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1.
J Card Surg ; 2020 Sep 28.
Artigo em Inglês | MEDLINE | ID: mdl-32985014

RESUMO

BACKGROUND: The Carpentier-Edwards Perimount valves have a proven track record in aortic valve replacement: good durability, hemodynamic performance, rates of survival, and low rates of valve-related complications and prosthesis-patient mismatch. The St. Jude Medical Trifecta is a newer valve that has shown comparable early and midterm outcomes. Studies show reoperation rates of Trifecta are comparable with Perimount valves, with a few recent studies bringing into focus early structural valve deterioration (SVD), and increased midterm SVD in younger patients. Given that midterm data for Trifecta is still sparse, we wanted to confirm the early low reoperation rates of Trifecta persist over time compared with Perimount. METHODS: The Maritime Heart Centre Database was searched for AVR between 2011 and 2016, inclusive. The primary endpoint of the study was all-cause reoperation rate. RESULTS: In total, 711 Perimount and 453 Trifecta implantations were included. The reoperation hazards were determined for age: 0.96 (0.92-0.99; p = .02), female (vs. male): 0.35 (0.08-1.53; p = .16), smoker (vs. nonsmoker): 2.44 (0.85-7.02; p = .1), and Trifecta (vs. Perimount): 2.68 (0.97-7.39; p = .06). Kaplan-Meier survival analysis in subgroups-age <60, age ≥60, male, female, smoker, and nonsmoker-showed Perimount having lower reoperation rates than Trifecta in patients younger than 60 (p = .02) and current smokers (p < .01). CONCLUSIONS: The rates of reoperation of Perimount and Trifecta were comparable, with Trifecta showing higher rates in patients younger than 60 years, and current smokers. Continued diligence and further independent reporting of midterm reoperation and SVD rates of the Trifecta, including detailed echocardiographic follow-up, are needed to confirm these findings.

2.
Arthritis Rheumatol ; 72(1): 67-77, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31390162

RESUMO

OBJECTIVE: To determine the frequency, clinical characteristics, associations, and outcomes of different types of peripheral nervous system (PNS) disease in a multiethnic/multiracial, prospective inception cohort of systemic lupus erythematosus (SLE) patients. METHODS: Patients were evaluated annually for 19 neuropsychiatric (NP) events including 7 types of PNS disease. SLE disease activity, organ damage, autoantibodies, and patient and physician assessment of outcome were measured. Time to event and linear regressions were used as appropriate. RESULTS: Of 1,827 SLE patients, 88.8% were female, and 48.8% were white. The mean ± SD age was 35.1 ± 13.3 years, disease duration at enrollment was 5.6 ± 4.2 months, and follow-up was 7.6 ± 4.6 years. There were 161 PNS events in 139 (7.6%) of 1,827 patients. The predominant events were peripheral neuropathy (66 of 161 [41.0%]), mononeuropathy (44 of 161 [27.3%]), and cranial neuropathy (39 of 161 [24.2%]), and the majority were attributed to SLE. Multivariate Cox regressions suggested longer time to resolution in patients with a history of neuropathy, older age at SLE diagnosis, higher SLE Disease Activity Index 2000 scores, and for peripheral neuropathy versus other neuropathies. Neuropathy was associated with significantly lower Short Form 36 (SF-36) physical and mental component summary scores versus no NP events. According to physician assessment, the majority of neuropathies resolved or improved over time, which was associated with improvements in SF-36 summary scores for peripheral neuropathy and mononeuropathy. CONCLUSION: PNS disease is an important component of total NPSLE and has a significant negative impact on health-related quality of life. The outcome is favorable for most patients, but our findings indicate that several factors are associated with longer time to resolution.


Assuntos
Doenças dos Nervos Cranianos/fisiopatologia , Lúpus Eritematoso Sistêmico/fisiopatologia , Vasculite Associada ao Lúpus do Sistema Nervoso Central/fisiopatologia , Doenças do Sistema Nervoso Periférico/fisiopatologia , Adulto , Fatores Etários , Estudos de Coortes , Doenças dos Nervos Cranianos/etiologia , Feminino , Humanos , Lúpus Eritematoso Sistêmico/complicações , Masculino , Pessoa de Meia-Idade , Mononeuropatias/etiologia , Mononeuropatias/fisiopatologia , Análise Multivariada , Doenças do Sistema Nervoso Periférico/etiologia , Modelos de Riscos Proporcionais , Índice de Gravidade de Doença , Adulto Jovem
3.
Transfusion ; 59(9): 2849-2856, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31283032

RESUMO

BACKGROUND: Phlebotomy for diagnostic testing is among the commonest hospital procedures, but hospital-wide surveys of all inpatients characterizing blood draw volumes have not been published. The objectives were to characterize the daily blood volumes drawn for diagnostic testing from patients discharged from a Canadian tertiary care center, describe the daily distributions of phlebotomy volumes across service locations, and describe changes in hemoglobin (Hb) and transfusion across service locations. STUDY DESIGN AND METHODS: Data were obtained on all patients discharged between 2012 and 2014 using linked discharge abstract and laboratory data. Cumulative daily blood volume and draw frequency were reported by service and days since admission. Changes in Hb and red blood cell (RBC) transfusion rates were reported for nontransfused and transfused patients. RESULTS: Data were included on 59,715 subjects. Mean daily estimated blood loss varied from 8.5 ± 6.5 mL/day onward to 27.2 ± 20.0 mL/day in the intensive care unit (ICU; p < 0.001). Phlebotomy volumes were highest on the first day of admission and declined thereafter (p < 0.001). For nontransfused individuals in the first week of admission, Hb levels decreased by the highest percentage in the ICU. The rate of RBC unit transfusion was highest in the ICU (232.4 units/1000 patient-days; 95% confidence interval, 225.8-239.2; p < 0.0001 compared with all other locations). CONCLUSION: Considerable variation was observed in estimated blood loss due to diagnostic phlebotomy across different services within one teaching hospital. Thi information is foundational for planning interventions to minimize estimated blood loss from phlebotomy.


Assuntos
Volume Sanguíneo , Testes Diagnósticos de Rotina/métodos , Testes Diagnósticos de Rotina/estatística & dados numéricos , Flebotomia/métodos , Flebotomia/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anemia/sangue , Anemia/epidemiologia , Transfusão de Sangue/estatística & dados numéricos , Volume Sanguíneo/fisiologia , Canadá/epidemiologia , Censos , Testes Diagnósticos de Rotina/tendências , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Pacientes Internados/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Flebotomia/tendências , Padrões de Prática em Enfermagem/estatística & dados numéricos , Centros de Atenção Terciária/estatística & dados numéricos , Adulto Jovem
4.
Disabil Rehabil Assist Technol ; 14(6): 590-594, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-29916750

RESUMO

Purpose: The tilt-rest skill consists of tipping the wheelchair back and allowing it to rest against a solid object with the wheel locks applied (e.g., for pressure redistribution, neck comfort or hands-free activities). The objective of this study was to determine the proportion of experienced manual wheelchair users who are aware of this skill and who can perform it. Materials and methods: We conducted a cross-sectional survey of 49 manual wheelchair users using a questionnaire developed for the purpose. The tilt-rest skill was attempted by those who reported that they were capable of performing it. Results: Participants' mean (SD) age was 55.1 (18.2) years, 38 (77.6%) were male, their median (IQR) duration of wheelchair use was 2 (7.2) years and their mean (SD) daily time spent in the wheelchair was 9.5 (4.6) hours. Twenty-seven (55.1%) participants were aware of the skill, 19 (38.8%) reported being able to perform the skill and 16 of 47 (34.0%) were able to demonstrate the skill. Multivariate modelling with the question "Can you complete the tilt-rest skill?" as the dependent measure revealed an inverse relationship with age - Odds Ratio (95% Confidence Interval) of 0.476 (0.293, 0.774) (p = .0028) for each 10 year increase in age. Conclusions: Only just over half of manual wheelchair users are aware of the tilt-rest skill and one-third of users can perform it. Older people are less likely to report being able to complete the skill. These findings have implications for wheelchair skills training during the wheelchair-provision process. Implications for Rehabilitation Only just over half of manual wheelchair users are aware of the tilt-rest skill and only about one-third of users can perform it. Older people are less likely to report being able to complete the skill. These findings have clinical implications for wheelchair skills training during the, specifically that clinicians responsible for manual wheelchair-provision process should ensure that appropriate wheelchair users have the opportunity to learn this skill.


Assuntos
Pessoas com Deficiência , Conhecimentos, Atitudes e Prática em Saúde , Destreza Motora , Cadeiras de Rodas , Adulto , Idoso , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários
5.
Arthritis Rheumatol ; 71(2): 281-289, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30375754

RESUMO

OBJECTIVE: To determine, in a large, multiethnic/multiracial, prospective inception cohort of patients with systemic lupus erythematosus (SLE), the frequency, attribution, clinical, and autoantibody associations with lupus psychosis and the short- and long-term outcomes as assessed by physicians and patients. METHODS: Patients were evaluated annually for 19 neuropsychiatric (NP) events including psychosis. Scores on the Systemic Lupus Erythematosus Disease Activity Index 2000, the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index, and the Short Form 36 (SF-36) were recorded. Time to event and linear regressions were used as appropriate. RESULTS: Of 1,826 SLE patients, 88.8% were female and 48.8% were Caucasian. The mean ± SD age was 35.1 ± 13.3 years, the mean ± SD disease duration was 5.6 ± 4.2 months, and the mean ± SD follow-up period was 7.4 ± 4.5 years. There were 31 psychotic events in 28 of 1,826 patients (1.53%), and most patients had a single event (26 of 28 [93%]). In the majority of patients (20 of 25 [80%]) and events (28 of 31 [90%]), psychosis was attributed to SLE, usually either in the year prior to or within 3 years of SLE diagnosis. Positive associations (hazard ratios [HRs] and 95% confidence intervals [95% CIs]) with lupus psychosis were previous SLE NP events (HR 3.59 [95% CI 1.16-11.14]), male sex (HR 3.0 [95% CI 1.20-7.50]), younger age at SLE diagnosis (per 10 years) (HR 1.45 [95% CI 1.01-2.07]), and African ancestry (HR 4.59 [95% CI 1.79-11.76]). By physician assessment, most psychotic events resolved by the second annual visit following onset, in parallel with an improvement in patient-reported SF-36 summary and subscale scores. CONCLUSION: Psychosis is an infrequent manifestation of NPSLE. Generally, it occurs early after SLE onset and has a significant negative impact on health status. As determined by patient and physician report, the short- and long-term outlooks are good for most patients, although careful follow-up is required.


Assuntos
Vasculite Associada ao Lúpus do Sistema Nervoso Central/epidemiologia , Transtornos Psicóticos/epidemiologia , Adulto , Fatores Etários , Anticorpos Anticardiolipina/imunologia , Autoanticorpos/imunologia , Estudos de Coortes , Feminino , Humanos , Estimativa de Kaplan-Meier , Modelos Lineares , Inibidor de Coagulação do Lúpus/imunologia , Lúpus Eritematoso Sistêmico/epidemiologia , Lúpus Eritematoso Sistêmico/imunologia , Vasculite Associada ao Lúpus do Sistema Nervoso Central/imunologia , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Prospectivos , Transtornos Psicóticos/imunologia , Receptores de N-Metil-D-Aspartato/imunologia , Fatores Sexuais , Adulto Jovem , beta 2-Glicoproteína I/imunologia
6.
Endocr Connect ; 7(5): 768-776, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29712721

RESUMO

PURPOSE: Sellar masses may present either with clinical manifestations of mass effect/hormonal dysfunction (CMSM) or incidentally on imaging (pituitary incidentaloma (PI)). This novel population-based study compares these two entities. METHODS: Retrospective analysis of all patients within a provincial pituitary registry between January 2006 and June 2014. RESULTS: Nine hundred and three patients were included (681 CMSM, 222 PI). CMSM mainly presented with secondary hormone deficiencies (SHDs) or stalk compression (29.7%), whereas PIs were found in association with neurological complaints (34.2%) (P < 0.0001). PIs were more likely to be macroadenomas (70.7 vs 49.9%; P < 0.0001). The commonest pathologies among CMSM were prolactinomas (39.8%) and non-functioning adenomas (NFAs) (50%) in PI (P < 0.0001). SHDs were present in 41.3% CMSM and 31.1% PI patients (P < 0.0001) and visual field deficit in 24.2 and 29.3%, respectively (P = 0.16). CMSM were more likely to require surgery (62.9%) than PI (35.8%) (P < 0.0005). The commonest surgical indications were impaired vision and radiological evidence of optic nerve compression. Over a follow-up period of 5.7 years for CMSM and 5.0 years for PI, tumour growth/recurrence occurred in 7.8% of surgically treated CMSM and 2.6% without surgery and PI, 0 and 4.9%, respectively (P = 1.0). There were no significant differences in the risk of new-onset SHD in CMSM vs PI in those who underwent surgery (P = 0.7) and those who were followed without surgery (P = 0.58). CONCLUSIONS: This novel study compares the long-term trends of PI with CMSM, highlighting the need for comprehensive baseline and long-term radiological and hormonal evaluations in both entities.

7.
N Engl J Med ; 378(8): 699-707, 2018 02 22.
Artigo em Inglês | MEDLINE | ID: mdl-29466159

RESUMO

BACKGROUND: Clinical trials and meta-analyses have suggested that aspirin may be effective for the prevention of venous thromboembolism (proximal deep-vein thrombosis or pulmonary embolism) after total hip or total knee arthroplasty, but comparisons with direct oral anticoagulants are lacking for prophylaxis beyond hospital discharge. METHODS: We performed a multicenter, double-blind, randomized, controlled trial involving patients who were undergoing total hip or knee arthroplasty. All the patients received once-daily oral rivaroxaban (10 mg) until postoperative day 5 and then were randomly assigned to continue rivaroxaban or switch to aspirin (81 mg daily) for an additional 9 days after total knee arthroplasty or for 30 days after total hip arthroplasty. Patients were followed for 90 days for symptomatic venous thromboembolism (the primary effectiveness outcome) and bleeding complications, including major or clinically relevant nonmajor bleeding (the primary safety outcome). RESULTS: A total of 3424 patients (1804 undergoing total hip arthroplasty and 1620 undergoing total knee arthroplasty) were enrolled in the trial. Venous thromboembolism occurred in 11 of 1707 patients (0.64%) in the aspirin group and in 12 of 1717 patients (0.70%) in the rivaroxaban group (difference, 0.06 percentage points; 95% confidence interval [CI], -0.55 to 0.66; P<0.001 for noninferiority and P=0.84 for superiority). Major bleeding complications occurred in 8 patients (0.47%) in the aspirin group and in 5 (0.29%) in the rivaroxaban group (difference, 0.18 percentage points; 95% CI, -0.65 to 0.29; P=0.42). Clinically important bleeding occurred in 22 patients (1.29%) in the aspirin group and in 17 (0.99%) in the rivaroxaban group (difference, 0.30 percentage points; 95% CI, -1.07 to 0.47; P=0.43). CONCLUSIONS: Among patients who received 5 days of rivaroxaban prophylaxis after total hip or total knee arthroplasty, extended prophylaxis with aspirin was not significantly different from rivaroxaban in the prevention of symptomatic venous thromboembolism. (Funded by the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT01720108 .).


Assuntos
Artroplastia de Quadril , Artroplastia do Joelho , Aspirina/uso terapêutico , Inibidores do Fator Xa/uso terapêutico , Inibidores da Agregação de Plaquetas/uso terapêutico , Complicações Pós-Operatórias/prevenção & controle , Rivaroxabana/uso terapêutico , Tromboembolia Venosa/prevenção & controle , Idoso , Aspirina/efeitos adversos , Método Duplo-Cego , Inibidores do Fator Xa/efeitos adversos , Hemorragia/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/efeitos adversos , Fatores de Risco , Rivaroxabana/efeitos adversos
8.
Arthritis Care Res (Hoboken) ; 70(10): 1478-1487, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29316357

RESUMO

OBJECTIVE: To determine the frequency, characteristics, and outcomes of cerebrovascular events (CerVEs), as well as clinical and autoantibody associations in a multiethnic/racial inception cohort of patients with systemic lupus erythematosus (SLE). METHODS: A total of 1,826 patients were assessed annually for 19 neuropsychiatric (NP) events, including 5 types of CerVEs: 1) stroke, 2) transient ischemia, 3) chronic multifocal ischemia, 4) subarachnoid/intracranial hemorrhage, and 5) sinus thrombosis. Global disease activity (Systemic Lupus Erythematosus Disease [SLE] Activity Index 2000), damage scores (SLE International Collaborating Clinics/American College of Rheumatology Damage Index), and Short Form 36 (SF-36) scores were collected. Time to event, linear and logistic regressions, and multistate models were used as appropriate. RESULTS: CerVEs were the fourth most frequent NP event: 82 of 1,826 patients had 109 events; of these events, 103 were attributed to SLE, and 44 were identified at the time of enrollment. The predominant events were stroke (60 of 109 patients) and transient ischemia (28 of 109 patients). CerVEs were associated with other NP events attributed to SLE, non-SLE-attributed NP events, African ancestry (at US SLICC sites), and increased organ damage scores. Lupus anticoagulant increased the risk of first stroke and sinus thrombosis and transient ischemic attack. Physician assessment indicated resolution or improvement in the majority of patients, but patients reported sustained reduction in SF-36 summary and subscale scores following a CerVE. CONCLUSION: CerVEs, the fourth most frequent NP event in SLE, are usually attributable to lupus. In contrast to good physician-reported outcomes, patients reported a sustained reduction in health-related quality of life following a CerVE.


Assuntos
Transtornos Cerebrovasculares/imunologia , Lúpus Eritematoso Sistêmico/complicações , Adulto , Transtornos Cerebrovasculares/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Qualidade de Vida , Adulto Jovem
9.
Arch Phys Med Rehabil ; 99(7): 1295-1302.e9, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29305847

RESUMO

OBJECTIVE: To test the hypothesis that caregivers enhance the wheelchair skills capacity and confidence of the power wheelchair users to whom they provide assistance, and to describe the nature of that assistance. DESIGN: Multicenter cross-sectional study. SETTING: Rehabilitation centers and communities. PARTICIPANTS: Participants (N=152) included caregivers (n=76) and wheelchair users (n=76). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Version 4.3 of the Wheelchair Skills Test (WST) and the Wheelchair Skills Test-Questionnaire (WST-Q). For each of the 30 individual skills, we recorded data about the wheelchair user alone and in combination (blended) with the caregiver. RESULTS: The mean total WST capacity scores ± SD for the wheelchair users alone and blended were 78.1%±9.3% and 92.4%±6.1%, respectively, with a mean difference of 14.3%±8.7% (P<.0001). The mean WST-Q capacity scores ± SD were 77.0%±10.6% and 93.2%±6.4%, respectively, with a mean difference of 16.3%±9.8% (P<.0001). The mean WST-Q confidence scores ± SD were 75.5%±12.7% and 92.8%±6.8%, respectively, with a mean difference of 17.5%±11.7% (P<.0001). The mean differences corresponded to relative improvements of 18.3%, 21.0%, and 22.9%, respectively. The nature and benefits of the caregivers' assistance could be summarized in 7 themes (eg, caregiver provides verbal support [cueing, coaching, reporting about the environment]). CONCLUSIONS: Caregivers significantly enhance the wheelchair skills capacity and confidence of the power wheelchair users to whom they provide assistance, and they do so in a variety of ways. These findings have significance for wheelchair skills assessment and training.


Assuntos
Cuidadores/psicologia , Pessoas com Deficiência/psicologia , Autoimagem , Cadeiras de Rodas/psicologia , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Centros de Reabilitação , Inquéritos e Questionários
10.
Arthritis Care Res (Hoboken) ; 70(9): 1294-1302, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29193883

RESUMO

OBJECTIVE: Little is known about the long-term costs of lupus nephritis (LN). The costs were compared between patients with and without LN using multistate modeling. METHODS: Patients from 32 centers in 11 countries were enrolled in the Systemic Lupus International Collaborating Clinics inception cohort within 15 months of diagnosis and provided annual data on renal function, hospitalizations, medications, dialysis, and selected procedures. LN was diagnosed by renal biopsy or the American College of Rheumatology classification criteria. Renal function was assessed annually using the estimated glomerular filtration rate (GFR) or estimated proteinuria. A multistate model was used to predict 10-year cumulative costs by multiplying annual costs associated with each renal state by the expected state duration. RESULTS: A total of 1,545 patients participated; 89.3% were women, the mean ± age at diagnosis was 35.2 ± 13.4 years, 49% were white, and the mean followup duration was 6.3 ± 3.3 years. LN developed in 39.4% of these patients by the end of followup. Ten-year cumulative costs were greater in those with LN and an estimated glomerular filtration rate (GFR) <30 ml/minute ($310,579 2015 Canadian dollars versus $19,987 if no LN and estimated GFR >60 ml/minute) or with LN and estimated proteinuria >3 gm/day ($84,040 versus $20,499 if no LN and estimated proteinuria <0.25 gm/day). CONCLUSION: Patients with estimated GFR <30 ml/minute incurred 10-year costs 15-fold higher than those with normal estimated GFR. By estimating the expected duration in each renal state and incorporating associated annual costs, disease severity at presentation can be used to anticipate future health care costs. This is critical knowledge for cost-effectiveness evaluations of novel therapies.


Assuntos
Nefrite Lúpica/economia , Adulto , Estudos de Coortes , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Econômicos , Adulto Jovem
11.
Arch Phys Med Rehabil ; 98(10): 2097-2099.e7, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28579369

RESUMO

OBJECTIVES: To (1) document the success of learners' attempts to overcome a threshold in a manual wheelchair while using the momentum method; (2) describe the frequency and nature of any errors observed; and (3) compare the characteristics of participants who were or were not successful on their first attempts. DESIGN: Cross-sectional, observational study following Strengthening the Reporting of Observational Studies in Epidemiology guidelines. SETTING: Indoor obstacle course in a rehabilitation center. PARTICIPANTS: Able-bodied students (N=214) learning the threshold skill. INTERVENTION: Participants attempted to get over the Wheelchair Skills Test (WST) threshold (2cm high, 1.5m wide, and 10cm in the line of progression) in a manual wheelchair. MAIN OUTCOME MEASURES: From each participant's video recording of the first attempt, we assigned a WST score for the skill and described any errors noted. RESULTS: The WST scores for the first attempts were "pass" for 16 (7.5%), "pass with difficulty" for 100 (46.7%), and "fail" for 98 (45.8%). Eventually, requiring up to 6 attempts, 203 participants (94.9%) were successful (pass or pass with difficulty). Twenty-six different error types were identified. With the use of logistic regression analysis, the odds ratio of failing on the first attempt for women versus men was 2.71 (95% confidence interval, 1.23-6.00) (P=.0138). CONCLUSIONS: Only about half of able-bodied people learning the threshold skill using the momentum method are successful on their first attempts, although almost all are successful with further practice and feedback. During the first attempts, there are a wide variety of errors, primarily in the popping phase of the skill. Those who are successful on their first attempts are more likely to be men. These findings have implications for the assessment and training of the threshold skill.


Assuntos
Pessoas com Deficiência/reabilitação , Curva de Aprendizado , Cadeiras de Rodas , Estudos Transversais , Feminino , Humanos , Masculino , Centros de Reabilitação
12.
Int J Cardiol ; 244: 169-174, 2017 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-28634036

RESUMO

BACKGROUND: Post-hoc analyses of clinical trials and population-based studies have shown no difference in mortality between men and women, but often show that men are more likely to receive appropriate ICD therapy. We utilized a population-based registry to investigate the interaction of sex and age and the occurrence of ventricular arrhythmia in an ICD population. METHODS AND RESULTS: A total of 776 consecutive patients receiving an ICD for primary or secondary prevention in a provincial ICD registry were studied. No significant mortality difference was found between men and women (27.5% versus 23.7%, p=0.39). Overall, men were more likely to receive appropriate ICD therapy compared to women (39.3% versus 26.7%, p=0.006). The hazard ratio for appropriate therapy in men vs. women <60years of age was 3.22, CI 95% (1.56-6.65), p=0.002, and the same comparison in men vs. women over the age of 60 showed no significant difference (HR 1.11, CI 95% [0.74-1.65], p=0.61). This interaction between age and sex remained significant when adjusted for New York Heart Associated Class, ejection fraction, coronary artery disease and indication for ICD (p=0.02). CONCLUSIONS: This study demonstrates that the risk of appropriate ICD therapy increases as women are older, reaching similar risk as men in that age group. Further study of the mechanism of the interaction of age and sex as they modulate the occurrence of ventricular arrhythmia may be warranted.


Assuntos
Desfibriladores Implantáveis/tendências , Vigilância da População , Sistema de Registros , Fibrilação Ventricular/diagnóstico , Fibrilação Ventricular/fisiopatologia , Fatores Etários , Idoso , Estudos de Coortes , Desfibriladores Implantáveis/efeitos adversos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores Sexuais , Taxa de Sobrevida/tendências , Fibrilação Ventricular/mortalidade
13.
Can Urol Assoc J ; 11(9): E326-E329, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29382453

RESUMO

INTRODUCTION: Provincial/territorial cancer registries (PTCRs) are the mainstay for Canadian population-based cancer statistics. Each jurisdiction captures this data in a population-based registry, including the Nova Scotia Cancer Registry (NSCR). The goal of this study was to describe data from the NSCR regarding renal cell carcinoma (RCC) pathology subtype and method of diagnosis and compare it to the actual pathology reports to determine the accuracy of diagnosis and histological subtype assignment. METHODS: This retrospective analysis included patients diagnosed with RCC in the NSCR from 2006-2010 with an ICD-O-3 code C64.9 seen or treated in the largest NS health district. From the NSCR, method of diagnosis and pathological diagnosis was recorded. All diagnoses of non-clear-cell RCC (nonccRCC) from NSCR were compared to the actual pathology report for descriptive comparison and reasons for discordance. RESULTS: 723 patients make up the study cohort. 81.3% of patients were diagnosed by nephrectomy, 11.1% radiography, 6.9 % biopsy, and 0.7% autopsy. By NSCR data, 52.8% had clear-cell (ccRCC), 20.5% RCC not otherwise specified (NOS), 12.7% papillary, 4% chromophobe, and the rest had other nonccRCC subtypes. By pathology reports, 69.5% had clear-cell, 15% papillary, 5% chromophobe, only 2.7% RCC NOS. There was a discordance rate of 15.4% between NSCR data and diagnosis from pathology report. Reasons for discordance were not enough information by the pathologist in 45.5%, misinterpretation of report by data coder in 22.2%, and true coding error in 32.3%. CONCLUSIONS: When using PTCR for RCC incidence data, it is important to understand how the diagnosis is made, as not all are based on pathological confirmation; in this cohort 11% were based on radiology. One must also be aware that clear-cell and non-clear-cell subtypes may differ between the PTCR data and pathology reports. In this study, ccRCC made up 52.8% of the registry diagnoses, but increased to 69.6% on pathology report review. Use of synoptic reporting and ongoing education may improve accuracy of registry data.

14.
Eur J Endocrinol ; 175(1): 1-9, 2016 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-27037179

RESUMO

OBJECTIVES: Pituitary incidentalomas (PI) are frequently found on brain imaging. Despite their high prevalence, little is known about their long-term natural history and there are limited guidelines on how to monitor them. METHODS: We conducted a retrospective study to compare epidemiological characteristics at presentation and the natural history of PI in population-based vs referral-based registries from two tertiary-care referral centers in Canada. RESULTS: A total of 328 patients with PI were included, of whom 73% had pituitary adenomas (PA) and 27% had non-pituitary sellar masses. The commonest indications for imaging were headache (28%), dizziness (12%) and stroke/transient ischemic attack (TIA) (9%). There was a slight female preponderance (52%) with a median age of 55 years at diagnosis; 71% presented as macroadenomas (>10mm). Of PA, 25% were functioning tumors and at presentation 36% of patients had evidence of secondary hormonal deficiency (SHD). Of the total cohort, 68% were treated medically or conservatively whereas 32% required surgery. Most tumors (87% in non-surgery and 68% in post-surgery group) remained stable during follow-up. Similarly, 84% of patients in the non-surgery and 73% in the surgery group did not develop additional SHD during follow-up. The diagnosis of non-functioning adenoma was a risk factor for tumor enlargement and a change in SHD status was associated with a change in tumor size. CONCLUSIONS: Our data suggest that most PI seen in tertiary-care referral centers present as macroadenomas and may frequently be functional, often requiring medical or surgical intervention.


Assuntos
Adenoma/diagnóstico por imagem , Achados Incidentais , Neoplasias Hipofisárias/diagnóstico por imagem , Adenoma/epidemiologia , Adenoma/cirurgia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Hipofisárias/epidemiologia , Neoplasias Hipofisárias/cirurgia , Prevalência , Sistema de Registros , Estudos Retrospectivos , Resultado do Tratamento
15.
Arthritis Rheumatol ; 68(8): 1932-44, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-26991067

RESUMO

OBJECTIVE: To study bidirectional change and predictors of change in estimated glomerular filtration rate (GFR) and proteinuria in lupus nephritis (LN) using a multistate modeling approach. METHODS: Patients in the Systemic Lupus International Collaborating Clinics inception cohort were classified annually into estimated GFR state 1 (>60 ml/minute), state 2 (30-60 ml/minute), or state 3 (<30 ml/minute) and estimated proteinuria state 1 (<0.25 gm/day), state 2 (0.25-3.0 gm/day), or state 3 (>3.0 gm/day), or end-stage renal disease (ESRD) or death. Using multistate modeling, relative transition rates between states indicated improvement and deterioration. RESULTS: Of 1,826 lupus patients, 700 (38.3%) developed LN. During a mean ± SD follow-up of 5.2 ± 3.5 years, the likelihood of improvement in estimated GFR and estimated proteinuria was greater than the likelihood of deterioration. After 5 years, 62% of patients initially in estimated GFR state 3 and 11% of patients initially in estimated proteinuria state 3 transitioned to ESRD. The probability of remaining in the initial states 1, 2, and 3 was 85%, 11%, and 3%, respectively, for estimated GFR and 62%, 29%, and 4%, respectively, for estimated proteinuria. Male sex predicted improvement in estimated GFR states; older age, race/ethnicity, higher estimated proteinuria state, and higher renal biopsy chronicity scores predicted deterioration. For estimated proteinuria, race/ethnicity, earlier calendar years, damage scores without renal variables, and higher renal biopsy chronicity scores predicted deterioration; male sex, presence of lupus anticoagulant, class V nephritis, and mycophenolic acid use predicted less improvement. CONCLUSION: In LN, the expected improvement or deterioration in renal outcomes can be estimated by multistate modeling and is preceded by identifiable risk factors. New therapeutic interventions for LN should meet or exceed these expectations.


Assuntos
Taxa de Filtração Glomerular , Falência Renal Crônica/etiologia , Nefrite Lúpica/complicações , Nefrite Lúpica/fisiopatologia , Proteinúria/etiologia , Adulto , Feminino , Humanos , Internacionalidade , Estudos Longitudinais , Masculino , Modelos Estatísticos
16.
Rheumatology (Oxford) ; 55(2): 252-62, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26342222

RESUMO

OBJECTIVE: To determine nephritis outcomes in a prospective multi-ethnic/racial SLE inception cohort. METHODS: Patients in the Systemic Lupus International Collaborating Clinics inception cohort (≤15 months of SLE diagnosis) were assessed annually for estimated glomerular filtration rate (eGFR), proteinuria and end-stage renal disease (ESRD). Health-related quality of life was measured by the Short Form (36 questions) health survey questionnaire (SF-36) subscales, mental and physical component summary scores. RESULTS: There were 1827 patients, 89% females, mean (s.d.) age 35.1 (13.3) years. The mean (s.d.) SLE duration at enrolment was 0.5 (0.3) years and follow-up 4.6 (3.4) years. LN occurred in 700 (38.3%) patients: 566/700 (80.9%) at enrolment and 134/700 (19.1%) during follow-up. Patients with nephritis were younger, more frequently men and of African, Asian and Hispanic race/ethnicity. The estimated overall 10-year incidence of ESRD was 4.3% (95% CI: 2.8%, 5.8%), and with nephritis was 10.1% (95% CI: 6.6%, 13.6%). Patients with nephritis had a higher risk of death (HR = 2.98, 95% CI: 1.48, 5.99; P = 0.002) and those with eGFR <30 ml/min at diagnosis had lower SF-36 physical component summary scores (P < 0.01) and lower Physical function, Physical role and Bodily pain scores. Over time, patients with abnormal eGFR and proteinuria had lower SF-36 mental component summary (P ≤ 0.02) scores compared to patients with normal values. CONCLUSION: LN occurred in 38.3% of SLE patients, frequently as the initial presentation, in a large multi-ethnic inception cohort. Despite current standard of care, nephritis was associated with ESRD and death, and renal insufficiency was linked to lower health-related quality of life. Further advances are required for the optimal treatment of LN.


Assuntos
Grupos Étnicos , Nefrite Lúpica/etnologia , Avaliação de Resultados em Cuidados de Saúde , Adulto , Progressão da Doença , Feminino , Seguimentos , Saúde Global , Humanos , Incidência , Nefrite Lúpica/diagnóstico , Masculino , Estudos Prospectivos , Qualidade de Vida , Fatores de Risco , Inquéritos e Questionários , Taxa de Sobrevida/tendências
17.
Can J Neurol Sci ; 43(2): 291-7, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26522017

RESUMO

BACKGROUND: Sellar masses (SM) are mostly benign growths of pituitary or nonpituitary origin that are increasingly encountered in clinical practice. To date, no comprehensive population-based study has reported the epidemiology of SM from North America. AIM: To determine the epidemiology of SM in the province of Nova Scotia, Canada. METHODS: Data from all pituitary-related referrals within the province were prospectively collected in interlinked computerized registries starting in November 2005. We conducted a retrospective analysis on all patients with SM seen within the province between November 2005 and December 2013. RESULTS: A total of 1107 patients were identified, of which 1005 were alive and residing within the province. The mean age at presentation was 44.6±18 years, with an overall female preponderance (62%) and a population prevalence rate of 0.1%. Of patients with SM, 837 (83%) had pituitary adenomas and 168 (17%) had nonpituitary lesions. The relative prevalence and standardized incidence ratio, respectively, of various SM were: nonfunctioning adenomas (38.4%; 2.34), prolactinomas (34.3%; 2.22), Rathke's cyst (6.5%; 0.5), growth hormone-secreting adenomas (6.5%; 0.3), craniopharyngiomas (4.5%; 0.2), adrenocorticotropic hormone-secreting adenomas (3.8%; 0.2), meningiomas (1.9%), and others (3.9%; 0.21). At presentation, 526 (52.3%) had masses ≥1 cm, 318 (31.6%) at <1 cm, and 11 (1.1%) had functioning pituitary adenomas without discernible tumor, whereas tumor size data were unavailable in 150 (14.9%) patients. The specific pathologies and their most common presenting features were: nonfunctioning adenoma (incidental, headaches, and vision loss), prolactinomas (galactorrhea, menstrual irregularity, and headache), growth hormone-secreting adenomas (enlarging extremities and sweating), adrenocorticotropic hormone-secreting adenoma (easy bruising, muscle wasting, and weight gain) and nonpituitary lesions (incidental, headaches, and vision problems). Secondary hormonal deficiencies were common, ranging from 19.6% to 65.7%; secondary hypogonadism, hypothyroidism, and growth hormone deficiencies constituted the majority of these abnormalities. CONCLUSIONS: This is the largest North American study to date to assess the epidemiology of SM in a large stable population. Given their significant prevalence in the general population, more studies are needed to evaluate the natural history of these masses and to help allocate appropriate resources for their management.


Assuntos
Neoplasias Hipofisárias/epidemiologia , Adulto , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Nova Escócia/epidemiologia , Prevalência , Sistema de Registros
18.
Arch Phys Med Rehabil ; 96(11): 2017-26.e3, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26232684

RESUMO

OBJECTIVES: To test the hypothesis that powered wheelchair users who receive the Wheelchair Skills Training Program (WSTP) improve their wheelchair skills in comparison with a control group that receives standard care, and secondarily to assess goal achievement, satisfaction with training, retention, injury rate, confidence with wheelchair use, and participation. DESIGN: Randomized controlled trial. SETTING: Rehabilitation centers and communities. PARTICIPANTS: Powered wheelchair users (N=116). INTERVENTION: Five 30-minute WSTP training sessions. MAIN OUTCOME MEASURES: Assessments were done at baseline (t1), posttraining (t2), and 3 months posttraining (t3) using the Wheelchair Skills Test Questionnaire (WST-Q version 4.1), Goal Attainment Score (GAS), Satisfaction Questionnaire, injury rate, Wheelchair Use Confidence Scale for Power Wheelchair Users (WheelCon), and Life Space Assessment (LSA). RESULTS: There was no significant t2-t1 difference between the groups for WST-Q capacity scores (P=.600), but the difference for WST-Q performance scores was significant (P=.016) with a relative (t2/t1 × 100%) improvement of the median score for the intervention group of 10.8%. The mean GAS ± SD for the intervention group after training was 92.8%±11.4%, and satisfaction with training was high. The WST-Q gain was not retained at t3. There was no clinically significant difference between the groups in injury rate and no statistically significant differences in WheelCon or LSA scores at t3. CONCLUSIONS: Powered wheelchair users who receive formal wheelchair skills training demonstrate modest, transient posttraining improvements in their WST-Q performance scores, have substantial improvements on individualized goals, and are positive about training.


Assuntos
Pessoas com Deficiência/reabilitação , Educação de Pacientes como Assunto/organização & administração , Centros de Reabilitação , Cadeiras de Rodas , Adulto , Idoso , Fontes de Energia Elétrica , Feminino , Objetivos , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Método Simples-Cego
19.
Arthritis Rheumatol ; 67(7): 1837-47, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25778456

RESUMO

OBJECTIVE: To examine the frequency, characteristics, and outcome of mood disorders, as well as clinical and autoantibody associations, in a multiethnic/racial, prospective inception cohort of patients with systemic lupus erythematosus (SLE). METHODS: Patients were assessed annually for mood disorders (4 types, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) and 18 other neuropsychiatric events. Global disease activity scores (SLE Disease Activity Index 2000 [SLEDAI-2K]), damage scores (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index [SDI]), and Short Form 36 subscales, mental and physical component summary scores were collected. Time to event, linear and ordinal regressions, and multi-state models were used as appropriate. RESULTS: Among the 1,827 patients with SLE, 88.9% were female, and 48.9% were Caucasian. The mean ± SD age of the patients was 35.1 ± 13.3 years, disease duration was 5.6 ± 4.8 months, and the length of followup was 4.7 ± 3.5 years. During the course of the study, 863 (47.2%) of the 1,827 patients had 1,627 neuropsychiatric events. Mood disorders occurred in 232 (12.7%) of 1,827 patients, and 98 (38.3%) of 256 mood disorder events were attributed to SLE. The estimated cumulative incidence of any mood disorder after 10 years was 17.7% (95% confidence interval 15.1, 20.2%). A greater risk of mood disorder was associated with concurrent neuropsychiatric events (P ≤ 0.01), and a lower risk was associated with Asian race/ethnicity (P = 0.01) and treatment with immunosuppressive drugs (P = 0.003). Mood disorders were associated with lower mental health and mental component summary scores but not with the SLEDAI-2K, SDI, or lupus autoantibodies. Among the 232 patients with depression, 168 (72.4%) were treated with antidepressants. One hundred twenty-six (49.2%) of 256 mood disorders resolved in 117 (50.4%) of 232 patients. CONCLUSION: Mood disorders, the second most frequent neuropsychiatric event in patients with SLE, have a negative impact on health-related quality of life and improve over time. The lack of association with global SLE disease activity, cumulative organ damage, and lupus autoantibodies emphasizes the multifactorial etiology of mood disorders and a role for non-lupus-specific therapies.


Assuntos
Internacionalidade , Lúpus Eritematoso Sistêmico/etnologia , Lúpus Eritematoso Sistêmico/psicologia , Transtornos do Humor/epidemiologia , Transtornos do Humor/psicologia , Qualidade de Vida/psicologia , Adulto , Grupo com Ancestrais do Continente Africano , Grupo com Ancestrais do Continente Asiático , Autoanticorpos/sangue , Estudos de Coortes , Progressão da Doença , Grupo com Ancestrais do Continente Europeu , Feminino , Hispano-Americanos , Humanos , Incidência , Lúpus Eritematoso Sistêmico/imunologia , Masculino , Pessoa de Meia-Idade , Transtornos do Humor/etnologia , Estudos Prospectivos , Análise de Regressão
20.
Arthritis Rheum ; 65(11): 2887-97, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-24166793

RESUMO

OBJECTIVE: To examine the frequency and characteristics of headaches and their association with global disease activity and health-related quality of life (HRQOL) in patients with systemic lupus erythematosus (SLE). METHODS: A disease inception cohort was assessed annually for headache (5 types) and 18 other neuropsychiatric (NP) events. Global disease activity scores (SLE Disease Activity Index 2000 [SLEDAI-2K]), damage scores (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index [SDI]), and Short Form 36 (SF-36) mental and physical component summary scores were collected. Time to first headache and associations with SF-36 scores were analyzed using Cox proportional hazards and linear regression models with generalized estimating equations. RESULTS: Among the 1,732 SLE patients enrolled, 89.3% were female and 48.3% were white. The mean ± SD age was 34.6 ± 13.4 years, duration of disease was 5.6 ± 5.2 months, and length of followup was 3.8 ± 3.1 years. At enrollment, 17.8% of patients had headache (migraine [60.7%], tension [38.6%], intractable nonspecific [7.1%], cluster [2.6%], and intracranial hypertension [1.0%]). The prevalence of headache increased to 58% after 10 years. Only 1.5% of patients had lupus headache, as identified in the SLEDAI-2K. In addition, headache was associated with other NP events attributed to either SLE or non-SLE causes. There was no association of headache with SLEDAI-2K scores (without the lupus headache variable), SDI scores, use of corticosteroids, use of antimalarials, use of immunosuppressive medications, or specific autoantibodies. SF-36 mental component scores were lower in patients with headache compared with those without headache (mean ± SD 42.5 ± 12.2 versus 47.8 ± 11.3; P < 0.001), and similar differences in physical component scores were seen (38.0 ± 11.0 in those with headache versus 42.6 ± 11.4 in those without headache; P < 0.001). In 56.1% of patients, the headaches resolved over followup. CONCLUSION: Headache is frequent in SLE, but overall, it is not associated with global disease activity or specific autoantibodies. Although headaches are associated with a lower HRQOL, the majority of headaches resolve over time, independent of lupus-specific therapies.


Assuntos
Autoanticorpos/sangue , Cefaleia/epidemiologia , Cefaleia/imunologia , Lúpus Eritematoso Sistêmico/epidemiologia , Lúpus Eritematoso Sistêmico/imunologia , Adulto , Cefaleia Histamínica/epidemiologia , Cefaleia Histamínica/imunologia , Feminino , Seguimentos , Humanos , Internacionalidade , Hipertensão Intracraniana/epidemiologia , Hipertensão Intracraniana/imunologia , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Transtornos de Enxaqueca/epidemiologia , Transtornos de Enxaqueca/imunologia , Modelos de Riscos Proporcionais , Estudos Prospectivos , Qualidade de Vida , Cefaleia do Tipo Tensional/epidemiologia , Cefaleia do Tipo Tensional/imunologia , Adulto Jovem
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