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1.
Emerg Infect Dis ; 27(4): 1164-1168, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33754981
2.
J Thorac Cardiovasc Surg ; 161(5): 1605-1614.e4, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33419537

RESUMO

OBJECTIVE: This study aimed to provide an insight into the impact of the early outbreak of the novel Coronavirus Disease 2019 on the care management for patients with congenital heart disease. METHODS: This study respectively enrolled a cohort of surgical patients who underwent surgery in 2018 (group I), 2019 (group II), and 2020 (group III) and a cohort of follow-up patients who had follow-up in 2017 (group A), 2018 (group B), and 2019 (group C) in 13 children hospitals. RESULTS: During the Coronavirus Disease 2019 era, there was a significant decrease in total surgical volume and a change in case mix in terms of an increase in the proportion of emergency operations. Decrease in migration scale index was correlated to the decrease in both surgical volume (r = 0.64, P = .02) and outpatient visit volume (r = 0.61, P = .03). There was a significantly higher proportion of patients who had follow-up through the internet or phone in group C (26.4% vs 9.6% in group B and 8.9% in group A; P < .0001). There was no statistical difference in death or rehospitalization among the 3 follow-up groups (P = .49). There was higher parents' anxiety score (P < .0001) and more use of telemedicine (P = .004) in group C compared with groups A and B. CONCLUSIONS: The Coronavirus Disease 2019 pandemic has resulted in a considerable decrease in total surgical volume and a change of case mix, which seems to be related to the strict traffic ban. Follow-up through the online medical service appears to be an effective alternative to the conventional method.


Assuntos
/epidemiologia , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Cardiopatias Congênitas/cirurgia , Pandemias , Criança , China/epidemiologia , Surtos de Doenças/estatística & dados numéricos , Cardiopatias Congênitas/epidemiologia , Humanos , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Estudos Retrospectivos , Cirurgia Torácica/estatística & dados numéricos
3.
JAMA Netw Open ; 3(12): e2030427, 2020 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-33337496

RESUMO

Importance: In 2019, hepatitis C virus (HCV) infection contributed to more deaths in the US than 60 other notifiable infectious diseases combined. The incidence of and mortality associated with HCV infection are highest among American Indian and Alaska Native individuals. Objective: To evaluate the association of the Cherokee Nation (CN) HCV elimination program with each element of the cascade of care: HCV screening, linkage to care, treatment, and cure. Design, Setting, and Participants: This cohort study used data from the CN Health Services (CNHS), which serves approximately 132 000 American Indian and Alaska Native individuals residing in the 14-county CN reservation in rural northeastern Oklahoma. Data from the first 22 months of implementation (November 1, 2015, to August 31, 2017) of an HCV elimination program were compared with those from the pre-elimination program period (October 1, 2012, to October 31, 2015). The analysis included American Indian and Alaska Native individuals aged 20 to 69 years who accessed care through the CNHS between October 1, 2012, and August 31, 2017. Cure data were recorded through April 15, 2018. Exposure: The CN HCV elimination program. Main Outcomes and Measures: The main outcomes were the proportions of the population screened for HCV, diagnosed with current HCV infection, linked to care, treated, and cured during the initial 22 months of the elimination program period and the pre-elimination program period. Data from electronic health records and an HCV treatment database were analyzed. The cumulative incidence of HCV infection in this population was estimated using bayesian analyses. Results: Among the 74 039 eligible individuals accessing care during the elimination program period, the mean (SD) age was 36.0 (13.5) years and 55.9% were women. From the pre-elimination program period to the elimination program period, first-time HCV screening coverage increased from 20.9% to 38.2%, and identification of current HCV infection and treatment in newly screened individuals increased from a mean (SD) of 170 (40) per year to 244 (4) per year and a mean of 95 (133) per year to 215 (9) per year, respectively. During the implementation period, of the 793 individuals with current HCV infection accessing the CNHS, 664 were evaluated (83.7%), 394 (59.3%) initiated treatment, and 335 (85.0%) had documented cure. In less than 2 years, the 85% 3-year goal was reached for cure (85.0%), and the goal for linkage to care was nearly reached (83.7%), whereas screening (44.1%) and treatment initiation (59.3%) required more time and resources. Conclusions and Relevance: This cohort study found that after 22 months of implementation, the CNHS community-based HCV elimination program was associated with an improved cascade of care. The facilitators and lessons learned in this program may be useful to other organizations planning similar programs.


Assuntos
Erradicação de Doenças , Hepatite C , Programas de Rastreamento , Administração dos Cuidados ao Paciente , Adulto , Estudos de Coortes , Erradicação de Doenças/métodos , Erradicação de Doenças/organização & administração , Erradicação de Doenças/estatística & dados numéricos , Feminino , Hepatite C/etnologia , Hepatite C/prevenção & controle , Humanos , Incidência , Masculino , Programas de Rastreamento/métodos , Programas de Rastreamento/organização & administração , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde/estatística & dados numéricos , Estados Unidos/epidemiologia
4.
Gut ; 69(7): 1213-1217, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32354990

RESUMO

OBJECTIVES: COVID-19 has rapidly become a major health emergency worldwide. Patients with IBD are at increased risk of infection, especially when they have active disease and are taking immunosuppressive therapy. The characteristics and outcomes of COVID-19 in patients with IBD remain unclear. DESIGN: This Italian prospective observational cohort study enrolled consecutive patients with an established IBD diagnosis and confirmed COVID-19. Data regarding age, sex, IBD (type, treatments and clinical activity), other comorbidities (Charlson Comorbidity Index (CCI)), signs and symptoms of COVID-19 and therapies were compared with COVID-19 outcomes (pneumonia, hospitalisation, respiratory therapy and death). RESULTS: Between 11 and 29 March 2020, 79 patients with IBD with COVID-19 were enrolled at 24 IBD referral units. Thirty-six patients had COVID-19-related pneumonia (46%), 22 (28%) were hospitalised, 7 (9%) required non-mechanical ventilation, 9 (11%) required continuous positive airway pressure therapy, 2 (3%) had endotracheal intubation and 6 (8%) died. Four patients (6%) were diagnosed with COVID-19 while they were being hospitalised for a severe flare of IBD. Age over 65 years (p=0.03), UC diagnosis (p=0.03), IBD activity (p=0.003) and a CCI score >1 (p=0.04) were significantly associated with COVID-19 pneumonia, whereas concomitant IBD treatments were not. Age over 65 years (p=0.002), active IBD (p=0.02) and higher CCI score were significantly associated with COVID-19-related death. CONCLUSIONS: Active IBD, old age and comorbidities were associated with a negative COVID-19 outcome, whereas IBD treatments were not. Preventing acute IBD flares may avoid fatal COVID-19 in patients with IBD. Further research is needed.


Assuntos
Betacoronavirus/isolamento & purificação , Infecções por Coronavirus , Doenças Inflamatórias Intestinais , Pandemias , Administração dos Cuidados ao Paciente , Pneumonia Viral , Fatores Etários , Comorbidade , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/fisiopatologia , Infecções por Coronavirus/terapia , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Imunossupressores/uso terapêutico , Doenças Inflamatórias Intestinais/epidemiologia , Doenças Inflamatórias Intestinais/terapia , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Gravidade do Paciente , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Pneumonia Viral/diagnóstico , Pneumonia Viral/etiologia , Pneumonia Viral/mortalidade , Pneumonia Viral/fisiopatologia , Pneumonia Viral/terapia , Estudos Prospectivos , Fatores de Risco
5.
Am J Gastroenterol ; 115(6): 801-804, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32427684
6.
Disaster Med Public Health Prep ; 14(1): 150-154, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-32148222

RESUMO

The 2017 Atlantic hurricane season was especially memorable for 3 major hurricanes-Harvey, Irma, and Maria-that devastated population centers across Texas, Florida, and Puerto Rico, respectively. Each storm had unique hazard properties that posed distinctive challenges for persons living with type 1 diabetes (T1D). Diabetes care specialists and educators took on leadership roles for coordinating care and establishing insulin supply lifelines for people with T1D living in the hardest-hit neighborhoods affected by these extreme storms. Strategies and resources were customized for each population. Diabetes specialists strategized to provide mutual support and shared insulins and supplies across sites.


Assuntos
Tempestades Ciclônicas/estatística & dados numéricos , Diabetes Mellitus Tipo 1/terapia , Administração dos Cuidados ao Paciente/normas , Diabetes Mellitus Tipo 1/epidemiologia , Florida/epidemiologia , Humanos , Liderança , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Porto Rico/epidemiologia , Texas/epidemiologia
7.
Acad Med ; 95(7): 1098-1105, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32134783

RESUMO

PURPOSE: Vygotsky's zone of proximal development (ZPD) refers to the space between what learners have mastered and what they should master in the next developmental stage. Physicians' tasks are ZPD activities for medical students, with high-acuity tasks such as resuscitation representing activities at the ZPD's frontier. This type of task can be taught and assessed with simulation but may be demanding and stressful for students. Highly challenging simulation may lead to a negative simulated patient outcome and can affect the participant's emotional state, learning, and motivation. This study aimed to increase understanding of the psychosocial and educational impact of simulation at the frontier of the ZPD. METHOD: The authors conducted 11 phenomenological interviews between September 2016 and May 2017, to describe medical students' experiences with a challenging residency-level simulation test of acute care competence at the start of the final undergraduate year at University Medical Center Utrecht. Interviews took place within 2 weeks after the participants' simulation experience. The authors analyzed transcripts using a modified Van Kaam method. RESULTS: Students experienced a significant amount of stress fueled by uncertainty about medical management, deterioration of critically ill simulated patients, and disappointment about their performance. Stress manifested mainly mentally, impeding cognitive function. Students reported that awareness of the practice setting, anticipation of poor performance, the debriefing, a safe environment, and the prospect of training opportunities regulated their emotional responses to stress. These stress-regulating factors turned stressful simulation into a motivating educational experience. CONCLUSIONS: Simulation at the ZPD's frontier evoked stress and generated negative emotions. However, stress-regulating factors transformed this activity into a positive and motivating experience.


Assuntos
Tratamento de Emergência/métodos , Aprendizagem/fisiologia , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Ressuscitação/educação , Competência Clínica , Cognição/fisiologia , Estado Terminal/terapia , Currículo/tendências , Educação de Graduação em Medicina , Emoções/fisiologia , Feminino , Humanos , Internato e Residência/métodos , Internato e Residência/estatística & dados numéricos , Entrevistas como Assunto , Masculino , Motivação/fisiologia , Países Baixos/epidemiologia , Simulação de Paciente , Pesquisa Qualitativa , Treinamento por Simulação/métodos , Estudantes de Medicina/psicologia
8.
Injury ; 51(2): 136-141, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31679834

RESUMO

BACKGROUND: Injuries remain an important public health concern, resulting in considerable annual morbidity and mortality. In low- and middle-income countries (LMICs), the lack of appropriate infrastructure, equipment and skilled personnel compound the burden of injury, leading to higher mortality rates. As Advanced Trauma Life Support (ATLS) courses remain uneconomical and inappropriate in LMICs, the Primary Trauma Care (PTC) course was introduced to provide an alternative that is both sustainable and appropriate to local resources. METHODS: A systematic review was performed in May 2019, utilising MEDLINE, EMBASE, Cochrane Library and Google Scholar. All studies reporting patient related outcomes (mortality and morbidity rates) and course participant related outcomes (knowledge, confidence and skills) in LMICs were included. PRISMA guidelines were adhered to throughout. RESULTS: Nine observational studies were identified (Level 3 evidence). Six studies reported improved knowledge in injury management post-PTC course (p < 0.05). Two studies reported improvements in confidence (p < 0.05) and one on skill attainment (p < 0.0001). One study reported a reduction in mortality rates post-PTC course (p < 0.01). CONCLUSION: Departmental, institutional and personal improvements may occur in clinical practice as a result of formal PTC training of trauma team members in LMICs. Further high-quality research is needed to evaluate this course's effects on observed change in clinical practice and patient outcomes. This may require long-term observational and epidemiological studies to assess improvements in morbidity and mortality. PROSPERO Registration Number: CRD42019133986.


Assuntos
Países em Desenvolvimento/estatística & dados numéricos , Traumatologia/educação , Ferimentos e Lesões/economia , Ferimentos e Lesões/terapia , Cuidados de Suporte Avançado de Vida no Trauma/economia , Cuidados de Suporte Avançado de Vida no Trauma/estatística & dados numéricos , Competência Clínica/estatística & dados numéricos , Currículo/normas , Pessoal de Saúde/educação , Pessoal de Saúde/estatística & dados numéricos , Recursos em Saúde , Humanos , Estudos Observacionais como Assunto , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Ferimentos e Lesões/mortalidade
9.
Int J Cardiol ; 299: 192-198, 2020 01 15.
Artigo em Inglês | MEDLINE | ID: mdl-31281047

RESUMO

INTRODUCTION: Chest X-ray (CXR) widely used, but the prognostic value of congestion quantification using CXR remains uncertain. The main objective of the present study was to assess whether initial quantification of lung congestion evaluated by CXR [and its interplay with estimated plasma volume status (ePVS)] in patients with worsening heart failure (WHF) is associated with in-hospital and short-term clinical outcome. METHODS: We studied 117 patients hospitalized for WHF in the ICALOR HF disease management program. Pulmonary congestion was estimated using congestion score index (CSI, range 0 to 3) evaluated from 6 lung areas on CXR. Systemic congestion was assessed by ePVS. Logistic regression analysis was used to assess length of stay and the composite of all-cause death or HF re-hospitalization at 90 days. RESULTS: Patients were divided according to the median of admission CSI (median = 2.20) and ePVS (median = 5.38). Higher CSI was significantly associated with higher pulmonary arterial systolic pressure in multivariable models. Multivariable models showed patients with high CSI/high ePVS had a 6-day longer length of stay [OR (95% CI) = 6.78 (1.82-29.79), p < 0.01] and 5-fold higher risk of 90-day composite outcome [OR (95% CI) = 5.13 (1.26-25.11) p = 0.03] compared to patients with low CSI/low ePVS, while other configurations (either isolated high CSI or high ePVS) yielded neutral associations. Furthermore, CSI and ePVS significantly improved reclassification on top of clinical covariates for the composite outcome [Net reclassification index = 37.3% (0.52-87.0), p = 0.046]. CONCLUSION: An admission assessment of pulmonary and systemic congestion in WHF patients using CSI and ePVS can identify a cluster of high-risk patients at short-term outcomes.


Assuntos
Insuficiência Cardíaca , Hipertensão Pulmonar , Pulmão , Volume Plasmático , Edema Pulmonar , Idoso , Regras de Decisão Clínica , Progressão da Doença , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Hospitalização/estatística & dados numéricos , Humanos , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/fisiopatologia , Pulmão/irrigação sanguínea , Pulmão/diagnóstico por imagem , Masculino , Escores de Disfunção Orgânica , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Valor Preditivo dos Testes , Prognóstico , Edema Pulmonar/diagnóstico , Edema Pulmonar/etiologia , Radiografia Torácica/métodos
10.
JAMA Netw Open ; 2(12): e1918169, 2019 12 02.
Artigo em Inglês | MEDLINE | ID: mdl-31860111

RESUMO

Importance: Chronic kidney disease (CKD) is serious and common, yet recognition and public health responses are limited. Objective: To describe clinical features of, prevalence of, major risk factors for, and care for CKD among patients treated in 2 large US health care systems. Design, Setting, and Participants: This cohort study collected data from the Center for Kidney Disease Research, Education, and Hope (CURE-CKD) registry, an electronic health record-based registry jointly curated and sponsored by Providence St Joseph Health and the University of California, Los Angeles. Patients were adults and children with CKD (excluding end-stage kidney disease) and adults at risk of CKD (ie, with diabetes, hypertension, or prediabetes) identified by laboratory values, vital signs, prescriptions, and administrative codes. Data were collected from January 2006 through December 2017, with analyses performed from March 2019 through November 2019. Exposures: Diabetes, hypertension, and prediabetes. Main Outcomes and Measures: Clinical and demographic characteristics, prevalence, and prescribed medications. Results: Of 2 625 963 adults and children in the sample, 606 064 adults (23.1%) with CKD had a median (interquartile range [IQR]) age of 70 (59-81) years, with 338 785 women (55.9%) and 434 474 non-Latino white individuals (71.7%). A total of 12 591 children (0.4%) with CKD had a median (IQR) age of 6 (1-13) years, with 7079 girls (56.2%) and 6653 non-Latino white children (52.8%). Median (IQR) estimated glomerular filtration rate was 53 (41-61) mL/min/1.73 m2 among adults and 70 (50-95) mL/min/1.73 m2 in children. Prevalence rates for CKD in adults were 4.8% overall (606 064 of 12 669 700) with 1.6% (93 644 of 6 011 129) during 2006 to 2009, 5.7% (393 455 of 6 903 084) during 2010 to 2013, and 8.4% (683 574 of 8 179 860) during 2014 to 2017 (P < .001). A total of 226 693 patients (37.4%) had category 3a CKD; 100 239 (16.5%), category 3b CKD; 39 125 (6.5%), category 4 CKD; and 20 328 (3.4%), category 5 CKD. Among adults with CKD, albuminuria and proteinuria assessments were available in 52 551 (8.7%) and 25 035 (4.1%) patients, respectively. A renin-angiotensin system inhibitor was prescribed to 124 575 patients (20.6%), and 204 307 (33.7%) received nonsteroidal anti-inflammatory drugs or proton pump inhibitors. Of 1 973 258 adults (75.1%) at risk, one-quarter had diabetes or prediabetes (512 299 [26.0%]), nearly half had hypertension (955 812 [48.4%]), and one-quarter had both hypertension and diabetes or prediabetes (505 147 [25.6%]). Conclusions and Relevance: This registry-based cohort study revealed a burgeoning number of patients with CKD and its major risk factors. Rates of identification and use of kidney protective agents were low, while potential nephrotoxin use was widespread, underscoring the pressing need for practice-based improvements in CKD prevention, recognition, and treatment.


Assuntos
Registros Eletrônicos de Saúde/estatística & dados numéricos , Taxa de Filtração Glomerular , Sistema de Registros/estatística & dados numéricos , Insuficiência Renal Crônica/epidemiologia , Adolescente , Adulto , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Lactente , Falência Renal Crônica/epidemiologia , Testes de Função Renal/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Prevalência , Saúde Pública , Insuficiência Renal Crônica/terapia , Distribuição por Sexo , Adulto Jovem
11.
Am J Manag Care ; 25(12): e395-e402, 2019 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-31860234

RESUMO

OBJECTIVES: To identify care needs among Medicaid and Medicare patients in an all-condition care management program involving case managers (CMs) and community health workers (CHWs), and to examine the relationship between intervention intensity and healthcare utilization. STUDY DESIGN: Retrospective longitudinal evaluation of managed care-hired CMs and CHWs based at 8 primary care sites participating in the Johns Hopkins Community Health Partnership (J-CHiP). METHODS: Patients at high risk for hospitalization were enrolled in J-CHiP. CMs provided care coordination and CHWs addressed barriers to care. Four program intensity categories were created: low CM-low CHW, low CM-high CHW, high CM-low CHW, and high CM-high CHW. We evaluated the adjusted relative risk (RR) of emergency department (ED) visits, hospitalizations, and 30-day hospital readmissions pre- and post enrollment in the program using CM documentation, electronic health record data, and insurance claims. RESULTS: Among 1408 Medicaid and 2196 Medicare patients, the predominant barriers to care were lack of transportation, unstable housing, medication payment, and healthy food access. Among Medicaid and Medicare patients, high CM-high CHW and high CM-low CHW intensities were associated with a higher adjusted risk of hospitalization and 30-day hospital readmission after program implementation compared with low CM-low CHW intensity. Among patients with low CM-high CHW intensity, Medicaid patients had a higher risk of readmission (RR, 1.47; P = .016) and Medicare patients had a higher risk of ED visit (RR, 1.33; P = .001) post program implementation. CONCLUSIONS: In this longitudinal evaluation of an all-condition, unstructured, managed care organization-led program, preprogram trajectories of healthcare utilization rates among patients increased rather than decreased after program implementation, especially among patients receiving the highest care management program intensity.


Assuntos
Programas de Assistência Gerenciada/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Estudos Longitudinais , Masculino , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos
12.
BMC Nephrol ; 20(1): 420, 2019 11 25.
Artigo em Inglês | MEDLINE | ID: mdl-31760936

RESUMO

BACKGROUND: Arteriovenous fistula (AVF) is the vascular access of choice for patients on hemodialysis. Recent evidence suggests that AVF creation may slow estimated glomerular filtration rate (eGFR) decline. The study objective was to assess the impact of the AVF creation on eGFR decline, after controlling for key confounding factors. METHODS: This retrospective cohort study included adult patients followed in a single-center predialysis clinic between 1999 and 2016. Patients with a patent AVF were followed up to 2 years pre- and post-AVF creation. Estimated GFR trajectory was reported using linear mixed models adjusted for demographic characteristics, comorbidities and use of renin-angiotensin-aldosterone blockade. RESULTS: A total of 146 patients were studied with a median age 68.7 (60.5-75.4) years and a median eGFR at time of AVF creation of 12.8 (11.3-13.9) mL/min/1.73m2. The crude annual eGFR decline rates were - 3.60 ± 4.00 mL/min/1.73 m2 pre- and - 2.28 ± 3.56 mL/min/1.73 m2 post-AVF, resulting in a mean difference of 1.28 mL/min/1.73 m2 (95% CI 0.49, 2.07). In a mixed effect linear regression model, monthly eGFR decline was - 0.63 (95% CI -0.81, - 0.46; p <  0.001) mL/min/1.73m2/month. The period after AVF creation was associated with a relatively higher eGFR (ß 0.94, 95% CI 0.61-1.26, p <  0.001). There was a significant association between follow-up time and the period pre/post AVF (ß 0.19, 95% CI 0.16, 0.22; p <  0.001) such that eGFR decline was more attenuated each month after AVF creation. CONCLUSIONS: In this cohort, AVF creation was associated with a significant reduction of eGFR decline. Further prospective studies are needed to confirm this association.


Assuntos
Derivação Arteriovenosa Cirúrgica , Taxa de Filtração Glomerular , Administração dos Cuidados ao Paciente , Diálise Renal , Insuficiência Renal Crônica , Idoso , Derivação Arteriovenosa Cirúrgica/métodos , Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Canadá/epidemiologia , Estudos de Coortes , Progressão da Doença , Feminino , Humanos , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Diálise Renal/métodos , Diálise Renal/estatística & dados numéricos , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/epidemiologia , Insuficiência Renal Crônica/terapia , Estudos Retrospectivos
14.
Diagnosis (Berl) ; 6(4): 351-359, 2019 11 26.
Artigo em Inglês | MEDLINE | ID: mdl-31373897

RESUMO

Background Though incidental pulmonary nodules are common, rates of guideline-recommended surveillance and associations between surveillance and mortality are unclear. In this study, we describe adherence (categorized as complete, partial, late and none) to guideline-recommended surveillance among patients with incidental 5-8 mm pulmonary nodules and assess associations between adherence and mortality. Methods This was a retrospective cohort study of 551 patients (≥35 years) with incidental pulmonary nodules conducted from September 1, 2008 to December 31, 2016, in an integrated safety-net health network. Results Of the 551 patients, 156 (28%) had complete, 87 (16%) had partial, 93 (17%) had late and 215 (39%) had no documented surveillance. Patients were followed for a median of 5.2 years [interquartile range (IQR), 3.6-6.7 years] and 82 (15%) died during follow-up. Adjusted all-cause mortality rates ranged from 2.24 [95% confidence interval (CI), 1.24-3.25] deaths per 100 person-years for complete follow-up to 3.30 (95% CI, 2.36-4.23) for no follow-up. In multivariable models, there were no statistically significant associations between the levels of surveillance and mortality (p > 0.16 for each comparison with complete surveillance). Compared with complete surveillance, adjusted mortality rates were non-significantly increased by 0.45 deaths per 100 person-years (95% CI, -1.10 to 2.01) for partial, 0.55 (95% CI, -1.08 to 2.17) for late and 1.05 (95% CI, -0.35 to 2.45) for no surveillance. Conclusions Although guideline-recommended surveillance of small incidental pulmonary nodules was incomplete or absent in most patients, gaps in surveillance were not associated with statistically significant increases in mortality in a safety-net population.


Assuntos
Fidelidade a Diretrizes/normas , Neoplasias Pulmonares/diagnóstico por imagem , Nódulos Pulmonares Múltiplos/diagnóstico por imagem , Provedores de Redes de Segurança/métodos , Idoso , Grupos Étnicos , Feminino , Seguimentos , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Achados Incidentais , Neoplasias Pulmonares/epidemiologia , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/patologia , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Nódulos Pulmonares Múltiplos/epidemiologia , Nódulos Pulmonares Múltiplos/mortalidade , Nódulos Pulmonares Múltiplos/patologia , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Administração dos Cuidados ao Paciente/tendências , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodos
15.
BMC Gastroenterol ; 19(1): 145, 2019 Aug 16.
Artigo em Inglês | MEDLINE | ID: mdl-31420025

RESUMO

BACKGROUND: This study aimed to understand the disease characteristics and treatment outcomes of Crohn's disease (CD) in a real-world setting in China. METHODS: In this prospective, non-interventional, multicenter disease registry, adults (≥18 years) with existing and newly diagnosed CD were recruited from 14 medical centers across China from January 2015 to January 2017. The study consisted of the enrollment and follow-up periods, of 12 months each. Demographic, clinical characteristics, diagnostic duration and management of CD at enrollment were evaluated. Logistic regression analysis and stepwise multivariate logistic regression analysis used to assess the relationship between the risk factors and CD. RESULTS: Of 504 enrolled patients, 499 (99.0%) were eligible for analysis. The mean (SD) age at study enrollment was 32.3 (11.43) years and the majority (69.7%) of participants were male. In the past 15 years, a sustained decrease of the period of time in the diagnosis of CD was observed, at about 39.4 (24.11) months in 2010, which decreased to 3.1 (2.13) months in 2015. The most common presenting symptoms of CD included abdominal pain (78.0%), diarrhea (58.1%), weight loss (52.9%) and fever (30.1%). Oral ulcer (19.4%) and arthritis (9.8%) were the most common extra-intestinal manifestations. Non-stricturing non-penetrating (B1) (49.9%) behavior and ileocolonic involvement (L3) (56.2%) location were more frequent. Perianal disease was observed in 29.1% of the patients. Around 23.8% (119/499) patients had CD-related surgery other than perianal disease surgery. Older age at enrollment, longer disease course, complicated disease behavior and absence of perianal disease were all surgery risk factors (p < 0.05). The most common medications was immunomodulators (e.g., azathioprine) (41.5%), anti-TNFα agents (32.9%) and aminosalicylates (20.6%). The mean (SD) Crohn's Disease Active Index (CDAI) score was 159.1 (91.45) and almost half of the patients (49.1%, 81/165) were in remission. CONCLUSIONS: This study demonstrated the CD-disease characteristics, risk factors of CD-related surgery and perianal disease, and treatment strategies in a real-world setting in China and may help in developing programs to diagnose and manage patients with CD.


Assuntos
Doença de Crohn , Fatores Imunológicos/uso terapêutico , Administração dos Cuidados ao Paciente , Adulto , China/epidemiologia , Doença de Crohn/diagnóstico , Doença de Crohn/epidemiologia , Doença de Crohn/fisiopatologia , Doença de Crohn/terapia , Progressão da Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Determinação de Necessidades de Cuidados de Saúde , Avaliação de Processos e Resultados em Cuidados de Saúde , Gravidade do Paciente , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Sistema de Registros/estatística & dados numéricos , Fatores de Risco , Tempo para o Tratamento/estatística & dados numéricos
16.
Breast J ; 25(6): 1225-1229, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31310384

RESUMO

Overall survival (OS), disease-free survival (DFS), and distant recurrence-free interval (DRFI) were evaluated from 169 patients diagnosed with early triple negative breast cancer. Overall, 5 and 10 years OS, DFS, and DRFI were 77% and 65%; 60% and 46%; and 74% and 73%, respectively. Forty-seven patients did not receive chemotherapy. A separate analysis was performed excluding those patients. In this subgroup, 5- and 10-year OS, DFS, and DRFI were 86% and 77%; 68% and 54%, 77% both at 5 and 10 years. Prognosis is better than previously described; adjuvant chemotherapy should be offered to fit elderly patients if clinically warranted.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Administração dos Cuidados ao Paciente , Neoplasias de Mama Triplo Negativas/terapia , Fatores Etários , Idoso , Quimioterapia Adjuvante/métodos , Intervalo Livre de Doença , Feminino , Humanos , Itália/epidemiologia , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Administração dos Cuidados ao Paciente/tendências , Prognóstico , Estudos Retrospectivos , Neoplasias de Mama Triplo Negativas/epidemiologia , Neoplasias de Mama Triplo Negativas/patologia
17.
Breast J ; 25(6): 1245-1250, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31273861

RESUMO

Idiopathic granulomatous mastitis is a rare benign breast disease. A systematic review was designed. Clinical and therapeutic characteristics were analyzed. Human Development Index (HDI) was used to define two groups of study: group A (very high and high HDI) and group B (medium and low HDI). Corticosteroid therapy was done in 69% group A and 78% group B. Surgery was done in 63% in group A and 83% in group B. Antibiotics were used in 68% group A and 88% group B. There is no consensus about optimal treatment for granulomatous mastitis.


Assuntos
Mastite Granulomatosa/terapia , Administração dos Cuidados ao Paciente , Feminino , Humanos , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Resultado do Tratamento
18.
BMC Med Res Methodol ; 19(1): 116, 2019 06 06.
Artigo em Inglês | MEDLINE | ID: mdl-31170922

RESUMO

BACKGROUND: We determined whether it is feasible to identify important changes in care management resulting from cardiovascular magnetic resonance (CMR) in patients who activate the primary percutaneous coronary intervention (PPCI) pathway from hospital episode data, in order to construct a composite primary outcome (hypothesised to reduce the risk of major adverse cardiac-related events, MACE) to compare patients exposed to CMR or not. METHODS: We used Hospital Episode Statistics (HES) and Patient Episode Database for Wales (PEDW) to identify clinical events that reflected important changes in management in the year following the index admission in five subgroups of patients who activated the PPCI pathway recruited as part of a feasibility cohort study (n = 1655 with HES/PEDW data). For all subgroups, we identified frequency of events and time to the first event for each change in management. RESULTS: We identified all clinical events (new diagnoses, additional diagnostic tests and procedures) except for medication prescriptions. Diagnostic tests were underestimated because most are carried out in outpatient clinics and outpatient datasets had missing procedure codes for 74% of patients (some tests done in hospital may also not be recorded). We successfully tabulated frequencies of events and distributions of times to first event for most changes in management by CMR status and in CMR / non CMR centres. CONCLUSIONS: It is feasible to identify changes in care management between patients who have / do not have CMR within relevant patient subgroups. Further work to derive a weighting algorithm is required before attempting to combine the events in a composite endpoint.


Assuntos
Angiografia Coronária/estatística & dados numéricos , Angiografia por Ressonância Magnética/estatística & dados numéricos , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/terapia , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Intervenção Coronária Percutânea/estatística & dados numéricos , Registros Eletrônicos de Saúde , Estudos de Viabilidade , Registros Hospitalares , Humanos , Infarto do Miocárdio/diagnóstico , Resultado do Tratamento
19.
Am J Manag Care ; 25(6): e173-e178, 2019 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-31211549

RESUMO

OBJECTIVES: To examine whether a care transitions program, Bridges, differentially reduced rehospitalizations among patients who underwent percutaneous coronary intervention (PCI) based on insurance status and zip code poverty level. STUDY DESIGN: Retrospective observational cohort. METHODS: We examined data from a single health system in Delaware, collected as part of a care transitions program for patients who underwent PCI from 2012 to 2015 compared with an unmatched historical control cohort from 2010 to 2011. Socioeconomic status was assessed by insurance status and zip code-level poverty data. Patients were divided into tertiles based on the proportion of their zip code of residence living under 100% of the federal poverty level. Rehospitalization rates were analyzed by negative binomial regression and included interaction terms to examine differential effects of Bridges by insurance and poverty level. RESULTS: There were 4638 patients representing 5710 hospitalizations: 3212 in the historical control and 2498 in the Bridges cohort. Among patients with Medicaid who received the Bridges intervention, those living in the wealthiest zip codes were 15.5% less likely to be rehospitalized than patients with Medicare and 9.4% less likely than patients with commercial insurance (P = .04). However, patients with Medicaid who lived in the poorest zip codes and those with dual Medicare/Medicaid status had higher rates of rehospitalization post intervention. CONCLUSIONS: The Bridges intervention was associated with improved rehospitalization rates for Medicaid patients compared with those with Medicare or commercial insurance within Delaware's wealthier communities. Care transitions programs may differentially affect Medicaid patients based on the wealth of the communities in which they reside.


Assuntos
Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Intervenção Coronária Percutânea/estatística & dados numéricos , Características de Residência/estatística & dados numéricos , Idoso , Delaware , Feminino , Humanos , Masculino , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Classe Social , Estados Unidos
20.
Diabetes Metab Syndr ; 13(3): 2292-2298, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31235171

RESUMO

OBJECTIVE: To evaluate if the recommendations of appropriate health care for Chronic Kidney Disease (CKD) are implemented in patients with Diabetes Mellitus (DM) and Systemic Arterial Hypertension (SAH). METHODS: This is a descriptive study conducted between January and March 2019 in Divinópolis, in the Brazilian state of Minas Gerais. Patients aged 18 years or older with CKD, DM and/or SAH were followed up at the municipal nephrology outpatient clinic. An interview was conducted using a structured questionnaire to assess care, which was categorized as adequate or inadequate, based on the health care recommendations of the national guidelines for care of patients with CKD. RESULTS: 42 participants with CKD participated in the study. All participants had SAH and 42.9% (n = 18) also had DM. It was evidenced that 81.0% (n = 34) of the individuals with CKD had adequate health care, especially among patients in earlier stages (3A and 3B) and those who progressed to renal replacement therapy. However, 80.0% (n = 8) of the participants in the intermediate stage (stage 4) were inadequately followed up by the nephrologist and multidisciplinary team. CONCLUSIONS: Patients in intermediate stages do not receive follow-up with a multidisciplinary team at the recommended frequency. The preventive approach of the progression of renal disease in the intermediate stage in the studied municipality was not within the recommendations of the Ministry of Health.


Assuntos
Diabetes Mellitus/fisiopatologia , Hipertensão Pulmonar/complicações , Administração dos Cuidados ao Paciente/normas , Artéria Pulmonar/patologia , Insuficiência Renal Crônica/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Progressão da Doença , Feminino , Seguimentos , Taxa de Filtração Glomerular , Humanos , Masculino , Pessoa de Meia-Idade , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Prognóstico , Insuficiência Renal Crônica/etiologia , Fatores de Risco
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