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1.
Circulation ; 2019 Sep 26.
Artigo em Inglês | MEDLINE | ID: mdl-31557056

RESUMO

Background: The safety and efficacy of antithrombotic regimens may differ between patients with atrial fibrillation (AF) who have acute coronary syndromes (ACS), treated medically or with percutaneous coronary intervention (PCI), and those undergoing elective PCI. Methods: Using a 2×2 factorial design we compared apixaban with vitamin K antagonists (VKA) and aspirin with placebo in patients with AF who had ACS or were undergoing PCI and were receiving a P2Y12 inhibitor. We explored bleeding, death, and hospitalization as well as death and ischemic events by antithrombotic strategy in three pre-specified subgroups: patients with ACS treated medically, ACS treated with PCI, and those undergoing elective PCI. Results: Of 4614 patients enrolled, 1097 (23.9%) had ACS treated medically, 1714 (37.3%) had ACS treated with PCI, and 1784 (38.8%) had elective PCI. Apixaban compared with VKA reduced ISTH major or CRNM bleeding in patients with ACS treated medically (HR 0.44, 95% CI 0.28-0.68), ACS treated with PCI (HR 0.68, 95% CI 0.52-0.89), and undergoing elective PCI (HR 0.82, 95% CI 0.64-1.04) (pinteraction=0.052); and reduced death or hospitalization in ACS treated medically (HR 0.71, 95% CI 0.54-0.92), ACS treated with PCI (HR 0.88, 95% CI 0.74-1.06), and elective PCI (HR 0.87, 95% CI 0.72-1.04) (pinteraction=0.345). Compared with VKA, apixaban resulted in a similar effect on death and ischemic events in the ACS treated medically, ACS treated with PCI, and elective PCI groups (pinteraction=0.356). Compared with placebo, aspirin had a higher rate of bleeding than placebo in patients with ACS treated medically (HR 1.49, 95% CI 0.98-2.26), ACS treated with PCI (HR 2.02, 95% CI 1.53-2.67) and elective PCI groups (HR 1.91, 95% CI 1.48-2.47) (pinteraction=0.479). For the same comparison, there was no difference in outcomes among the three groups for the composite of death or hospitalization (pinteraction=0.787) and death and ischemic events (pinteraction=0.710). Conclusions: An antithrombotic regimen consisting of apixaban and a P2Y12 inhibitor without aspirin provides superior safety and similar efficacy in patients with AF who have ACS, whether managed medically or with PCI, or those undergoing elective PCI than regimens that include VKAs, aspirin, or both. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT02415400.

3.
Diabetes Res Clin Pract ; : 107829, 2019 Aug 26.
Artigo em Inglês | MEDLINE | ID: mdl-31465811

RESUMO

AIMS: This study aimed (1) to estimate the prevalence of prediabetes according to different definitions, (2) to evaluate regression to normal glucose levels and progression towards T2DM, and (3) to determine factors associated with regression and progression across four diverse geographical settings in a Latin American country. METHODS: The CRONICAS Cohort Study was conducted in four different areas in Peru. Enrollment started in September 2010 and follow-up was conducted in 2013. Prediabetes, T2DM and normal glucose levels were defined according to the World Health Organization (WHO), American Diabetes Association (ADA), and National Institute for Health and Care Excellence (NICE) definitions. The main outcomes were regression to normal glucose levels and incidence of T2DM. Prevalence estimates and 95% confidence intervals (95% CI) were calculated. Crude and adjusted regression models using Poisson were performed and relative risk ratios (RRR) and 95% CI were calculated. RESULTS: At baseline, the prevalence of prediabetes varied markedly by definition used: 6.5%(95% CI 5.6% - 7.6%), 53.6%(95% CI 51.6% - 55.6%), and 24.6%(95% CI 22.8% - 26.4%) according to WHO, ADA and NICE criteria, respectively. After 2.2 years of follow-up, in those with prediabetes, the cumulative incidence of regression to euglycemia ranged between 31.4% and 68.9%, whereas the incidence of T2DM varied from 5.5% to 28.8%. Factors associated with regression to normal glucose levels and progression to diabetes were age, body mass index, and insulin resistance. CONCLUSIONS: Regression from pre-diabetes back to euglycemia was much more common than progression to diabetes.

4.
Rev Peru Med Exp Salud Publica ; 36(2): 214-221, 2019.
Artigo em Espanhol | MEDLINE | ID: mdl-31460632

RESUMO

OBJECTIVES.: To assess the level of health literacy and treatment compliance in high-blood pressure patients attending an outpatient clinic in a hospital in Lima, Peru. MATERIALS AND METHODS.: A cross-sectional study was conducted in 276 patients, who filled out a questionnaire with general characteristics, the SAHLSA-50 Test, and the Morisky-Green Test. The Chi-square test was used to assess the association between independent variables with treatment compliance and health literacy. RESULTS.: We found a 36% of inadequate health literacy and 15% treatment compliance. No association was found between these variables (p=0.155). There was an association between being a head of household (p=0.033) and having a partner (p=0.044) with the degree of health literacy. CONCLUSIONS.: The percentage of health literacy was similar to that of Peruvian and Latin American studies, and the degree of treatment compliance was one of the lowest reported. No significant association was found between these two variables.

5.
J. Hypertens ; 37(9): 1813-1821, Jul., 31, 2019. ilus, tab
Artigo em Inglês | Sec. Est. Saúde SP, SESSP-IDPCPROD, Sec. Est. Saúde SP | ID: biblio-1015823

RESUMO

OBJECTIVES: The objective is to describe hypertension (HTN) prevalence, awareness, treatment and control in urban and rural communities in Latin America to inform public and policy-makers. METHODS: Cross-sectional analysis from urban (n = 111) and rural (n = 93) communities including 33 276 participants from six Latin American countries (Argentina, Brazil, Chile, Colombia, Peru and Uruguay)were included. HTN was defined as self-reported HTN on blood pressure (BP)medication or average BP over 140/90 mmHg, awareness as self-reported HTN, and controlled as those with BP under 140/90 mmHg. RESULTS: Mean age was 52 years,60% were Female and 32% belonged to rural communities. HTN prevalence was 44.0%, with the lowest rates in Peru (17.7%) and the highest rates in Brazil (52.5%)58.9% were aware of HTN diagnosis and 53.3% were receiving treatment. Prevalence of HTN were higher in urban (44.8%) than rural (42.1%) communities in all countries. Most participants who were aware of HTN were receiving medical treatment (90.5%), but only 37.6% of patients receiving medical treatment had their BP controlled (<140/<90 mmHg), with the rates being higher in urban (39.6%) than in rural (32.4%) communities. The rate of use of two or more drugs was low [36.4%, lowest in Argentina (29.6%) and highest in Brazil (44.6%)]. Statin use was low (12.3%), especially in rural areas (7.0%). Most modifiable risk factors were higher in people with HTN than people without HTN. CONCLUSION: HTN prevalence is high but BP control is low in Latin America, with marked differences between countries and between urban and rural settings. There is na urgent need for systematic approaches for better detection, treatment optimization and risk factor modification among those with HTN in Latin America.(AU)


Assuntos
Humanos , Hipertensão/epidemiologia , América Latina/epidemiologia
6.
Eur Heart J ; 2019 Jun 25.
Artigo em Inglês | MEDLINE | ID: mdl-31237939

RESUMO

AIMS: To determine the 1-year risk of stroke and other adverse outcomes in patients with a new diagnosis of perioperative atrial fibrillation (POAF) after non-cardiac surgery. METHODS AND RESULTS: The PeriOperative ISchemic Evaluation (POISE)-1 trial evaluated the effects of metoprolol vs. placebo in 8351 patients, and POISE-2 compared the effect of aspirin vs. placebo, and clonidine vs. placebo in 10 010 patients. These trials included patients with, or at risk of, cardiovascular disease who were undergoing non-cardiac surgery. For the purpose of this study, we combined the POISE datasets, excluding 244 patients who were in atrial fibrillation (AF) at the time of randomization. Perioperative atrial fibrillation was defined as new AF that occurred within 30 days after surgery. Our primary outcome was the incidence of stroke at 1 year of follow-up; secondary outcomes were mortality and myocardial infarction (MI). We compared outcomes among patients with and without POAF using multivariable adjusted Cox proportional hazards models. Among 18 117 patients (mean age 69 years, 57.4% male), 404 had POAF (2.2%). The stroke incidence 1 year after surgery was 5.58 vs. 1.54 per 100 patient-years in patients with and without POAF, adjusted hazard ratio (aHR) 3.43, 95% confidence interval (CI) 2.00-5.90; P < 0.001. Patients with POAF also had an increased risk of death (incidence 31.37 vs. 9.34; aHR 2.51, 95% CI 2.01-3.14; P < 0.001) and MI (incidence 26.20 vs. 8.23; aHR 5.10, 95% CI 3.91-6.64; P < 0.001). CONCLUSION: Patients with POAF have a significantly increased risk of stroke, MI, and death at 1 year. Intervention studies are needed to evaluate risk reduction strategies in this high-risk population.

7.
Rev. peru. med. exp. salud publica ; 36(2): 214-221, abr.-jun. 2019. tab
Artigo em Espanhol | LILACS-Express | ID: biblio-1020792

RESUMO

RESUMEN Objetivos . Evaluar el nivel de alfabetización en salud y el grado de adherencia al tratamiento en pacientes hipertensos que acuden al consultorio externo en un hospital de Lima, Perú. Materiales y métodos. Se realizó un estudio transversal en 276 pacientes, quienes llenaron un cuestionario con características generales, el test de SAHLSA-50 y el test de Morisky-Green. Se utilizó la prueba de Chi Cuadrado para evaluar la asociación entre las variables independientes con la adherencia al tratamiento y con la alfabetización en salud. Resultados. Se encontró un 36% de inadecuada alfabetización sanitaria en salud y un 15% de adherencia al tratamiento. No se halló asociación entre estas variables (p=0,155). Hubo asociación entre ser jefe de familia (p=0,033) y tener pareja (p=0,044) con el grado de alfabetización en salud. Conclusiones. El porcentaje de alfabetización en salud fue similar al de estudios peruanos y latinoamericanos, y el grado de adherencia al tratamiento fue una de las más bajas reportadas. No se encontró asociación significativa entre éstas dos variables.


ABSTRACT Objectives. To assess the level of health literacy and treatment compliance in high-blood pressure patients attending an outpatient clinic in a hospital in Lima, Peru. Materials and Methods. A cross-sectional study was conducted in 276 patients, who filled out a questionnaire with general characteristics, the SAHLSA-50 Test, and the Morisky-Green Test. The Chi-square test was used to assess the association between independent variables with treatment compliance and health literacy. Results. We found a 36% of inadequate health literacy and 15% treatment compliance. No association was found between these variables (p=0.155). There was an association between being a head of household (p=0.033) and having a partner (p=0.044) with the degree of health literacy. Conclusions. The percentage of health literacy was similar to that of Peruvian and Latin American studies, and the degree of treatment compliance was one of the lowest reported. No significant association was found between these two variables.

8.
JAMA Neurol ; 2019 May 06.
Artigo em Inglês | MEDLINE | ID: mdl-31058947

RESUMO

Importance: Translating evidence into clinical practice in the management of acute ischemic stroke (AIS) and transient ischemic attack (TIA) is challenging, especially in low- and middle-income countries. Objective: To assess the effect of a multifaceted quality improvement intervention on adherence to evidence-based therapies for care of patients with AIS and TIA. Design, Setting and Participants: This 2-arm cluster-randomized clinical trial assessed 45 hospitals and 2336 patients with AIS and TIA for eligibility before randomization. Eligible hospitals were able to provide care for patients with AIS and TIA in Brazil, Argentina, and Peru. Recruitment started September 12, 2016, and ended February 26, 2018; follow-up ended June 29, 2018. Data were analyzed using the intention-to-treat principle. Interventions: The multifaceted quality improvement intervention included case management, reminders, a roadmap and checklist for the therapeutic plan, educational materials, and periodic audit and feedback reports to each intervention cluster. Main Outcomes and Measures: The primary outcome was a composite adherence score for AIS and TIA performance measures. Secondary outcomes included an all-or-none composite end point of performance measures, the individual process measure components of the composite end points, and clinical outcomes at 90 days after admission (stroke recurrence, death, and disability measured by the modified Rankin scale). Results: A total of 36 hospitals and 1624 patients underwent randomization. Nineteen hospitals were randomized to the quality improvement intervention and 17 to routine care. The overall mean (SD) age of patients enrolled in the study was 69.4 (13.5) years, and 913 (56.2%) were men. Overall mean (SD) composite adherence score for the 10 performance measures in the intervention group hospitals compared with control group hospitals was 85.3% (20.1%) vs 77.8% (18.4%) (mean difference, 4.2%; 95% CI, -3.8% to 12.2%). As a secondary end point, 402 of 817 patients (49.2%) at intervention hospitals received all the therapies that they were eligible for vs 203 of 807 (25.2%) in the control hospitals (odds ratio, 2.59; 95% CI, 1.22-5.53; P = .01). Conclusions and Relevance: A multifaceted quality improvement intervention did not result in a significant increase in composite adherence score for evidence-based therapies in patients with AIS or TIA. However, when using an all-or-none approach, the intervention resulted in improved adherence to evidence-based therapies. Trial Registration: ClinicalTrials.gov Identifier: NCT02223273.

9.
J Hypertens ; 37(9): 1813-1821, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30964825

RESUMO

OBJECTIVES: The objective is to describe hypertension (HTN) prevalence, awareness, treatment and control in urban and rural communities in Latin America to inform public and policy-makers. METHODS: Cross-sectional analysis from urban (n = 111) and rural (n = 93) communities including 33 276 participants from six Latin American countries (Argentina, Brazil, Chile, Colombia, Peru and Uruguay) were included. HTN was defined as self-reported HTN on blood pressure (BP) medication or average BP over 140/90 mmHg, awareness as self-reported HTN, and controlled as those with BP under 140/90 mmHg. RESULTS: Mean age was 52 years, 60% were Female and 32% belonged to rural communities. HTN prevalence was 44.0%, with the lowest rates in Peru (17.7%) and the highest rates in Brazil (52.5%). 58.9% were aware of HTN diagnosis and 53.3% were receiving treatment. Prevalence of HTN were higher in urban (44.8%) than rural (42.1%) communities in all countries. Most participants who were aware of HTN were receiving medical treatment (90.5%), but only 37.6% of patients receiving medical treatment had their BP controlled (<140/<90 mmHg), with the rates being higher in urban (39.6%) than in rural (32.4%) communities. The rate of use of two or more drugs was low [36.4%, lowest in Argentina (29.6%) and highest in Brazil (44.6%)]. Statin use was low (12.3%), especially in rural areas (7.0%). Most modifiable risk factors were higher in people with HTN than people without HTN. CONCLUSION: HTN prevalence is high but BP control is low in Latin America, with marked differences between countries and between urban and rural settings. There is an urgent need for systematic approaches for better detection, treatment optimization and risk factor modification among those with HTN in Latin America.

10.
J Am Coll Cardiol ; 73(22): 2819-2828, 2019 Jun 11.
Artigo em Inglês | MEDLINE | ID: mdl-30898608

RESUMO

BACKGROUND: The efficacy of ticagrelor in the long-term post-ST-segment elevation myocardial infarction (STEMI) treated with fibrinolytic therapy remains uncertain. OBJECTIVES: The purpose of this study was to evaluate the efficacy of ticagrelor when compared with clopidogrel in STEMI patients treated with fibrinolytic therapy. METHODS: This international, multicenter, randomized, open-label with blinded endpoint adjudication trial enrolled 3,799 patients (age <75 years) with STEMI receiving fibrinolytic therapy. Patients were randomized to ticagrelor (180-mg loading dose, 90 mg twice daily thereafter) or clopidogrel (300- to 600-mg loading dose, 75 mg daily thereafter). The key outcomes were cardiovascular mortality, myocardial infarction, or stroke, and the same composite outcome with the addition of severe recurrent ischemia, transient ischemic attack, or other arterial thrombotic events at 12 months. RESULTS: The combined outcome of cardiovascular mortality, myocardial infarction, or stroke occurred in 129 of 1,913 patients (6.7%) receiving ticagrelor and in 137 of 1,886 patients (7.3%) receiving clopidogrel (hazard ratio: 0.93; 95% confidence interval: 0.73 to 1.18; p = 0.53). The composite of cardiovascular mortality, myocardial infarction, stroke, severe recurrent ischemia, transient ischemic attack, or other arterial thrombotic events occurred in 153 of 1,913 patients (8.0%) treated with ticagrelor and in 171 of 1,886 patients (9.1%) receiving clopidogrel (hazard ratio: 0.88; 95% confidence interval: 0.71 to 1.09; p = 0.25). The rates of major, fatal, and intracranial bleeding were similar between the ticagrelor and clopidogrel groups. CONCLUSION: Among patients age <75 years with STEMI, administration of ticagrelor after fibrinolytic therapy did not significantly reduce the frequency of cardiovascular events when compared with clopidogrel. (Ticagrelor in Patients With ST Elevation Myocardial Infarction Treated With Pharmacological Thrombolysis [TREAT]; NCT02298088).

11.
Acta méd. peru ; 36(1): 32-37, ene.-mar. 2019. tab
Artigo em Espanhol | LILACS-Express | ID: biblio-1010930

RESUMO

Objetivo: Determinar la trayectoria, características clínicas y calidad de vida en pacientes con fibromialgia (FM) que se atienden en un hospital de tercer nivel, en Lima-Perú. Materiales y métodos: Se seleccionó a pacientes con diagnóstico validado por un médico reumatólogo; en quienes se recolecto información sociodemográfica, clínica, y se aplicaron las escalas de depresión y ansiedad hospitalaria (HADS, así como el cuestionario de Impacto de Fibromialgia en español (S-FIQ). Resultados: Se entrevistó a 75 pacientes mujeres, con una edad promedio de 54,9 años. Alrededor de 5,2 años tuvieron que pasar desde el inicio de los síntomas hasta que se hizo el diagnóstico. Setenta y uno pacientes (94,7%) reportaron que el dolor musculoesquelético era el síntoma principal y 60 pacientes (80%) presentaron un impacto moderado o grave en la calidad de vida. Seis pacientes tuvieron "depresión probable" y 22 fueron un "caso probable de ansiedad". Además, 55 pacientes (73,3%) reportaron haber sufrido algún tipo de violencia y 12 reportaron violencia sexual. Conclusión: Transcurren alrededor de cinco años desde la aparición de los síntomas hasta que se hace el diagnóstico de FM. Esta enfermedad causa un impacto severo en la calidad de vida, afectando la salud mental, el trabajo y los ingresos. Hasta dos tercios de las mujeres reportan algún tipo de violencia, con un porcentaje elevado de violencia sexual.


Objective: To determine the disease progression, its clinical characteristics, and its impact in patients diagnosed with fibromyalgia in a tertiary care hospital in Lima, Peru. Materials and methods: Patients with a diagnosis of fibromyalgia validated by a rheumatologist were selected. Sociodemographic and clinical information was collected, and both the Hospital Depression and Anxiety Scales (HADS) and the Fibromyalgia Impact Questionnaire in Spanish (S-FIQ) were administered. Results: Seventy-five female patients were interviewed, with an average age of 54.93 years. Approximately 5.24 years had to elapse since symptoms started until a diagnosis was made. Seventy-one patients (94.67%) reported musculoskeletal pain as their main symptom and 60 (80%) patients had a moderate or severe impact in their quality of life. Six patients had "likely depression" and 22 were described as a "likely anxiety case". Also, 55 patients (73.33%) reported suffering some type of violence, and 12 reported sexual violence. Conclusions: It takes about 5 years from fibromyalgia symptom onset until a diagnosis is made. This condition has a severe impact on quality of life, affecting mental health, work, and income. Up to two thirds of women reported having suffered some type of violence, with an elevated percentage of sexual violence.

12.
Am Heart J ; 207: 49-57, 2018 Sep 30.
Artigo em Inglês | MEDLINE | ID: mdl-30415083

RESUMO

BACKGROUND: Translating evidence into clinical practice in the management of acute ischemic stroke (AIS) and transient ischemic attack (TIA) is challenging especially in low- and middle-income countries. OBJECTIVES: The aim of this study is to assess the effect of a multifaceted quality improvement intervention on adherence to evidence-based therapies for AIS and TIA patients care. DESIGN: We designed a pragmatic, 2-arm cluster-randomized trial involving 36 clusters and 1624 patients from Brazil, Argentina, and Peru. Hospitals are randomized to receive a multifaceted quality improvement intervention (intervention group) or to routine care (control group). The BRIDGE Stroke multifaceted quality improvement intervention includes case management, reminders, health care providers' educational materials (including treatment algorithms), interactive workshops, and audit and feedback reports. Primary outcome is a composite adherence score to AIS and TIA performance measures. Secondary outcomes include an "all or none" composite end point to performance measures, the individual components of the composite end points, and clinical outcomes at 90 days following admission (stroke recurrence, death, and disability measured by the modified Rankin scale). SUMMARY: The BRIDGE Stroke Trial is an international pragmatic evaluation of a multifaceted quality improvement intervention. If effective, this intervention could be potentially extended widely to improve the quality of care and outcomes of patients with AIS or TIA.

13.
Lancet Diabetes Endocrinol ; 6(10): 790-797, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30057170

RESUMO

BACKGROUND: Myocardial injury after non-cardiac surgery (MINS) is the most common perioperative cardiovascular complication and is independently associated with 30-day mortality. We aimed to assess the association between preoperative glucose concentration and postoperative MINS and mortality. METHODS: The VISION study is a prospective cohort study done at 12 centres in eight countries. Patients aged 45 years or older who required at least one overnight hospital admission for non-cardiac surgery were enrolled from Aug 6, 2007, to Jan 11, 2011. In the GlucoVISION analysis, we assessed the relations between preoperative casual or fasting glucose concentration and MINS within 3 days after surgery using logistic regression, and 30-day mortality using Cox proportional regression, in people with and without diabetes. FINDINGS: 11 954 patients were included in this analysis, of whom 2809 (23%) had diabetes. Within the first three postoperative days, MINS occurred in 813 (7%) patients. 249 (2%) patients died by day 30. More patients with diabetes had MINS (odds ratio [OR] 1·98 [95% CI 1·70-2·30]; p<0·0001), and died (OR 1·41 [1·08-1·86]; p=0·016) than did patients without diabetes. Casual glucose concentrations were associated with MINS in all patients (adjusted OR 1·06 [1·04-1·09] per 1 mmol/L increment in glucose; p=0·0003), and with death in patients without diabetes (adjusted hazard ratio [HR] 1·13 [95% CI 1·05-1·23] per mmol/L; p=0·002). We noted a progressive relation between unadjusted fasting glucose concentration and both MINS (OR 1·14 [1·08-1·20] per mmol/L; p<0·0001), driven by the effect in the subgroup without previous diabetes (pinteraction=0·025), and 30-day mortality (HR 1·10 [1·02-1·19] per mmol/L; p=0·013). For patients without diabetes, casual glucose of more than 6·86 mmol/L and fasting glucose of more than 6·41 mmol/L predicted MINS (OR 1·71 [1·36-2·15]; p<0·0001, and OR 2·71 [1·85-3·98]; p<0·0001, respectively). For patients with diabetes, only casual glucose concentration more than 7·92 mmol/L predicted MINS (OR 1·47 [1·10-1·96]; p=0·0096). INTERPRETATION: Preoperative glucose concentration, particularly casual glucose concentration, predicts risk for postoperative cardiovascular outcomes, especially in patients without diabetes. FUNDING: Full funding sources listed at the end of the paper (see Acknowledgments).

14.
BMJ Open ; 8(7): e021521, 2018 Jul 06.
Artigo em Inglês | MEDLINE | ID: mdl-29982215

RESUMO

OBJECTIVES: Covert stroke after non-cardiac surgery may have substantial impact on duration and quality of life. In non-surgical patients, covert stroke is more common than overt stroke and is associated with an increased risk of cognitive decline and dementia. Little is known about covert stroke after non-cardiac surgery.NeuroVISION is a multicentre, international, prospective cohort study that will characterise the association between perioperative acute covert stroke and postoperative cognitive function. SETTING AND PARTICIPANTS: We are recruiting study participants from 12 tertiary care hospitals in 10 countries on 5 continents. PARTICIPANTS: We are enrolling patients ≥65 years of age, requiring hospital admission after non-cardiac surgery, who have an anticipated length of hospital stay of at least 2 days after elective non-cardiac surgery that occurs under general or neuraxial anaesthesia. PRIMARY AND SECONDARY OUTCOME MEASURES: Patients are recruited before elective non-cardiac surgery, and their cognitive function is measured using the Montreal Cognitive Assessment (MoCA) instrument. After surgery, a brain MRI study is performed between postoperative days 2 and 9 to determine the presence of acute brain infarction. One year after surgery, the MoCA is used to assess postoperative cognitive function. Physicians and patients are blinded to the MRI study results until after the last patient follow-up visit to reduce outcome ascertainment bias.We will undertake a multivariable logistic regression analysis in which the dependent variable is the change in cognitive function 1 year after surgery, and the independent variables are acute perioperative covert stroke as well as other clinical variables that are associated with cognitive dysfunction. CONCLUSIONS: The NeuroVISION study will characterise the epidemiology of covert stroke and its clinical consequences. This will be the largest and the most comprehensive study of perioperative stroke after non-cardiac surgery. TRIAL REGISTRATION NUMBER: NCT01980511; Pre-results.

15.
Lancet ; 391(10134): 2019-2027, 2018 05 19.
Artigo em Inglês | MEDLINE | ID: mdl-29864018

RESUMO

BACKGROUND: Stroke disproportionately affects people in low-income and middle-income countries. Although improvements in stroke care and outcomes have been reported in high-income countries, little is known about practice and outcomes in low and middle-income countries. We aimed to compare patterns of care available and their association with patient outcomes across countries at different economic levels. METHODS: We studied the patterns and effect of practice variations (ie, treatments used and access to services) among participants in the INTERSTROKE study, an international observational study that enrolled 13 447 stroke patients from 142 clinical sites in 32 countries between Jan 11, 2007, and Aug 8, 2015. We supplemented patient data with a questionnaire about health-care and stroke service facilities at all participating hospitals. Using univariate and multivariate regression analyses to account for patient casemix and service clustering, we estimated the association between services available, treatments given, and patient outcomes (death or dependency) at 1 month. FINDINGS: We obtained full information for 12 342 (92%) of 13 447 INTERSTROKE patients, from 108 hospitals in 28 countries; 2576 from 38 hospitals in ten high-income countries and 9766 from 70 hospitals in 18 low and middle-income countries. Patients in low-income and middle-income countries more often had severe strokes, intracerebral haemorrhage, poorer access to services, and used fewer investigations and treatments (p<0·0001) than those in high-income countries, although only differences in patient characteristics explained the poorer clinical outcomes in low and middle-income countries. However across all countries, irrespective of economic level, access to a stroke unit was associated with improved use of investigations and treatments, access to other rehabilitation services, and improved survival without severe dependency (odds ratio [OR] 1·29; 95% CI 1·14-1·44; all p<0·0001), which was independent of patient casemix characteristics and other measures of care. Use of acute antiplatelet treatment was associated with improved survival (1·39; 1·12-1·72) irrespective of other patient and service characteristics. INTERPRETATION: Evidence-based treatments, diagnostics, and stroke units were less commonly available or used in low and middle-income countries. Access to stroke units and appropriate use of antiplatelet treatment were associated with improved recovery. Improved care and facilities in low-income and middle-income countries are essential to improve outcomes. FUNDING: Chest, Heart and Stroke Scotland.


Assuntos
Padrões de Prática Médica , Acidente Vascular Cerebral/terapia , Idoso , Estudos de Casos e Controles , Países Desenvolvidos , Países em Desenvolvimento , Medicina Baseada em Evidências , Feminino , Acesso aos Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados da Assistência ao Paciente , Pobreza , Inquéritos e Questionários , Análise de Sobrevida , Resultado do Tratamento
16.
Rev Peru Med Exp Salud Publica ; 35(1): 62-67, 2018 Jan-Mar.
Artigo em Espanhol | MEDLINE | ID: mdl-29924279

RESUMO

A cross-sectional study was conducted aimed at determining the frequency and the risk factors for bacteremia caused by extended-spectrum Beta-Lactamase (ESBL)-producing Enterobacteriaceae in patients hospitalized in a public hospital in Lima. The study included patients over 14 years of age, with positive blood cultures during their hospitalization in Hospital Nacional Cayetano Heredia in 2016. Patients were classified according to the isolated bacterium (ESBL-producing or not). Bacteremia was caused by ESBL-producing Enterobacteriacea in 50.6% of the cases; 55.8% and 32.6% by E. Coli and K. pneumoniae, respectively. No differences were found regarding co-morbidity, or prior antibiotic use (62.8% of bacteremia due to ESBLproducing strains and 57% in the non-producing strains [p=0.595]). Half of the bacteremia cases due to Enterobacteriaceae in hospitalized patients are produced by ESBL-producing Enterobacteriaceae and, of these, 40% are acquired in the community.

17.
Am Heart J ; 202: 89-96, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29908420

RESUMO

BACKGROUND: The safety and efficacy of ticagrelor in patients with ST-elevation myocardial infarction (STEMI) treated with fibrinolytic therapy remain uncertain. OBJECTIVES: The primary objective of the TicagRElor in pAtients with ST elevation myocardial infarction treated with Thrombolysis (TREAT) trial is to evaluate the short-term safety of ticagrelor when compared with clopidogrel in STEMI patients treated with fibrinolytic therapy. Key secondary objectives are to assess the safety and efficacy of ticagrelor compared with clopidogrel at 12-months. DESIGN: The TREAT trial is a multicenter, randomized, phase III, Prospective randomized open blinded end-point (PROBE) study that enrolled 3,799 patients in 152 sites from 10 countries. Following administration of fibrinolytic therapy patients were randomized to a loading dose of ticagrelor 180 mg or clopidogrel 300 mg followed by a maintenance dose of ticagrelor 90 mg twice daily or clopidogrel 75 mg/day for 12-months. The primary outcome is the rate of TIMI major bleeding at 30-days and will be assessed for non-inferiority using an intention-to-treat analysis. Co-treatments include aspirin and anticoagulants. Other evidence based therapies are also recommended. Secondary efficacy outcome include a composite of death from vascular causes, myocardial infarction, stroke, severe recurrent ischemia, transient ischemic attack or other arterial thrombotic event. All-cause mortality as well as individual components of the combined efficacy endpoint will also be ascertained. SUMMARY: TREAT is an international randomized controlled trial comparing ticagrelor with clopidogrel in STEMI patients treated with fibrinolytic therapy. The results of this trial will inform clinical practice and international guidelines.

18.
Can J Surg ; 61(3): 185-194, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29806816

RESUMO

BACKGROUND: Myocardial injury after noncardiac surgery (MINS) is a mostly asymptomatic condition that is strongly associated with 30-day mortality; however, it remains mostly undetected without systematic troponin T monitoring. We evaluated the cost and consequences of postoperative troponin T monitoring to detect MINS. METHODS: We conducted a model-based cost-consequence analysis to compare the impact of routine troponin T monitoring versus standard care (troponin T measurement triggered by ischemic symptoms) on the incidence of MINS detection. Model inputs were based on Canadian patients enrolled in the Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) study, which enrolled patients aged 45 years or older undergoing inpatient noncardiac surgery. We conducted probability analyses with 10 000 iterations and extensive sensitivity analyses. RESULTS: The data were based on 6021 patients (48% men, mean age 65 [standard deviation 12] yr). The 30-day mortality rate for MINS was 9.6%. We determined the incremental cost to avoid missing a MINS event as $1632 (2015 Canadian dollars). The cost-effectiveness of troponin monitoring was higher in patient subgroups at higher risk for MINS, e.g., those aged 65 years or more, or with a history of atherosclerosis or diabetes ($1309). CONCLUSION: The costs associated with a troponin T monitoring program to detect MINS were moderate. Based on the estimated incremental cost per health gain, implementation of postoperative troponin T monitoring seems appealing, particularly in patients at high risk for MINS.

19.
Acta méd. peru ; 35(2): 121-126, abr. 2018. ilus, tab
Artigo em Espanhol | LILACS-Express | ID: biblio-1010898

RESUMO

La Medicina Basada en la Evidencia (MBE) promovida desde hace 25 años, como un enfoque de la práctica clínica que integre la ciencia a traves del uso juicioso de la mejor evidencia disponible con la pericia clínica y el respeto de valores y preferencias de los pacientes para la toma de decisiones. En su evolución promovió la corriente de toma de decisiones compartidas, la que buscó el involucramiento y empoderamiento de las personas en lo concerniente al cuidado de su salud, pero denotando que la sóla decisión informada no es suficiente, sino que se necesita de la complicidad con el médico para que esta decisión sea realmente compartida. Esto, ha permitido entender lo que implica el trabajo de ser paciente y como el cuidado de de la salud, depende del equilibrio entre la carga y la capacidad para sobrellevar ese trabajo y que sólo, a traves de la conversación empática, se podrá dirigir exitosamente el curso de la salud, estableciendo una medicina mínimamente intrusiva, proceso que entraña una profunda humanidad y convierte a la MBE en expresión humana de una práctica médica científica cuidadosa y afectuosa


Evidence-based medicine (EBM), has been into practice for the last 25 years, being an approach for clinical practice integrating science with the use of the best available evidence alongside clinical ability and also respecting patient's values and preferences for decision making. During its progress, EBM incorporated shared decision making, aiming to involve and empower persons with respect to their healthcare, but noting that isolated informed decision making is not enough; instead, a deep collaboration between patients and physicians is needed, so that decision making may really be a shared act. This has led to understanding what is the meaning of being a patient and how healthcare depends upon an equilibrium between the workload and the ability to manage it, and that only through an empathetic conversation we may successfully manage patients care, establishing a 'minimally intrusive medicine', a process that implies plenty of humanity and turns EBM into 'a human expression of a careful and caring scientific medical practice'

20.
BMC Public Health ; 18(1): 353, 2018 03 14.
Artigo em Inglês | MEDLINE | ID: mdl-29540170

RESUMO

BACKGROUND: Childhood obesity is emerging as a major public health problem worldwide. To date, most studies of obesity and overweight in Peru are focused on adults, with few of them involving children, a population at a critical stage of development. The trend in overweight and obesity prevalence in Peruvian children under the age of five has not yet been determined. Thus, the objective of the present study is to evaluate the prevalence rates of overweight and obesity between 2010 and 2015 in children under the age of five, stratified by geographical areas in Peru. METHODS: Data were obtained from the Nutritional Status Information System of Peru. The total number of children evaluated was 14,155,914. For the Geographic Information Systems (GIS), the program Geo Da 1.8® was used to ascertain the spatial distribution of prevalence rates and was mapped for children under five. To assess the degree of spatial dependence, exploratory spatial data analysis was performed using the Moran's I statistic and was assessed with the Local Indicators of Spatial Association (LISA) analysis to identify geographic concentrations of high and low of obesity and overweight levels. RESULTS: Between 2010 and 2015, the national prevalence of childhood overweight and obesity ranged from 6.2%- 6.8% and 1.5%-2.7%, respectively. The highest prevalence of childhood overweight and obesity was found in 2014 and 2013, respectively. During these years, we observed that obesity decreased, but overweight remained stable. The highest prevalence of overweight and obesity was found in the departments located on the coast. Significant positive spatial autocorrelation was found for both overweight and obesity. The departments with the highest prevalence of overweight and obesity were concentrated in Lima, Callao, Ica, Moquegua and Tacna. The lowest were found in Loreto, Cusco and San Martin. CONCLUSION: The decrease in obesity and the stabilisation of overweight are positive results for the Peruvian childhood. However, in comparison with other Latin American countries, Peru still lags in obesity prevention.


Assuntos
Disparidades nos Níveis de Saúde , Obesidade Pediátrica/epidemiologia , Pré-Escolar , Geografia , Humanos , Lactente , Peru/epidemiologia , Prevalência , Análise Espacial
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