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3.
Med Clin North Am ; 104(2): 199-211, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32035564

RESUMO

This article summarizes stroke rehabilitation, with a particular focus on rehabilitation from acute diagnosis to chronic impairments of stroke. The emphasis is on both pharmacologic and nonpharmacologic intervention and interdisciplinary collaboration.


Assuntos
Comunicação Interdisciplinar , Administração dos Cuidados ao Paciente/métodos , Reabilitação do Acidente Vascular Cerebral/métodos , Humanos
4.
Med Clin North Am ; 104(2): 213-238, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32035565

RESUMO

Traumatic brain injury (TBI) is an acquired insult to the brain from an external mechanical force that may result in temporary or permanent impairment. The goal of this article is to provide a general review of the epidemiology, pathophysiology and medical management of adult patients with TBI for providers practicing outside the field of physical medicine and rehabilitation. The medical and rehabilitation management of moderate to severe TBI is the focus of this article, with a brief discussion of the management of mild injuries.


Assuntos
Lesões Encefálicas Traumáticas , Administração dos Cuidados ao Paciente/métodos , Lesões Encefálicas Traumáticas/epidemiologia , Lesões Encefálicas Traumáticas/fisiopatologia , Lesões Encefálicas Traumáticas/terapia , Humanos , Prognóstico , Resultado do Tratamento
5.
Med Clin North Am ; 104(2): 263-278, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32035568

RESUMO

Individuals with spinal cord injuries or disorders (SCI/D), whether of traumatic or nontraumatic cause, require multidisciplinary management by their care team to achieve optimal health outcomes. SCI/D is relatively rare in the general population and primary care providers (PCPs) may not have extensive experience managing people with these disorders. Spinal cord injuries, impair the body's autonomic and biomechanical performance by interrupting the communications to and from major bodily systems. This article provides a framework to help PCPs understand how these changes impact their patient's physiologic function and subsequent risks for health complications with guidance for initial treatment approaches.


Assuntos
Administração dos Cuidados ao Paciente/métodos , Traumatismos da Medula Espinal , Doença Crônica , Humanos , Equipe de Assistência ao Paciente/organização & administração , Traumatismos da Medula Espinal/fisiopatologia , Traumatismos da Medula Espinal/terapia
6.
Med Clin North Am ; 104(2): 279-292, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32035569

RESUMO

Neck pain is the fourth leading cause of disability. Acute neck pain largely resolves within 2 months. History and physical examination play a key role in ruling out some of the more serious causes for neck pain. The evidence for pharmacologic interventions for acute and chronic musculoskeletal neck pain is limited. Lower back pain is the leading cause of disability and productivity loss. Consultation with a physical medicine and rehabilitation spine specialist within 48 hours for acute pain and within 10 days for all patients with lower back pain may significantly decrease rate of surgical interventions and increase patient satisfaction.


Assuntos
Dor Lombar , Cervicalgia , Administração dos Cuidados ao Paciente/métodos , Humanos , Dor Lombar/diagnóstico , Dor Lombar/terapia , Cervicalgia/diagnóstico , Cervicalgia/terapia , Prognóstico , Tempo para o Tratamento
7.
Med Clin North Am ; 104(2): 293-311, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32035570

RESUMO

Osteoarthritis (OA) is a worldwide endemic and debilitating disease. Previously thought to simply be damaged from "wear and tear," OA is now understood to be a complex interaction of local and systemic factors. This article reviews the pathology, symptoms, diagnosis, and various conservative, surgical, and novel treatments of OA.


Assuntos
Osteoartrite , Administração dos Cuidados ao Paciente/métodos , Humanos , Osteoartrite/diagnóstico , Osteoartrite/fisiopatologia , Osteoartrite/terapia
8.
Med Clin North Am ; 104(2): 313-325, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32035571

RESUMO

Each year increasing numbers of people participate in a wider variety of athletic endeavors. Unlike previous generations, many patients remain in these activities later into their lives, some well beyond retirement. As the population ages and their activities continue, they are subject to injury of various forms affecting all aspects of their bodies.


Assuntos
Traumatismos em Atletas , Atividades de Lazer , Administração dos Cuidados ao Paciente/métodos , Traumatismos em Atletas/classificação , Traumatismos em Atletas/etiologia , Traumatismos em Atletas/prevenção & controle , Traumatismos em Atletas/terapia , Comportamentos de Risco à Saúde/fisiologia , Humanos , Comportamento Sedentário , Fatores de Tempo
9.
Isr Med Assoc J ; 22(2): 111-115, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32043329

RESUMO

BACKGROUND: Despite advances in therapeutic modalities, especially with biologic treatments, the number of hospitalizations due to complications for Crohn's disease did not decrease. We examined the prevalence and possible predictive factors of hospitalizations in Crohn's disease. A systematic literature search was conducted until 31 October 2018. Relevant studies were screened according to established protocol. Retrospective cohort studies describing hospitalizations of Crohn's disease patients were included. Meta-analysis was performed by using comprehensive meta-analysis software. Pooled odds ratios (ORs) and 95% confidence intervals (95%CIs) were calculated for the number of patients hospitalized. Twelve studies published before 31 March 2018 fulfilled the inclusion criteria and were comprised of 23 data-sets and included 4421 patients from six countries. A funnel plot demonstrates a moderate publication bias. We reported the event rates for the number of patients hospitalized, in a follow-up survey of 20,987 patient-years, and for the patients who underwent surgery in a follow-up of 5061 patient-years, with ORs of 0.233 with 95%CI 0.227-0.239, and 0.124 with 95%CI 0.114-0.135 (P < 0.001), respectively. Thus, when collecting the data from 12 cohort studies we found that hospitalization takes place in 23.3% of the patients, and operation in 12.4% along their disease duration. Patients with Crohn's disease may be hospitalized due to exacerbation of their inflammatory disease, because of non-inflammatory disease (such as fistula or stricture), or due to medical complications. The goal of therapy should be to keep the Crohn's disease patients in their natural environment and out of the hospital and to prevent surgery as much as possible.


Assuntos
Doença de Crohn/terapia , Hospitalização/estatística & dados numéricos , Humanos , Administração dos Cuidados ao Paciente/métodos , Estudos Retrospectivos
10.
Dis Colon Rectum ; 63(2): 217-225, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31914114

RESUMO

BACKGROUND: The true incidence of, and risk factors for, readmission for treatment failure after nonoperative management of acute diverticulitis remain poorly understood. OBJECTIVE: The purpose of this study was to describe the incidence and risk factors for readmission for treatment failure after nonoperative management of acute diverticulitis using a large national database. DESIGN: This was a retrospective cohort study. SETTINGS: A representative sample of admissions and discharges from hospitals in the United States captured in the National Readmissions Database were included. PATIENTS: Adult patients (age ≥18 y) admitted with a primary diagnostic of colonic diverticulitis between 2010 and 2015 and who were managed nonoperatively and discharged from hospital alive were included. INTERVENTIONS: Study intervention included nonoperative management, consisting of medical therapy with or without percutaneous drainage. MAIN OUTCOME MEASURES: Readmission for treatment failure (defined as a nonelective readmission for diverticulitis within 90 d of discharge), complicated treatment failure (defined as a treatment failure with complicated diverticulitis), and time-to-treatment failure were measured. RESULTS: In total, 201,384 patients were included. The overall incidence of readmission for treatment failure was 6.6%. Treatment failure was significantly higher among patients with an index episode of acute complicated diverticulitis compared with acute uncomplicated diverticulitis (12.5% vs 5.7%; p < 0.001). The median time-to-readmission for treatment failure was 21.0 days (range, 20.4-21.6 d), and 85% of all readmissions occurred within 60 days of discharge. On multiple logistic regression, factors independently associated with readmission for treatment failure were an index admission of complicated diverticulitis (OR = 2.06 (95% CI, 1.97-2.16)), disposition on discharge (against medical advice: OR = 1.92 (95% CI, 1.66-2.20); home health care arrangements: OR = 1.24 (95% CI, 1.16-1.33)), and immunosuppression (OR = 1.42 (95% CI, 1.28-1.57)), among others. Risk factors for a complicated treatment failure were also described, after an index episode of complicated and uncomplicated diverticulitis. LIMITATIONS: The study was limited by residual confounding from missing covariates and its observational study design. CONCLUSIONS: The incidence of readmission for treatment failure after an episode of diverticulitis managed nonoperatively is 6.6%, and an index episode of complicated diverticulitis is the strongest risk factor for treatment failure. See Video Abstract at http://links.lww.com/DCR/B92. REINGRESO POR FRACASO DEL TRATAMIENTO DESPUÉS DEL TRATAMIENTO NO QUIRÚRGICO DE LA DIVERTICULITIS AGUDA: UN ANÁLISIS DE LA BASE DE DATOS DE REINGRESOS A NIVEL NACIONAL: La verdadera incidencia y los factores de riesgo para el reingreso por fracaso del tratamiento después de manejo no quirúrgico de la diverticulitis aguda siguen siendo mal definidos.Definir la incidencia y los factores de riesgo de reingreso por fracaso del tratamiento no quirúrgico de la diverticulitis aguda utilizando una base de datos nacional.Estudio de cohorte retrospectivo.Una muestra representativa de ingresos y egresos de hospitales en los Estados Unidos capturados en la base de datos nacional de reingresos hospitalarios.Pacientes adultos (≥18 años) ingresados con un diagnóstico primario de diverticulitis colónica entre 2010-2015, y que fueron tratados de forma no operativa y dados de alta del hospital vivos.Manejo no quirúrgico, que consiste en terapia médica con o sin drenaje percutáneo.Reingreso por fracaso del tratamiento (definido como un reingreso no electivo por diverticulitis dentro de los 90 días despues de ser dados de alta), fracaso del tratamiento complicado (definido como un fracaso del tratamiento con diverticulitis complicada) y el tiempo hasta el tratamiento en casos fracasaados.201.384 pacientes incluidos en total. La incidencia global de reingreso por fracaso del tratamiento fue del 6,6%. El fracaso del tratamiento fue significativamente mayor entre los pacientes con un episodio índice de diverticulitis aguda complicada en comparación con la diverticulitis aguda no complicada (12.5% vs. 5.7%, p <0.001). La mediana del tiempo hasta el reingreso por fracaso del tratamiento fue de 21.0 (20.4 - 21.6) días, y el 85% de todos los reingresos ocurrieron dentro de los 60 días posteriores a ser dados de alta. En la regresión logística múltiple, los factores asociados independientemente con el reingreso por fracaso del tratamiento fueron un índice de admisión de diverticulitis complicada (OR 2.06, IC 95% 1.97-2.16), disposición (de alta en contra del consejo médico: OR 1.92, IC 95% 1.66-2.2; atención médica domiciliaria: OR 1.24, IC 95% 1.16-1.33) e inmunosupresión (OR 1.42, IC 95% 1.28-1.57), entre otros. Los factores de riesgo para un fracaso del tratamiento complicado también se describieron, respectivamente, después de un episodio índice de diverticulitis complicada y no complicada.Covariables faltantes y diseño de estudio observacional.La incidencia de reingreso por fracaso del tratamiento después de un episodio de diverticulitis manejado de forma no operativa es del 6,6%, y un episodio índice de diverticulitis complicada es el factor de riesgo más fuerte para el fracaso del tratamiento. Consulte Video Resumen en http://links.lww.com/DCR/B92. (Traducción-Dr. Adrian E. Ortega).


Assuntos
Diverticulite/terapia , Administração dos Cuidados ao Paciente/tendências , Readmissão do Paciente/estatística & dados numéricos , Doença Aguda , Idoso , Bases de Dados Factuais , Diverticulite/epidemiologia , Drenagem/métodos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Tempo para o Tratamento/estatística & dados numéricos , Falha de Tratamento , Estados Unidos/epidemiologia
11.
Mayo Clin Proc ; 95(1): 136-156, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31902409

RESUMO

Globally, cardiovascular disease remains a major cause of adverse outcomes in young individuals, unlike its decline in other age groups. This group is not well studied and has a unique risk profile with less traditional cardiovascular risk factors compared with older populations. Plaque rupture still remains the most common etiology of myocardial infarction, but unique syndromes such as plaque erosion, coronary microvascular dysfunction, spontaneous coronary artery dissection, and coronary spasm related to drug use are more prevalent in this age group. Such diversity of diagnosis and presentation, along with therapeutic implications, underscore the need to study the profile of myocardial infarction in young persons. We searched PubMed for articles published from 1980 to 218 using the terms acute myocardial infarction, young, plaque rupture, plaque erosion, spontaneous coronary artery dissection (SCAD), coronary vasospasm, variant or Prinzmetal angina, drug-induced myocardial infarction, myocarditis, coronary embolism, microvascular dysfunction, MINOCA, and myocardial infarction in pregnancy and reviewed all the published studies. With the data from this search, we aim to inform readers of the prevalence, risk factors, presentation, and management of acute myocardial infarction in young patients and elaborate on special subgroups with diagnostic and therapeutic challenges. We also outline a parsimonious method designed to simplify management of these complex patients.


Assuntos
Infarto do Miocárdio , Administração dos Cuidados ao Paciente/métodos , Adulto , Idade de Início , Causalidade , Humanos , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/terapia , Prognóstico , Fatores de Risco
13.
N Engl J Med ; 382(2): 152-162, 2020 01 09.
Artigo em Inglês | MEDLINE | ID: mdl-31914242

RESUMO

BACKGROUND: There is widespread interest in programs aiming to reduce spending and improve health care quality among "superutilizers," patients with very high use of health care services. The "hotspotting" program created by the Camden Coalition of Healthcare Providers (hereafter, the Coalition) has received national attention as a promising superutilizer intervention and has been expanded to cities around the country. In the months after hospital discharge, a team of nurses, social workers, and community health workers visits enrolled patients to coordinate outpatient care and link them with social services. METHODS: We randomly assigned 800 hospitalized patients with medically and socially complex conditions, all with at least one additional hospitalization in the preceding 6 months, to the Coalition's care-transition program or to usual care. The primary outcome was hospital readmission within 180 days after discharge. RESULTS: The 180-day readmission rate was 62.3% in the intervention group and 61.7% in the control group. The adjusted between-group difference was not significant (0.82 percentage points; 95% confidence interval, -5.97 to 7.61). In contrast, a comparison of the intervention-group admissions during the 6 months before and after enrollment misleadingly suggested a 38-percentage-point decline in admissions related to the intervention because the comparison did not account for the similar decline in the control group. CONCLUSIONS: In this randomized, controlled trial involving patients with very high use of health care services, readmission rates were not lower among patients randomly assigned to the Coalition's program than among those who received usual care. (Funded by the National Institute on Aging and others; ClinicalTrials.gov number, NCT02090426; American Economic Association registry number, AEARCTR-0000329.).


Assuntos
Doença Crônica/terapia , Hospitalização/estatística & dados numéricos , Administração dos Cuidados ao Paciente/métodos , Readmissão do Paciente/estatística & dados numéricos , Adulto , Idoso , Assistência Ambulatorial/estatística & dados numéricos , Custos de Cuidados de Saúde , Visita Domiciliar , Humanos , Modelos Lineares , Pessoa de Meia-Idade , New Jersey , Administração dos Cuidados ao Paciente/organização & administração , Sumários de Alta do Paciente Hospitalar , Estudos Prospectivos , Fatores Socioeconômicos , Estados Unidos
14.
BMJ ; 368: l6968, 2020 01 29.
Artigo em Inglês | MEDLINE | ID: mdl-31996352

RESUMO

OBJECTIVE: To examine the distribution and patterns of opioid prescribing in the United States. DESIGN: Retrospective, observational study. SETTING: National private insurer covering all 50 US states and Washington DC. PARTICIPANTS: An annual average of 669 495 providers prescribing 8.9 million opioid prescriptions to 3.9 million patients from 2003 through 2017. MAIN OUTCOME MEASURES: Standardized doses of opioids in morphine milligram equivalents (MMEs) and number of opioid prescriptions. RESULTS: In 2017, the top 1% of providers accounted for 49% of all opioid doses and 27% of all opioid prescriptions. In absolute terms, the top 1% of providers prescribed an average of 748 000 MMEs-nearly 1000 times more than the middle 1%. At least half of all providers in the top 1% in one year were also in the top 1% in adjacent years. More than two fifths of all prescriptions written by the top 1% of providers were for more than 50 MMEs a day and over four fifths were for longer than seven days. In contrast, prescriptions written by the bottom 99% of providers were below these thresholds, with 86% of prescriptions for less than 50 MMEs a day and 71% for fewer than seven days. Providers prescribing high amounts of opioids and patients receiving high amounts of opioids persisted over time, with over half of both appearing in adjacent years. CONCLUSIONS: Most prescriptions written by the majority of providers are under the recommended thresholds, suggesting that most US providers are careful in their prescribing. Interventions focusing on this group of providers are unlikely to effect beneficial change and could induce unnecessary burden. A large proportion of providers have established relationships with their patients over multiple years. Interventions to reduce inappropriate opioid prescribing should be focused on improving patient care, management of patients with complex pain, and reducing comorbidities rather than seeking to enforce a threshold for prescribing.


Assuntos
Analgésicos Opioides/uso terapêutico , Prescrição Inadequada/prevenção & controle , Administração dos Cuidados ao Paciente/normas , Médicos , Padrões de Prática Médica , Adulto , Prescrições de Medicamentos/normas , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Revisão da Utilização de Seguros/estatística & dados numéricos , Masculino , Médicos/classificação , Médicos/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Padrões de Prática Médica/tendências , Medicamentos sob Prescrição/uso terapêutico , Melhoria de Qualidade , Estudos Retrospectivos , Estados Unidos/epidemiologia
15.
J Clin Psychiatry ; 81(2)2020 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-31995679

RESUMO

Valbenazine and deutetrabenazine are FDA-approved as treatment for tardive dyskinesia (TD). Both medications are vesicular monoamine transporter type 2 (VMAT2) inhibitors, and both are effective for reducing TD symptoms. Clinicians need to be aware of the adverse effects of valbenazine and deutetrabenazine, as well as other key differences between the two, in order to individualize treatment. Using the Abnormal Involuntary Movement Scale assists clinicians in assessing progress for each patient. Treating TD effectively with these new medications will reduce the burden of the condition for patients.


Assuntos
Exame Neurológico/métodos , Discinesia Tardia , Tetrabenazina/análogos & derivados , Valina/análogos & derivados , Proteínas Vesiculares de Transporte de Monoamina/antagonistas & inibidores , Monitoramento de Medicamentos/métodos , Humanos , Conduta do Tratamento Medicamentoso , Moduladores de Transporte de Membrana/administração & dosagem , Moduladores de Transporte de Membrana/efeitos adversos , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/normas , Psiquiatria/educação , Discinesia Tardia/induzido quimicamente , Discinesia Tardia/diagnóstico , Discinesia Tardia/tratamento farmacológico , Tetrabenazina/administração & dosagem , Tetrabenazina/efeitos adversos , Resultado do Tratamento , Valina/administração & dosagem , Valina/efeitos adversos
16.
BJOG ; 127(3): 416-423, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31677228

RESUMO

OBJECTIVE: To develop a sepsis care bundle for the initial management of maternal sepsis in low resource settings. DESIGN: Modified Delphi process. SETTING: Participants from 34 countries. POPULATION: Healthcare practitioners working in low resource settings (n = 143; 34 countries), members of an expert panel (n = 11) and consultation with the World Health Organization Global Maternal and Neonatal Sepsis Initiative technical working group. METHODS: We reviewed the literature to identify all potential interventions and practices around the initial management of sepsis that could be bundled together. A modified Delphi process, using an online questionnaire and in-person meetings, was then undertaken to gain consensus on bundle items. Participants ranked potential bundle items in terms of perceived importance and feasibility, considering their use in both hospitals and health centres. Findings from the healthcare practitioners were then triangulated with those of the experts. MAIN OUTCOME MEASURE: Consensus on bundle items. RESULTS: Consensus was reached after three consultation rounds, with the same items deemed most important and feasible by both the healthcare practitioners and expert panel. Final bundle items selected were: (1) Fluids, (2) Antibiotics, (3) Source identification and control, (4) Transfer (to appropriate higher-level care) and (5) Monitoring (of both mother and neonate as appropriate). The bundle was given the acronym 'FAST-M'. CONCLUSION: A clinically relevant maternal sepsis bundle for low resource settings has been developed by international consensus. TWEETABLE ABSTRACT: A maternal sepsis bundle for low resource settings has been developed by international consensus.


Assuntos
Pacotes de Assistência ao Paciente/métodos , Administração dos Cuidados ao Paciente , Complicações Infecciosas na Gravidez , Consenso , Técnica Delfos , Feminino , Humanos , Recém-Nascido , Cooperação Internacional , Área Carente de Assistência Médica , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/organização & administração , Gravidez , Complicações Infecciosas na Gravidez/diagnóstico , Complicações Infecciosas na Gravidez/terapia , Organização Mundial da Saúde
17.
Cancer Treat Rev ; 82: 101929, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31770695

RESUMO

Autologous stem cell transplantation (ASCT) has been the mainstay of multiple myeloma (MM) treatment for approximately 30 years. Although the continuous introduction of novel agents in the armamentarium against MM has questioned its value, ASCT remains a backbone treatment for fit MM patients. However, there is no unanimous approach for several aspects including the positioning of ASCT in the therapeutic algorithm either upfront or following the first relapse, the need for single or tandem ASCT, as well as the role of ASCT as salvage therapy. Furthermore, the anti-CD38 monoclonal antibodies along with the next generation proteasome inhibitors and immunomodulatory drugs provide a platform for optimizing the induction and consolidation/maintenance regimens. In this review, we present current data pertaining to all aspects of ASCT in MM, whereas we highlight the open issues that should be addressed in the design of future clinical trials in the field.


Assuntos
Mieloma Múltiplo/terapia , Administração dos Cuidados ao Paciente , Transplante de Células-Tronco/métodos , Antineoplásicos Imunológicos/farmacologia , Humanos , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/normas , Inibidores de Proteassoma/farmacologia , Transplante Autólogo
18.
Dis Colon Rectum ; 63(2): 160-171, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31842159

RESUMO

BACKGROUND: Health care costs and wait times for colorectal cancer treatment are increasing in Canada, but the association between the 2 remains unclear. OBJECTIVE: This study aimed to determine the association between wait times and health care costs and utilization. DESIGN: This is a population-based retrospective cohort study. SETTING: This study was conducted in Manitoba, Canada. PATIENTS: Patients diagnosed with colorectal cancer between 2004 and 2014 were sorted and ranked into quintiles based on the time from index contact for a colorectal cancer-related symptom to first treatment. MAIN OUTCOME MEASURES: The primary outcome is risk-adjusted health care costs, and the secondary outcomes include health care utilization and overall mortality. RESULTS: We included a total of 6936 patients. Total wait times ranged between 0 and 762 days. In comparison with very short wait times, longer wait times were associated with significantly increased costs (short: mean cost ratio 1.21; 95% CI, 1.10-1.32; moderate: mean cost ratio 1.30; 95% CI, 1.19-1.43; long: mean cost ratio 1.48; 95% CI, 1.33-1.64; and very long: mean cost ratio 1.39; 95% CI, 1.26-1.54). Compared with very short wait times, longer wait times were associated with significantly lower risk of mortality (short: HR, 0.78; 95% CI, 0.71-0.86; moderate: HR, 0.72; 95% CI, 0.65-0.80; long: HR, 0.73; 95% CI, 0.66-0.82; very long: HR, 0.76; 95% CI, 0.68-0.85). The median number of pretreatment radiological and endoscopic investigations and surgeon clinic visits increased over the study period across all wait time categories. LIMITATIONS: This is a nonrandomized, retrospective cohort study with potentially limited generalizability. CONCLUSION: Patients with very short and short wait times are likely those diagnosed with life-threatening complications of colorectal cancer. Outside this window, patients with longer wait times experience increased health care costs and utilization with similar overall mortality. Improved care coordination and patient navigation may help contain the increasing wait times and associated increasing health care costs and utilization. See Video Abstract at http://links.lww.com/DCR/B81. ASOCIACIÓN ENTRE LOS TIEMPOS DE ESPERA PARA EL TRATAMIENTO DE UN CÁNCER COLORRECTAL Y LOS COSTOS DE ATENCIÓN MÉDICA: UN ANÁLISIS DE POBLACIÓN: los costos de atención médica y los tiempos de espera para el tratamiento del cáncer colorrectal están aumentando en Canadá, pero la asociación entre los dos sigue sin estar clara.determinar la asociación entre los tiempos de espera y los costos y la utilización de la atención médicaun estudio de cohorte retrospectivo basado en la población.Manitoba, Canadálos pacientes diagnosticados con cáncer colorrectal entre 2004-2014 se clasificaron y sub-clasificaron en quintiles según el tiempo desde el primer contacto índice de síntomas relacionados con cáncer colorrectal hasta el primer tratamiento.El resultado primario son los costos de atención médica ajustados al riesgo, y los resultados secundarios incluyen la utilización de la atención médica y la mortalidad general.Incluimos un total de 6,936 pacientes. Los tiempos de espera totales oscilaron entre 0-762 días. En comparación con los tiempos de espera muy cortos, los tiempos de espera más largos se asociaron con costos significativamente mayores (Corto: relación de costo promedio 1.21, intervalo de confianza del 95% 1.10-1.32; Moderado: relación de costo promedio 1.30, intervalo de confianza del 95% 1.19-1.43; Largo: media relación de costo 1.48, intervalo de confianza del 95% 1.33-1.64; Muy largo: relación de costo promedio 1.39, intervalo de confianza del 95% 1.26-1.54). En comparación con tiempos de espera muy cortos, los tiempos de espera más largos se asociaron con un riesgo de mortalidad significativamente menor (Corto: razón de riesgo 0.78, intervalo de confianza del 95% 0.71-0.86; Moderado: razón de riesgo 0.72, intervalo de confianza del 95% 0.65-0.80; Largo: peligro cociente 0.73, intervalo de confianza del 95% 0.66-0.82; Muy largo: cociente de riesgos 0.76, intervalo de confianza del 95% 0.68-0.85). La mediana del número de investigaciones radiológicas y endoscópicas previas al tratamiento y las visitas al cirujano aumentaron durante el período de estudio en todas las categorías de tiempo de espera.estudio de cohortes retrospectivo, no aleatorio con generalización potencialmente limitadalos pacientes con tiempos de espera « muy cortos ¼ y « cortos ¼ son probablemente aquellos diagnosticados con complicaciones potencialmente mortales del cáncer colorrectal. Fuera de esta ventana, los pacientes con tiempos de espera más largos experimentan mayores costos de atención médica y utilización con una mortalidad general similar. La coordinación mejorada de la atención y la navegación del paciente pueden ayudar a contener el aumento de los tiempos de espera y el aumento de los costos y la utilización de la atención médica. Consulte Video Resumen en http://links.lww.com/DCR/B81. (Traducción-Dr. Edgar Xavier Delgadillo).


Assuntos
Neoplasias Colorretais/terapia , Custos de Cuidados de Saúde/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Tempo para o Tratamento/tendências , Adulto , Idoso , Canadá/epidemiologia , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade , Ensaios Clínicos Controlados não Aleatórios como Assunto , Administração dos Cuidados ao Paciente/métodos , Navegação de Pacientes/métodos , Estudos Retrospectivos
19.
Thorac Surg Clin ; 30(1): 15-24, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31761280

RESUMO

Nonintubated video-assisted thoracoscopic surgery for the treatment of primary and secondary pneumothorax was first reported in 1997 by Nezu. However, studies on this technique are few. Research in the past 20 years has focused on the perioperative outcomes, including the surgical duration, length of hospital stay, and postoperative morbidity and respiratory complication rates, which appear to be better than those of surgery under intubated general anesthesia. This study provides information pertaining to the physiologic, surgical, and anesthetic aspects and describes the potential benefits of nonintubated thoracoscopic surgery for the management of primary and secondary spontaneous pneumothorax.


Assuntos
Administração dos Cuidados ao Paciente/métodos , Pneumotórax/cirurgia , Complicações Pós-Operatórias , Cirurgia Torácica Vídeoassistida , Anestesia Geral/métodos , Humanos , Pneumotórax/etiologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/prevenção & controle , Cirurgia Torácica Vídeoassistida/efeitos adversos , Cirurgia Torácica Vídeoassistida/métodos
20.
Thorac Surg Clin ; 30(1): 25-32, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31761281

RESUMO

Video-assisted thoracic surgery has considerably improved the care of the thoracic surgical patient. Patients are able to leave the hospital sooner and experience less pain with equal oncologic outcomes when compared with open surgery. Nonintubated thoracic surgery has more recently been applied in the management of both benign and malignant pleural effusions. This article provides the general thoracic surgeon a detailed description on how to manage pleural effusions using video-assisted thoracoscopic surgery in a nonintubated patient. Surgical techniques and pearls are also presented.


Assuntos
Administração dos Cuidados ao Paciente/métodos , Derrame Pleural , Cirurgia Torácica Vídeoassistida/métodos , Humanos , Derrame Pleural/etiologia , Derrame Pleural/cirurgia
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