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1.
Eur J Heart Fail ; 2021 Feb 09.
Artigo em Inglês | MEDLINE | ID: mdl-33565237

RESUMO

AIMS: Prognostic models of sudden cardiac death (SCD) typically incorporate data at only a single time-point. We investigated independent predictors of SCD addressing the impact of integrating time-varying covariates to improve prediction assessment. METHODS AND RESULTS: We studied 8,399 patients enrolled in the PARADIGM-HF trial and identified independent predictors of SCD (n=561, 36% of total deaths) using time-updated multivariable-adjusted Cox models, classification and regression tree (CART), and logistic regression analysis. Compared with patients who were alive or died from non-sudden cardiovascular deaths, patients who suffered a SCD displayed a distinct temporal profile of New York Heart Association (NYHA) class, heart rate and levels of 3 biomarkers (albumin, uric acid and total bilirubin), with significant differences observed more than 1 year prior to the event (p interaction <0.001). In multivariable models adjusted for baseline covariates, 7 time-updated variables independently contributed to SCD risk (incremental likelihood chi-square=46.2). CART analysis identified that baseline variables (implantable cardioverter defibrillator use and N-terminal prohormone of B-type natriuretic peptide levels) and time-updated covariates (NYHA class, total bilirubin, and total cholesterol) improved risk stratification. CART-defined subgroup of highest risk had nearly an 8-fold increment in SCD hazard (hazard ratio=7.7, 95% confidence interval 3.6-16.5; p<0.001). Finally, changes over time in heart rate, NYHA class, blood urea nitrogen and albumin levels were associated with differential risk of sudden versus non-sudden cardiovascular deaths (p<0.05). CONCLUSIONS: Beyond single time-point assessments, distinct changes in multiple cardiac-specific and systemic variables improved SCD risk prediction and were helpful in differentiating mode of death in chronic HF.

2.
Int J Infect Dis ; 2021 Jan 11.
Artigo em Inglês | MEDLINE | ID: mdl-33444752

RESUMO

OBJECTIVES: To describe clinical characteristics, laboratory and imaging findings, as well as in-hospital outcomes of COVID-19 patients admitted to Brazilian hospitals. METHODS: Cohort study of laboratory-confirmed COVID-19 patients hospitalized from March to September 2020 at 25 hospitals. Study data were collected from medical records using Research Electronic Data Capture (REDCap) tools. Multivariate Poisson regression model was used to assess risk factors for in-hospital mortality. RESULTS: Of 2054 patients (52.6% male, median age 58 years old), in-hospital mortality was 22.0%, and 47.6% among those treated in the ICU. Hypertension (52.9%), diabetes (29.2%) and obesity (17.2%) were the most prevalent comorbidities. Overall, 32.5% required invasive mechanical ventilation and 12.1% kidney replacement therapy. Septic shock was observed in 15.0%, nosocomial infection in 13.1%, thromboembolism in 4.1% and acute heart failure in 3.6%. Age ≥65 years-old, chronic kidney disease, hypertension, C-reactive protein ≥100 mg/dL, platelet count <100 × 109/L, oxygen saturation <90%, supplementary oxygen requirement and invasive mechanical ventilation at admission were independently associated with a higher risk of in-hospital mortality. The overall use of antimicrobials was 87.9%. CONCLUSIONS: This study provides characteristics and in-hospital outcomes of consecutively hospitalized patients with confirmed COVID-19 in Brazil. Easily assessed parameters at hospital admission were independently associated with a higher risk of death. The high frequency of antibiotic use points to an over-use of antimicrobials in COVID-19 patients.

4.
Heart ; 2020 Dec 23.
Artigo em Inglês | MEDLINE | ID: mdl-33361353

RESUMO

OBJECTIVE: New York Heart Association (NYHA) functional class plays a central role in heart failure (HF) assessment but might be unreliable in mild presentations. We compared objective measures of HF functional evaluation between patients classified as NYHA I and II in the Rede Brasileira de Estudos em Insuficiência Cardíaca (ReBIC)-1 Trial. METHODS: The ReBIC-1 Trial included outpatients with stable HF with reduced ejection fraction. All patients had simultaneous protocol-defined assessment of NYHA class, 6 min walk test (6MWT), N-terminal pro-brain natriuretic peptide (NT-proBNP) levels and patient's self-perception of dyspnoea using a Visual Analogue Scale (VAS, range 0-100). RESULTS: Of 188 included patients with HF, 122 (65%) were classified as NYHA I and 66 (35%) as NYHA II at baseline. Although NYHA class I patients had lower dyspnoea VAS Scores (median 16 (IQR, 4-30) for class I vs 27.5 (11-49) for class II, p=0.001), overlap between classes was substantial (density overlap=60%). A similar profile was observed for NT-proBNP levels (620 pg/mL (248-1333) vs 778 (421-1737), p=0.015; overlap=78%) and for 6MWT distance (400 m (330-466) vs 351 m (286-408), p=0.028; overlap=64%). Among NYHA class I patients, 19%-34% had one marker of HF severity (VAS Score >30 points, 6MWT <300 m or NT-proBNP levels >1000 pg/mL) and 6%-10% had two of them. Temporal change in functional class was not accompanied by variation on dyspnoea VAS (p=0.14). CONCLUSIONS: Most patients classified as NYHA classes I and II had similar self-perception of their limitation, objective physical capabilities and levels of natriuretic peptides. These results suggest the NYHA classification poorly discriminates patients with mild HF.

5.
J Telemed Telecare ; : 1357633X20906648, 2020 Mar 18.
Artigo em Inglês | MEDLINE | ID: mdl-32188310

RESUMO

INTRODUCTION: Evidence of telehealth for chronic disease management is scarce and contradictory. OBJECTIVES: We aimed to evaluate the safety and efficacy of teleconsultations as support in the care transition of patients with stable coronary artery disease (CAD) from tertiary to primary care. METHODS: A randomized noninferiority clinical trial was undertaken in patients with CAD from a tertiary hospital in a middle-income country. Patients with functional angina class 1 or 2 and meeting discharge criteria were randomized to remain in the cardiology outpatient clinic for 12 months (control group, CG) or continue follow-up in a primary care unit with clinical support via telemedicine (intervention group, IG). The primary outcome was the maintenance of the functional angina class after 12 months. Secondary outcomes included control of risk factors and clinical outcomes. RESULTS: In total 271 patients (mean age, 66 years) were included; 81.1% and 91% of the IG and CG, respectively, maintained stable angina symptoms, thus noninferiority could not be shown between the groups. Regarding emergency room visits at 1 year, the IG (7.6%) was noninferior to the CG (6.0%) (absolute difference, 1.6%; noninferiority margin (NIM), -4.8% to 8.2%). For control of risk factors, 30.7% and 29.6% of the IG and CG, respectively, had blood pressure <130/80 mmHg (absolute difference, 1.1%; NIM, -10.5% to 12.8%), and 48.9% and 33.3% of diabetic patients in the IG and CG, respectively, had glycated haemoglobin <7% (absolute difference, 15.6%; NIM, -6.8% to 36%). CONCLUSIONS: In our study, the difference in the patients' angina functional class did not result in greater seeking of emergency care, supporting that discharge from the outpatient clinic with telemedicine is safe for patients with stable CAD treated at the tertiary level. The control of risk factors in these patients was noninferior to patients followed up in primary care. ClinicalTrials.gov (NCT02489565).

6.
Crit Pathw Cardiol ; 19(1): 9-13, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31899707

RESUMO

Coronary computed tomography with myocardial perfusion imaging (CCTA-MPI) provides data on coronary anatomy and perfusion and may be useful in the assessment of ischemic coronary artery disease (CAD). Management of angiographically intermediate coronary lesions is challenging, and coronary fractional flow reserve (FFR) evaluation is recommended to assess whether these lesions are functionally significant. Our aim was to evaluate the diagnostic accuracy of CCTA-MPI in patients with stable CAD and at least 1 angiographically intermediate coronary lesion submitted to FFR. In this single-center prospective study, patients with stable CAD and at least 1 moderate coronary stenosis (50%-70% by visual estimation) were referred for CCTA-MPI (64-row multidetector) assessment before coronary FFR evaluation. Patients with severe coronary obstructions (≥70%) were excluded. The significance level adopted for all tests was 5%. Twenty-eight patients (mean age 60 ± SD years, 54% women) with 33 intermediate coronary obstructions were enrolled. Ten patients (30%) had functionally significant coronary obstructions characterized by FFR ≤0.8. The sensitivity, specificity, and accuracy of CCTA-MPI for the detection of functionally significant coronary obstructions were 30%, 100%, and 78.8%, respectively. CCTA-MPI positive predictive value was 100%, whereas negative predictive value was 76.7%. Correlation coefficient between tests was 0.48 (P = 0.005). On a novel approach to evaluate intermediate coronary lesions, accuracy of CCTA-MPI was 78.8%. The positive predictive value of an abnormal CCTA-MPI on this population was 100%, suggesting that CCTA-MPI may have a role in the assessment of patients with anatomically identified intermediate coronary lesions.

7.
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
8.
Curr Probl Cardiol ; : 100429, 2019 Jun 29.
Artigo em Inglês | MEDLINE | ID: mdl-31326099

RESUMO

Myocardial injury after noncardiac surgery (MINS) includes patients with traditional myocardial infarction and those with ischemic myocardial injury after surgery. This study evaluated the prognostic value of MINS on major cardiovascular events and 30-day mortality, and determined independent preoperative predictors of MINS in patients after noncardiac surgery. This multicenter prospective cohort study was part of the VISION Study. The sample consisted of 2504 patients who underwent noncardiac surgery at 2 tertiary hospitals in Brazil between September 2008 and July 2012. Troponin Ts were measured 6-12 hours, and on days 1-3 after surgery. Cox regression analyses were performed to identify independent variables of major outcomes. A total of 314 (13%) patients were diagnosed with MINS, of which 26 (8%) died. Length-of-hospital stay of MINS patients was 3 times higher (18 ± 22 days vs 5.8 ± 11 days). In multivariate analysis, 30-day mortality was significantly higher among patients with MINS (hazard ratio [HR] 3.17 (95% confidence interval [CI] 1.56-6.41)), and major bleeding (HR 5.76 (95% CI 2.75-12.05)), sepsis (HR 5.08 (95% CI 2.25-11.46)), active cancer (HR 4.22 (95% CI 1.98-8.98)), and general surgery (HR 3.11 (95% CI 1.51-6.41)). Multivariable analysis indicated a higher chance of MINS in patients ≥75 years of age, history of diabetes mellitus, hypertension, heart failure, coronary disease, and end-stage renal failure. The incidence of MINS within 30 days after noncardiac surgery is related to higher mortality. Postoperative troponin monitoring in elder patients and with risk factors for atherosclerotic disease may help reduce postoperative cardiovascular events.

9.
J Periodontol ; 90(10): 1096-1105, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31049952

RESUMO

BACKGROUND: Despite the association between cardiovascular diseases and periodontitis, there are scarce data on the impact of oral health in the dietary intake of patients with coronary artery disease (CAD). The aim of this study was to assess the association between dietary intake with periodontitis and present teeth in individuals with stable CAD. METHODS: This cross-sectional study included 115 patients with stable CAD (76 males, aged 61.0 ± 8.3 years) who were under cardiovascular care in an outpatient clinic for at least 3 months. Dietary intake was recorded applying a food frequency questionnaire previously validated. Periodontal examinations were performed by two calibrated examiners in six sites per tooth from all present teeth. Blood samples were collected to determine serum levels of lipids. Multivariable logistic and linear regression models were fitted to evaluate the association between dietary outcomes and oral health variables. RESULTS: Individuals with periodontitis had significantly higher percentage of total energy intake from fried foods, sweets, and beans, and also had lower consumption of fruits than those without periodontitis. Presence of periodontitis was associated with lower percentage of individuals who reached the nutritional recommendation of monounsaturated fatty acids and higher blood concentration of triglycerides. Having a greater number of present teeth (≥20 teeth) was associated with higher intake of fibers and total calories. CONCLUSION: In patients with stable CAD, the presence of periodontitis and tooth loss were associated with a poor dietary intake of nutrients and healthy foods, which are important for cardiovascular prevention.


Assuntos
Doença da Artéria Coronariana , Periodontite , Perda de Dente , Idoso , Estudos Transversais , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco
10.
Curr Heart Fail Rep ; 16(1): 1-6, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30712145

RESUMO

PURPOSE OF REVIEW: This paper reviews performance measure in health, their importance, and methodologic issues, focusing on metrics for health failure patients. Quality measures are instruments to assess structural aspects or processes of care aiming to guarantee that optimal patient outcomes are achieved. As heart failure is a chronic condition in which established therapies reduce mortality and hospital admissions, there are quite a lot of initiatives that aim to monitor for quality of care and to coordinate the disease management. RECENT FINDINGS: Several performance measures were validated for these patients, from process of care (left ventricular function assessment and use of ACEi/ARBs and beta-blockers) to health outcomes (hospital mortality and readmissions). In the early years, studies demonstrated a relationship between quality measurements and health outcomes. Nonetheless, more recent ones based on large databases of patients' medical records have shown that traditional indicators explain only a small fraction of health and patient reported- and perceived outcomes. Public reporting of quality measures and payment conditioned to the quality of care provided were not able to show benefit in terms of hard outcomes. Data science and big data methods are promising in providing actionable knowledge for quality improvement, with real-time data that could support decision-making. Heart failure is a chronic condition that has proven to be useful for measuring medical and healthcare quality. Evidence-based indicators have already reached high rates of adherence and are currently poorly correlated with outcomes. Using real-life data and based on the patient's perspective can be useful tools to improve these indicators.


Assuntos
Tomada de Decisões , Gerenciamento Clínico , Insuficiência Cardíaca/terapia , Qualidade da Assistência à Saúde/normas , Hospitalização/tendências , Humanos
11.
J Clin Periodontol ; 46(3): 321-331, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30761568

RESUMO

AIM: To assess the effect of periodontal therapy (PT) on cardiovascular blood biomarkers. MATERIALS AND METHODS: This single-blind, parallel-design, randomized controlled trial included patients with stable coronary artery disease and periodontitis. The test group (TG) received non-surgical PT, whereas the control group (CG) received one session of plaque removal. Plasma levels of C-reactive protein (CRP), glycated haemoglobin, lipids and cytokines (IL-1ß, IL-6, IL-8, IL-10, IFN-γ and TNF-α) were measured at baseline and after 3 months. RESULTS: Eighty-two patients (74.4% women, mean age 59.6 years) were analysed. TG had significantly better periodontal parameters than CG after 3 months, but no significant differences in blood markers were observed between them. In a post hoc subgroup analysis in patients with baseline CRP <3 mg/L, a significant increase in CRP was observed in CG (1.44 ± 0.82 mg/L to 4.35 ± 7.85 mg/L, p = 0.01), whereas CRP remained unchanged in TG (1.40 ± 0.96 mg/L to 1.33 ± 1.26 mg/L, p = 0.85), resulting in a significant difference between groups at 3 months. In patients with CRP ≥3 mg/L, a significant reduction in CRP was observed only in TG (11.3 ± 12.8 mg/L to 5.7 ± 4.1 mg/L, p = 0.04). Levels of IL-6 and IL-8 were significantly lower in TG than CG at 3 months. CONCLUSIONS: PT leads to lower levels of CRP, IL-6 and IL-8 in cardiovascular patients with high CRP levels.


Assuntos
Doenças Cardiovasculares , Doença da Artéria Coronariana , Biomarcadores , Proteína C-Reativa , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Método Simples-Cego
12.
Front Oncol ; 8: 156, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29872641

RESUMO

Background: Several (neo)adjuvant treatments for patients with HER2-positive breast cancer have been compared in different randomized clinical trials. Since it is not feasible to conduct adequate pairwise comparative trials of all these therapeutic options, network meta-analysis offers an opportunity for more detailed inference for evidence-based therapy. Methods: Phase II/III randomized clinical trials comparing two or more different (neo)adjuvant treatments for HER2-positive breast cancer patients were included. Relative treatment effects were pooled in two separate network meta-analyses for overall survival (OS) and disease-free survival (DFS). Results: 17 clinical trials met our eligibility criteria. Two different networks of trials were created based on the availability of the outcomes: OS network (15 trials: 37,837 patients); and DFS network (17 trials: 40,992 patients). Two studies-the ExteNET and the NeoSphere trials-were included only in this DFS network because OS data have not yet been reported. The concept of the dual anti-HER2 blockade proved to be the best option in terms of OS and DFS. Chemotherapy (CT) plus trastuzumab (T) and lapatinib (L) and CT + T + Pertuzumab (P) are probably the best treatment options in terms of OS, with 62.47% and 22.06%, respectively. In the DFS network, CT + T + Neratinib (N) was the best treatment option with 50.55%, followed by CT + T + P (26.59%) and CT + T + L (20.62%). Conclusion: This network meta-analysis suggests that dual anti-HER2 blockade with trastuzumab plus either lapatinib or pertuzumab are probably the best treatment options in the (neo)adjuvant setting for HER2-positive breast cancer patients in terms of OS gain. Mature OS results are still expected for the Aphinity trial and for the sequential use of trastuzumab followed by neratinib, the treatment that showed the best performance in terms of DFS in our analysis.

13.
Oral Dis ; 24(7): 1349-1357, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29873864

RESUMO

OBJECTIVE: To assess the effects of periodontal treatment on endothelial function in patients with coronary artery disease. MATERIALS AND METHODS: A randomized controlled trial was conducted with 69 patients with stable coronary disease and severe periodontitis. The test group received nonsurgical periodontal therapy consisting of personalized oral hygiene instructions, subgingival scaling, and root planing per quadrant, whereas the control group received equal treatment after the study period. Endothelial function was assessed by measurement of brachial artery flow-mediated dilation, concentrations of sVCAM-1, sICAM-1, and P-selectin in serum before and 3 months after periodontal therapy. RESULTS: The test group exhibited statistically better periodontal parameters-plaque, probing depth, periodontal attachment loss, and bleeding on probing. No significant improvements were observed in the control (1.37%) and test (1.39%) groups in flow-mediated dilation, with no significant between-group difference. sVCAM-1 concentration increased in the control group (997.6 ± 384.4-1201.8 ± 412.5; p = 0.03), whereas in the test group, no significant changes were observed (915.1 ± 303.8-1050.3 ± 492.3; p = 0.17), resulting in a significant difference between the two groups (p = 0.04). The same pattern was observed for concentrations of sICAM-1. CONCLUSION: Periodontal treatment did not provide better vasodilation in patients with coronary disease in a short-term follow-up period, although it maintained blood concentrations of markers of vascular inflammation.


Assuntos
Doença da Artéria Coronariana/fisiopatologia , Endotélio Vascular/fisiopatologia , Periodontite/terapia , Idoso , Doença da Artéria Coronariana/complicações , Feminino , Humanos , Molécula 1 de Adesão Intercelular/sangue , Masculino , Pessoa de Meia-Idade , Higiene Bucal , Selectina-P/sangue , Educação de Pacientes como Assunto , Periodontite/complicações , Aplainamento Radicular , Método Simples-Cego , Molécula 1 de Adesão de Célula Vascular/sangue , Vasodilatação/fisiologia
14.
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.


Assuntos
Análise Custo-Benefício , Isquemia Miocárdica , Avaliação de Resultados em Cuidados de Saúde , Cuidados Pós-Operatórios , Complicações Pós-Operatórias , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Troponina T/sangue , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/sangue , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/economia , Isquemia Miocárdica/mortalidade , Avaliação de Resultados em Cuidados de Saúde/economia , Cuidados Pós-Operatórios/economia , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/normas , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/mortalidade , Risco
15.
Value Health Reg Issues ; 17: 81-87, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29754015

RESUMO

OBJECTIVE: Estimate the cost-effectiveness of a nurse-led home visit (HV) intervention as compared with the standard HF management, within a randomized clinical trial in Brazil. STUDY DESIGN: Cost-effectiveness study within a randomized trial. METHODS: To assess the cost-effectiveness of four home visits and four telephone calls by nurses in the management of patients with HF within a randomized clinical trial (RCT: NCT01213875) in a perspective Public (PHS-Public Healthcare System) and private healthcare systems of Brazil during time frame of 24 weeks. The outcome was a composite endpoint hospital readmission rate (first visit to the emergency room (ER) and hospital readmission), or all-cause death and incremental cost-effectiveness ratio (ICER) of the study intervention to conventional management. RESULTS: Home-based intervention was associated with a reduction in composite endpoint (RR 0.73; 95% confidence interval 0.54 - 0.99; P = 0.049), but at greater cost from the PHS perspective. The ICER at 24 weeks was R$585 per hospital readmission visit prevented. Within the private health insurance framework, home visits were associated with lower costs and lower readmission rates. Results were sensitive to the relative risk of the study intervention, admissions and intervention costs. CONCLUSIONS: In Brazil, an intervention based on nurse-led home visits of patients with HF showed a favorable cost-effectiveness profile within the framework of the PHS and was dominant within the private healthcare system. Our analysis suggests that implementation of this program could not only benefit patients, but also provide a financial incentive to health administrators.


Assuntos
Análise Custo-Benefício , Insuficiência Cardíaca/terapia , Visita Domiciliar , Enfermeiros de Saúde Comunitária , Brasil , Causas de Morte , Feminino , Hospitalização , Visita Domiciliar/economia , Humanos , Masculino , Pessoa de Meia-Idade , Enfermeiros de Saúde Comunitária/economia , Readmissão do Paciente
16.
Rev. bras. psiquiatr ; 40(1): 26-34, Jan.-Mar. 2018. tab, graf
Artigo em Inglês | LILACS | ID: biblio-899409

RESUMO

Objective: To assess the effectiveness of three mood disorder treatment algorithms in a sample of patients seeking care in the Brazilian public healthcare system. Methods: A randomized pragmatic trial was conducted with an algorithm developed for treating episodes of major depressive disorder (MDD), bipolar depressive episodes and mixed episodes of bipolar disorder (BD). Results: The sample consisted of 259 subjects diagnosed with BD or MDD (DSM-IV-TR). After the onset of symptoms, the first treatment occurred ∼6 years and the use of mood stabilizers began ∼12 years. All proposed algorithms were effective, with response rates around 80%. The majority of the subjects took 20 weeks to obtain a therapeutic response. Conclusions: The algorithms were effective with the medications available through the Brazilian Unified Health System. Because therapeutic response was achieved in most subjects by 20 weeks, a follow-up period longer than 12 weeks may be required to confirm adequate response to treatment. Remission of symptoms is still the main desired outcome. Subjects who achieved remission recovered more rapidly and remained more stable over time. Clinical trial registration: NCT02901249, NCT02870283, NCT02918097


Assuntos
Humanos , Masculino , Feminino , Adulto , Antipsicóticos/uso terapêutico , Transtorno Bipolar/tratamento farmacológico , Transtornos do Humor/tratamento farmacológico , Transtorno Depressivo Maior/tratamento farmacológico , Fatores Socioeconômicos , Algoritmos , Brasil , Inquéritos e Questionários , Resultado do Tratamento , Programas Nacionais de Saúde
17.
Cardiovasc Interv Ther ; 33(3): 224-231, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28540634

RESUMO

Contrast-induced acute kidney injury (CI-AKI) is a common event after percutaneous coronary intervention (PCI). Presently, the main strategy to avoid CI-AKI lies in saline hydration, since to date none pharmacologic prophylaxis proved beneficial. Our aim was to determine if a low complexity mortality risk model is able to predict CI-AKI in patients undergoing PCI after ST elevation myocardial infarction (STEMI). We have included patients with STEMI submitted to primary PCI in a tertiary hospital. The definition of CI-AKI was a raise of 0.3 mg/dL or 50% in post procedure (24-72 h) serum creatinine compared to baseline. Age, glomerular filtration and ejection fraction were used to calculate ACEF-MDRD score. We have included 347 patients with mean age of 60 years. In univariate analysis, age, diabetes, previous ASA use, Killip 3 or 4 at admission, ACEF-MDRD and Mehran scores were predictors of CI-AKI. After multivariate adjustment, only ACEF-MDRD score and diabetes remained CI-AKI predictors. Areas under the ROC curve of ACEF-MDRD and Mehran scores were 0.733 (0.68-0.78) and 0.649 (0.59-0.70), respectively. When we compared both scores with DeLong test ACEF-MDRDs AUC was greater than Mehran's (P = 0.03). An ACEF-MDRD score of 2.33 or lower has a negative predictive value of 92.6% for development of CI-AKI. ACEF-MDRD score is a user-friendly tool that has an excellent CI-AKI predictive accuracy in patients undergoing primary percutaneous coronary intervention. Moreover, a low ACEF-MDRD score has a very good negative predictive value for CI-AKI, which makes this complication unlikely in patients with an ACEF-MDRD score of <2.33.


Assuntos
Lesão Renal Aguda/induzido quimicamente , Meios de Contraste/efeitos adversos , Intervenção Coronária Percutânea/efeitos adversos , Medição de Risco/métodos , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Lesão Renal Aguda/diagnóstico , Fatores Etários , Idoso , Brasil , Creatinina/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/métodos , Curva ROC , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Volume Sistólico/fisiologia
18.
Ann Surg ; 268(2): 357-363, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-28486392

RESUMO

OBJECTIVE: To determine the prognostic relevance, clinical characteristics, and 30-day outcomes associated with myocardial injury after noncardiac surgery (MINS) in vascular surgical patients. BACKGROUND: MINS has been independently associated with 30-day mortality after noncardiac surgery. The characteristics and prognostic importance of MINS in vascular surgery patients are poorly described. METHODS: This was an international prospective cohort study of 15,102 noncardiac surgery patients 45 years or older, of whom 502 patients underwent vascular surgery. All patients had fourth-generation plasma troponin T (TnT) concentrations measured during the first 3 postoperative days. MINS was defined as a TnT of 0.03 ng/mL of higher secondary to ischemia. The objectives of the present study were to determine (i) if MINS is prognostically important in vascular surgical patients, (ii) the clinical characteristics of vascular surgery patients with and without MINS, (iii) the 30-day outcomes for vascular surgery patients with and without MINS, and (iv) the proportion of MINS that probably would have gone undetected without routine troponin monitoring. RESULTS: The incidence of MINS in the vascular surgery patients was 19.1% (95% confidence interval (CI), 15.7%-22.6%). 30-day all-cause mortality in the vascular cohort was 12.5% (95% CI 7.3%-20.6%) in patients with MINS compared with 1.5% (95% CI 0.7%-3.2%) in patients without MINS (P < 0.001). MINS was independently associated with 30-day mortality in vascular patients (odds ratio, 9.48; 95% CI, 3.46-25.96). The 30-day mortality was similar in MINS patients with (15.0%; 95% CI, 7.1-29.1) and without an ischemic feature (12.2%; 95% CI, 5.3-25.5, P = 0.76). The proportion of vascular surgery patients who suffered MINS without overt evidence of myocardial ischemia was 74.1% (95% CI, 63.6-82.4). CONCLUSIONS: Approximately 1 in 5 patients experienced MINS after vascular surgery. MINS was independently associated with 30-day mortality. The majority of patients with MINS were asymptomatic and would have gone undetected without routine postoperative troponin measurement.


Assuntos
Isquemia Miocárdica/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Troponina T/sangue , Procedimentos Cirúrgicos Vasculares , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/sangue , Isquemia Miocárdica/epidemiologia , Isquemia Miocárdica/etiologia , Razão de Chances , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/epidemiologia , Prognóstico , Modelos de Riscos Proporcionais , Estudos Prospectivos
19.
Braz J Psychiatry ; 40(1): 26-34, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-28832750

RESUMO

OBJECTIVE: To assess the effectiveness of three mood disorder treatment algorithms in a sample of patients seeking care in the Brazilian public healthcare system. METHODS: A randomized pragmatic trial was conducted with an algorithm developed for treating episodes of major depressive disorder (MDD), bipolar depressive episodes and mixed episodes of bipolar disorder (BD). RESULTS: The sample consisted of 259 subjects diagnosed with BD or MDD (DSM-IV-TR). After the onset of symptoms, the first treatment occurred ∼6 years and the use of mood stabilizers began ∼12 years. All proposed algorithms were effective, with response rates around 80%. The majority of the subjects took 20 weeks to obtain a therapeutic response. CONCLUSIONS: The algorithms were effective with the medications available through the Brazilian Unified Health System. Because therapeutic response was achieved in most subjects by 20 weeks, a follow-up period longer than 12 weeks may be required to confirm adequate response to treatment. Remission of symptoms is still the main desired outcome. Subjects who achieved remission recovered more rapidly and remained more stable over time. CLINICAL TRIAL REGISTRATION: NCT02901249, NCT02870283, NCT02918097.


Assuntos
Antipsicóticos/uso terapêutico , Transtorno Bipolar/tratamento farmacológico , Transtorno Depressivo Maior/tratamento farmacológico , Transtornos do Humor/tratamento farmacológico , Adulto , Algoritmos , Brasil , Feminino , Humanos , Masculino , Programas Nacionais de Saúde , Fatores Socioeconômicos , Inquéritos e Questionários , Resultado do Tratamento
20.
Arq Bras Cardiol ; 109(4): 321-330, 2017 Oct.
Artigo em Português, Inglês | MEDLINE | ID: mdl-28977049

RESUMO

BACKGROUND: Although heart failure (HF) has high morbidity and mortality, studies in Latin America on causes and predictors of in-hospital mortality are scarce. We also do not know the evolution of patients with compensated HF hospitalized for other reasons. OBJECTIVE: To identify causes and predictors of in-hospital mortality in patients hospitalized for acute decompensated HF (ADHF), compared to those with HF and admitted to the hospital for non-HF related causes (NDHF). METHODS: Historical cohort of patients hospitalized in a public tertiary hospital in Brazil with a diagnosis of HF identified by the Charlson Comorbidity Index (CCI). RESULTS: A total of 2056 patients hospitalized between January 2009 and December 2010 (51% men, median age of 71 years, length of stay of 15 days) were evaluated. There were 17.6% of deaths during hospitalization, of which 58.4% were non-cardiovascular (63.6% NDHF vs 47.4% ADHF, p = 0.004). Infectious causes were responsible for most of the deaths and only 21.6% of the deaths were attributed to HF. The independent predictors of in-hospital mortality were similar between the groups and included: age, length of stay, elevated potassium, clinical comorbidities, and CCI. Renal insufficiency was the most relevant predictor in both groups. CONCLUSION: Patients hospitalized with HF have high in-hospital mortality, regardless of the primary reason for hospitalization. Few deaths are directly attributed to HF; Age, renal function and levels of serum potassium, length of stay, comorbid burden and CCI were independent predictors of in-hospital death in a Brazilian tertiary hospital.


Assuntos
Insuficiência Cardíaca/mortalidade , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Centros de Atenção Terciária/estatística & dados numéricos , Fatores Etários , Idoso , Brasil/epidemiologia , Causas de Morte , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Valor Preditivo dos Testes , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Estatísticas não Paramétricas
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