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1.
BMC Health Serv Res ; 21(1): 901, 2021 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-34470636

RESUMO

BACKGROUND: Advance Care Planning (ACP) has emerged to improve end-of-life processes and experiences. However, the available evidence presents the gloomy picture of increasing number of older people living with chronic diseases and the mismatch between their preferences for and the actual place of death. The study aimed to investigate the efficacy of normalisation of an Advance Care Planning (NACP) service delivered by specially trained Registered Nurses (RNs) in hospital and community settings. METHODS: A quasi-experimental study was conducted involving 16 sites (eight hospital and eight community sites) in Australia. Patients who were aged ≥18 years, who had at least one of nine chronic conditions, and who did not have an Advance Care Directive (ACD) were offered the NACP service. ACP was normalised as part of routine service on admission. The intervention, NACP, was a series of facilitated conversations about the components of ACP. The primary outcomes which included the completion of ACDs, and/or appointment of an Enduring Guardian (EG), were assessed in both intervention and control sites at pre and post intervention stages. Numbers of patients who completed an ACD or appointed an EG were described by count (percentage). ACD completion was compared between intervention and control sites using a logistic mixed effects regression model. The model includes fixed effects for treatment group, period, and their interaction, as well as random site level intercepts. Secondary model included potentially confounding variables as covariates, including age, sex and chronic diseases. RESULTS: The prevalence of legally binding ACDs in intervention sites has increased from five to 85 (from 0.85% in pre to 17.6% in post), whereas it has slightly decreased from five to 2 (from 1.2% in pre and to 0.49% in post) in control sites (the difference in these changes being statistically significant p < 0.001). ACD completion rate was 3.6% (n = 4) in LHD1 and 1.2% (n = 3) in LHD2 in hospital whereas it was 53% (n = 26) in LHD1 and 80% (n = 52) in LHD2 in community. CONCLUSIONS: The study demonstrated that NACP service delivered by ACP RNs was effective in increasing completion of ACDs (interaction odds ratio = 50) and was more effective in community than hospital settings. Involvement of various healthcare professionals are warranted to ensure concordance of care. TRIAL REGISTRATION: The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246 ) on 03/10/2018. The URL of the trial registry record http://www.anzctr.org.au/trial/MyTrial.aspx.


Assuntos
Planejamento Antecipado de Cuidados , Adolescente , Adulto , Diretivas Antecipadas , Idoso , Austrália/epidemiologia , Doença Crônica , Hospitais , Humanos , Ensaios Clínicos Controlados não Aleatórios como Assunto
2.
Clin Oral Implants Res ; 32(9): 1021-1040, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34352130

RESUMO

OBJECTIVES: To summarize the clinical performance of anodized implants connected to different prostheses design after immediate/early (IL) or conventional loading (CL) protocols. MATERIALS AND METHODS: Seven databases were surveyed for randomized (RCTs) and non-randomized controlled clinical trials (CCTs). Studies comparing IL vs. CL protocol of anodized implants supporting single crown, fixed partial denture (FPD), full-arch fixed dental prosthesis (FDP), or overdenture were included. Risk-of-bias was evaluated using Cochrane Collaboration tools. Meta-analyses for different follow-up were analyzed, followed by heterogeneity source assessment and GRADE approach. The outcomes included implant survival rate, marginal bone loss (MBL), implant stability quotient (ISQ), probing depth (PD), plaque index (PI), and peri-implantitis prevalence. RESULTS: From 24 eligible studies, 22 were included for quantitative evaluation. Most RCTs (58%, n = 11) and all the 5 CCTs had high and serious risk-of-bias, respectively. Overall, pooling all prosthesis design, no difference between IL vs. CL protocols was observed for all outcomes (p > .05). However, according to prosthesis type subgroups, CL reduced MBL for full-arch FDP (p < .05). In a point-in-time assessment, with overdenture, although IL presented higher PI (12 months), it showed lower MBL (≥24 months), higher ISQ (3 months), and lower PD (6 and 12 months) (p < .05). Conversely, PD was higher for IL in single crown (3 and 6 months) (p < .05). Regarding MBL, IL demonstrated higher mean difference for full-arch FDP (36 months) and FPD (12 and 36 months) (p < .05). CONCLUSION: Within the limitations of this study, overall, there is no significant difference in the outcomes between IL and CL loading protocols.


Assuntos
Perda do Osso Alveolar , Implantes Dentários , Carga Imediata em Implante Dentário , Implantação Dentária Endo-Óssea , Prótese Dentária Fixada por Implante , Falha de Restauração Dentária , Humanos , Ensaios Clínicos Controlados não Aleatórios como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
3.
Diabetes Metab J ; 45(4): 461-481, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34352984

RESUMO

The Committee of Clinical Practice Guidelines of the Korean Diabetes Association (KDA) updated the previous clinical practice guidelines for Korean adults with diabetes and prediabetes and published the seventh edition in May 2021. We performed a comprehensive systematic review of recent clinical trials and evidence that could be applicable in real-world practice and suitable for the Korean population. The guideline is provided for all healthcare providers including physicians, diabetes experts, and certified diabetes educators across the country who manage patients with diabetes or the individuals at the risk of developing diabetes mellitus. The recommendations for screening diabetes and glucose-lowering agents have been revised and updated. New sections for continuous glucose monitoring, insulin pump use, and non-alcoholic fatty liver disease in patients with diabetes mellitus have been added. The KDA recommends active vaccination for coronavirus disease 2019 in patients with diabetes during the pandemic. An abridgement that contains practical information for patient education and systematic management in the clinic was published separately.


Assuntos
Diabetes Mellitus , COVID-19/epidemiologia , COVID-19/prevenção & controle , Vacinas contra COVID-19/administração & dosagem , Diabetes Mellitus/terapia , Humanos , Ensaios Clínicos Controlados não Aleatórios como Assunto , Pandemias , Ensaios Clínicos Controlados Aleatórios como Assunto , República da Coreia/epidemiologia , Sociedades Médicas
4.
Arch. argent. pediatr ; 119(4): 273-: I-276, VI, agosto 2021. Tab, graf
Artigo em Inglês, Espanhol | LILACS, BINACIS | ID: biblio-1280991

RESUMO

La incidencia del paro cardíaco pediátrico es desconocida; sus principales etiologías son cardiopatías congénitas, miocardiopatías y arritmias ventriculares. El electrocardiograma es un método diagnóstico que podría detectarlas precozmente y disminuir la morbimortalidad. El objetivo del estudio fue describir las habilidades de residentes de Pediatría para reconocer si un electrocardiograma era normal o anormal y realizar un diagnóstico electrocardiográfico preciso, antes y después de una intervención educativa. Participaron médicos residentes de primer año de Pediatría. Se tomó una evaluación con 12 trazados de electrocardiogramas, antes y después de un módulo educativo, y se compararon los puntajes mediante la prueba de "t" para datos pareados. No se halló diferencia entre ambas evaluaciones para la interpretación de electrocardiogramas como normales o anormales (p: 0,42). Sin embargo, hubo una diferencia estadísticamente significativa en cuanto a los diagnósticos de certeza (p < 0,002). Los diagnósticos de certeza electrocardiográficos mejoraron luego de implementar un módulo educacional


The incidence of pediatric cardiac arrest is unknown; its main etiologies are congenital heart diseases, cardiomyopathies, and ventricular arrhythmias. An electrocardiogram (ECG) is a diagnostic method that may allow to detect them in an early manner and reduce morbidity and mortality.The objective of this study was to describe pediatric residents' skills to determine if an ECG was normal or abnormal and make an accurate electrocardiographic diagnosis before and after an educational intervention. First-year pediatric residents participated in this study. An assessment including 12 ECG tracings was done before and after an educational module, and scores were compared using the t-test for paired data. No differences were observed between both assessments regarding the interpretation of ECG as normal or abnormal (p: 0.42). However, a statistically significant difference was observed in definitive diagnoses (p < 0.002). Definitive electrocardiographic diagnoses improved after the implementation of an educational module.


Assuntos
Humanos , Cardiologia/educação , Educação Médica , Eletrocardiografia , Competência Clínica , Ensaios Clínicos Controlados não Aleatórios como Assunto , Internato e Residência
5.
Lancet Public Health ; 6(8): e566-e578, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34274050

RESUMO

BACKGROUND: Smoke-free policies in outdoor areas and semi-private and private places (eg, cars) might reduce the health harms caused by tobacco smoke exposure (TSE). We aimed to investigate the effect of smoke-free policies covering outdoor areas or semi-private and private places on TSE and respiratory health in children, to inform policy. METHODS: In this systematic review and meta-analysis, we searched 13 electronic databases from date of inception to Jan 29, 2021, for published studies that assessed the effects of smoke-free policies in outdoor areas or semi-private or private places on TSE, respiratory health outcomes, or both, in children. Non-randomised and randomised trials, interrupted time series, and controlled before-after studies, without restrictions to the observational period, publication date, or language, were eligible for the main analysis. Two reviewers independently extracted data, including adjusted test statistics from each study using a prespecified form, and assessed risk of bias for effect estimates from each study using the Risk of Bias in Non-Randomised Studies of Interventions tool. Primary outcomes were TSE in places covered by the policy, unplanned hospital attendance for wheezing or asthma, and unplanned hospital attendance for respiratory tract infections, in children younger than 17 years. Random-effects meta-analyses were done when at least two studies evaluated policies that regulated smoking in similar places and reported on the same outcome. This study is registered with PROSPERO, CRD42020190563. FINDINGS: We identified 5745 records and assessed 204 full-text articles for eligibility, of which 11 studies met the inclusion criteria and were included in the qualitative synthesis. Of these studies, seven fit prespecified robustness criteria as recommended by the Cochrane Effective Practice and Organization of Care group, assessing smoke-free cars (n=5), schools (n=1), and a comprehensive policy covering multiple areas (n=1). Risk of bias was low in three studies, moderate in three, and critical in one. In the meta-analysis of ten effect estimates from four studies, smoke-free car policies were associated with an immediate TSE reduction in cars (risk ratio 0·69, 95% CI 0·55-0·87; 161 466 participants); heterogeneity was substantial (I2 80·7%; p<0·0001). One additional study reported a gradual TSE decrease in cars annually. Individual studies found TSE reductions on school grounds, following a smoke-free school policy, and in hospital attendances for respiratory tract infection, following a comprehensive smoke-free policy. INTERPRETATION: Smoke-free car policies are associated with reductions in reported child TSE in cars, which could translate into respiratory health benefits. Few additional studies assessed the effect of policies regulating smoking in outdoor areas and semi-private and private places on children's TSE or health outcomes. On the basis of these findings, governments should consider including private cars in comprehensive smoke-free policies to protect child health. FUNDING: Dutch Heart Foundation, Lung Foundation Netherlands, Dutch Cancer Society, Dutch Diabetes Research Foundation, Netherlands Thrombosis Foundation, and Health Data Research UK.


Assuntos
Exposição Ambiental/prevenção & controle , Doenças Respiratórias/prevenção & controle , Política Antifumo , Poluição por Fumaça de Tabaco/prevenção & controle , Criança , Exposição Ambiental/efeitos adversos , Humanos , Ensaios Clínicos Controlados não Aleatórios como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Doenças Respiratórias/epidemiologia , Poluição por Fumaça de Tabaco/efeitos adversos
6.
J Consult Clin Psychol ; 89(6): 514-527, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34264699

RESUMO

OBJECTIVE: To assess the effectiveness of noninstitutional psychosocial interventions in preventing recidivism among criminal adolescents. METHOD: We performed a systematic review and meta-analysis of randomized and nonrandomized controlled trials assessing the impact on recidivism among juveniles aged 12-17. The included studies had a low to medium risk of bias and were published between 2000 and 2019. Standardized mean differences or risk differences were calculated. RESULTS: We included 35 (20 randomized, 15 nonrandomized) studies evaluating 17 unique, noninstitutional psychosocial interventions. A meta-analysis found no significant reductions in recidivism for studied interventions compared to control conditions. Although single studies suggested some positive effects, the evidence provided by these studies was found to have very low certainty. Post hoc analyses indicated that studies including a low-intensity control condition might have stronger relative intervention effects compared to studies with medium or high-intensity control conditions. CONCLUSION: This systematic review did not find any one noninstitutional psychosocial intervention to be more effective than control treatments in reducing future criminality among juvenile offenders aged 12-17. We discuss the implications of the present findings for social work and child and adolescent psychiatry practices. (PsycInfo Database Record (c) 2021 APA, all rights reserved).


Assuntos
Criminosos/psicologia , Delinquência Juvenil/psicologia , Intervenção Psicossocial/métodos , Reincidência/prevenção & controle , Adolescente , Criança , Humanos , Delinquência Juvenil/prevenção & controle , Ensaios Clínicos Controlados não Aleatórios como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto
7.
Medicine (Baltimore) ; 100(25): e26330, 2021 Jun 25.
Artigo em Inglês | MEDLINE | ID: mdl-34160396

RESUMO

PURPOSE: This systematic review aimed to identify the available evidence regarding the comparative effectiveness and safety of various operative treatments in adult patients with osteochondral lesions of the talus (OLT). MATERIALS AND METHODS: The PubMed, Embase, ISI Web of Knowledge, and the Cochrane Controlled Trial Register of Controlled Trials were searched from their inception date to September 2019. Two reviewers selected the randomized controlled trials (RCTs) and non-RCTs assessing the comparative effectiveness and safety of various operative treatments for OLT. The meta-analysis was performed using Revman 5.3. RESULTS: Eight studies (1 RCT and 7 non-RCTs) with 375 patients were included in this review. The difference in the American Orthopaedic Foot and Ankle Society (AOFAS) score between the cartilage repair and replacement was not significant. The cartilage regeneration with or without cartilage repair had significant superiority in improving the AOFAS score compared with the cartilage repair. The difference in the magnetic resonance observation of cartilage repair tissue score between the cartilage repair and replacement and between cartilage repair and cartilage repair plus regeneration was significant. CONCLUSIONS: Cartilage regeneration and cartilage repair plus regeneration had significant superiority in improving the ankle function and radiological evaluation of OLT, although the trials included did not have high-level evidence. Moreover, which treatment between the 2 was safer could not be addressed in this review as most of the trials did not report the safety outcome. Further studies are needed to define the best surgical option for treating OLT.


Assuntos
Articulação do Tornozelo/cirurgia , Cartilagem Articular/cirurgia , Osteocondrite/cirurgia , Tálus/cirurgia , Adulto , Articulação do Tornozelo/diagnóstico por imagem , Articulação do Tornozelo/patologia , Artroplastia Subcondral/estatística & dados numéricos , Transplante de Medula Óssea/estatística & dados numéricos , Cartilagem Articular/diagnóstico por imagem , Cartilagem Articular/patologia , Condrócitos/transplante , Humanos , Imageamento por Ressonância Magnética , Ensaios Clínicos Controlados não Aleatórios como Assunto , Osteocondrite/diagnóstico , Osteocondrite/patologia , Plasma Rico em Plaquetas , Ensaios Clínicos Controlados Aleatórios como Assunto , Tálus/diagnóstico por imagem , Tálus/patologia , Transplante Autólogo/métodos , Transplante Autólogo/estatística & dados numéricos , Resultado do Tratamento
8.
J Surg Oncol ; 124(5): 894-905, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34137038

RESUMO

BACKGROUND: Management of coagulopathy during major oncologic surgery can be multifactorial and challenging. Viscoelastic assays (VEAs) can be useful in providing vital data about the mechanism of coagulopathy in these dynamic circumstances. OBJECTIVES: A prospective nonrandomized observational study with the aim of describing the coagulation parameters of patients undergoing major oncologic surgery using the Quantra® and TEG® 5000 systems. Our secondary objectives included the correlation between Quantra and TEG parameters, and the times to result for both technologies. METHODS: This study included 74 adults undergoing oncologic surgery with an anticipated blood loss of more than 500 ml. For each subject, whole blood samples for each device were collected at multiple points perioperatively for comparison. RESULTS: Correlation coefficients between Quantra and TEG parameters were 0.8 and above, indicating a very strong correlation (p < .001). Correlation coefficients between conventional laboratory tests and Quantra ranged from 0.74 to 0.83, indicating a moderate correlation (p < .001). The mean time to obtain results and total processing time was shorter for Quantra in comparison to TEG. CONCLUSIONS: Quantra parameters strongly correlated with TEG parameters; however, Quantra parameters were available in shorter amount of time as it is specifically designed as a closed point of care device.


Assuntos
Transtornos da Coagulação Sanguínea/diagnóstico , Técnicas Hemostáticas/instrumentação , Neoplasias/cirurgia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Tromboelastografia/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Transtornos da Coagulação Sanguínea/etiologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/patologia , Ensaios Clínicos Controlados não Aleatórios como Assunto , Prognóstico , Estudos Prospectivos , Adulto Jovem
9.
J Orthop Surg Res ; 16(1): 356, 2021 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-34074300

RESUMO

BACKGROUND: The coronavirus disease (COVID-19) pandemic has had a massive impact on individuals globally. The Chinese government has formulated effective response measures, and medical personnel have been actively responding to challenges associated with the epidemic prevention and control strategies. This study aimed to evaluate the effect of the implementation of a care transition pathway on patients that underwent joint replacement during the COVID-19 pandemic. METHODS: A quasi-experimental study was designed to evaluate the effect of implementing a care transition pathway for patients who underwent joint replacement during the COVID-19 pandemic in the orthopedic department of a tertiary care hospital in Beijing, China. Using a convenient sampling method, a total of 96 patients were selected. Of these, 51 patients who had undergone joint replacement in 2019 and received treatment via the routine nursing path were included in the control group. The remaining 45 patients who underwent joint replacement during the COVID-19 epidemic in 2020 and received therapy via the care transition pathway due to the implementation of epidemic prevention and control measures were included in the observation group. The quality of care transition was assessed by the Care Transition Measure (CTM), and patients were followed up 1 week after discharge. RESULTS: The observation group was determined to have better general self-care preparation, written planning materials, doctor-patient communication, health monitoring, and quality of care transition than the control group. CONCLUSIONS: A care transition pathway was developed to provide patients with care while transitioning through periods of treatment. It improved the patient perceptions of nursing quality. The COVID-19 pandemic is a huge challenge for health professionals, but we have the ability to improve features of workflows to provide the best possible patient care.


Assuntos
Artroplastia de Substituição/tendências , COVID-19/epidemiologia , Ensaios Clínicos Controlados não Aleatórios como Assunto/tendências , Procedimentos Ortopédicos/tendências , Centros de Atenção Terciária/tendências , Cuidado Transicional/tendências , Idoso , Artroplastia de Substituição/métodos , Artroplastia de Substituição/reabilitação , Pequim/epidemiologia , COVID-19/prevenção & controle , China/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados não Aleatórios como Assunto/métodos , Procedimentos Ortopédicos/métodos , Procedimentos Ortopédicos/reabilitação , Pandemias , Resultado do Tratamento
10.
Ann Emerg Med ; 78(3): 370-380, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-33975733

RESUMO

STUDY OBJECTIVE: Tetanus is the most common vaccination given in the emergency department; yet, administrations of tetanus vaccine boosters in the ED may not comply with the US Centers for Disease Control and Prevention's recommended vaccination schedule. We implemented a clinical decision support alert in the electronic health record that warned providers when ordering a tetanus vaccine if a prior one had been given within 10 years and studied its efficacy to reduce potentially unnecessary vaccines in the ED. METHODS: This was a retrospective, quasi-experimental, 1-group, pretest-posttest study in 3 hospital EDs in Boston, MA. We studied adult patients for whom tetanus vaccines were ordered despite a history of vaccination within the prior 10 years. We compared the number of potentially unnecessary tetanus vaccine administrations in a baseline phase (when the clinical decision support alert was not visible) versus an intervention phase. RESULTS: Of eligible patients, 22.1% (95% confidence interval [CI] 21.8% to 22.4%) had prior tetanus vaccines within 5 years, 12.8% (95% CI 12.5% to 13.0%) within 5 to 10 years, 3.8% (95% CI 3.6% to 3.9%) more than 10 years ago, and 61.3% (95% CI 60.9% to 61.7%) had no prior tetanus vaccination documentation. Of 60,983 encounters, 337 met the inclusion criteria. A tetanus vaccination was administered in 91% (95% CI 87% to 96%) of encounters in the baseline phase, compared to 55% (95% CI 47% to 62%) during the intervention. The absolute risk reduction was 36.7% (95% CI 28.0% to 45.4%), and the number of encounters needed to alert to avoid 1 potentially unnecessary tetanus vaccine (number needed to treat) was 2.7 (95% CI 2.2% to 3.6%). For patients with tetanus vaccines within the prior 5 years, the absolute risk reduction was 47.9% (95% CI 35.5 % to 60.3%) and the number needed to treat was 2.1 (95% CI 1.7% to 2.8%). CONCLUSION: A clinical decision support alert that warns ED clinicians that a patient may have an up-to-date tetanus vaccination status reduces potentially unnecessary vaccinations.


Assuntos
Sistemas de Apoio a Decisões Clínicas/normas , Esquemas de Imunização , Toxoide Tetânico/administração & dosagem , Vacinação/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados não Aleatórios como Assunto , Melhoria de Qualidade , Estudos Retrospectivos , Toxoide Tetânico/efeitos adversos , Toxoide Tetânico/imunologia , Procedimentos Desnecessários , Adulto Jovem
11.
Cochrane Database Syst Rev ; 5: CD013600, 2021 05 20.
Artigo em Inglês | MEDLINE | ID: mdl-34013969

RESUMO

BACKGROUND: Convalescent plasma and hyperimmune immunoglobulin may reduce mortality in patients with viral respiratory diseases, and are being investigated as potential therapies for coronavirus disease 2019 (COVID-19). A thorough understanding of the current body of evidence regarding benefits and risks of these interventions is required.  OBJECTIVES: Using a living systematic review approach, to assess whether convalescent plasma or hyperimmune immunoglobulin transfusion is effective and safe in the treatment of people with COVID-19; and to maintain the currency of the evidence. SEARCH METHODS: To identify completed and ongoing studies, we searched the World Health Organization (WHO) COVID-19 Global literature on coronavirus disease Research Database, MEDLINE, Embase, the Cochrane COVID-19 Study Register, the Epistemonikos COVID-19 L*OVE Platform, and trial registries. Searches were done on 17 March 2021. SELECTION CRITERIA: We included randomised controlled trials (RCTs) evaluating convalescent plasma or hyperimmune immunoglobulin for COVID-19, irrespective of disease severity, age, gender or ethnicity. For safety assessments, we also included non-controlled non-randomised studies of interventions (NRSIs) if 500 or more participants were included. We excluded studies that included populations with other coronavirus diseases (severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS)), as well as studies evaluating standard immunoglobulin. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methodology. To assess bias in included studies, we used the Cochrane 'Risk of Bias 2' tool for RCTs, and for NRSIs, the assessment criteria for observational studies, provided by Cochrane Childhood Cancer. We rated the certainty of evidence, using the GRADE approach, for the following outcomes: all-cause mortality, improvement and worsening of clinical status (for individuals with moderate to severe disease), development of severe clinical COVID-19 symptoms (for individuals with asymptomatic or mild disease), quality of life (including fatigue and functional independence), grade 3 or 4 adverse events, and serious adverse events. MAIN RESULTS: We included 13 studies (12 RCTs, 1 NRSI) with 48,509 participants, of whom 41,880 received convalescent plasma. We did not identify any completed studies evaluating hyperimmune immunoglobulin. We identified a further 100 ongoing studies evaluating convalescent plasma or hyperimmune immunoglobulin, and 33 studies reporting as being completed or terminated. Individuals with a confirmed diagnosis of COVID-19 and moderate to severe disease Eleven RCTs and one NRSI investigated the use of convalescent plasma for 48,349 participants with moderate to severe disease. Nine RCTs compared convalescent plasma to placebo treatment or standard care alone, and two compared convalescent plasma to standard plasma (results not included in abstract). Effectiveness of convalescent plasma We included data on nine RCTs (12,875 participants) to assess the effectiveness of convalescent plasma compared to placebo or standard care alone.  Convalescent plasma does not reduce all-cause mortality at up to day 28 (risk ratio (RR) 0.98, 95% confidence interval (CI) 0.92 to 1.05; 7 RCTs, 12,646 participants; high-certainty evidence). It has little to no impact on clinical improvement for all participants when assessed by liberation from respiratory support (RR not estimable; 8 RCTs, 12,682 participants; high-certainty evidence). It has little to no impact on the chance of being weaned or liberated from invasive mechanical ventilation for the subgroup of participants requiring invasive mechanical ventilation at baseline (RR 1.04, 95% CI 0.57 to 1.93; 2 RCTs, 630 participants; low-certainty evidence). It does not reduce the need for invasive mechanical ventilation (RR 0.98, 95% CI 0.89 to 1.08; 4 RCTs, 11,765 participants; high-certainty evidence). We did not identify any subgroup differences.  We did not identify any studies reporting quality of life, and therefore, do not know whether convalescent plasma has any impact on quality of life. One RCT assessed resolution of fatigue on day 7, but we are very uncertain about the effect (RR 1.21, 95% CI 1.02 to 1.42; 309 participants; very low-certainty evidence).  Safety of convalescent plasma We included results from eight RCTs, and one NRSI, to assess the safety of convalescent plasma. Some of the RCTs reported on safety data only for the convalescent plasma group.  We are uncertain whether convalescent plasma increases or reduces the risk of grade 3 and 4 adverse events (RR 0.90, 95% CI 0.58 to 1.41; 4 RCTs, 905 participants; low-certainty evidence), and serious adverse events (RR 1.24, 95% CI 0.81 to 1.90; 2 RCTs, 414 participants; low-certainty evidence).  A summary of reported events of the NRSI (reporting safety data for 20,000 of 35,322 transfused participants), and four RCTs reporting safety data only for transfused participants (6125 participants) are included in the full text. Individuals with a confirmed diagnosis of SARS-CoV-2 infection and asymptomatic or mild disease We identified one RCT reporting on 160 participants, comparing convalescent plasma to placebo treatment (saline).  Effectiveness of convalescent plasma We are very uncertain about the effect of convalescent plasma on all-cause mortality (RR 0.50, 95% CI 0.09 to 2.65; very low-certainty evidence). We are uncertain about the effect of convalescent plasma on developing severe clinical COVID-19 symptoms (RR not estimable; low-certainty evidence).  We identified no study reporting quality of life.  Safety of convalescent plasma We do not know whether convalescent plasma is associated with a higher risk of grade 3 or 4 adverse events (very low-certainty evidence), or serious adverse events (very low-certainty evidence). This is a living systematic review. We search weekly for new evidence and update the review when we identify relevant new evidence. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review. AUTHORS' CONCLUSIONS: We have high certainty in the evidence that convalescent plasma for the treatment of individuals with moderate to severe disease does not reduce mortality and has little to no impact on measures of clinical improvement. We are uncertain about the adverse effects of convalescent plasma. While major efforts to conduct research on COVID-19 are being made, heterogeneous reporting of outcomes is still problematic. There are 100 ongoing studies and 33 studies reporting in a study registry as being completed or terminated. Publication of ongoing studies might resolve some of the uncertainties around hyperimmune immunoglobulin therapy for people with any disease severity, and convalescent plasma therapy for people with asymptomatic or mild disease.


Assuntos
COVID-19/terapia , Viés , COVID-19/mortalidade , Causas de Morte , Humanos , Imunização Passiva/efeitos adversos , Imunização Passiva/métodos , Imunização Passiva/mortalidade , Imunização Passiva/estatística & dados numéricos , Ensaios Clínicos Controlados não Aleatórios como Assunto/estatística & dados numéricos , Pandemias , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Resultado do Tratamento , Desmame do Respirador/estatística & dados numéricos
12.
Cochrane Database Syst Rev ; 5: CD007899, 2021 05 05.
Artigo em Inglês | MEDLINE | ID: mdl-33951190

RESUMO

BACKGROUND: There is growing interest in paying for performance (P4P) as a means to align the incentives of healthcare providers with public health goals. Rigorous evidence on the effectiveness of these strategies in improving health care and health in low- and middle-income countries (LMICs) is lacking; this is an update of the 2012 review on this topic. OBJECTIVES: To assess the effects of paying for performance on the provision of health care and health outcomes in low- and middle-income countries. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and 10 other databases between April and June 2018. We also searched two trial registries, websites, online resources of international agencies, organizations and universities, and contacted experts in the field. Studies identified from rerunning searches in 2020 are under 'Studies awaiting classification.' SELECTION CRITERIA: We included randomized or non-randomized trials, controlled before-after studies, or interrupted time series studies conducted in LMICs (as defined by the World Bank in 2018). P4P refers to the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target. To be included, a study had to report at least one of the following outcomes: patient health outcomes, changes in targeted measures of provider performance (such as the delivery of healthcare services), unintended effects, or changes in resource use. DATA COLLECTION AND ANALYSIS: We extracted data as per original review protocol and narratively synthesised findings. We used standard methodological procedures expected by Cochrane. Given diversity and variability in intervention types, patient populations, analyses and outcome reporting, we deemed meta-analysis inappropriate. We noted the range of effects associated with P4P against each outcome of interest. Based on intervention descriptions provided in documents, we classified design schemes and explored variation in effect by scheme design. MAIN RESULTS: We included 59 studies: controlled before-after studies (19), non-randomized (16) or cluster randomized trials (14);  and interrupted time-series studies (9). One study included both an interrupted time series and a controlled before-after study. Studies focused on a wide range of P4P interventions, including target payments and payment for outputs as modified by quality (or quality and equity assessments). Only one study assessed results-based aid. Many schemes were funded by national governments (23 studies) with the World Bank funding most externally funded schemes (11 studies). Targeted services varied; however, most interventions focused on reproductive, maternal and child health indicators. Participants were predominantly located in public or in a mix of public, non-governmental and faith-based facilities (54 studies). P4P was assessed predominantly at health facility level, though districts and other levels were also involved. Most studies assessed the effects of P4P against a status quo control (49 studies); however, some studies assessed effects against comparator interventions (predominantly enhanced financing intended to match P4P funds (17 studies)). Four studies reported intervention effects against both comparator and status quo. Controlled before-after studies were at higher risk of bias than other study designs. However, some randomised trials were also downgraded due to risk of bias. The interrupted time-series studies provided insufficient information on other concurrent changes in the study context. P4P compared to a status quo control For health services that are specifically targeted, P4P may slightly improve health outcomes (low certainty evidence), but few studies assessed this. P4P may also improve service quality overall (low certainty evidence); and probably increases the availability of health workers, medicines and well-functioning infrastructure and equipment (moderate certainty evidence). P4P may have mixed effects on the delivery and use of services (low certainty evidence) and may have few or no distorting unintended effects on outcomes that were not targeted (low-certainty evidence), but few studies assessed these. For secondary outcomes, P4P may make little or no difference to provider absenteeism, motivation or satisfaction (low certainty evidence); but may improve patient satisfaction and acceptability (low certainty evidence); and may positively affect facility managerial autonomy (low certainty evidence). P4P probably makes little to no difference to management quality or facility governance (low certainty evidence). Impacts on equity were mixed (low certainty evidence). For health services that are untargeted, P4P probably improves some health outcomes (moderate certainty evidence); may improve the delivery, use and quality of some health services but may make little or no difference to others (low certainty evidence); and may have few or no distorting unintended effects (low certainty evidence). The effects of P4P on the availability of medicines and other resources are uncertain (very low certainty evidence). P4P compared to other strategies For health outcomes and services that are specifically targeted, P4P may make little or no difference to health outcomes (low certainty evidence), but few studies assessed this. P4P may improve service quality (low certainty evidence); and may have mixed effects on the delivery and use of health services and on the availability of equipment and medicines (low certainty evidence). For health outcomes and services that are untargeted, P4P may make little or no difference to health outcomes and to the delivery and use of health services (low certainty evidence). The effects of P4P on service quality, resource availability and unintended effects are uncertain (very low certainty evidence). Findings of subgroup analyses Results-based aid, and schemes using payment per output adjusted for service quality, appeared to yield the greatest positive effects on outcomes. However, only one study evaluated results-based aid, so the effects may be spurious. Overall, schemes adjusting both for quality of service and rewarding equitable delivery of services appeared to perform best in relation to service utilization outcomes. AUTHORS' CONCLUSIONS: The evidence base on the impacts of P4P schemes has grown considerably, with study quality gradually increasing. P4P schemes may have mixed effects on outcomes of interest, and there is high heterogeneity in the types of schemes implemented and evaluations conducted. P4P is not a uniform intervention, but rather a range of approaches. Its effects depend on the interaction of several variables, including the design of the intervention (e.g., who receives payments ), the amount of additional funding,  ancillary components (such as technical support) and contextual factors (including organizational context).


Assuntos
Países em Desenvolvimento , Melhoria de Qualidade/economia , Reembolso de Incentivo , Viés , Estudos Controlados Antes e Depois , Humanos , Análise de Séries Temporais Interrompida , Ensaios Clínicos Controlados não Aleatórios como Assunto , Melhoria de Qualidade/normas , Qualidade da Assistência à Saúde/economia , Qualidade da Assistência à Saúde/normas
13.
Medicine (Baltimore) ; 100(20): e25998, 2021 May 21.
Artigo em Inglês | MEDLINE | ID: mdl-34011094

RESUMO

ABSTRACT: To examine the impact of inadequate health insurance coverage on physician utilization among older adults using a novel quasi-experimental design in the time period following the elimination of cost sharing for most preventative services under the US Affordable Care Act of 2010.The Medical Expenditure Panel Survey full year consolidated data files for the period 2010 to 2017 were used to construct a pooled cross-sectional dataset of adults aged 60 to 70. Regression discontinuity design was used to estimate the impact of transitioning between non-Medicare and Medicare plans on use of routine office-based physician visits and emergency room visits.For the overall population, gaining access to Medicare at age 65 is associated with a higher propensity to make routine office-based visits (2.94 percentage points [pp]; P < .01) and lower out-of-pocket costs (-23.86 pp; P < .01) Similarly, disenrollment from non-Medicare insurance plans at age 66 was associated with more routine office-based visits (3.01 pp; P < .01) and less out-of-pocket costs (-8.09 pp; P < .10). However, some minority groups reported no changes in visits and out-of-pocket costs or reported an increased propensity to make emergency department visits.Enrollment into Medicare from non-Medicare insurance plans was associated with increased use of routine office-based services and lower out-of-pocket costs. However, some subgroups reported no changes in routine visits or costs or an increased propensity to make emergency department visits. These findings suggest other nonfinancial, structural barriers may exist that limit patient's ability to access routine services.


Assuntos
Cobertura do Seguro/estatística & dados numéricos , Medicare/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Patient Protection and Affordable Care Act/legislação & jurisprudência , Idoso , Custo Compartilhado de Seguro/economia , Custo Compartilhado de Seguro/legislação & jurisprudência , Custo Compartilhado de Seguro/estatística & dados numéricos , Feminino , Gastos em Saúde/estatística & dados numéricos , Humanos , Cobertura do Seguro/economia , Masculino , Medicare/economia , Pessoa de Meia-Idade , Grupos Minoritários/estatística & dados numéricos , Ensaios Clínicos Controlados não Aleatórios como Assunto , Visita a Consultório Médico/economia , Visita a Consultório Médico/estatística & dados numéricos , Patient Protection and Affordable Care Act/economia , Estados Unidos
14.
Cochrane Database Syst Rev ; 4: CD010682, 2021 04 16.
Artigo em Inglês | MEDLINE | ID: mdl-33860531

RESUMO

BACKGROUND: Depressive disorders are the most common psychiatric comorbidity in people with epilepsy, affecting around one-third, with a significant negative impact on quality of life. There is concern that people may not be receiving appropriate treatment for their depression because of uncertainty regarding which antidepressant or class works best, and the perceived risk of exacerbating seizures. This review aimed to address these issues, and inform clinical practice and future research. This is an updated version of the original Cochrane Review published in Issue 12, 2014. OBJECTIVES: To evaluate the efficacy and safety of antidepressants in treating depressive symptoms and the effect on seizure recurrence, in people with epilepsy and depression. SEARCH METHODS: For this update, we searched CRS Web, MEDLINE, SCOPUS, PsycINFO, and ClinicalTrials.gov (February 2021). We searched the World Health Organization Clinical Trials Registry in October 2019, but were unable to update it because it was inaccessible. There were no language restrictions. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and prospective non-randomised studies of interventions (NRSIs), investigating children or adults with epilepsy, who were treated with an antidepressant and compared to placebo, comparative antidepressant, psychotherapy, or no treatment for depressive symptoms.  DATA COLLECTION AND ANALYSIS: The primary outcomes were changes in depression scores (proportion with a greater than 50% improvement, mean difference, and proportion who achieved complete remission) and change in seizure frequency (mean difference, proportion with a seizure recurrence, or episode of status epilepticus). Secondary outcomes included the number of participants who withdrew from the study and reasons for withdrawal, quality of life, cognitive functioning, and adverse events. Two review authors independently extracted data for each included study. We then cross-checked the data extraction. We assessed risk of bias using the Cochrane tool for RCTs, and the ROBINS-I for NRSIs. We presented binary outcomes as risk ratios (RRs) with 95% confidence intervals (CIs) or 99% CIs for specific adverse events. We presented continuous outcomes as standardised mean differences (SMDs) with 95% CIs, and mean differences (MDs) with 95% CIs.  MAIN RESULTS: We included 10 studies in the review (four RCTs and six NRSIs), with 626 participants with epilepsy and depression, examining the effects of antidepressants. One RCT was a multi-centre study comparing an antidepressant with cognitive behavioural therapy (CBT). The other three RCTs were single-centre studies comparing an antidepressant with an active control, placebo, or no treatment. The NRSIs reported on outcomes mainly in participants with focal epilepsy before and after treatment for depression with a selective serotonin reuptake inhibitor (SSRI); one NRSI compared SSRIs to CBT.  We rated one RCT at low risk of bias, three RCTs at unclear risk of bias, and all six NRSIs at serious risk of bias. We were unable to conduct any meta-analysis of RCT data due to heterogeneity of treatment comparisons. We judged the certainty of evidence to be moderate to very low across comparisons, because single studies contributed limited outcome data, and because of risk of bias, particularly for NRSIs, which did not adjust for confounding variables. More than 50% improvement in depressive symptoms ranged from 43% to 82% in RCTs, and from 24% to 97% in NRSIs, depending on the antidepressant given. Venlafaxine improved depressive symptoms by more than 50% compared to no treatment (mean difference (MD) -7.59 (95% confidence interval (CI) -11.52 to -3.66; 1 study, 64 participants; low-certainty evidence); the results between other comparisons were inconclusive. Two studies comparing SSRIs to CBT reported inconclusive results for the proportion of participants who achieved complete remission of depressive symptoms.  Seizure frequency data did not suggest an increased risk of seizures with antidepressants compared to control treatments or baseline. Two studies measured quality of life; antidepressants did not appear to improve quality of life over control. No studies reported on cognitive functioning. Two RCTs and one NRSI reported comparative data on adverse events; antidepressants did not appear to increase the severity or number of adverse events compared to controls. The NSRIs reported higher rates of withdrawals due to adverse events than lack of efficacy. Reported adverse events for antidepressants included nausea, dizziness, sedation, headache, gastrointestinal disturbance, insomnia, and sexual dysfunction.  AUTHORS' CONCLUSIONS: Existing evidence on the effectiveness of antidepressants in treating depressive symptoms associated with epilepsy is still very limited. Rates of response to antidepressants were highly variable. There is low certainty evidence from one small RCT (64 participants) that venlafaxine may improve depressive symptoms more than no treatment; this evidence is limited to treatment between 8 and 16 weeks, and does not inform longer-term effects. Moderate to low evidence suggests neither an increase nor exacerbation of seizures with SSRIs.  There are no available comparative data to inform the choice of antidepressant drug or classes of drug for efficacy or safety for treating people with epilepsy and depression. RCTs of antidepressants utilising interventions from other treatment classes besides SSRIs, in large samples of patients with epilepsy and depression, are needed to better inform treatment policy. Future studies should assess interventions across a longer treatment duration to account for delayed onset of action, sustainability of treatment responses, and to provide a better understanding of the impact on seizure control.


Assuntos
Antidepressivos/uso terapêutico , Depressão/tratamento farmacológico , Epilepsia/tratamento farmacológico , Adolescente , Adulto , Antidepressivos/efeitos adversos , Viés , Criança , Terapia Cognitivo-Comportamental , Depressão/etiologia , Epilepsia/induzido quimicamente , Epilepsia/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados não Aleatórios como Assunto , Estudos Prospectivos , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Inibidores de Captação de Serotonina/efeitos adversos , Inibidores de Captação de Serotonina/uso terapêutico , Adulto Jovem
15.
PLoS One ; 16(4): e0249529, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33793655

RESUMO

BACKGROUND: Dilation and evacuation is a method of second trimester pregnancy termination introduced recently in Ethiopia. However, little is known about the safety and effectiveness of this method in an Ethiopian setting. Therefore, the study is intended to determine the safety and effectiveness of dilation and evacuation for surgical abortion as compared to medical abortion between 13-20 weeks' gestational age. METHODS: This is a quasi-experimental study of women receiving second trimester termination of pregnancy between 13-20 weeks. Patients were allocated to either medical or surgical abortion based on their preference. A structured questionnaire was used to collect demographic information and clinical data upon admission. Procedure related information was collected after the procedure was completed and before the patient was discharged. Additionally, women were contacted 2 weeks after the procedure to evaluate for post-procedural complications. The primary outcome of the study was a composite complication rate. Data were collected using Open Data Kit and then analyzed using Stata version 14.2. Univariate analyses were performed using means (standard deviation), or medians (interquartile range) when the distribution was not normal. Multiple logistic regression was also performed to control for confounders. RESULTS: Two hundred nineteen women chose medical abortion and 60 chose surgical abortion. The composite complication rate is not significantly different among medical and surgical abortion patients (15% versus 10%; p = 0.52). Nine patients (4.1%) in the medical arm required additional intervention to complete the abortion, while none of the surgical abortion patients required additional intervention. Median (IQR) hospital stay was significantly longer in the medical group at 24 (12-24) hours versus 6(4-6) hours in the surgical group p<0.001. CONCLUSION: From the current study findings, we concluded that there is no difference in safety between surgical and medical methods of abortion. This study demonstrates that surgical abortion can be used as a safe and effective alternative to medical abortion and should be offered equivalently with medical abortion, per the patient's preference.


Assuntos
Abortivos Esteroides/administração & dosagem , Aborto Induzido/métodos , Mifepristona/administração & dosagem , Cuidados Pré-Operatórios/estatística & dados numéricos , Aborto Induzido/efeitos adversos , Adulto , Etiópia , Extração Obstétrica/métodos , Feminino , Humanos , Tempo de Internação , Modelos Logísticos , Ensaios Clínicos Controlados não Aleatórios como Assunto , Gravidez , Primeiro Trimestre da Gravidez , Segundo Trimestre da Gravidez , Inquéritos e Questionários , Adulto Jovem
16.
Clin Orthop Relat Res ; 479(7): 1484-1494, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-33856366

RESUMO

BACKGROUND: Most patients who report a penicillin allergy can tolerate cefazolin, the preferred prophylaxis in a total joint arthroplasty (TJA). Regardless, patients with a reported penicillin allergy are less likely to receive first-line perioperative antibiotics as a result of inaccurate penicillin allergy documentation and misconceptions regarding cross-reactivity between penicillin and cephalosporins. The over-reporting of penicillin allergies and the safety of cephalosporins in patients with reported penicillin allergies have been well established throughout the evidence [13]. QUESTIONS/PURPOSES: The study sought to answer two questions: (1) Do antibiotic stewardship interventions improve adherence to appropriate prophylactic antibiotic usage in patients with a documented penicillin allergy undergoing primary TJA? (2) What is the risk of allergic or adverse reactions secondary to cefazolin use in patients with a documented penicillin allergy? METHODS: This was a single-center, retrospective study of orthopaedic patients older than 18 years who underwent a primary elective TJA at a 261-bed community hospital. The study had two periods: the preintervention period ran from March 1, 2017 to August 30, 2017 and the postintervention period was from March 1, 2019 to August 30, 2019. A total of 396 patients with a history of a documented penicillin allergy underwent a THA or TKA during the study periods. After reviewing every fourth patient with a history of a documented penicillin allergy who met study inclusion criteria and excluding those patients who had a codocumented cephalosporin allergy, a total of 180 patients with a documented penicillin allergy were evaluated (90 patients in the preintervention group and 90 patients in the postintervention group). To answer our first study question, regarding whether antibiotic stewardship interventions improve adherence to appropriate prophylactic antibiotic usage in patients with a documented penicillin allergy undergoing primary TJA, we evaluated appropriate antibiotic usage pre- and postintervention. To answer our second study question, concerning the risk of allergic or adverse reactions secondary to cefazolin use in patients with a documented penicillin allergy, we reviewed signs of allergic reactions in patients who received cefazolin for a primary TJA and had a documented penicillin allergy. RESULTS: Postintervention antibiotic use was more appropriate (91% [82 of 90] versus 54% [49 of 90], risk ratio 1.67 [95% confidence interval 1.37 to 2.04]; p < 0.01), particularly in patients with nonsevere allergy (preintervention: 47% [36 of 76] versus postintervention: 96% [76 of 79]; p < 0.01). No patients had signs of an allergic reaction related to cefazolin, including eight patients with severe penicillin allergy. CONCLUSION: A multifaceted antibiotic stewardship intervention increased the appropriateness of antibiotic prophylaxis in elective primary TJA. Patients with nonsevere penicillin allergies, even those reporting hives or local swelling, tolerated cefazolin. Antibiotic stewardship interventions can be implemented across institutions to expand cephalosporin use in patients with a reported penicillin allergy within orthopaedic TJA patients. LEVEL OF EVIDENCE: Level III, therapeutic study.


Assuntos
Antibioticoprofilaxia/métodos , Gestão de Antimicrobianos/métodos , Artroplastia de Substituição/efeitos adversos , Cefazolina/administração & dosagem , Hipersensibilidade a Drogas/prevenção & controle , Infecções Relacionadas à Prótese/prevenção & controle , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados não Aleatórios como Assunto , Penicilinas/efeitos adversos , Estudos Retrospectivos , Resultado do Tratamento
17.
Lancet Child Adolesc Health ; 5(6): 408-416, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33891879

RESUMO

BACKGROUND: Therapeutic hypothermia is standard of care in high-income countries for babies born with signs of hypoxic ischaemic encephalopathy, but optimal feeding during treatment is uncertain and practice is variable. This study aimed to assess the association between feeding during therapeutic hypothermia and clinically important outcomes. METHODS: We did a population-level retrospective cohort study using the UK National Neonatal Research Database. We included all babies admitted to National Health Service neonatal units in England, Scotland, and Wales between Jan 1, 2010, and Dec 31, 2017, who received therapeutic hypothermia for 72 h or died during this period. For analysis, we created matched groups using propensity scores and compared outcomes in babies who were fed versus unfed enterally during therapeutic hypothermia. The primary outcome was severe necrotising enterocolitis, either confirmed at surgery or causing death. Secondary outcomes include pragmatically defined necrotising enterocolitis (a recorded diagnosis of necrotising enterocolitis in babies who received at least 5 consecutive days of antibiotics while also nil by mouth during their neonatal unit stay), late-onset infection (pragmatically defined as 5 consecutive days of antibiotic treatment commencing after day 3), survival to discharge, measures of breastmilk feeding, and length of stay in neonatal unit. FINDINGS: 6030 babies received therapeutic hypothermia, of whom 1873 (31·1%) were fed during treatment. Seven (0·1%) babies were diagnosed with severe necrotising enterocolitis and the number was too small for further analyses. We selected 3236 (53·7%) babies for the matched feeding analysis (1618 pairs), achieving a good balance for all recorded background variables. Pragmatically defined necrotising enterocolitis was rare in both groups (incidence 0·5%, 95% CI 0·2-0·9] in the fed group vs 1·1% [0·7-1·4] in the unfed group). The enterally fed group had fewer pragmatically defined late-onset infections (difference -11·6% [95% CI -14·0 to -9·3]; p<0·0001), higher survival to discharge (5·2% [3·9-6·6]; p<0·0001), higher proportion of breastfeeding at discharge (8·0% [5·1-10·8]; p<0·0001), and shorter neonatal unit stays (-2·2 [-3·0 to -1·2] days; p<0·0001) compared with the unfed group. INTERPRETATION: Necrotising enterocolitis is rare in babies receiving therapeutic hypothermia. Enteral feeding during hypothermia is safe and associated with beneficial outcomes compared with not feeding, although residual confounding could not be completely ruled out. Our findings support starting milk feeds during therapeutic hypothermia. FUNDING: UK National Institute for Health Research Health Technology Assessment programme 16/79/13.


Assuntos
Nutrição Enteral/métodos , Enterocolite Necrosante/etiologia , Hipotermia Induzida/efeitos adversos , Hipóxia-Isquemia Encefálica/terapia , Ensaios Clínicos Controlados não Aleatórios como Assunto/métodos , Aleitamento Materno/estatística & dados numéricos , Estudos de Casos e Controles , Estudos de Coortes , Inglaterra/epidemiologia , Nutrição Enteral/estatística & dados numéricos , Enterocolite Necrosante/diagnóstico , Enterocolite Necrosante/epidemiologia , Enterocolite Necrosante/mortalidade , Feminino , Idade Gestacional , Humanos , Hipotermia Induzida/estatística & dados numéricos , Incidência , Recém-Nascido , Tempo de Internação/estatística & dados numéricos , Masculino , Leite Humano , Avaliação de Resultados em Cuidados de Saúde , Estudos Retrospectivos , Escócia/epidemiologia , Medicina Estatal , País de Gales/epidemiologia
18.
Nutrients ; 13(3)2021 Mar 23.
Artigo em Inglês | MEDLINE | ID: mdl-33807053

RESUMO

Research comparing the adherence to food-based dietary guidelines (FBDGs) across countries with different socio-economic status is lacking, which may be a concern for developing nutrition policies. The aim was to report on the adherence to FBDGs in high-income (HIC) and low-and-middle-income countries (LMIC). A systematic review with searches in six databases was performed up to June 2020. English language articles were included if they investigated a population of healthy children and adults (7-65 years), using an observational or experimental design evaluating adherence to national FBDGs. Findings indicate that almost 40% of populations in both HIC and LMIC do not adhere to their national FBDGs. Fruit and vegetables (FV) were most adhered to and the prevalence of adhering FV guidelines was between 7% to 67.3%. HIC have higher consumption of discretionary foods, while results were mixed for LMIC. Grains and dairy were consumed below recommendations in both HIC and LMIC. Consumption of animal proteins (>30%), particularly red meat, exceeded the recommendations. Individuals from HIC and LMIC may be falling short of at least one dietary recommendation from their country's guidelines. Future health policies, behavioral-change strategies, and dietary guidelines may consider these results in their development.


Assuntos
Países em Desenvolvimento , Dieta/normas , Política Nutricional , Laticínios , Bases de Dados Factuais , Frutas , Humanos , Ensaios Clínicos Controlados não Aleatórios como Assunto , Cooperação do Paciente , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores Socioeconômicos , Verduras , Grãos Integrais
19.
Paediatr Drugs ; 23(3): 299-305, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33830468

RESUMO

BACKGROUND: Vancomycin is an antibiotic that is widely used in pediatric intensive care, but the safe and effective use of this drug is challenging. OBJECTIVE: This study aimed to assess the impact of a vancomycin protocol on trough serum concentrations. METHODS: We conducted a retrospective quasiexperimental study in patients aged ≤ 18 years in intensive care who received vancomycin for at least 5 days. Patients were divided into two groups: before and after a protocol implemented in 2017 that suggested an initial vancomycin dose of 60 mg/kg/day, target serum levels of 15-20 µg/mL, and dose adjustments. We compared patient characteristics, target serum level achievement, and vancomycin levels over time. RESULTS: Each group contained 65 patients; most were male infants with heart disease as the main reason for hospitalization. Only 29.2% of the patients had pretreatment cultures for bacteria identification recorded, with 1.5% identified as methicillin-resistant Staphylococcus aureus. For the first serum levels, 10.8% of patients in the pre-protocol group and 21.5% in the post-protocol group achieved the 15-20 µg/mL target (p = 0.153); during the first 5 days of treatment, this proportion significantly increased from 52.3 to 73.8% (p = 0.018). We observed a difference between the first and fifth levels: 8.9 µg/mL (95% confidence interval [CI] - 3.1 to 21) pre-protocol and 0.4 µg/mL (95% CI - 6.1 to 6.9) post-protocol (p = 0.175). CONCLUSIONS: Reaching adequate trough vancomycin concentrations in critically ill pediatric patients remains a challenge, and clinical practice protocols allow better dose adjustment and control even when monitoring technologies are unavailable.


Assuntos
Unidades de Terapia Intensiva Pediátrica/normas , Vancomicina/uso terapêutico , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Ensaios Clínicos Controlados não Aleatórios como Assunto , Estudos Retrospectivos , Vancomicina/farmacologia
20.
Eur J Vasc Endovasc Surg ; 61(5): 837-847, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33810977

RESUMO

OBJECTIVE: Near infrared spectroscopy (NIRS) has been suggested as a new diagnostic tool in patients with lower extremity artery disease (LEAD). The aim of this systematic review was to summarise the impact of exercise therapy on lower limb muscle oxygenation, evaluated by NIRS, in patients with LEAD, and to give an overview on NIRS instruments and methodology. DATA SOURCES: MEDLINE and Embase. REVIEW METHODS: A systematic search was conducted in MEDLINE and Embase, from the earliest date available until 16 March 2020, to identify peer reviewed studies involving the use of NIRS in the evaluation of exercise training on muscle oxygenation in patients with LEAD. Primary outcomes were NIRS derived variables during treadmill exercise. Effect sizes were calculated as standardised mean differences. Assessment of methodological quality was done using a combined checklist from the Cochrane bias and the quality assessment tool for before and after studies without a control group. RESULTS: Eleven original trials were included involving 16 exercise groups and four control groups. Tissue saturation index (TSI) at rest remained unchanged following the exercise interventions. Exercise training increased time to minimum TSI during exercise (range effect sizes: +0.172 to +0.927). In addition, exercise training led to a faster recovery to half and full TSI rest values in most intervention groups (range effect sizes -0.046 to -0.558 and -0.269 to -0.665, respectively). Finally, NIRS data reproducibility and analytic methods were under reported in the included studies. CONCLUSION: The available data suggest that exercise training improves de-oxygenation and re-oxygenation patterns, as measured with NIRS, in patients with LEAD. Whereas NIRS is a promising tool in the evaluation of LEAD, the low number of randomised controlled trials, as well as large heterogeneity in NIRS assessment methods, outcome measures, and instrumentation, warrants more research to better understand the role of muscle oxygenation associated with exercise induced improvements in walking capacity.


Assuntos
Terapia por Exercício , Claudicação Intermitente/terapia , Músculo Esquelético/metabolismo , Oxigênio/análise , Doença Arterial Periférica/terapia , Humanos , Claudicação Intermitente/diagnóstico , Claudicação Intermitente/etiologia , Extremidade Inferior/irrigação sanguínea , Músculo Esquelético/irrigação sanguínea , Ensaios Clínicos Controlados não Aleatórios como Assunto , Oxigênio/metabolismo , Doença Arterial Periférica/complicações , Doença Arterial Periférica/diagnóstico , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Reprodutibilidade dos Testes , Espectroscopia de Luz Próxima ao Infravermelho , Resultado do Tratamento
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