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1.
JAMA Netw Open ; 3(1): e1919954, 2020 Jan 03.
Artigo em Inglês | MEDLINE | ID: mdl-31995214

RESUMO

Importance: The number of patients presenting to emergency departments (EDs) for psychiatric care continues to increase. Psychiatrists often make a conservative recommendation to admit patients because robust outpatient services for close follow-up are lacking. Objective: To assess whether the availability of a 45-day behavioral health-virtual patient navigation program decreases hospitalization among patients presenting to the ED with a behavioral health crisis or need. Design, Setting, and Participants: This randomized clinical trial enrolled 637 patients who presented to 6 EDs spanning urban and suburban locations within a large integrated health care system in North Carolina from June 12, 2017, through February 14, 2018; patients were followed up for up to 45 days. Eligible patients were aged 18 years or older, with a behavioral health crisis and a completed telepsychiatric ED consultation. The availability of the behavioral health-virtual patient navigation intervention was randomly allocated to specific days (Monday through Friday from 7 am to 7 pm) so that, in a 2-week block, there were 5 intervention days and 5 usual care days; 323 patients presented on days when the program was offered, and 314 presented on usual care days. Data analysis was performed from March 7 through June 13, 2018, using an intention-to-treat approach. Interventions: The behavioral health-virtual patient navigation program included video contact with a patient while in the ED and telephonic outreach 24 to 72 hours after discharge and then at least weekly for up to 45 days. Main Outcomes and Measures: The primary outcome was the conversion of an ED encounter to hospital admission. Secondary outcomes included 45-day follow-up encounters with a self-harm diagnosis and postdischarge acute care use. Results: Among 637 participants, 358 (56.2%) were men, and the mean (SD) age was 39.7 (16.6) years. The conversion rates were 55.1% (178 of 323) in the intervention group vs 63.1% (198 of 314) in the usual care group (odds ratio, 0.74; 95% CI, 0.54-1.02; P = .06). The percentage of patient encounters with follow-up encounters having a self-harm diagnosis was significantly lower in the intervention group compared with the usual care group (36.8% [119 of 323] vs 45.5% [143 of 314]; P = .03). Conclusions and Relevance: Although the primary result did not reach statistical significance, there is a strong signal of potential positive benefit in an area that lacks evidence, suggesting that there should be additional investment and inquiry into virtual behavioral health programs. Trial Registration: ClinicalTrials.gov identifier: NCT03204643.


Assuntos
Terapia Comportamental/métodos , Serviço Hospitalar de Emergência , Transtornos Mentais/terapia , Admissão do Paciente/estatística & dados numéricos , Telemedicina/organização & administração , Adulto , Medicina do Comportamento/métodos , Feminino , Humanos , Masculino , Transtornos Mentais/psicologia , Pessoa de Meia-Idade , North Carolina , Autogestão/educação , Resultado do Tratamento , Adulto Jovem
2.
Arch Dis Child Fetal Neonatal Ed ; 105(1): 50-55, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31123055

RESUMO

OBJECTIVE: Higher rates of neonatal morbidity and mortality at term combined with earlier spontaneous delivery have led to the hypothesis that babies born to South Asian born (SA-born) women may mature earlier and/or their placental function decreases earlier than babies born to Australian and New Zealand born (Aus/NZ-born) women. Whether babies born to SA-born women do better in the preterm period, however, has yet to be evaluated. In this study we investigated respiratory outcomes, indicative of functional maturity, of preterm babies born to SA-born women compared with those of Aus/NZ-born women to explore this hypothesis further. STUDY DESIGN AND SETTING: This retrospective cohort study was conducted at Monash Health. PATIENTS: Data were collected from neonatal and birth records of moderate-late preterm (32-36 weeks) infants born between 2012 and 2015 to SA-born and Aus/NZ-born women. OUTCOME MEASURES: Rates of nursery admissions and neonatal respiratory outcomes were compared. RESULTS: Babies born to Aus/NZ-born women were more likely to be admitted to a nursery (80%) compared with SA-born babies (72%, p=0.004). Babies born to SA-born mothers experienced significantly less hyaline membrane disease (7.8%), required less resuscitation at birth (28.6%) and were less likely to require ventilation (20%) than babies born to Aus/NZ-born mothers (18%, 42.2%, 34.6%; p<0.001). There was no difference in the duration of ventilation or length of stay in hospital. CONCLUSIONS: Moderate-late preterm babies born to SA-born women appear to have earlier functional maturity, as indicated by respiratory outcomes, than Aus/NZ-born babies. Our findings support the hypothesis of earlier fetal maturation in SA-born women.


Assuntos
Grupo com Ancestrais do Continente Asiático , Grupo com Ancestrais do Continente Europeu , Doença da Membrana Hialina/epidemiologia , Nascimento Prematuro , Ressuscitação/estatística & dados numéricos , Adulto , Ásia Sudeste/etnologia , Austrália , Peso ao Nascer , Índice de Massa Corporal , Estudos de Coortes , Feminino , Glucocorticoides/uso terapêutico , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Mães , Nova Zelândia , Admissão do Paciente/estatística & dados numéricos , Cuidado Pré-Natal , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos
3.
Ann R Coll Surg Engl ; 102(1): 36-42, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31660752

RESUMO

INTRODUCTION: The temporal patterns and unit-based distributions of trauma patients requiring surgical intervention are poorly described in the UK. We describe the distribution of trauma patients in the UK and assess whether changes in working patterns could provide greater exposure for operative trauma training. METHODS: We searched the Trauma Audit and Research Network database to identify all patients between 1 January 2014 to 31 December 2016. Operative cases were defined as all patients who underwent laparotomy, thoracotomy or open vascular intervention. We assessed time of arrival, correlations between mechanism of injury and surgery, and the effect of changing shift patterns on exposure to trauma patients by reference to a standard 10-hour shift assuming a dedicated trauma rotation or fellowship. RESULTS: There were 159,719 patients from 194 hospitals submitted to the Network between 2014 and 2016. The busiest 20 centres accounted for 57,568 (36.0%) of cases in total. Of these 2147/57,568 patients (3.7%) required a general surgical operation; 43% of penetrating admissions (925 cases) and 2.2% of blunt admissions (1222 cases). The number of operations correlated more closely with the number of penetrating rather than blunt admissions (r = 0.89 vs r = 0.51). A diurnal pattern in trauma admissions enabled significant increases in trauma exposure with later start times. CONCLUSIONS: Centres with high volume and high penetrating rates are likely to require more general surgical input and should be identified as locations for operative trauma training. It is possible to improve the number of trauma patients seen in a shift by optimising shift start time.


Assuntos
Educação de Pós-Graduação em Medicina/métodos , Cirurgia Geral/educação , Admissão do Paciente/estatística & dados numéricos , Traumatologia/educação , Ferimentos e Lesões/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Inglaterra , Feminino , Hospitais com Alto Volume de Atendimentos , Humanos , Irlanda , Masculino , Pessoa de Meia-Idade , Admissão e Escalonamento de Pessoal/organização & administração , Admissão e Escalonamento de Pessoal/estatística & dados numéricos , Estudos Retrospectivos , Jornada de Trabalho em Turnos/estatística & dados numéricos , Fatores de Tempo , Centros de Traumatologia/organização & administração , Centros de Traumatologia/estatística & dados numéricos , País de Gales , Local de Trabalho/organização & administração , Local de Trabalho/estatística & dados numéricos , Ferimentos e Lesões/cirurgia
4.
J Surg Res ; 245: 13-21, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31394403

RESUMO

BACKGROUND: Geriatric trauma patients who require an unplanned ICU admission (UIA) may experience worse outcomes. As such, the American College of Surgeons initiated the Trauma Quality Improvement Program which tracks UIA as a quality benchmark. We sought to determine the overall rate and impact of UIA in our geriatric trauma population and to identify predictive risk factors. METHODS: All geriatric trauma patients (≥65) admitted to an urban, level I trauma center from January 2012 to June 2018 were identified. A retrospectively collected administrative database was queried for demographics, comorbidities, injury characteristics, and outcomes. UIA were identified and medical records were queried. Univariate analysis followed by binary logistic regression analysis were performed (P < 0.05 = significant). RESULTS: Of the 2923 geriatric patients identified, 95 (3.3%) patients experienced UIA, most commonly secondary to respiratory (34.7%) and cardiac (22.1%) events. Patients with UIA were older (81 versus 78, P = 0.04), and had higher injury severity score (10 versus 9, P < 0.01) and Charlson comorbidity indices (5 versus 4, P = 0.02). On logistic regression, age (OR 1.027, P = 0.04) and injury severity score (OR 1.032, P < 0.01) were predictive of unplanned ICU admission. Of the UIA, 69.4% were readmissions, or "bounce backs". Patients initially admitted to the ICU had 2.5 increased odds of requiring UIA. Patients with UIA experienced longer hospital stays (15 versus 5, P < 0.01), more days in the ICU (6 versus 1, P < 0.01), and higher rates of mortality (11.6% versus 5.0%, P = 0.02). CONCLUSIONS: Despite relatively low injury severity, geriatric trauma patients requiring UIA have a significant increase in morbidity and mortality. Those initially admitted to the ICU are at especially high risk for UIA, suggesting the benefit of strategies to provide an extra layer of care post-ICU.


Assuntos
Unidades de Terapia Intensiva/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Ferimentos e Lesões/terapia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação/estatística & dados numéricos , Masculino , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Centros de Traumatologia/estatística & dados numéricos , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/epidemiologia
5.
J Surg Res ; 245: 492-499, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31446191

RESUMO

BACKGROUND: Older adults with isolated rib fractures are often admitted to an intensive care unit (ICU) because of presumedly increased morbidity and mortality. However, evidence-based guidelines are limited. We sought to identify characteristics of these patients that predict the need for ICU care. MATERIALS AND METHODS: We analyzed patients ≥50 y old at our center during 2013-2017 whose only indication for ICU admission, if any, was isolated rib fractures. The primary outcome was any critical care intervention (e.g., intubation) or adverse event (e.g., hypoxemia) (CCIE) based on accepted critical care guidelines. We used stepwise logistic regression to identify characteristics that predict CCIEs. RESULTS: Among 401 patients, 251 (63%) were admitted to an ICU. Eighty-three patients (33%) admitted to an ICU and 7 (5%) admitted to the ward experienced a CCIE. The most common CCIEs were hypotension (10%), frequent respiratory therapy (9%), and oxygen desaturation (8%). Predictors of CCIEs included incentive spirometry <1 L (OR 4.72, 95% CI 2.14-10.45); use of a walker (OR 2.86, 95% CI 1.29-6.34); increased chest Abbreviated Injury Scale score (AIS 3 OR 5.83, 95% CI 2.34-14.50); age ≥72 y (OR 2.68, 95% CI 1.48-4.86); and active smoking (OR 2.11, 95% CI 1.06-4.20). CONCLUSIONS: Routine ICU admission is not necessary for most older adults with isolated rib fractures. The predictors we identified warrant prospective evaluation for development of a clinical decision rule to preclude unnecessary ICU admissions.


Assuntos
Hipotensão/epidemiologia , Unidades de Terapia Intensiva/normas , Admissão do Paciente/normas , Fraturas das Costelas/terapia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Cuidados Críticos/normas , Cuidados Críticos/estatística & dados numéricos , Feminino , Humanos , Hipotensão/etiologia , Hipotensão/terapia , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Fraturas das Costelas/complicações , Medição de Risco , Centros de Traumatologia/normas , Centros de Traumatologia/estatística & dados numéricos
6.
Angiology ; 71(1): 38-47, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31554413

RESUMO

This study investigated whether a novel index of stress hyperglycemia might have a better prognostic value compared to admission glycemia alone in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). The acute-to-chronic glycemic ratio was expressed as admission blood glucose (ABG) devided by the estimated average glucose (eAG), and eAG was derived from the glycated hemoglobin (HbA1c). A total of 1300 consecutive patients with STEMI treated with PCI were included. Baseline data and outcomes were analyzed. The study end point was a composite of in-hospital all-cause death, cardiogenic shock, and acute pulmonary edema. Accuracy was defined with area under the curve (AUC) by a receiver-operating characteristic (ROC) curve analysis. After multivariate adjustment, both ABG/eAG and ABG were closely associated with an increased risk of the composite end point in nondiabetic patients. However, only ABG/eAG (odds ratio = 2.45, 95% confidence interval: 1.24-4.82, P = .010), instead of ABG, was associated with the outcomes in diabetic patients. Compared to ABG, ABG/eAG had an equivalent predictive value in nondiabetic patients but a superior discriminatory ability in diabetic patients (AUC improved from 0.52-0.63, P < .001). Taken together, ABG/eAG provides more significant in-hospital prognostic information than ABG in diabetic patients with STEMI after PCI.


Assuntos
Glicemia/metabolismo , Hemoglobina A Glicada/metabolismo , Admissão do Paciente , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Idoso , Biomarcadores/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Infarto do Miocárdio com Supradesnível do Segmento ST/sangue , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Fatores de Tempo , Resultado do Tratamento
7.
Ther Adv Cardiovasc Dis ; 13: 1753944719894509, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31854243

RESUMO

BACKGROUND: It is known that once heart failure occurs in older patients with diabetes, the overall prognosis is extremely poor. We investigated whether early initiation of SGLT2 inhibitor therapy after admission was beneficial for diabetic patients requiring inpatient treatment for acute heart failure. METHODS: We retrospectively assessed consecutive patients with comorbid diabetes who were admitted to the Department of Cardiology in Tosei General Hospital for treatment of acute heart failure. Patients were divided into two groups: those who initiated SGLT2 inhibitor therapy (SGLT2 inhibitor group; mean age: 73 ± 9 years) and those who did not receive the inhibitors during hospitalization (conventional treatment group; mean age: 75 ± 10 years). RESULTS: No intergroup differences were observed in the distribution of either the severity or classes of heart failure on admission. Glycosylated hemoglobin levels were significantly higher in the SGLT2 inhibitor group (HbA1c: 8.1% ± 0.8%) than in the conventional treatment group (HbA1c: 7.1% ± 0.8%) (p = 0.003). After admission, patients in both groups recovered equally well, and in almost the same period of time, before discharge. The rate of diuretics use at the time of discharge in the SGLT2 inhibitor group (n = 8, 67%) was significantly lower than that in the conventional treatment group (n = 19, 100%) (p = 0.016). In particular, the dose of loop diuretics in the conventional treatment group was 34 ± 4 mg/day while that in the SGLT2 inhibitor group was significantly lower at 13 ± 5 mg/day (p = 0.008). During hospitalization, the incidence of acute kidney injury was significantly higher in the conventional treatment group (n = 11, 58%) than in the SGLT2 inhibitor group (n = 2, 16%) (p = 0.031). CONCLUSIONS: For the treatment and management of heart failure in patients with diabetes, early initiation of SGLT2 inhibitor therapy appears to be effective.


Assuntos
Glicemia/efeitos dos fármacos , Diabetes Mellitus Tipo 2/tratamento farmacológico , Insuficiência Cardíaca/tratamento farmacológico , Inibidores de Simportadores de Cloreto de Sódio e Potássio/administração & dosagem , Inibidores do Transportador 2 de Sódio-Glicose/administração & dosagem , Doença Aguda , Lesão Renal Aguda/epidemiologia , Lesão Renal Aguda/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Glicemia/metabolismo , Comorbidade , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/epidemiologia , Feminino , Hemoglobina A Glicada/metabolismo , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/fisiopatologia , Humanos , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Admissão do Paciente , Intervalo Livre de Progressão , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Inibidores de Simportadores de Cloreto de Sódio e Potássio/efeitos adversos , Inibidores do Transportador 2 de Sódio-Glicose/efeitos adversos , Fatores de Tempo
9.
Afr Health Sci ; 19(2): 1910-1923, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31656474

RESUMO

Background: There is a high prevalence of paediatric emergency cases in less developed countries. However, prolonged hospital stay at emergency units may further overstretch the facilities. Objective: To assess the patterns of presentations, services offered and predictors of a prolonged stay at the Children Emergency Room of a tertiary hospital in Southern Nigeria. Methods: This prospective cross-sectional, study was conducted at the University of Calabar Teaching Hospital, Nigeria from 1st January-31st December 2014. Socio-demographic and clinical characteristics of consecutively recruited children (n=633) were recorded in a proforma. Binary logistic regression was conducted to determine predictors of prolonged stay (>72 hours). Result: The median age of participants was 2 (1 - 4.6) years. Three-fifths of children were admitted at off-hours and the commonest symptom was fever (73.9%). About 16.4% (95%CI:13.6% - 19.4%, n= 103/633) of the children had prolonged stay while those with sepsis had the longest mean stay (65.5±72.1 hours). Children admitted on account of Sickle cell disease (OR:11.2, 95%CI:1.3-95.1, P-value = 0.03), Malaria (OR:10.7, 95%CI:1.4-82.5, P-value = 0.02) or sepsis (OR:10.5, 95%CI:1.3 - 82.7, P-value = 0.03) had higher odds of prolonged hospital stay. There was no significant difference in hospital stay among children admitted by the consultant as compared to other health personnel (P-value = 0.08). Conclusion: Prevention and proper management of Sickle cell disease and malaria reduces paediatric hospital stay in our environment. Paediatric emergency medicine should be re-organized to cater for high volume of off-hour admissions.


Assuntos
Emergências/epidemiologia , Hospitais de Ensino/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Anemia Falciforme/epidemiologia , Criança , Pré-Escolar , Estudos Transversais , Serviço Hospitalar de Emergência , Feminino , Febre/epidemiologia , Mortalidade Hospitalar , Humanos , Lactente , Malária/epidemiologia , Masculino , Nigéria/epidemiologia , Estudos Prospectivos , Sepse/epidemiologia , Fatores Socioeconômicos , Fatores de Tempo
10.
Isr Med Assoc J ; 21(10): 686-691, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31599512

RESUMO

BACKGROUND: C-reactive protein (CRP) blood level is associated with clinical outcomes of several diseases. However, the independent predictive role of CRP in the heterogeneous population of patients admitted to internal medicine wards is not known. OBJECTIVES: To determine whether single CRP levels at admission independently predicts clinical outcome and flow of patients in general medicine wards. METHODS: This study comprised 275 patients (50.5% female) with a mean age of 68.25 ± 17.0 years, hospitalized with acute disease in a general internal medicine ward. The association between admission CRP levels and clinical outcomes including mortality, the need for mechanical ventilation, duration of hospitalization, and re-admission within 6 months was determined. RESULTS: A significant association was found between CRP increments of 80 mg/L and risk for the major clinical outcomes measured. The mortality odds ratio (OR) was 1.89 (95% confidence interval (95%CI, 1.37-2.61, P < 0.001), mechanical ventilation OR 1.67 (95%CI, 1.10-2.34, P = 0.006), re-admission within 6 months OR 2.29 (95%CI, 1.66-3.15 P < 0.001), and prolonged hospitalization >7 days OR 2.09 (95%CI, 1.59-2.74, P < 0.001). Lower increments of10 mg/L in CRP levels were associated with these outcomes although with lower ORs. Using a stepwise regression model for admission CRP levels resulted in area under the receiver operating characteristics curves between 0.70 and 0.76 for these outcomes. CONCLUSIONS: A single admission CRP blood level is independently associated with major parameters of clinical outcomes in acute care patients hospitalized in internal medicine wards.


Assuntos
Proteína C-Reativa/análise , Hospitalização/estatística & dados numéricos , Medicina Interna/métodos , Avaliação de Resultados da Assistência ao Paciente , Doença Aguda , Adulto , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Admissão do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Valor Preditivo dos Testes , Prognóstico , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
11.
Rev Cardiovasc Med ; 20(3): 111-120, 2019 Sep 30.
Artigo em Inglês | MEDLINE | ID: mdl-31601085

RESUMO

Randomized controlled trials have demonstrated the benefits of guideline-directed medical therapy in the outpatient setting for treatment of chronic heart failure. However, the benefits of continuation (or discontinuation) of major chronic heart failure therapies when treating acute heart failure during hospitalization are less clear. Real and anticipated worsening renal function, hyperkalemia and hypotension are the three major reasons for discontinuation of renin-angiotensin-aldosterone system inhibitors during hospitalization, and a failure to resume renin-angiotensin-aldosterone system inhibitors before discharge could worsen cardiovascular outcomes. Available data, mostly observational, shows that continuation or initiation of renin-angiotensin-aldosterone system inhibitors appears efficacious, safe, and well tolerated in majority of acute heart failure patients during hospitalization. Worsening renal function portends poor prognosis only if associated with congestion in acute heart failure, and clinicians should not de-escalate diuretic therapy routinely for worsening renal function.


Assuntos
Antagonistas de Receptores de Angiotensina/administração & dosagem , Inibidores da Enzima Conversora de Angiotensina/administração & dosagem , Síndrome Cardiorrenal/tratamento farmacológico , Diuréticos/administração & dosagem , Insuficiência Cardíaca/tratamento farmacológico , Admissão do Paciente , Sistema Renina-Angiotensina/efeitos dos fármacos , Antagonistas de Receptores de Angiotensina/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Síndrome Cardiorrenal/diagnóstico , Síndrome Cardiorrenal/mortalidade , Síndrome Cardiorrenal/fisiopatologia , Tomada de Decisão Clínica , Diuréticos/efeitos adversos , Esquema de Medicação , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Humanos , Fatores de Risco , Resultado do Tratamento
12.
Z Gerontol Geriatr ; 52(Suppl 4): 222-228, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31620876

RESUMO

BACKGROUND: Risk stratification of older patients in the emergency department (ED) is seen as a promising and efficient solution for handling the increase in demand for geriatric emergency medicine. Previously, the predictive validity of commonly used tools for risk stratification, such as the identification of seniors at risk (ISAR), have found only limited evidence in German geriatric patient samples. Given that the adverse outcomes in question, such as rehospitalization, nursing home admission and mortality, are substantially associated with cognitive impairment, the potential of the short portable mental status questionnaire (SPMSQ) as a tool for risk stratification of older ED patients was investigated. OBJECTIVE: To estimate the predictive validity of the SPMSQ for a composite endpoint of adverse events (e.g. rehospitalization, nursing home admission and mortality). METHOD: This was a prospective cohort study with 260 patients aged 70 years and above, recruited in a cardiology ED. Patients with a likely life-expectancy below 24 h were excluded. Follow-up examinations were conducted at 1, 3, 6 and 12 month(s) after recruitment. RESULTS: The SPMSQ was found to be a significant predictor of adverse outcomes not at 1 month (area under the curve, AUC 0.55, 95% confidence interval, CI 0.46-0.63) but at 3 months (AUC 0.61, 95% CI 0.54-0.68), 6 months (AUC 0.63, 95% CI 0.56-0.70) and 12 months (AUC 0.63, 95% CI 0.56-0.70) after initial contact. CONCLUSION: For longer periods of observation the SPMSQ can be a predictor of a composite endpoint of adverse outcomes even when controlled for a range of confounders. Its characteristics, specifically the low sensitivity, make it unsuitable as an accurate risk stratification tool on its own.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Avaliação Geriátrica , Programas de Rastreamento/métodos , Admissão do Paciente/estatística & dados numéricos , Medição de Risco/métodos , Idoso , Cuidados Críticos , Feminino , Serviços de Saúde para Idosos , Hospitalização , Humanos , Masculino , Alta do Paciente/estatística & dados numéricos , Estudos Prospectivos , Medição de Risco/normas
13.
Mayo Clin Proc ; 94(10): 1994-2003, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31585582

RESUMO

OBJECTIVE: To determine whether a low Braden skin score (BSS), reflecting increased risk for skin pressure injury, would predict lower survival in cardiac intensive care unit (CICU) patients after adjustment for illness severity and comorbidities. PATIENTS AND METHODS: This retrospective cohort study included consecutive unique adult patients admitted to a single tertiary care referral hospital CICU from January 1, 2007, through December 31, 2015, who had a BSS documented on CICU admission. The primary outcome was all-cause hospital mortality, using elastic net penalized logistic regression to determine predictors of hospital mortality. The secondary outcome was all-cause post-discharge mortality, using Cox proportional hazards models to determine predictors of post-discharge mortality. RESULTS: The study included 9552 patients with a mean age of 67.4±15.2 years (3589 [37.6%] were females) and a hospital mortality rate of 8.3%. Admission BSS was inversely associated with hospital mortality (unadjusted odds ratio, 0.70; 95% CI, 0.68-0.72; P<.001; area under the receiver operator curve, 0.80; 95% CI, 0.78-0.82), with increased short-term mortality as a function of decreasing admission BSS. After adjustment for illness severity and comorbidities using multivariable analysis, admission BSS remained inversely associated with hospital mortality (adjusted odds ratio, 0.88; 95% CI, 0.85-0.92; P<.001). Among hospital survivors, admission BSS was inversely associated with post-discharge mortality after adjustment for illness severity and comorbidities (adjusted hazard ratio, 0.89; 95% CI, 0.88-0. 90; P<.001). CONCLUSION: The admission BSS, a simple inexpensive bedside nursing assessment potentially reflecting frailty and overall illness acuity, was independently associated with hospital and post-discharge mortality when added to established multiparametric illness severity scores among contemporary CICU patients.


Assuntos
Fragilidade/diagnóstico , Fragilidade/mortalidade , Avaliação Geriátrica/métodos , Mortalidade Hospitalar , Lesão por Pressão/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Estudos de Coortes , Unidades de Cuidados Coronarianos , Feminino , Fragilidade/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente , Valor Preditivo dos Testes , Lesão por Pressão/complicações , Prognóstico , Estudos Retrospectivos
14.
Tidsskr Nor Laegeforen ; 139(14)2019 10 08.
Artigo em Norueguês | MEDLINE | ID: mdl-31592615

RESUMO

BACKGROUND: Acute dizziness may have a number of causes, including cerebrovascular stroke which can present as isolated acute vestibular syndrome. It is recommended that acute episodic dizziness be assessed using positioning tests, and acute persistent dizziness with a focus on the HINTS (Head Impulse, Nystagmus, Test of Skew) battery of tests, which can distinguish cerebrovascular stroke from vestibular neuritis. We wished to identify the prevalence, diagnostic spectrum and approach to acute dizziness in a neurological department. MATERIAL AND METHOD: We undertook a retrospective review of the medical records of all patients with acute dizziness as the primary symptom who where admitted to the department of neurology at Sørlandet Hospital, Kristiansand in 2015. RESULTS: Of 2 231 patients admitted to the department of neurology in 2015, altogether 243 (11 %) had dizziness as the primary symptom. A total of 106 patients (44 %) were examined using HINTS in its entirety. A cranial CT was performed in 213 (88 %) and MRI in 91 (37 %), and these showed relevant pathology in 1 and 4 patients, respectively. Upon discharge, 122 patients (50 %) were given a non-specific symptom diagnosis, 59 (24 %) received the diagnosis vestibular neuritis, 41 (17 %) benign paroxysmal positional vertigo, and 5 (2 %) were diagnosed with cerebrovascular stroke. Four out of five cases of cerebrovascular stroke could be classified retrospectively as acute vestibular syndrome, whereof three had typical findings determined by the HINTS test. INTERPRETATION: Acute dizziness is a frequent symptom in patients admitted to the department of neurology. Evidence-based diagnostic recommendations for the assessment of acute dizziness were not satisfactorily implemented in practice.


Assuntos
Tontura , Departamentos Hospitalares , Neurologia , Doença Aguda , Vertigem Posicional Paroxística Benigna/complicações , Vertigem Posicional Paroxística Benigna/diagnóstico , Tontura/diagnóstico , Tontura/etiologia , Medicina Baseada em Evidências , Medições dos Movimentos Oculares , Teste do Impulso da Cabeça , Humanos , Registros Médicos , Noruega , Nistagmo Patológico/diagnóstico , Admissão do Paciente , Posicionamento do Paciente , Utilização de Procedimentos e Técnicas , Estudos Retrospectivos , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Neuronite Vestibular/complicações , Neuronite Vestibular/diagnóstico
15.
Acta Gastroenterol Belg ; 82(3): 397-400, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31566327

RESUMO

BACKGROUND AND AIMS: Early prediction of severe acute pancreatitis (SAP)would be helpful for triaging patients to the appropriate level of care and intervention. The aim of this study is to compare the performance of the Change in Amylase And Body mass index (CAB) score and BISAP score for predicting SAP. PATIENTS AND METHODS: A total of 406 with AP were enrolled. The age, gender, body mass index(BMI), blood urea nitrogen determined at the time of admission and serum amylase determined on day 1 and day 2 after hospitalization were collected and analyzed statistically. RESULTS: Multivariable analysis confirmed that blood urea nitrogen (OR 1.06; 95%CI 1.03-1.09) and percentage change in amylase day 2 (OR 0.75; 95%CI 0.65-0.87) were independently associated with development of SAP. No statistically significant association was observed between BMI (OR 1.04; 95%CI 0.951.13) and severity of acute pancreatitis. The area under the receiver operating characteristic curve for Body mass index (BMI), percentage change in amylase day 2, BISAP score and CAB score were 0.57±0.05, 0.68±0.04, 0.84±0.03 and0.53±0.05, respectively. CONCLUSION: BISAP is more accurate for predicting the severity of acute pancreatitis than the CAB score.


Assuntos
Amilases/sangue , Nitrogênio da Ureia Sanguínea , Índice de Massa Corporal , Pancreatite/diagnóstico , Índice de Gravidade de Doença , Doença Aguda , Biomarcadores/sangue , Humanos , Pancreatite/classificação , Pancreatite/patologia , Admissão do Paciente/estatística & dados numéricos , Valor Preditivo dos Testes , Prognóstico , Curva ROC , Estudos Retrospectivos
16.
Medicine (Baltimore) ; 98(41): e17479, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31593111

RESUMO

BACKGROUND: Community-acquired pneumonia (CAP) is a potentially life-threatening condition. The aim of this study is to investigate the stratified and prognostic value of admission lactate and severity scores (confusion, urea >7 mmol/L, respiratory rate ≥30/min, blood pressure <90 mm Hg systolic and/or ≤60 mm Hg diastolic, and age ≥65 years [CURB65], pneumonia severity index [PSI], sequential organ failure assessment [SOFA], qSOFA) in patients with CAP in emergency department. METHODS: Adult patients diagnosed with CAP admitted between January 2017 and January 2019 were enrolled and divided into severe CAP (SCAP) group and nonSCAP (NSCAP) group according to international guidelines, death group, and survival group according to 28-day prognosis. Predicting performance of parameters above was compared using receiver operating characteristic curves and logistic regression model. Cox proportional hazard regression model was used to identify variables independently associated with 28-day mortality. RESULTS: A total of 350 patients with CAP were enrolled. About 196 patients were classified as SCAP and 74 patients died after a 28-day follow-up. The levels of CURB65, PSI, SOFA, qSOFA, and admission lactate were higher in the SCAP group and death group. SOFA showed advantage in predicting SCAP, while qSOFA is superior in predicting 28-day mortality. The combination of SOFA and admission lactate outperformed other combinations in predicting SCAP, and the combination of qSOFA and lactate showed highest superiority over other combinations in predicting 28-day mortality. CONCLUSION: The SOFA is a valuable predictor for SCAP and qSOFA is superior in predicting 28-day mortality. Combination of qSOFA and admission lactate can improve the predicting performance of single qSOFA.


Assuntos
Infecções Comunitárias Adquiridas/mortalidade , Ácido Láctico/sangue , Escores de Disfunção Orgânica , Admissão do Paciente/estatística & dados numéricos , Pneumonia/mortalidade , Idoso , Idoso de 80 Anos ou mais , Infecções Comunitárias Adquiridas/sangue , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Seguimentos , Humanos , Modelos Logísticos , Masculino , Pneumonia/sangue , Prognóstico , Curva ROC , Estudos Retrospectivos
17.
Med. intensiva (Madr., Ed. impr.) ; 43(7): 427-434, oct. 2019. tab
Artigo em Espanhol | IBECS | ID: ibc-185870

RESUMO

La cirugía representa uno de los principales pilares terapéuticos en todo el mundo, ofreciendo una mayor supervivencia y esperanza de vida para muchos pacientes. En general, se estima una mortalidad postoperatoria baja, alrededor del 1-4%. Un 13% de los procedimientos quirúrgicos tienen un riesgo alto de complicaciones, representando un 80% de las muertes postoperatorias. Recientemente, se han producido avances significativos relacionados con aspectos organizativos, nuevas técnicas anestésicas y quirúrgicas, escalas pronósticas, manejo perioperatorio y una mayor participación e implicación del paciente. En esta nueva serie de MedicinaIntensiva se abordarán aspectos fundamentales de cómo los servicios de medicina intensiva pueden aportar valor al proceso quirúrgico, de forma coordinada con otros servicios. Se requieren políticas institucionales que aseguren la detección de pacientes en riesgo en plantas de hospitalización, el ingreso precoz en UCI de aquellos pacientes en los que está indicado, adecuando el tratamiento en la UCI y optimizando los criterios al alta. La detección y prevención del síndrome post-UCI en pacientes y familiares, y el seguimiento al alta de UCI y de hospitalización de forma multidisciplinar, pueden reducir las secuelas del enfermo crítico quirúrgico, mejorando los resultados y la calidad de vida y restituyendo al paciente a la sociedad. En futuras publicaciones de esta serie dirigida al paciente quirúrgico se presentarán actualizaciones del manejo perioperatorio de algunas de las cirugías de mayor complejidad


Surgery represents one of the main therapeutic references in the world, affording greater survival and life expectancy for many patients. In general, the estimated postoperative mortality is low (around 1-4%). Thirteen percent of the surgical procedures have a high risk of complications, accounting for 80% of all postoperative deaths. Recently, there have been significant advances related to organizational aspects, new anesthetic and surgical techniques, prognostic scales, perioperative management and greater participation and involvement of the patient. This new series of Medicina Intensiva will address fundamental aspects of how Departments of Intensive Care Medicine can add value to the surgical process, in a coordinated manner with other services. Institutional policies are required to ensure the detection of patients at risk in hospitalization wards, with early admission to the ICU of those patients in whom admission is indicated, adapting the treatment in the ICU and optimizing the criteria for discharge. The detection and prevention of post-ICU syndrome in patients and relatives, and the follow-up of ICU discharge and hospitalization in a multidisciplinary manner can reduce the sequelae among critical surgical patients, improving the outcomes and quality of life, and restoring the patient to society. In future publications of this series directed to the surgical patient, updates will be provided on the perioperative management of some of the most complex surgeries


Assuntos
Humanos , Assistência Perioperatória/métodos , Unidades de Terapia Intensiva/tendências , Admissão do Paciente , Período Perioperatório , Diagnóstico Precoce
18.
J Stroke Cerebrovasc Dis ; 28(11): 104331, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31519457

RESUMO

BACKGROUND: Stroke is a leading cause of death and disability. Tissue plasminogen activator (tPA) improves the clinical outcome when administered properly; however, the most important factor to receive tPA is time. The main reason for late hospital arrival is a considerable delay in onset-to-alarm time (OAT), comprising more than 50% of the onset-to-door time. AIMS: To identify the factors associated with a delay in OAT and evaluate its contribution to onset-to-door time in ischemic stroke patients. METHODS: Prospective cohort of stroke patients admitted to the UANL University Hospital. OAT was defined as the time from identification of stroke symptoms to the decision to seek medical attention. RESULTS: A total of 189 patients were included. Mean age was 61 ± 13 years, 62% were men. One-hundred and one patients had a short OAT, but only 20.9% arrived during the first 3 hours after stroke onset. Being employed (P = 0032; odds ratio [OR] 2.784, 95% confidence interval [CI] 1.091-7.104), attributing symptoms to stroke (P = 0016; OR 3.348, 95% CI 1.254-8.936), and perceiving stroke symptoms as severe (P = 0031;OR 2.428, 95% CI 1.083-5.445) were associated with a shorter OAT. CONCLUSIONS: OAT consumes a considerable amount of the onset-to-door time. It is necessary to increase stroke knowledge and emphasize the severity of stroke, regardless of the severity of its clinical manifestations to reduce the prehospital delay, especially in countries with limited access to treatment with an extended time frame.


Assuntos
Serviços Médicos de Emergência , Admissão do Paciente , Acidente Vascular Cerebral/terapia , Terapia Trombolítica , Tempo para o Tratamento , Idoso , Emprego , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , México , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
19.
Tidsskr Nor Laegeforen ; 139(13)2019 Sep 24.
Artigo em Norueguês, Inglês | MEDLINE | ID: mdl-31556525

RESUMO

BACKGROUND: Self-inflicted poisoning is common in adolescents and is a risk factor for suicide. The aim of this study was to survey the circumstances surrounding hospitalisations due to acute poisoning in patients aged up to 18 years. MATERIAL AND METHOD: All hospitalisations in the Departments of Paediatric and Adolescent Medicine, Sørlandet Hospital Trust (Arendal and Kristiansand) due to acute poisoning in the period 1 August 2014-31 July 2015 were prospectively recorded with the aid of a form completed during the admission. RESULTS: There were 88 hospitalisations distributed among 68 adolescents (mean age 15.5 years, SD 1.5) and 13 children (mean age 2.8 years, SD 2.8). The poisoning was categorised as self-harm behaviour in 32 (47 %) of the adolescents, and as substance misuse-related in 35 (52 %). In total, 37 (54 %) of the adolescents had been or were under treatment at the Department of Child and Adolescent Psychiatry. Fifteen (22 %) of the adolescents were deemed to be suicidal. Thirty (94 %) of the adolescents who reported self-harm as the intention behind their poisoning were offered further follow-up at the Department of Child and Adolescent Psychiatry, along with 7 (20 %) of the group with substance misuse-related poisoning. INTERPRETATION: Adolescents who reported self-harm as their intention were usually offered further follow-up, whereas adolescents with substance misuse-related poisoning were rarely offered follow-up.


Assuntos
Envenenamento/epidemiologia , Doença Aguda , Adolescente , Assistência ao Convalescente , Intoxicação Alcoólica/epidemiologia , Criança , Orientação Infantil , Pré-Escolar , Drogas Desenhadas/envenenamento , Feminino , Humanos , Lactente , Masculino , Noruega/epidemiologia , Admissão do Paciente , Estudos Prospectivos , Características de Residência , Comportamento Autodestrutivo/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Ideação Suicida
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