds ratio = 3.4 (95% CI = 3.3-3.6)) was an independent predictor of 1-year mortality among haemodialysis patients. Mean total inpatient payments in dialysis patients with HCV remained stable during 2005 ($73 803) through 2016 ($72 133) (trend P = 0.54) while mean total outpatient payment decreased from 2005 ($53 497) to 2016 ($35 439; trend P = 0.0013). In multivariate analysis, after adjustment for age, gender, race and location, both HCV and cirrhosis remained significant contributors to greater spending [HCV: inpatient +22.1% (+19.2%-25%), HCV: outpatient +18.4% (+14.6%-22.2%), cirrhosis: inpatient +59.7% (+56.9%-62.6%), cirrhosis: outpatient +9.4% (+6.2%-12.6%)]. In conclusion, HCV-infected Medicare patients receiving haemodialysis incur greater resource utilization; mortality is higher in patients with cirrhosis only. Although HCV prevalence in Medicare haemodialysis recipients is higher than in patients without haemodialysis, these rates are lower than reported, suggesting potential under-screening for HCV in this high-risk population.

6.
J Hand Surg Am ; 44(10): 853-859, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31255374

RESUMO

PURPOSE: To compare plate positioning in clinical practice of 2 commonly used volar locking plate designs with respect to the watershed line as classified by the Soong grading system. METHODS: For this retrospective study, we included a total of 400 patients who underwent open reduction and internal fixation between May 2013 and February 2018. Cohort 1 was defined as patients treated with distal volar radius (DVR) plates during this period. Cohort 2 comprised 200 patients who had volar plate fixation with variable angle locking compression plates (LCP) during the same period. Standardized lateral wrist radiographs were categorized into Soong grade 0, 1, or 2. RESULTS: In cohort 1, 87 plates (43.5%) were not prominent volar to the watershed line, grade 0; 95 plates (47.5%) demonstrated grade 1 prominence; and 18 plates (9.0%) demonstrated grade 2 prominence. In cohort 2, 63 plates (31.5%) were grade 0; 103 plates (51.5%) were grade 1; and 34 plates (17%) had grade 2 prominence on, and volar to, the watershed line. These radiographic results show a greater incidence of volar plate prominence with respect to the watershed line, as defined as Soong grading, in cohort 2. CONCLUSION: This study shows that the use of the variable angle LCP plate is associated with more prominent volar positioning with respect to the watershed line compared with the DVR plate. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

7.
JACC Cardiovasc Interv ; 12(9): 805-819, 2019 May 13.
Artigo em Inglês | MEDLINE | ID: mdl-31072504

RESUMO

The Academic Research Consortium (ARC) and the Standardized Data Collection for Cardiovascular Trials Initiative have recently published updated clinical and angiographic endpoint definitions for percutaneous coronary intervention trials. The aim of this document is to provide practical guidance to facilitate and harmonize the implementation of those definitions in randomized trials or registries, as well as to foster consistency among independent adjudication committees. The authors compared the ARC-2 and Standardized Data Collection for Cardiovascular Trials Initiative definitions to identify areas of consistency, complex scenarios, and definitions in need of further standardization. Furthermore, the authors compared the fourth universal definition of myocardial infarction with the ARC-2 definition of myocardial infarction. The Society for Cardiovascular Angiography and Interventions definition of periprocedural myocardial infarction was also compared with the ARC-2 definition and the fourth universal definition of myocardial infarction. An in-depth assessment was done for each individual clinical endpoint to guide clinical investigators on reporting and classifying clinical adverse events. Finally, the authors propose standard streamlined data capture templates for reporting and adjudicating death, myocardial infarction, stroke, revascularization, stent or scaffold thrombosis, and bleeding.

8.
J Surg Educ ; 76(2): 554-559, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30121166

RESUMO

BACKGROUND: Image-guided microwave ablation (MWA) is a technically demanding procedure, involving advanced visual-spatial perception skills. This study sought to create and evaluate a low-cost model and training curriculum for open ultrasound-guided liver tumor MWA. METHODS: Simulated tumors were created, implanted into bovine livers, and visualized by ultrasound. A high-fidelity abdominal model was constructed, with a total cost of $30. Experienced physicians in MWA performed simulated ablations and evaluated the model. Expert performance metrics were established and served as targets for our training curriculum. These included time, number of passes, number of repositionings, and percentage of tumor ablated. Next, 8 novice trainees completed our deliberate practice curriculum. Participants' performances were recorded throughout. RESULTS: Physicians completed a structured feedback questionnaire rating the model's realism and training utility at 8/10 and 10/10, respectively. Tumors appeared hyperechoic and were clearly visualized on ultrasound. Trainees performed a total of 32 ablations. Our trainees' performance improved significantly in all outcomes of interest in the postcurriculum ablations compared to precurriculum ablations. CONCLUSION: We have created a cost-effective, high-fidelity model of MWA, with a deliberate practice curriculum. Trainees can practice to proficiency with clear target metrics prior to participating in clinical cas.

9.
J Pediatr Psychol ; 44(2): 164-175, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30101320

RESUMO

Objective: Many children with autism spectrum disorder (ASD) have feeding and mealtime problems. To address these, we conducted a pilot randomized trial of a new 11-session, individually delivered parent training program that integrated behavioral strategies and nutritional guidance (PT-F). Methods: Forty-two young children (age: 2 to 7-11 years) with ASD and feeding problems were assigned to 11 sessions of PT-F intervention over 20 weeks or a waitlist control. Outcomes included attendance, parent satisfaction, therapist fidelity, and preliminary assessments of child and parent outcomes. Results: Of the 21 PT-F families, attendance was high (85%) as was parent satisfaction (94% would recommend to others). Treatment fidelity was also high (97%-therapist integrity; 94%-parent adherence). Compared with waitlist, children whose parents participated in PT-F showed significantly greater reductions on the two parent-completed primary outcomes (Brief Autism Mealtime Behavior Inventory-Revised; Twald = -2.79; p = .003; About Your Child's Eating; Twald = -3.58; p = .001). On the independent evaluator-completed secondary eating outcome, the Clinical Global Impression-Improvement, 48.8% of the participants in PT-F were rated as "responders" compared with 0% in waitlist (p = .006). General child disruptive behavior outcomes decreased more in PT-F but not significantly. Parent outcomes of caregiver stress showed nonsignificant trends favoring PT-F with moderate to small effect sizes. Conclusions: This trial provides evidence for feasibility, satisfaction, and fidelity of implementation of PT-F for feeding problems in young children with ASD. Feeding outcomes also appeared favorable and lends support for conducting a larger efficacy trial.

10.
J Christ Nurs ; 36(1): E5-E10, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30531520

RESUMO

This research investigated the spiritual care educational preparation that nursing students perceive they have received as they transition to practice. A survey using the Spirituality and Spiritual Care Rating Scale and interviews with senior BSN students at a Christian university demonstrated students' perceptions that their spiritual care education focused primarily on the practice of presence, emphasis on prayer, and the integration of faith in the curricula. Survey results showed a strong perception of readiness to provide spiritual care as graduate nurses.


Assuntos
Cristianismo , Bacharelado em Enfermagem/métodos , Espiritualidade , Estudantes de Enfermagem/psicologia , Currículo , Feminino , Humanos , Masculino , Filosofia em Enfermagem , Inquéritos e Questionários
11.
Neonatology ; 115(1): 28-35, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30278459

RESUMO

INTRODUCTION: Bubble continuous positive airway pressure (bCPAP) generates a variable pressure due to bubble size and frequency, and these pressure oscillations may contribute to lung recruitment and gas exchange. Single-outlet bCPAP devices generate larger pressure fluctuation than bCPAP devices with diffusers, but clinical efficacy is unclear. Our hypothesis was that a single-outlet bCPAP device (B&B Bubbler©) would decrease extubation failure and improve oxygenation compared with a bCPAP device with a diffuser (BabiPlus©). METHODS: Bench testing of bCPAP devices with the RAM© cannula determined pressure averages, fluctuations, and CPAP transmission at prongs. The B&B Bubbler© and the BabiPlus© devices were compared for oxygenation and bCPAP failure within 72 h of extubation in a randomized trial in infants less than 1,250 g (n = 43). Additionally, a cohort study with infants extubated to BabiPlus© (n = 128), B&B Bubbler© (n = 119), and noninvasive positive pressure ventilation (NIPPV) (n = 107) were compared. RESULTS: Small differences in pressure fluctuations between bCPAP devices are attenuated by the RAM© cannula. Pressures at RAM© prongs are 62% of set pressure. The bCPAP extubation failure rate (35%) and oxygenation were similar between the bCPAP devices. bCPAP success was associated with lower FiO2 at extubation and decreased need for additional FiO2 in both groups. In the setting of the RAM© cannula, there were no differences in extubation failure rate for infants extubated to bCPAP or NIPPV. CONCLUSIONS: There were no clinical differences at extubation between the B&B Bubbler© and BabiPlus© devices. Oxygenation may predict bCPAP failure. The use of the RAM© cannula as a bCPAP interface should be more closely examined.


Assuntos
Pressão Positiva Contínua nas Vias Aéreas/instrumentação , Remoção de Dispositivo , Recém-Nascido de muito Baixo Peso , Síndrome do Desconforto Respiratório do Recém-Nascido/terapia , Desmame do Respirador/métodos , Cânula , Feminino , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Intubação Intratraqueal , Masculino , Estudos Retrospectivos , Falha de Tratamento
12.
Am J Manag Care ; 24(9): 421-427, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30222920

RESUMO

OBJECTIVES: Effective screening, diagnosis, and treatment are needed to reduce chronic hepatitis C virus (HCV) infection-associated morbidity and mortality. In order to successfully increase HCV treatment, it is necessary to identify and understand gaps in linkage of antibody-positive patients with newly identified HCV to subsequent HCV RNA testing, clinical evaluation, and treatment. STUDY DESIGN: To estimate attainment of HCV care cascade steps among antibody-positive patients with newly identified HCV, we conducted chart reviews of patients with a new positive HCV antibody test at 3 academic medical centers participating in the Birth-Cohort Evaluation to Advance Screening and Testing of Hepatitis C (BEST-C) study. METHODS: We tracked receipt of RNA testing, clinical evaluation, treatment initiation, and treatment completion among individuals born between 1945 and 1965 who were newly diagnosed as HCV antibody-positive between December 2012 and October 2015 at 3 BEST-C centers, predominantly from the participating medical centers' primary care practices and emergency departments. RESULTS: Of the 130 HCV-seropositive individuals identified, 118 (91%) had an RNA or genotype test, 75 (58%) were RNA-positive, 73 (56%) were linked to care, 22 (17% overall; 29% among RNA-positive) started treatment, and 21 (16%; 28% among RNA-positive) completed treatment. CONCLUSIONS: This analysis showed that although linkage to care was largely successful in the target birth cohort, the largest gap in the HCV care cascade was seen in initiating treatment. Greater emphasis on linking patients to clinical evaluation and treatment is necessary in order to achieve the public health benefits promised by birth-cohort testing.


Assuntos
Continuidade da Assistência ao Paciente , Hepatite C Crônica/diagnóstico , Hepatite C Crônica/terapia , Idoso , Testes Diagnósticos de Rotina , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Programas de Rastreamento , Atenção Primária à Saúde , RNA Viral/análise , Estados Unidos
13.
J Hand Surg Eur Vol ; 43(9): 988-993, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30114990

RESUMO

The purpose of this study was to establish normal asymptomatic population values for the Disability of Arm, Shoulder and Hand and Patient-Rated Wrist/Hand Evaluation in healthy, asymptomatic individuals of different age, gender, ethnicity, handedness and nationality, using electronic data collection. Two-hundred and ninety-two Australian and 293 Canadian citizens with no active wrist pain, injury or pathology in their dominant hand, were evaluated. Participants completed an electronically administered questionnaire and were assessed clinically. There was no statistically significant association between both wrist scores and nationality. There was a statistically significant association between both wrist scores and age, demonstrating that as age increased, normal wrist function declined. This study has established an electronic, asymptomatic control group for future studies using these scores. When using the Disability of Arm, Shoulder and Hand and Patient-Rated Wrist/Hand Evaluation, the control group can be sourced from a pre-established control group within a database, without necessarily being sourced from the same country of origin. Level of evidence: II.


Assuntos
Avaliação da Deficiência , Mãos/fisiologia , Punho/fisiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Envelhecimento/fisiologia , Austrália , Canadá , Feminino , Voluntários Saudáveis , Humanos , Masculino , Pessoa de Meia-Idade , Valores de Referência
14.
Transpl Int ; 2018 May 02.
Artigo em Inglês | MEDLINE | ID: mdl-29722081

RESUMO

The new Organ Procurement and Transplant Network/United Organ Sharing Network (OPTN/UNOS) simultaneous liver-kidney transplant (SLK) policy has been implemented. The aim of this study was to review liver transplant outcomes utilizing the new SLK policy. Liver transplant alone (LTA) and SLK patients between 2009 and 2015 were reviewed. Graft survival and post-transplant kidney function were investigated among LTA patients meeting the chronic kidney disease (CKD) criteria of the new policy (LTA-CKD group). To validate our findings, we reviewed and applied our analysis to the OPTN/UNOS registry. A total of 535 patients were eligible from our series. The LTA-CKD group (n = 27) showed worse 1-year graft survival, compared with the SLK group (n = 44), but not significant (81% vs. 93%, P = 0.15). The LTA-CKD group significantly increased a risk of post-transplant dialysis (odds ratio = 5.59 [95% CI = 1.27-24.7], P = 0.02 [Ref. normal kidney function]). Post-transplant dialysis was an independent risk factor for graft loss (hazard ratio = 7.25, 95% CI = 3.3-15.91, P < 0.001 [Ref. SLK]). In the validation analysis based on the OPTN/UNOS registry, the hazard of 1-year-graft loss in the LTA-CKD group (n = 751) was 34.8% higher than the SLK group (n = 2856) (hazard ratio = 1.348, 95% CI = 1.157-1.572, P < 0.001). Indicating SLK for patients who meet the CKD criteria may significantly improve transplant outcomes.

15.
Behav Sci Law ; 36(3): 317-324, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29676495

RESUMO

Much has been written about how to conduct insanity defense evaluations, as well as how to operationalize the legal definitions of insanity. However, the insanity defense has never been categorized by a typology. This article describes a typology of six subtypes of the insanity defense: paranoid self-defense, "but it's mine," erotomanic stalking, deific decree, disorganized, and false report. Knowledge of these subtypes, while not all inclusive, can inform insanity defense evaluations, guide training, and potentially increase the reliability of forensic evaluators' opinions. In addition, such subtypes can generate future research regarding prevalence, interrater reliability, and associated features of the different subtypes.


Assuntos
Defesa por Insanidade/classificação , Psiquiatria Legal/classificação , Psiquiatria Legal/legislação & jurisprudência , Humanos , Transtornos Psicóticos , Reprodutibilidade dos Testes , Projetos de Pesquisa , Tennessee
16.
J Surg Educ ; 75(5): 1236-1244, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29545129

RESUMO

OBJECTIVE: Although key clinical skills have been defined in the Core Entrustable Professional Activities, there is a need to improve medical school curricula with standardized training opportunities and assessments of these skills. Thus, we aimed to develop an innovative curriculum that emphasized critical thinking and clinical skills. We hypothesized that we would be able to observe measurable improvement on assessments of students' critical thinking and clinical skills after the implementation of the new curriculum. DESIGN: Prospective, Quasi-Experimental study with the use of historical controls. SETTING: This study took place through the third-year surgical clerkship at the University of Texas Medical Branch at the Galveston, Houston, and Austin, Texas, locations. PARTICIPANTS: A total of 214 students taking the third-year surgical clerkship for the first time during the periods of interest were included. RESULTS: Although the students with traditional curriculum improved 9.5% on a short answer exam from preclerkship to postclerkship completion, the students with new curriculum improved by 40%. Students under the new curriculum performed significantly better on the Objective Structured Clinical Exam; however, their shelf scores were lower. CONCLUSIONS: Under this new curriculum and grading system, we demonstrated that students can be incentivized to improve critical thinking and clinical skills, but this needs to be balanced with knowledge-based incentives.


Assuntos
Estágio Clínico/métodos , Competência Clínica , Tomada de Decisão Clínica , Educação Baseada em Competências/métodos , Educação de Graduação em Medicina/organização & administração , Cirurgia Geral/educação , Currículo , Avaliação Educacional , Estudos de Avaliação como Assunto , Feminino , Humanos , Relações Interprofissionais , Masculino , Profissionalismo , Estudos Prospectivos , Faculdades de Medicina/organização & administração , Estudantes de Medicina/estatística & dados numéricos , Texas , Adulto Jovem
17.
J Genet Couns ; 27(5): 1049-1054, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29429040

RESUMO

Four to 5 % of cystic fibrosis (CF) patients are diagnosed as adults and often have subtler symptoms. Their siblings are at genetic risk to also have a subtler disease state. Diagnostic testing is recommended for siblings of newly diagnosed infants, but recommendations are less clear for later diagnoses. This study explored sibling testing recommendations in pediatric and adult practice using a survey that was emailed to CF clinicians. There were 58 respondents. Results revealed that 82.5% of pediatric and 36.4% of adult care respondents reported always recommending diagnostic testing for siblings of a newly diagnosed patient. In adult care, another 33.3% reported recommending diagnostic testing if the sibling has symptoms. In pediatric care, whether the sibling had newborn screening was most influential. Most pediatric respondents prefer the sweat chloride test, while 40% in adult practice prefer familial mutation analysis. Perceived barriers included cost, insurance coverage and logistical concerns in both settings, parental emotional state in pediatrics, and concern making recommendations for someone who is not the patient in adult care. Genetic counselors may be able to meet familial needs in CF care, including sibling testing. Many newly diagnosed patients/families do not see a genetic counselor, especially in adult care. These data reveal opportunities for practice guidelines and standardization.


Assuntos
Fibrose Cística/diagnóstico , Triagem de Portadores Genéticos/métodos , Irmãos , Adulto , Criança , Estudos de Coortes , Conselheiros , Fibrose Cística/genética , Regulador de Condutância Transmembrana em Fibrose Cística/genética , Análise Mutacional de DNA , Tomada de Decisões , Feminino , Aconselhamento Genético/métodos , Testes Genéticos , Genótipo , Humanos , Lactente , Recém-Nascido , Masculino , Mutação , Triagem Neonatal/métodos , Pais , Pediatria , Fenótipo , Gravidez , Inquéritos e Questionários
18.
Ann Surg ; 267(1): 26-34, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28562397

RESUMO

: A workshop on "Simulation Research in Gastrointestinal and Urologic Care: Challenges and Opportunities" was held at the National Institutes of Health in June 2016. The purpose of the workshop was to examine the extent to which simulation approaches have been used by skilled proceduralists (not trainees) caring for patients with gastrointestinal and urologic diseases. The current status of research findings in the use and effectiveness of simulation applications was reviewed, and numerous knowledge gaps and research needs were identified by the faculty and the attendees. The paradigm of "deliberate practice," rather than mere repetition, and the value of coaching by experts was stressed by those who have adopted simulation in music and sports. Models that are most useful for the adoption of simulation by expert clinicians have yet to be fully validated. Initial studies on the impact of simulation on safety and error reduction have demonstrated its value in the training domain, but the role of simulation as a strategy for increased procedural safety remains uncertain in the world of the expert practitioner. Although the basic requirements for experienced physicians to acquire new skills have been explored, the widespread availability of such resources is an unrealized goal, and there is a need for well-designed outcome studies to establish the role of simulation in improving the quality of health care.


Assuntos
Bioengenharia/educação , Pesquisa Biomédica/educação , Simulação por Computador , Educação Médica/métodos , National Institute of Biomedical Imaging and Bioengineering (U.S.) , National Institute of Diabetes and Digestive and Kidney Diseases (U.S.) , Docentes , Humanos , Estados Unidos
19.
Exp Clin Transplant ; 16(2): 182-190, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27855589

RESUMO

OBJECTIVES: Our objective was to determine the safety, efficacy, and pharmacokinetics of telaprevir plus pegylated interferon alfa 2a and ribavirin for chronic, posttransplant genotype 1 hepatitis C virus infection. MATERIALS AND METHODS: A prospective, single-arm, multicenter, open-label, phase 2b study was conducted at 22 North American sites to assess the safety, efficacy, and pharmacokinetics of pegylated interferon alfa 2a, ribavirin, and twice daily telaprevir in liver transplant recipients with recurrent, chronic hepatitis C without cirrhosis. Baseline liver biopsies were read by a central pathologist. There were planned safety reviews after a sentinel cohort reached treatment weeks 4 and 16. Serial pharmacokinetic sampling was performed for calcineurin inhibitors, telaprevir, and ribavirin. RESULTS: Sixty-one patients were enrolled and received ≥ 1 dose of study medication; 37 (61%) achieved sustained virologic response. Thirteen of 18 treatment-naive patients (72%), 10 of 11 patients with no or minimal fibrosis (91%), 13 of 15 patients (87%) with interleukin 28B genotype CC, and 36 of 45 patients (80%) with either undetectable or unquantifiable hepatitis C virus RNA at treatment week 4 achieved sustained virologic response. Nine patients (15%) had ≥ 1 drug-related serious adverse event and 7 (11%) discontinued all study drugs due to an adverse event. There were no deaths or acute cellular rejection episodes. During telaprevir treatment, median doses of tacrolimus and cyclosporine were 0.5 mg weekly and 25 mg daily. Target exposures were achieved for telaprevir with twice daily dosing and for ribavirin with reduced initial dosing. CONCLUSIONS: Telaprevir combination therapy for posttransplant hepatitis C virus infection yielded superior efficacy than historical controls. Adverse events were similar to, but exceeded, those in immunocompetent patients. Calcineurin inhibitor dosing levels were substantially reduced with telaprevir.


Assuntos
Antivirais/administração & dosagem , Antivirais/farmacocinética , Hepacivirus/efeitos dos fármacos , Hepatite C Crônica/tratamento farmacológico , Transplante de Fígado/efeitos adversos , Oligopeptídeos/administração & dosagem , Oligopeptídeos/farmacocinética , Adulto , Idoso , Antivirais/efeitos adversos , Inibidores de Calcineurina/administração & dosagem , Inibidores de Calcineurina/efeitos adversos , Esquema de Medicação , Interações Medicamentosas , Quimioterapia Combinada , Feminino , Genótipo , Hepacivirus/genética , Hepatite C Crônica/diagnóstico , Hepatite C Crônica/virologia , Humanos , Imunossupressores/administração & dosagem , Imunossupressores/efeitos adversos , Interferon-alfa/administração & dosagem , Masculino , Pessoa de Meia-Idade , América do Norte , Oligopeptídeos/efeitos adversos , Fenótipo , Polietilenoglicóis/administração & dosagem , Estudos Prospectivos , RNA Viral/sangue , RNA Viral/genética , Proteínas Recombinantes/administração & dosagem , Ribavirina/administração & dosagem , Resposta Viral Sustentada , Resultado do Tratamento
20.
Hepatology ; 67(2): 524-533, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-28941361

RESUMO

The Centers for Disease Control and Prevention and US Preventive Services Task Force recommend one-time hepatitis C virus (HCV) testing for persons born during 1945-1965 (birth cohort). However, few studies estimate the effect of birth cohort (BC) testing implementation on HCV diagnoses in primary care settings. We aimed to determine the probability of identifying HCV infections in primary care using targeted BC testing compared with usual care at three academic medical centers. From December 2012 to March 2014, each center compared one of three distinct interventions with usual care using an independently designed randomized controlled trial. Across centers, BC patients with no clinical documentation of previous HCV testing or diagnosis were randomly assigned to receive a one-time offering of HCV antibody (anti-HCV) testing via one of three independent implementation strategies (repeated-mailing outreach, electronic medical record-integrated provider best practice alert [BPA], and direct patient solicitation) or assigned to receive usual care. We estimated model-adjusted risk ratios (aRR) of anti-HCV-positive (anti-HCV+) identification using BC testing versus usual care. In the repeated mailing trial, 8992 patients (intervention, n = 2993; control, n = 5999) were included in the analysis. The intervention was eight times as likely to identify anti-HCV+ patients compared with controls (aRR, 8.0; 95% confidence interval [CI], 2.8-23.0; adjusted probabilities: intervention, 0.27%; control, 0.03%). In the BPA trial, data from 14,475 patients (BC, n = 8928; control, n = 5,547) were analyzed. The intervention was 2.6 times as likely to identify anti-HCV+ patients versus controls (aRR, 2.6; 95% CI, 1.1-6.4; adjusted probabilities: intervention, 0.29%; control, 0.11%). In the patient-solicitation trial, 8873 patients (BC, n = 4307; control, n = 4566) were analyzed. The intervention was five times as likely to identify anti-HCV+ patients compared with controls (aRR, 5.3; 95% CI, 2.3-12.3; adjusted probabilities: intervention, 0.68%; control, 0.11%). Conclusion: BC testing was effective in identifying previously undiagnosed HCV infections in primary care settings. (Hepatology 2018;67:524-533).


Assuntos
Anticorpos Anti-Hepatite C/sangue , Hepatite C/diagnóstico , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Atenção Primária à Saúde , Ensaios Clínicos Controlados Aleatórios como Assunto
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