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2.
S Afr Med J ; 110(7): 621-624, 2020 06 17.
Artigo em Inglês | MEDLINE | ID: mdl-32880335

RESUMO

Infectious diseases pandemics have devastating health, social and economic consequences, especially in developing countries such as South Africa. Scarce medical resources must often be rationed effectively to contain the disease outbreak. In the case of COVID-19, even the best-resourced countries will have inadequate intensive care facilities for the large number of patients needing admission and ventilation. The scarcity of medical resources creates the need for national governments to establish admission criteria that are evidence-based and fair. Questions have been raised whether infection with HIV or tuberculosis (TB) may amplify the risk of adverse COVID-19 outcomes and therefore whether these conditions should be factored in when deciding on the rationing of intensive care facilities. In light of these questions, clinical evidence regarding inclusion of these infections as comorbidities relevant to intensive care unit admission triage criteria is investigated in the first of a two-part series of articles. There is currently no evidence to indicate that HIV or TB infection on their own predispose to an increased risk of infection with SARS-CoV-2 or worse outcomes for COVID-19. It is recommended that, as for other medical conditions, validated scoring systems for poor prognostic factors should be applied. A subsequent article examines the ethicolegal implications of limiting intensive care access of persons living with HIV or TB.


Assuntos
Infecções por Coronavirus , Infecções por HIV/epidemiologia , Alocação de Recursos para a Atenção à Saúde/métodos , Unidades de Terapia Intensiva , Pandemias , Pneumonia Viral , Triagem/organização & administração , Tuberculose/epidemiologia , Betacoronavirus/isolamento & purificação , Coinfecção , Infecções por Coronavirus/economia , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Necessidades e Demandas de Serviços de Saúde/organização & administração , Humanos , Unidades de Terapia Intensiva/economia , Unidades de Terapia Intensiva/normas , Pandemias/economia , Seleção de Pacientes , Pneumonia Viral/economia , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia , Prognóstico , Medição de Risco , África do Sul/epidemiologia
3.
S Afr Med J ; 110(7): 625-628, 2020 06 17.
Artigo em Inglês | MEDLINE | ID: mdl-32880336

RESUMO

The COVID-19 pandemic has brought discussions around the appropriate and fair rationing of scare resources to the forefront. This is of special importance in a country such as South Africa (SA), where scarce resources interface with high levels of need. A large proportion of the SA population has risk factors associated with worse COVID-19 outcomes. Many people are also potentially medically and socially vulnerable secondary to the high levels of infection with HIV and tuberculosis (TB) in the country. This is the second of two articles. The first examined the clinical evidence regarding the inclusion of HIV and TB as comorbidities relevant to intensive care unit (ICU) admission triage criteria. Given the fact that patients with HIV or TB may potentially be excluded from admission to an ICU on the basis of an assumption of lack of clinical suitability for critical care, in this article we explore the ethicolegal implications of limiting ICU access of persons living with HIV or TB. We argue that all allocation and rationing decisions must be in terms of SA law, which prohibits unfair discrimination. In addition, ethical decision-making demands accurate and evidence-based strategies for the fair distribution of limited resources. Rationing decisions and processes should be fair and based on visible and consistent criteria that can be subjected to objective scrutiny, with the ultimate aim of ensuring accountability, equity and fairness.


Assuntos
Infecções por Coronavirus , Infecções por HIV/epidemiologia , Alocação de Recursos para a Atenção à Saúde/métodos , Unidades de Terapia Intensiva , Pandemias , Seleção de Pacientes/ética , Pneumonia Viral , Alocação de Recursos , Triagem , Tuberculose/epidemiologia , Betacoronavirus/isolamento & purificação , Coinfecção , Infecções por Coronavirus/economia , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Necessidades e Demandas de Serviços de Saúde/organização & administração , Humanos , Unidades de Terapia Intensiva/economia , Unidades de Terapia Intensiva/normas , Pandemias/economia , Pneumonia Viral/economia , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia , Alocação de Recursos/ética , Alocação de Recursos/legislação & jurisprudência , África do Sul/epidemiologia , Triagem/economia , Triagem/ética , Triagem/legislação & jurisprudência
4.
BMC Med ; 18(1): 270, 2020 09 03.
Artigo em Inglês | MEDLINE | ID: mdl-32878619

RESUMO

BACKGROUND: The COVID-19 pandemic has placed an unprecedented strain on health systems, with rapidly increasing demand for healthcare in hospitals and intensive care units (ICUs) worldwide. As the pandemic escalates, determining the resulting needs for healthcare resources (beds, staff, equipment) has become a key priority for many countries. Projecting future demand requires estimates of how long patients with COVID-19 need different levels of hospital care. METHODS: We performed a systematic review of early evidence on length of stay (LoS) of patients with COVID-19 in hospital and in ICU. We subsequently developed a method to generate LoS distributions which combines summary statistics reported in multiple studies, accounting for differences in sample sizes. Applying this approach, we provide distributions for total hospital and ICU LoS from studies in China and elsewhere, for use by the community. RESULTS: We identified 52 studies, the majority from China (46/52). Median hospital LoS ranged from 4 to 53 days within China, and 4 to 21 days outside of China, across 45 studies. ICU LoS was reported by eight studies-four each within and outside China-with median values ranging from 6 to 12 and 4 to 19 days, respectively. Our summary distributions have a median hospital LoS of 14 (IQR 10-19) days for China, compared with 5 (IQR 3-9) days outside of China. For ICU, the summary distributions are more similar (median (IQR) of 8 (5-13) days for China and 7 (4-11) days outside of China). There was a visible difference by discharge status, with patients who were discharged alive having longer LoS than those who died during their admission, but no trend associated with study date. CONCLUSION: Patients with COVID-19 in China appeared to remain in hospital for longer than elsewhere. This may be explained by differences in criteria for admission and discharge between countries, and different timing within the pandemic. In the absence of local data, the combined summary LoS distributions provided here can be used to model bed demands for contingency planning and then updated, with the novel method presented here, as more studies with aggregated statistics emerge outside China.


Assuntos
Infecções por Coronavirus , Alocação de Recursos para a Atenção à Saúde , Tempo de Internação , Pandemias/estatística & dados numéricos , Pneumonia Viral , Betacoronavirus , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Alocação de Recursos para a Atenção à Saúde/métodos , Alocação de Recursos para a Atenção à Saúde/tendências , Número de Leitos em Hospital , Hospitalização/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Tempo de Internação/tendências , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia
6.
Eur J Cardiothorac Surg ; 58(4): 738-744, 2020 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-32951033

RESUMO

OBJECTIVES: The goal of this study was to describe the clinical features and outcomes of thoracic surgery patients during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: Thirty-five patients were treated at the 12 de Octubre University Hospital in Madrid between 1 March 2020 and 24 April 2020 during the COVID-19 pandemic. Patient demographics, surgical procedures, complications, COVID-19 symptoms and outcomes were recorded. A protocol was introduced to reduce the risk of operating on patients with COVID-19, including symptom screening, a polymerase chain reaction test for severe acute respiratory syndrome coronavirus 2 and computed tomography scans of the chest. Surgical activity changed significantly during this time, from an initial period of near-normal activity, through an emergency-only period and finally a recovery period when some oncological surgical cases were restarted. Selection criteria for surgical patients are also described. RESULTS: A total of 34 patients underwent surgery during the pandemic period. We performed 22 lung resections (11 lobectomies and 11 sublobar resections). No hospital deaths were recorded. An elective surgery patient and an emergency surgery patient were diagnosed with COVID-19 (5.88%). The former died within 30 days after surgery. CONCLUSIONS: Severe acute respiratory syndrome coronavirus 2 represents a tremendous limitation for thoracic surgical practice. Preoperative practices to exclude asymptomatic cases infected with the virus allowed us to perform thoracic surgical procedures.


Assuntos
Betacoronavirus , Infecções por Coronavirus/prevenção & controle , Controle de Infecções/métodos , Pandemias/prevenção & controle , Assistência Perioperatória/métodos , Pneumonia Viral/prevenção & controle , Procedimentos Cirúrgicos Torácicos , Adulto , Idoso , Idoso de 80 Anos ou mais , Protocolos Clínicos , Infecções por Coronavirus/complicações , Infecções por Coronavirus/diagnóstico , Feminino , Alocação de Recursos para a Atenção à Saúde/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Seleção de Pacientes , Pneumonia Viral/complicações , Pneumonia Viral/diagnóstico , Estudos Retrospectivos , Espanha , Centros de Atenção Terciária , Procedimentos Cirúrgicos Torácicos/mortalidade
8.
Surg Endosc ; 34(10): 4225-4232, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32749615

RESUMO

BACKGROUND: Healthcare systems and general surgeons are being challenged by the current pandemic. The European Association for Endoscopic Surgery (EAES) aimed to evaluate surgeons' experiences and perspectives, to identify gaps in knowledge, to record shortcomings in resources and to register research priorities. METHODS: An ad hoc web-based survey of EAES members and affiliates was developed by the EAES Research Committee. The questionnaire consisted of 69 items divided into the following sections: (Ι) demographics, (II) institutional burdens and management strategies, and (III) analysis of resource, knowledge, and evidence gaps. Descriptive statistics were summarized as frequencies, medians, ranges,, and interquartile ranges, as appropriate. RESULTS: The survey took place between March 25th and April 16th with a total of 550 surgeons from 79 countries. Eighty-one percent had to postpone elective cases or suspend their practice and 35% assumed roles not related to their primary expertise. One-fourth of respondents reported having encountered abdominal pathologies in COVID-19-positive patients, most frequently acute appendicitis (47% of respondents). The effect of protective measures in surgical or endoscopic procedures on infected patients, the effect of endoscopic surgery on infected patients, and the infectivity of positive patients undergoing laparoscopic surgery were prioritized as knowledge gaps and research priorities. CONCLUSIONS: Perspectives and priorities of EAES members in the era of the pandemic are hereto summarized. Research evidence is urgently needed to effectively respond to challenges arisen from the pandemic.


Assuntos
Betacoronavirus , Pesquisa Biomédica , Infecções por Coronavirus , Endoscopia , Pandemias , Pneumonia Viral , Pesquisa Biomédica/métodos , Pesquisa Biomédica/organização & administração , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Europa (Continente) , Alocação de Recursos para a Atenção à Saúde/métodos , Alocação de Recursos para a Atenção à Saúde/estatística & dados numéricos , Humanos , Controle de Infecções/métodos , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Padrões de Prática Médica/tendências , Sociedades Médicas , Cirurgiões , Inquéritos e Questionários
9.
J Bone Joint Surg Am ; 102(13): e66, 2020 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-32618914

RESUMO

BACKGROUND: Closed reduction and percutaneous pinning (CRPP) of supracondylar humeral fractures is one of the most common procedures performed in pediatric orthopaedics. The use of full, standard preparation and draping with standard personal protective equipment (PPE) may not be necessary during this procedure. This is of particular interest in the current climate as we face unprecedented PPE shortages due to the current COVID-19 pandemic. METHODS: This is a retrospective chart review of 1,270 patients treated with CRPP of a supracondylar humeral fracture at 2 metropolitan pediatric centers by 10 fellowship-trained pediatric orthopaedic surgeons. One surgeon in the group did not wear a mask when performing CRPP of supracondylar humeral fractures, and multiple surgeons in the group utilized a semisterile preparation technique (no sterile gown or drapes). Infectious outcomes were compared between 2 groups: full sterile preparation and semisterile preparation. We additionally analyzed a subgroup of patients who had semisterile preparation without surgeon mask use. Hospital cost data were used to estimate annual cost savings with the adoption of the semisterile technique. RESULTS: In this study, 1,270 patients who underwent CRPP of a supracondylar humeral fracture and met inclusion criteria were identified. There were 3 deep infections (0.24%). These infections all occurred in the group using full sterile preparation and surgical masks. No clinically relevant pin-track infections were noted. There were no known surgeon occupational exposures to bodily fluid. It is estimated that national adoption of this technique in the United States could save between 18,612 and 22,162 gowns and masks with costs savings of $3.7 million to $4.4 million annually. CONCLUSIONS: We currently face critical shortages of PPE due to the COVID-19 pandemic. Data from this large series suggest that a semisterile technique during CRPP of supracondylar humeral fractures is a safe practice. We anticipate that this could preserve approximately 20,000 gowns and masks in the United States over the next year. Physicians are encouraged to reevaluate their daily practice to identify safe opportunities for resource preservation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Infecções por Coronavirus , Fixação de Fratura/normas , Alocação de Recursos para a Atenção à Saúde/organização & administração , Fraturas do Úmero/cirurgia , Pandemias , Equipamento de Proteção Individual/provisão & distribução , Pneumonia Viral , Infecção da Ferida Cirúrgica/prevenção & controle , Betacoronavirus , Pinos Ortopédicos , Criança , Pré-Escolar , Redução Fechada/efeitos adversos , Redução Fechada/normas , Feminino , Fixação de Fratura/efeitos adversos , Alocação de Recursos para a Atenção à Saúde/economia , Alocação de Recursos para a Atenção à Saúde/métodos , Humanos , Controle de Infecções/economia , Controle de Infecções/normas , Masculino , Equipamento de Proteção Individual/economia , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/etiologia , Estados Unidos/epidemiologia
10.
Medicina (B Aires) ; 80 Suppl 3: 67-76, 2020.
Artigo em Espanhol | MEDLINE | ID: mdl-32658850

RESUMO

This document aims to provide evidence-based recommendations to estimate the personal protective equipments (PPE), medical devices, and drugs commonly used in the Intensive Care Unit during the COVID-19 pandemic. A systematic literature review and gray literature assessment was performed, and the evidence was categorized using the GRADE methodology. Then a predictive model was built to support the estimation of resources needed during 30 days of the pandemic. In the development of these recommendations, 33 publications were included, with variable quality of evidence (low to very low quality). They refer to the use of PPE according to the risk of exposure; management and reuse of PPE, and the stock of drugs and medical devices needed for the care of patients with COVID-19. It is important to remark the difficult in estimating and managing the number of essential supplies and equipment required during a pandemic. The model allowed us to predict the resources required to provide critical care during 30 days of pandemic activity. Given the constant evolution of COVID-19, these recommendations might change as evidence evolves.


Assuntos
Coronavirus , Alocação de Recursos para a Atenção à Saúde/métodos , Unidades de Terapia Intensiva/economia , Equipamento de Proteção Individual/provisão & distribução , Alocação de Recursos/organização & administração , Betacoronavirus , Infecções por Coronavirus/epidemiologia , Humanos , Unidades de Terapia Intensiva/organização & administração , Pandemias , Pneumonia Viral/epidemiologia
11.
J Thorac Cardiovasc Surg ; 160(4): 937-947.e2, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32624303

RESUMO

BACKGROUND: The onset of the coronavirus disease 2019 (COVID-19) pandemic has forced our cardiac surgery program and hospital to enact drastic measures that has forced us to change how we care for cardiac surgery patients, assist with COVID-19 care, and enable support for the hospital in terms of physical resources, providers, and resident training. METHODS: In this review, we review the cardiovascular manifestations of COVID-19 and describe our system-wide adaptations to the pandemic, including the use of telemedicine, how a severe reduction in operative volume affected our program, the process of redeployment of staff, repurposing of residents into specific task teams, the creation of operation room intensive care units, and the challenges that we faced in this process. RESULTS: We offer a revised set of definitions of surgical priority during this pandemic and how this was applied to our system, followed by specific considerations in coronary/valve, aortic, heart failure and transplant surgery. Finally, we outline a path forward for cardiac surgery for the near future. CONCLUSIONS: We recognize that individual programs around the world will eventually face COVID-19 with varying levels of infection burden and different resources, and we hope this document can assist programs to plan for the future.


Assuntos
Centros Médicos Acadêmicos/organização & administração , Betacoronavirus , Procedimentos Cirúrgicos Cardíacos , Infecções por Coronavirus , Alocação de Recursos para a Atenção à Saúde , Acesso aos Serviços de Saúde/organização & administração , Pandemias , Assistência Perioperatória/métodos , Pneumonia Viral , Adulto , Betacoronavirus/isolamento & purificação , Procedimentos Cirúrgicos Cardíacos/tendências , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/terapia , Doenças Cardiovasculares/virologia , Infecções por Coronavirus/complicações , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Feminino , Alocação de Recursos para a Atenção à Saúde/métodos , Alocação de Recursos para a Atenção à Saúde/organização & administração , Humanos , Controle de Infecções/métodos , Controle de Infecções/organização & administração , Unidades de Terapia Intensiva/organização & administração , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Salas Cirúrgicas/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Admissão e Escalonamento de Pessoal/organização & administração , Pneumonia Viral/complicações , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia , Telemedicina/métodos , Telemedicina/organização & administração
13.
Crit Care Med ; 48(8): 1196-1202, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32697491

RESUMO

OBJECTIVES: Coronavirus disease 2019 patients are currently overwhelming the world's healthcare systems. This article provides practical guidance to front-line physicians forced to make critical rationing decisions. DATA SOURCES: PubMed and Medline search for scientific literature, reviews, and guidance documents related to epidemic ICU triage including from professional bodies. STUDY SELECTION: Clinical studies, reviews, and guidelines were selected and reviewed by all authors and discussed by internet conference and email. DATA EXTRACTION: References and data were based on relevance and author consensus. DATA SYNTHESIS: We review key challenges of resource-driven triage and data from affected ICUs. We recommend that once available resources are maximally extended, triage is justified utilizing a strategy that provides the greatest good for the greatest number of patients. A triage algorithm based on clinical estimations of the incremental survival benefit (saving the most life-years) provided by ICU care is proposed. "First come, first served" is used to choose between individuals with equal priorities and benefits. The algorithm provides practical guidance, is easy to follow, rapidly implementable and flexible. It has four prioritization categories: performance score, ASA score, number of organ failures, and predicted survival. Individual units can readily adapt the algorithm to meet local requirements for the evolving pandemic. Although the algorithm improves consistency and provides practical and psychologic support to those performing triage, the final decision remains a clinical one. Depending on country and operational circumstances, triage decisions may be made by a triage team or individual doctors. However, an experienced critical care specialist physician should be ultimately responsible for the triage decision. Cautious discharge criteria are proposed acknowledging the difficulties to facilitate the admission of queuing patients. CONCLUSIONS: Individual institutions may use this guidance to develop prospective protocols that assist the implementation of triage decisions to ensure fairness, enhance consistency, and decrease provider moral distress.


Assuntos
Betacoronavirus , Infecções por Coronavirus/terapia , Alocação de Recursos para a Atenção à Saúde/métodos , Unidades de Terapia Intensiva/organização & administração , Pandemias , Pneumonia Viral/terapia , Triagem/métodos , Adulto , Infecções por Coronavirus/epidemiologia , Cuidados Críticos/normas , Alocação de Recursos para a Atenção à Saúde/normas , Humanos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Guias de Prática Clínica como Assunto , Triagem/normas
14.
Eur Spine J ; 29(10): 2409-2412, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32601848

RESUMO

INTRODUCTION: At the time of writing, we are all coping with the global COVID-19 pandemic. Amongst other things, this has had a significant impact on postponing virtually all routine clinic visits and elective surgeries. Concurrently, the Magnetic Expansion Control (MAGEC) rod has been issued with a number of field safety notices and UK regulator medical device alerts. METHODS: This document serves to provide an overview of the current situation regarding the use of MAGEC rods, primarily in the UK, and the impact that the pandemic has had on the management of patients with these rods. RESULTS AND CONCLUSION: The care of each patient must of course be determined on an individual basis; however, the experience of the authors is that a short delay in scheduled distractions and clinic visits will not adversely impact patient treatment. The authors caution against a gap in distractions of longer than 6 months and emphasise the importance of continued remote patient monitoring to identify those who may need to be seen more urgently.


Assuntos
Betacoronavirus , Infecções por Coronavirus/prevenção & controle , Imãs , Osteogênese por Distração/métodos , Pandemias/prevenção & controle , Segurança do Paciente , Pneumonia Viral/prevenção & controle , Próteses e Implantes , Escoliose/cirurgia , Criança , Alocação de Recursos para a Atenção à Saúde/métodos , Alocação de Recursos para a Atenção à Saúde/normas , Humanos , Controle de Infecções/métodos , Controle de Infecções/normas , Osteogênese por Distração/instrumentação , Osteogênese por Distração/normas , Segurança do Paciente/normas , Guias de Prática Clínica como Assunto , Telemedicina/métodos , Telemedicina/normas , Fatores de Tempo , Reino Unido
15.
Int J Gynecol Cancer ; 30(8): 1097-1100, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32487685
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