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2.
Gut ; 69(2): 201-223, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31776230

RESUMO

These consensus guidelines were jointly commissioned by the British Society of Gastroenterology (BSG), the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and Public Health England (PHE). They provide an evidence-based framework for the use of surveillance colonoscopy and non-colonoscopic colorectal imaging in people aged 18 years and over. They are the first guidelines that take into account the introduction of national bowel cancer screening. For the first time, they also incorporate surveillance of patients following resection of either adenomatous or serrated polyps and also post-colorectal cancer resection. They are primarily aimed at healthcare professionals, and aim to address:Which patients should commence surveillance post-polypectomy and post-cancer resection?What is the appropriate surveillance interval?When can surveillance be stopped? two or more premalignant polyps including at least one advanced colorectal polyp (defined as a serrated polyp of at least 10 mm in size or containing any grade of dysplasia, or an adenoma of at least 10 mm in size or containing high-grade dysplasia); or five or more premalignant polyps The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument provided a methodological framework for the guidelines. The BSG's guideline development process was used, which is National Institute for Health and Care Excellence (NICE) compliant.two or more premalignant polyps including at least one advanced colorectal polyp (defined as a serrated polyp of at least 10 mm in size or containing any grade of dysplasia, or an adenoma of at least 10 mm in size or containing high-grade dysplasia); or five or more premalignant polyps The key recommendations are that the high-risk criteria for future colorectal cancer (CRC) following polypectomy comprise either:two or more premalignant polyps including at least one advanced colorectal polyp (defined as a serrated polyp of at least 10 mm in size or containing any grade of dysplasia, or an adenoma of at least 10 mm in size or containing high-grade dysplasia); or five or more premalignant polyps This cohort should undergo a one-off surveillance colonoscopy at 3 years. Post-CRC resection patients should undergo a 1 year clearance colonoscopy, then a surveillance colonoscopy after 3 more years.


Assuntos
Pólipos do Colo/cirurgia , Neoplasias Colorretais/cirurgia , Vigilância da População/métodos , Colonoscopia/normas , Medicina Baseada em Evidências/métodos , Humanos , Assistência de Longa Duração/métodos , Assistência de Longa Duração/normas , Recidiva Local de Neoplasia/diagnóstico , Seleção de Pacientes , Período Pós-Operatório
3.
BMJ ; 367: l5887, 2019 11 05.
Artigo em Inglês | MEDLINE | ID: mdl-31690574

RESUMO

Diabetes is a major and costly health concern worldwide, with high morbidity, disability, mortality, and impaired quality of life. The vast majority of people living with diabetes have type 2 diabetes. Historically, the main strategy to reduce complications of type 2 diabetes has been intensive glycemic control. However, the body of evidence shows no meaningful benefit of intensive (compared with moderate) glycemic control for microvascular and macrovascular outcomes important to patients, with the exception of reduced rates of non-fatal myocardial infarction. Intensive glycemic control does, however, increase the risk of severe hypoglycemia and incurs additional burden by way of polypharmacy, side effects, and cost. Additionally, data from cardiovascular outcomes trials showed that cardiovascular, kidney, and mortality outcomes may be improved with use of specific classes of glucose lowering drugs largely independently of their glycemic effects. Therefore, delivering evidence based, patient centered care to people with type 2 diabetes requires a paradigm shift and departure from the predominantly glucocentric view of diabetes management. Instead of prioritizing intensive glycemic control, the focus needs to be on ensuring access to adequate diabetes care, aligning glycemic targets to patients' goals and situations, minimizing short term and long term complications, reducing the burden of treatment, and improving quality of life.


Assuntos
Complicações do Diabetes/prevenção & controle , Diabetes Mellitus Tipo 2/tratamento farmacológico , Hipoglicemia/epidemiologia , Hipoglicemiantes/administração & dosagem , Qualidade de Vida , Glicemia/análise , Glicemia/efeitos dos fármacos , Complicações do Diabetes/sangue , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/complicações , Medicina Baseada em Evidências/métodos , Medicina Baseada em Evidências/normas , Humanos , Hiperglicemia/sangue , Hiperglicemia/tratamento farmacológico , Hipoglicemia/induzido quimicamente , Hipoglicemiantes/efeitos adversos , Incidência , Metanálise como Assunto , Assistência Centrada no Paciente/métodos , Assistência Centrada no Paciente/normas , Guias de Prática Clínica como Assunto , Revisão Sistemática como Assunto , Resultado do Tratamento
4.
Lancet ; 394(10211): 1816-1826, 2019 11 16.
Artigo em Inglês | MEDLINE | ID: mdl-31668726

RESUMO

BACKGROUND: Uncertainty remains about the optimal monotherapy for hypertension, with current guidelines recommending any primary agent among the first-line drug classes thiazide or thiazide-like diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, dihydropyridine calcium channel blockers, and non-dihydropyridine calcium channel blockers, in the absence of comorbid indications. Randomised trials have not further refined this choice. METHODS: We developed a comprehensive framework for real-world evidence that enables comparative effectiveness and safety evaluation across many drugs and outcomes from observational data encompassing millions of patients, while minimising inherent bias. Using this framework, we did a systematic, large-scale study under a new-user cohort design to estimate the relative risks of three primary (acute myocardial infarction, hospitalisation for heart failure, and stroke) and six secondary effectiveness and 46 safety outcomes comparing all first-line classes across a global network of six administrative claims and three electronic health record databases. The framework addressed residual confounding, publication bias, and p-hacking using large-scale propensity adjustment, a large set of control outcomes, and full disclosure of hypotheses tested. FINDINGS: Using 4·9 million patients, we generated 22 000 calibrated, propensity-score-adjusted hazard ratios (HRs) comparing all classes and outcomes across databases. Most estimates revealed no effectiveness differences between classes; however, thiazide or thiazide-like diuretics showed better primary effectiveness than angiotensin-converting enzyme inhibitors: acute myocardial infarction (HR 0·84, 95% CI 0·75-0·95), hospitalisation for heart failure (0·83, 0·74-0·95), and stroke (0·83, 0·74-0·95) risk while on initial treatment. Safety profiles also favoured thiazide or thiazide-like diuretics over angiotensin-converting enzyme inhibitors. The non-dihydropyridine calcium channel blockers were significantly inferior to the other four classes. INTERPRETATION: This comprehensive framework introduces a new way of doing observational health-care science at scale. The approach supports equivalence between drug classes for initiating monotherapy for hypertension-in keeping with current guidelines, with the exception of thiazide or thiazide-like diuretics superiority to angiotensin-converting enzyme inhibitors and the inferiority of non-dihydropyridine calcium channel blockers. FUNDING: US National Science Foundation, US National Institutes of Health, Janssen Research & Development, IQVIA, South Korean Ministry of Health & Welfare, Australian National Health and Medical Research Council.


Assuntos
Anti-Hipertensivos/uso terapêutico , Hipertensão/tratamento farmacológico , Adolescente , Adulto , Idoso , Antagonistas de Receptores de Angiotensina/efeitos adversos , Antagonistas de Receptores de Angiotensina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Anti-Hipertensivos/efeitos adversos , Bloqueadores dos Canais de Cálcio/efeitos adversos , Bloqueadores dos Canais de Cálcio/uso terapêutico , Criança , Estudos de Coortes , Pesquisa Comparativa da Efetividade/métodos , Bases de Dados Factuais , Diuréticos/efeitos adversos , Diuréticos/uso terapêutico , Medicina Baseada em Evidências/métodos , Feminino , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/prevenção & controle , Humanos , Hipertensão/complicações , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/prevenção & controle , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Adulto Jovem
7.
J Couns Psychol ; 66(5): 639, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31580126

RESUMO

Reports an error in "Investigating the impact of early alliance on predicting subjective change at posttreatment: An evidence-based souvenir of overlooked clinical perspectives" by Christoph Flückiger, Peter Hilpert, Simon B. Goldberg, Franz Caspar, Christine Wolfer, Judith Held and Andreea Vîsla (Journal of Counseling Psychology, Advanced Online Publication, Jan 31, 2019, np). In the article, a portion, +γ40ERit, was omitted in the Model 3 formula. The corrected formula is presented in the erratum. All versions of this article have been corrected. (The following abstract of the original article appeared in record 2019-05150-001.) Despite meta-analytic evidence showing that alliance is associated with posttreatment outcomes, several open questions still remain regarding this relation. First, we investigate whether (or not) the progressive aggregation of early alliance assessments increases the alliance-outcome relation across 2 distress and 4 subjective change measures. Second, we investigate whether the alliance-outcome relations using subjective change measures are independent from intake distress and early response. Third, we explore whether the progressive aggregation of the alliance on outcomes becomes particularly apparent between or within therapists again investigating these six outcome measures. Data were drawn from N = 430 patients treated by N = 151 therapists. Patient ratings of early alliance were assessed after Session 1 to 6. For outcome, 2 commonly used distress measures at intake and at posttreatment and 4 measures of retrospectively evaluated subjective change at posttreatment are integrated into a series of multilevel models. The proportion of variance in outcome predicted by alliance scores varied considerably depending on the number of alliance assessments which were aggregated, as well as on the type of outcome assessment (distress vs. subjective change measures) explaining up to 15% of outcome variance. Improvements in the strength of prediction with aggregated alliance assessments were most pronounced for subjective change measures for between-therapist components of the alliance. Examining associations with subjective change measures provides an additional, patient-centered perspective of the relation between early alliance and treatment outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).


Assuntos
Medicina Baseada em Evidências/tendências , Relações Profissional-Paciente , Adulto , Medicina Baseada em Evidências/métodos , Feminino , Previsões , Humanos , Masculino , Estudos Retrospectivos , Resultado do Tratamento
8.
Glob Health Action ; 12(1): 1670449, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31575331

RESUMO

Policy-makers worldwide are increasingly interested in scaling up evidence-based interventions (EBIs) to larger populations, and implementation scientists are developing frameworks and methodologies for achieving this. But scaling-up does not always produce the desired results. Why not? We aimed to enhance awareness of the various pitfalls to be anticipated when planning scale-up. In lower- and middle-income countries (LMICs), the scale-up of health programs to prevent or respond to outbreaks of communicable diseases has been occurring for many decades. In high-income countries, there is new interest in the scaling up of interventions that address communicable and non-communicable diseases alike. We scanned the literature worldwide on problems encountered when implementing scale-up plans revealed a number of potential pitfalls that we discuss in this paper. We identified and discussed the following six major pitfalls of scaling-up EBIs: 1) the cost-effectiveness estimation pitfall, i.e. accurate cost-effectiveness estimates about real-world implementation are almost impossible, making predictions of economies of scale unreliable; 2) the health inequities pitfall, i.e. some people will necessarily be left out and therefore not benefit from the scaled-up EBIs; 3) the scaled-up harm pitfall, i.e. the harms as well as the benefits may be amplified by the scaling-up; 4) the ethical pitfall, i.e. informed consent may be a challenge on a grander scale; 5) the top-down pitfall, i.e. the needs, preferences and culture of end-users may be forgotten when scale-up is directed from above; and 6) the contextual pitfall, i.e. it may not be possible to adapt the EBIs to every context. If its pitfalls are addressed head on, scaling-up may be a powerful process for translating research data into practical improvements in healthcare in both LMICs and high-income countries, ensuring that more people benefit from EBIs.


Assuntos
Assistência à Saúde , Medicina Baseada em Evidências , Análise Custo-Benefício , Assistência à Saúde/economia , Assistência à Saúde/ética , Medicina Baseada em Evidências/métodos , Disparidades em Assistência à Saúde , Humanos , Renda , Pobreza
9.
Ann R Coll Surg Engl ; 101(8): 584-588, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31537105

RESUMO

INTRODUCTION: The National Institute for Health and Care Excellence published a draft consultation update on abdominal aortic aneurysm, which was expected to be published on 7 November 2018. This article analyses the readiness of NHS hospitals and their workforce to embrace the proposed guidelines. METHODS: The trust and individual surgeon-level anonymised data in the public domain for elective, rupture and complex abdominal aortic aneurysm cases were collected and analysed for all the acute care trusts providing these services from the Vascular Society of Great Briton and Ireland's prospective National Vascular Registry database. RESULTS: Of the 95 acute care trusts providing the service for the year 2017, the annual volume of infrarenal abdominal aortic aneurysm (both endovascular and open repairs) ranged between 0 and 137. Of these, 64 (67.36%) trusts had an annual volume of fewer than 60 cases. A total of 366 (approximately 75% of 490) vascular surgeons have performed 10 or fewer open abdominal aortic aneurysm repairs in three years (2014-2016) with a mean operating volume of 1.452 procedures per surgeon per three years (n = 254, median 0, interquartile range, IQR, 0-3, 0.484 procedures per surgeon per year) and about 51% of the vascular surgeons have only performed five or fewer procedures in those three years with a mean operating volume of 3.455 per surgeon per three years (n = 367, median 3, IQR 0-3, 1.151 per surgeon per year). CONCLUSION: The observations show that most UK acute hospitals lack the optimum case volume necessary to embrace the proposed change in the guideline.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Guias de Prática Clínica como Assunto , Procedimentos Cirúrgicos Vasculares/normas , Aneurisma da Aorta Abdominal/epidemiologia , Ruptura Aórtica/epidemiologia , Ruptura Aórtica/cirurgia , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos/normas , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Emergências , Medicina Baseada em Evidências/métodos , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Irlanda/epidemiologia , Sistema de Registros , Medicina Estatal/normas , Medicina Estatal/estatística & dados numéricos , Reino Unido/epidemiologia , Procedimentos Cirúrgicos Vasculares/métodos , Procedimentos Cirúrgicos Vasculares/estatística & dados numéricos , Carga de Trabalho/estatística & dados numéricos
11.
Z Evid Fortbild Qual Gesundhwes ; 144-145: 90-99, 2019 Aug.
Artigo em Alemão | MEDLINE | ID: mdl-31399391

RESUMO

BACKGROUND: Guideline developers can: (1) adopt existing recommendations from others; (2) adapt existing recommendations to their own context; or (3) create recommendations de novo. Monetary and nonmonetary resources, credibility, maximization of uptake, as well as logical arguments should guide the choice of the approach and processes. OBJECTIVES: To describe a potentially efficient model for guideline production based on adoption, adaptation, and/or de novo development of recommendations utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence to Decision (EtD) frameworks. STUDY DESIGN AND SETTING: We applied the model in a new national guideline program producing 22 practice guidelines. We searched for relevant evidence that informs the direction and strength of a recommendation. We then produced GRADE EtDs for guideline panels to develop recommendations. RESULTS: In two waves, a total of 80 EtD frameworks was produced approximately 4 months and 146 EtDs in about 6 months. Use of the EtD frameworks allowed panel members to understand judgments of other guideline groups about the criteria that bear on guideline recommendations and then make their own judgments about those criteria in a systematic approach. CONCLUSION: The "GRADE-ADOLOPMENT" approach to guideline production combines adoption, adaptation, and, as needed, de novo development of recommendations. If guideline developers apply EtD criteria more widely and make their work publically available, this approach should prove even more useful.


Assuntos
Tomada de Decisões , Medicina Baseada em Evidências , Guias de Prática Clínica como Assunto , Técnicas de Apoio para a Decisão , Assistência à Saúde , Medicina Baseada em Evidências/métodos , Medicina Baseada em Evidências/normas , Alemanha , Recursos em Saúde , Humanos , Guias de Prática Clínica como Assunto/normas
12.
Expert Rev Pharmacoecon Outcomes Res ; 19(5): 509-515, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31370715

RESUMO

Introduction: Sick persons need doctors who understand their pathology, know how to treat their problem, and accompany them through their illness. This study aimed to synthesize the state of knowledge regarding the concept of value-based medicine (VBM) through an integrative literature review, and establish how VBM can be applied in palliative care. Areas covered: An integrative review was conducted with the keywords 'value-based medicine,' 'patient-centered care,' and 'medicina baseada em valor' (Portuguese for VBM) in PubMed and Virtual Health Library, identifying 17,189 articles in total. Of these, 10 articles met the eligibility criteria. VBM combines the highest level of technical-scientific data with patients' values. It is defined as the combination of evidence-based medicine, patient-centered care, and cost-effectiveness. Patients' values are a set of preferences, concerns, and expectations that contribute toward accommodating their needs in the treatment clinic. Expert opinion: Like VBM, palliative care focuses on patients' values and quality of life, respecting natural limits. The early development of a care plan with active participation of the patient in the face of life-threatening diseases should be encouraged and can bring peace and comfort in a person's final moments.


Assuntos
Medicina Baseada em Evidências/métodos , Cuidados Paliativos/métodos , Qualidade de Vida , Análise Custo-Benefício , Tomada de Decisões , Medicina Baseada em Evidências/economia , Humanos , Cuidados Paliativos/economia , Assistência Centrada no Paciente/economia , Assistência Centrada no Paciente/métodos
13.
World J Gastroenterol ; 25(27): 3546-3562, 2019 Jul 21.
Artigo em Inglês | MEDLINE | ID: mdl-31367156

RESUMO

Current evidence shows that individuals with gastric dysplasia, severe and extensive gastric atrophy, extensive gastric intestinal metaplasia and the incomplete subtype of intestinal metaplasia are at high risk for gastric cancer (GC) development. There are several approaches to identifying these subjects, including noninvasive methods, esophagogastroduodenoscopy and histology. The main approach in Western countries is histology-based while that in Eastern countries with a high prevalence of GC is endoscopy-based. Regarding asymptomatic individuals, the key issues in selecting applicable approaches are the ability to reduce GC mortality and the cost-effectiveness of the approach. At present, population-based screening programs have only been applied in a few Asian countries with a high risk of GC. Pre-endoscopic risk assessment based on demographic and clinical features, such as ethnicity, age, gender, smoking and Helicobacter pylori status, is helpful for identifying subjects with high pre-test probability for a possibly cost-effective approach, especially in intermediate- and low-risk countries. Regarding symptomatic patients with indications for esophagogastroduodenoscopy, the importance of opportunistic screening should be emphasized. The combination of endoscopic and histological approaches should always be considered as endoscopy provides a real-time assessment of the patient's risk level. In addition, imaging enhanced endoscopy (IEE) has been shown to facilitate targeted biopsies resulting in better correlation between endoscopic and histological findings. Currently, the use of IEE is recommended for endoscopic examinations, and the Operative Link for Gastric Intestinal Metaplasia or Operative Link on Gastritis Assessment grading systems are recommended for histological examinations whenever available. However, resource limitations are an important barrier in many regions worldwide. Thus, for an approach to be applicable in real-life practice, it should be not only evidence-based but also resource-sensitive. In this review, we discuss the current understanding and approaches to identifying high-risk individuals from western and eastern perspectives, as well as the possibility of an integrated, resource-sensitive approach.


Assuntos
Detecção Precoce de Câncer/métodos , Endoscopia do Sistema Digestório/métodos , Programas de Rastreamento/métodos , Lesões Pré-Cancerosas/diagnóstico , Neoplasias Gástricas/diagnóstico , Biópsia , Comparação Transcultural , Prestação Integrada de Cuidados de Saúde/métodos , Progressão da Doença , Medicina Baseada em Evidências/métodos , Mucosa Gástrica/diagnóstico por imagem , Mucosa Gástrica/patologia , Carga Global da Doença , Humanos , Incidência , Imagem Multimodal/métodos , Lesões Pré-Cancerosas/epidemiologia , Lesões Pré-Cancerosas/patologia , Medição de Risco/métodos , Fatores de Risco , Neoplasias Gástricas/epidemiologia , Neoplasias Gástricas/patologia
15.
Cient. dent. (Ed. impr.) ; 16(2): 129-136, mayo-ago. 2019. tab
Artigo em Espanhol | IBECS | ID: ibc-183724

RESUMO

El objetivo, establecer si existe una evidencia científica que avale una relación entre la administración de anticuerpos monoclonales y la aparición de osteonecrosis de los maxilares (ONM). En la literatura que revisamos nos muestra determinados casos en los que la ONM está relacionada con los anticuerpos monoclonales (denosumab, sunitib, etc.) siempre y cuando el paciente sea sometido a un tratamiento dental. También se evalúan aquellos artículos en los que se administra anticuerpos monoclonales y bifosfonatos de manera simultánea y se observa que la frecuencia de ONM es más elevada. Como conclusión se establece que no hay evidencia científica suficiente para asegurar una relación entre ONM y anticuerpos monoclonales, aunque sí la hay para demostrar relación entre ONM y anticuerpos monoclonales si se administra junto a los bifosfonatos


The aim is establish if there is a scientific evidence to support a relationship between the administration of monoclonal antibodies and the appearance of osteonecrosis of the jaws (ONJ). In the literature we review shows certain cases in which ONJ is related to monoclonal antibodies (denosumab, sunitib, etc.) as long as the patient undergoes dental treatment. Those articles in which monoclonal antibodies and bisphosphonates are administered simultaneously are also evaluated and it is observed that the frequency of ONJ is higher. As conclusión it is established that there is not enough scientific evidence to ensure a relationship between ONJ and monoclonal antibodies, but there is evidence to show that the relationship between ONJ and monoclonal antibodies if administered with bisphosphonates


Assuntos
Humanos , Medicina Baseada em Evidências/métodos , Osteonecrose/induzido quimicamente , Osteonecrose/complicações , Anticorpos Monoclonais/efeitos adversos , Difosfonatos/efeitos adversos , Osteonecrose da Arcada Osseodentária Associada a Difosfonatos/epidemiologia , Antissépticos Bucais
16.
Br J Anaesth ; 123(3): 269-287, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31351590

RESUMO

BACKGROUND: Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes. METHODS: The International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) systematic review, including randomised controlled and observational studies comparing neuraxial to general anaesthesia regarding major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, genitourinary, thromboembolic, neurological, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, from 1946 to May 17, 2018 were queried. Meta-analysis and Grading of Recommendations Assessment, Development and Evaluation approach was utilised to assess evidence quality and to develop recommendations. RESULTS: The analysis of 94 studies revealed that neuraxial anaesthesia was associated with lower odds or no difference in virtually all reported complications, except for urinary retention. Excerpt of complications for neuraxial vs general anaesthesia in hip/knee arthroplasty, respectively: mortality odds ratio (OR): 0.67, 95% confidence interval (CI): 0.57-0.80/OR: 0.83, 95% CI: 0.60-1.15; pulmonary OR: 0.65, 95% CI: 0.52-0.80/OR: 0.69, 95% CI: 0.58-0.81; acute renal failure OR: 0.69, 95% CI: 0.59-0.81/OR: 0.73, 95% CI: 0.65-0.82; deep venous thrombosis OR: 0.52, 95% CI: 0.42-0.65/OR: 0.77, 95% CI: 0.64-0.93; infections OR: 0.73, 95% CI: 0.67-0.79/OR: 0.80, 95% CI: 0.76-0.85; and blood transfusion OR: 0.85, 95% CI: 0.82-0.89/OR: 0.84, 95% CI: 0.82-0.87. CONCLUSIONS: Recommendation: primary neuraxial anaesthesia is preferred for knee arthroplasty, given several positive postoperative outcome benefits; evidence level: low, weak recommendation. RECOMMENDATION: neuraxial anaesthesia is recommended for hip arthroplasty given associated outcome benefits; evidence level: moderate-low, strong recommendation. Based on current evidence, the consensus group recommends neuraxial over general anaesthesia for hip/knee arthroplasty. TRIAL REGISTRY NUMBER: PROSPERO CRD42018099935.


Assuntos
Anestesia Epidural/efeitos adversos , Anestesia Geral/efeitos adversos , Raquianestesia/efeitos adversos , Artroplastia de Quadril/métodos , Artroplastia do Joelho/métodos , Anestesia Epidural/mortalidade , Anestesia Geral/mortalidade , Raquianestesia/mortalidade , Artroplastia de Quadril/mortalidade , Artroplastia do Joelho/mortalidade , Medicina Baseada em Evidências/métodos , Humanos , Complicações Pós-Operatórias/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
17.
Br J Anaesth ; 123(3): 325-334, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31327465

RESUMO

BACKGROUND: Ketamine is a phencyclidine intravenous anaesthetic that blocks N-methyl-d-aspartate receptors and HCN channels in the CNS. Lately it has gained acceptance in a low-dose form, with studies showing an analgesic benefit in orthopaedic surgery. Our goal was to critically appraise and synthesise current evidence regarding use of low-dose ketamine in major, painful orthopaedic surgeries. METHODS: We conducted searches in Medline, Embase, Cochrane, and specialty journals for randomised controlled trials (RCTs) that compared low-dose ketamine to placebo. Primary outcomes included total opioid use, time to first opioid, and VAS pain scores. Meta-analyses were undertaken in RevMan software using a random effects model. We rated the quality of the evidence using the GRADE Working Group criteria. RESULTS: We included 20 studies across four subgroups for meta-analysis. The overall quality of the evidence was moderate. Ketamine significantly decreased total opioid use and pain scores (VAS) at 24 and 48 h (Opioid: standardised mean difference [SMD] -0.82 [-1.24, -0.40], p=0.0001, and -0.65 [-1.03,-0.27], p=0.0008; VAS: SMD -0.53 [-0.91, -0.15], p=0.006 and -0.60 [-1.05, -0.16], p=0.008), and delayed the time to first opioid dose (SMD 0.64 [0.01, 1.27], p=0.05). Results for nausea and hallucinations were equivocal, whereas results for chronic pain were inconclusive. The most prominent effects were seen in total joint operations. CONCLUSION: Low-dose ketamine is an effective adjuvant that decreases pain and opioid requirements in painful orthopaedic procedures, especially in the first 24 h after procedure. Future research should focus on arthroscopic procedures and the incidence of chronic pain.


Assuntos
Analgésicos/administração & dosagem , Ketamina/administração & dosagem , Procedimentos Ortopédicos/efeitos adversos , Dor Pós-Operatória/tratamento farmacológico , Analgésicos Opioides/administração & dosagem , Anestésicos Dissociativos/administração & dosagem , Relação Dose-Resposta a Droga , Esquema de Medicação , Quimioterapia Combinada , Medicina Baseada em Evidências/métodos , Medicina Baseada em Evidências/normas , Humanos , Medição da Dor/métodos
18.
World J Gastroenterol ; 25(26): 3283-3290, 2019 Jul 14.
Artigo em Inglês | MEDLINE | ID: mdl-31341355

RESUMO

Since the 1970s, non-selective beta-blockers (NSBB) have been used to prevent variceal upper bleeding in advanced cirrhotic patients. However, several recent studies have raised the doubt about the benefit of NSBB in end-stage cirrhotic patients. In fact, they suggested a detrimental effect in these patients that even reduced survival. All of these studies have been assembled to compose the "window therapy hypothesis", in which NSBB would have traditional indication to be initiated to prevent variceal upper bleeding; however, treatment should be stopped (or not be initiated) in patients with end-stage cirrhosis. NSBB would reduce the cardiac reserve of these patients, worsening systemic perfusion and prognosis. However, it should be emphasized that these studies present important bias issues, and their results also suggested that diuretic treatment may also be behind the effects observed. In this opinion review, we changed the point of view from NSBB to diuretic treatment, based on a physiopathogenic approach of circulatory parameters of cirrhotic patients studied, and based on diuretic effect in blood pressure lowering and in other hypervolemic disease, as heart failure. We suggest a "diuretic window hypothesis", composed by an open window in hypervolemic phase, an attention window when patient present in a normal plasma volume phase, and a closed window during the plasma hypovolemic phase.


Assuntos
Diuréticos/administração & dosagem , Doença Hepática Terminal/complicações , Varizes Esofágicas e Gástricas/tratamento farmacológico , Hemorragia Gastrointestinal/prevenção & controle , Cirrose Hepática/complicações , Antagonistas Adrenérgicos beta/administração & dosagem , Doença Hepática Terminal/mortalidade , Doença Hepática Terminal/patologia , Varizes Esofágicas e Gástricas/etiologia , Varizes Esofágicas e Gástricas/mortalidade , Medicina Baseada em Evidências/métodos , Gastroenterologia/métodos , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/mortalidade , Humanos , Cirrose Hepática/mortalidade , Cirrose Hepática/patologia , Prognóstico , Análise de Sobrevida , Resultado do Tratamento
19.
Complement Ther Med ; 45: 114-123, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31331547

RESUMO

OBJECTIVES: To summarize the evidence from systematic reviews (SRs) and meta-analyses that evaluated the efficacy of ginger in treating any conditions and critically assess the quality of these evidence. METHODS: A systematic search of the literature was conducted from inception until February 28, 2019 using the PubMed, EMBASE, Web of science, Cochrane library, and four Chinese databases. Literature selection and data extraction were conducted by two independent reviewers. The quality of SRs was evaluated using the AMSTAR-2 tool. The GRADE system was used to assess the quality of evidence. RESULTS: Twenty-seven SRs were included. The number of included studies were various, range from 3 to 27. The condition with the most included SRs was nausea and vomiting (n = 12, 44.4%). Many SRs showed a promising efficacy of ginger, including nausea and vomiting, metabolic syndrome and pain, while the effect of ginger for platelet aggregation failed to draw a certain conclusion. The quality of SRs was heterogeneous. All of included SRs well complied with the Item 1 ("research questions included the components of PICO") and Item 3 ("explained selection of the study designs for inclusion"). Twenty review failed to provide registration information. Only one SR reported the sources of funding for studies included. CONCLUSIONS: In our overview, most of SRs suggest ginger is a promising herbal medicine for health care, which is beneficial for nausea and vomiting, metabolic syndrome and pain. However, considering the limited quality of included evidence and heterogeneity of different clinical trials, more well-design studies are required to confirm the conclusion further.


Assuntos
Gengibre/química , Preparações de Plantas/uso terapêutico , Assistência à Saúde/métodos , Medicina Baseada em Evidências/métodos , Humanos , Náusea/tratamento farmacológico , Fitoterapia/métodos , Projetos de Pesquisa , Vômito/tratamento farmacológico
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