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1.
Rev. Esc. Enferm. USP ; 53: e03470, Jan.-Dez. 2019. tab
Artigo em Inglês, Português | LILACS, BDENF - Enfermagem | ID: biblio-1020385

RESUMO

RESUMO Objetivo Avaliar a frequência e as razões da omissão do cuidado de enfermagem e verificar se as razões de omissão diferem entre categorias profissionais. Método Estudo quantitativo e transversal realizado nas unidades de internação adulto de hospital público de uma instituição de ensino. A coleta de dados foi realizada no período de fevereiro a abril de 2017, por meio de uma ficha de caracterização pessoal e profissional e pelo instrumento MISSCARE-BRASIL. Resultados Participaram do estudo 58 profissionais de enfermagem responsáveis pela assistência direta ao paciente, dos quais 74,1% relataram pelo menos uma atividade de enfermagem omitida no turno de trabalho. As principais razões atribuídas à omissão do cuidado foram o dimensionamento inadequado dos profissionais, as situações de urgência com os pacientes durante o turno de trabalho e a não disponibilidade de medicamentos, materiais ou equipamentos quando necessário. Conclusão A maioria dos cuidados foi "sempre" ou "frequentemente" realizada, e as razões atribuídas para a omissão do cuidado estão relacionadas aos recursos laborais, materiais e estilo de gestão. Os enfermeiros diferem dos técnicos quanto às razões para a não realização dos cuidados.


RESUMEN Objetivo Evaluar la frecuencia y las razones de la omisión del cuidado de enfermería y verificar si las razones de omisión difieren entre categorías profesionales. Método Estudio cuantitativo y transversal llevado a cabo en las unidades de hospitalización de adultos de un hospital público de un centro de enseñanza. La recolección de datos fue realizada en el período de febrero a abril de 2017, mediante una ficha de caracterización personal y profesional y por el instrumento MISSCARE-BRASIL. Resultados Participaron en el estudio 58 profesionales de enfermería responsables de la asistencia directa al paciente, de los que el 74,1% relataron por lo menos una actividad de enfermería omitida en el turno de trabajo. Las principales razones atribuidas a la omisión del cuidado fueron el dimensionamiento inadecuado de los profesionales, las situaciones de urgencias con los pacientes durante el turno de trabajo y la no disponibilidad de fármacos, materiales o equipos cuando necesario. Conclusión La mayoría de los cuidados fue "siempre" o "a menudo" realizada, y las razones atribuidas para la omisión del cuidado están relacionadas con los recursos laborales, materiales y estilo de gestión. Los enfermeros difieren de los técnicos en cuanto a las razones para la no realización de los cuidados.


ABSTRACT Objective To evaluate the frequency and reasons for missed nursing care and to verify whether the reasons for omission differ between professional categories. Method A quantitative and cross-sectional study carried out in the adult hospitalization units of a public hospital of a teaching institution. Data collection was performed from February to April 2017, through a personal and professional characterization form and the MISSCARE-BRASIL instrument. Results Fifty-eight (58) nursing professionals responsible for direct patient care participated in the study, of which 74.1% reported at least one missed nursing care activity during the work shift. The main reasons attributed to missed care situations were an inadequate amount of professionals, urgent situations with the patients during the work shift, and the non-availability of medicine, materials or equipment when necessary. Conclusion Most care was "always" or "often" performed, and the reasons given for missed care are related to work resources, materials, and management style. Nurses differ from the technicians as to the reasons for not performing care.


Assuntos
Humanos , Avaliação de Resultados da Assistência ao Paciente , Cuidados de Enfermagem , Avaliação em Saúde , Estudos Transversais , Segurança do Paciente
2.
Am Surg ; 85(9): 961-964, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31638507

RESUMO

Enmeshment of emergency trauma providers (ETPs) into the United States health-care fabric resulted in the establishment of a formalized surgical critical care fellowship and certification for emergency medicine trainees. The aim of this study was to compare trauma outcomes for surgery-trained providers (STPs) and ETPs at our institution, hypothesizing patient outcome equivalency. We performed an institutional review board-exempt institutional registry review (January 1, 2004 to August 1, 2018), comparing 74 STPs and 6 ETPs. Comparator variables included all-cause mortality, all-cause morbidity, CT imaging studies per provider, time in ED (min), hospital/ICU lengths of stay, ICU admissions, and functional outcomes on discharge. Statistical comparisons included chi-square test for categorical data and analysis of covariance for continuous data (adjustments made for patient age, Injury Severity Score, and trauma mechanism; all P < 0.20). Statistical significance was set at P < 0.05, with an equivalence study design. A total of 33,577 trauma resuscitations were reviewed (32,299 STP-led and 1,278 ETP-led). Except for patient age (STP 50.2 ± 25.9 vs ETP 54.9 ± 25.3 years), Injury Severity Score (8.47 ± 8.14 vs 9.22 ± 8.40), and ICU admissions (16.1% vs 18.8%), we noted no significant intergroup differences. ETPs' performance was equivalent to that of STPs for all primary comparator variables (mortality, morbidity, CT utilization, time in the ED, lengths of stay, and functional outcomes). Incorporation of ETPs into our trauma center resulted in outcome parity between ETPs and STPs, while simultaneously expanding the expertise and experiential diversity within our multidisciplinary team. This study provides support for further incorporation of ETPs as equal partners across the growing network of United States regional trauma centers.


Assuntos
Competência Clínica , Medicina de Emergência/normas , Cirurgia Geral/normas , Ferimentos e Lesões/cirurgia , Cuidados Críticos , Medicina de Emergência/educação , Cirurgia Geral/educação , Mortalidade Hospitalar , Humanos , Tempo de Internação , Duração da Cirurgia , Avaliação de Resultados da Assistência ao Paciente , Pennsylvania , Complicações Pós-Operatórias , Tomografia Computadorizada por Raios X , Centros de Traumatologia , Estados Unidos
3.
Isr Med Assoc J ; 21(10): 676-680, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31599510

RESUMO

BACKGROUND: In developed countries, hepatitis A virus (HAV) infection occurs mainly in adults. It is usually symptomatic and may cause acute liver failure (ALF). In patients with chronic liver disease, serum ferritin levels (SFL) can predict short-term prognosis. OBJECTIVES: To determine whether admission SFL can serve as a prognostic marker in patients with HAV infection. METHODS: A retrospective analysis of 33 adults with HAV infection was conducted. Because none of our patients presented with ALF, the parameter "length of hospital stay," was used as a surrogate marker of disease severity. RESULTS: The mean (± SD) at admission SFL was 2529 ± 4336 ng/ml. SFL correlated with the levels of international normalized ratio (INR), liver enzymes, and degree of hemolysis that occurred during the disease course. SFL did not correlate with the levels of either albumin or bilirubin or with the length of the hospital stay. The mean length of hospital stay was 5.1 ± 2.0 days, which correlated with the levels of INR, albumin, and bilirubin as well as the degree of hemolysis. However, in multivariate analysis only albumin and bilirubin predicted the length of the hospital stay. Follow-up SFL, which were available only in eight patients, decreased during the hospital stay. CONCLUSIONS: In adults with acute HAV infection, SFL may be increased. SFL correlated with the degree of liver injury and hemolysis that occur during the disease. However, in our cohort of HAV patients, who had a relatively benign disease course, SFL were of no prognostic value.


Assuntos
Ferritinas/sangue , Hepatite A/sangue , Avaliação de Resultados da Assistência ao Paciente , Adolescente , Adulto , Idoso , Feminino , Hepatite A/complicações , Humanos , Israel , Tempo de Internação/estatística & dados numéricos , Falência Hepática Aguda/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Índice de Gravidade de Doença , Adulto Jovem
4.
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
5.
Medicine (Baltimore) ; 98(39): e17079, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31574807

RESUMO

Advancements in diagnostic modalities have improved the diagnosis of meconium peritonitis (MP) both in utero and ex utero. This study aimed to determine the efficacy of prompt prenatal and postnatal diagnoses of MP on the postnatal outcomes of these patients.We conducted a retrospective chart review of neonates with MP admitted to the Mackay Memorial Hospital Systems from 2005 to 2016. The prenatal diagnoses, postnatal presentations, surgical indications, operative methods, types of MP, operative findings, associated anomalies, morbidities, patient outcomes, and survival rates were analyzed. Morbidities included postoperative adhesion ileus, bacteremia, and short bowel syndrome. We also performed subgroup analyses of the morbidity and survival rates of prenatally versus postnatally diagnosed patients, as well as inborn versus outborn neonates.Thirty-seven neonates with MP were enrolled. Of this number, 24 (64.9%) were diagnosed prenatally. Twenty-two (59.5%) were born preterm. The most common prenatal sonographic findings included fetal ascites followed by dilated bowel loops. Abdominal distention was the most frequent postnatal symptom. Thirty-four (91.9%) neonates underwent surgery, whereas 3 were managed conservatively. Volvulus of the gastrointestinal tract was the most frequent anatomic anomaly. The total morbidity and survival rates were 37.8% and 91.9%, respectively. The morbidity and survival rates did not differ significantly between prenatally and postnatally diagnosed patients (37.5% vs 33.3%, P = 1.00; 91.7% vs 92.3%, P = 1.00, respectively). Inborn and outborn patients did not differ in terms of morbidity and survival rates (27.3% vs 53.3%, P = .17; 100% vs 80.0%, P = .06, respectively).Although not statistically significant, inborn MP neonates had higher survival rates when compared with outborn MP neonates. Prompt postnatal management at tertiary centers seemed crucial.


Assuntos
Mecônio , Peritonite/diagnóstico por imagem , Ultrassonografia Pré-Natal , Ascite/etiologia , Dilatação Patológica/etiologia , Diagnóstico Precoce , Feminino , Humanos , Recém-Nascido , Volvo Intestinal/etiologia , Intestinos/patologia , Avaliação de Resultados da Assistência ao Paciente , Peritonite/complicações , Peritonite/mortalidade , Peritonite/terapia , Gravidez , Estudos Retrospectivos , Taxa de Sobrevida , Tempo para o Tratamento
6.
Lancet ; 394(10207): 1425-1436, 2019 10 19.
Artigo em Inglês | MEDLINE | ID: mdl-31522846

RESUMO

BACKGROUND: Heavy menstrual bleeding affects 25% of women in the UK, many of whom require surgery to treat it. Hysterectomy is effective but has more complications than endometrial ablation, which is less invasive but ultimately leads to hysterectomy in 20% of women. We compared laparoscopic supracervical hysterectomy with endometrial ablation in women seeking surgical treatment for heavy menstrual bleeding. METHODS: In this parallel-group, multicentre, open-label, randomised controlled trial in 31 hospitals in the UK, women younger than 50 years who were referred to a gynaecologist for surgical treatment of heavy menstrual bleeding and who were eligible for endometrial ablation were randomly allocated (1:1) to either laparoscopic supracervical hysterectomy or second generation endometrial ablation. Women were randomly assigned by either an interactive voice response telephone system or an internet-based application with a minimisation algorithm based on centre and age group (<40 years vs ≥40 years). Laparoscopic supracervical hysterectomy involves laparoscopic (keyhole) surgery to remove the upper part of the uterus (the body) containing the endometrium. Endometrial ablation aims to treat heavy menstrual bleeding by destroying the endometrium, which is responsible for heavy periods. The co-primary clinical outcomes were patient satisfaction and condition-specific quality of life, measured with the menorrhagia multi-attribute quality of life scale (MMAS), assessed at 15 months after randomisation. Our analysis was based on the intention-to-treat principle. The trial was registered with the ISRCTN registry, number ISRCTN49013893. FINDINGS: Between May 21, 2014, and March 28, 2017, we enrolled and randomly assigned 660 women (330 in each group). 616 (93%) of 660 women were operated on within the study period, 588 (95%) of whom received the allocated procedure and 28 (5%) of whom had an alternative surgery. At 15 months after randomisation, more women allocated to laparoscopic supracervical hysterectomy were satisfied with their operation compared with those in the endometrial ablation group (270 [97%] of 278 women vs 244 [87%] of 280 women; adjusted percentage difference 9·8, 95% CI 5·1-14·5; adjusted odds ratio [OR] 2·53, 95% CI 1·83-3·48; p<0·0001). Women randomly assigned to laparoscopic supracervical hysterectomy were also more likely to have the best possible MMAS score of 100 than women assigned to endometrial ablation (180 [69%] of 262 women vs 146 [54%] of 268 women; adjusted percentage difference 13·3, 95% CI 3·8-22·8; adjusted OR 1·87, 95% CI 1·31-2·67; p=0·00058). 14 (5%) of 309 women in the laparoscopic supracervical hysterectomy group and 11 (4%) of 307 women in the endometrial ablation group had at least one serious adverse event (adjusted OR 1·30, 95% CI 0·56-3·02; p=0·54). INTERPRETATION: Laparoscopic supracervical hysterectomy is superior to endometrial ablation in terms of clinical effectiveness and has a similar proportion of complications, but takes longer to perform and is associated with a longer recovery. FUNDING: UK National Institute for Health Research Health Technology Assessment Programme.


Assuntos
Técnicas de Ablação Endometrial , Histerectomia/métodos , Laparoscopia/métodos , Menorragia/cirurgia , Adulto , Técnicas de Ablação Endometrial/efeitos adversos , Feminino , Seguimentos , Humanos , Histerectomia/efeitos adversos , Análise de Intenção de Tratamento , Laparoscopia/efeitos adversos , Pessoa de Meia-Idade , Duração da Cirurgia , Avaliação de Resultados da Assistência ao Paciente , Satisfação do Paciente , Complicações Pós-Operatórias , Qualidade de Vida , Reino Unido
7.
Br J Anaesth ; 123(5): 664-670, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31493848

RESUMO

BACKGROUND: Patient-centred outcomes are increasingly used in perioperative clinical trials. The Standardised Endpoints in Perioperative Medicine (StEP) initiative aims to define which measures should be used in future research to facilitate comparison between studies and to enable robust evidence synthesis. METHODS: A systematic review was conducted to create a longlist of patient satisfaction, health-related quality of life, functional status, patient well-being, and life-impact measures for consideration. A three-stage Delphi consensus process involving 89 international experts was then conducted in order to refine this list into a set of recommendations. RESULTS: The literature review yielded six patient-satisfaction measures, seven generic health-related quality-of-life measures, eight patient well-being measures, five functional-status measures, and five life-impact measures for consideration. The Delphi response rates were 92%, 87%, and 100% for Rounds 1, 2, and 3, respectively. Three additional measures were added during the Delphi process as a result of contributions from the StEP group members. Firm recommendations have been made about one health-related quality-of-life measure (EuroQol 5 Dimension, five-level version with visual analogue scale), one functional-status measure (WHO Disability Assessment Schedule version 2.0, 12-question version), and one life-impact measure (days alive and out of hospital at 30 days after surgery). Recommendations with caveats have been made about the Bauer patient-satisfaction measure and two life-impact measures (days alive and out of hospital at 1 yr after surgery, and discharge destination). CONCLUSIONS: Several patient-centred outcome measures have been recommended for use in future perioperative studies. We suggest that every clinical study should consider using at least one patient-centred outcome within a suite of endpoints.


Assuntos
Determinação de Ponto Final/normas , Avaliação de Resultados da Assistência ao Paciente , Assistência Perioperatória/normas , Atividades Cotidianas , Técnica Delfos , Humanos , Satisfação do Paciente , Assistência Perioperatória/métodos , Psicometria , Qualidade de Vida , Procedimentos Cirúrgicos Operatórios/reabilitação
8.
Artigo em Inglês | MEDLINE | ID: mdl-31426735

RESUMO

The Australian Group on Antimicrobial Resistance (AGAR) performs regular period-prevalence studies to monitor changes in antimicrobial resistance in selected enteric Gram-negative pathogens. The 2017 survey was the fifth year to focus on blood stream infections, and included Enterobacterales, Pseudomonas aeruginosa and Acinetobacter species. Seven thousand nine hundred and ten isolates, comprising Enterobacterales (7,100, 89.8%), P. aeruginosa (697, 8.8%) and Acinetobacter species (113, 1.4%), were tested using commercial automated methods. The results were analysed using Clinical and Laboratory Standards Institute (CLSI) and European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoints (January 2018). Of the key resistances, non-susceptibility to the third-generation cephalosporin, ceftriaxone, was found in 11.3%/11.3% of Escherichia coli (CLSI/EUCAST criteria), 8.8%/8.8% of Klebsiella pneumoniae, and 5.7%/5.7% of K. oxytoca. Non-susceptibility rates to ciprofloxacin were 12.1%/18.0% for E. coli, 4.4%/11.2% for K. pneumoniae, 1.3%/3.5% for K. oxytoca, 3.0%/8.5% for Enterobacter cloacae complex, and 5.1%/9.8% for P. aeruginosa. Resistance rates to piperacillin-tazobactam were 2.8%/5.9%, 3.7%/7.3%, 9.6%/11.0%, 22.5%/27.6%, and 6.4%/13.2% for the same five species respectively. Twenty-seven isolates from 25 patients were shown to harbour a carbapenemase gene: 12 blaIMP (11 patients), five blaOXA-181 (four patients), three blaOXA-23, two blaNDM, two blaKPC, two blaVIM, and one blaGES.


Assuntos
Antibacterianos/farmacologia , Farmacorresistência Bacteriana/efeitos dos fármacos , Infecções por Bactérias Gram-Negativas/tratamento farmacológico , Sepse/tratamento farmacológico , Sepse/epidemiologia , Sepse/microbiologia , Relatórios Anuais como Assunto , Austrália/epidemiologia , Proteínas de Bactérias/genética , Proteínas de Bactérias/metabolismo , Infecção Hospitalar/tratamento farmacológico , Infecções por Enterobacteriaceae/tratamento farmacológico , Escherichia coli/efeitos dos fármacos , Humanos , Klebsiella pneumoniae/efeitos dos fármacos , Testes de Sensibilidade Microbiana , Tipagem Molecular , Avaliação de Resultados da Assistência ao Paciente , Pseudomonas aeruginosa/efeitos dos fármacos , beta-Lactamases/genética , beta-Lactamases/metabolismo
9.
Lancet ; 394(10198): 604-610, 2019 Aug 17.
Artigo em Inglês | MEDLINE | ID: mdl-31395443

RESUMO

Human genomic sequencing has potential diagnostic, prognostic, and therapeutic value across a wide breadth of clinical disciplines. One barrier to widespread adoption is the paucity of evidence for improved outcomes in patients who do not already have an indication for more focused testing. In this Series paper, we review clinical outcome studies in genomic medicine and discuss the important features and key challenges to building evidence for next generation sequencing in the context of routine patient care.


Assuntos
Genômica/métodos , Medicina de Precisão/métodos , Testes Diagnósticos de Rotina , Genoma Humano , Sequenciamento de Nucleotídeos em Larga Escala , Humanos , Avaliação de Resultados da Assistência ao Paciente , Padrão de Cuidado
10.
Br J Anaesth ; 123(2): 135-150, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31255291

RESUMO

Surgery is an important treatment modality for the majority of solid organ cancers. Unfortunately, cancer recurrence following surgery of curative intent is common, and typically results in refractory disease and patient death. Surgery and other perioperative interventions induce a biological state conducive to the survival and growth of residual cancer cells released from the primary tumour intraoperatively, which may influence the risk of a subsequent metastatic disease. Evidence is accumulating that anaesthetic and analgesic interventions could affect many of these pathophysiological processes, influencing risk of cancer recurrence in either a beneficial or detrimental way. Much of this evidence is from experimental in vitro and in vivo models, with clinical evidence largely limited to retrospective observational studies or post hoc analysis of RCTs originally designed to evaluate non-cancer outcomes. This narrative review summarises the current state of evidence regarding the potential effect of perioperative anaesthetic and analgesic interventions on cancer biology and clinical outcomes. Proving a causal link will require data from prospective RCTs with oncological outcomes as primary endpoints, a number of which will report in the coming years. Until then, there is insufficient evidence to recommend any particular anaesthetic or analgesic technique for patients undergoing tumour resection surgery on the basis that it might alter the risk of recurrence or metastasis.


Assuntos
Analgesia/métodos , Anestesia/métodos , Neoplasias/cirurgia , Avaliação de Resultados da Assistência ao Paciente , Assistência Perioperatória/métodos , Humanos
11.
Knee ; 26(4): 933-940, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31262634

RESUMO

BACKGROUND: Increasing numbers of Total Knee Arthroplasty (TKA) operations are carried out worldwide each year. This brings with it an ever-increasing revision burden and it is therefore important to appreciate both the functional outcome and survivorship of established arthroplasties when considering new designs. We aim to evaluate the long-term survivorship of a fully cemented mobile bearing Total Knee Arthroplasty. METHODS: This study prospectively analyses the 20-year survivorship of a cohort of 487 consecutive patients who underwent cemented TKA under the care of a single surgeon using the Low Contact Stress (LCS) rotating platform (RP) implant. These patients were followed up prospectively with patient reported and functional outcomes recorded at regular intervals postoperatively. RESULTS: Five hundred and forty-two consecutive primary TKAs were carried out in 487 patients. A total of 139 knees (25.6%) were reviewed at 20 years post-operation. Overall cumulative survivorship, using revision for any reason as primary endpoint, was 98.0%. Mean Knee Society Scores for the patient cohort were 87.3 (Clinical score) and 52.5 (Functional score). Eleven (2.0%) were revised within 20 years - two for aseptic loosening, two for unexplained pain, five secondary patellar resurfacings for anterior knee pain, one for late infection and one liner exchange following spin-out. CONCLUSION: This series demonstrates excellent survivorship and satisfactory outcome of a cemented mobile bearing TKA at 20 years.


Assuntos
Artroplastia do Joelho , Prótese do Joelho , Adulto , Idoso , Idoso de 80 Anos ou mais , Cimentos para Ossos , Feminino , Seguimentos , Humanos , Articulação do Joelho/cirurgia , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados da Assistência ao Paciente , Estudos Prospectivos , Reoperação/estatística & dados numéricos
12.
EBioMedicine ; 43: 460-472, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31162113

RESUMO

BACKGROUND: Disease progression and delayed neurological complications are common after aneurysmal subarachnoid hemorrhage (aSAH). We explored the potential of quantitative blood-brain barrier (BBB) imaging to predict disease progression and neurological outcome. METHODS: Data were collected as part of the Co-Operative Studies of Brain Injury Depolarizations (COSBID). We analyzed retrospectively, blinded and semi-automatically magnetic resonance images from 124 aSAH patients scanned at 4 time points (24-48 h, 6-8 days, 12-15 days and 6-12 months) after the initial hemorrhage. Volume of brain with apparent pathology and/or BBB dysfunction (BBBD), subarachnoid space and lateral ventricles were measured. Neurological status on admission was assessed using the World Federation of Neurosurgical Societies and Rosen-Macdonald scores. Outcome at ≥6 months was assessed using the extended Glasgow outcome scale and disease course (progressive or non-progressive based on imaging-detected loss of normal brain tissue in consecutive scans). Logistic regression was used to define biomarkers that best predict outcomes. Receiver operating characteristic analysis was performed to assess accuracy of outcome prediction models. FINDINGS: In the present cohort, 63% of patients had progressive and 37% non-progressive disease course. Progressive course was associated with worse outcome at ≥6 months (sensitivity of 98% and specificity of 97%). Brain volume with BBBD was significantly larger in patients with progressive course already 24-48 h after admission (2.23 (1.23-3.17) folds, median with 95%CI), and persisted at all time points. The highest probability of a BBB-disrupted voxel to become pathological was found at a distance of ≤1 cm from the brain with apparent pathology (0·284 (0·122-0·594), p < 0·001, median with 95%CI). A multivariate logistic regression model revealed power for BBBD in combination with RMS at 24-48 h in predicting outcome (ROC area under the curve = 0·829, p < 0·001). INTERPRETATION: We suggest that early identification of BBBD may serve as a key predictive biomarker for neurological outcome in aSAH. FUND: Dr. Dreier was supported by grants from the Deutsche Forschungsgemeinschaft (DFG) (DFG DR 323/5-1 and DFG DR 323/10-1), the Bundesministerium für Bildung und Forschung (BMBF) Center for Stroke Research Berlin 01 EO 0801 and FP7 no 602150 CENTER-TBI. Dr. Friedman was supported by grants from Israel Science Foundation and Canada Institute for Health Research (CIHR). Dr. Friedman was supported by grants from European Union's Seventh Framework Program (FP7/2007-2013; grant #602102).


Assuntos
Barreira Hematoencefálica/metabolismo , Aneurisma Intracraniano/complicações , Hemorragia Subaracnóidea/etiologia , Hemorragia Subaracnóidea/metabolismo , Adulto , Idoso , Biomarcadores , Encéfalo/diagnóstico por imagem , Encéfalo/metabolismo , Encéfalo/patologia , Angiografia por Tomografia Computadorizada , Progressão da Doença , Diagnóstico Precoce , Feminino , Escala de Resultado de Glasgow , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Razão de Chances , Avaliação de Resultados da Assistência ao Paciente , Prognóstico , Curva ROC , Reprodutibilidade dos Testes , Hemorragia Subaracnóidea/diagnóstico , Adulto Jovem
13.
Knee ; 26(4): 897-904, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31174980

RESUMO

PURPOSE: The purpose of this study was to describe mid- to long-term outcomes of anterior cruciate ligament (ACL) reconstruction with simultaneous or staged medial unicompartmental knee replacement (UKR), and compare outcomes between (1) young patients aged younger than 55 at surgery and those older, (2) those with long-term follow-up greater than 10 years, (3) cemented and cementless UKR, and (4) compare outcomes to those with an intact ACL. PATIENTS AND METHODS: We identified knees with staged or simultaneous ACL reconstruction and medial UKR from a prospectively followed designer UKR cohort, and describe mean Oxford Knee Score (OKS), mean Tegner activity score and Kaplan-Meier survival estimates. We matched these knees to ACL-intact knees. RESULTS: Seventy-six consecutive UKR with staged or simultaneous ACL reconstruction were identified with mean six-year follow-up (range 1-15). There was significant improvement in OKS and Tegner score with surgery. At most recent follow-up, OKS was 41.0 (range 11 to 48), and Tegner score 3.6 (0 to 8). There were three revisions occurring at a mean of five years post-operatively. The five-, 10- and 15-year survival estimates were 97% (95% confidence interval [CI] 93-100), 92% (83-100), and 92% (83-100). There was no difference in functional scores or implant survival in young patients, those with long-term follow-up (>10 years), those with cementless fixation, or when compared to ACL intact knees. CONCLUSION: These results demonstrate excellent mid- to long-term function and survival of selected patients who have undergone ACL reconstruction and medial UKR. Their outcome was similar to those with intact ACLs.


Assuntos
Reconstrução do Ligamento Cruzado Anterior , Artroplastia do Joelho , Avaliação de Resultados da Assistência ao Paciente , Adulto , Idoso , Estudos de Coortes , Feminino , Seguimentos , Humanos , Prótese do Joelho , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/cirurgia , Desenho de Prótese , Reoperação/estatística & dados numéricos
14.
J Rehabil Med ; 51(8): 566-574, 2019 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-31243467

RESUMO

OBJECTIVE: To determine whether the UK Functional Assessment Measure (UK FIM+FAM) fits the Rasch model in patients with complex disability following traumatic brain injury. DESIGN: Psychometric evaluation including preliminary exploratory and confirmatory factor analyses followed by Rasch analysis. PARTICIPANTS: A multicentre UK national cohort of 1,956 patients admitted for specialist rehabilitation following traumatic brain injury. RESULTS: The suitability of the Partial Credit Model was confirmed by the likelihood-ratio test (χ2 (df86) =7,325.0, p < 0.001). Exploratory and confirmatory factor analyses supported 3 factors (Motor, Communication, Psychosocial). Rasch analysis of the full scale incorporating the 3 factors as super-items resulted in an acceptable overall model fit (χ2 (df24)=36.72, p = 0.05) and strict uni-dimensionality when tested on a sub-sample of n = 320. These results were replicated in a full sample (n = 1,956) showing uni-dimensionality and good reliability with Person Separation Index = 0.81, but item trait interaction was significant due to the large sample size. No significant differential item functioning was observed for any personal factors. Neither uniform re-scoring of items nor exclusion of participants with extreme scores improved the model fit. CONCLUSION: The UK FIM+FAM scale satisfies the Rasch model reasonably in traumatic brain injury. A conversion table was produced, but its usefulness in clinical practice requires further exploration and clinical translation.


Assuntos
Lesões Encefálicas Traumáticas/fisiopatologia , Lesões Encefálicas Traumáticas/reabilitação , Avaliação de Resultados da Assistência ao Paciente , Adolescente , Adulto , Idoso , Estudos de Coortes , Bases de Dados Factuais , Análise Fatorial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Psicometria , Reprodutibilidade dos Testes , Reino Unido , Adulto Jovem
15.
Gynecol Oncol ; 154(2): 405-410, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31208738

RESUMO

OBJECTIVE: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a national survey of inpatient experience. This study evaluated the association between HCAHPS survey results and outcomes in gynecologic cancer surgery. METHODS: This observational study used HCAHPS survey data from 2009 to 2011 to assign hospitals into score terciles. The Nationwide Inpatient Sample (NIS) database was used to identify admissions during the same time period for gynecologic cancer-specific surgeries. Data sources were linked at the hospital level. Postoperative complications, mortality, and prolonged length of stay were compared between higher and lower scoring hospitals. Complications were grouped as 'surgical', 'medical', or 'care team'. Mixed effects models were used to evaluate the associations between hospitals' HCAHPS scores and outcomes after adjustment for patient and hospital-level variables. RESULTS: 17,509 linked encounters in 651 hospitals across the U.S. were identified, with 51% uterine, 40% ovarian, and 9% cervical cancer surgical admissions. In-hospital mortality was lower in hospitals in the top HCAHPS score terciles compared to bottom HCAHPS score tercile (odds ratio (OR) 0.54, 95% CI: 0.31-0.94). Surgery in higher scoring HCAHPS hospitals was associated with less 'surgical' complications (OR 0.82, 95% CI 0.69-0.98). No association was found between 'medical', 'care team', overall complications, or prolonged hospitalization (p > 0.05) and HCAHPS scores. CONCLUSIONS: Gynecologic oncology surgeries performed in top HCAHPS tercile hospitals were associated with lower in-hospital mortality and surgical complications compared to surgeries performed in bottom tercile hospitals. Associations between HCAHPS scores and other adverse events were not seen.


Assuntos
Hospitais/estatística & dados numéricos , Neoplasias Ovarianas/cirurgia , Avaliação de Resultados da Assistência ao Paciente , Satisfação do Paciente/estatística & dados numéricos , Neoplasias do Colo do Útero/cirurgia , Centers for Medicare and Medicaid Services (U.S.) , Feminino , Inquéritos Epidemiológicos , Mortalidade Hospitalar , Hospitais/normas , Humanos , Tempo de Internação/estatística & dados numéricos , Pessoa de Meia-Idade , Neoplasias Ovarianas/mortalidade , Complicações Pós-Operatórias/epidemiologia , Estados Unidos , Neoplasias do Colo do Útero/mortalidade
16.
Anticancer Res ; 39(6): 2927-2933, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31177131

RESUMO

BACKGROUND/AIM: The aim of this study was to assess the 3-year health status of cholecystectomy patients by the RAND-36 Survey. PATIENTS AND METHODS: Initially, 110 patients with symptomatic gallstone disease were randomized to undergo either minicholecystectomy (MC) (n=58) or laparoscopic cholecystectomy (LC) (n=52). RAND-36 survey was performed preoperatively, 4 weeks, 6 months and 3 years following surgery. RESULTS: RAND-36 scores improved in several RAND-36 domains in MC and LC groups with a similar postoperative course over the 3-year study period. In addition, at the 3-year follow-up telephone interview, no significant differences in patient-reported outcome measures between MC and LC patients were shown. The linear mixed effect model was used to test the overall significance of the RAND-36 survey during a 36-month follow-up period and the overall p-values were statistically significant in vitality, mental health (0.03), role physical and bodily pain domains. CONCLUSION: During the three years following cholecystectomy, four RAND-36 domains remained significantly higher, indicating a significant positive change in quality of life. RAND-36-Item Health Survey is a comprehensive test for analyzing long-term outcome and health status after cholecystectomy.


Assuntos
Colecistectomia/métodos , Cálculos Biliares/cirurgia , Avaliação de Resultados da Assistência ao Paciente , Adulto , Idoso , Colecistectomia/psicologia , Feminino , Cálculos Biliares/psicologia , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos Prospectivos , Qualidade de Vida , Distribuição Aleatória , Resultado do Tratamento
17.
Chin J Traumatol ; 22(3): 172-176, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31047796

RESUMO

PURPOSE: Fat embolism syndrome (FES) is systemic manifestation of fat emboli in the circulation seen mostly after long bone fractures. FES is considered a lethal complication of trauma. There are various case reports and series describing FES. Here we describe the clinical characteristics, management in ICU and outcome of these patients in level I trauma center in a span of 6 months. METHODS: In this prospective study, analysis of all the patients with FES admitted in our polytrauma intensive care unit (ICU) of level I trauma center over a period of 6 months (from August 2017 to January 2018) was done. Demographic data, clinical features, management in ICU and outcome were analyzed. RESULTS: We admitted 10 cases of FES. The mean age of patients was 31.2 years. The mean duration from time of injury to onset of symptoms was 56 h. All patients presented with hypoxemia and petechiae but central nervous system symptoms were present in 70% of patients. The mean duration of mechanical ventilation was 11.7 days and the mean length of ICU stay was 14.7 days. There was excellent recovery among patients with no neurological deficit. CONCLUSION: FES is considered a lethal complication of trauma but timely management can result in favorable outcome. FES can occur even after fixation of the fracture. Hypoxia is the most common and earliest feature of FES followed by CNS manifestations. Any patient presenting with such symptoms should raise the suspicion of FES and mandate early ICU referral.


Assuntos
Embolia Gordurosa/etiologia , Embolia Gordurosa/prevenção & controle , Fraturas Ósseas/complicações , Adolescente , Adulto , Doenças do Sistema Nervoso Central/etiologia , Diagnóstico Precoce , Embolia Gordurosa/diagnóstico , Humanos , Hipóxia/etiologia , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Avaliação de Resultados da Assistência ao Paciente , Fatores de Tempo , Centros de Traumatologia/estatística & dados numéricos , Adulto Jovem
18.
Int Heart J ; 60(3): 560-568, 2019 May 30.
Artigo em Inglês | MEDLINE | ID: mdl-31105155

RESUMO

Right ventricular infarction (RVI) is a complication following inferior ST-elevation myocardial infarction (STEMI). The aim of the present study was to investigate the clinical outcomes of RVI in the contemporary primary percutaneous coronary intervention (PCI) era. The primary endpoint was in-hospital death, and the secondary endpoint was major adverse cardiac events (MACE), defined as the composite of cardiovascular death, re-hospitalization for heart failure, and non-fatal acute myocardial infarction (AMI). Event-free survival curves for MACE were constructed using the Kaplan-Meier method, and statistical differences between curves were assessed using the log-lank test. A total of 1354 patients with AMI were screened from January 2010 to December 2016. The final study population involved 315 patients with STEMI whose infarct related artery (IRA) was the right coronary artery (RCA). We categorized these 315 patients into the RVI group (n = 85) and the non-RVI group (n = 230). Median follow-up duration was 358 (IQR: 208-987) days. In-hospital deaths were more frequently observed in the RVI group (9.4%) than in the non-RVI group (3.0%) (P = 0.018). However, the incidence of MACE was not different between the groups (P = 0.537). In conclusion, in-hospital clinical outcomes were poorer in the RVI group than in the non-RVI group. However, mid-term MACE was not different between the two groups, suggesting the importance of aggressive acute treatment for STEMI patients with RVI.


Assuntos
Ventrículos do Coração/fisiopatologia , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Avaliação de Resultados da Assistência ao Paciente , Readmissão do Paciente/estatística & dados numéricos , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia
20.
Crit Care Nurs Clin North Am ; 31(2): 237-247, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31047096

RESUMO

Emergency departments across the United States struggle to balance the overutilization of emergency services. Nurse practitioners (NPs) practicing in emergency departments improve quality indicators leading to the increased efficiency, timeliness, and effectiveness of care. NPs providing emergency services improve multiple national metrics, such as door-to-provider time, patient satisfaction, diagnostic test ordering, and left without being seen rates. NPs should be aware of the positive impact they make on the quality of care. NPs should monitor and trend patient outcomes they directly effect. More research is needed to identify ways NPs can continue to improve the quality of emergency services provided.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Profissionais de Enfermagem , Avaliação de Resultados da Assistência ao Paciente , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Humanos , Estados Unidos
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