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1.
Anaesthesia ; 76(1): 19-26, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32406071

RESUMO

Over 30,000 adult cardiac operations are carried out in the UK annually. A small number of these patients need to return to theatre in the first few days after the initial surgery, but the exact proportion is unknown. The majority of these resternotomies are for bleeding or cardiac tamponade. The Association of Cardiothoracic Anaesthesia and Critical Care carried out a 1-year national audit of resternotomy in 2018. Twenty-three of the 35 centres that were eligible participated. The overall resternotomy rate (95%CI) within the period of admission for the initial operation in these centres was 3.6% (3.37-3.85). The rate varied between centres from 0.69% to 7.6%. Of the 849 patients who required resternotomy, 127 subsequently died, giving a mortality rate (95%CI) of 15.0% (12.7-17.5). In patients who underwent resternotomy, the median (IQR [range]) length of stay on ICU was 5 (2-10 [0-335]) days, and time to tracheal extubation was 20 (12-48 [0-2880]) hours. A total of 89.3% of patients who underwent resternotomy were transfused red cells, with a median (IQR [range]) of 4 (2-7 [1-1144]) units of red blood cells. The rate (95%CI) of needing renal replacement therapy was 23.4% (20.6-26.5). This UK-wide audit has demonstrated that resternotomy after cardiac surgery is associated with prolonged intensive care stay, high rates of blood transfusion, renal replacement therapy and very high mortality. Further research into this area is required to try to improve patient care and outcomes in patients who require resternotomy in the first 24 h after cardiac surgery.


Assuntos
Procedimentos Cirúrgicos Cardíacos/mortalidade , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Reoperação/mortalidade , Reoperação/estatística & dados numéricos , Esternotomia/mortalidade , Esternotomia/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Extubação , Tamponamento Cardíaco/etiologia , Tamponamento Cardíaco/cirurgia , Cuidados Críticos/estatística & dados numéricos , Transfusão de Eritrócitos/mortalidade , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Humanos , Incidência , Tempo de Internação , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/cirurgia , Terapia de Substituição Renal/mortalidade , Terapia de Substituição Renal/estatística & dados numéricos , Reino Unido/epidemiologia
2.
Acta Anaesthesiol Scand ; 65(1): 76-81, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32892337

RESUMO

BACKGROUND: Information on characteristics and outcomes of intensive care unit (ICU) patients with COVID-19 remains limited. We examined characteristics, clinical course and early outcomes of patients with COVID-19 admitted to ICU. METHODS: We included all 260 patients with COVID-19 admitted to nine ICUs at the Karolinska University Hospital (Stockholm, Sweden) between 9 March and 20 April 2020. Primary outcome was in-hospital mortality among patients with definite outcomes (discharged from ICU or death), as of 30 April 2020 (study end point). Secondary outcomes included ICU length of stay, the proportion of patients receiving mechanical ventilation and renal replacement therapy, and hospital discharge destination. RESULTS: Of 260 ICU patients with COVID-19, 208 (80.0%) were men, the median age was 59 (IQR 51-65) years, 154 (59.2%) had at least one comorbidity, and the median duration of symptoms preceding ICU admission was 11 (IQR 8-14) days. Sixty-two (23.8%) patients remained in ICU at study end point. Among the 198 patients with definite outcomes, ICU length of stay was 12 (IQR, 6-18) days, 163 (82.3%) received mechanical ventilation, 28 (14.1%) received renal replacement therapy, 60 (30.3%) died, 62 (31.3%) were discharged home, 47 (23.7%) were discharged to ward, and 29 (14.6%) were discharged to another health care facility. On multivariable logistic regression analysis, older age and admission from the emergency department was associated with higher mortality. CONCLUSION: This study presents detailed data on clinical characteristics and early outcomes of consecutive patients with COVID-19 admitted to ICU in a large tertiary hospital in Sweden.


Assuntos
/terapia , Cuidados Críticos/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Determinação de Ponto Final , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Pacientes , Terapia de Substituição Renal , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Suécia , Centros de Atenção Terciária , Resultado do Tratamento
3.
Ann Med ; 53(1): 103-116, 2021 12.
Artigo em Inglês | MEDLINE | ID: mdl-33063540

RESUMO

BACKGROUND: Hyperglycaemia has emerged as an important risk factor for death in coronavirus disease 2019 (COVID-19). The aim of this study was to evaluate the association between blood glucose (BG) levels and in-hospital mortality in non-critically patients hospitalized with COVID-19. METHODS: This is a retrospective multi-centre study involving patients hospitalized in Spain. Patients were categorized into three groups according to admission BG levels: <140 mg/dL, 140-180 mg/dL and >180 mg/dL. The primary endpoint was all-cause in-hospital mortality. RESULTS: Of the 11,312 patients, only 2128 (18.9%) had diabetes and 2289 (20.4%) died during hospitalization. The in-hospital mortality rates were 15.7% (<140 mg/dL), 33.7% (140-180 mg) and 41.1% (>180 mg/dL), p<.001. The cumulative probability of mortality was significantly higher in patients with hyperglycaemia compared to patients with normoglycaemia (log rank, p<.001), independently of pre-existing diabetes. Hyperglycaemia (after adjusting for age, diabetes, hypertension and other confounding factors) was an independent risk factor of mortality (BG >180 mg/dL: HR 1.50; 95% confidence interval (CI): 1.31-1.73) (BG 140-180 mg/dL; HR 1.48; 95%CI: 1.29-1.70). Hyperglycaemia was also associated with requirement for mechanical ventilation, intensive care unit (ICU) admission and mortality. CONCLUSIONS: Admission hyperglycaemia is a strong predictor of all-cause mortality in non-critically hospitalized COVID-19 patients regardless of prior history of diabetes. KEY MESSAGE Admission hyperglycaemia is a stronger and independent risk factor for mortality in COVID-19. Screening for hyperglycaemia, in patients without diabetes, and early treatment of hyperglycaemia should be mandatory in the management of patients hospitalized with COVID-19. Admission hyperglycaemia should not be overlooked in all patients regardless prior history of diabetes.


Assuntos
Infecções por Coronavirus/mortalidade , Hiperglicemia/complicações , Pneumonia Viral/mortalidade , Sistema de Registros , Idoso , Idoso de 80 Anos ou mais , Glicemia , Infecções por Coronavirus/sangue , Infecções por Coronavirus/complicações , Cuidados Críticos/estatística & dados numéricos , Feminino , Humanos , Hiperglicemia/mortalidade , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/sangue , Pneumonia Viral/complicações , Respiração Artificial/estatística & dados numéricos , Espanha/epidemiologia
4.
JMIR Public Health Surveill ; 6(4): e22471, 2020 12 07.
Artigo em Inglês | MEDLINE | ID: mdl-33284130

RESUMO

BACKGROUND: Recent studies have shown that diabetes is a major risk factor that contributes to the severity of COVID-19 and resulting mortality. Poor glycemic control is also associated with poor patient outcomes (eg, hospitalization and death). OBJECTIVE: This study aimed to describe the clinical characteristics and outcomes of patients with diabetes who were admitted to our hospital for COVID-19 treatment. METHODS: This cross-sectional, observational study comprised patients with diabetes admitted with COVID-19 to Mediclinic Parkview Hospital in Dubai, United Arab Emirates, from March 30 to June 7, 2020. We studied the differences among characteristics, length of hospital stay, diabetes status, comorbidities, treatments, and outcomes among these patients. RESULTS: Of the cohort patients, 25.1% (103/410) had coexistent diabetes or prediabetes. These patients represented 17 different ethnicities, with 59.2% (61/103) from Asian countries and 35% (36/103) from Arab countries. Mean patient age was 54 (SD 12.5) years, and 66.9% (69/103) of patients were male. Moreover, 85.4% (88/103) of patients were known to have diabetes prior to admission, and 14.6% (15/103) were newly diagnosed with either diabetes or prediabetes at admission. Most cohort patients had type 2 diabetes or prediabetes, and only 2.9% (3/103) of all patients had type 1 diabetes. Furthermore, 44.6% (46/103) of patients demonstrated evidence suggesting good glycemic control during the 4-12 weeks prior to admission, as defined arbitrarily by admission hemoglobin A1c level <7.5%, and 73.8% (76/103) of patients had other comorbidities, including hypertension, ischemic heart disease, and dyslipidemia. Laboratory data (mean and SD values) at admission for patients who needed ward-based care versus those who needed intensive care were as follows: fibrinogen, 462.8 (SD 125.1) mg/dL vs 660.0 (SD 187.6) mg/dL; D-dimer, 0.7 (SD 0.5) µg/mL vs 2.3 (SD 3.5) µg/mL; ferritin, 358.0 (SD 442.0) mg/dL vs 1762.4 (SD 2586.4) mg/dL; and C-reactive protein, 33.9 (SD 38.6) mg/L vs 137.0 (SD 111.7) mg/L. Laboratory data were all significantly higher for patients in the intensive care unit subcohort (P<.05). The average length of hospital stay was 14.55 days for all patients, with 28.2% (29/103) of patients requiring intensive care. In all, 4.9% (5/103) died during hospitalization-all of whom were in the intensive care unit. CONCLUSIONS: Majority of patients with diabetes or prediabetes and COVID-19 had other notable comorbidities. Only 4 patients tested negative for COVID-19 RT-PCR but showed pathognomonic changes of COVID-19 radiologically. Laboratory analyses revealed distinct abnormal patterns of biomarkers that were associated with a poor prognosis: fibrinogen, D-dimer, ferritin, and C-reactive protein levels were all significantly higher at admission in patients who subsequently needed intensive care than in those who needed ward-based care. More studies with larger sample sizes are needed to compare data of COVID-19 patients admitted with and without diabetes within the UAE region.


Assuntos
/mortalidade , Diabetes Mellitus/mortalidade , Hospitalização/estatística & dados numéricos , Estado Pré-Diabético/mortalidade , Adulto , Idoso , Biomarcadores/sangue , /virologia , Comorbidade , Cuidados Críticos/estatística & dados numéricos , Estudos Transversais , Diabetes Mellitus/sangue , Diabetes Mellitus/virologia , Feminino , Hemoglobina A Glicada/análise , Humanos , Masculino , Pessoa de Meia-Idade , Estado Pré-Diabético/sangue , Estado Pré-Diabético/virologia , Prognóstico , Fatores de Risco , Emirados Árabes Unidos/epidemiologia
5.
Trials ; 21(1): 1005, 2020 Dec 09.
Artigo em Inglês | MEDLINE | ID: mdl-33298149

RESUMO

BACKGROUND: The peak of the global COVID-19 pandemic has not yet been reached, and many countries face the prospect of a second wave of infections before effective vaccinations will be available. After an initial phase of viral replication, some patients develop a second illness phase in which the host thrombotic and inflammatory responses seem to drive complications. Severe COVID-19 disease is linked to high mortality, hyperinflammation, and a remarkably high incidence of thrombotic events. We hypothesize a crucial pathophysiological role for the contact pathway of coagulation and the kallikrein-bradykinin pathway. Therefore, drugs that modulate this excessive thromboinflammatory response should be investigated in severe COVID-19. METHODS: In this adaptive, open-label multicenter randomized clinical trial, we compare low molecular weight heparins at 50 IU anti-Xa/kg twice daily-or 75 IU anti-Xa twice daily for intensive care (ICU) patients-in combination with aprotinin to standard thromboprophylaxis in hospitalized COVID-19 patients. In the case of hyperinflammation, the interleukin-1 receptor antagonist anakinra will be added on top of the drugs in the interventional arm. In a pilot phase, the effect of the intervention on thrombotic markers (D-dimer) will be assessed. In the full trial, the primary outcome is defined as the effect of the interventional drugs on clinical status as defined by the WHO ordinal scale for clinical improvement. DISCUSSION: In this trial, we target the thromboinflammatory response at multiple levels. We intensify the dose of low molecular weight heparins to reduce thrombotic complications. Aprotinin is a potent kallikrein pathway inhibitor that reduces fibrinolysis, activation of the contact pathway of coagulation, and local inflammatory response. Additionally, aprotinin has shown in vitro inhibitory effects on SARS-CoV-2 cellular entry. Because the excessive thromboinflammatory response is one of the most adverse prognostic factors in COVID-19, we will add anakinra, a recombinant interleukin-1 receptor antagonist, to the regimen in case of severely increased inflammatory parameters. This way, we hope to modulate the systemic response to SARS-CoV-2 and avoid disease progressions with a potentially fatal outcome. TRIAL REGISTRATION: The EU Clinical Trials Register 2020-001739-28 . Registered on April 10, 2020.


Assuntos
/complicações , Inflamação/etiologia , Tromboembolia Venosa/etiologia , Antirreumáticos/administração & dosagem , Antirreumáticos/uso terapêutico , Aprotinina/administração & dosagem , Aprotinina/uso terapêutico , Bélgica/epidemiologia , Bradicinina/efeitos dos fármacos , Bradicinina/metabolismo , /virologia , Cuidados Críticos/estatística & dados numéricos , Quimioterapia Combinada , Feminino , Heparina de Baixo Peso Molecular/administração & dosagem , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Incidência , Inflamação/epidemiologia , Inflamação/metabolismo , Inflamação/prevenção & controle , Proteína Antagonista do Receptor de Interleucina 1/administração & dosagem , Proteína Antagonista do Receptor de Interleucina 1/uso terapêutico , Calicreínas/efeitos dos fármacos , Calicreínas/metabolismo , Masculino , Avaliação de Resultados em Cuidados de Saúde , Índice de Gravidade de Doença , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/metabolismo , Tromboembolia Venosa/prevenção & controle
6.
Medicine (Baltimore) ; 99(50): e23108, 2020 Dec 11.
Artigo em Inglês | MEDLINE | ID: mdl-33327232

RESUMO

To explore the effect of Joanna Briggs Institute (JBI) physical restraint standards in improving physical restraint in critical and emergency department patients.Enrolled 300 critical patients admitted in our hospital's emergency department from January to December 2019: 150 patients admitted January to June 2019 as control group and 150 patients admitted July to December 2019 as observation group. Routine restraints were applied in control group. Emergency department nurses in the observation group received thematic and practical JBI standardized training. This included pre-restraint assessment, principles of physical restraint, informed consent, using a restraint decision-making wheel, and alternatives to physical restraint. The incidence of restraint-associated adverse events (e.g., skin bruising, swelling) and restraint utilization rate were examined between 2 groups.The incidence of adverse events and the restraint utilization rate were significantly lower in the observation group (P < .05).The application of JBI physical restraint standards for emergency department patients can effectively reduce the incidence of adverse events and the restraint utilization rate.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Recursos Humanos de Enfermagem no Hospital/ética , Restrição Física/efeitos adversos , Restrição Física/ética , Estudos de Casos e Controles , Cuidados Críticos/tendências , Enfermagem de Cuidados Críticos/normas , Tomada de Decisões , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Consentimento Livre e Esclarecido , Masculino , Pessoa de Meia-Idade , Avaliação em Enfermagem/métodos , Recursos Humanos de Enfermagem no Hospital/educação , Estudos Prospectivos , Padrões de Referência
7.
Medwave ; 20(10): e8066, 2020 Nov 17.
Artigo em Espanhol | MEDLINE | ID: mdl-33361751

RESUMO

Introduction: Since the beginning of the COVID-19 pandemic, extensive research has been done on the prognosis of patients with SARS-CoV-2 associated with age, biodemographic conditions, comorbidities, social factors, clinical parameters, inflammatory blood markers, coagulation, biochemical and blood gas parameters, among others. Few studies have addressed this problem in Latin America, so it is of interest to know how the disease plays out in this region. Objective: The purpose of our study is to evaluate the course of COVID-19 in patients admitted to a tertiary center in Chile and to assess factors measured close to hospital admission that may be associated with death and the need for invasive mechanical ventilation. Methods: We did a retrospective cohort study at Indisa Clinic in Santiago, Chile. We included all patients aged 15 years and older hospitalized between March 11 and July 25, 2020. Hospital mortality and severity of the cases were analyzed, and logistic regression models were applied to identify predictors of outcome variables. Results: The sample included 785 subjects. The mean age was 59 years, 59% were men, and 61.3% had comorbidities. Forty five per cent required intensive care, and 24% invasive mechanical ventilation. The overall hospital fatality rate was 18.7%. In intensive care patients, the case fatality was 32.1%, and in those who received invasive mechanical ventilation, it was 59.4%. Independent risk factors for death included age (odds ratio 1.09; 95% confidence interval: 1.07 to 1.12), diabetes (1.68; 1.06 to 2.67), chronic lung disease (2.80; 1.48 to 5.28), increased C-reactive protein, creatinine, and ferritin. No association with sex, public health insurance, history of heart disease, oxygen saturation upon admission, or D-dimer was found. Similar factors were predictors of invasive mechanical ventilation. Discussion: The prognosis and predictive factors in this cohort of patients hospitalized in Chile for COVID-19 were comparable to those reported in similar studies from higher-income countries. Male sex was not associated with a poor prognosis in this group of patients.


Assuntos
/fisiopatologia , Cuidados Críticos/estatística & dados numéricos , Hospitalização , Respiração Artificial/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , /terapia , Chile , Estudos de Coortes , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Centros de Atenção Terciária , Adulto Jovem
8.
Epidemiol Serv Saude ; 29(5): e2020361, 2020.
Artigo em Inglês, Português | MEDLINE | ID: mdl-33331394

RESUMO

OBJECTIVE: To build scenarios and analyze the impact of social distancing policies on the spread of COVID-19 and the need for intensive care unit beds. METHODS: Three dissemination scenarios were built according to level of adherence to social distancing measures in the context of Brazil's Federal District, based on a dynamic transition compartmental model and Monte Carlo simulations. The model's parameter values were based on official sources, indexed bibliographic databases and public data repositories. RESULTS: The favorable scenario, with constant 58% adherence to social distancing, estimated a peak of 189 (interquartile range [IQR]: 57 - 394) ICU hospitalizations on March 3rd2021. Absence of social distancing would result in an unfavorable scenario with a peak of 6,214 (IQR: 4,618 - 8,415) ICU hospitalizations probably as soon as July 14th2020. CONCLUSION: The projections indicate the high impact of social distancing measures and emphasize the applicability of public indicators for COVID-19 monitoring.


Assuntos
/terapia , Cuidados Críticos/estatística & dados numéricos , Unidades de Terapia Intensiva , Modelos Teóricos , Brasil , Hospitalização/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Método de Monte Carlo
9.
Turk J Med Sci ; 50(8): 1771-1780, 2020 12 17.
Artigo em Inglês | MEDLINE | ID: mdl-33315350

RESUMO

Background/aim: Based on the antiviral and antibacterial properties of aluminum salts, we aimed to find out the influence of aluminum salts on COVID-19 infected patients. Materials and methods: We performed an observational retrospective cohort study which includes the patients diagnosed as COVID-19 and received aluminum salts in addition to actual treatments during hospitalization as the treatment group (Alum Group). Patients who received standard COVID-19 treatment protocols in the Infectious Diseases Clinics were included as the Control Group. Clinical findings, laboratory parameters, length of stay, survival, radiological follow-up, intensive care and mechanical ventilation needs, the presence of comorbidity, polymerase chain reaction (PCR) tests, symptoms, symptom recovery times, hospital stay times, treatment protocols, and clinical presence of pneumonia were examined in all patients. Advanced chemical composition analyzes of existing aluminum salts were also performed. Results: A total of 109 patients, 54 in the alum group and 55 in the control group, were included in the study. None of the patients in the aluminum group developed side effects due to the intake of aluminum salt. Survival status was significantly different between the two groups as there were 5 loss in the Control Group and none in the Alum Group (P = 0.023). The symptom recovery time was significantly shorter in the Alum Group; 2 (1­3) vs. 1 (1­2) days, P = 0.003. According to the paired samples analyses of the comparison between hospitalization and discharge, CRP levels significantly drops in the Alum Group (from 54.09 to 27, P = 0.001) but not in the Control Group. The drop was significantly same for the lactate dehydrogenase (LDH) and procalcitonin levels with P = 0.001. Conclusion: It has been observed that aluminum salts have beneficial effects in COVID-19 infected cases. Considering the low systemic toxicity of intermittent oral intake of aluminum salts as food supplements and the fact that pandemic control is still not achieved, the use of aluminum salts is promising.


Assuntos
Compostos de Alúmen , Hospitalização/estatística & dados numéricos , Recuperação de Função Fisiológica/efeitos dos fármacos , Compostos de Alúmen/administração & dosagem , Compostos de Alúmen/efeitos adversos , Antivirais/administração & dosagem , Antivirais/efeitos adversos , /tratamento farmacológico , /fisiopatologia , Cuidados Críticos/métodos , Cuidados Críticos/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento , Turquia/epidemiologia
10.
Rev Med Suisse ; 16(714): 2160-2164, 2020 Nov 11.
Artigo em Francês | MEDLINE | ID: mdl-33174697

RESUMO

What are the criteria for admitting an elderly polymorbid patient to intensive care ? The multidimensional geriatric evaluation is a tool to screen for geriatric syndromes, with the division of elderly patients into 3 categories: robust, vulnerable and dependent. Targeting certain co-morbidities such as cognitive disorders, delirium, frailty, polymedication and malnutrition, allows clinicians to estimate the risks of mortality and functional and cognitive handicaps during a stay in intensive care. Based on a review of the literature, this article offers some guidelines for triage of older patients for admission to intensive care, using an ethical, multidisciplinary approach that takes into account the patient's fears and preferences.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Idoso Fragilizado , Fragilidade/diagnóstico , Avaliação Geriátrica , Idoso , Transtornos Cognitivos/diagnóstico , Delírio/diagnóstico , Idoso Fragilizado/psicologia , Humanos , Desnutrição/diagnóstico
11.
Acta Med Port ; 33(11): 733-741, 2020 Nov 02.
Artigo em Inglês | MEDLINE | ID: mdl-33160423

RESUMO

INTRODUCTION: Portugal took early action to control the COVID-19 epidemic, initiating lockdown measures on March 16th when it recorded only 62 cases of COVID-19 per million inhabitants and reported no deaths. The Portuguese public complied quickly, reducing their overall mobility by 80%. The aim of this study was to estimate the initial impact of the lockdown in Portugal in terms of the reduction of the burden on the healthcare system. MATERIAL AND METHODS: We forecasted epidemic curves for: Cases, hospital inpatients (overall and in intensive care), and deaths without lockdown, assuming that the impact of containment measures would start 14 days after initial lockdown was implemented. We used exponential smoothing models for deaths, intensive care and hospitalizations and an ARIMA model for number of cases. Models were selected considering fitness to the observed data up to the 31st March 2020. We then compared observed (with intervention) and forecasted curves (without intervention). RESULTS: Between April 1st and April 15th, there were 146 fewer deaths (-25%), 5568 fewer cases (-23%) and, as of April 15th, there were 519 fewer intensive care inpatients (-69%) than forecasted without the lockdown. On April 15th, the number of intensive care inpatients could have reached 748, three times higher than the observed value (229) if the intervention had been delayed. DISCUSSION: If the lockdown had not been implemented in mid-March, Portugal intensive care capacity (528 beds) would have likely been breached during the first half of April. The lockdown seems to have been effective in reducing transmission of SARS-CoV-2, serious COVID-19 disease, and associated mortality, thus decreasing demand on health services. CONCLUSION: An early lockdown allowed time for the National Health Service to mobilize resources and acquire personal protective equipment, increase testing, contact tracing and hospital and intensive care capacity and to promote broad prevention and control measures. When lifting more stringent measures, strong surveillance and communication strategies that mobilize individual prevention efforts are necessary.


Assuntos
Betacoronavirus , Infecções por Coronavirus/prevenção & controle , Emergências/epidemiologia , Epidemias/prevenção & controle , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Política Pública/legislação & jurisprudência , Quarentena/métodos , Ocupação de Leitos , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/transmissão , Cuidados Críticos/estatística & dados numéricos , Epidemias/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Pneumonia Viral/epidemiologia , Pneumonia Viral/mortalidade , Pneumonia Viral/transmissão , Portugal/epidemiologia , Quarentena/estatística & dados numéricos
12.
Pan Afr Med J ; 37: 32, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33209159

RESUMO

Diabetes is considered a risk factor for complications due to COVID-19. In order to clarify this association, we are exploring the characteristics, the clinical signs, the outcomes and death in diabetic patients with COVID-19. In this retrospective observational study we are evaluating the demographic characteristics, the comorbidities of the patients, the clinical signs of the infection, the signs of clinical severity, the biological assessment at admission, the treatment, the outcomes and the deaths of 133 patients with COVID-19, of which 25 (19,4%) had diabetes. In the compared COVID-19 patients, with and without diabetes, the patients with diabetes were older, had higher blood pressure and more cardio-vascular diseases. Severe forms were more present in diabetic patients (56% versus 27.1%). Weight loss was higher in diabetic patients (6kg versus 3kg). Biologically, diabetic patients had higher levels of C-reactive protein (28 versus 5.8mg/l), procalcitonin (0.28 versus 0,13ng/l), ferritin (501 versus 140ng/ml), lactic dehydrogenase (268 versus 226IU/l) and of D. dimer (665 versus 444µg/l). Diabetic patients required more oxygen therapy (60% versus 26.9%), more mechanical ventilation (20% versus 8.3%) and more frequent admission to the intensive care unit (60% versus 27.8%). They presented more thromboembolic complications (12% versus 9%) but there were not significant differences in the other outcomes and in death rates. The excess of morbidity and mortality due to diabetes was still not fully clarified; the role of demographic factors, the interaction of mediations with ACE-2 receptors and the role of co-morbidities will all need to be studied in order to identify the patient at risk profile, i.e. who can develop severe forms of the diseases and more outcomes. The early identification of a possible hyper inflammation could be very valuable. More attention should be paid to patients with COVID-19 with diabetes because they are at a high risk of complications.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Diabetes Mellitus/epidemiologia , Pneumonia Viral/epidemiologia , Fatores Etários , Proteína C-Reativa/análise , Doenças Cardiovasculares/epidemiologia , Infecções por Coronavirus/sangue , Infecções por Coronavirus/complicações , Infecções por Coronavirus/mortalidade , Cuidados Críticos/estatística & dados numéricos , Complicações do Diabetes/sangue , Complicações do Diabetes/epidemiologia , Complicações do Diabetes/mortalidade , Diabetes Mellitus/sangue , Diabetes Mellitus/mortalidade , Ferritinas/sangue , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Hipertensão/epidemiologia , L-Lactato Desidrogenase/sangue , Pessoa de Meia-Idade , Marrocos/epidemiologia , Oxigênio/uso terapêutico , Pandemias , Pneumonia Viral/sangue , Pneumonia Viral/complicações , Pneumonia Viral/mortalidade , Pró-Calcitonina/sangue , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Tromboembolia/epidemiologia
13.
BMJ Open ; 10(11): e040736, 2020 11 27.
Artigo em Inglês | MEDLINE | ID: mdl-33247020

RESUMO

OBJECTIVE: The COVID-19 pandemic is a global public health crisis, with over 33 million cases and 999 000 deaths worldwide. Data are needed regarding the clinical course of hospitalised patients, particularly in the USA. We aimed to compare clinical characteristic of patients with COVID-19 who had in-hospital mortality with those who were discharged alive. DESIGN: Demographic, clinical and outcomes data for patients admitted to five Mount Sinai Health System hospitals with confirmed COVID-19 between 27 February and 2 April 2020 were identified through institutional electronic health records. We performed a retrospective comparative analysis of patients who had in-hospital mortality or were discharged alive. SETTING: All patients were admitted to the Mount Sinai Health System, a large quaternary care urban hospital system. PARTICIPANTS: Participants over the age of 18 years were included. PRIMARY OUTCOMES: We investigated in-hospital mortality during the study period. RESULTS: A total of 2199 patients with COVID-19 were hospitalised during the study period. As of 2 April, 1121 (51%) patients remained hospitalised, and 1078 (49%) completed their hospital course. Of the latter, the overall mortality was 29%, and 36% required intensive care. The median age was 65 years overall and 75 years in those who died. Pre-existing conditions were present in 65% of those who died and 46% of those discharged. In those who died, the admission median lymphocyte percentage was 11.7%, D-dimer was 2.4 µg/mL, C reactive protein was 162 mg/L and procalcitonin was 0.44 ng/mL. In those discharged, the admission median lymphocyte percentage was 16.6%, D-dimer was 0.93 µg/mL, C reactive protein was 79 mg/L and procalcitonin was 0.09 ng/mL. CONCLUSIONS: In our cohort of hospitalised patients, requirement of intensive care and mortality were high. Patients who died typically had more pre-existing conditions and greater perturbations in inflammatory markers as compared with those who were discharged.


Assuntos
/sangue , Cuidados Críticos , Mortalidade Hospitalar , Hospitalização , Pandemias , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Proteína C-Reativa/metabolismo , /mortalidade , Comorbidade , Cuidados Críticos/estatística & dados numéricos , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Hospitais , Humanos , Linfócitos/metabolismo , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Pró-Calcitonina/sangue , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
14.
J Clin Psychiatry ; 81(6)2020 10 06.
Artigo em Inglês | MEDLINE | ID: mdl-33027560

RESUMO

OBJECTIVE: This study aimed to examine the effects of suvorexant on delirium prevention in a real-world setting. Previous studies have demonstrated the efficacy of suvorexant for delirium prevention in limited randomized clinical trial settings; however, its effectiveness in everyday clinical settings remains unknown. METHODS: A single-center, retrospective cohort study was conducted in the intensive care unit of an academic hospital. Patients (aged ≥ 3 years) admitted from January 2016 to December 2018 were eligible if they stayed in the intensive care unit for at least 72 hours. Suvorexant was prescribed by the attending physician for insomnia as part of everyday clinical practice. A Cox proportional hazards regression analysis was conducted on delirium-free survival for suvorexant users, adjusting for delirium-related covariates. As part of routine clinical practice, the Confusion Assessment Method for the Intensive Care Unit was used to detect the existence of delirium at least twice daily throughout the intensive care unit stay. RESULTS: There were 699 patients-84 suvorexant users and 615 suvorexant nonusers. Delirium was detected in 214 patients. Delirium prevalence was significantly lower in suvorexant users than in nonusers (17.9% vs 32.4%, respectively; P = .007). Cox regression analysis revealed a significantly lower hazard ratio (0.472; 95% CI, 0.268-0.832; P = .009) of delirium in suvorexant users than in nonusers. Trazodone also had a preventive effect on delirium (hazard ratio 0.345; 95% CI, 0.149-0.802; P = .013). CONCLUSIONS: The present study extends to real-world settings previous findings that suvorexant is effective for delirium prevention.


Assuntos
Azepinas/administração & dosagem , Cuidados Críticos/estatística & dados numéricos , Delírio/prevenção & controle , Antagonistas dos Receptores de Orexina/administração & dosagem , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Distúrbios do Início e da Manutenção do Sono/tratamento farmacológico , Triazóis/administração & dosagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Cuidados Críticos/métodos , Delírio/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Inibidores de Captação de Serotonina/farmacologia , Trazodona/farmacologia , Adulto Jovem
15.
Anesth Analg ; 131(5): 1607-1615, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33079885

RESUMO

BACKGROUND: Utilizing the intrinsic surgical risk (ISR) and the patient's chronic and acute conditions, this study aims to develop and validate a comprehensive predictive model of perioperative morbidity in children undergoing noncardiac surgery. METHODS: Following institutional review board (IRB) approval at a tertiary care children's hospital, data for all noncardiac surgical encounters for a derivation dataset from July 2017 to December 2018 including 16,724 cases and for a validation dataset from January 2019 to December 2019 including 9043 cases were collected retrospectively. The primary outcome was a composite morbidity score defined by unplanned transfer to an intensive care unit (ICU), acute respiratory failure requiring intubation, postoperative need for noninvasive or invasive positive pressure ventilation, or cardiac arrest. Internal model validation was performed using 1000 bootstrap resamples, and external validation was performed using the 2019 validation cohort. RESULTS: A total of 1519 surgical cases (9.1%) experienced the defined composite morbidity. Using multivariable logistic regression, the Risk Assessment of Morbidity in Pediatric Surgery (RAMPS) score was developed with very good predictive ability in the derivation cohort (area under the curve [AUC] = 0.805; 95% confidence interval [CI], 0.795-0.816), very good internal validity using 1000 bootstrap resamples (bias-corrected Nagelkerke R = 0.21 and Brier score = 0.07), and good external validity (AUC = 0.783; 95% CI, 0.770-0.797). The included variables are age <5 years, critically ill, chronic condition indicator (CCI) ≥3, significant CCI ≥2, and ISR quartile ≥3. The RAMPS score ranges from 0 to 10, with the risk of composite morbidity ranging from 1.8% to 42.7%. CONCLUSIONS: The RAMPS score provides the ability to identify a high-risk cohort of pediatric patients using a 5-component tool, and it demonstrated good internal and external validity and generalizability. It also provides an opportunity to improve perioperative planning with the intent of improving both individual-patient outcomes and the appropriate allocation of health care resources.


Assuntos
Medição de Risco/métodos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adolescente , Fatores Etários , Criança , Pré-Escolar , Cuidados Críticos/estatística & dados numéricos , Estado Terminal , Feminino , Parada Cardíaca/epidemiologia , Parada Cardíaca/terapia , Mortalidade Hospitalar , Humanos , Lactente , Masculino , Transferência de Pacientes/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Insuficiência Respiratória/epidemiologia , Insuficiência Respiratória/terapia , Estudos Retrospectivos , Centros de Atenção Terciária , Resultado do Tratamento
16.
Can J Surg ; 63(5): E442-E448, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33026310

RESUMO

BACKGROUND: The role of physician assistants (PAs) in surgical care in Canada is expanding. Similarly, the acute care surgery (ACS) model continues to evolve, and PAs are increasingly being considered as members of ACS teams. However, their exact impact and contribution has not been well studied. Our study describes the contribution of a PA who worked full time on weekdays on an ACS team in a Canadian academic tertiary hospital. METHODS: To quantify the PA's contributions, an ACS database was created in September 2016. Data on the number of ACS patient encounters, the number of ACS surgical consults, the number of ACS admissions, the PA's involvement in the operating room, the number of PA patient encounters and the number of multidisciplinary meetings were prospectively collected. We report data for 365 consecutive days from Dec. 30, 2016, to Dec. 29, 2017. RESULTS: The ACS team had 11 651 patient encounters during the year, with a mean of 31.92 per day. The mean number of surgical consults per day was 5.89, and a mean of 2.08 surgical procedures were performed per day. The PA was involved in 53.5% of all patient encounters, despite working only during daytime hours on weekdays. Multidisciplinary meetings were conducted by the PA 94.9% of the time. Alternate level of care patients were seen by the PA 96.2% of the time. The PA was directly involved in 2.0% of the operating room procedures during the study period. CONCLUSION: Integrating a PA on an ACS team adds value to patient care by providing consistency and efficient management of ward issues and patient care plans, including multidisciplinary discharge planning, timely emergency department consultations and effective organization of the ACS team members.


Assuntos
Cuidados Críticos/organização & administração , Salas Cirúrgicas/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Assistentes Médicos/organização & administração , Papel Profissional , Centros Médicos Acadêmicos/organização & administração , Centros Médicos Acadêmicos/estatística & dados numéricos , Canadá , Cuidados Críticos/estatística & dados numéricos , Prestação Integrada de Cuidados de Saúde/organização & administração , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Salas Cirúrgicas/estatística & dados numéricos , Equipe de Assistência ao Paciente/estatística & dados numéricos , Assistentes Médicos/estatística & dados numéricos , Centros de Atenção Terciária/organização & administração , Centros de Atenção Terciária/estatística & dados numéricos
17.
Clin Rheumatol ; 39(12): 3529-3531, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33011932
18.
Intensive Care Med ; 46(11): 2035-2047, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33034689

RESUMO

PURPOSE: To describe critical care patients with COVID-19 across England, Wales and Northern Ireland and compare them with a historic cohort of patients with other viral pneumonias (non-COVID-19) and with international cohorts of COVID-19. METHODS: Extracted data on patient characteristics, acute illness severity, organ support and outcomes from the Case Mix Programme, the national clinical audit for adult critical care, for a prospective cohort of patients with COVID-19 (February to August 2020) are compared with a recent retrospective cohort of patients with other viral pneumonias (non-COVID-19) (2017-2019) and with other international cohorts of critical care patients with COVID-19, the latter identified from published reports. RESULTS: 10,834 patients with COVID-19 (70.1% male, median age 60 years, 32.6% non-white ethnicity, 39.4% obese, 8.2% at least one serious comorbidity) were admitted across 289 critical care units. Of these, 36.9% had a PaO2/FiO2 ratio of ≤ 13.3 kPa (≤ 100 mmHg) consistent with severe ARDS and 72% received invasive ventilation. Acute hospital mortality was 42%, higher than for 5782 critical care patients with other viral pneumonias (non-COVID-19) (24.7%), and most COVID-19 deaths (88.7%) occurred before 30 days. Meaningful international comparisons were limited due to lack of standardised reporting. CONCLUSION: Critical care patients with COVID-19 were disproportionately non-white, from more deprived areas and more likely to be male and obese. Conventional severity scoring appeared not to adequately reflect their acute severity, with the distribution across PaO2/FiO2 ratio categories indicating acutely severe respiratory disease. Critical care patients with COVID-19 experience high mortality and place a great burden on critical care services.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Cuidados Críticos/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Idoso , Estudos de Coortes , Infecções por Coronavirus/terapia , Inglaterra/epidemiologia , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Irlanda do Norte/epidemiologia , Pandemias , Pneumonia Viral/terapia , Medicina Estatal , País de Gales/epidemiologia
20.
BMJ Open ; 10(10): e039887, 2020 10 05.
Artigo em Inglês | MEDLINE | ID: mdl-33020106

RESUMO

OBJECTIVES: To determine the age-specific clinical presentations and incidence of adverse outcomes among patients with COVID-19 in Jiangsu, China. DESIGN AND SETTING: Retrospective, multicentre cohort study performed at 24 hospitals in Jiangsu, China. PARTICIPANTS: 625 patients with COVID-19 enrolled between 10 January and 15 March 2020. RESULTS: Of the 625 patients (median age, 46 years; 329 (52.6%) men), 37 (5.9%) were children (18 years or younger), 261 (41.8%) young adults (19-44 years), 248 (39.7%) middle-aged adults (45-64 years) and 79 (12.6%) elderly adults (65 years or older). The incidence of hypertension, coronary heart disease, chronic obstructive pulmonary disease and diabetes comorbidities increased with age (trend test, p<0.0001, p=0.0003, p<0.0001 and p<0.0001, respectively). Fever, cough and shortness of breath occurred more commonly among older patients, especially the elderly, compared with children (χ2 test, p=0.0008, 0.0146 and 0.0282, respectively). The quadrant score and pulmonary opacity score increased with age (trend test, both p<0.0001). Older patients had many significantly different laboratory parameters from younger patients. Elderly patients had the highest proportion of severe or critically-ill cases (33.0%, χ2 test p<0.0001), intensive care unit use (35.4%, χ2 test p<0.0001), respiratory failure (31.6%, χ2 test p<0.0001) and the longest hospital stay (median 21 days, Kruskal-Wallis test p<0.0001). CONCLUSIONS: Elderly (≥65 years) patients with COVID-19 had the highest risk of severe or critical illness, intensive care use, respiratory failure and the longest hospital stay, which may be due partly to their having a higher incidence of comorbidities and poor immune responses to COVID-19.


Assuntos
Fatores Etários , Infecções por Coronavirus , Cuidados Críticos , Pulmão/diagnóstico por imagem , Pandemias , Pneumonia Viral , Avaliação de Sintomas , Adolescente , Idoso , Betacoronavirus/isolamento & purificação , China/epidemiologia , Estudos de Coortes , Comorbidade , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/fisiopatologia , Cuidados Críticos/métodos , Cuidados Críticos/estatística & dados numéricos , Estado Terminal/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Pneumonia Viral/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Avaliação de Sintomas/métodos , Avaliação de Sintomas/estatística & dados numéricos
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