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1.
Swiss Med Wkly ; 152: w30209, 2022 07 18.
Artigo em Inglês | MEDLINE | ID: mdl-35964324

RESUMO

TRIAL DESIGN: In the Special Program University Medicine-Acute Coronary Syndromes (SPUM-ACS) observational study (clinical trial registration: NCT01000701), a multicentre before-after clinical trial, we assessed 5-year outcome after acute coronary syndrome, comparing a systematic with an opportunistic smoking cessation counselling phase. METHODS: We studied smokers who were hospitalised for acute coronary syndromes (ACS), and we assessed self-reported smoking cessation, incidence of cardiovascular events and mortality 5 years after hospital discharge. In the observational phase, from August 2009 to October 2010, only smokers who requested smoking cessation counselling received it during hospitalisation. In the interventional phase, from November 2010 to February 2012, hospitalised smokers with ACS were systematically offered intensive smoking cessation counselling including four telephone calls within 2 months of discharge. Because of the before-after design, the care givers were aware of study phase. The objective was to assess whether systematic counselling to every smoker with ACS has an impact on the long-term smoking cessation rate, incidence of cardiovascular events and mortality. Missing data on smoking cessation were analysed with multiple imputation. The study was not powered to assess differences in 5-year smoking cessation rates or cardiovascular outcomes. RESULTS: Overall, 458 smokers with ACS were included at baseline (225 during the intervention phase and 233 during the observation phase). At 5 years, 286 (62.4%) reported their smoking status (140 for the intervention phase and 146 for the observation phase) and 51 (11.1%) had died. There was no statistically significant difference in the abstinence rate between the interventional phase (75/140, 54%), and the observational phase (68/146, 47%), with a risk ratio with multiple imputation adjusted for age, sex, education and ACS type of 1.13 (95% confidence interval [CI] 0.84-1.51, p = 0.4). The 5-year risk of major acute cardiovascular event was similar in the intervention phase as compared with the observational phase. The multivariate adjusted hazard ratio for all-cause mortality was 0.84 (95% CI 0.45-1.60, p = 0.6). CONCLUSIONS: In this controlled long-term interventional study, systematic intensive smoking cessation counselling in all hospitalised smokers with ACS did not increase 5-year smoking cessation rates, nor decrease cardiovascular event recurrence, as compared with opportunistic smoking cessation counselling during hospitalization.


Assuntos
Síndrome Coronariana Aguda , Abandono do Hábito de Fumar , Estudos Controlados Antes e Depois , Aconselhamento , Hospitalização , Humanos
2.
BMJ Open ; 12(8): e056262, 2022 08 24.
Artigo em Inglês | MEDLINE | ID: mdl-36002215

RESUMO

INTRODUCTION: Research on public health interventions to improve hypertension care and control in low-income and middle-income countries remains scarce. This study aims to evaluate the effectiveness and assess the process and fidelity of implementation of a multi-component intervention to reduce the gaps in hypertension care and control at a population level in low-income communes of Medellin, Colombia. METHODS AND ANALYSIS: A multi-component intervention was designed based on international guidelines, cross-sectional population survey results and consultation with the community and institutional stakeholders. Three main intervention components integrate activities related to (1) health services redesign, (2) clinical staff training and (3) patient and community engagement. The effectiveness of the intervention will be evaluated in a controlled before-after quasi-experimental study, with two deprived communes of the city selected as intervention and control arms. We will conduct a baseline and an endline survey 2 years after the start of the intervention. The primary outcomes will be the gaps in hypertension diagnosis, treatment, follow-up and control. Effectiveness will be evaluated with the difference-in-difference measures. Generalised estimation equation models will be fitted considering the clustered nature of data and adjusting for potential confounding variables. The implementation process will be studied with mixed methods. Implementation fidelity will be documented to assess to which degree the intervention components were implemented as intended. ETHICS AND DISSEMINATION: The study protocol has been approved by the Ethics Research Committee of Metrosalud in Colombia (reference 1400/5.2), the Medical Ethics Committee of the Antwerp University Hospital (reference 18/40/424) and the Institutional Review Board of the Antwerp Institute of Tropical Medicine (reference 1294/19). We will share and discuss the study results with the community, institutional stakeholders and national health policymakers. We will publish them in national and international peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER: NCT05011838.


Assuntos
Hipertensão , Colômbia , Estudos Controlados Antes e Depois , Estudos Transversais , Humanos , Hipertensão/prevenção & controle , Pobreza , Saúde Pública
3.
BMJ Open ; 12(7): e062298, 2022 07 21.
Artigo em Inglês | MEDLINE | ID: mdl-35863840

RESUMO

OBJECTIVES: Our objective was to evaluate the impact of a service delivery model led by membership-based associations called Iddirs formed by women on tuberculosis preventive treatment (TPT) initiation and completion rates among children. DESIGN: Comparative, before-and-after study design. SETTING: Three intervention and two control districts in Ethiopia. PARTICIPANTS: Children who had a history of close contact with adults with infectious forms of tuberculosis (TB). Child contacts in whom active TB and contraindications to TPT regimens were excluded were considered eligible for TPT. INTERVENTIONS: Between July 2020 and June 2021, trained women Iddir members visited households of index TB patients, screened child household contacts for TB, provided education and information on the benefits of TPT, linked them to the nearby health centre and followed them at home for TPT adherence and side effects. Two control zones received the standard of care, which comprised of facility-based provision of TPT to children. We analysed quarterly TPT data for treatment initiation and completion and compared intervention and control zones before and after the interventions and tested for statistical significance using Poisson regression. PRIMARY AND SECONDARY OUTCOME MEASURES: There were two primary outcome measures: proportion of eligible children initiated TPT and proportion completed treatment out of those eligible. RESULTS: TPT initiation rate among eligible under-15-year-old children (U15C) increased from 28.7% to 63.5% in the intervention zones, while it increased from 34.6% to 43.2% in the control zones, and the difference was statistically significant (p<0.001). TPT initiation rate for U5C increased from 13% (17 out of 131) to 93% (937 out of 1010). Of the U5C initiated, 99% completed treatment; two discontinued due to side effects; three parents refused to continue; and one child was lost to follow-up. CONCLUSION: Women-led Iddirs contributed to significant increase in TPT initiation and completion rates. The model of TPT delivery should be scaled-up.


Assuntos
Tuberculose , Adulto , Antibioticoprofilaxia , Antituberculosos/uso terapêutico , Criança , Estudos Controlados Antes e Depois , Etiópia/epidemiologia , Características da Família , Feminino , Humanos , Tuberculose/tratamento farmacológico , Tuberculose/epidemiologia , Tuberculose/prevenção & controle
4.
J Endod ; 48(9): 1121-1128, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-35690274

RESUMO

INTRODUCTION: Inadequate management of external cervical resorption (ECR) lesions may impact the treatment outcome. This study aimed to ascertain the influence of cone-beam computed tomography (CBCT) in clinical decision-making choices in cases of ECR among dentistry specialists (endodontics, prosthodontics, oral surgery, periodontics orthodontics, and general dentistry). A secondary objective was to evaluate the self-reported level of difficulty in choosing a treatment plan before and after viewing the CBCT images. METHODS: Sixty examiners from different specialties were chosen to evaluate 12 cases of ECR lesions. Each case included clinical photographs, digital periapical radiographs, and a small-volume CBCT scan. In the first assessment, the examiners were given all the relevant information of each case, except the CBCT scan. Each examiner was asked to select 1 of the proposed treatment options and assess the difficulty of decision-making. Four weeks later, the examiners randomly reviewed the same 12 cases with additional information from the CBCT data. RESULTS: After the CBCT evaluation, the clinicians changed their treatment plan in 72.2% of the cases (P < .05). The self-reported level of difficulty in choosing a treatment changed in all groups after evaluating the CBCT scans (P < .05). After viewing the CBCT scan, the extraction option increased significantly in all groups (P < .05). CONCLUSIONS: CBCT scan had a significant impact on clinical decision-making in cases of ECR evaluated by different specialists.


Assuntos
Tomografia Computadorizada de Feixe Cônico , Endodontia , Tomada de Decisão Clínica , Tomografia Computadorizada de Feixe Cônico/métodos , Estudos Controlados Antes e Depois , Odontologia Geral , Humanos
5.
BMJ Open ; 12(4): e055822, 2022 04 07.
Artigo em Inglês | MEDLINE | ID: mdl-35393312

RESUMO

INTRODUCTION: The enhanced recovery after surgery (ERAS) programmes following hysterectomies have been studied since 2010, and their positive effects on clinical or economic criteria are now well established. However, the benefits on health outcomes, especially rapid recovery after surgery from patients' perspective is lacking in literature, leading to develop scores supporting person-centred and value-based care such as patient-reported outcome measures. The aim of this study is to assess the impact of an ERAS programme on patients' well-being after undergoing hysterectomy. METHODS AND ANALYSIS: This is an observational, prospective single-centre before-after clinical trial. 148 patients are recruited and allocated into two groups, before and after ERAS programme implementation, respectively. The ERAS programme consists in optimising factors dealing with early rehabilitation, such as preoperative patient education, multimodal pain management, early postoperative fluid taken and mobilisation. A self-questionnaire quality of recovery-15 (QoR-15) on the preoperative day 1 (D-1), postoperative day 0 evening (D0) and the postoperative day 1 (D+1) is completed by patients. Patients scheduled to undergo hysterectomy, aged 18 years and above, whose physical status are classified as American Society of Anesthesiologists score 1-3 and who are able to return home after being discharged from hospital and contact their physician or the medical department if necessary are recruited for this study. The total duration of inclusion is 36 months. The primary outcome is the difference in QoR-15 scores measured on D+1 which will be compared between the 'before' and the 'after' group, using multiple linear regression model. ETHICS AND DISSEMINATION: Approval was obtained from the Ethical Committee (Paris, France). Subjects are actually being recruited after giving their oral agreement or non-objection to participate in this clinical trial and following the oral and written information given by the anaesthesiologist practitioner.Trial registration number: ClinicalTrials.gov: NCT04268576 (Pre-result).


Assuntos
Recuperação Pós-Cirúrgica Melhorada , Estudos Controlados Antes e Depois , Feminino , Humanos , Histerectomia , Tempo de Internação , Estudos Observacionais como Assunto , Estudos Prospectivos
6.
BMC Musculoskelet Disord ; 23(1): 193, 2022 Mar 02.
Artigo em Inglês | MEDLINE | ID: mdl-35236311

RESUMO

BACKGROUND: Systemic sclerosis (SSc) is a rare connective tissue disease characterised by immune dysfunction, vasculopathy, cellular inflammation, fibrosis of the skin associated with multiple internal organs involvement. Ischaemic digital ulcers (IDU) of the hands commonly occur in patients with SSc adversely affecting functional independence. PURPOSE: Aim of the study is to investigate the effectiveness of a rehabilitation protocol based on the combined use of ultrasound (US) therapy and therapeutic exercise in terms of ulcers healing, pain relief, and hand functioning in patients affected by SSc with IDUs. Moreover, we also investigated the safety of the proposed intervention. STUDY DESIGN: Prospective before-after study. METHODS: We included 20 patients with IDUs secondary to SSc. All patients were treated with US combined with manual therapy, including McMennel joint manipulation, pompage mobilization technique and connective tissue massage, for 10 sessions. We evaluated softness, dyschromia, pain, and hand mobility using the Pressure Sore Status Tool (PSST), the Numerical Rating Scale (NRS), and the Duruoz Hand Index (DHI) at T0 and at the end of the treatment (T1). RESULTS: Treatment with US combined with manual therapy significantly reduced ulcers depth, improved ulcers margins, and reduced periwound skin damage (median PSST score 16 at T1, p<0.0001). Moreover, significant benefits were reported in terms of pain relief (NRS 3 at T1; p<0.0005), and hand function (DHI score 19 at T1; p<0.0005). Finally, this approach seems to be safe, without side effects reported at the end of treatment, along with an optimal compliance. CONCLUSION: Therapeutic US combined with manual therapy should be used as additional intervention to manage IDUs in SSc patients.


Assuntos
Escleroderma Sistêmico , Úlcera , Estudos Controlados Antes e Depois , Dedos , Mãos , Humanos , Dor , Estudos Prospectivos , Escleroderma Sistêmico/complicações , Úlcera/complicações
7.
Cochrane Database Syst Rev ; 3: CD012892, 2022 03 07.
Artigo em Inglês | MEDLINE | ID: mdl-35253911

RESUMO

BACKGROUND: The demand for residential aged care is increasing due to the ageing population. Optimising the design or adapting the physical environment of residential aged care facilities has the potential to influence quality of life, mood and function. OBJECTIVES: To assess the effects of changes to the physical environment, which include alternative models of residential aged care such as a 'home-like' model of care (where residents live in small living units) on quality of life, behaviour, mood and depression and function in older people living in residential aged care. SEARCH METHODS: CENTRAL, MEDLINE, Embase, six other databases and two trial registries were searched on 11 February 2021. Reference lists and grey literature sources were also searched. SELECTION CRITERIA: Non-randomised trials, repeated measures or interrupted time series studies and controlled before-after studies with a comparison group were included. Interventions which had modified the physical design of a care home or built a care home with an alternative model of residential aged care (including design alterations) in order to enhance the environment to promote independence and well-being were included. Studies which examined quality of life or outcomes related to quality of life were included. Two reviewers independently assessed the abstracts identified in the search and the full texts of all retrieved studies. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data, assessed the risk of bias in each included study and evaluated the certainty of evidence according to GRADE criteria. Where possible, data were represented in forest plots and pooled. MAIN RESULTS: Twenty studies were included with 77,265 participants, although one large study included the majority of participants (n = 74,449). The main comparison was home-like models of care incorporating changes to the scale of the building which limit the capacity of the living units to smaller numbers of residents and encourage the participation of residents with domestic activities and a person-centred care approach, compared to traditional designs which may include larger-scale buildings with a larger number of residents, hospital-like features such as nurses' stations, traditional hierarchical organisational structures and design which prioritises safety. Six controlled before-after studies compared the home-like model and the traditional environment (75,074 participants), but one controlled before-after study included 74,449 of the participants (estimated on weighting). It is uncertain whether home-like models improve health-related quality of life, behaviour, mood and depression, function or serious adverse effects compared to traditional designs because the certainty of the evidence is very low. The certainty of the evidence was downgraded from low-certainty to very low-certainty for all outcomes due to very serious concerns due to risk of bias, and also serious concerns due to imprecision for outcomes with more than 400 participants. One controlled before-after study examined the effect of home-like models on quality of life. The author stated "No statistically significant differences were observed between the intervention and control groups." Three studies reported on global behaviour (N = 257). One study found little or no difference in global behaviour change at six months using the Neuropsychiatric Inventory where lower scores indicate fewer behavioural symptoms (mean difference (MD) -0.04 (95% confidence interval (CI) -0.13 to 0.04, n = 164)), and two additional studies (N = 93) examined global behaviour, but these were unsuitable for determining a summary effect estimate. Two controlled before-after studies examined the effect of home-like models of care compared to traditional design on depression. After 18 months, one study (n = 242) reported an increase in the rate of depressive symptoms (rate ratio 1.15 (95% CI 1.02 to 1.29)), but the effect of home-like models of care on the probability of no depressive symptoms was uncertain (odds ratio 0.36 (95% CI 0.12 to 1.07)). One study (n = 164) reported little or no difference in depressive symptoms at six months using the Revised Memory and Behaviour Problems Checklist where lower scores indicate fewer depressive symptoms (MD 0.01 (95% CI -0.12 to 0.14)). Four controlled before-after studies examined function. One study (n = 242) reported little or no difference in function over 18 months using the Activities of Daily Living long-form scale where lower scores indicate better function (MD -0.09 (95% CI -0.46 to 0.28)), and one study (n = 164) reported better function scores at six months using the Interview for the Deterioration of Daily Living activities in Dementia where lower scores indicate better function (MD -4.37 (95% CI -7.06 to -1.69)). Two additional studies measured function but could not be included in the quantitative analysis. One study examined serious adverse effects (physical restraints), and reported a slight reduction in the important outcome of physical restraint use in a home-like model of care compared to a traditional design (MD between the home-like model of care and traditional design -0.3% (95% CI -0.5% to -0.1%), estimate weighted n = 74,449 participants at enrolment).  The remaining studies examined smaller design interventions including refurbishment without changes to the scale of the building, special care units for people with dementia, group living corridors compared to a non-corridor design, lighting interventions, dining area redesign and a garden vignette. AUTHORS' CONCLUSIONS: There is currently insufficient evidence on which to draw conclusions about the impact of physical environment design changes for older people living in residential aged care. Outcomes directly associated with the design of the built environment in a supported setting are difficult to isolate from other influences such as health changes of the residents, changes to care practices over time or different staff providing care across shifts. Cluster-randomised trials may be feasible for studies of refurbishment or specific design components within residential aged care. Studies which use a non-randomised design or cluster-randomised trials should consider approaches to reduce risk of bias to improve the certainty of evidence.


Assuntos
Atividades Cotidianas , Qualidade de Vida , Idoso , Viés , Estudos Controlados Antes e Depois , Humanos , Análise de Séries Temporais Interrompida
8.
Gynecol Obstet Fertil Senol ; 50(6): 475-480, 2022 06.
Artigo em Francês | MEDLINE | ID: mdl-35151915

RESUMO

OBJECTIVE: The rate of induction of labor represented 22 % of deliveries in 2016 in France. Oral misoprostol (Angusta®) was marketed in France in the last quarter of 2018. The objective of our study was to compare the efficacy and safety of induction of labor with oral misoprostol compared to vaginal misoprostol in women with an unripe cervix. MATERIAL AND METHODS: We carried out a retrospective study before and after the implementation of oral misoprostol including all women with an unripe cervix who benefited from an induction of labor with a viable infant in vertex presentation, without uterine scar. During the first two-year period, women received 50µg of misoprostol in the posterior fornix, repeated 6hours later if needed. If labor had not started after 24hours, women received another dose of 50µg, which was repeated every 4hours until labor was established, up to a total dose of 150µg. During the second two-year period, women received two tablets of oral misoprostol 25µg every four hours if necessary, up to a total dose of 200µg. The primary endpoints were mode of delivery and neonatal safety. RESULTS: During the two study periods, 1199 women received vaginal misoprostol and 1199 women received oral misoprostol including. The cesarean delivery rate was 21.8% during the first period and 21,3% during the second period (P=0.83). A 5-minutes Apgar score<7 was observed in 23 (1.9%) and 14 (1.2%) newborns in the vaginal misoprostol and oral misoprostol groups (P=0.14), respectively. An arterial cord pH<7.00 was observed in 6 (0.5%) and 7 (0.6%) newborns (P=0.99), respectively. CONCLUSION: Oral misoprostol administered at the dose of 50µg every 4hours (up to a total dose of 200µg) is as effective and safe as the vaginal misoprostol to induce labor in women with an unripe cervix.


Assuntos
Misoprostol , Ocitócicos , Administração Intravaginal , Estudos Controlados Antes e Depois , Feminino , Humanos , Recém-Nascido , Trabalho de Parto Induzido , Gravidez , Estudos Retrospectivos , Fatores de Tempo
9.
BMC Pregnancy Childbirth ; 22(1): 102, 2022 Feb 04.
Artigo em Inglês | MEDLINE | ID: mdl-35120476

RESUMO

BACKGROUND: The birth of premature newborns and their separation from family due to their hospitalization in the Neonatal Intensive Care Unit (NICU) cause stress in the parents, especially mothers. We conducted this study aimed to evaluate whether training the fathers to support their wives impacts premature newborn mothers' stress and self-efficacy or not? METHODS: A quasi-experimental (before-after study) including one experimental and control group was used. Data were collected from Seventy-five parents with newborns hospitalized in NICU (n = 30) in the intervention and (n = 45) in usual care groups. Settings were the NICUs of the two international, educational, specialty, and subspecialty Nemazee and Hafez hospitals of the Shiraz University of Medical Science. Fathers in the intervention group learned how to support their wives and provide care for their premature newborns. The control group received the usual care. Mother's stress and self-efficacy were measured using validated questionnaires. RESULTS: Data analysis showed that the mean scores of mothers' stress and self-efficacy from pre-intervention to post-intervention were significantly decreased and increased respectively in the intervention group (p <0.001). At the same time, there was no significant difference in the control group. CONCLUSION: When fathers are trained to support their wives and do so, it relieves the stress and improves the mothers' self-efficacy, and has a direct effect on providing care to their premature newborns. Therefore, it is recommended that measures should be taken so that the fathers be present, participate in providing care, and support their wives and newborns in NICU. TRIAL REGISTRATION: IRCT20171130037691N1 .


Assuntos
Pai/educação , Recém-Nascido Prematuro , Unidades de Terapia Intensiva Neonatal , Mães/psicologia , Autoeficácia , Estresse Psicológico/prevenção & controle , Adulto , Estudos Controlados Antes e Depois , Feminino , Humanos , Recém-Nascido , Masculino , Cônjuges/educação , Cônjuges/psicologia
10.
BMC Surg ; 22(1): 38, 2022 Feb 02.
Artigo em Inglês | MEDLINE | ID: mdl-35109840

RESUMO

BACKGROUND: Early structured mobilization has become a key element of Enhanced Recovery After Surgery programs to improve patient outcomes and decrease length of hospital stay. With the intention to assess and improve early mobilization levels, the 8-point ordinal John Hopkins Highest Level of Mobility (JH-HLM) scale was implemented at two gastrointestinal and oncological surgery wards in the Netherlands. After the implementation, however, healthcare professionals perceived a ceiling effect in assessing mobilization after gastrointestinal and oncological surgery. This study aimed to quantify this perceived ceiling effect, and aimed to determine if extending the JH-HLM scale with four additional response categories into the AMsterdam UMC EXtension of the JOhn HOpkins Highest Level of mObility (AMEXO) scale reduced this ceiling effect. METHODS: All patients who underwent gastrointestinal and oncological surgery and had a mobility score on the first postoperative day before (July-December 2018) or after (July-December 2019) extending the JH-HLM into the AMEXO scale were included. The primary outcome was the before-after difference in the percentage of ceiling effects on the first three postoperative days. Furthermore, the before-after changes and distributions in mobility scores were evaluated. Univariable and multivariable logistic regression analysis were used to assess these differences. RESULTS: Overall, 373 patients were included (JH-HLM n = 135; AMEXO n = 238). On the first postoperative day, 61 (45.2%) patients scored the highest possible mobility score before extending the JH-HLM into the AMEXO as compared to 4 (1.7%) patients after (OR = 0.021, CI = 0.007-0.059, p < 0.001). During the first three postoperative days, 118 (87.4%) patients scored the highest possible mobility score before compared to 40 (16.8%) patients after (OR = 0.028, CI = 0.013-0.060, p < 0.001). A change in mobility was observed in 88 (65.2%) patients before as compared to 225 (94.5%) patients after (OR = 9.101, CI = 4.046-20.476, p < 0.001). Of these 225 patients, the four additional response categories were used in 165 (73.3%) patients. CONCLUSIONS: A substantial ceiling effect was present in assessing early mobilization in patients after gastrointestinal and oncological surgery using the JH-HLM. Extending the JH-HLM into the AMEXO scale decreased the ceiling effect significantly, making the tool more appropriate to assess early mobilization and set daily mobilization goals after gastrointestinal and oncological surgery.


Assuntos
Deambulação Precoce , Objetivos , Estudos Controlados Antes e Depois , Hospitais , Humanos , Tempo de Internação
11.
Accid Anal Prev ; 167: 106563, 2022 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-35131654

RESUMO

Converting minor-approach-only stop (MAS) intersections to all-way-stop (AWS) intersections is a prevailing safety countermeasure in North American urban areas. Although the general population positively perceives the installation of stop-signs in residential areas, little research has investigated the impact of AWS on road safety and road user behaviour. This paper investigated the safety effectiveness of converting MAS to AWS intersections using an observational before and after approach and surrogate measures of safety. More specifically, the safety impacts of AWS conversion were investigated using multiple indicators, including vehicle speed measures, vehicle-pedestrian, vehicle-cyclist, vehicles-vehicle interactions as well as yielding rates before and after the treatment implementation. A multi-level regression approach was adopted to determine the effect of stop signs controlling for built environments, traffic exposure, and intersection geometry factors as well as site-specific unobserved heterogeneity. A unique sample of 31 intersections were used in this before-after study. From this sample, video data were collected before and after implementing AWS. In total, 245 h of video were automatically processed and corrected using a specialized computer vision software. More than 68,000 (37,668 before and 31,305 after AWS treatment) road user trajectories were obtained from 104 approaches. The results show that the conversion of MAS to AWS intersections significantly decreased vehicle speed and increased post-encroachment time. This work also shows that implementing AWS significantly increased the yielding rates from 45.7% to 76.7% in MAS conditions and reduced the average speed of motor-vehicles. Using multi-level regression model, it is estimated that when the intersection was converted from MAS to AWS, the minimum speed in the major approaches was reduced by 60.0%.


Assuntos
Acidentes de Trânsito , Pedestres , Acidentes de Trânsito/prevenção & controle , Estudos Controlados Antes e Depois , Planejamento Ambiental , Humanos , Veículos Automotores , Segurança
12.
Int J Clin Pharm ; 44(2): 480-488, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-35076810

RESUMO

Background Despite several international studies demonstrating that ward-based pharmacists improve medication quality, ward pharmacists are not generally established in German hospitals. Aim We assessed the effect of a ward-based clinical pharmacist on the medication quality of geriatric inpatients in a German university hospital. Method The before-after study with a historic control group was conducted on the geriatric ward. During the control phase, patients received standard care without the involvement of a pharmacist. The intervention consisted of a clinical pharmacist providing pharmaceutical care from admission to discharge. Medication quality was measured on admission and discharge using the Medication Appropriateness Index (MAI). A linear regression analysis was conducted to calculate the influence of the intervention on the MAI. Results Patients in the intervention group (n = 152, mean 83 years) were older and took more drugs at admission compared to the control group (n = 159, 81 years). For both groups, the MAI per patient improved significantly from admission to discharge. Although the intervention did not influence the summated MAI score per patient, the intervention significantly reduced the MAI criteria Dosage (p = 0.006), Correct Directions (p = 0.016) and Practical Directions (p = 0.004) as well as the proportion of overall inappropriate MAI ratings (at least 1 of 9 criteria inappropriate) (p = 0.015). Conclusion Although medication quality was already high in the control group, a ward-based clinical pharmacist could contribute meaningfully to the medication quality on an acute geriatric ward.


Assuntos
Farmacêuticos , Serviço de Farmácia Hospitalar , Idoso , Estudos Controlados Antes e Depois , Hospitais Universitários , Humanos , Pacientes Internados , Reconciliação de Medicamentos , Serviço de Farmácia Hospitalar/métodos , Lista de Medicamentos Potencialmente Inapropriados
13.
J Clin Psychopharmacol ; 42(2): 125-132, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35001061

RESUMO

PURPOSE/BACKGROUND: Data on the effect of treatment with antidepressant drugs on metabolic control in diabetes are sparse. In this controlled within-subject before-after study, the impact of initiation and discontinuation of antidepressant treatment on hemoglobin A1c (HbA1c) and low-density lipoprotein (LDL) levels in type 2 diabetes was estimated. METHODS/PROCEDURES: All individuals with newly developed type 2 diabetes (first HbA1c ≥ 6.5%) between 2000 and 2016 in Northern and Central Denmark were identified using register-based health care data. Among these, we identified individuals initiating and discontinuing antidepressant treatment. Using a within-subject before-after design, we examined HbA1c and LDL in the 16 months leading up to and the 16 months after antidepressant treatment initiation or discontinuation, respectively. For comparison, we ran similar time trend analyses in a reference population of age- and sex-matched type 2 diabetes individuals not receiving antidepressant treatment. FINDINGS/RESULTS: Mean HbA1c decreased after initiation of antidepressant treatment (-0.16%; 95% confidence interval [CI], -0.18 to -0.13%). In the reference population, no material change in HbA1c over time (-0.03%; 95% CI, -0.04 to -0.01%) was seen. Mean LDL decreased not only in antidepressant initiators (-0.17 mmol/L; 95% CI, -0.19 to -0.15 mmol/L) but also in the reference population (-0.15 mmol/L; 95% CI, -0.16 to -0.13 mmol/L). Among antidepressant discontinuers, there was also a decrease in HbA1c (-0.32%; 95% CI, -0.37 to -0.28%), with no change in the reference population (-0.02%; 95% CI, -0.04 to 0.00%). Decreases in LDL were found both in antidepressant discontinuers (-0.09 mmol/L; 95% CI, -0.14 to -0.04 mmol/L) and in the reference population (-0.16 mmol/L0; 95% CI, -0.18 to -0.13 mmol/L). IMPLICATIONS/CONCLUSIONS: Antidepressant treatment in type 2 diabetes may have a beneficial effect on glycemic control, as the decrease in HbA1c after discontinuation of antidepressants likely reflects remission of depression. Conversely, antidepressant treatment does not seem to affect LDL levels.


Assuntos
Diabetes Mellitus Tipo 2 , Antidepressivos/farmacologia , Antidepressivos/uso terapêutico , Glicemia/metabolismo , Estudos Controlados Antes e Depois , Diabetes Mellitus Tipo 2/tratamento farmacológico , Hemoglobina A Glicada/metabolismo , Humanos , Lipoproteínas LDL/uso terapêutico
14.
PLoS One ; 17(1): e0262681, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35073351

RESUMO

BACKGROUND: Road traffic injuries are among the top ten causes of death globally, with the highest burden in low and middle-income countries, where over a third of deaths occur among pedestrians and cyclists. Several interventions to mitigate the burden among pedestrians have been widely implemented, however, the effectiveness has not been systematically examined. OBJECTIVES: To assess the effectiveness of interventions to reduce road traffic crashes, injuries, hospitalizations and deaths among pedestrians. METHODS: We considered studies that evaluated interventions to reduce road traffic crashes, injuries, hospitalizations and/or deaths among pedestrians. We considered randomized controlled trials, interrupted time-series studies, and controlled before-after studies. We searched MEDLINE, EMBASE, Web of Science, WHO Global Health Index, Health Evidence, Transport Research International Documentation and ClinicalTrials.gov through 31 August 2020, and the reference lists of all included studies. Two reviewers independently screened titles and abstracts and full texts, extracted data and assessed the risk of bias. We summarized findings narratively with text and tables. RESULTS: A total of 69123 unique records were identified through the searches, with 26 of these meeting our eligibility criteria. All except two of these were conducted in high-income countries and most were from urban settings. The majority of studies observed either a clear effect favoring the intervention or an unclear effect potentially favoring the intervention and these included: changes to the road environment (19/27); changes to legislation and enforcement (12/12); and road user behavior/education combined with either changes to the road environment (3/3) or with legislation and enforcement (1/1). A small number of studies observed either a null effect or an effect favoring the control. CONCLUSIONS: Although the highest burden of road traffic injuries exists in LMICs, very few studies have examined the effectiveness of available interventions in these settings. Studies indicate that road environment, legislation and enforcement interventions alone produce positive effects on pedestrian safety. In combination with or with road user behavior/education interventions they are particularly effective in improving pedestrian safety.


Assuntos
Acidentes de Trânsito/prevenção & controle , Pedestres , Estudos Controlados Antes e Depois , Humanos , Análise de Séries Temporais Interrompida , Ensaios Clínicos Controlados Aleatórios como Assunto
15.
PLoS One ; 17(1): e0262605, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35061830

RESUMO

Nurse practitioners are increasingly now members of intensive care teams in Japan, but no data exist about their effect on the outcomes for critically ill patients. This study aimed to compare the outcomes of postoperative patients on mechanical ventilators before and after the participation of nurse practitioners in intensive care teams. We retrospectively identified 387 patients who underwent postoperative mechanical ventilation at a University Hospital in Japan, using data from medical records from 1 April 2015 to 31 March 2017. We extracted data and compared patients' length of stay in the intensive care unit and the hospital, mechanical ventilation days, postoperative rehabilitation start date, rehabilitation prescription, intensive care unit and hospital mortality, and intensive care unit readmission. Multiple regression analysis was used to analyze the factors affecting length of stay in the intensive care unit. Patients who received care from nurse practitioners and physicians had significantly shorter stays in intensive care (4.8 ± 4.8 days versus 6.7 ± 10.3 days, p < 0.021). Mechanical ventilation days, total length of hospital stay, rehabilitation prescription, mortality in intensive care and hospital, and readmission to intensive care were all similar to those who received care only from physicians. The multiple regression analysis suggests that participation of nurse practitioners in intensive care reduced the length of stay in the unit by 2.6 days (p = 0.003). These findings could help to increase use of non-physician healthcare providers in intensive care. Our results demonstrated that it is both effective and safe for nurse practitioners to participate in intensive care teams that provide care for postoperative patients receiving mechanical ventilation.


Assuntos
Cuidados Críticos/métodos , Profissionais de Enfermagem , Cuidados Pós-Operatórios/métodos , Idoso , Estudos Controlados Antes e Depois , Feminino , Humanos , Japão , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento
16.
Transfus Apher Sci ; 61(2): 103322, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-34799243

RESUMO

BACKGROUND: Perioperative blood products transfusion is correlated with increased morbidity and mortality in liver transplantation (LTx). The objectives of our study are to assess the effect of a standardized viscoelastic test (VET)-guided bleeding management algorithm implementation on intraoperative bleeding, allogenic blood products and factor concentrates requirements and on early postoperative complications in LTx. METHODS: Retrospective before-after study comparing two matched cohorts of patients undergoing LTx before (control cohort) and after (intervention cohort) the implementation of a VET-based bleeding algorithm in a single center academic hospital. RESULTS: After propensity score matching, we included 94 patients in each cohort. Patients in intervention cohort received significantly less blood products, fresh frozen plasma (FFP), and cryoprecipitate (p < 0.001 for each), while the amount of fibrinogen concentrate used was significantly higher (p < 0.001). Postoperatively, intervention cohort patients had significantly lower postoperative hemoglobin and fibrinogen levels and longer prothrombin time compared to control cohort. There were no significant differences in red blood cells transfusions, intraoperative bleeding, early postoperative complications, and short term survival. CONCLUSIONS: The implementation of a VET-guided bleeding algorithm decreases allogenic blood products requirements, mainly FFP use and allows a more restrictive management of coagulopathy in patients with chronic liver disease undergoing LTx.


Assuntos
Transplante de Fígado , Adulto , Algoritmos , Estudos Controlados Antes e Depois , Fibrinogênio/uso terapêutico , Hemorragia/terapia , Humanos , Complicações Pós-Operatórias , Pontuação de Propensão , Estudos Retrospectivos , Tromboelastografia
17.
Am J Emerg Med ; 51: 378-383, 2022 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-34823194

RESUMO

OBJECTIVE: To improve the timely diagnosis and treatment of sepsis many institutions implemented automated sepsis alerts. Poor specificity, time delays, and a lack of actionable information lead to limited adoption by bedside clinicians and no change in practice or clinical outcomes. We aimed to compare sepsis care compliance before and after a multi-year implementation of a sepsis surveillance coupled with decision support in a tertiary care center. DESIGN: Single center before and after study. SETTING: Large academic Medical Intensive Care Unit (MICU) and Emergency Department (ED). POPULATION: Patients 18 years of age or older admitted to *** Hospital MICU and ED from 09/4/2011 to 05/01/2018 with severe sepsis or septic shock. INTERVENTIONS: Electronic medical record-based sepsis surveillance system augmented by clinical decision support and completion feedback. MEASUREMENTS AND MAIN RESULTS: There were 1950 patients admitted to the MICU with the diagnosis of severe sepsis or septic shock during the study period. The baseline characteristics were similar before (N = 854) and after (N = 1096) implementation of sepsis surveillance. The performance of the alert was modest with a sensitivity of 79.9%, specificity of 76.9%, positive predictive value (PPV) 27.9%, and negative predictive value (NPV) 97.2%. There were 3424 unique alerts and 1131 confirmed sepsis patients after the sniffer implementation. During the study period average care bundle compliance was higher; however after taking into account improvements in compliance leading up to the intervention, there was no association between intervention and improved care bundle compliance (Odds ratio: 1.16; 95% CI: 0.71 to 1.89; p-value 0.554). Similarly, the intervention was not associated with improvement in hospital mortality (Odds ratio: 1.55; 95% CI: 0.95 to 2.52; p-value: 0.078). CONCLUSIONS: A sepsis surveillance system incorporating decision support or completion feedback was not associated with improved sepsis care and patient outcomes.


Assuntos
Sistemas de Apoio a Decisões Clínicas , Serviço Hospitalar de Emergência/estatística & dados numéricos , Unidades de Terapia Intensiva/provisão & distribuição , Sepse/diagnóstico , Centros Médicos Acadêmicos , Idoso , Idoso de 80 Anos ou mais , Estudos Controlados Antes e Depois , Serviço Hospitalar de Emergência/normas , Retroalimentação , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/normas , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Pacotes de Assistência ao Paciente/normas , Estudos Retrospectivos , Vigilância de Evento Sentinela , Sepse/mortalidade , Sepse/terapia , Choque Séptico/diagnóstico , Choque Séptico/mortalidade , Choque Séptico/terapia
18.
Eur J Trauma Emerg Surg ; 48(4): 2859-2865, 2022 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34146122

RESUMO

PURPOSE: Early geriatric involvement is recommended for older trauma patients. We wished to determine the impact of geriatric consultation on mortality, hospital length of stay and discharge disposition in older patients who were admitted to our Level 1 trauma unit. METHODS: We completed a health records review of trauma unit patients, age ≥ 75 years old with Injury Severity Score (ISS) ≥ 12, before (11/2015-10/2017) and after (11/2017-10/2019) implementation of a geriatric trauma consultation initiative. Primary outcomes were mortality, hospital length of stay and discharge destination. Secondary objectives were adherence to the geriatric trauma consult process and identification of geriatric-specific issues. A multivariable analysis controlling for age, gender, multi-morbidity and ISS was undertaken. RESULTS: 157 patients pre-implementation and 172 post-implementation with mean age 83.8 years and 53.8% females were included. Geriatric consultation had no impact on in-hospital mortality [OR 0.70 (95% CI 0.31-1.58)] or length of stay [ß 0.68 (95%CI - 1.35-2.72)]. Patients who received a geriatric consultation were more likely to be discharged home (OR 2.01 (95% CI 1.24-3.24). The adherence to consultation process was 99.4%. Mobility, pain and cognitive impairment were the most common geriatric concerns, identified in 76.6, 61.1 and 50.0% of older trauma patients, respectively. CONCLUSION: Older trauma patients that receive geriatric trauma consultation are more likely to be discharged home. Collaboration between trauma and geriatric specialists is beneficial and may lead to meaningful improvements in outcomes for older trauma patients.


Assuntos
Centros de Traumatologia , Ferimentos e Lesões , Idoso , Idoso de 80 Anos ou mais , Estudos Controlados Antes e Depois , Feminino , Avaliação Geriátrica , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação , Masculino , Encaminhamento e Consulta , Estudos Retrospectivos , Ferimentos e Lesões/terapia
19.
Neurol Sci ; 43(3): 1701-1708, 2022 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-34409516

RESUMO

OBJECTIVE: We intend to evaluate the change of different cognitive functions after a guard shift in physicians. METHODS: A descriptive observational study was performed. The study population included Spanish physicians who were asked to complete before and immediately after their guard shift the following tests: Digit Span, TMT-A, TMT-B, Symbol Digit, Stroop, Free and Cued Selective Reminding, creep and formal fluency, Visual Orientation and Space Perception tests, and the Leeds Sleep Questionnaire. RESULTS: Thirty subjects were included in the study among which 43.3% were female. The mean subjective impression of the guard shift was 4.47/10 (2.57) and was correlated with the number of sleep hours during the guard shift (r = 0.72, p < 0.001). Statistically significant differences in the comparison between pre- and post-guard period results were found for the Symbol Digit test (88.27 vs. 81.47, p = 0.005), Digit Span test (7.43 vs. 7.00, p = 0.025), Free and Cued Selective Reminding Test (22.73 vs. 21.20, p = 0.002), categorical fluency (39.03 vs. 34.53, p = 0.008), and phonemic fluency (19.57 vs. 16.13, p = 0.001). CONCLUSIONS: The realization of guard shift was associated with a lower yield in several cognitive functions, especially in tasks related to executive function and attention.


Assuntos
Função Executiva , Médicos , Cognição , Estudos Controlados Antes e Depois , Feminino , Humanos , Testes Neuropsicológicos
20.
Am J Perinatol ; 39(2): 172-179, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-32702772

RESUMO

OBJECTIVE: This study aimed to compare maternal and neonatal outcomes in women with severe preeclampsia before and after implementation of the American College of Obstetricians and Gynecologists (ACOG) taskforce hypertensive guidelines. STUDY DESIGN: Single-center retrospective cohort study of women with severe preeclampsia delivering live nonanomalous singletons 23 to 342/7 weeks from 2013 to 2017. In 2015, the ACOG guidelines for expectant management of severe preeclampsia were implemented at our institution. Based on this, patients were categorized as preguideline (January 2013-December 2015) or postguideline adoption (January 2016-December 2017). Primary outcomes included composite maternal morbidity and composite neonatal morbidity; secondary outcomes included composite components, length of stay, birth weight, and delivery gestational age. Groups were compared with Student's t-test, Chi-square, and Wilcoxon's rank-sum tests; adjusted odds ratios (aOR; 95% confidence intervals [CIs]) were calculated. Yearly composite outcomes were compared using the Cochran-Armitage trend test. We estimated a sample size of 250 per group would provide 80% power at α = 0.05 to detect a 50% reduction in neonatal morbidity from a baseline rate of 21.5%. RESULTS: From 2013 to 2017, a total of 543 women with severe preeclampsia were identified: 278 (51%) preguideline and 265 (49%) postguideline. Baseline characteristics were overall similar between groups. There were no significant differences in maternal (aOR = 0.96, 95% CI: 0.6-1.41) or neonatal (aOR = 0.88, 95% CI: 0.61-1.28) composite morbidity between groups. Furthermore, there were no differences in composite maternal or neonatal morbidity over time. CONCLUSION: Perinatal outcomes were similar before and after implementation of severe preeclampsia management guidelines at our institution. Studies to evaluate if benefits are limited to subsets of this population, such as earlier gestational ages, are needed. KEY POINTS: · Expectant management of severe preeclampsia has yet to be fully evaluated outside of trial conditions.. · We did not see a significant improvement in neonatal composite morbidity/mortality.. · We also did not see a worsened composite maternal morbidity/mortality..


Assuntos
Guias de Prática Clínica como Assunto , Pré-Eclâmpsia/diagnóstico , Adulto , Alabama , Estudos Controlados Antes e Depois , Feminino , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Modelos Logísticos , Mortalidade Materna , Pré-Eclâmpsia/epidemiologia , Gravidez , Resultado da Gravidez , Estudos Retrospectivos , Sociedades Médicas , Adulto Jovem
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