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1.
BMJ Open ; 12(8): e060913, 2022 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-35914913

RESUMO

INTRODUCTION: There is an increased demand for services for hospitalised older patients with acute medical conditions due to rapidly ageing population. The COMPrehensive geriatric AsseSSment and multidisciplinary team intervention for hospitalised older adults (COMPASS) study will test the effectiveness of comprehensive geriatric assessment (CGA) and multidisciplinary intervention by comparing it with conventional care among acute hospitalised older adults in Korea. METHODS AND ANALYSIS: A multicentre trial within a cohort comprising three substudies (randomised controlled trials) will be conducted. The intervention includes CGA and CGA-based multidisciplinary interventions by physicians (geriatricians, oncologists), nurses, nutritionists and pharmacists. The multidisciplinary intervention includes nutritional support, medication review and adjustment, rehabilitation, early discharge planning and prevention of geriatric syndromes (falls, delirium, pressure sore and urinary retention). The analysis will be based on an intention-to-treat principle. The primary outcome is living at home 3 months after discharge. In addition to assessing the economic effects of the intervention, a cost-utility analysis will be conducted. ETHICS AND DISSEMINATION: The study protocol was reviewed and approved by the ethics committees of Seoul National University Bundang Hospital and each study site. The study findings will be published in peer-reviewed journals. Subgroup and further in-depth analyses will subsequently be published. TRIAL REGISTRATION NUMBER: KCT0006270.


Assuntos
Avaliação Geriátrica , Geriatras , Idoso , Estudos de Coortes , Avaliação Geriátrica/métodos , Humanos , Estudos Multicêntricos como Assunto , Equipe de Assistência ao Paciente , Alta do Paciente , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto
2.
Praxis (Bern 1994) ; 111(10): 539-548, 2022 Aug.
Artigo em Alemão | MEDLINE | ID: mdl-35920014

RESUMO

Interprofessional Training for Discharge Planning: Effects of Self-Efficacy in Nursing and Medical Students Abstract. Concordant and methodical briefing about a patient's disposition for discharge from hospital within the interprofessional ward round can facilitate a timely discharge. However, interprofessional ward rounds require not only professional skills but also knowledge of interprofessional cooperation between all the occupational groups involved. The question arose whether students of the various professions could learn the necessary competencies during their studies. To this end, a training course on interprofessional discharge planning was developed for nursing and medical students. The training includes four phases consisting of flipped classroom and interprofessional skills training. After each phase, a questionnaire was distributed to assess the self-efficacy of participating nursing and medical students regarding their interprofessional collaboration skills. The results showed that self-efficacy increased steadily with increasing study duration from phase 1 to 4. The study also shows that despite the differences between nursing and medical school curricula, students' self-efficacy regarding interprofessional collaboration skills increased during the IAVI training, which strongly suggests that they benefited from the training.


Assuntos
Estudantes de Medicina , Competência Clínica , Currículo , Humanos , Alta do Paciente , Autoeficácia
3.
Age Ageing ; 51(8)2022 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-35930719

RESUMO

INTRODUCTION: our objective was to describe trends in returning home after hospitalisation for hip fracture and identify predictive factors of this important patient-focussed outcome. METHODS: a cohort of hip fracture patients from England and Wales (2018-2019) resident in their own home pre-admission were analysed to identify patient and service factors associated with returning home after hospital discharge, and with living in their own home at 120 days. Geographical variation was also analysed. RESULTS: analysis of returning home at discharge included 87,797 patients; 57,104 (65%) were discharged home. Patient factors associated with lower likelihood of discharge home included cognitive impairment (odds ratio (OR) 0.60 [95% CI: 0.57, 0.62]), malnutrition (OR 0.81 [0.76, 0.86]), being at risk of malnutrition (OR 0.81 [0.78, 0.85]) and experiencing delay to surgery due to reversal of anti-coagulant medication (OR 0.84 [0.77, 0.92]). Corresponding service factors included surgery delay due to hospital logistical reasons (OR 0.91 [0.87, 0.95]) and early morning admission between 4:00 and 7:59 am (OR 0.83 [0.78, 0.89]). Nerve block prior to arrival at the operating theatre was associated with higher likelihood of discharge home (OR 1.07 [1.03, 1.11]). Most of these associations were stronger when analysing the outcome 'living in their own home at 120 days', in which two out of 11 geographic regions were found to have significantly more patients returning home. CONCLUSION: we identify numerous modifiable factors associated with short-term and medium-term return to own home after hip fracture, in addition to significant geographical variation. These findings should support improvements to care and inform future research.


Assuntos
Fraturas do Quadril , Desnutrição , Estudos de Coortes , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/epidemiologia , Fraturas do Quadril/terapia , Humanos , Alta do Paciente , Estudos Prospectivos , Reino Unido/epidemiologia
4.
Perm J ; 26(2): 11-20, 2022 Jun 29.
Artigo em Inglês | MEDLINE | ID: mdl-35933663

RESUMO

Introduction This study describes the parental perspective of the management and care experience of patients experiencing a pregnancy complicated by a fetal diagnosis to inform more supportive patient-centered care. Methods We conducted a prospective multicenter qualitative patient experience study at three metropolitan children's hospitals' advanced fetal care centers: the Cincinnati, Colorado, and Midwest Fetal Care Centers. Data were collected from pregnant patients who experienced the management of a pregnancy complicated by a fetal anomaly. Clinical journey data were obtained using qualitative research methods in post-birth semistructured interviews. We assembled a generalizable patient journey map to identify the general clinical encounters, and present common participant experiences from diagnosis to post-birth discharge. Results Fifteen families were interviewed; four experienced a loss (27%). Common experiences of trust, education, surrounding support, consistency, and abandonment emerged across all centers. Participant trust in their care team was gained through strong referrals, institutional reputation, and transparent outcomes. Unconditional care team support and continual reassurance was paramount to maintaining participant trust throughout their care journey. Participants appreciated both active and passive educational techniques at clinical touch points. A consistent point of contact assured participants. All families mentioned they felt close to their fetal care team; however, several mentioned that the post-birth transition of care created feelings of abandonment. Conclusions When a family understands the clinical information and feels supported, they are empowered and confident in their ability to navigate their circumstances. Listening to the parental perspective is important to delivering sensitive fetal care.


Assuntos
Pais , Cuidado Pré-Natal , Criança , Feminino , Humanos , Alta do Paciente , Gravidez , Estudos Prospectivos , Pesquisa Qualitativa
6.
Creat Nurs ; 28(3): 192-197, 2022 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-35927008

RESUMO

Background: Discharge planning is crucial to ensuring that patients' care and recovery needs are addressed. A new nurse graduate must be prepared to enter a clinical practice environment in which hospitals face penalties for patient readmissions. Methods: Student nurses were assigned simulated patients with a variety of health disparities and health-care diagnoses to address. A qualitative research design evaluated student perceptions of discharge planning and cultural competency. Results: Students found the simulation to be vital to their clinical experience. Students were able to develop discharge teaching that was culturally congruent for each simulated patient. Conclusions: Incorporating discharge teaching simulation into the nursing curriculum can positively impact students' ability to transition to clinical practice and build confidence in a skill that is rarely incorporated into nursing curricula.


Assuntos
Bacharelado em Enfermagem , Estudantes de Enfermagem , Competência Cultural/educação , Currículo , Humanos , Alta do Paciente , Pesquisa Qualitativa , Ensino
7.
BMC Neurol ; 22(1): 290, 2022 Aug 04.
Artigo em Inglês | MEDLINE | ID: mdl-35927616

RESUMO

BACKGROUND: Even with high standards of acute care and neurological early rehabilitation (NER) a substantial number of patients with neurological conditions still need mechanical ventilation and/or airway protection by tracheal cannulas when discharged and hence home-based specialised intensive care nursing (HSICN). It may be possible to improve the home care situation with structured specialized long-term neurorehabilitation support and following up patients with neurorehabilitation teams. Consequently, more people might recover over an extended period to a degree that they were no longer dependent on HSICN. METHODS: This healthcare project and clinical trial implements a new specialised neurorehabilitation outreach service for people being discharged from NER with the need for HSICN. The multicentre, open, parallel-group RCT compares the effects of one year post-discharge specialized outpatient follow-up to usual care in people receiving HSICN. Participants will randomly be assigned to receive the new form of healthcare (intervention) or the standard healthcare (control) on a 2:1 basis. Primary outcome is the rate of weaning from mechanical ventilation and/or decannulation (primary outcome) after one year, secondary outcomes include both clinical and economic measures. 173 participants are required to corroborate a difference of 30 vs. 10% weaning success rate statistically with 80% power at a 5% significance level allowing for 15% attrition. DISCUSSION: The OptiNIV-Study will implement a new specialised neurorehabilitation outreach service and will determine its weaning success rates, other clinical outcomes, and cost-effectiveness compared to usual care for people in need for mechanical ventilation and/or tracheal cannula and hence HSICN after discharge from NER. TRIAL REGISTRATION: The trial OptiNIV has been registered in the German Clinical Trials Register (DRKS) since 18.01.2022 with the ID DRKS00027326 .


Assuntos
Assistência ao Convalescente , Reabilitação Neurológica , Cuidados Críticos , Humanos , Estudos Multicêntricos como Assunto , Alta do Paciente , Ensaios Clínicos Controlados Aleatórios como Assunto , Respiração Artificial
8.
BMC Pulm Med ; 22(1): 299, 2022 Aug 04.
Artigo em Inglês | MEDLINE | ID: mdl-35927662

RESUMO

OBJECTIVE: To investigate the circumstances that lead to acute exacerbation readmission of elderly patients with chronic obstructive pulmonary disease (COPD) within 30 days and to explore the influencing factors of readmission using a structural equation model to provide evidence for medical staff so that effective intervention measures can be taken. METHODS: The convenience sampling method was used to select 1120 elderly patients with COPD from the respiratory departments of thirteen general hospitals in the Ningxia region, China, from April 2019 to August 2020, who then completed a survey questionnaire. The survey questionnaire contained a general data questionnaire and the modified Medical Research Council, activities of daily living, geriatric depression scale and COPD assessment test scales. RESULTS: The readmission rate of patients with COPD presenting with acute exacerbation within 30 days was determined to be 21.52%. Therefore, the modified model measures data accurately. The results showed that seasonal factors, family rehabilitation, age factors and overall health status were direct factors in the acute exacerbation readmission of patients with COPD within 30 days of hospital discharge. Smoking is not only a direct factor for acute exacerbation readmission within 30 days but also an indirect factor through disease status; disease status and chronic disease are not only direct factors for acute exacerbation readmission within 30 days but also indirect factors through the patient's overall health status. CONCLUSIONS: The rate of patients with COPD presenting with acute exacerbation within 30 days is high; while taking measures to prevent readmission based on influencing factors that directly impact admission rates, attention should also be paid to the interaction between these factors.


Assuntos
Readmissão do Paciente , Doença Pulmonar Obstrutiva Crônica , Atividades Cotidianas , Idoso , Progressão da Doença , Humanos , Alta do Paciente , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Estudos Retrospectivos
9.
BMJ Open Qual ; 11(3)2022 08.
Artigo em Inglês | MEDLINE | ID: mdl-35914816

RESUMO

INTRODUCTION: Pain management after elective, unilateral total hip and knee arthroplasty (THA and TKA) should use a multimodal approach. At discharge, challenges include ensuring correct prescribing practices to optimise analgesia and rationalise opioid use as well as ensuring patients are adequately educated to take these medications safely and effectively in the community. This audit cycle reports on a prescriber and patient education intervention using printed guidelines, educational outreach and prescription standardisation along with a patient information sheet to address the high unplanned readmission rate following THA and TKA at our institution. METHODS: Two cohorts of patients were identified before (2016) and after (2019) the introduction of the educational package. The primary outcome was the unplanned hospital readmission rate in the 42 days following discharge. Secondary outcomes were the compliance with the set prescribing standards and the prescription of strong opioid medications (morphine or oxycodone) on discharge. RESULTS: There was a reduction in the readmission rate from 20.4% to 10.0% (p=0.004). Readmission rates for pain and constipation were also reduced. The prescribing of tramadol (p<0.001) and non-steroidal anti-inflammatory drugs (p<0.001) both increased while the number of patients who received a strong opioid at discharge decreased (p<0.001) as did the number of patients who received a sustained release strong opioid (p<0.001). CONCLUSION: We have observed significant improvement in discharge prescribing which coincided with a reduction in unplanned readmissions after elective TKA and THA. Our approach used prescriber guidelines, education and standardisation with printed information for patients to enhance understanding and recall.


Assuntos
Analgesia , Artroplastia de Quadril , Artroplastia do Joelho , Analgésicos Opioides/uso terapêutico , Humanos , Dor/induzido quimicamente , Manejo da Dor , Alta do Paciente , Readmissão do Paciente
10.
Sci Rep ; 12(1): 13225, 2022 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-35918463

RESUMO

Acute kidney injury (AKI) increases the risk of morbidity, mortality, and progression to chronic kidney disease (CKD). There are few data on the risk of CKD following community-acquired AKI (CA-AKI) and its predictors from developing countries. We evaluated the association of a panel of serum and urine biomarkers at the time of hospital discharge with 4-month renal outcome in CA-AKI. Patients of either sex, aged between 18 and 70 years, with no underlying CKD, and with CA-AKI were recruited at the time of discharge from hospital in this prospective observational study. Levels of serum and urine biomarkers were analyzed and association between these markers and development of CKD, defined as eGFR < 60 ml/min/1.73 m2 or dialysis dependence at 4 month after discharge, were analyzed using multivariate logistic regression analysis and penalized least absolute shrinkage and selection operator logistic regression. Out of a total 126 patients followed up for 4 months, 25 developed CKD. Those who developed CKD were older (p = 0.008), had higher serum creatinine (p < 0.001) and lower serum albumin (p = 0.001) at discharge. Adjusted logistic regression showed that each 10% increase in standardized serum myo-inositol oxygenase (MIOX) level increased the odds of progression to CKD by 13.5%. With 10% increase in standardized urine Neutrophil gelatinase-associated lipocalin (NGAL), serum creatinine and urine protein creatinine ratio (uPCR), increase in the odds of progression to CKD was 10.5%, 9.6% and 8%, respectively. Multivariable logistic model including serum MIOX, discharge serum creatinine and discharge uPCR, was able to predict the progression of CKD [AUC ROC 0.88; (95% CI 0.81, 0.95)]. High level serum MIOX levels at the time of discharge from hospital are associated with progression to CKD in patients with CA-AKI.


Assuntos
Injúria Renal Aguda , Insuficiência Renal Crônica , Injúria Renal Aguda/metabolismo , Adolescente , Adulto , Idoso , Biomarcadores , Creatinina , Hospitais , Humanos , Inositol Oxigenase/metabolismo , Lipocalina-2/urina , Pessoa de Meia-Idade , Alta do Paciente , Diálise Renal , Insuficiência Renal Crônica/complicações , Adulto Jovem
11.
PLoS One ; 17(8): e0271982, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35921383

RESUMO

BACKGROUND: Although respiratory distress is one of the most common complaints of patients requiring emergency medical services (EMS), there is a lack of evidence on important aspects. OBJECTIVES: Our study aims to determine the accuracy of EMS physician diagnostics in the out-of-hospital setting, identify examination findings that correlate with diagnoses, investigate hospital mortality, and identify mortality-associated predictors. METHODS: This retrospective observational study examined EMS encounters between December 2015 and May 2016 in the city of Aachen, Germany, in which an EMS physician was present at the scene. Adult patients were included if the EMS physician initially detected dyspnea, low oxygen saturation, or pathological auscultation findings at the scene (n = 719). The analyses were performed by linking out-of-hospital data to hospital records and using binary logistic regressions. RESULTS: The overall diagnostic accuracy was 69.9% (485/694). The highest diagnostic accuracies were observed in asthma (15/15; 100%), hypertensive crisis (28/33; 84.4%), and COPD exacerbation (114/138; 82.6%), lowest accuracies were observed in pneumonia (70/142; 49.3%), pulmonary embolism (8/18; 44.4%), and urinary tract infection (14/35; 40%). The overall hospital mortality rate was 13.8% (99/719). The highest hospital mortality rates were seen in pneumonia (44/142; 31%) and urinary tract infection (7/35; 20%). Identified risk factors for hospital mortality were metabolic acidosis in the initial blood gas analysis (odds ratio (OR) 11.84), the diagnosis of pneumonia (OR 3.22) reduced vigilance (OR 2.58), low oxygen saturation (OR 2.23), and increasing age (OR 1.03 by 1 year increase). CONCLUSIONS: Our data highlight the diagnostic uncertainties and high mortality in out-of-hospital emergency patients presenting with respiratory distress. Pneumonia was the most common and most frequently misdiagnosed cause and showed highest hospital mortality. The identified predictors could contribute to an early detection of patients at risk.


Assuntos
Serviços Médicos de Emergência , Síndrome do Desconforto Respiratório , Adulto , Estudos de Coortes , Dispneia , Mortalidade Hospitalar , Hospitais , Humanos , Alta do Paciente , Síndrome do Desconforto Respiratório/diagnóstico , Estudos Retrospectivos
12.
BMC Health Serv Res ; 22(1): 991, 2022 Aug 04.
Artigo em Inglês | MEDLINE | ID: mdl-35922849

RESUMO

BACKGROUND: This article investigates the hospital costs related to the management of COVID-19 positive patients, requiring a hospitalization (from the positivity confirmation to discharge, including rehabilitation activities). METHODS: A time-driven activity-based costing analysis, grounding on administrative and accounting flows provided by the management control, was implemented to define costs related to the hospital management of COVID-19 positive patients, according to real-word data, derived from six public Italian Hospitals, in 2020. RESULTS: Results reported that the higher the complexity of care, the higher the hospitalization cost per day (low-complexity = €475.86; medium-complexity = €700.20; high-complexity = €1,401.65). Focusing on the entire clinical pathway, the overall resources absorption, with the inclusion of rehabilitation costs, ranged from 6,198.02€ to 32,141.20€, dependent from the patient's clinical condition. CONCLUSIONS: Data could represent the baseline cost for COVID-19 hospital management, thus being useful for the further development of proper reimbursement tariffs devoted to hospitalized infected patients.


Assuntos
COVID-19 , COVID-19/epidemiologia , Custos Hospitalares , Hospitalização , Hospitais Públicos , Humanos , Alta do Paciente
14.
BMJ Open Qual ; 11(3)2022 08.
Artigo em Inglês | MEDLINE | ID: mdl-35926982

RESUMO

BACKGROUND: This study aimed to assess the impact of a standardised rapid response systems (the Between the Flags (BTF)) implemented across New South Wales (NSW), Australia, among female patients. METHODS: We conducted an interrupted time series (2007-2013) population-based linkage study including 5 114 170 female patient (≥18 years old) admissions in all 232 public hospitals in NSW. We studied changes in levels and trends of patient outcomes after BTF implementation among four age groups of female patients. RESULTS: Before the BTF system introduction (2007-2009), for the female patients as a whole, there was a progressive decrease in rates of in-hospital cardiopulmonary arrest (IHCA), IHCA-related mortality and hospital mortality for female patients. However, there were no changes in deaths in low-mortality diagnostic-related groups (DLMDRGs), IHCA survival to discharge and 1-year post-discharge mortality after surviving an IHCA. Only the female patients aged 55 years and older showed the same results as the whole sample. After the BTF programme (2010-2013), the same trends (except for DLMDRG) continued for female patients as a whole and for those aged 55 years or older. There was a significant reduction in DLMDRG among female patients aged 35-54 years (p<0.001), those aged 75 years and over (p<0.05) and female patients as a whole (p<0.05). The decreasing secular trend of surviving an IHCA to hospital discharge before the BTF system (p<0.05) among patients aged 18-34 years old was reversed after the BTF implementation (p<0.01). CONCLUSIONS: For female patients the BTF programme introduction was associated with continued reductions in the rates of IHCA, IHCA-related mortality and hospital mortality, as well as a new reduction in DLMDRG for 35-54 years old patients and those aged 75 years and older, and increased survival for those aged 18-34 years who had suffered an IHCA.


Assuntos
Assistência ao Convalescente , Parada Cardíaca , Adolescente , Adulto , Feminino , Parada Cardíaca/terapia , Hospitais Públicos , Humanos , Análise de Séries Temporais Interrompida , Pessoa de Meia-Idade , Alta do Paciente , Adulto Jovem
15.
J Prim Care Community Health ; 13: 21501319221112584, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35938489

RESUMO

INTRODUCTION/OBJECTIVE: This review aimed to summarize articles describing caregiver burden and the relationship between health outcomes as well as describing interventions focusing on this population. METHODS: The review used the PRISMA statement and Whittemore and Knafl guidelines. The search engines Scopus, PubMed, Ovid (PsycINFO), and CINAHL were searched for articles published in English. RESULTS: This review included 30 studies that met the criteria. Physical, psychological, and social factors were associated with HF caregiver burden. HF caregiver interventions included health education, post-discharge home visits, phone calls, counseling, and support groups that demonstrated some potential to reduce the caregivers' burden. DISCUSSION: Healthcare provider team should screen for caregiver burden and promote healthy behaviors, and strategies to improve quality of life. Further studies should include caregivers as care team members and embed social networking in the interventions for reducing HF caregiver burden. The caregivers' burden could influence the poor outcomes of care, including physical, psychological, societal, and functional dimensions. Future interventions should develop to alleviate HF caregiver burden.


Assuntos
Fardo do Cuidador , Insuficiência Cardíaca , Assistência ao Convalescente , Cuidadores , Insuficiência Cardíaca/terapia , Humanos , Alta do Paciente , Qualidade de Vida
16.
BMJ Open Qual ; 11(3)2022 08.
Artigo em Inglês | MEDLINE | ID: mdl-35940697

RESUMO

BACKGROUND: Surgery is recommended within 48 hours of hip fractures for better perioperative outcomes. Yet, such targets still commonly remain a challenge. Our institution is no exception.As part of a hospital-wide initiative, our anaesthesia department focused on improving perioperative processes with aims to reduce the time to first anaesthesia consult and surgery for hip fracture patients. Acknowledging multiple causes for surgical delay, we decided first to address anaesthesia-specific factors-(a) first anaesthetist contact usually happens after surgery is offered which leaves a short runway for preoptimisation, (b) this is compounded by varying degrees of anaesthetist involvement for follow-up thereafter. (c) There is a need to calibrate our perioperative care standards and (d) enforce more consistent auditing in quality assurance. This project was conducted in a 1000-bed hospital serving eastern Singapore. INTERVENTION: We created an integrated anaesthesia consultant-led outreach service for hip fracture patients, based on a perioperative workflow system to provide proactive anaesthetist consults within 24 hours of admission in advance of surgical decision. This was streamlined with a coordinated follow-up system for preoptimisation until surgery. METHODS: Our quality improvement project applied the iterative Plan-Do-Study-Act model from pilot to sustainability stage. We collected data at baseline followed by 6-monthly audits from electronic databases.Primary outcomes measured were time to first anaesthesia consult and surgery. Secondary outcomes included rate of critical care reviews and admission, mortality rate, length of stay and time to nerve blocks. RESULTS: Post implementation, our service reviewed >600 hip fracture patients. Median time to anaesthesia consult reduced significantly from 35.3 hours (2019) to 21.5 hours (2021) (p=0.029). Median time to surgery was reduced from 61.5 hours (2019) to 50 hours (2021) (p=0.897) with a 13.6% increase in patients operated <48 hours. Critical care admissions, 6-monthly and 12-monthly mortality rates and time to nerve block were reduced with a greater percentage of patients discharged within 10 days. CONCLUSION: Our project focused on improving anaesthesia perioperative processes to address surgical delays in hip fracture patients. Our consultant-led anaesthesia service ensured that proactive anaesthesia care was delivered to provide sufficient time for preoptimisation with greater standardisation to follow-up, better communication and quality assurance.


Assuntos
Fraturas do Quadril , Bloqueio Nervoso , Consultores , Fraturas do Quadril/cirurgia , Humanos , Alta do Paciente , Melhoria de Qualidade
17.
Spinal Cord Ser Cases ; 8(1): 71, 2022 08 02.
Artigo em Inglês | MEDLINE | ID: mdl-35918325

RESUMO

INTRODUCTION: Cauda equina syndrome (CES) is most caused by lumbar disc herniation, and the associated treatment involves prompt surgical decompression. Rarer causes of CES include perineural (Tarlov) cysts. CLINICAL PRESENTATION: A 62-year-old female with history of rheumatoid arthritis, hip and knee replacements, and chronic low back pain presented with worsening back pain, left leg weakness and pain for 6 weeks, and bowel/bladder incontinence with diminished sensation in the perianal region for 24 h prior to presentation. MRI demonstrated severe spinal stenosis at L4-S1, central disc herniation at L5-S1, and compression of the cauda equina, consistent with CES. A lumbar decompression was performed. Patient did well at 2-week follow up, but presented 5 weeks post-discharge with increased left leg pain/weakness and genitalia anesthesia. Imaging was unremarkable. Two months later, the patient presented with diminished sensation in the buttocks and bilateral lower extremities and bowel/bladder incontinence. Imaging demonstrated a large cystic presacral mass with involvement of the left sciatic foramen and S3 neural foramen. A team of plastic, orthopedic, and neurological surgeons performed an S3 sacral laminectomy, foraminotomy, partial sacrectomy, and S3 rhizotomy, and excision of the large left hemorrhagic pudendal mass. Final pathology demonstrated a perineural cyst with organizing hemorrhage. On follow-up, the patient's pain and weakness improved. CONCLUSION: CES-like symptoms were initially attributed to a herniated disk. However, lumbar decompression did not resolve symptoms, prompting further radiographic evaluation at two separate presentations. This represents the first reported case of a pudendal tumor causing symptoms initially attributed to a herniated disc.


Assuntos
Síndrome da Cauda Equina , Deslocamento do Disco Intervertebral , Neoplasias , Radiculopatia , Assistência ao Convalescente , Síndrome da Cauda Equina/diagnóstico , Síndrome da Cauda Equina/etiologia , Síndrome da Cauda Equina/cirurgia , Feminino , Humanos , Deslocamento do Disco Intervertebral/diagnóstico , Deslocamento do Disco Intervertebral/diagnóstico por imagem , Vértebras Lombares/cirurgia , Pessoa de Meia-Idade , Neoplasias/complicações , Neoplasias/patologia , Dor , Alta do Paciente
18.
Kidney360 ; 3(7): 1144-1157, 2022 07 28.
Artigo em Inglês | MEDLINE | ID: mdl-35919520

RESUMO

Background: Hypernatremia is a frequently encountered electrolyte disorder in hospitalized patients. Controversies still exist over the relationship between hypernatremia and its outcomes in hospitalized patients. This study examines the relationship of hypernatremia to outcomes among hospitalized patients and the extent to which this relationship varies by kidney function and age. Methods: We conducted an observational study to investigate the association between hypernatremia, eGFR, and age at hospital admission and in-hospital mortality, and discharge dispositions. We analyzed the data of 1.9 million patients extracted from the Cerner Health Facts databases (2000-2018). Adjusted multinomial regression models were used to estimate the relationship of hypernatremia to outcomes of hospitalized patients. Results: Of all hospitalized patients, 3% had serum sodium (Na) >145 mEq/L at hospital admission. Incidence of in-hospital mortality was 12% and 2% in hyper- and normonatremic patients, respectively. The risk of all outcomes increased significantly for Na >155 mEq/L compared with the reference interval of Na=135-145 mEq/L. Odds ratios (95% confidence intervals) for in-hospital mortality and discharge to a hospice or nursing facility were 34.41 (30.59-38.71), 21.14 (17.53-25.5), and 12.21 (10.95-13.61), respectively (all P<0.001). In adjusted models, we found that the association between Na and disposition was modified by eGFR (P<0.001) and by age (P<0.001). Sensitivity analyses were performed using the eGFR equation without race as a covariate, and the inferences did not substantially change. In all hypernatremic groups, patients aged 76-89 and ≥90 had higher odds of in-hospital mortality compared with younger patients (all P<0.001). Conclusions: Hypernatremia was significantly associated with in-hospital mortality and discharge to a hospice or nursing facility. The risk of in-hospital mortality and other outcomes was highest among those with Na >155 mEq/L. This work demonstrates that hypernatremia is an important factor related to discharge disposition and supports the need to study whether protocolized treatment of hypernatremia improves outcomes.


Assuntos
Hipernatremia , Mortalidade Hospitalar , Hospitalização , Humanos , Hipernatremia/epidemiologia , Alta do Paciente , Sódio
20.
BMC Pediatr ; 22(1): 467, 2022 08 03.
Artigo em Inglês | MEDLINE | ID: mdl-35922792

RESUMO

BACKGROUND: Findings from manometry studies and contrast imaging reveal functioning gastric physiology in newborns with duodenal atresia and stenosis. Stomach reservoir function should therefore be valuable in aiding the postoperative phase of gastric feeding. The aim of this study was therefore to compare the feasibility of initiating oral or large volume(s) gavage feeds vs small volume bolus feeds following operation for congenital duodenal anomalies. METHODS: Single-center electronic medical records of all babies with duodenal atresia and stenosis admitted to a university surgical center during January 1997-September 2021 were analyzed. A fast-fed group (FF) included newborns fed with oral or gavage feeds advanced at a rate of at least 2.5 ml/kg and then progressed more than once a day vs slow-fed group (SF) fed with gavage feeds at incremental rate less than 2.5 ml/kg/day for each time period of oral tolerance or by drip feeds. Total feed volume was limited to 120-150 ml/kg/day in the respective study cohort populations. RESULTS: Fifty-one eligible patients were recruited in the study - twenty-six in FF group and twenty-five in SF group. Statistically significant differences were observed in the (i) date of first oral feeds (POD 7.7 ± 3.2 vs 16.1 ± 7.7: p < 0.001), and (ii) first full feeds (POD 12.5 ± 5.3 vs 18.8 ± 9.7: p < 0.01) in FF vs SF study groups. CONCLUSION: Initial feeding schedules with oral or incremental gavage-fed rates of at least 2.5 ml/kg in stepwise increments and multi-steps per day is wholly feasible in the postoperative feeding regimens of neonates with congenital duodenal disorders. Significant health benefits are thus achievable in these infants allowing an earlier time to acquiring full enteral feeding and their hospital discharge.


Assuntos
Obstrução Duodenal , Constrição Patológica , Obstrução Duodenal/etiologia , Obstrução Duodenal/cirurgia , Nutrição Enteral/métodos , Humanos , Lactente , Recém-Nascido , Atresia Intestinal , Alta do Paciente
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