Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 35.521
Filtrar
1.
BMC Infect Dis ; 20(1): 645, 2020 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-32873242

RESUMO

BACKGROUND: During the outbreak of cutaneous leishmaniasis in the Kurdistan Region of Iraq that started in 2015, the course of the disease and the treatment were not consistent with the available literature. Physicians, particularly dermatologists, faced challenges with treating the cutaneous leishmaniasis lesions with high rates of treatment failure and resistance to treatment. We used Q-methodology to understand the range and diversities of opinions and the practical experiences of dermatologists about the treatment difficulties of cutaneous leishmaniasis. METHODS: This Q-methodology study was carried out in Erbil, Kurdistan Region of Iraq, and involved 37 dermatologists. A set of 40 statements related to different aspects of difficulties and uncertainties of treating cutaneous leishmaniasis was prepared. The dermatologists were requested to distribute the 40 statements into a scaled grid of nine piles from least agree to most agree. We applied by-person factor analysis using PQMethod 2.35 for the data analysis. RESULTS: The analysis revealed two different viewpoints about the treatment of cutaneous leishmaniasis and a consensus viewpoint. The first viewpoint emphasized the use of sodium stibogluconate-based combination therapy, concerns with treatment failure, and lack of compliance with the treatment. The second viewpoint emphasized the lack of standard treatment and advances in the treatment of cutaneous leishmaniasis. There was a consensus between both groups of respondents about many aspects of the treatment of cutaneous leishmaniasis, including considering sodium stibogluconate the first drug of choice for cutaneous leishmaniasis treatment. CONCLUSIONS: This study revealed a diversity of viewpoints and uncertainties about the effectiveness of the available treatment modalities and treatment difficulties and failure. Interrupted supply and poor quality of the available drugs and lack of a standard and advanced treatment are the main problems facing the treatment of cutaneous leishmaniasis. More research is required to determine the best treatment modalities for the different types of cutaneous leishmaniasis. There is a need for the development of treatment guidelines specific to the Iraqi context with a particular focus on the treatment of the resistant and atypical cases of cutaneous leishmaniasis.


Assuntos
Gluconato de Antimônio e Sódio/uso terapêutico , Atitude , Consenso , Dermatologistas/psicologia , Leishmania , Leishmaniose Cutânea/tratamento farmacológico , Leishmaniose Cutânea/epidemiologia , Adulto , Terapia Combinada , Análise Fatorial , Feminino , Humanos , Incidência , Iraque/epidemiologia , Leishmaniose Cutânea/parasitologia , Masculino , Pessoa de Meia-Idade , Pesquisa Qualitativa , Falha de Tratamento
2.
Lancet HIV ; 7(9): e620-e628, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32890497

RESUMO

BACKGROUND: Antiretroviral therapy (ART) scale-up in sub-Saharan Africa combined with weak routine virological monitoring has driven increasing HIV drug resistance. We investigated ART failure, drug resistance, and early mortality among patients with HIV admitted to hospital in Malawi. METHODS: This observational cohort study was nested within the rapid urine-based screening for tuberculosis to reduce AIDS-related mortality in hospitalised patients in Africa (STAMP) trial, which recruited unselected (ie, irrespective of clinical presentation) adult (aged ≥18 years) patients with HIV-1 at admission to medical wards. Patients were included in our observational cohort study if they were enrolled at the Malawi site (Zomba Central Hospital) and were taking ART for at least 6 months at admission. Patients who met inclusion criteria had frozen plasma samples tested for HIV-1 viral load. Those with HIV-1 RNA of at least 1000 copies per mL had drug resistance testing by ultra-deep sequencing, with drug resistance defined as intermediate or high-level resistance using the Stanford HIVDR program. Mortality risk was calculated 56 days from enrolment. Patients were censored at death, at 56 days, or at last contact if lost to follow-up. The modelling strategy addressed the causal association between HIV multidrug resistance and mortality, excluding factors on the causal pathway (most notably, CD4 cell count, clinical signs of advanced HIV, and poor functional and nutritional status). FINDINGS: Of 1316 patients with HIV enrolled in the STAMP trial at the Malawi site between Oct 26, 2015, and Sept 19, 2017, 786 had taken ART for at least 6 months. 252 (32%) of 786 patients had virological failure (viral load ≥1000 copies per mL). Mean age was 41·5 years (SD 11·4) and 528 (67%) of 786 were women. Of 237 patients with HIV drug resistance results available, 195 (82%) had resistance to lamivudine, 128 (54%) to tenofovir, and 219 (92%) to efavirenz. Resistance to at least two drugs was common (196, 83%), and this was associated with increased mortality (adjusted hazard ratio 1·7, 95% CI 1·2-2·4; p=0·0042). INTERPRETATION: Interventions are urgently needed and should target ART clinic, hospital, and post-hospital care, including differentiated care focusing on patients with advanced HIV, rapid viral load testing, and routine access to drug resistance testing. Prompt diagnosis and switching to alternative ART could reduce early mortality among inpatients with HIV. FUNDING: Joint Global Health Trials Scheme of the Medical Research Council, UK Department for International Development, and Wellcome Trust.


Assuntos
Farmacorresistência Viral , Infecções por HIV/epidemiologia , Infecções por HIV/virologia , HIV-1/efeitos dos fármacos , Carga Viral , Adulto , Terapia Antirretroviral de Alta Atividade , Duração da Terapia , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/mortalidade , HIV-1/genética , Hospitalização , Humanos , Malaui/epidemiologia , Masculino , Mortalidade , RNA Viral , Falha de Tratamento
3.
Dermatol Online J ; 26(7)2020 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-32898403

RESUMO

Poorly controlled and long-standing hidradenitis suppurativa (HS) increases the risk of squamous cell carcinoma (SCC). We report a 54-year-old woman with an over 20-year history of HS, who had previously undergone wide perineal excision with secondary intention healing and presented with a painful verrucous vulvar plaque and proximal non-healing perineal wound. The patient had four perineal scouting biopsies performed and excisional biopsy with no evidence of high-grade dysplasia or carcinoma on histology. Chromogenic in situ hybridization was negative for HPV 16 and 18 mRNA; the patient's HIV and HSV PCR were also negative. Our patient was treated with interferon alfa-2b with notable clinical improvement. There is currently no standardized stepwise approach to monitoring verrucous lesions in HS patients with significant risk factors for SCC. Our report highlights a vigilant approach to monitoring. If scouting biopsies are negative, complete testing for high risk HPV strains (HPV 16 and 18) is warranted. If negative, we recommend follow up every 6 months with no further biopsies except if overt clinical changes are observed. We also recommend treatment of verrucous changes to decrease risk of possible malignant conversion. Interferon alfa-2b was effective in decreasing the verrucous lesion burden in our patient and may be considered.


Assuntos
Hidradenite Supurativa/complicações , Interferon alfa-2/uso terapêutico , Verrugas/tratamento farmacológico , Biópsia , Carcinoma de Células Escamosas/prevenção & controle , Transformação Celular Neoplásica , Condiloma Acuminado/patologia , Diagnóstico Diferencial , Feminino , Hidradenite Supurativa/cirurgia , Papillomavirus Humano 16/genética , Papillomavirus Humano 16/isolamento & purificação , Papillomavirus Humano 18/genética , Papillomavirus Humano 18/isolamento & purificação , Humanos , Pessoa de Meia-Idade , Períneo/patologia , RNA Viral/análise , Falha de Tratamento , Vulva/patologia , Verrugas/etiologia , Cicatrização
4.
BMC Infect Dis ; 20(1): 668, 2020 Sep 12.
Artigo em Inglês | MEDLINE | ID: mdl-32919458

RESUMO

BACKGROUND: The study was to evaluate initial antimicrobial regimen and clinical outcomes and to explore risk factors for clinical failure (CF) in elderly patients with community-acquired pneumonia (CAP). METHODS: 3011 hospitalized elderly patients were enrolled from 13 national teaching hospitals between January 1, 2014 and December 31, 2014 initiated by the CAP-China network. Risk factors for CF were screened by multivariable logistic regression analysis. RESULTS: The incidence of CF in elderly CAP patients was 13.1%. CF patients were older, longer hospital stays and higher treatment costs than clinical success (CS) patients. The CF patients were more prone to present hyperglycemia, hyponatremia, hypoproteinemia, pleural effusion, respiratory failure and cardiovascular events. Inappropriate initial antimicrobial regimens in CF group were significantly higher than CS group. Undertreatment, CURB-65, PH < 7.3, PaO2/FiO2 < 200 mmHg, sodium < 130 mmol/L, healthcare-associated pneumonia, white blood cells > 10,000/mm3, pleural effusion and congestive heart failure were independent risk factors for CF in multivariable logistic regression analysis. Male and bronchiectasis were protective factors. CONCLUSIONS: Discordant therapy was a cause of CF. Early accurate detection and management of prevention to potential causes is likely to improve clinical outcomes in elderly patients CAP. TRIAL REGISTRATION: A Retrospective Study on Hospitalized Patients With Community-acquired Pneumonia in China (CAP-China) (RSCAP-China), NCT02489578. Registered 16 March 2015, https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0005E5S&selectaction=Edit&uid=U0000GWC&ts=2&cx=1bnotb.


Assuntos
Antibacterianos/uso terapêutico , Pneumonia Associada a Assistência à Saúde/diagnóstico , Pneumonia Associada a Assistência à Saúde/tratamento farmacológico , Pneumonia Associada a Assistência à Saúde/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Infecções Comunitárias Adquiridas/diagnóstico , Infecções Comunitárias Adquiridas/tratamento farmacológico , Infecções Comunitárias Adquiridas/epidemiologia , Feminino , Hospitais de Ensino/estatística & dados numéricos , Humanos , Incidência , Masculino , Mortalidade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Falha de Tratamento
5.
Medicine (Baltimore) ; 99(37): e21661, 2020 Sep 11.
Artigo em Inglês | MEDLINE | ID: mdl-32925712

RESUMO

To support optimal third-line antiretroviral therapy (ART) selection in Namibia, we investigated the prevalence of HIV drug resistance (HIVDR) at time of failure of second-line ART. A cross-sectional study was conducted between August 2016 and February 2017. HIV-infected people ≥15 years of age with confirmed virological failure while receiving ritonavir-boosted protease inhibitor (PI/r)-based second-line ART were identified at 15 high-volume ART clinics representing over >70% of the total population receiving second-line ART. HIVDR genotyping of dried blood spots obtained from these individuals was performed using standard population sequencing methods. The Stanford HIVDR algorithm was used to identify sequences with predicted resistance; genotypic susceptibility scores for potential third-line regimens were calculated. Two hundred thirty-eight individuals were enrolled; 57.6% were female. The median age and duration on PI/r-based ART at time of enrolment were 37 years and 3.46 years, respectively. 97.5% received lopinavir/ritonavir-based regimens. The prevalence of nucleoside reverse transcriptase inhibitor (NRTI), non-nucleoside reverse transcriptase inhibitor (NNRTI), and PI/r resistance was 50.6%, 63.1%, and 13.1%, respectively. No significant association was observed between HIVDR prevalence and age or sex. This study demonstrates high levels of NRTI and NNRTI resistance and moderate levels of PI resistance in people receiving PI/r-based second-line ART in Namibia. Findings underscore the need for objective and inexpensive measures of adherence to identify those in need of intensive adherence counselling, routine viral load monitoring to promptly detect virological failure, and HIVDR genotyping to optimize selection of third-line drugs in Namibia.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Farmacorresistência Viral , Infecções por HIV/tratamento farmacológico , Adolescente , Adulto , Estudos Transversais , Feminino , HIV/efeitos dos fármacos , Humanos , Lopinavir/uso terapêutico , Masculino , Pessoa de Meia-Idade , Namíbia/epidemiologia , Prevalência , Inibidores da Transcriptase Reversa/uso terapêutico , Ritonavir/uso terapêutico , Falha de Tratamento , Adulto Jovem
6.
Lancet Neurol ; 19(10): 814-825, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32949542

RESUMO

BACKGROUND: Many patients who require migraine preventive treatment have not been able to tolerate or have not responded to multiple previous preventive medications. We aimed to assess the safety and efficacy of galcanezumab, an antibody to calcitonin gene-related peptide, in patients with migraine who had not benefited from preventive medications from two to four categories. METHODS: CONQUER was a multicentre, randomised, double-blind, placebo-controlled, phase 3b trial done at 64 sites (hospitals, clinics, or research centres) in 12 countries (Belgium, Canada, Czech Republic, France, Germany, Hungary, Japan, the Netherlands, South Korea, Spain, the UK, and the USA). Patients were 18-75 years of age, with episodic or chronic migraine, with migraine onset before the age of 50 years, who had a documented failure of preventive medications from two to four drug categories in the past 10 years owing to lack of efficacy or tolerability, or both. Patients were randomised 1:1 to receive subcutaneous placebo or galcanezumab 120 mg per month (with a 240 mg loading dose administered as two 120 mg injections) for 3 months. For masking purposes, patients receiving placebo also received two injections during the first dosing visit. Randomisation was done by a computer-generated random sequence by means of an interactive web-response system stratified by country and migraine frequency (low frequency episodic migraine, four to fewer than eight migraine headache days per month; high frequency episodic migraine, eight to 14 migraine headache days per month and fewer than 15 headache days per month; chronic migraine, at least eight migraine headache days per month and at least 15 headache days per month). The primary endpoint was the overall mean change from baseline in number of monthly migraine headache days during the 3-month treatment period in all patients who were randomly assigned and received at least one dose of study drug. This trial is registered with ClinicalTrials.gov, NCT03559257, and is now completed. FINDINGS: Between Sept 10, 2018, and March 21, 2019, 462 participants with episodic (269 [58%]) or chronic (193 [42%]) migraine were randomly assigned and received at least one injection with placebo (n=230) or galcanezumab (n=232). Galcanezumab-treated patients had significantly greater reduction in migraine headache days versus placebo across months 1-3. The galcanezumab group had on average 4·1 fewer monthly migraine headache days compared with baseline (13·4), while the placebo group had on average 1·0 fewer than at baseline (13·0; between-group difference -3·1 [95% CI -3·9 to -2·3]; p<0·0001; effect size=0·72). Types and number of treatment-emergent adverse events were similar between galcanezumab and placebo. Treatment-emergent adverse events were reported in 122 (53%) of 230 patients in the placebo group and 119 (51%) of 232 patients in the galcanezumab group. There were four serious adverse events during the study, two (1%) reported in the placebo group and two (1%) reported in the galcanezumab group. INTERPRETATION: Galcanezumab was superior to placebo in the preventive treatment of migraine and was safe and well tolerated in patients for whom multiple previous standard-of-care preventive treatments had failed. Galcanezumab might represent an important treatment option for patients who have not benefited from or tolerated previous standard-of-care treatments. FUNDING: Eli Lilly.


Assuntos
Anticorpos Monoclonais Humanizados/uso terapêutico , Transtornos de Enxaqueca/diagnóstico , Transtornos de Enxaqueca/tratamento farmacológico , Falha de Tratamento , Adolescente , Adulto , Idoso , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Adulto Jovem
7.
Medicine (Baltimore) ; 99(36): e22044, 2020 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-32899064

RESUMO

BACKGROUND: Malaria remains a global health threat for centuries. In recent years, a rising resistance of Plasmodium falciparum to current standard artemisinin-based combination therapies (ACTs) leads to increasing treatment failures and requires for optimized treatment. Here, we intend to make a systematic review and meta-analysis of optimizing treatment for malaria, so as to find a potential optimal treatment. METHODS: We will search electronic databases: the Cochrane Infectious Diseases Group (CIDG) Specialized Register, the Cochrane Central Register of Controlled Trials (CEN-TRAL), PubMed, Embase, Web of Science from their inception to 1 July, 2020. We will also search International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov, and contact with authors when necessary. Two authors will independently collect and select data, and the statistical analyses will be conducted by Revman V.5.3 software. RESULTS: We will evaluate efficacy and safety of modified ACTs for uncomplicate malaria, comparing with standard ACTs in all eligible clinical studies. CONCLUSION: In this study, we will offer clinical evidence for optimizing treatment for malaria. REGISTRATION NUMBER: INPLASY202070115.


Assuntos
Anti-Infecciosos/uso terapêutico , Artemisininas/uso terapêutico , Malária/tratamento farmacológico , Antimaláricos/uso terapêutico , Terapia Combinada , Feminino , Humanos , Malária/epidemiologia , Malária/parasitologia , Masculino , Plasmodium falciparum/efeitos dos fármacos , Ensaios Clínicos Controlados Aleatórios como Assunto , Projetos de Pesquisa , Segurança , Falha de Tratamento , Resultado do Tratamento
8.
Int Heart J ; 61(5): 936-943, 2020 Sep 29.
Artigo em Inglês | MEDLINE | ID: mdl-32879265

RESUMO

On the basis of radiofrequency ablation of atrial fibrillation (AF), some studies suggested that early recurrences of atrial tachyarrhythmia (ERATs) were associated with late AF recurrence (LAFR), and some also suspected and challenged the current recommended 90 day blanking period. We aim to evaluate the impact of ERAT on long-term success and to determine the optimum blanking period after AF ablation using second-generation cryoballoon (sg-CB). From August 2016 to October 2018, 369 consecutive patients who successfully underwent initial AF ablation using sg-CB at the Fuwai Hospital were finally enrolled. All patients were followed up no less than 12 months. Receiver operating characteristic curve analysis was used to determine the optimum blanking period after AF ablation. There were 62 (16.8%) who experienced ERAT. After a median follow-up of 615 days, 74.5% were free of LAFR after the 90 day blanking period. Incidence of freedom from LAFR during the long-term follow-up was markedly lower in patients with ERAT than in those without ERAT (27.4% versus 84.0%; log-rank P < 0.001). Furthermore, only ERAT (HR 8.579; 95% CI 5.604-13.133; P < 0.001) was significantly associated with an increased risk of LAFR after adjusting for other factors. The optimum cut-off time point for the blanking period was 21.5 days (sensitivity: 71.1%, specificity: 94.1%). In conclusion, ERAT was an independent predictor of LAFR after AF ablation using sg-CB. Based on our findings, blanking period was advised to be shorten to 21.5 days or about 3 weeks instead of 90 days after CB ablation.


Assuntos
Fibrilação Atrial/cirurgia , Criocirurgia , Veias Pulmonares/cirurgia , Recidiva , Falha de Tratamento , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo
9.
Am J Case Rep ; 21: e927304, 2020 Sep 26.
Artigo em Inglês | MEDLINE | ID: mdl-32978364

RESUMO

BACKGROUND This case series describes 5 patients with SARS-CoV-2 infection and COVID-19 in Ecuador who had been treated with hydroxychloroquine for systemic lupus erythematosus (SLE) prior to their COVID-19 illness. CASE REPORT Case #1 reports a 29-year-old woman who had been treated with 200 mg of hydroxychloroquine per day for 1 year and presented with flu-like symptoms, chest pain, fever, odynophagia, asthenia, dry cough, and chills. Case #2 was a 34-year-old woman whose treatment for SLE included 200 mg of hydroxychloroquine per day since 2017. She arrived at the clinic with a dry cough, asthenia, and myalgias. Case #3 was a 24-year-old woman who had been using 200 mg of hydroxychloroquine per day since 2010. She presented with asthenia, myalgias, headaches, hypogeusia, and anosmia. Case #4 was a 39-year-old woman taking 200 mg of hydroxychloroquine every day for SLE who presented with dyspnea, chest pain, odynophagia, hypogeusia, anosmia, diarrhea, and fever. Case #5 was a 46-year-old woman who had been taking 200 mg of hydroxychloroquine since 2019. She came to our hospital complaining of chest pain, fever, and dyspnea. In all 5 patients, SARS-CoV-2 infection was confirmed with a nasopharyngeal SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) test using the Cepheid/GeneXpert system. CONCLUSIONS All 5 of our patients with SLE who were taking hydroxychloroquine presented with SARS-CoV-2 infection and symptoms of COVID-19. This case series provides support for a lack of prevention of COVID-19 by hydroxychloroquine.


Assuntos
Infecções por Coronavirus/prevenção & controle , Hidroxicloroquina/administração & dosagem , Lúpus Eritematoso Sistêmico/tratamento farmacológico , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Adulto , Técnicas de Laboratório Clínico , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Dispneia/diagnóstico , Dispneia/etiologia , Equador , Serviço Hospitalar de Emergência , Feminino , Febre/diagnóstico , Febre/etiologia , Humanos , Pessoa de Meia-Idade , Pandemias/estatística & dados numéricos , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , RNA Viral/análise , Reação em Cadeia da Polimerase em Tempo Real/métodos , Medição de Risco , Amostragem , Falha de Tratamento , Adulto Jovem
10.
Crit Care ; 24(1): 489, 2020 08 06.
Artigo em Inglês | MEDLINE | ID: mdl-32762701

RESUMO

BACKGROUND: High-flow nasal cannula (HFNC) oxygen therapy is being increasingly used to prevent post-extubation hypoxemic respiratory failure and reintubation. However, evidence to support the use of HFNC in chronic obstructive pulmonary disease (COPD) patients with hypercapnic respiratory failure after extubation is limited. This study was conducted to test if HFNC is non-inferior to non-invasive ventilation (NIV) in preventing post-extubation treatment failure in COPD patients previously intubated for hypercapnic respiratory failure. METHODS: COPD patients with hypercapnic respiratory failure who were already receiving invasive ventilation were randomized to HFNC or NIV at extubation at two large tertiary academic teaching hospitals. The primary endpoint was treatment failure, defined as either resumption of invasive ventilation or switching to the other study treatment modality (NIV for patients in the NFNC group or vice versa). RESULTS: Ninety-six patients were randomly assigned to the HFNC group or NIV group. After secondary exclusion, 44 patients in the HFNC group and 42 patients in the NIV group were included in the analysis. The treatment failure rate in the HFNC group was 22.7% and 28.6% in the NIV group-risk difference of - 5.8% (95% CI, - 23.8-12.4%, p = 0.535), which was significantly lower than the non-inferior margin of 9%. Analysis of the causes of treatment failure showed that treatment intolerance in the HFNC group was significantly lower than that in the NIV group, with a risk difference of - 50.0% (95% CI, - 74.6 to - 12.9%, p = 0.015). One hour after extubation, the mean respiratory rates of both groups were faster than their baseline levels before extubation (p < 0.050). Twenty-four hours after extubation, the respiratory rate of the HFNC group had returned to baseline, but the NIV group was still higher than the baseline. Forty-eight hours after extubation, the respiratory rates of both groups were not significantly different from the baseline. The average number of daily airway care interventions in the NIV group was 7 (5-9.3), which was significantly higher than 6 (4-7) times in the HFNC group (p = 0.006). The comfort score and incidence of nasal and facial skin breakdown of the HFNC group was also significantly better than that of the NIV group [7 (6-8) vs 5 (4-7), P < 0.001] and [0 vs 9.6%, p = 0.027], respectively. CONCLUSION: Among COPD patients with severe hypercapnic respiratory failure who received invasive ventilation, the use of HFNC after extubation did not result in increased rates of treatment failure compared with NIV. HFNC also had better tolerance and comfort than NIV. TRIAL REGISTRATION: chictr.org ( ChiCTR1800018530 ). Registered on 22 September 2018, http://www.chictr.org.cn/usercenter.aspx.


Assuntos
Extubação , Cânula , Ventilação de Alta Frequência/métodos , Ventilação não Invasiva , Oxigenoterapia/métodos , Doença Pulmonar Obstrutiva Crônica/terapia , Idoso , Feminino , Humanos , Masculino , Insuficiência Respiratória/prevenção & controle , Falha de Tratamento
12.
JAMA ; 324(7): 642-650, 2020 Aug 18.
Artigo em Inglês | MEDLINE | ID: mdl-32809003

RESUMO

Importance: The combination of ascorbic acid, corticosteroids, and thiamine has been identified as a potential therapy for septic shock. Objective: To determine whether the combination of ascorbic acid, corticosteroids, and thiamine attenuates organ injury in patients with septic shock. Design, Setting, and Participants: Randomized, blinded, multicenter clinical trial of ascorbic acid, corticosteroids, and thiamine vs placebo for adult patients with septic shock. Two hundred five patients were enrolled between February 9, 2018, and October 27, 2019, at 14 centers in the United States. Follow-up continued until November 26, 2019. Interventions: Patients were randomly assigned to receive parenteral ascorbic acid (1500 mg), hydrocortisone (50 mg), and thiamine (100 mg) every 6 hours for 4 days (n = 103) or placebo in matching volumes at the same time points (n = 102). Main Outcomes and Measures: The primary outcome was change in the Sequential Organ Failure Assessment (SOFA) score (range, 0-24; 0 = best) between enrollment and 72 hours. Key secondary outcomes included kidney failure and 30-day mortality. Patients who received at least 1 dose of study drug were included in analyses. Results: Among 205 randomized patients (mean age, 68 [SD, 15] years; 90 [44%] women), 200 (98%) received at least 1 dose of study drug, completed the trial, and were included in the analyses (101 with intervention and 99 with placebo group). Overall, there was no statistically significant interaction between time and treatment group with regard to SOFA score over the 72 hours after enrollment (mean SOFA score change from 9.1 to 4.4 [-4.7] points with intervention vs 9.2 to 5.1 [-4.1] points with placebo; adjusted mean difference, -0.8; 95% CI, -1.7 to 0.2; P = .12 for interaction). There was no statistically significant difference in the incidence of kidney failure (31.7% with intervention vs 27.3% with placebo; adjusted risk difference, 0.03; 95% CI, -0.1 to 0.2; P = .58) or in 30-day mortality (34.7% vs 29.3%, respectively; hazard ratio, 1.3; 95% CI, 0.8-2.2; P = .26). The most common serious adverse events were hyperglycemia (12 patients with intervention and 7 patients with placebo), hypernatremia (11 and 7 patients, respectively), and new hospital-acquired infection (13 and 12 patients, respectively). Conclusions and Relevance: In patients with septic shock, the combination of ascorbic acid, corticosteroids, and thiamine, compared with placebo, did not result in a statistically significant reduction in SOFA score during the first 72 hours after enrollment. These data do not support routine use of this combination therapy for patients with septic shock. Trial Registration: ClinicalTrials.gov Identifier: NCT03389555.


Assuntos
Corticosteroides/uso terapêutico , Ácido Ascórbico/uso terapêutico , Insuficiência de Múltiplos Órgãos/prevenção & controle , Choque Séptico/tratamento farmacológico , Tiamina/uso terapêutico , Corticosteroides/efeitos adversos , Adulto , Idoso , Ácido Ascórbico/efeitos adversos , Infecção Hospitalar , Quimioterapia Combinada , Feminino , Humanos , Hiperglicemia/induzido quimicamente , Hipernatremia/induzido quimicamente , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/etiologia , Escores de Disfunção Orgânica , Modelos de Riscos Proporcionais , Choque Séptico/complicações , Tiamina/efeitos adversos , Falha de Tratamento
13.
JAMA ; 324(8): 752-760, 2020 08 25.
Artigo em Inglês | MEDLINE | ID: mdl-32840597

RESUMO

Importance: Severe asthma exacerbations cause significant morbidity and costs. Whether vitamin D3 supplementation reduces severe childhood asthma exacerbations is unclear. Objective: To determine whether vitamin D3 supplementation improves the time to a severe exacerbation in children with asthma and low vitamin D levels. Design, Setting, and Participants: The Vitamin D to Prevent Severe Asthma Exacerbations (VDKA) Study was a randomized, double-blind, placebo-controlled clinical trial of vitamin D3 supplementation to improve the time to severe exacerbations in high-risk children with asthma aged 6 to 16 years taking low-dose inhaled corticosteroids and with serum 25-hydroxyvitamin D levels less than 30 ng/mL. Participants were recruited from 7 US centers. Enrollment started in February 2016, with a goal of 400 participants; the trial was terminated early (March 2019) due to futility, and follow-up ended in September 2019. Interventions: Participants were randomized to vitamin D3, 4000 IU/d (n = 96), or placebo (n = 96) for 48 weeks and maintained with fluticasone propionate, 176 µg/d (6-11 years old), or 220 µg/d (12-16 years old). Main Outcomes and Measures: The primary outcome was the time to a severe asthma exacerbation. Secondary outcomes included the time to a viral-induced severe exacerbation, the proportion of participants in whom the dose of inhaled corticosteroid was reduced halfway through the trial, and the cumulative fluticasone dose during the trial. Results: Among 192 randomized participants (mean age, 9.8 years; 77 girls [40%]), 180 (93.8%) completed the trial. A total of 36 participants (37.5%) in the vitamin D3 group and 33 (34.4%) in the placebo group had 1 or more severe exacerbations. Compared with placebo, vitamin D3 supplementation did not significantly improve the time to a severe exacerbation: the mean time to exacerbation was 240 days in the vitamin D3 group vs 253 days in the placebo group (mean group difference, -13.1 days [95% CI, -42.6 to 16.4]; adjusted hazard ratio, 1.13 [95% CI, 0.69 to 1.85]; P = .63). Vitamin D3 supplementation, compared with placebo, likewise did not significantly improve the time to a viral-induced severe exacerbation, the proportion of participants whose dose of inhaled corticosteroid was reduced, or the cumulative fluticasone dose during the trial. Serious adverse events were similar in both groups (vitamin D3 group, n = 11; placebo group, n = 9). Conclusions and Relevance: Among children with persistent asthma and low vitamin D levels, vitamin D3 supplementation, compared with placebo, did not significantly improve the time to a severe asthma exacerbation. The findings do not support the use of vitamin D3 supplementation to prevent severe asthma exacerbations in this group of patients. Trial Registration: ClinicalTrials.gov Identifier: NCT02687815.


Assuntos
Asma/tratamento farmacológico , Colecalciferol/uso terapêutico , Suplementos Nutricionais , Deficiência de Vitamina D/tratamento farmacológico , Vitaminas/uso terapêutico , Adolescente , Corticosteroides/uso terapêutico , Asma/sangue , Asma/complicações , Criança , Colecalciferol/efeitos adversos , Método Duplo-Cego , Feminino , Humanos , Masculino , Exacerbação dos Sintomas , Falha de Tratamento , Vitamina D/sangue , Deficiência de Vitamina D/complicações , Vitaminas/efeitos adversos
14.
BMC Infect Dis ; 20(1): 631, 2020 Aug 26.
Artigo em Inglês | MEDLINE | ID: mdl-32842977

RESUMO

BACKGROUND: The drug resistance and the virologic failure of antiretroviral therapy (ART) are quite severe in Liangshan. A better understanding of the virologic failure of ART and the HIV-1 transmission network dynamics is essential for the surveillance and prevention of HIV. Here, we analyzed the HIV-1 CRF07_BC strain genetic transmission networks and their associated factors among people living with HIV-1 (PLWH) who had virologic failure of ART by using close genetic links. METHODS: The drug-resistant mutations were determined using the Stanford University HIV Drug Resistance Database. HIV-1 pol genes sequences were used for phylogenetic and genotypic drug resistance analysis. The genetic transmission networks were performed by comparing sequences, constructing the phylogenetic tree, calculating the pairwise distance, and visualizing the network. RESULTS: A total of 1050 PLWH with CRF07_BC pol sequences were finally identified and included in the genetic transmission network analysis from 2016 to 2017. Of the 1050 CRF07_BC pol sequences, 346 (32.95%) fell into clusters at a genetic distance of 0.006, resulting in 137 clusters ranging in size from 2 to 40 individuals. Subjects who were widowed or divorced were less likely to form a genetic transmission network (adjusted OR: 0.50), while subjects who had shared a needle ≥ five times were more likely to form a network (adjusted OR: 1.88). CONCLUSIONS: The genetic transmission networks revealed the complex transmission pattern, highlighting the urgent need for transmission monitoring of virologic failure of ART and selection of more effective therapeutic regimens to promote viral suppression.


Assuntos
Fármacos Anti-HIV/efeitos adversos , Fármacos Anti-HIV/uso terapêutico , Farmacorresistência Viral/genética , Infecções por HIV/tratamento farmacológico , Infecções por HIV/transmissão , HIV-1/genética , Grupos Minoritários , Adolescente , Adulto , China/epidemiologia , Estudos Transversais , Feminino , Genes pol , Infecções por HIV/virologia , Humanos , Masculino , Mutação , Filogenia , Falha de Tratamento , Adulto Jovem
15.
Plast Reconstr Surg ; 146(3): 516-525, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32842102

RESUMO

BACKGROUND: Capsular contracture following breast augmentation is prone to recurrence with conventional surgical therapy. Adding acellular dermal matrix improves results but significantly increases operating time and cost. This study tested a new treatment algorithm that uses acellular dermal matrix selectively to optimize success rates while minimizing its drawbacks. METHODS: All patients surgically treated by the authors for Baker grade III/IV capsular contracture between 2007 and 2018 were included in this retrospective cohort study. Data were collected on patient, breast augmentation, capsular contracture, and surgical treatment characteristics, in addition to follow-up findings. Treatment success was defined as Baker grade II or better. RESULTS: One hundred eighty patients underwent 217 surgical treatments for capsular contracture. Conventional treatment was used in 185 cases and acellular dermal matrix in 32. Twenty-six patients were treated for a second occurrence and four were treated for a third. The average follow-up was 2.4 years. Conventional treatment was successful in 72.5 percent of first occurrences, 62.5 percent of second occurrences, and 50.0 percent of third occurrences. Acellular dermal matrix was successful in 96.9 percent of cases. The odds of failure were increased by bilateral capsular contracture (3.9 times) and previous treatment failure (3.5 times). When acellular dermal matrix was used selectively for bilateral capsular contracture or in unilateral cases with a previous treatment failure, the overall treatment success rate improved to 85.6 percent compared with 64.2 percent when this algorithm was not followed (p < 0.001). CONCLUSION: This study demonstrates that selective acellular dermal matrix use can increase success rate to over 85 percent in the overall treatment of capsular contracture, and to nearly 100 percent in individual cases.


Assuntos
Algoritmos , Implantes de Mama/efeitos adversos , Contratura Capsular em Implantes/cirurgia , Mamoplastia/efeitos adversos , Complicações Pós-Operatórias/cirurgia , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos , Falha de Tratamento , Resultado do Tratamento
16.
Arthroscopy ; 36(8): 2145-2146, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32747060

RESUMO

Adults between the ages of 40 and 49 with hip injuries can be challenging to treat, as they are often deemed "too young" for hip arthroplasty and yet have less predictable outcomes after hip arthroscopy. Moreover, in this population, hip arthroscopy with labral repair results in greater risk of treatment failure than labral reconstruction. Subclinical degenerative changes to the labral tissue may be responsible for this finding. In my practice, however, labral reconstruction is generally reserved for scenarios such as a failed labral repair in the setting of poor tissue, labral hypoplasia/calcification in the primary setting (<2 mm viable cuff of tissue), or complex irreparable tissue in the primary setting.


Assuntos
Cartilagem Articular , Lesões do Quadril , Adulto , Artroscopia , Articulação do Quadril , Humanos , Pessoa de Meia-Idade , Falha de Tratamento
17.
BMC Infect Dis ; 20(1): 622, 2020 Aug 24.
Artigo em Inglês | MEDLINE | ID: mdl-32831044

RESUMO

BACKGROUND: To improve treatment outcomes for tuberculosis (TB), efforts to reduce treatment failure are necessary. The aim of our study was to describe the characteristics of subjects who had failed treatment of tuberculosis and identify the risk factors for treatment failure and poor compliance using national data. METHODS: A multicenter cross-sectional study was performed on tuberculosis subjects whose final outcome was reported as treatment failure during 2015-2017. The same number of subjects with treatment success during the same study period were randomly selected for comparison. Demographics, microbiological, radiographic, and clinical data were collected based on in-depth interviews by TB nurse specialists at all Public Private Mix (PPM) participating hospitals in South Korea. RESULTS: A total of 52 tuberculosis patients with treatment failure were enrolled. In a multivariable analysis, the presence of diabetes, previous history of tuberculosis, and cavity were identified as risk factors for treatment failure; and Medicaid support was a favorable factor for treatment success (area under the curve [AUC]: 0.79). Age, low body mass index (BMI), presence of diabetes, preexisting lung disease, positive sputum acid-fast bacilli (AFB) smear result, and the presence of multidrug-resistant tuberculosis (MDR-TB) were significantly associated with presence of cavities. Younger age, lower BMI and previous history of TB were associated with poor compliance during treatment (AUC: 0.76). CONCLUSION: To reduce treatment failure, careful evaluation of the presence of diabetes, previous TB history, underlying lung disease, cavity, results of sputum AFB smears, and socioeconomic status are needed. To enhance treatment compliance, more attention should be paid to younger patients with lower BMIs during follow-up.


Assuntos
Cooperação do Paciente , Falha de Tratamento , Tuberculose/tratamento farmacológico , Adulto , Idoso , Índice de Massa Corporal , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , República da Coreia , Fatores de Risco , Escarro/microbiologia , Resultado do Tratamento , Tuberculose/psicologia , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico
19.
PLoS One ; 15(8): e0237534, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32797110

RESUMO

BACKGROUND: Drug resistance is a key obstacle to the global target set to end tuberculosis by 2030. Clinical complexities in drug-resistant tuberculosis and HIV-infection co-management could worsen outcomes of second-line anti-tuberculosis drugs. A comprehensive estimate for risks of unsuccessful outcomes to second-line tuberculosis therapy in HIV-infected versus HIV-uninfected patients is mandatory to address such aspects in segments of the target set. Therefore, this meta-analysis was aimed to estimate the pooled risk ratios of unfavorable outcomes to second-line tuberculosis therapy between HIV-infected and HIV-uninfected patients in sub-Saharan Africa. METHODS: We conducted a literature search from PubMed/MEDLINE, EMBASE, SCOPUS and Google Scholar. We screened the retrieved records by titles and abstracts. Finally, we assessed eligibility and quality of full-text articles for the records retained by employing appraisal checklist of the Joanna Briggs Institute. We analyzed the data extracted from the included studies by using Review Manager Software, version 5.3 and presented our findings in forest and funnel plots. Protocol for this study was registered on PROSPERO (ID: CRD42020160473). RESULTS: A total of 19 studies with 1,766 from 4,481 HIV-infected and 1,164 from 3,820 HIV-uninfected patients had unfavorable outcomes. The risk ratios we estimated between HIV-infected and HIV-uninfected drug-resistant tuberculosis patients were 1.18 (95% CI: 1.07-1.30; I2 = 48%; P = 0.01) for the overall unfavorable outcome; 1.50 (95% CI: 1.30-1.74) for death; 0.66 (95% CI: 0.38-1.13) for treatment failure; and 0.82 (95% CI: 0.74-0.92) for loss from treatment. Variable increased risks of unfavorable outcomes estimated for subgroups with significance in mixed-age patients (RR: 1.22; 95% CI: 1.10-1.36) and eastern region of sub-Saharan Africa (RR: 1.47; 95% CI: 1.23-1.75). CONCLUSIONS: We found a higher risk of unfavorable treatment outcome in drug-resistant tuberculosis patients with death highly worsening in HIV-infected than in those HIV-uninfected patients. The risks for the unfavorable outcomes were significantly higher in mixed-age patients and in the eastern region of sub-Saharan Africa. Therefore, special strategies that reduce the risks of death should be discovered and implemented for HIV and drug-resistant tuberculosis co-infected patients on second-line tuberculosis therapy with optimal integration of the two programs in the eastern region of sub-Saharan Africa.


Assuntos
Antituberculosos/uso terapêutico , Infecções por HIV/epidemiologia , Tuberculose/tratamento farmacológico , África ao Sul do Saara , Coinfecção , Humanos , Prevalência , Falha de Tratamento , Resultado do Tratamento , Tuberculose/virologia , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Tuberculose Resistente a Múltiplos Medicamentos/virologia
20.
J Am Acad Orthop Surg ; 28(15): 607-616, 2020 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-32732652

RESUMO

Primary arthroscopic Bankart repair is a common procedure that is increasing in popularity; however, failure rates can approach up to 6% to 30%. Factors commonly attributed to failure include repeat trauma, poor or incomplete surgical technique, humeral and/or glenoid bone loss, hyperlaxity, or a failure to identify and address rare pathology such as a humeral avulsion of the glenohumeral ligament lesion. A thorough clinical and radiographic assessment may provide insight into the etiology, which can assist the clinician in making treatment recommendations. Surgical management of a failed primary arthroscopic Bankart repair without bone loss can include revision arthroscopic repair or open repair; however, in the setting of bone loss, the anterior-inferior glenoid can be reconstructed using a coracoid transfer, tricortical iliac crest, or structural allograft, whereas posterolateral humeral head bone loss (the Hill-Sachs defect) can be addressed with remplissage, structural allograft, or partial humeral head implant. In addition to the technical demands of revision stabilization surgery, patient and procedure selection to optimize outcomes can be challenging. This review will focus on the etiology, evaluation, and management of patients after a failed primary arthroscopic Bankart repair, including an evidence-based treatment algorithm.


Assuntos
Artroscopia/métodos , Lesões de Bankart/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Falha de Tratamento , Lesões de Bankart/diagnóstico por imagem , Lesões de Bankart/etiologia , Lesões de Bankart/patologia , Medicina Baseada em Evidências , Humanos , Instabilidade Articular/etiologia , Instabilidade Articular/cirurgia , Reoperação , Escápula/cirurgia , Articulação do Ombro/cirurgia , Tomografia Computadorizada por Raios X
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA