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1.
CJC Open ; 2(6): 577-584, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33305218

RESUMO

Background: Physicians commonly judge whether a myocardial infarction (MI) is type 1 (thrombotic) vs type 2 (supply/demand mismatch) based on clinical information. Little is known about the accuracy of physicians' clinical judgement in this regard. We aimed to determine the accuracy of physicians' judgement in the classification of type 1 vs type 2 MI in perioperative and nonoperative settings. Methods: We performed an online survey using cases from the Optical Coherence Tomographic Imaging of Thrombus (OPTIMUS) Study, which investigated the prevalence of a culprit lesion thrombus based on intracoronary optical coherence tomography (OCT) in patients experiencing MI. Four MI cases, 2 perioperative and 2 nonoperative, were selected randomly, stratified by etiology. Physicians were provided with the patient's medical history, laboratory parameters, and electrocardiograms. Physicians did not have access to intracoronary OCT results. The primary outcome was the accuracy of physicians' judgement of MI etiology, measured as raw agreement between physicians and intracoronary OCT findings. Fleiss' kappa and Gwet's AC1 were calculated to correct for chance. Results: The response rate was 57% (308 of 536). Respondents were 62% male; median age was 45 years (standard deviation ± 11); 45% had been in practice for > 15 years. Respondents' overall accuracy for MI etiology was 60% (95% confidence interval [CI] 57%-63%), including 63% (95% CI 60%-68%) for nonoperative cases, and 56% (95% CI 52%-60%) for perioperative cases. Overall chance-corrected agreement was poor (kappa = 0.05), consistent across specialties and clinical scenarios. Conclusions: Physician accuracy in determining MI etiology based on clinical information is poor. Physicians should consider results from other testing, such as invasive coronary angiography, when determining MI etiology.

2.
Can J Diabetes ; 2020 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-33308985

RESUMO

OBJECTIVES: Annual general meetings (AGMs) are often seen and promoted as great sources of contemporary information for the modern health care professional. The quality of research evidence presented at these conferences, however, remains unclear. This paper evaluates the level of evidence (LoE) of research presented at the 2015 to 2019 AGMs of Diabetes Canada (DC). METHODS: Using the framework we first published to evaluate the LoE presented at the Canadian Society of Nephrology (CSN) AGMs, 2 authors independently assigned eligible abstracts a study type and grade. Research assistants separately recorded corresponding author and city affiliations. RESULTS: Of 832 published abstracts, 68% (N=568) met the inclusion criteria. These abstracts were classified as follows: 12% Level I (highest quality); 30% Level II; 36% Level III; 14% Level IV and 8% Level V (lowest quality). The LoE remained consistent over the 5-year study period, as observed by the Jonckheere-Terpstra test (p=0 754). The LoE of DC AGMs was similar to that of CSN AGMs (p=0.125). The number of authors was positively associated with improved LoE (p<0 .001). CONCLUSIONS: Based on our novel auditing methodology, the LoE of DC AGMs is on par with other analyzed national AGMs. Adoption of this metric for all AGMs would aid in identifying unfavourable trends and alert planning and abstract selection committees of trends in LoE. Such studies will increase transparency for stakeholders and facilitate quality improvement initiatives.

3.
Anesthesiology ; 132(1): 121-130, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31651439

RESUMO

BACKGROUND: Low 25-hydroxyvitamin D is associated with cardiovascular, renal, and infectious risks. Postsurgical patients are susceptible to similar complications, but whether vitamin D deficiency contributes to postoperative complications remains unclear. We tested whether low preoperative vitamin D is associated with cardiovascular events within 30 days after noncardiac surgery. METHODS: We evaluated a subset of patients enrolled in the biobank substudy of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) study, who were at least 45 yr with at least an overnight hospitalization. Blood was collected preoperatively, and 25-hydroxyvitamin D was measured in stored samples. The primary outcome was the composite of cardiovascular events (death, myocardial injury, nonfatal cardiac arrest, stroke, congestive heart failure) within 30 postoperative days. Secondary outcomes were kidney injury and infectious complications. RESULTS: A total of 3,851 participants were eligible for analysis. Preoperative 25-hydroxyvitamin D concentration was 70 ± 30 nmol/l, and 62% of patients were vitamin D deficient. Overall, 26 (0.7%) patients died, 41 (1.1%) had congestive heart failure or nonfatal cardiac arrest, 540 (14%) had myocardial injury, and 15 (0.4%) had strokes. Preoperative vitamin D concentration was not associated with the primary outcome (average relative effect odds ratio [95% CI]: 0.93 [0.85, 1.01] per 10 nmol/l increase in preoperative vitamin D, P = 0.095). However, it was associated with postoperative infection (average relative effect odds ratio [95% CI]: 0.94 [0.90, 0.98] per 10 nmol/l increase in preoperative vitamin D, P adjusted value = 0.005) and kidney function (estimated mean change in postoperative estimated glomerular filtration rate [95% CI]: 0.29 [0.11, 0.48] ml min 1.73 m per 10 nmol/l increase in preoperative vitamin D, P adjusted value = 0.004). CONCLUSIONS: Preoperative vitamin D was not associated with a composite of postoperative 30-day cardiac outcomes. However, there was a significant association between vitamin D deficiency and a composite of infectious complications and decreased kidney function. While renal effects were not clinically meaningful, the effect of vitamin D supplementation on infectious complications requires further study.


Assuntos
Doenças Transmissíveis/epidemiologia , Cardiopatias/epidemiologia , Nefropatias/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Período Pré-Operatório , Deficiência de Vitamina D/sangue , Deficiência de Vitamina D/epidemiologia , Idoso , Doenças Transmissíveis/sangue , Comorbidade , Feminino , Cardiopatias/sangue , Humanos , Nefropatias/sangue , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/sangue , Vitamina D/análogos & derivados , Vitamina D/sangue
4.
Ann Intern Med ; 172(2): 96-104, 2020 01 21.
Artigo em Inglês | MEDLINE | ID: mdl-31869834

RESUMO

Background: Preliminary data suggest that preoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP) may improve risk prediction in patients undergoing noncardiac surgery. Objective: To determine whether preoperative NT-proBNP has additional predictive value beyond a clinical risk score for the composite of vascular death and myocardial injury after noncardiac surgery (MINS) within 30 days after surgery. Design: Prospective cohort study. Setting: 16 hospitals in 9 countries. Patients: 10 402 patients aged 45 years or older having inpatient noncardiac surgery. Measurements: All patients had NT-proBNP levels measured before surgery and troponin T levels measured daily for up to 3 days after surgery. Results: In multivariable analyses, compared with preoperative NT-proBNP values less than 100 pg/mL (the reference group), those of 100 to less than 200 pg/mL, 200 to less than 1500 pg/mL, and 1500 pg/mL or greater were associated with adjusted hazard ratios of 2.27 (95% CI, 1.90 to 2.70), 3.63 (CI, 3.13 to 4.21), and 5.82 (CI, 4.81 to 7.05) and corresponding incidences of the primary outcome of 12.3% (226 of 1843), 20.8% (542 of 2608), and 37.5% (223 of 595), respectively. Adding NT-proBNP thresholds to clinical stratification (that is, the Revised Cardiac Risk Index [RCRI]) resulted in a net absolute reclassification improvement of 258 per 1000 patients. Preoperative NT-proBNP values were also statistically significantly associated with 30-day all-cause mortality (less than 100 pg/mL [incidence, 0.3%], 100 to less than 200 pg/mL [incidence, 0.7%], 200 to less than 1500 pg/mL [incidence, 1.4%], and 1500 pg/mL or greater [incidence, 4.0%]). Limitation: External validation of the identified NT-proBNP thresholds in other cohorts would reinforce our findings. Conclusion: Preoperative NT-proBNP is strongly associated with vascular death and MINS within 30 days after noncardiac surgery and improves cardiac risk prediction in addition to the RCRI. Primary Funding Source: Canadian Institutes of Health Research.


Assuntos
Biomarcadores/sangue , Doenças Cardiovasculares/sangue , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Complicações Pós-Operatórias/sangue , Procedimentos Cirúrgicos Operatórios , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Período Pré-Operatório , Estudos Prospectivos , Troponina T/sangue
5.
BMJ Open ; 9(9): e033150, 2019 09 24.
Artigo em Inglês | MEDLINE | ID: mdl-31551393

RESUMO

INTRODUCTION: Inflammation, dehydration, hypotension and bleeding may all contribute to the development of acute kidney injury (AKI). Accelerated surgery after a hip fracture can decrease the exposure time to such contributors and may reduce the risk of AKI. METHODS AND ANALYSIS: Hip fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) is a multicentre, international, parallel-group randomised controlled trial (RCT). Patients who suffer a hip fracture are randomly allocated to either accelerated medical assessment and surgical repair with a goal of surgery within 6 hours of diagnosis or standard care where a repair typically occurs 24 to 48 hours after diagnosis. The primary outcome of this substudy is the development of AKI within 7 days of randomisation. We anticipate at least 1998 patients will participate in this substudy. ETHICS AND DISSEMINATION: We obtained ethics approval for additional serum creatinine recordings in consecutive patients enrolled at 70 participating centres. All patients provide consent before randomisation. We anticipate reporting substudy results by 2021. TRIAL REGISTRATION NUMBER: NCT02027896; Pre-results.


Assuntos
Lesão Renal Aguda , Fixação de Fratura , Fraturas do Quadril , Complicações Pós-Operatórias/prevenção & controle , Risco Ajustado/métodos , Tempo para o Tratamento/normas , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/prevenção & controle , Adulto , Feminino , Fixação de Fratura/efeitos adversos , Fixação de Fratura/métodos , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/fisiopatologia , Fraturas do Quadril/cirurgia , Humanos , Masculino , Planejamento de Assistência ao Paciente/normas , Medição de Risco/métodos , Fatores de Risco
6.
CMAJ ; 191(30): E830-E837, 2019 07 29.
Artigo em Inglês | MEDLINE | ID: mdl-31358597

RESUMO

BACKGROUND: Among adults undergoing contemporary noncardiac surgery, little is known about the frequency and timing of death and the associations between perioperative complications and mortality. We aimed to establish the frequency and timing of death and its association with perioperative complications. METHODS: We conducted a prospective cohort study of patients aged 45 years and older who underwent inpatient noncardiac surgery at 28 centres in 14 countries. We monitored patients for complications until 30 days after surgery and determined the relation between these complications and 30-day mortality using a Cox proportional hazards model. RESULTS: We included 40 004 patients. Of those, 715 patients (1.8%) died within 30 days of surgery. Five deaths (0.7%) occurred in the operating room, 500 deaths (69.9%) occurred after surgery during the index admission to hospital and 210 deaths (29.4%) occurred after discharge from the hospital. Eight complications were independently associated with 30-day mortality. The 3 complications with the largest attributable fractions (AF; i.e., potential proportion of deaths attributable to these complications) were major bleeding (6238 patients, 15.6%; adjusted hazard ratio [HR] 2.6, 95% confidence interval [CI] 2.2-3.1; AF 17.0%); myocardial injury after noncardiac surgery [MINS] (5191 patients, 13.0%; adjusted HR 2.2, 95% CI 1.9-2.6; AF 15.9%); and sepsis (1783 patients, 4.5%; adjusted HR 5.6, 95% CI 4.6-6.8; AF 12.0%). INTERPRETATION: Among adults undergoing noncardiac surgery, 99.3% of deaths occurred after the procedure and 44.9% of deaths were associated with 3 complications: major bleeding, MINS and sepsis. Given these findings, focusing on the prevention, early identification and management of these 3 complications holds promise for reducing perioperative mortality. Study registration: ClinicalTrials.gov, no. NCT00512109.


Assuntos
Complicações Pós-Operatórias/mortalidade , Procedimentos Cirúrgicos Operatórios/mortalidade , Idoso , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/mortalidade , Estudos Prospectivos , Sepse/mortalidade
7.
BMJ Open ; 9(4): e028537, 2019 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-31048449

RESUMO

INTRODUCTION: Annually, millions of adults suffer hip fractures. The mortality rate post a hip fracture is 7%-10% at 30 days and 10%-20% at 90 days. Observational data suggest that early surgery can improve these outcomes in hip fracture patients. We designed a clinical trial-HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) to determine the effect of accelerated surgery compared with standard care on the 90-day risk of all-cause mortality and major perioperative complications. METHODS AND ANALYSIS: HIP ATTACK is a multicentre, international, parallel group randomised controlled trial (RCT) that will include patients ≥45 years of age and diagnosed with a hip fracture from a low-energy mechanism requiring surgery. Patients are randomised to accelerated medical assessment and surgical repair (goal within 6 h) or standard care. The co-primary outcomes are (1) all-cause mortality and (2) a composite of major perioperative complications (ie, mortality and non-fatal myocardial infarction, pulmonary embolism, pneumonia, sepsis, stroke, and life-threatening and major bleeding) at 90 days after randomisation. All patients will be followed up for a period of 1 year. We will enrol 3000 patients. ETHICS AND DISSEMINATION: All centres had ethics approval before randomising patients. Written informed consent is required for all patients before randomisation. HIP ATTACK is the first large international trial designed to examine whether accelerated surgery can improve outcomes in patients with a hip fracture. The dissemination plan includes publishing the results in a policy-influencing journal, conference presentations, engagement of influential medical organisations, and providing public awareness through multimedia resources. TRIAL REGISTRATION NUMBER: NCT02027896; Pre-results.


Assuntos
Fraturas do Quadril/cirurgia , Idoso , Feminino , Fraturas do Quadril/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Projetos de Pesquisa , Fatores de Tempo
8.
J Contin Educ Health Prof ; 39(2): 152-157, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30908402

RESUMO

INTRODUCTION: Health care professionals rely on annual general meetings (AGMs) to obtain up-to-date information and practice guidelines relevant to their specialty. The majority of such information at meetings is presented through abstract sessions. However, the quality of the evidence presented during such abstract sessions is unclear. Standardized measures were applied to assess the quality of evidence of abstracts presented at the Canadian Society of Nephrology AGM over a 5-year period. METHODS: Two authors independently reviewed all CSN AGM abstracts presented from 2012 to 2016. Using a schema published in 2011 by the Oxford Centre for Evidence-Based Medicine (OCEBM), each abstract was subsequently ranked based on the quality of evidence. Schema categories ranged from level I, representing the highest evidence quality, to level V, representing the lowest. The number of authors and the authors' institution affiliations were also collected from the abstracts, where available, or if affiliations were unclear, an internet search of the author was performed. RESULTS: Six hundred forty-two articles were screened. In total, 70% (n = 450) met the inclusion criteria. When assessed, 15% of articles were level I (highest quality), 17% level II, 53% level III, 12% level IV, and 3% level V (lowest quality). A Jonckheere-Terpstra test demonstrated a significant trend of increasing quality of evidence (P < .05) and collaboration (P < .005) over the 5-year study period. There was a significant correlation between level of evidence and collaboration across years reviewed in the study, rs(98) = -0.226, P < .001. DISCUSSION: The results indicate a consistent increase in quality of evidence and collaborative submissions over time. To the authors' knowledge, this is the first assessment and analysis of AGM presentation quality within internal medicine and its subspecialties. Documenting and monitoring changes in the quality of evidence with a standardized framework may offer valuable insight pertaining to the medical field and the research community.


Assuntos
Congressos como Assunto/tendências , Prática Clínica Baseada em Evidências/normas , Pesquisa/normas , Congressos como Assunto/normas , Prática Clínica Baseada em Evidências/educação , Humanos , Pesquisa/tendências , Estudos Retrospectivos
9.
BMC Cancer ; 19(1): 130, 2019 Feb 08.
Artigo em Inglês | MEDLINE | ID: mdl-30736754

RESUMO

BACKGROUND: Cancer is the leading cause of death in the developed world, and yet healthcare practitioners infrequently discuss goals of care (GoC) with hospitalized cancer patients. We sought to identify barriers to GoC discussions from the perspectives of staff oncologists, oncology residents, and oncology nurses. METHODS: This was a single center survey of staff oncologists, oncology residents, and inpatient oncology nurses. Barriers to GoC discussions were assessed on a 7-point Likert scale (1 = extremely unimportant; 7 = extremely important). RESULTS: Between July 2013 and May 2014, of 185 eligible oncology clinicians, 30 staff oncologists, 10 oncology residents, and 28 oncology nurses returned surveys (response rate of 37%). The most important barriers to GoC discussions were patient and family factors. They included family members' difficulty accepting poor prognoses (mean score 5.9, 95% CI [5.7, 6.2]), lack of family agreement in the goals of care (mean score 5.8, 95% CI [5.5, 6.1]), difficulty understanding the limitations of life-sustaining treatments (mean score 5.8, 95% CI [5.6, 6.1]), lack of patients' capacity to make goals of care decisions (mean score 5.7, 95% CI [5.5, 6.0]), and language barriers (mean score 5.7, 95% CI [5.4, 5.9]). Participants viewed system factors and healthcare provider factors as less important barriers. CONCLUSIONS: Oncology practitioners perceive patient and family factors as the most limiting barriers to GoC discussions. Our findings underscore the need for oncology clinicians to be equipped with strong communication skills to help patients and families navigate GoC discussions.


Assuntos
Oncologia , Oncologistas , Planejamento de Assistência ao Paciente/estatística & dados numéricos , Adulto , Atitude do Pessoal de Saúde , Comunicação , Estudos Transversais , Tomada de Decisões , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Masculino , Oncologia/métodos , Oncologia/estatística & dados numéricos , Pessoa de Meia-Idade , Inquéritos e Questionários
10.
CMAJ Open ; 6(2): E241-E247, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29934292

RESUMO

BACKGROUND: Allied health care professionals can contribute meaningfully to goals-of-care discussions with seriously ill hospitalized patients and their families. We sought to explore the perspective of hospital-based allied health care professionals on their role in goals-of-care discussions and to identify barriers to their participation. METHODS: We surveyed allied health care professionals (social workers, physiotherapists, occupational therapists, registered dietitians, speech-language pathologists and pharmacists) on internal medicine, hematology-oncology, medical oncology and radiation oncology wards at 2 tertiary care hospitals in Hamilton, Ontario, from April 2013 to May 2014. We modified a validated questionnaire originally designed to assess barriers to discussing goals of care from the perspective of nurses, residents and staff physicians on hospital medical wards. Respondents rated the questionnaire items on a 7-point Likert scale. RESULTS: Of the 47 allied health care professionals invited, 32 (68%) participated: 9 physiotherapists, 7 social workers, 6 occupational therapists, 4 registered dietitians, 3 pharmacists and 2 speech-language pathologists; in 1 case, the profession was unknown. The greatest perceived barriers to engaging in goals-of-care discussions were lack of patient decision-making capacity (mean rating 5.9 [standard error (SE) 0.3]), lack of awareness of patients' previous discussions with other team members (mean rating 5.7 [SE 0.3]) and family members' difficulty accepting a poor prognosis (mean rating 5.6 [SE 0.2]). Although the respondents felt it was most acceptable for staff physicians, residents and advanced practice nurses to exchange information and reach a final decision during goals-of-care discussions, they felt it was acceptable for a broader range of allied health care professionals to initiate discussions (mean rating 4.7-5.8) and to act as decision coaches (clarifying values, weighing options) with patients and families (mean rating 5.3-6.1). INTERPRETATION: Allied health care professionals are willing to initiate goals-of-care discussions and to act as a decision coach with seriously ill hospitalized patients and their families. By improving interprofessional collaboration, we can engage the entire health care team in this process.

11.
Musculoskeletal Care ; 16(1): 152-157, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-28417529

RESUMO

OBJECTIVE: Rheumatoid arthritis (RA) portends significant cardiovascular morbidity and mortality. We therefore determined how often rheumatologists screened for and managed cardiovascular risk factors in RA patients, and the barriers to doing so. METHODS: We examined 300 patient charts from 10 university-affiliated rheumatology practices, to ascertain if they had been screened, treated and/or referred over a 3-year period. We subsequently distributed a national survey to Canadian rheumatologists to elucidate challenges in performing optimal cardiovascular risk modification. RESULTS: Most patients were screened for hypertension. Forty-one per cent were found to be hypertensive; however, the majority of these patients were neither treated nor referred to another provider for management. A small minority of patients were screened for diabetes and/or hyperlipidaemia, and these were usually not addressed if abnormal. Men were referred more frequently than women. Consistent with these findings, the majority of rheumatologists from the national survey felt that they did not manage cardiovascular risk adequately; 79.4% cited a lack of time as a major barrier, and 82.5% felt that it should be managed by the primary care provider. CONCLUSION: There is marked underdiagnosis and undertreatment of cardiac risk in RA. Several major barriers exist, including lack of time. Most rheumatologists feel that this aspect of care is the responsibility of primary care physicians.


Assuntos
Artrite Reumatoide/complicações , Doenças Cardiovasculares/diagnóstico , Idoso , Doenças Cardiovasculares/etiologia , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/terapia , Dislipidemias/diagnóstico , Dislipidemias/terapia , Feminino , Fidelidade a Diretrizes , Humanos , Hipertensão/diagnóstico , Hipertensão/terapia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco
12.
Perspect Med Educ ; 6(4): 237-245, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28744821

RESUMO

INTRODUCTION: Evidence of the benefit of distributed instruction and interleaved practice comes from studies using simple materials (e. g. word pairs). Furthermore, there is currently no evidence of the combined impact of these strategies in undergraduate medical education. The present study evaluated the impact of varying both instruction and practice schedules for the acquisition of ECG interpretation skills. METHODS: We conducted a 2 × 2 factorial study with two levels of instruction (massed and distributed) and two levels of practice (interleaved and blocked). A three-module introductory course in ECG interpretation was delivered to 80 first year medical undergraduate students. Students were assigned to one of four Instruction-Practice conditions: Massed-Interleaved, Massed-Blocked, Distributed-Interleaved and Distributed-Blocked. Learning was evaluated by a multiple choice quiz at the end of each module and a final multiple choice quiz at the end of the course. RESULTS: End of module mean scores showed that distributed instruction was consistently superior to massed instruction (52% vs 42%, p < 0.01). However, there was no effect of practice and no interaction between teaching and practice methods. The delayed final test scores revealed an advantage for blocked over mixed practice (34% vs 24%, p < 0.05) and distributed over massed instruction (34% vs 24%, p < 0.05). DISCUSSION: These results suggest that these popular strategies may have varying effects with complex learning materials. Further research is required to understand how these strategies affect the learning of simple and very complex skills.

13.
JAMA ; 317(16): 1642-1651, 2017 Apr 25.
Artigo em Inglês | MEDLINE | ID: mdl-28444280

RESUMO

Importance: Little is known about the relationship between perioperative high-sensitivity troponin T (hsTnT) measurements and 30-day mortality and myocardial injury after noncardiac surgery (MINS). Objective: To determine the association between perioperative hsTnT measurements and 30-day mortality and potential diagnostic criteria for MINS (ie, myocardial injury due to ischemia associated with 30-day mortality). Design, Setting, and Participants: Prospective cohort study of patients aged 45 years or older who underwent inpatient noncardiac surgery and had a postoperative hsTnT measurement. Starting in October 2008, participants were recruited at 23 centers in 13 countries; follow-up finished in December 2013. Exposures: Patients had hsTnT measurements 6 to 12 hours after surgery and daily for 3 days; 40.4% had a preoperative hsTnT measurement. Main Outcomes and Measures: A modified Mazumdar approach (an iterative process) was used to determine if there were hsTnT thresholds associated with risk of death and had an adjusted hazard ratio (HR) of 3.0 or higher and a risk of 30-day mortality of 3% or higher. To determine potential diagnostic criteria for MINS, regression analyses ascertained if postoperative hsTnT elevations required an ischemic feature (eg, ischemic symptom or electrocardiography finding) to be associated with 30-day mortality. Results: Among 21 842 participants, the mean age was 63.1 (SD, 10.7) years and 49.1% were female. Death within 30 days after surgery occurred in 266 patients (1.2%; 95% CI, 1.1%-1.4%). Multivariable analysis demonstrated that compared with the reference group (peak hsTnT <5 ng/L), peak postoperative hsTnT levels of 20 to less than 65 ng/L, 65 to less than 1000 ng/L, and 1000 ng/L or higher had 30-day mortality rates of 3.0% (123/4049; 95% CI, 2.6%-3.6%), 9.1% (102/1118; 95% CI, 7.6%-11.0%), and 29.6% (16/54; 95% CI, 19.1%-42.8%), with corresponding adjusted HRs of 23.63 (95% CI, 10.32-54.09), 70.34 (95% CI, 30.60-161.71), and 227.01 (95% CI, 87.35-589.92), respectively. An absolute hsTnT change of 5 ng/L or higher was associated with an increased risk of 30-day mortality (adjusted HR, 4.69; 95% CI, 3.52-6.25). An elevated postoperative hsTnT (ie, 20 to <65 ng/L with an absolute change ≥5 ng/L or hsTnT ≥65 ng/L) without an ischemic feature was associated with 30-day mortality (adjusted HR, 3.20; 95% CI, 2.37-4.32). Among the 3904 patients (17.9%; 95% CI, 17.4%-18.4%) with MINS, 3633 (93.1%; 95% CI, 92.2%-93.8%) did not experience an ischemic symptom. Conclusions and Relevance: Among patients undergoing noncardiac surgery, peak postoperative hsTnT during the first 3 days after surgery was significantly associated with 30-day mortality. Elevated postoperative hsTnT without an ischemic feature was also associated with 30-day mortality.


Assuntos
Infarto do Miocárdio/mortalidade , Isquemia Miocárdica/mortalidade , Troponina T/sangue , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Período Pós-Operatório , Estudos Prospectivos , Medição de Risco
14.
Anesthesiology ; 126(1): 16-27, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27775997

RESUMO

BACKGROUND: The effect on cardiovascular outcomes of withholding angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers in chronic users before noncardiac surgery is unknown. METHODS: In this international prospective cohort study, the authors analyzed data from 14,687 patients (including 4,802 angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users) at least 45 yr old who had in-patient noncardiac surgery from 2007 to 2011. Using multivariable regression models, the authors studied the relationship between withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers and a primary composite outcome of all-cause death, stroke, or myocardial injury after noncardiac surgery at 30 days, with intraoperative and postoperative clinically important hypotension as secondary outcomes. RESULTS: Compared to patients who continued their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, the 1,245 (26%) angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users who withheld their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers in the 24 h before surgery were less likely to suffer the primary composite outcome of all-cause death, stroke, or myocardial injury (150/1,245 [12.0%] vs. 459/3,557 [12.9%]; adjusted relative risk, 0.82; 95% CI, 0.70 to 0.96; P = 0.01) and intraoperative hypotension (adjusted relative risk, 0.80; 95% CI, 0.72 to 0.93; P < 0.001). The risk of postoperative hypotension was similar between the two groups (adjusted relative risk, 0.92; 95% CI, 0.77 to 1.10; P = 0.36). Results were consistent across the range of preoperative blood pressures. The practice of withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers was only modestly correlated with patient characteristics and the type and timing of surgery. CONCLUSIONS: Withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers before major noncardiac surgery was associated with a lower risk of death and postoperative vascular events. A large randomized trial is needed to confirm this finding. In the interim, clinicians should consider recommending that patients withhold angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers 24 h before surgery.


Assuntos
Antagonistas de Receptores de Angiotensina/administração & dosagem , Inibidores da Enzima Conversora de Angiotensina/administração & dosagem , Complicações Intraoperatórias/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios , Suspensão de Tratamento/estatística & dados numéricos , Idoso , Estudos de Coortes , Feminino , Humanos , Hipotensão/epidemiologia , Internacionalidade , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
15.
Anesthesiology ; 125(6): 1121-1129, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27627817

RESUMO

BACKGROUND: The PeriOperative ISchemia Evaluation-2 (POISE-2) trial compared aspirin with placebo after noncardiac surgery. METHODS: The authors randomly assigned 10,010 patients undergoing noncardiac surgery to receive 200 mg aspirin or placebo 2 to 4 h before surgery and then 100 mg aspirin daily or placebo daily for up to 30 days after surgery. Herein, the authors report the effect of aspirin on venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, as well as an updated pooled analysis of randomized trials of antiplatelet therapy for VTE prevention in noncardiac surgery patients. RESULTS: Six thousand five hundred forty-eight patients (65.4%) received anticoagulant prophylaxis. VTE occurred in 53 patients (1.1%) allocated to aspirin and in 60 patients (1.2%) allocated to placebo (hazard ratio, 0.89; 95% CI, 0.61 to 1.28). Major or life-threatening bleeding occurred in 312 patients (6.3%) allocated to aspirin and in 256 patients (5.1%) allocated to placebo (hazard ratio, 1.22; 95% CI, 1.04 to 1.44). Concomitant use of anticoagulant prophylaxis did not modify the effect of aspirin on VTE or bleeding. Pooled analysis of the POISE-2 and Pulmonary Embolism Prevention trials demonstrated that symptomatic VTE occurred in 173 (1.3%) of 13,724 patients allocated to aspirin and in 246 (1.8%) of 13,730 patients allocated to placebo (odds ratio, 0.71; 95% CI, 0.56 to 0.89; heterogeneity P = 0.27; I = 17%); the impact of aspirin was very similar in those who did and did not receive pharmacologic prophylaxis. Pooled estimates for symptomatic VTE were similar to the pooled estimates for any deep vein thrombosis and pulmonary embolism from the POISE-2 trial, Pulmonary Embolism Prevention trial, and the Antiplatelet Trialists' Collaboration meta-analysis. CONCLUSIONS: Aspirin in the POISE-2 trial did not reduce VTE, but two thirds of patients received anticoagulant prophylaxis, there were few VTE events, and results were consistent with a wide range of aspirin effects. A pooled analysis of the randomized trials demonstrates evidence for the efficacy of aspirin for VTE prevention in hospitalized surgical patients.


Assuntos
Aspirina/uso terapêutico , Fibrinolíticos/uso terapêutico , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/prevenção & controle , Tromboembolia Venosa/prevenção & controle , Idoso , Feminino , Humanos , Masculino , Razão de Chances , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Procedimentos Cirúrgicos Operatórios , Resultado do Tratamento
16.
BMJ Open ; 6(12): e013663, 2016 12 30.
Artigo em Inglês | MEDLINE | ID: mdl-28039294

RESUMO

BACKGROUND: Medication reconciliation (MedRec) has been a mandated or recommended activity in Canada, the USA and the UK for nearly 10 years. Accreditation bodies in North America will soon require MedRec for every admission, transfer and discharge of every patient. Studies of MedRec have revealed unintentional discrepancies in prescriptions but no clear evidence that clinically important outcomes are improved, leading to widely variable practices. Our objective was to apply process mapping methodology to MedRec to clarify current processes and resource usage, identify potential efficiencies and gaps in care, and make recommendations for improvement in the light of current literature evidence of effectiveness. METHODS: Process engineers observed and recorded all MedRec activities at 3 academic teaching hospitals, from initial emergency department triage to patient discharge, for general internal medicine patients. Process maps were validated with frontline staff, then with the study team, managers and patient safety leads to summarise current problems and discuss solutions. RESULTS: Across all of the 3 hospitals, 5 general problem themes were identified: lack of use of all available medication sources, duplication of effort creating inefficiency, lack of timeliness of completion of the Best Possible Medication History, lack of standardisation of the MedRec process, and suboptimal communication of MedRec issues between physicians, pharmacists and nurses. DISCUSSION: MedRec as practised in this environment requires improvements in quality, timeliness, consistency and dissemination. Further research exploring efficient use of resources, in terms of personnel and costs, is required.


Assuntos
Hospitais de Ensino , Erros de Medicação/prevenção & controle , Reconciliação de Medicamentos , Melhoria de Qualidade/normas , Acreditação , Canadá/epidemiologia , Sistemas de Informação em Farmácia Clínica , Pesquisa sobre Serviços de Saúde , Hospitais de Ensino/organização & administração , Hospitais de Ensino/normas , Humanos , Reconciliação de Medicamentos/organização & administração , Reconciliação de Medicamentos/normas , Sistemas de Medicação no Hospital , Alta do Paciente/normas , Avaliação de Processos em Cuidados de Saúde , Melhoria de Qualidade/organização & administração , Reino Unido/epidemiologia , Estados Unidos/epidemiologia
17.
J Gen Intern Med ; 30(9): 1270-4, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26173528

RESUMO

BACKGROUND: An experimenter controlled form of reflection has been shown to improve the detection and correction of diagnostic errors in some situations; however, the benefits of participant-controlled reflection have not been assessed. OBJECTIVE: The goal of the current study is to examine how experience and a self-directed decision to reflect affect the accuracy of revised diagnoses. DESIGN: Medical residents diagnosed 16 medical cases (pass 1). Participants were then given the opportunity to reflect on each case and revise their diagnoses (pass 2). PARTICIPANTS: Forty-seven medical Residents in post-graduate year (PGY) 1, 2 and 3 were recruited from Hamilton Health Care Centres. MAIN MEASURES: Diagnoses were scored as 0 (incorrect), 1 (partially correct) and 2 (correct). Accuracies and response times in pass 1 were analyzed using an ANOVA with three factors-PGY, Decision to revise yes/no, and Case 1-16, averaged across residents. The extent to which additional reflection affected accuracy was examined by analyzing only those cases that were revised, using a repeated measures ANOVA, with pass 1 or 2 as a within subject factor, and PGY and Case or Resident as a between-subject factor. KEY RESULTS: The mean score at pass 1 for each level was PGY1, 1.17 (SE 0.50); PGY2, 1.35 (SE 0.67) and PGY3, 1.27 (SE 0.94). While there was a trend for increased accuracy with level, this did not achieve significance. The number of residents at each level who revised at least one diagnosis was 12/19 PGY1 (63 %), 9/11 PGY2 (82 %) and 8/17 PGY3 (47 %). Only 8 % of diagnoses were revised resulting in a small but significant increase in scores from Pass 1 to 2, from 1.20/2 to 1.22 /2 (t = 2.15, p = 0.03). CONCLUSIONS: Participants did engage in self-directed reflection for incorrect diagnoses; however, this strategy provided minimal benefits compared to knowing the correct answer. Education strategies should be directed at improving formal and experiential knowledge.


Assuntos
Competência Clínica , Erros de Diagnóstico/psicologia , Medicina Interna/educação , Internato e Residência , Pensamento , Adulto , Tomada de Decisões , Educação de Pós-Graduação em Medicina , Avaliação Educacional , Feminino , Humanos , Masculino
19.
Inflammopharmacology ; 22(6): 319-26, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25300964

RESUMO

Hepatic encephalopathy (HE) is a common complication of cirrhosis of the liver. It is also extremely debilitating, with an untreated 3-year survival of only 23 %. While the exact pathophysiology of HE has yet to be elucidated, a number of contributing factors have been described. Abnormal levels and altered metabolism of ammonia play a central role. Recently, inflammation has also been identified as a contributor to HE. Improved understanding of the pathophysiology of HE is crucial, as current therapy centers on reduction of the body's ammonia load. Lactulose is the first-line therapy for HE, with some antibiotics recently showing promise for improved outcomes in patients with HE. The role of anti-inflammatory therapies has yet to be evaluated.


Assuntos
Amônia/metabolismo , Encefalopatia Hepática/fisiopatologia , Cirrose Hepática/complicações , Antibacterianos/uso terapêutico , Anti-Inflamatórios/uso terapêutico , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/terapia , Humanos , Inflamação/complicações , Inflamação/tratamento farmacológico , Inflamação/patologia , Lactulose/uso terapêutico
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