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1.
Acad Med ; 90(2): 185-90, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25354070

RESUMO

PROBLEM: Many health care organizations seek physicians to lead quality improvement (QI) efforts, yet struggle to find individuals with the necessary expertise. Although most residency programs incorporate QI and patient safety principles into their curricula, few provide a specialized training program for residents exploring careers as physician leaders in quality. APPROACH: Recognizing this training void, the authors designed and implemented the Healthcare Leadership in Quality (HLQ) track for residents at the University of Pennsylvania Health System in 2010. This longitudinal, two-year graduate medical education (GME) track aligns with the quality goals of the University of Pennsylvania Health System and includes a core curriculum, integration into an interprofessional health care leadership team that is accountable for quality and safety outcomes on a hospital unit, a capstone QI project, and mentorship. OUTCOMES: Early evaluation has demonstrated the feasibility and efficacy of the track diverse graduate medical education training programs. Using Yardley and Dornan's interpretation of the Kirkpatrick framework, the authors have demonstrated the track's impact on four levels of educational and organizational outcomes. NEXT STEPS: Building on their early experiences, the authors are integrating project and time management skills into the core curriculum, and they are focusing more effort on faculty development in QI mentorship. Additionally, the authors plan to follow HLQ track graduates to determine whether they seek leadership roles in quality and safety and to assess the influence of the program on their careers.


Assuntos
Educação de Pós-Graduação em Medicina/organização & administração , Internato e Residência/organização & administração , Desenvolvimento de Programas , Melhoria de Qualidade , Currículo , Humanos , Liderança , Mentores , Pennsylvania , Papel do Médico
2.
Surg Obes Relat Dis ; 10(6): 1028-39, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25443077

RESUMO

BACKGROUND: Bariatric surgery is the most effective treatment for the reduction of weight and resolution of type 2 diabetes mellitus (T2 DM). The objective of this study was to longitudinally assess hormonal and tissue responses after RYGB. METHODS: Eight patients (5 with T2 DM) were studied before and after RYGB. A standardized test meal (STM) was administered before and at 1, 3, 6, 9, 12, and 15 months. Separately, a 2-hour hyperinsulinemic-euglycemic clamp (E-clamp) and a 2-hour hyperglycemic clamp (H-clamp) were performed before and at 1, 3, 6, and 12 months. Glucagon-like peptide-1 (GLP-1) was infused during the last hour of the H-clamp. Body composition was assessed with DXA methodology. RESULTS: Enrollment body mass index was 49±3 kg/m(2) (X±SE). STM glucose and insulin responses were normalized by 3 and 6 months. GLP-1 level increased dramatically at 1, 3, and 6 months, normalizing by 12 and 15 months. Insulin sensitivity (M of E-clamp) increased progressively at 3-12 months as fat mass decreased. The insulin response to glucose alone fell progressively over 12 months but the glucose clearance/metabolism (M of H-clamp) did not change significantly until 12 months. In response to GLP-1 infusion, insulin levels fell progressively throughout the 12 months. CONCLUSION: The early hypersecretion of GLP-1 leads to hyperinsulinemia and early normalization of glucose levels. The GLP-1 response normalizes within 1 year after surgery. Enhanced peripheral tissue sensitivity to insulin starts at 3 months and is associated with fat mass loss. ß-cell sensitivity improves at 12 months and after the loss of ≈33% of excess weight. There is a tightly controlled feedback loop between peripheral tissue sensitivity and ß-cell and L-cell (GLP-1) responses.


Assuntos
Diabetes Mellitus Tipo 2/prevenção & controle , Derivação Gástrica/métodos , Obesidade Mórbida/cirurgia , Absorciometria de Fóton , Biomarcadores/sangue , Glicemia/análise , Composição Corporal , Índice de Massa Corporal , Peptídeo C/sangue , Ensaio de Imunoadsorção Enzimática , Feminino , Glucagon/sangue , Peptídeo 1 Semelhante ao Glucagon/administração & dosagem , Peptídeo 1 Semelhante ao Glucagon/sangue , Técnica Clamp de Glucose , Humanos , Insulina/sangue , Masculino , Pessoa de Meia-Idade , Perda de Peso
3.
Cardiovasc Diabetol ; 13: 115, 2014 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-25078106

RESUMO

BACKGROUND: We previously demonstrated that older beagles have impaired whole body and myocardial insulin responsiveness (MIR), and that glucagon-like peptide-1 (GLP-1 [7-36] amide) improves MIR in young beagles with dilated cardiomyopathy (DCM). Here, we sought to determine if aging alone predisposes to an accelerated course of DCM, and if GLP-1 [7-36] amide would restore MIR and impact the course of DCM in older beagles. METHODS: Eight young beagles (Young-Control) and sixteen old beagles underwent chronic left ventricle (LV) instrumentation. Seven old beagles were treated with GLP-1 (7-36) amide (2.5 pmol/kg/min) for 2 weeks prior to instrumentation and for 35 days thereafter (Old + GLP-1), while other 9 served as control (Old-Control). All dogs underwent baseline metabolic determinations and LV biopsy for mitochondria isolation prior to the development of DCM induced by rapid pacing (240 min-1). Hemodynamic measurements were performed routinely as heart failure progressed. RESULTS: At baseline, all old beagles had elevated non-esterifed fatty acids (NEFA), and impaired MIR. GLP-1 reduced plasma NEFA (Old-Control: 853 ± 34; Old + GLP-1: 531 ± 33 µmol/L, p < 0.02), improved MIR (Old-Control: 289 ± 54; Old + GLP-1: 512 ± 44 mg/min/100 mg, p < 0.05), and increased uncoupling protein-3 (UCP-3) expression in isolated mitochondria. Compared to the Young-Control, the Old-Controls experienced an accelerated course of DCM (7 days versus 29 days, p < 0.005) and excess mortality, while the Old + GLP-1 experienced increased latency to the onset of DCM (7 days versus 23 days, p < 0.005) and reduced mortality. CONCLUSION: Aging is associated with myocardial insulin resistance, which predispose to an accelerated course of DCM. GLP-1 treatment is associated with increased MIR and protection against an accelerated course of DCM in older beagles.


Assuntos
Envelhecimento/sangue , Progressão da Doença , Peptídeo 1 Semelhante ao Glucagon/administração & dosagem , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/prevenção & controle , Resistência à Insulina/fisiologia , Fragmentos de Peptídeos/administração & dosagem , Envelhecimento/efeitos dos fármacos , Envelhecimento/patologia , Animais , Cardiotônicos/administração & dosagem , Cães , Insuficiência Cardíaca/patologia , Infusões Intravenosas , Miocárdio/metabolismo , Miocárdio/patologia , Distribuição Aleatória
4.
Front Horm Res ; 43: 144-57, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24943305

RESUMO

As cardiovascular (CV) disease remains the major cause of mortality and morbidity in type 2 diabetes mellitus, reducing macrovascular complications has been a major target of antiglycemic therapies. Emerging evidence suggests that incretin-based therapies are safe and may provide CV and cerebrovascular (CBV) benefits beyond those attributable to glycemic control, making the class an attractive therapeutic option. However, the mechanisms whereby the various classes of incretin-based therapies exert CV and CBV benefits may be distinct and may not necessarily lead to similar outcomes. In this chapter, we will discuss the potential mechanisms and current understanding of CV and CBV benefits of native glucagon-like peptide (GLP)-1, GLP-1 receptor agonists and analogues, and of dipeptidyl peptidase-4 inhibitor therapies as a means to better understand differences in safety and efficacy.


Assuntos
Glicemia/metabolismo , Doenças Cardiovasculares/prevenção & controle , Diabetes Mellitus Tipo 2/tratamento farmacológico , Inibidores da Dipeptidil Peptidase IV/uso terapêutico , Peptídeo 1 Semelhante ao Glucagon/uso terapêutico , Incretinas/uso terapêutico , Receptores de Glucagon/agonistas , Pressão Sanguínea/efeitos dos fármacos , Cardiotônicos/uso terapêutico , Peptídeo 1 Semelhante ao Glucagon/metabolismo , Peptídeo 1 Semelhante ao Glucagon/fisiologia , Receptor do Peptídeo Semelhante ao Glucagon 1 , Coração/efeitos dos fármacos , Humanos , Fragmentos de Peptídeos/metabolismo , Receptores de Glucagon/fisiologia
5.
Peptides ; 59: 20-4, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24937653

RESUMO

We have previously demonstrated in human subjects who under euglycemic clamp conditions GLP-1(9-36)amide infusions inhibit endogenous glucose production without substantial insulinotropic effects. An earlier report indicates that GLP-1(9-36)amide is cleaved to a nonapeptide, GLP-1(28-36)amide and a pentapeptide GLP-1(32-36)amide (LVKGR amide). Here we study the effects of the pentapeptide on whole body glucose disposal during hyperglycemic clamp studies. Five dogs underwent indwelling catheterizations. Following recovery, the dogs underwent a 180 min hyperglycemic clamp (basal glucose +98 mg/dl) in a cross-over design. Saline or pentapeptide (30 pmol kg(-1) min(-1)) was infused during the last 120 min after commencement of the hyperglycemic clamp in a primed continuous manner. During the last 30 min of the pentapeptide infusion, glucose utilization (M) significantly increased to 21.4±2.9 mg kg(-1) min(-1)compared to M of 14.3±1.1 mg kg(-1)min(-1) during the saline infusion (P=0.026, paired t-test; P=0.062, Mann-Whitney U test). During this interval, no significant differences in insulin (26.6±3.2 vs. 23.7±2.5 µU/ml, P=NS) or glucagon secretion (34.0±2.1 vs. 31.7±1.8 pg/ml, P=NS) were observed. These findings demonstrate that under hyperglycemic clamp studies the pentapeptide modulates glucose metabolism by a stimulation of whole-body glucose disposal. Further, the findings suggest that the metabolic benefits previously observed during GLP-1(9-36)amide infusions in humans might be due, at least in part, to the metabolic effects of the pentapeptide that is cleaved from the pro-peptide, GLP-1(9-36)amide in the circulation.


Assuntos
Glicemia/metabolismo , Peptídeo 1 Semelhante ao Glucagon/química , Peptídeo 1 Semelhante ao Glucagon/farmacologia , Animais , Cães , Peptídeo 1 Semelhante ao Glucagon/metabolismo
6.
JAMA Intern Med ; 174(4): 535-43, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24515422

RESUMO

IMPORTANCE Socioeconomic and behavioral factors can negatively influence posthospital outcomes among patients of low socioeconomic status (SES). Traditional hospital personnel often lack the time, skills, and community linkages required to address these factors. OBJECTIVE To determine whether a tailored community health worker (CHW) intervention would improve posthospital outcomes among low-SES patients. DESIGN, SETTING, AND PARTICIPANTS A 2-armed, single-blind, randomized clinical trial was conducted between April 10, 2011, and October 30, 2012, at 2 urban, academically affiliated hospitals. Of 683 eligible general medical inpatients (ie, low-income, uninsured, or Medicaid) that we screened, 237 individuals (34.7%) declined to participate. The remaining 446 patients (65.3%) were enrolled and randomly assigned to study arms. Nearly equal percentages of control and intervention group patients completed the follow-up interview (86.6% vs 86.9%). INTERVENTIONS During hospital admission, CHWs worked with patients to create individualized action plans for achieving patients' stated goals for recovery. The CHWs provided support tailored to patient goals for a minimum of 2 weeks. MAIN OUTCOMES AND MEASURES The prespecified primary outcome was completion of primary care follow-up within 14 days of discharge. Prespecified secondary outcomes were quality of discharge communication, self-rated health, satisfaction, patient activation, medication adherence, and 30-day readmission rates. RESULTS Using intention-to-treat analysis, we found that intervention patients were more likely to obtain timely posthospital primary care (60.0% vs 47.9%; P = .02; adjusted odds ratio [OR], 1.52; 95% CI, 1.03-2.23), to report high-quality discharge communication (91.3% vs 78.7%; P = .002; adjusted OR, 2.94; 95% CI, 1.5-5.8), and to show greater improvements in mental health (6.7 vs 4.5; P = .02) and patient activation (3.4 vs 1.6; P = .05). There were no significant differences between groups in physical health, satisfaction with medical care, or medication adherence. Similar proportions of patients in both arms experienced at least one 30-day readmission; however, intervention patients were less likely to have multiple 30-day readmissions (2.3% vs 5.5%; P = .08; adjusted OR, 0.40; 95% CI, 0.14-1.06). Among the subgroup of 63 readmitted patients, recurrent readmission was reduced from 40.0% vs 15.2% (P = .03; adjusted OR, 0.27; 95% CI, 0.08-0.89). CONCLUSIONS AND RELEVANCE Patient-centered CHW intervention improves access to primary care and quality of discharge while controlling recurrent readmissions in a high-risk population. Health systems may leverage the CHW workforce to improve posthospital outcomes by addressing behavioral and socioeconomic drivers of disease. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01346462.


Assuntos
Agentes Comunitários de Saúde , Alta do Paciente , Assistência Centrada no Paciente/organização & administração , Adulto , Feminino , Acesso aos Serviços de Saúde , Humanos , Análise de Intenção de Tratamento , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Pennsylvania , Atenção Primária à Saúde/estatística & dados numéricos , Método Simples-Cego , Fatores Socioeconômicos
7.
Crit Care Med ; 42(3): 638-45, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24247476

RESUMO

OBJECTIVES: Intensive insulin therapy for tight glycemic control in critically ill surgical patients has been shown to reduce mortality; however, intensive insulin therapy is associated with iatrogenic hypoglycemia and increased variability of blood glucose levels. The incretin glucagon-like peptide-1 (7-36) amide is both insulinotropic and insulinomimetic and has been suggested as an adjunct to improve glycemic control in critically ill patients. We hypothesized that the addition of continuous infusion of glucagon-like peptide-1 to intensive insulin therapy would result in better glucose control, reduced requirement of exogenous insulin administration, and fewer hypoglycemic events. DESIGN: Prospective, randomized, double-blind, placebo-controlled clinical trial. SETTING: Surgical or burn ICU. PATIENTS: Eighteen patients who required intensive insulin therapy. INTERVENTIONS: A 72-hour continuous infusion of either glucagon-like peptide-1 (1.5 pmol/kg/min) or normal saline plus intensive insulin therapy. MEASUREMENTS AND MAIN RESULTS: The glucagon-like peptide-1 cohort (n = 9) and saline cohort (n = 9) were similar in age, Acute Physiology and Chronic Health Evaluation score, and history of diabetes. Blood glucose levels in the glucagon-like peptide-1 group were better controlled with much less variability. The coefficient of variation of blood glucose ranged from 7.2% to 30.4% in the glucagon-like peptide-1 group and from 19.8% to 56.8% in saline group. The mean blood glucose coefficient of variation for the glucagon-like peptide-1 and saline groups was 18.0% ± 2.7% and 30.3% ± 4.0% (p = 0.010), respectively. The 72-hour average insulin infusion rates were 3.37 ± 0.61 and 4.57 ± 1.18 U/hr (p = not significant). The incidents of hypoglycemia (≤ 2.78 mmol/L) in both groups were low (one in the glucagon-like peptide-1 group, three in the saline group). CONCLUSIONS: Glucagon-like peptide-1 (7-36) amide is a safe and efficacious form of adjunct therapy in patients with hyperglycemia in the surgical ICU setting. Improved stability of blood glucose is a favorable outcome, which enhances the safety of intensive insulin therapy. Larger studies of this potentially valuable therapy for glycemic control in the ICU are justified.


Assuntos
Glicemia/efeitos dos fármacos , Cuidados Críticos/métodos , Peptídeo 1 Semelhante ao Glucagon/administração & dosagem , Mortalidade Hospitalar , Hiperglicemia/tratamento farmacológico , Insulina/administração & dosagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Glicemia/análise , Estado Terminal , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Seguimentos , Humanos , Hiperglicemia/diagnóstico , Hiperglicemia/mortalidade , Hipoglicemiantes/administração & dosagem , Infusões Intravenosas , Insulina/sangue , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Segurança do Paciente , Projetos Piloto , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/tratamento farmacológico , Complicações Pós-Operatórias/mortalidade , Estudos Prospectivos , Medição de Risco , Estatísticas não Paramétricas , Taxa de Sobrevida , Resultado do Tratamento
8.
J Endocrinol ; 221(1): T17-30, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23926280

RESUMO

Glucagon-like (GLP-1) is a peptide hormone secreted from the small intestine in response to nutrient ingestion. GLP-1 stimulates insulin secretion in a glucose-dependent manner, inhibits glucagon secretion and gastric emptying, and reduces appetite. Because of the short circulating half-life of the native GLP-1, novel GLP-1 receptor (GLP-1R) agonists and analogs and dipeptidyl peptidase 4 (DPP-4) inhibitors have been developed to facilitate clinical use. Emerging evidence indicates that GLP-1-based therapies are safe and may provide cardiovascular (CV) benefits beyond glycemic control. Preclinical and clinical studies are providing increasing evidence that GLP-1 therapies may positively affect CV function and metabolism by salutary effects on CV risk factors as well as via direct cardioprotective actions. However, the mechanisms whereby the various classes of incretin-based therapies exert CV effects may be mechanistically distinct and may not necessarily lead to similar CV outcomes. In this review, we will discuss the potential mechanisms and current understanding of CV benefits of native GLP-1, GLP-1R agonists and analogs, and of DPP-4 inhibitor therapies as a means to compare their putative CV benefits.


Assuntos
Sistema Cardiovascular/efeitos dos fármacos , Diabetes Mellitus Tipo 2/tratamento farmacológico , Hipoglicemiantes/uso terapêutico , Incretinas/uso terapêutico , Animais , Glicemia/metabolismo , Sistema Cardiovascular/fisiopatologia , Diabetes Mellitus Tipo 2/metabolismo , Diabetes Mellitus Tipo 2/fisiopatologia , Peptídeo 1 Semelhante ao Glucagon/uso terapêutico , Humanos
10.
Am J Manag Care ; 18(4): e121-5, 2012 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-22554037

RESUMO

The emergence of information technology in healthcare holds the promise to transform the industry through the creation of highly reliable information exchange. These same technologies have a central role in the patient safety movement. Organizations that wish to deliver safe and high-quality healthcare will only be successful if they plan, develop, and use health information systems with the principles of high-performing organizations in mind. We discuss the current state of health information technology in the patient safety movement, how this technology can contribute to high organizational performance, and some caveats.


Assuntos
Informática Médica/normas , Segurança do Paciente , Guias de Prática Clínica como Assunto , Humanos , Resolução de Problemas , Estados Unidos
11.
Eur J Heart Fail ; 13(11): 1224-30, 2011 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-21926073

RESUMO

AIMS: Renal neurohormonal activation leading to a reduction in glomerular filtration rate (GFR) has been suggested as a mechanism for renal insufficiency (RI) in the setting of heart failure. We hypothesized that RI occurring in the presence of renal neurohormonal activation may be prognostically more important than RI in the absence of renal neurohormonal activation. METHODS AND RESULTS: Subjects in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial (n = 429), Beta-Blocker Evaluation of Survival Trial (BEST) (n = 2691), and Studies Of Left Ventricular Dysfunction (SOLVD) trial (n = 6782) limited datasets were studied. The blood urea nitrogen to creatinine ratio (BUN/Creatinine) was employed as a surrogate for renal neurohormonal activation and the primary outcome was the interaction between BUN/Creatinine and RI associated mortality. Baseline RI (GFR < 60 mL/min/1.73 m²) was associated with mortality in all study populations (P < 0.001). In patients with higher BUN/Creatinine, the risk of mortality was consistently greater in patients with RI [adjusted hazard ratio (HR) ESCAPE = 2.8, 95% confidence interval (CI) 1.3-14.3, P = 0.019; BEST = 1.6, 95% CI 1.2-2.2, P = 0.002; SOLVD = 1.6, 95% CI 1.3-2.0, P = 0.001]. However, in patients with lower BUN/Creatinine, the risk of mortality was not elevated in patients with RI (adjusted HR ESCAPE = 0.94, 95% CI 0.35-2.4, P = 0.90, P interaction = 0.005; BEST = 0.97, 95% CI 0.64-1.4, P = 0.90, P interaction = 0.02; SOLVD = 1.0, 95% CI 0.8-1.3, P = 0.71, P interaction = 0.005). CONCLUSION: The association between RI and poor survival observed in heart failure populations appears to be contingent not simply on the presence of a reduced GFR, but possibly on the mechanism by which GFR is reduced.


Assuntos
Insuficiência Cardíaca/mortalidade , Insuficiência Renal/mortalidade , Adulto , Idoso , Estudos de Coortes , Feminino , Taxa de Filtração Glomerular , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Fenótipo , Prognóstico , Ensaios Clínicos Controlados Aleatórios como Assunto , Insuficiência Renal/etiologia , Insuficiência Renal/fisiopatologia , Estudos Retrospectivos
12.
J Am Coll Cardiol ; 58(4): 375-82, 2011 Jul 19.
Artigo em Inglês | MEDLINE | ID: mdl-21757114

RESUMO

OBJECTIVES: The purpose of this study was to investigate whether a surrogate for renal neurohormonal activation, blood urea nitrogen (BUN), could identify patients destined to experience adverse outcomes associated with the use of high-dose loop diuretics (HDLD). BACKGROUND: Loop diuretics are commonly used to control congestive symptoms in heart failure; however, these agents cause neurohormonal activation and have been associated with worsened survival. METHODS: Subjects in the BEST (Beta-Blocker Evaluation of Survival Trial) receiving loop diuretics at baseline were analyzed (N = 2,456). The primary outcome was the interaction between BUN- and HDLD-associated mortality. RESULTS: In the overall cohort, HDLD use (≥160 mg/day) was associated with increased mortality (hazard ratio [HR]: 1.56; 95% confidence interval [CI]: 1.35 to 1.80). However, after extensively controlling for baseline characteristics, this association did not persist (HR: 1.06; 95% CI: 0.89 to 1.25). In subjects with BUN levels above the median (21.0 mg/dl), both the unadjusted (HR: 1.59; 95% CI: 1.34 to 1.88) and adjusted (HR: 1.29; 95% CI: 1.07 to 1.60) risk of death was higher in the HDLD group. In patients with BUN levels below the median, there was no associated risk with HDLD (HR: 0.99; 95% CI: 0.75 to 1.34) and after controlling for baseline characteristics, the HDLD group had significantly improved survival (HR: 0.71; 95% CI: 0.49 to 0.96) (p interaction = 0.018). CONCLUSIONS: The risk associated with HDLD use is strongly dependent on BUN concentrations with reduced survival in patients with an elevated BUN level and improved survival in patients with a normal BUN level. These data suggest a role for neurohormonal activation in loop diuretic-associated mortality.


Assuntos
Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/mortalidade , Inibidores de Simportadores de Cloreto de Sódio e Potássio/efeitos adversos , Idoso , Nitrogênio da Ureia Sanguínea , Relação Dose-Resposta a Droga , Feminino , Insuficiência Cardíaca/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
13.
Eur J Heart Fail ; 13(8): 877-84, 2011 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-21693504

RESUMO

AIMS: One of the primary determinants of blood flow in regional vascular beds is perfusion pressure. Our aim was to investigate if reduction in blood pressure during the treatment of decompensated heart failure would be associated with worsening renal function (WRF). Our secondary aim was to evaluate the prognostic significance of this potentially treatment-induced form of WRF. METHODS AND RESULTS: Subjects included in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial limited data were studied (386 patients). Reduction in systolic blood pressure (SBP) was greater in patients experiencing WRF (-10.3 ± 18.5 vs. -2.8 ± 16.0 mmHg, P < 0.001) with larger reductions associated with greater odds for WRF (odds ratio = 1.3 per 10 mmHg reduction, P < 0.001). Systolic blood pressure reduction (relative change > median) was associated with greater doses of in-hospital oral vasodilators (P ≤ 0.017), thiazide diuretic use (P = 0.035), and greater weight reduction (P = 0.023). In patients with SBP-reduction, WRF was not associated with worsened survival [adjusted hazard ratio (HR) = 0.76, P = 0.58]. However, in patients without SBP-reduction, WRF was strongly associated with increased mortality (adjusted HR = 5.3, P < 0.001, P interaction = 0.001). CONCLUSION: During the treatment of decompensated heart failure, significant blood pressure reduction is strongly associated with WRF. However, WRF that occurs in the setting of SBP-reduction is not associated with an adverse prognosis, whereas WRF in the absence of this provocation is strongly associated with increased mortality. These data suggest that WRF may represent the final common pathway of several mechanistically distinct processes, each with potentially different prognostic implications.


Assuntos
Pressão Sanguínea/efeitos dos fármacos , Taxa de Filtração Glomerular/efeitos dos fármacos , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Nefropatias/fisiopatologia , Rim/fisiopatologia , Doença Aguda , Adulto , Idoso , Feminino , Humanos , Rim/irrigação sanguínea , Rim/efeitos dos fármacos , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Prognóstico , Resultado do Tratamento
14.
Trans Am Clin Climatol Assoc ; 122: 103-14, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-21686213

RESUMO

An estimated 2 million hospital-acquired infections (HAI) are now reported annually in the US, and are associated with an estimated $5 billion in additional health care costs. With this, the growing incidence of HAI has become "ground zero" in the campaign to improve patient safety and eliminate waste in health care.We studied the characteristics of high-performing organizations and their leaders outside of health care to determine how such organizations become "best in class." We then sought to apply the principles that led to this status to eliminating HAI associated with central venous catheters.Observations of the current condition of health care revealed multiple defects in various processes, that were breeding grounds for error. Redesign of these processes by the people involved in them under the guidance of a leader resulted in an 86% reduction in infections in the blood. Overall, financial performance improved by $5.1 million over a 2-year period. Mortality in intensive care units declined by 29%.Using methods borrowed from highly reliable industries and engaging workers at the point of care can have profound and sustainable effects in nearly eliminating HAI, with significant clinical and financial benefits.


Assuntos
Cateterismo Venoso Central/efeitos adversos , Cateteres de Demora/efeitos adversos , Infecção Hospitalar/prevenção & controle , Custos Hospitalares , Controle de Infecções/métodos , Infecções Relacionadas à Prótese/prevenção & controle , Centros Médicos Acadêmicos/economia , Atitude do Pessoal de Saúde , Cateterismo Venoso Central/economia , Cateterismo Venoso Central/instrumentação , Cateteres de Demora/economia , Competência Clínica , Redução de Custos , Análise Custo-Benefício , Infecção Hospitalar/economia , Infecção Hospitalar/epidemiologia , Educação Médica Continuada , Conhecimentos, Atitudes e Prática em Saúde , Hospitais Gerais/economia , Humanos , Controle de Infecções/economia , Controle de Infecções/normas , Modelos Econômicos , Pennsylvania/epidemiologia , Infecções Relacionadas à Prótese/economia , Infecções Relacionadas à Prótese/epidemiologia , Indicadores de Qualidade em Assistência à Saúde/economia
15.
Lancet Infect Dis ; 11(6): 471-81, 2011 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-21616457

RESUMO

Benchmarking of surveillance data for health-care-associated infection (HCAI) has been used for more than three decades to inform prevention strategies and improve patients' safety. In recent years, public reporting of HCAI indicators has been mandated in several countries because of an increasing demand for transparency, although many methodological issues surrounding benchmarking remain unresolved and are highly debated. In this Review, we describe developments in benchmarking and public reporting of HCAI indicators in England, France, Germany, and the USA. Although benchmarking networks in these countries are derived from a common model and use similar methods, approaches to public reporting have been more diverse. The USA and England have predominantly focused on reporting of infection rates, whereas France has put emphasis on process and structure indicators. In Germany, HCAI indicators of individual institutions are treated confidentially and are not disseminated publicly. Although evidence for a direct effect of public reporting of indicators alone on incidence of HCAIs is weak at present, it has been associated with substantial organisational change. An opportunity now exists to learn from the different strategies that have been adopted.


Assuntos
Infecção Hospitalar/prevenção & controle , Controle de Infecções/métodos , Controle de Infecções/normas , Saúde Pública/métodos , Saúde Pública/normas , Benchmarking/métodos , Países Desenvolvidos , Inglaterra , França , Alemanha , Instalações de Saúde , Humanos , Pacientes , Estados Unidos
16.
Am Heart J ; 161(5): 944-9, 2011 May.
Artigo em Inglês | MEDLINE | ID: mdl-21570527

RESUMO

BACKGROUND: Worsening renal function (WRF) commonly complicates the treatment of acute decompensated heart failure. Despite considerable investigation in this area, it remains unclear to what degree WRF is a reflection of treatment- versus patient-related factors. We hypothesized that if WRF is significantly influenced by factors intrinsic to the patient, then WRF during an index hospitalization should predict WRF during subsequent hospitalization. METHODS: Consecutive admissions to the Hospital of the University of Pennsylvania with a discharge diagnosis of congestive heart failure were reviewed. Patients with >1 hospitalization were retained for analysis. RESULTS: In total, 181 hospitalization pairs met the inclusion criteria. Baseline patient characteristics demonstrated significant correlation between hospitalizations (P ≤ .002 for all) but minimal association with WRF. In contrast, variables related to the aggressiveness of diuresis were weakly correlated between hospitalizations but significantly associated with WRF (P ≤ .024 for all). Consistent with the primary hypothesis, WRF during the index hospitalization was strongly associated with WRF during subsequent hospitalization (odds ratio [OR] 2.7, P = .003). This association was minimally altered after controlling for traditional baseline characteristics (OR 2.5, P = .006) and in-hospital treatment-related parameters (OR 2.8, P = .005). CONCLUSIONS: A prior history of WRF is strongly associated with subsequent episodes of WRF, independent of in-hospital treatment received. These results suggest that baseline factors intrinsic to the patient's cardiorenal pathophysiology have substantial influence on the subsequent development of WRF.


Assuntos
Fármacos Cardiovasculares/efeitos adversos , Taxa de Filtração Glomerular/efeitos dos fármacos , Insuficiência Cardíaca/tratamento farmacológico , Hospitalização , Insuficiência Renal/induzido quimicamente , Fármacos Cardiovasculares/uso terapêutico , Progressão da Doença , Feminino , Seguimentos , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Pennsylvania/epidemiologia , Prognóstico , Insuficiência Renal/epidemiologia , Insuficiência Renal/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências
17.
Am J Cardiol ; 106(12): 1763-9, 2010 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-21055713

RESUMO

Worsening renal function (RF) and improved RF during the treatment of decompensated heart failure have traditionally been thought of as hemodynamically distinct events. We hypothesized that if the pulmonary artery catheter-derived measures are relevant in the evaluation of cardiorenal interactions, the comparison of patients with improved versus worsening RF should highlight any important hemodynamic differences. All subjects in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial limited data set with admission and discharge creatinine values available were included (n = 401). No differences were found in the baseline, final, or change in pulmonary artery catheter-derived hemodynamic variables, inotrope and intravenous vasodilator use, or survival between patients with improved versus worsening RF (p = NS for all). Both groups were equally likely to be in the bottom quartile of cardiac index (p = 0.32), have a 25% improvement in cardiac index (p = 0.97), or have any worsening in cardiac index (p = 0.90). When patients with any significant change in renal function (positive or negative) were compared to those with stable renal function, strong associations between variables such as a reduced cardiac index (odds ratio 2.2, p = 0.02), increased intravenous inotrope and vasodilator use (odds ratio 2.9, p <0.001), and worsened all-cause mortality (hazard ratio 1.8, p = 0.01) became apparent. In contrast to traditionally held views, the patients with improved RF and those with worsening RF had similar hemodynamic parameters and outcomes. Combining these groups identified a hemodynamically compromised population with significantly worse survival than patients with stable renal function. In conclusion, the changes in renal function, regardless of the direction, likely identify a population with an advanced disease state and a poor prognosis.


Assuntos
Cardiotônicos/administração & dosagem , Cateterismo de Swan-Ganz/métodos , Taxa de Filtração Glomerular/fisiologia , Insuficiência Cardíaca/terapia , Recuperação de Função Fisiológica , Insuficiência Renal/fisiopatologia , Vasodilatadores/administração & dosagem , Doença Aguda , Creatinina/sangue , Progressão da Doença , Feminino , Seguimentos , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/fisiopatologia , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Prognóstico , Pressão Propulsora Pulmonar/fisiologia , Insuficiência Renal/sangue , Insuficiência Renal/etiologia , Estudos Retrospectivos , Volume Sistólico/fisiologia
18.
J Diabetes Sci Technol ; 4(5): 1195-201, 2010 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-20920440

RESUMO

AIMS/HYPOTHESIS: The Andres clamp technique, which requires accurate and timely determination of glucose, utilizes the Beckman or Yellow Springs Instruments (YSI) glucose analyzers. Both instruments require maintenance, a dedicated operator, preparation of a plasma sample, and a duplicate measurement that takes ≥2 minutes. The Nova StatStrip glucose meter was evaluated for accuracy, reliability, and near-real-time availability of glucose. METHODS: Blood samples from 24 patients who underwent 6-hour clamp studies and 12 patients who had a standardized meal tolerance test (SMT) were measured. Specimens were analyzed simultaneously and immediately upon collection by Beckman, YSI, and Nova. RESULTS: Of 1004 data pairs for the Nova device versus Beckman, the Nova data points ranged from 32 to 444, while Beckman ranged from 42 to 412. The coefficient for the slope of Beckman versus Nova was 1.009 (r = 0.978). Using error grid analysis, the number and percentage of values for Nova were 976 (97.2%) in the A zone and 28 (2.8%) in the B zone. Of 399 data pairs for the Nova device versus YSI, the Nova data points ranged from 46 to 255, whereas YSI ranged from 47 to 231. The coefficient for the slope of YSI versus Nova was 1.023 (r = 0.989). All Nova readings fell in the A zone. Time required for final reading, in duplicate, was 15 seconds for Nova and 120-180 seconds for Beckman and YSI. CONCLUSIONS: The simplicity of Nova and its reliability, accuracy, and speed make it an acceptable replacement device for Beckman and YSI in the conduct of clamps, especially when perturbations require rapid glucose determination.


Assuntos
Automonitorização da Glicemia/instrumentação , Glicemia/metabolismo , Diabetes Mellitus/sangue , Monitorização Fisiológica/instrumentação , Automonitorização da Glicemia/métodos , Técnica Clamp de Glucose , Humanos , Monitorização Fisiológica/métodos , Reprodutibilidade dos Testes , Fatores de Tempo
19.
Cardiology ; 116(3): 206-12, 2010.
Artigo em Inglês | MEDLINE | ID: mdl-20689277

RESUMO

OBJECTIVES: Worsening renal function (WRF) during the treatment of decompensated heart failure, frequently defined as an absolute increase in serum creatinine >or=0.3 mg/dl, has been reported as a strong adverse prognostic factor in several studies. We hypothesized that this definition of WRF is biased by baseline renal function secondary to the exponential relationship between creatinine and renal function. METHODS: We reviewed consecutive admissions with a discharge diagnosis of heart failure. An increase in creatinine >or=0.3 mg/dl (WRF(CREAT)) was compared to a decrease in GFR >or=20% (WRF(GFR)). RESULTS: Overall, 993 admissions met eligibility. WRF(CREAT) occurred in 31.5% and WRF(GFR) in 32.7%. WRF(CREAT) and WRF(GFR) had opposing relationships with baseline renal function (OR = 1.9 vs. OR = 0.51, respectively, p < 0.001). Both definitions had similar unadjusted associations with death at 30 days [WRF(GFR) OR = 2.3 (95% CI 1.1-4.8), p = 0.026; WRF(CREAT) OR = 2.1 (95% CI 1.0-4.4), p = 0.047]. Controlling for baseline renal insufficiency, WRF(GFR) added incrementally in the prediction of mortality (p = 0.009); however, WRF(CREAT) did not (p = 0.11). CONCLUSIONS: WRF, defined as an absolute change in serum creatinine, is heavily biased by baseline renal function. An alternative definition of WRF should be considered for future studies of cardio-renal interactions.


Assuntos
Creatinina/sangue , Insuficiência Cardíaca/complicações , Nefropatias/sangue , Testes de Função Renal/normas , Rim/fisiopatologia , Idoso , Feminino , Taxa de Filtração Glomerular , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/terapia , Hospitais Universitários , Humanos , Nefropatias/complicações , Nefropatias/mortalidade , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Pennsylvania/epidemiologia , Prognóstico
20.
Circulation ; 122(3): 265-72, 2010 Jul 20.
Artigo em Inglês | MEDLINE | ID: mdl-20606118

RESUMO

BACKGROUND: Overly aggressive diuresis leading to intravascular volume depletion has been proposed as a cause for worsening renal function during the treatment of decompensated heart failure. If diuresis occurs at a rate greater than extravascular fluid can refill the intravascular space, the concentration of such intravascular substances as hemoglobin and plasma proteins increases. We hypothesized that hemoconcentration would be associated with worsening renal function and possibly would provide insight into the relationship between aggressive decongestion and outcomes. METHODS AND RESULTS: Subjects in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial limited data set with a baseline/discharge pair of hematocrit, albumin, or total protein values were included (336 patients). Baseline-to-discharge increases in these parameters were evaluated, and patients with >or=2 in the top tertile were considered to have evidence of hemoconcentration. The group experiencing hemoconcentration received higher doses of loop diuretics, lost more weight/fluid, and had greater reductions in filling pressures (P<0.05 for all). Hemoconcentration was strongly associated with worsening renal function (odds ratio, 5.3; P<0.001), whereas changes in right atrial pressure (P=0.36) and pulmonary capillary wedge pressure (P=0.53) were not. Patients with hemoconcentration had significantly lower 180-day mortality (hazard ratio, 0.31; P=0.013). This relationship persisted after adjustment for baseline characteristics (hazard ratio, 0.16; P=0.001). CONCLUSIONS: Hemoconcentration is significantly associated with measures of aggressive fluid removal and deterioration in renal function. Despite this relationship, hemoconcentration is associated with substantially improved survival. These observations raise the question of whether aggressive decongestion, even in the setting of worsening renal function, can positively affect survival.


Assuntos
Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/mortalidade , Rim/fisiologia , Inibidores de Simportadores de Cloreto de Sódio/uso terapêutico , Inibidores de Simportadores de Cloreto de Sódio e Potássio/uso terapêutico , Adulto , Idoso , Proteínas Sanguíneas/metabolismo , Volume Sanguíneo , Líquido Extracelular/metabolismo , Feminino , Taxa de Filtração Glomerular , Hematócrito , Humanos , Masculino , Pessoa de Meia-Idade , Pressão Propulsora Pulmonar , Albumina Sérica/metabolismo , Resultado do Tratamento , Pressão Ventricular
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