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1.
Am J Clin Oncol ; 2020 Jun 26.
Artigo em Inglês | MEDLINE | ID: mdl-32604161

RESUMO

OBJECTIVE: The objective of this study was to assess sexual minority and heterosexual survivors' perceived quality of cancer care and identify demographic, clinical, and psychosocial characteristics associated with patient-centered quality of care. MATERIALS AND METHODS: Four cancer registries provided data on 17,855 individuals who were diagnosed with stage I, II, or III colorectal cancer an average of 3 years prior and resided in predetermined diverse geographic areas. A questionnaire, which queried about sexual orientation and other eligibility criteria was mailed to all cancer survivors. Of these, 480 eligible survivors participated in a telephone survey. Quality of cancer care was defined by 3 measures of interpersonal care (physician communication, nursing care, and coordination of care) and by rating cancer care as excellent. We used generalized linear models and logistic regression with forward selection to obtain models that best explained each quality of care measure. RESULTS: Sexual minority survivors rated physician communication, nursing care, and coordination of care similarly to heterosexual survivors, yet a significantly higher percentage of sexual minority survivors rated the overall quality of their cancer care as excellent (59% vs. 49%). Sexual minority survivors' greater likelihood of reporting excellent care remained unchanged after adjusting for demographic, clinical, and psychosocial characteristics. CONCLUSIONS: Sexual minority survivors' ratings of quality of colorectal cancer care were comparable or even higher than heterosexual survivors. Sexual minority survivors' reports of excellent care were not explained by their interpersonal care experiences.

2.
Pediatr Emerg Care ; 2020 Apr 28.
Artigo em Inglês | MEDLINE | ID: mdl-32349076

RESUMO

BACKGROUND: Children with hemophilia frequently require long-term central venous access devices (CVADs) for regular infusion of factor products. Hemophilia patients are not immunocompromised, but the presence and use of CVADs are associated with infections including bacteremia. Currently, the utility of blood cultures in evaluation of the febrile hemophilia patient with an indwelling CVAD is unknown, nor is optimal empiric antibiotic use. METHODS: We performed a retrospective cross-sectional study of febrile immunocompetent hemophilia patients with CVADs presenting to a large academic urban pediatric emergency department from 1995 to 2017. We used a natural language processing electronic search, followed by manual chart review to construct the cohort. We analyzed rate of pathogen recovery from cultures of blood in subgroups of hemophilia patients, the pathogen profile, and the reported pathogen susceptibilities to ceftriaxone. RESULTS: Natural language processing electronic search identified 181 visits for fever among hemophilia patients with indwelling CVADs of which 147 cases from 44 unique patients met study criteria. Cultures of blood were positive in 56 (38%) of 147 patients (95% confidence interval, 30%-47%). Seventeen different organisms were isolated (10 pathogens and 7 possible pathogens) with Staphylococcus aureus and coagulase-negative Staphylococcus species as the most common. Thirty-four percent of isolates were reported as susceptible to ceftriaxone. Positive blood cultures were more common in cases involving patients with inhibitors (n = 71) versus those without (n = 76), odds ratio, 7.4 (95% confidence interval, 3.5-15.9). This was observed irrespective of hemophilia type. CONCLUSIONS: Febrile immunocompetent hemophilia patients with indwelling CVADs have high rates of bacteremia. Empiric antimicrobial therapy should be targeted to anticipated pathogens and take into consideration local susceptibility patterns for Staphylococcus aureus.

3.
Cancer ; 126(12): 2829-2836, 2020 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-32134515

RESUMO

BACKGROUND: Transgender individuals' cancer prevalence and transgender cancer survivors' health needs have received scarce attention. The current study compared transgender and cisgender individuals' cancer prevalence and described the health needs of transgender cancer survivors. METHODS: The authors used Behavioral Risk Factor Surveillance System data on 95,800 cisgender and transgender individuals who self-reported a cancer diagnosis. Using multiple logistic regression, they estimated cancer prevalence and calculated odds ratios with 95% confidence intervals of physical, psychological, overall health, and health behaviors of transgender survivors compared with cisgender survivors. RESULTS: After adjusting for confounders, transgender men had a significantly higher (>2-fold) number of cancer diagnoses compared with cisgender men, but not cisgender women. Cancer prevalence among gender nonconforming individuals and transgender women was not significantly different from that of cisgender men and cisgender women. Gender nonconforming survivors had significantly greater physical inactivity, heavy episodic alcohol use, and depression compared with cisgender men and cisgender women. Transgender men survivors were significantly more likely to report poor physical health and greater medical comorbidities and were less likely to report smoking compared with cisgender men and cisgender women. Transgender women survivors were significantly more likely to report diabetes compared with cisgender men and cisgender women and were more likely to report cardiovascular disease compared with cisgender women. CONCLUSIONS: Clinicians should be aware of the higher prevalence of cancer among transgender men and a potential survivorship bias among transgender individuals. Transgender survivors have considerable variation in their risk profile. Clinicians and health services can target gender nonconforming survivors' depression and health behaviors to improve survival and should address the complex comorbidities of transgender men and transgender women.

4.
Am J Trop Med Hyg ; 102(5): 1016-1021, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32124725

RESUMO

Children who travel internationally to visit friends and relatives (VFRs) are at risk for travel-related illness, but underuse pretravel health services. Although primary care clinics can identify travelers and address pretravel health needs, to date, there are few published reports on effective primary care-based pretravel interventions. We developed a quality improvement initiative to increase traveler identification at a primary care clinic serving families that frequently travel to VFRs. Interventions included a screening question asked at all clinic visits, provider and staff training, travel fliers, and health recommendation sheets for families. Interventions were implemented during 2017 and 2018 peak travel seasons. Travel visit rates and characteristics during the intervention period were compared with pre-intervention baseline periods (April-August, 2015-16). Surveys with providers were conducted to assess disruptiveness of the interventions, and rates of duplicate travel visits were assessed. A total of 738 unique travel events were identified during peak travel seasons from 2015 to 2018, encompassing travel to 29 countries across five continents. Overall, there were 428 unique travel events (3.0% of all clinic visits) during peak seasons 2017-18, compared with 310 unique travel events (2.2% of all clinic visits) during peak seasons 2015-16 (rate ratio 1.34 [95% CI: 1.16-1.56], P < 0.001). None of the 18 healthcare providers or staff surveyed found new travel screening processes to be disruptive or bothersome. Implementation of a primary care-based multimodal travel screening and education initiative was associated with a significantly increased rate of travel visits.


Assuntos
Atenção Primária à Saúde/métodos , Medicina de Viagem/métodos , Criança , Pré-Escolar , Humanos , Lactente , Recém-Nascido , Programas de Rastreamento/métodos , Programas de Rastreamento/normas , Massachusetts , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Atenção Primária à Saúde/normas , Atenção Primária à Saúde/estatística & dados numéricos , Melhoria de Qualidade , Estações do Ano , Viagem , Medicina de Viagem/normas , Medicina de Viagem/estatística & dados numéricos
5.
Vaccine ; 38(9): 2229-2240, 2020 Feb 24.
Artigo em Inglês | MEDLINE | ID: mdl-32005538

RESUMO

BACKGROUND: Bacille Calmette-Guérin (BCG), the live attenuated tuberculosis vaccine, is manufactured under different conditions across the globe generating formulations that may differ in clinical efficacy. Innate immune recognition of live BCG contributes to immunogenicity suggesting that differences in BCG viability may contribute to divergent activity of licensed formulations. METHODS: We compared BCG-Denmark (DEN), -Japan (JPN), -India (IND), -Bulgaria (BUL) and -USA in vitro with respect to a) viability as measured by colony-forming units (CFU), mycobacterial membrane integrity, and RNA content, and b) cytokine/chemokine production in newborn cord and adult peripheral blood. RESULTS: Upon culture, relative growth was BCG-USA > JPN â‰« DEN > BUL = IND. BCG-IND and -BUL demonstrated >1000-fold lower growth than BCG-JPN in 7H9 medium and >10-fold lower growth in commercial Middlebrook 7H11 medium. BCG-IND demonstrated significantly decreased membrane integrity, lower RNA content, and weaker IFN-γ inducing activity in whole blood compared to other BCGs. BCG-induced whole blood cytokines differed significantly by age, vaccine formulation and concentration. BCG-induced cytokine production correlated with CFU, suggesting that mycobacterial viability may contribute to BCG-induced immune responses. CONCLUSIONS: Licensed BCG vaccines differ markedly in their content of viable mycobacteria possibly contributing to formulation-dependent activation of innate and adaptive immunity and distinct protective effects.

6.
Pediatr Res ; 2019 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-31578034

RESUMO

BACKGROUND: Preterm infants are at high risk of infection and have distinct pathogen recognition responses. Suggested mechanisms include soluble mediators that enhance cellular levels of cAMP. The aim of this study was to assess the relationship between blood cAMP concentrations and TLR-mediated cytokine production in infants during the first month of life. METHODS: Cord and serial peripheral blood samples (days of life 1-28) were obtained from a cohort of very preterm (<30 weeks' gestational age) and term human infants. Whole-blood concentrations of cAMP and FSL-1 and LPS in vitro stimulated cytokine concentrations were measured by ELISA and multiplex bead assay. RESULTS: cAMP concentrations were higher in cord than in peripheral blood, higher in cord blood of female preterm infants, and lower at Days 1 and 7 in infants exposed to chorioamnionitis, even after adjusting for leukocyte counts. TLR2 and TLR4-mediated TNF-α, IL-1ß, IL-6, IL-12p70, and IL-10 production in vitro increased over the first month of life in preterm infants and were positively correlated with leukocyte-adjusted cAMP levels and reduced by exposure to chorioamnionitis. CONCLUSIONS: The ontogeny of blood cAMP concentrations and associations with chorioamnionitis and TLR-mediated production of cytokines suggest that this secondary messenger helps shape distinct neonatal pathogen responses in early life.

7.
Reprod Health ; 16(1): 150, 2019 Oct 22.
Artigo em Inglês | MEDLINE | ID: mdl-31640770

RESUMO

BACKGROUND: Reducing the maternal mortality ratio to less than 70 per 100,000 live births globally is one of the Sustainable Development Goals. Approximately 830 women die from pregnancy- or childbirth-related complications every day. Almost 99% of these deaths occur in developing countries. Increasing antenatal care quality and completion, and institutional delivery are key strategies to reduce maternal mortality, however there are many implementation challenges in rural and resource-limited settings. In Nepal, 43% of deliveries do not take place in an institution and 31% of women have insufficient antenatal care. Context-specific and evidence-based strategies are needed to improve antenatal care completion and institutional birth. We present an assessment of effectiveness outcomes for an adaptation of a group antenatal care model delivered by community health workers and midwives in close collaboration with government staff in rural Nepal. METHODS: The study was conducted in Achham, Nepal, via a public private partnership between the Nepali non-profit, Nyaya Health Nepal, and the Ministry of Health and Population, with financial and technical assistance from the American non-profit, Possible. We implemented group antenatal care as a prospective non-randomized, cluster-controlled, type I hybrid effectiveness-implementation study in six village clusters. The implementation approach allowed for iterative improvement in design by making changes to improve the quality of the intervention. We evaluated effectiveness through a difference in difference analysis of institutional birth rates between groups prior to implementation of the intervention and 1 year after implementation. Additionally, we assessed the change in knowledge of key danger signs and the acceptability of the group model compared with individual visits in a nested cohort of women receiving home visit care and home visit care plus group antenatal care. Using a directed content and thematic approach, we analyzed qualitative interviews to identify major themes related to implementation. RESULTS: At baseline, there were 457 recently-delivered women in the six village clusters receiving home visit care and 214 in the seven village clusters receiving home visit care plus group antenatal care. At endline, there were 336 and 201, respectively. The difference in difference analysis did not show a significant change in institutional birth rates nor antenatal care visit completion rates between the groups. There was, however, a significant increase in both institutional birth and antenatal care completion in each group from baseline to endline. We enrolled a nested cohort of 52 participants receiving home visit care and 62 participants receiving home visit care plus group antenatal care. There was high acceptability of the group antenatal care intervention and home visit care, with no significant differences between groups. A significantly higher percentage of women who participated in group antenatal care found their visits to be 'very enjoyable' (83.9% vs 59.6%, p = 0.0056). In the nested cohort, knowledge of key danger signs during pregnancy significantly improved from baseline to endline in the intervention clusters only (2 to 31%, p < 0.001), while knowledge of key danger signs related to labor and childbirth, the postpartum period, and the newborn did not in either intervention or control groups. Qualitative analysis revealed that women found that the groups provided an opportunity for learning and discussion, and the groups were a source of social support and empowerment. They also reported an improvement in services available at their village clinic. Providers noted the importance of the community health workers in identifying pregnant women in the community and linking them to the village clinics. Challenges in birth planning were brought up by both participants and providers. CONCLUSION: While there was no significant change in institutional birth and antenatal care completion at the population level between groups, there was an increase of these outcomes in both groups. This may be secondary to the primary importance of community health worker involvement in both of these groups. Knowledge of key pregnancy danger signs was significantly improved in the home visit plus group antenatal care cohort compared with the home visit care only group. This initial study of Nyaya Health Nepal's adapted group care model demonstrates the potential for impacting women's antenatal care experience and should be studied over a longer period as an intervention embedded within a community health worker program. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02330887 , registered 01/05/2015, retroactively registered.


Assuntos
Agentes Comunitários de Saúde/estatística & dados numéricos , Prestação Integrada de Cuidados de Saúde/organização & administração , Serviços de Saúde Materna/organização & administração , Educação de Pacientes como Assunto , Cuidado Pré-Natal/estatística & dados numéricos , Cuidado Pré-Natal/normas , Adolescente , Adulto , Feminino , Humanos , Pessoa de Meia-Idade , Nepal , Ensaios Clínicos Controlados não Aleatórios como Assunto , Parto , Gestantes , Estudos Prospectivos , População Rural , Adulto Jovem
8.
Cancer ; 125(17): 3079-3085, 2019 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-31106409

RESUMO

BACKGROUND: Adults with poor access to care are known to have worse quality of life (QOL). The purpose of the current study was to determine differences in cancer survivors' access to care by sexual orientation and to examine the association between access to care and QOL. METHODS: The current secondary data analysis used 4 years of Behavioral Risk Factor Surveillance System data regarding adult men and women who self-reported a history of cancer. Among the 70,524 cancer survivors, a total of 1931 self-identified as sexual minorities, defined as lesbian, gay, bisexual, or other nonheterosexual orientation. RESULTS: Sexual minority women had significantly more access deficits compared with heterosexual women (42.7% vs 28.0%; P < .0001), whereas men of different sexual orientations had similar access to care. Among sexual minority women, those with access deficits had higher odds of poor physical QOL compared with heterosexual women (odds ratio [OR], 2.0 [95% CI, 1.2-3.4] vs OR, 1.3 [95% CI, 1.2-1.5]), poor mental QOL (OR, 1.8 [95% CI, 1.1-3.1] vs OR, 1.5 [95% CI, 1.3-1.7]), and difficulties concentrating (OR, 2.0 [95% CI, 1.2-3.5] vs OR, 1.7 [95% CI, 1.4-1.9]). Sexual minority men with access deficits had greater odds of difficulty concentrating compared with heterosexual men (OR, 4.3 [95% CI, 2.0-9.3] vs OR, 1.5 [95% CI, 1.2-1.9]). Among men, sexual minority status increased the odds of poor mental QOL (OR, 1.49 [95% CI, 1.11-2.01]). CONCLUSIONS: Access to care among sexual minority cancer survivors needs improvement. Sexual minority women should be a focus of future research because their poor access to care more strongly relates to worse QOL.


Assuntos
Sobreviventes de Câncer , Acesso aos Serviços de Saúde , Qualidade de Vida , Minorias Sexuais e de Gênero , Adolescente , Adulto , Idoso , Sistema de Vigilância de Fator de Risco Comportamental , Bissexualidade , Sobreviventes de Câncer/estatística & dados numéricos , Feminino , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde , Homossexualidade Feminina , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos , Adulto Jovem
9.
Nat Commun ; 10(1): 1092, 2019 03 12.
Artigo em Inglês | MEDLINE | ID: mdl-30862783

RESUMO

Systems biology can unravel complex biology but has not been extensively applied to human newborns, a group highly vulnerable to a wide range of diseases. We optimized methods to extract transcriptomic, proteomic, metabolomic, cytokine/chemokine, and single cell immune phenotyping data from <1 ml of blood, a volume readily obtained from newborns. Indexing to baseline and applying innovative integrative computational methods reveals dramatic changes along a remarkably stable developmental trajectory over the first week of life. This is most evident in changes of interferon and complement pathways, as well as neutrophil-associated signaling. Validated across two independent cohorts of newborns from West Africa and Australasia, a robust and common trajectory emerges, suggesting a purposeful rather than random developmental path. Systems biology and innovative data integration can provide fresh insights into the molecular ontogeny of the first week of life, a dynamic developmental phase that is key for health and disease.


Assuntos
Desenvolvimento Infantil/fisiologia , Recém-Nascido/sangue , Recém-Nascido/imunologia , Quimiocinas/sangue , Estudos de Coortes , Citocinas/sangue , Gâmbia , Perfilação da Expressão Gênica , Humanos , Imunofenotipagem , Metabolômica , Papua Nova Guiné , Proteômica , Biologia de Sistemas
10.
J Patient Saf ; 15(4): e78-e81, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-29557933

RESUMO

OBJECTIVES: Italy is experiencing a crisis of malpractice litigation with important repercussions on the insurance industry (e.g., lower profits), physicians (e.g., defensive medicine), and the courts (e.g., work backlog, lengthy proceedings). We searched for common ground between legal systems in Italy and the United States and considered the implications for international collaborations in patient safety. METHODS: We examined the judicial frameworks of medical malpractice litigation in two countries with different legal foundations: the United States (a public-private system governed by common law) and Italy (a publicly financed healthcare system governed by civil law). RESULTS: We found important differences and similarities across the two systems that suggest a high compatibility for future comparisons and collaborations. Although many Italian hospitals maintain risk management programs, the U.S. emphasis on patient safety and quality has not yet been integrated into Italian healthcare systems. CONCLUSIONS: Based on our findings, we propose that the Italian system might benefit from assertively adopting some concepts from the U.S. system. In particular, we consider the role of the law and Italian medicolegal experts as key facilitators for the integration of patient safety and risk management units within Italian healthcare facilities.


Assuntos
Assistência à Saúde/legislação & jurisprudência , Imperícia , Segurança do Paciente/legislação & jurisprudência , Médicos , Gestão de Riscos/legislação & jurisprudência , Medicina Defensiva , Humanos , Cooperação Internacional , Itália , Responsabilidade Legal , Estados Unidos
11.
Telemed J E Health ; 25(1): 60-65, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-29727261

RESUMO

BACKGROUND: Despite being less costly than prolonged hospitalization, home parenteral nutrition (HPN) is associated with high rates of post-discharge complications, including frequent readmissions and central line-associated bloodstream infections (CLABSIs). Telemedicine has been associated with improved outcomes and reduced healthcare utilization in other high-risk populations, but no studies to date have supported effectiveness of telemedicine in pediatric HPN. METHODS: We prospectively collected data on pediatric patients managed at a single HPN program who participated in postdischarge telemedicine visits from March 1, 2014 to March 30, 2016. We excluded patients with a history of HPN and strictly palliative care goals. Univariate analysis was performed for primary outcomes: Community-acquired CLABSI and 30-day readmission rate. RESULTS: Twenty-six families participated in the pilot initiative with median (interquartile range) patient age 1.5 (5.7) years old, diagnosis of short bowel syndrome in 16 (62%), and in-state residence in 17 (55%). Ishikawa (fishbone) diagram identified causes of post-discharge HPN complications. Areas of focus during telemedicine visit included central venous catheter care methods, materials, clinical concerns, and equipment. Compared to historical comparison group, the telemedicine group experienced CLABSI rates of 1.0 versus 2.7 per 1,000 line days and readmission rates of 38% versus 17% (p = 0.03, 0.02, respectively). CONCLUSIONS: Telemedicine visits identified opportunities for improvement for families newly discharged on HPN. In a small cohort of patients who experienced telemedicine visits, we found lower CLABSI rates alongside higher readmission rates compared with a historical comparison group. Further studies are needed to optimize telemedicine in delivering care to this high-risk population.


Assuntos
Infecções Relacionadas a Cateter/prevenção & controle , Cateteres Venosos Centrais/efeitos adversos , Nutrição Parenteral no Domicílio/métodos , Melhoria de Qualidade/organização & administração , Telemedicina/organização & administração , Infecções Relacionadas a Cateter/epidemiologia , Criança , Pré-Escolar , Segurança Computacional , Feminino , Humanos , Lactente , Masculino , Readmissão do Paciente/estatística & dados numéricos , Estudos Prospectivos , Comunicação por Videoconferência
12.
Pediatrics ; 143(1)2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30518671

RESUMO

OBJECTIVES: The American Academy of Pediatrics' bronchiolitis guidelines recommend against albuterol and corticosteroids for treating and chest radiographs (CRs) for diagnosing infants with bronchiolitis. However, high rates of nonadherence have been documented. Our objective was to improve guideline adherence in infants with bronchiolitis. METHODS: This quality improvement study was conducted in 1 urban academic pediatric primary care clinic caring for predominately minority and publicly insured children. We tested provider guideline education, display of guidelines in patient care areas, and monthly e-mails to all providers documenting deviation rates, with individual e-mails to providers who deviated. P-charts and interrupted time series analysis were used to estimate the effect of the intervention. RESULTS: There were 380 children <2 years of age with a diagnosis of bronchiolitis in the 16 nonsummer months preintervention and 417 in the 15 postintervention months. Rates of prescribed and administered albuterol declined from 45.7% in the baseline period to 13.7% in the intervention period and CR use dropped from a mean of 10.1% to 3.4%, both demonstrating special cause variation. Steroid use did not change significantly. In interrupted time series analyses, the intervention was associated with a significant decrease in albuterol use (P < .001) but not in CR or steroid use. Emergency department visits declined slightly but admissions for bronchiolitis were stable. CONCLUSIONS: Traditional quality improvement efforts coupled with social psychology techniques resulted in improved guideline adherence in outpatient bronchiolitis management. Additional study will help identify which techniques are most effective for increasing guideline adherence in cases of low-value care.


Assuntos
Albuterol/administração & dosagem , Bronquiolite/tratamento farmacológico , Bronquiolite/psicologia , Broncodilatadores/administração & dosagem , Pessoal de Saúde/psicologia , Adesão à Medicação/psicologia , Pré-Escolar , Feminino , Fidelidade a Diretrizes , Pessoal de Saúde/educação , Humanos , Lactente , Recém-Nascido , Masculino , Psicologia Social
13.
Birth Defects Res ; 110(19): 1395-1403, 2018 11 15.
Artigo em Inglês | MEDLINE | ID: mdl-30394691

RESUMO

BACKGROUND: Improved treatment of congenital heart defects (CHDs) has increased survival of persons with CHDs; however, no U.S. population-based systems exist to assess prevalence, healthcare utilization, or longer-term outcomes among adolescents and adults with CHDs. METHODS: Novel approaches identified individuals aged 11-64 years who received healthcare with ICD-9-CM codes for CHDs at three sites: Emory University in Atlanta, Georgia (EU), Massachusetts Department of Public Health (MA), New York State Department of Health (NY) between January 1, 2008 (2009 for MA) and December 31, 2010. Case-finding sources included outpatient clinics; Medicaid and other claims data; and hospital inpatient, outpatient, and emergency visit data. Supplemental information came from state vital records (EU, MA), and birth defects registries (EU, NY). Demographics and diagnostic and procedural codes were linked, de-duplicated, and shared in a de-identified dataset. Cases were categorized into one of five mutually exclusive CHD severity groups; non-cardiac comorbidity codes were grouped into broad categories. RESULTS: 73,112 individuals with CHD codes in healthcare encounters were identified. Primary data source type varied: clinics (EU, NY for adolescents), claims (MA), hospital (NY for adults). There was a high rate of missing data for some variables and data varied in format and quality. Some diagnostic codes had poor specificity for CHD ascertainment. CONCLUSIONS: To our knowledge, this is the first population-based, multi-site CHD surveillance among adolescents and adults in the U.S. Identification of people living with CHDs through healthcare encounters using multiple data sources was feasible, though data quality varied and linkage/de-duplication was labor-intensive.


Assuntos
Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/epidemiologia , Vigilância da População/métodos , Adolescente , Adulto , Criança , Anormalidades Congênitas/epidemiologia , Bases de Dados Factuais , Monitoramento Epidemiológico , Feminino , Georgia , Hospitais , Humanos , Masculino , Massachusetts , Pessoa de Meia-Idade , New York , Prevalência , Saúde Pública , Sistema de Registros , Estados Unidos
14.
F1000Res ; 7: 616, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30271580

RESUMO

Background: There is a need to prevent and treat infection in newborns. One approach is administration of antimicrobial proteins and peptides (APPs) such as LL-37, a membrane-active cathelicidin antimicrobial peptide, and mannose-binding lectin (MBL), a pattern-recognition protein that binds to microbial surface polysaccharides resulting in opsonization and complement activation. Low plasma/serum levels of LL-37 and of MBL have been correlated with infection and exogenous administration of these agents may enhance host defense. Methods: The antimicrobial activity of LL-37 (15 µg/ml) or rMBL (0.5, 2 and 10 µg/ml) was tested in hirudin-anticoagulated preterm and term human cord blood (N = 12-14) against Staphylococcus aureus (SA) USA 300 (2x10 4 CFU/ml), Staphylococcus epidermis (SE) 1457 (2x10 4 CFU/ml) and Candida albicans (CA) SC5314 (1x10 4 CFU/ml). After incubation (1, 45, or 180 min), CFUs were enumerated by plating blood onto agar plates. Supernatants were collected for measurement of MBL via ELISA. Results: Preterm cord blood demonstrated impaired endogenous killing capacity against SA and SE compared to term blood. Addition of LL-37 strongly enhanced antimicrobial/antifungal activity vs SA, SE and CA in term blood and SE and CA in preterm blood. By contrast, rMBL showed modest fungistatic activity vs CA in a sub-analysis of term newborns with high basal MBL levels. Baseline MBL levels varied within preterm and term cohorts with no correlation to gestational age. In summary, exogenous LL-37 demonstrated significant antimicrobial activity against SA, SE and CA in term and SE and CA in preterm human blood tested in vitro. rMBL demonstrated modest antifungal activity in term cord blood of individuals with high baseline MBL levels. Conclusions: To the extent that our in vitro results predict the effects of APPs in vivo, development of APPs for prevention and treatment of infection should take into account host age as well as the target pathogen.


Assuntos
Catelicidinas/metabolismo , Sangue Fetal/imunologia , Lectina de Ligação a Manose/metabolismo , Peptídeos Catiônicos Antimicrobianos/farmacologia , Candida albicans/efeitos dos fármacos , Catelicidinas/farmacologia , Feminino , Sangue Fetal/química , Idade Gestacional , Humanos , Recém-Nascido , Masculino , Lectina de Ligação a Manose/farmacologia , Proteínas Recombinantes/metabolismo , Staphylococcus aureus , Staphylococcus epidermidis/efeitos dos fármacos
15.
LGBT Health ; 5(5): 295-302, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29878863

RESUMO

PURPOSE: Resilience could help protect the psychosocial wellbeing of sexual minority women (SMW) experiencing stressors from both breast cancer and sexual minority status; however, little research has assessed resilience among breast cancer survivors of different sexual orientations. METHODS: From 2011 to 2012, we surveyed a national sample of breast cancer survivors matched on sexual orientation, age, and cancer status. RESULTS: Among heterosexual (n = 339) and sexual minority (n = 201) breast cancer survivors (n = 540 overall), multivariable regression analyses revealed that more social support (coefficient: 0.87; 95% confidence interval [CI]: 0.56-1.19), fighting spirit combined with helplessness/hopelessness (coefficient: 0.30; 95% CI: 0.13-0.47), and fatalism (coefficient: 0.40; 95% CI: 0.14-0.65) were associated with greater resilience. Mental health counseling before breast cancer diagnosis and anxious preoccupation following cancer diagnosis were associated with reduced resilience (coefficient: -2.50; 95% CI: -3.83 to -1.18; and -0.46; 95% CI: -0.60 to -0.32). Although sexual orientation was not independently associated with resilience, among SMW, those who were unemployed had reduced resilience compared with those who were employed (coefficient: -3.52; 95% CI: -5.75 to -1.28), whereas there was no association between employment and resilience among heterosexual women. CONCLUSION: These findings suggest that social support and other factors associated with resilience could be leveraged by interventions to improve the health and wellbeing of diverse cancer survivors.


Assuntos
Neoplasias da Mama/psicologia , Sobreviventes de Câncer/psicologia , Heterossexualidade/psicologia , Resiliência Psicológica , Minorias Sexuais e de Gênero/psicologia , Neoplasias da Mama/terapia , Sobreviventes de Câncer/estatística & dados numéricos , Feminino , Heterossexualidade/estatística & dados numéricos , Humanos , Pessoa de Meia-Idade , Minorias Sexuais e de Gênero/estatística & dados numéricos , Apoio Social , Estresse Psicológico/psicologia
16.
J Pediatr Gastroenterol Nutr ; 67(4): e77-e81, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29912033

RESUMO

BACKGROUND: Although previous literature suggests home parenteral nutrition (HPN)-dependent children experience frequent complications like community-acquired central line-associated bloodstream infections (CLABSI), few studies have characterized the cost. OBJECTIVE: The aim of this study was to evaluate institutional cost of community-acquired CLABSI in pediatric patients with HPN. METHODS: This is a single-center retrospective review of institutional costs for patients with HPN with community-acquired CLABSI at a tertiary care children's hospital. Inclusion was age 18 years or less between October 2011 and April 2016. Exclusions were death during hospitalization and readmission within 2 days of discharge. Patient-level factors were compared between high-cost group and all others using Welch 2-sample t test and analysis of variance. Multivariable logistic regression was used to determine predictors of higher cost. RESULTS: There were 176 CLABSI admissions among 68 patients during the study period (median 2 hospitalizations per patients). The mean cost and length of stay per hospital admission are $28,375 (2015 US dollars) and 8 days, and both were associated with intensive care unit admission (ICU), central venous catheter removal, private insurance, and age <2 years at admission. Nine percent of patients were classified as "super-utilizers" whose 54 hospitalizations accounted for 28% of total institutional costs. CONCLUSIONS: Among pediatric patients with HPN, community-acquired CLABSI is associated with significant cost and length of stay. Healthcare utilization is disproportionately concentrated in a small number of patients. These study findings may help inform cost analysis for future CLABSI prevention strategies.


Assuntos
Infecções Relacionadas a Cateter/economia , Infecções Comunitárias Adquiridas/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitais Pediátricos/economia , Nutrição Parenteral no Domicílio/economia , Centros de Atenção Terciária/economia , Pré-Escolar , Feminino , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Estudos Retrospectivos
18.
Am J Infect Control ; 46(11): 1284-1289, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-29778436

RESUMO

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) cause substantial morbidity and increase antimicrobial use and length of stay among hospitalized children in the United States. CLABSI occurs more frequently among high-risk pediatric patients, such as those with intestinal failure (IF) who are parenteral nutrition (PN) dependent. Following an increase in CLABSI rates, a quality improvement (QI) initiative was implemented. METHODS: Using QI methodology, an enhanced central venous catheter (CVC) maintenance bundle was developed and implemented on 2 units for pediatric PN-dependent patients with IF. CLABSI rates were prospectively monitored pre- and postimplementation, and bundle element adherence was monitored. Enhanced bundle elements included chlorhexidine-impregnated patch, daily bathing, ethanol locks, 2 nurses for CVC care in a distraction-free zone, peripheral laboratory draws, bundling routine laboratory tests, and PN administration set changes every 24 hours. RESULTS: Adherence to enhanced bundle elements increased to >90% over 3 months. CLABSI rates averaged 1.41 per 1,000 central line days preimplementation compared with 0.40 per 1,000 device days postimplementation (P = .003), an 85% absolute reduction in CLABSI rates over 12 months. CONCLUSIONS: Patients with IF are at an increased risk for CLABSI. Enhanced CVC maintenance bundles that specifically target prevention practices in this population may be beneficial.


Assuntos
Cateterismo Venoso Central/efeitos adversos , Cateteres Venosos Centrais/efeitos adversos , Enteropatias/terapia , Nutrição Parenteral , Pacotes de Assistência ao Paciente/métodos , Adolescente , Infecções Relacionadas a Cateter , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Escores de Disfunção Orgânica , Melhoria de Qualidade
19.
JPEN J Parenter Enteral Nutr ; 42(8): 1295-1303, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-29603317

RESUMO

BACKGROUND: Home parenteral nutrition (HPN) is a life-sustaining therapy for short bowel syndrome (SBS) and other severe digestive diseases, but complications are common. We evaluated a predischarge HPN hands-on training course to reduce complications in children with SBS, including hospital readmissions. METHODS: We conducted a prospective, nonrandomized controlled research study between April 1, 2014, and April 30, 2017. Eligible participants were children aged <18 years old with SBS and anticipated HPN dependence duration ≥6 months. Excluded participants had a previous history of discharge with a central venous catheter (CVC), HPN, or intravenous fluids or strictly palliative goals of care. An intervention group practiced hands-on HPN within the hospital room for 24 hours using infusion equipment. The groups received standard teaching (CVC care, home infusion pump operation, HPN preparation and administration). RESULTS: Nine children were assigned to the intervention group and 12 served as controls. The median age was 8.4 months, and length of stay (LOS) was 82 days. All participants experienced ≥1 event, with a total of 47 issues related to HPN. There were no significant associations between group assignment and 30-day postdischarge events. Each additional week of LOS was associated with 11% increase in the odds of an emergency department visit (OR 1.11; 95% CI, 1.01-1.26) and 16% increase in the odds of readmission (OR 1.16; 95% CI, 1.04-1.37). CONCLUSIONS: Postdischarge events remained widespread despite HPN bedside interventions offered by this pilot intervention. With refinement of HPN discharge processes, quality benchmarks are needed.


Assuntos
Família , Nutrição Parenteral no Domicílio , Alta do Paciente , Educação de Pacientes como Assunto , Síndrome do Intestino Curto/terapia , Feminino , Humanos , Lactente , Tempo de Internação , Masculino , Readmissão do Paciente , Pediatria , Projetos Piloto , Estudos Prospectivos , Estudos Retrospectivos
20.
Hosp Pediatr ; 8(5): 293-299, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29700011

RESUMO

OBJECTIVES: Drug-drug interactions (DDIs) can result in patient harm. DDI alerts are intended to help prevent harm; when the majority of alerts presented to providers are being overridden, their value is diminished. Our objective was to evaluate the overall rates of DDI alert overrides and how rates varied by specialty, clinician type, and patient complexity. METHODS: A retrospective study of DDI alert overrides that occurred during 2012 and 2013 within the inpatient setting described at the medication-, hospital-, provider-, and patient encounter-specific levels was performed at an urban, quaternary-care, pediatric hospital. RESULTS: There were >41 000 DDI alerts presented to clinicians; ∼90% were overridden. The 5 DDI pairs that were most frequently presented and overridden included the following: potassium chloride-spironolactone, methadone-ondansetron, ketorolac-ibuprofen, cyclosporine-fluconazole, and potassium chloride-enalapril, each with an alert override rate of ≥0.89. Override rates across provider groups ranged between 0.84 and 0.97. In general, patients with high complexity had a higher frequency of alert overrides, but the rates of alert overrides for each DDI pairing did not differ significantly. CONCLUSIONS: High rates of DDI alert overrides occur across medications, provider groups, and patient encounters. Methods to decrease DDI alerts which are likely to be overridden exist, but it is also clear that more robust and intelligent tools are needed. Characteristics exist at the medication, hospital, provider, and patient levels that can be used to help specialize and enhance information transmission.


Assuntos
Interações Medicamentosas , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Hospitais Pediátricos , Sistemas de Registro de Ordens Médicas/estatística & dados numéricos , Erros de Medicação/prevenção & controle , Sistemas de Apoio a Decisões Clínicas , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Estudos Retrospectivos
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