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1.
J Glob Health ; 9(2): 020403, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31489186

RESUMO

Background: There is a need to develop sustainable emergency health care systems in low-resource settings, but data that analyses emergency health care needs in these settings are scarce. We aimed at assessing presenting complaints (PCs) and post-discharge mortality in a large emergency department population in Nepal. Methods: Characteristics of adult patients who entered the emergency department (ED) in a hospital in Nepal were prospectively recorded in the local emergency registry from September 2013 until December 2016. To assess post-ED mortality, patient households were followed-up by telephone interviews at 90 days. Results: In 21892 included adults, the major PC categories were injuries (29%), abdominal complaints (23%), and infections (16%). Median age was 40 years and sex distribution was balanced. Among 3793 patients followed at 90 days, 8% had died. For respiratory and cardiovascular PCs, 90-day mortality were 25% and 23%. The highest mortality was in individuals with known chronic lung disease, in this group 32% had died by 90 days of ED discharge, regardless of PC. In women, illiteracy compared to literacy (adjusted odds ratio (aOR) = 7.0, 95% confidence interval (CI) = 2.1-23.6) and being both exposed to tobacco-smoking and traditional cooking stove compared to no smoke (aOR = 2.8, 95% CI = 1.6-4.9) were associated with mortality. The mortality was much higher among family-initiated discharged patients (17%, aOR = 5.4, 95% CI = 3.3-8.9) compared to doctor-initiated discharged (3%). Conclusions: Our report suggests that nearly one in ten patients seeking emergency health care died within 90 days. This finding is alarming and novel. Post-discharge studies need to be replicated and appropriate follow-up programs in low-resource settings where primary health care is underdeveloped are urgently needed.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Mortalidade/tendências , Adulto , Idoso , Feminino , Hospitais Universitários , Humanos , Masculino , Pessoa de Meia-Idade , Nepal/epidemiologia , Estudos Prospectivos
2.
Am Surg ; 85(7): 685-689, 2019 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-31405408

RESUMO

Trauma recidivists are a high-risk patient population. The effects of recidivism on Geriatric trauma mortality have not been investigated. Our hypothesis is that trauma recidivism is associated with high postdischarge mortality after the initial index admission in both the geriatric and adult trauma populations. The trauma registry of our Level I trauma center was queried for patients evaluated between 2008 and 2012. Patients were stratified adult (18-64) and geriatric (≥65) groups and matched with mortality data from the National Death Index. Unique patients were identified and recidivists flagged. Statistical analysis was performed based on characteristics from the index admission using nonparametric tests, and Kaplan-Meier curves were plotted to examine postdischarge mortality after index admission for recidivists. A total of 8716 records met inclusion criteria; 800 recidivist records were identified representing 369 unique patients. Recidivists presented between 2 and 7 times. Recidivists were more likely to be male, required ICU admission and mechanical ventilation, had a longer median length of stay, were less likely to discharge home, and had a higher postdischarge mortality. Stratifying into adult and geriatric groups demonstrated significant differences in injury severity, injury patterns, length of stay, race, gender, mechanism, and postdischarge mortality. Recidivists demonstrated a higher postdischarge mortality in both groups with the geriatric group approaching 46 per cent. Trauma recidivists represent an at-risk group with significantly higher postdischarge mortality. Group characteristics differ significantly between the adult and geriatric recidivist populations. Further research is needed to identify modifiable risk factors in these populations to minimize risks of morbidity and mortality.


Assuntos
Mortalidade , Centros de Traumatologia/estatística & dados numéricos , Adolescente , Adulto , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Estimativa de Kaplan-Meier , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Adulto Jovem
3.
N Engl J Med ; 381(8): 705-715, 2019 08 22.
Artigo em Inglês | MEDLINE | ID: mdl-31433918

RESUMO

BACKGROUND: The systematic evaluation of the results of time-series studies of air pollution is challenged by differences in model specification and publication bias. METHODS: We evaluated the associations of inhalable particulate matter (PM) with an aerodynamic diameter of 10 µm or less (PM10) and fine PM with an aerodynamic diameter of 2.5 µm or less (PM2.5) with daily all-cause, cardiovascular, and respiratory mortality across multiple countries or regions. Daily data on mortality and air pollution were collected from 652 cities in 24 countries or regions. We used overdispersed generalized additive models with random-effects meta-analysis to investigate the associations. Two-pollutant models were fitted to test the robustness of the associations. Concentration-response curves from each city were pooled to allow global estimates to be derived. RESULTS: On average, an increase of 10 µg per cubic meter in the 2-day moving average of PM10 concentration, which represents the average over the current and previous day, was associated with increases of 0.44% (95% confidence interval [CI], 0.39 to 0.50) in daily all-cause mortality, 0.36% (95% CI, 0.30 to 0.43) in daily cardiovascular mortality, and 0.47% (95% CI, 0.35 to 0.58) in daily respiratory mortality. The corresponding increases in daily mortality for the same change in PM2.5 concentration were 0.68% (95% CI, 0.59 to 0.77), 0.55% (95% CI, 0.45 to 0.66), and 0.74% (95% CI, 0.53 to 0.95). These associations remained significant after adjustment for gaseous pollutants. Associations were stronger in locations with lower annual mean PM concentrations and higher annual mean temperatures. The pooled concentration-response curves showed a consistent increase in daily mortality with increasing PM concentration, with steeper slopes at lower PM concentrations. CONCLUSIONS: Our data show independent associations between short-term exposure to PM10 and PM2.5 and daily all-cause, cardiovascular, and respiratory mortality in more than 600 cities across the globe. These data reinforce the evidence of a link between mortality and PM concentration established in regional and local studies. (Funded by the National Natural Science Foundation of China and others.).


Assuntos
Poluição do Ar/efeitos adversos , Exposição Ambiental/análise , Mortalidade , Material Particulado/efeitos adversos , Poluição do Ar/análise , Doenças Cardiovasculares/mortalidade , Causas de Morte , Exposição Ambiental/efeitos adversos , Exposição Ambiental/legislação & jurisprudência , Saúde Global , Humanos , Tamanho da Partícula , Material Particulado/análise , Doenças Respiratórias/mortalidade , Risco
4.
BMJ ; 366: l4570, 2019 08 21.
Artigo em Inglês | MEDLINE | ID: mdl-31434697

RESUMO

OBJECTIVE: To examine the dose-response associations between accelerometer assessed total physical activity, different intensities of physical activity, and sedentary time and all cause mortality. DESIGN: Systematic review and harmonised meta-analysis. DATA SOURCES: PubMed, PsycINFO, Embase, Web of Science, Sport Discus from inception to 31 July 2018. ELIGIBILITY CRITERIA: Prospective cohort studies assessing physical activity and sedentary time by accelerometry and associations with all cause mortality and reported effect estimates as hazard ratios, odds ratios, or relative risks with 95% confidence intervals. DATA EXTRACTION AND ANALYSIS: Guidelines for meta-analyses and systematic reviews for observational studies and PRISMA guidelines were followed. Two authors independently screened the titles and abstracts. One author performed a full text review and another extracted the data. Two authors independently assessed the risk of bias. Individual level participant data were harmonised and analysed at study level. Data on physical activity were categorised by quarters at study level, and study specific associations with all cause mortality were analysed using Cox proportional hazards regression analyses. Study specific results were summarised using random effects meta-analysis. MAIN OUTCOME MEASURE: All cause mortality. RESULTS: 39 studies were retrieved for full text review; 10 were eligible for inclusion, three were excluded owing to harmonisation challenges (eg, wrist placement of the accelerometer), and one study did not participate. Two additional studies with unpublished mortality data were also included. Thus, individual level data from eight studies (n=36 383; mean age 62.6 years; 72.8% women), with median follow-up of 5.8 years (range 3.0-14.5 years) and 2149 (5.9%) deaths were analysed. Any physical activity, regardless of intensity, was associated with lower risk of mortality, with a non-linear dose-response. Hazards ratios for mortality were 1.00 (referent) in the first quarter (least active), 0.48 (95% confidence interval 0.43 to 0.54) in the second quarter, 0.34 (0.26 to 0.45) in the third quarter, and 0.27 (0.23 to 0.32) in the fourth quarter (most active). Corresponding hazards ratios for light physical activity were 1.00, 0.60 (0.54 to 0.68), 0.44 (0.38 to 0.51), and 0.38 (0.28 to 0.51), and for moderate-to-vigorous physical activity were 1.00, 0.64 (0.55 to 0.74), 0.55 (0.40 to 0.74), and 0.52 (0.43 to 0.61). For sedentary time, hazards ratios were 1.00 (referent; least sedentary), 1.28 (1.09 to 1.51), 1.71 (1.36 to 2.15), and 2.63 (1.94 to 3.56). CONCLUSION: Higher levels of total physical activity, at any intensity, and less time spent sedentary, are associated with substantially reduced risk for premature mortality, with evidence of a non-linear dose-response pattern in middle aged and older adults. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018091808.


Assuntos
Acelerometria/estatística & dados numéricos , Exercício , Mortalidade/tendências , Comportamento Sedentário , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Prospectivos , Fatores de Risco
5.
MMWR Morb Mortal Wkly Rep ; 68(34): 737-744, 2019 Aug 30.
Artigo em Inglês | MEDLINE | ID: mdl-31465320

RESUMO

From 2013 to 2017, the number of opioid-involved overdose deaths (opioid deaths) in the United States increased 90%, from 25,052 to 47,600.* This increase was primarily driven by substantial increases in deaths involving illicitly manufactured fentanyl (IMF) or fentanyl analogs† mixed with heroin, sold as heroin, or pressed into counterfeit prescription pills (1-3). Methamphetamine-involved and cocaine-involved deaths that co-involved opioids also substantially increased from 2016 to 2017 (4). Provisional 2018§ estimates of the number of opioid deaths suggest a small decrease from 2017. Investigating the extent to which decreases occurred broadly or were limited to a subset of opioid types (e.g., prescription opioids versus IMF) and drug combinations (e.g., IMF co-involving cocaine) can assist in targeting of intervention efforts. This report describes opioid deaths during January-June 2018 and changes from July-December 2017 in 25¶ of 32 states and the District of Columbia participating in CDC's State Unintentional Drug Overdose Reporting System (SUDORS).** Opioid deaths were analyzed by involvement (opioid determined by medical examiner or coroner to contribute to overdose death) of prescription or illicit opioids,†† as well as by the presence (detection of the drug in decedent) of co-occurring nonopioid drugs (cocaine, methamphetamine, and benzodiazepines). Three key findings emerged regarding changes in opioid deaths from July-December 2017 to January-June 2018. First, overall opioid deaths decreased 4.6%. Second, decreases occurred in prescription opioid deaths without co-involved illicit opioids and deaths involving non-IMF illicit synthetic opioids (fentanyl analogs and U-series drugs) (5). Third, IMF deaths, especially those with multiple illicit opioids and common nonopioids, increased. Consequently, IMF was involved in approximately two-thirds of opioid deaths during January-June 2018. Notably, during January-June 2018, 62.6% of all opioid deaths co-occurred with at least one common nonopioid drug. To maintain and accelerate reductions in opioid deaths, efforts to prevent IMF-involved deaths and address polysubstance misuse with opioids must be enhanced. Key interventions include broadening outreach to groups at high risk for IMF or fentanyl analog exposure and overdose. Improving linkage to and engagement in risk-reduction services and evidence-based treatment for persons with opioid and other substance use disorders with attention to polysubstance use or misuse is also needed.


Assuntos
Analgésicos Opioides/envenenamento , Overdose de Drogas/mortalidade , Analgésicos Opioides/química , Analgésicos Opioides/classificação , Benzodiazepinas/análise , Cocaína/análise , Humanos , Metanfetamina/análise , Mortalidade/tendências , Estados Unidos/epidemiologia
6.
J S Afr Vet Assoc ; 90(0): e1-e7, 2019 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-31368316

RESUMO

The objective of this study was to gain better insight into factors associated with the capture-related mortality rate in cheetahs. A link to an online questionnaire was sent to zoo and wildlife veterinarians through the Species Survival Plan Programme and European Endangered Species Programme coordinators and via the 'Wildlife VetNet' Google group forum. The questionnaire consisted of 50 questions relating to the veterinarians' country of residence and experience, the medicine combinations used, standard monitoring procedures, capture-related complications and mortalities experienced in this species under different capture conditions. In addition, necropsy data from the national wildlife disease database of the National Zoological Gardens of South Africa were examined for cases where anaesthetic death was listed as the cause of death in cheetahs. A total of 75 veterinarians completed the survey, with 38 from African countries and a combined total of 37 from Europe, the United States (US) and Asia. Of these, 24% (n = 18/75) had experienced at least one capture-associated cheetah mortality, with almost all of the fatalities (29/30) reported by veterinarians working in Africa. A lack of anaesthetic monitoring and the absence of supplemental oxygen were shown to be significant risk factors for mortality. Hyperthermia, likely to be associated with capture stress, was the most common reported complication (35%). The results suggest that free-ranging rather than habituated captive cheetahs are particularly at risk of dying during immobilisation and transport. The capture-related fatalities in this species do not appear to be associated with either the veterinarian's level of clinical experience or the immobilisation agents used.


Assuntos
Acinonyx , Anestésicos Dissociativos/efeitos adversos , Hipnóticos e Sedativos/efeitos adversos , Imobilização/veterinária , Mortalidade , Animais , Animais Selvagens , Animais de Zoológico , Autopsia/veterinária , Bases de Dados Factuais , Combinação de Medicamentos , Europa (Continente) , Imobilização/efeitos adversos , Imobilização/métodos , Ketamina/efeitos adversos , Modelos Logísticos , Medetomidina/efeitos adversos , Fatores de Risco , África do Sul/epidemiologia , Inquéritos e Questionários , Tranquilizantes/efeitos adversos , Médicos Veterinários
7.
BMJ ; 366: l4673, 2019 08 12.
Artigo em Inglês | MEDLINE | ID: mdl-31405892

RESUMO

OBJECTIVE: To investigate whether vitamin D supplementation is associated with lower mortality in adults. DESIGN: Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES: Medline, Embase, and the Cochrane Central Register from their inception to 26 December 2018. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomised controlled trials comparing vitamin D supplementation with a placebo or no treatment for mortality were included. Independent data extraction was conducted and study quality assessed. A meta-analysis was carried out by using fixed effects and random effects models to calculate risk ratio of death in the group receiving vitamin D supplementation and the control group. MAIN OUTCOME MEASURES: All cause mortality. RESULTS: 52 trials with a total of 75 454 participants were identified. Vitamin D supplementation was not associated with all cause mortality (risk ratio 0.98, 95% confidence interval 0.95 to 1.02, I2=0%), cardiovascular mortality (0.98, 0.88 to 1.08, 0%), or non-cancer, non-cardiovascular mortality (1.05, 0.93 to 1.18, 0%). Vitamin D supplementation statistically significantly reduced the risk of cancer death (0.84, 0.74 to 0.95, 0%). In subgroup analyses, all cause mortality was significantly lower in trials with vitamin D3 supplementation than in trials with vitamin D2 supplementation (P for interaction=0.04); neither vitamin D3 nor vitamin D2 was associated with a statistically significant reduction in all cause mortality. CONCLUSIONS: Vitamin D supplementation alone was not associated with all cause mortality in adults compared with placebo or no treatment. Vitamin D supplementation reduced the risk of cancer death by 16%. Additional large clinical studies are needed to determine whether vitamin D3 supplementation is associated with lower all cause mortality. STUDY REGISTRATION: PROSPERO registration number CRD42018117823.


Assuntos
Suplementos Nutricionais , Mortalidade , Vitamina D/administração & dosagem , Colecalciferol/administração & dosagem , Ergocalciferóis/administração & dosagem , Humanos , Neoplasias/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto
8.
BMJ ; 366: l4009, 2019 07 02.
Artigo em Inglês | MEDLINE | ID: mdl-31266749

RESUMO

OBJECTIVE: To assess the association of dietary fatty acids with cardiovascular disease mortality and total mortality among patients with type 2 diabetes. DESIGN: Prospective, longitudinal cohort study. SETTING: Health professionals in the United States. PARTICIPANTS: 11 264 participants with type 2 diabetes in the Nurses' Health Study (1980-2014) and Health Professionals Follow-Up Study (1986-2014). EXPOSURES: Dietary fat intake assessed using validated food frequency questionnaires and updated every two to four years. MAIN OUTCOME MEASURE: Total and cardiovascular disease mortality during follow-up. RESULTS: During follow-up, 2502 deaths including 646 deaths due to cardiovascular disease were documented. After multivariate adjustment, intake of polyunsaturated fatty acids (PUFAs) was associated with a lower cardiovascular disease mortality, compared with total carbohydrates: hazard ratios comparing the highest with the lowest quarter were 0.76 (95% confidence interval 0.58 to 0.99; P for trend=0.03) for total PUFAs, 0.69 (0.52 to 0.90; P=0.007) for marine n-3 PUFAs, 1.13 (0.85 to 1.51) for α-linolenic acid, and 0.75 (0.56 to 1.01) for linoleic acid. Inverse associations with total mortality were also observed for intakes of total PUFAs, n-3 PUFAs, and linoleic acid, whereas monounsaturated fatty acids of animal, but not plant, origin were associated with a higher total mortality. In models that examined the theoretical effects of substituting PUFAs for other fats, isocalorically replacing 2% of energy from saturated fatty acids with total PUFAs or linoleic acid was associated with 13% (hazard ratio 0.87, 0.77 to 0.99) or 15% (0.85, 0.73 to 0.99) lower cardiovascular disease mortality, respectively. A 2% replacement of energy from saturated fatty acids with total PUFAs was associated with 12% (hazard ratio 0.88, 0.83 to 0.94) lower total mortality. CONCLUSIONS: In patients with type 2 diabetes, higher intake of PUFAs, in comparison with carbohydrates or saturated fatty acids, is associated with lower total mortality and cardiovascular disease mortality. These findings highlight the important role of quality of dietary fat in the prevention of cardiovascular disease and total mortality among adults with type 2 diabetes.


Assuntos
Doenças Cardiovasculares , Diabetes Mellitus Tipo 2 , Carboidratos da Dieta/metabolismo , Ácidos Graxos Insaturados/metabolismo , Adulto , Idoso , Doenças Cardiovasculares/etiologia , Doenças Cardiovasculares/mortalidade , Doenças Cardiovasculares/prevenção & controle , Correlação de Dados , Diabetes Mellitus Tipo 2/epidemiologia , Diabetes Mellitus Tipo 2/metabolismo , Feminino , Pessoal de Saúde/estatística & dados numéricos , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Mortalidade , Estudos Prospectivos , Fatores de Risco , Estados Unidos/epidemiologia
9.
BMJ ; 364: l94, 2019 02 06.
Artigo em Inglês | MEDLINE | ID: mdl-31339847

RESUMO

OBJECTIVES: To use the estimates from the Global Burden of Disease Study 2016 to describe patterns of suicide mortality globally, regionally, and for 195 countries and territories by age, sex, and Socio-demographic index, and to describe temporal trends between 1990 and 2016. DESIGN: Systematic analysis. MAIN OUTCOME MEASURES: Crude and age standardised rates from suicide mortality and years of life lost were compared across regions and countries, and by age, sex, and Socio-demographic index (a composite measure of fertility, income, and education). RESULTS: The total number of deaths from suicide increased by 6.7% (95% uncertainty interval 0.4% to 15.6%) globally over the 27 year study period to 817 000 (762 000 to 884 000) deaths in 2016. However, the age standardised mortality rate for suicide decreased by 32.7% (27.2% to 36.6%) worldwide between 1990 and 2016, similar to the decline in the global age standardised mortality rate of 30.6%. Suicide was the leading cause of age standardised years of life lost in the Global Burden of Disease region of high income Asia Pacific and was among the top 10 leading causes in eastern Europe, central Europe, western Europe, central Asia, Australasia, southern Latin America, and high income North America. Rates for men were higher than for women across regions, countries, and age groups, except for the 15 to 19 age group. There was variation in the female to male ratio, with higher ratios at lower levels of Socio-demographic index. Women experienced greater decreases in mortality rates (49.0%, 95% uncertainty interval 42.6% to 54.6%) than men (23.8%, 15.6% to 32.7%). CONCLUSIONS: Age standardised mortality rates for suicide have greatly reduced since 1990, but suicide remains an important contributor to mortality worldwide. Suicide mortality was variable across locations, between sexes, and between age groups. Suicide prevention strategies can be targeted towards vulnerable populations if they are informed by variations in mortality rates.


Assuntos
Carga Global da Doença , Suicídio , Adolescente , Adulto , Distribuição por Idade , Fatores Etários , Idoso , Causas de Morte/tendências , Comparação Transcultural , Interpretação Estatística de Dados , Feminino , Carga Global da Doença/métodos , Carga Global da Doença/estatística & dados numéricos , Carga Global da Doença/tendências , Saúde Global , Humanos , Expectativa de Vida , Masculino , Mortalidade/tendências , Avaliação de Resultados (Cuidados de Saúde) , Distribuição por Sexo , Fatores Sexuais , Fatores Socioeconômicos , Suicídio/prevenção & controle , Suicídio/estatística & dados numéricos , Suicídio/tendências
10.
Sci Total Environ ; 690: 923-931, 2019 Nov 10.
Artigo em Inglês | MEDLINE | ID: mdl-31302556

RESUMO

BACKGROUND: The impact of heatwaves on public health has led to an urgent need to describe extremely hot weather events (EHWEs) and evaluate their health impacts. METHODS: In Hong Kong, a very hot day (VHD) can be defined when the daily maximum temperature ≥ 33 °C, and a hot night (HN) can be identified if the daily minimum temperature ≥ 28 °C. Three lengths of time, nine combinations of VHD and HN, and four categories of occurrence intervals between two EHWEs were considered over 2006-2015. The daily relative risk (RR) of all-cause mortality was estimated using Poisson generalized additive regression models, controlling for both short-term and long-term trends in temperature as well as four air pollutants. Lagged effects of the representative EHWEs were further examined for their association with mortality. Subgroup analysis was conducted for different sex and age groups. RESULTS: Significant associations with raised mortality risks were observed for a single HN, while stronger associations with mortality were observed as significant for five or more consecutive VHDs/HNs. More HNs between the consecutive VHDs also significantly amplified the impact on mortality, with the strongest association observed for EHWEs characterized as 2D3N, and the effect significantly lagged for five days. Therefore, with identifiable health impacts, three thresholds (5VHDs, 5HNs, & 2D3N) were determined to be representative of identical types of EHWEs in Hong Kong. Furthermore, by taking 2 (3) consecutive VHDs (HNs) as one daytime (nighttime) EHWE event, those occurring consecutively without non-hot days (nights) in between were found to be significantly associated with excess mortality risks. Moreover, females and older adults were determined to be relatively more vulnerable to all defined EHWEs. CONCLUSIONS: Among all the observed significant heat-mortality associations in highly urbanized cities, EHWEs that occurred during the nighttime, with extended length, consecutively without any break in between, or in the pattern of 2D3N might require the meteorological administration, healthcare providers, and urban planners to work interactively.


Assuntos
Exposição Ambiental/estatística & dados numéricos , Temperatura Alta , Mortalidade/tendências , Cidades , Feminino , Hong Kong/epidemiologia , Humanos , Masculino , Urbanização
11.
J Surg Oncol ; 120(4): 753-760, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31355444

RESUMO

BACKGROUND: Calls for multivisceral resection (MVR) of retroperitoneal sarcoma (RPS) are increasing, although the risks and benefits remain controversial. We sought to analyze current 30-day morbidity and mortality rates, and trends in utilization of MVR in a national database. METHODS: Overall morbidity, severe morbidity, mortality rates, and temporal trends were analyzed utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). RESULTS: From 2012 to 2015, a total of 564 patients underwent RPS resection with 233 patients (41%) undergoing MVR. The MVR group had a higher rate of preoperative weight loss and larger tumors overall. When comparing MVR to non-MVR, there was no significant difference in overall morbidity (22% vs 17%, P = .13), severe morbidity (11% vs 8%, P = .18), or mortality (<1% vs 2%, P = .25). On multivariate analysis, MVR was not associated with increased overall morbidity or severe morbidity. Mortality rates were too low for meaningful statistical analysis. Annual rates of MVR ranged from 37% to 46% with no significant change over time (P = .47). RESULTS: Short-term morbidity and mortality rates after MVR for RPS remain acceptable, but rates of MVR show little change over time in NSQIP hospitals. Concerns about increased morbidity and mortality should not be viewed as a contraindication to wider implementation of MVR for RPS.


Assuntos
Mortalidade/tendências , Complicações Pós-Operatórias/mortalidade , Neoplasias Retroperitoneais/mortalidade , Sarcoma/mortalidade , Procedimentos Cirúrgicos Operatórios/mortalidade , Bases de Dados Factuais , Gerenciamento Clínico , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade , Prognóstico , Melhoria de Qualidade , Neoplasias Retroperitoneais/patologia , Neoplasias Retroperitoneais/cirurgia , Sarcoma/patologia , Sarcoma/cirurgia , Taxa de Sobrevida
12.
Rev Med Chil ; 147(3): 322-329, 2019 Mar.
Artigo em Espanhol | MEDLINE | ID: mdl-31344169

RESUMO

BACKGROUND: The place of death is a fundamental indicator for the debate on equity and access to health care. AIM: To describe the place of death of the deceased population over 1 year of age in Chile between the years 1997 and 2014. To analyze tendencies in this variable and its association with socio-demographic characteristics. MATERIAL AND METHODS: Time series study covering deaths occurred between 1997 and 2014 in Chile. National death records were used, provided by the Department of Health Statistics and Information (DEIS) of the Chilean Ministry of Health. The following variables were chosen: place of death (home, hospital, other), sex, marital status, age, level of education, activity and area of residence. Temporal trends were evaluated using Prais Winsten regressions. Logistic regression was used to assess the association of the place of death with socio-demographic characteristics. RESULTS: Between 1997 and 2014 there were 1,576,392 deaths, at a mean age of 69 years (p25-p75:60-83 years). No temporal variations in the place of death were observed with the Prais Winsten regression, hospital (P-W coefficient (coef) = 0.06 (confidence intervals (CI): -0.30; 0.19), p = 0.64), home (P-W coef = -0.03 (CI: -0.15; 0.09), p = 0.57), and other places (P-W coef = 0.07; (CI: -0.08 - 0.22), p = 0.32). The multivariate analysis showed that being women under 70 years of age, being married or widowed, having a higher educational level, being inactive and living in a rural area were factors associated with a greater chance of dying at home. CONCLUSIONS: No significant temporal variation in the place of death was observed.


Assuntos
Mortalidade , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Chile/epidemiologia , Atestado de Óbito , Feminino , Mortalidade Hospitalar , Hospitais/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Características de Residência , Fatores Socioeconômicos , Fatores de Tempo
13.
Lancet ; 394(10197): 471-477, 2019 08 10.
Artigo em Inglês | MEDLINE | ID: mdl-31280965

RESUMO

BACKGROUND: The optimal surgical excision margins are uncertain for patients with thick (>2 mm) localised cutaneous melanomas. In our previous report of this multicentre, randomised controlled trial, with a median follow-up of 6·7 years, we showed that a narrow excision margin (2 cm vs 4 cm) did not affect melanoma-specific nor overall survival. Here, we present extended follow-up of this cohort. METHODS: In this open-label, multicentre randomised controlled trial, we recruited patients from 53 hospitals in Sweden, Denmark, Estonia, and Norway. We enrolled clinically staged patients aged 75 years or younger diagnosed with localised cutaneous melanoma thicker than 2 mm, and with primary site on the trunk or upper or lower extremities. Patients were randomly allocated (1:1) to treatment either with a 2-cm or a 4-cm excision margin. A physician enrolled the patients after histological confirmation of a cutaneous melanoma thicker than 2 mm. Some patients were enrolled by a physician acting as responsible for clinical care and as a trial investigator (follow-up, data collection, and manuscript writing). In other cases physicians not involved in running the trial enrolled patients. Randomisation was done by telephone call to a randomisation office, by sealed envelope, or by computer generated lists using permuted blocks. Patients were stratified according to geographical region. No part of the trial was masked. The primary outcome in this extended follow-up study was overall survival and the co-primary outcome was melanoma-specific survival. All analyses were done on an intention-to-treat basis. The study is registered with ClinicalTrials.gov, number NCT03638492. FINDINGS: Between Jan 22, 1992, and May 19, 2004, 936 clinically staged patients were recruited and randomly assigned to a 4-cm excision margin (n=465) or a 2-cm excision margin (n=471). At a median overall follow-up of 19·6 years (235 months, IQR 200-260), 621 deaths were reported-304 (49%) in the 2-cm group and 317 (51%) in the 4-cm group (unadjusted HR 0·98, 95% CI 0·83-1·14; p=0·75). 397 deaths were attributed to cutaneous melanoma-192 (48%) in the 2-cm excision margin group and 205 (52%) in the 4-cm excision margin group (unadjusted HR 0·95, 95% CI 0·78-1·16, p=0·61). INTERPRETATION: A 2-cm excision margin was safe for patients with thick (>2 mm) localised cutaneous melanoma at a follow-up of median 19·6 years. These findings support the use of 2-cm excision margins in current clinical practice. FUNDING: The Swedish Cancer Society, Stockholm Cancer Society, the Swedish Society for Medical Research, Radiumhemmet Research funds, Stockholm County Council, Wallström funds.


Assuntos
Extremidade Inferior/patologia , Melanoma/mortalidade , Melanoma/cirurgia , Neoplasias Cutâneas/mortalidade , Neoplasias Cutâneas/cirurgia , Tronco/patologia , Extremidade Superior/patologia , Idoso , Dinamarca , Estônia , Feminino , Humanos , Análise de Intenção de Tratamento , Extremidade Inferior/cirurgia , Masculino , Margens de Excisão , Melanoma/patologia , Pessoa de Meia-Idade , Mortalidade , Noruega , Neoplasias Cutâneas/patologia , Análise de Sobrevida , Suécia , Tronco/cirurgia , Resultado do Tratamento , Extremidade Superior/cirurgia
16.
Rev. Bras. Saúde Mater. Infant. (Online) ; 19(2): 391-400, Apr.-June 2019. tab, graf
Artigo em Inglês | LILACS | ID: biblio-1013143

RESUMO

Abstract Objectives: to evaluate the relation between the corrected mortality rates on breast cancer and the indicators of elderly women's living conditions in the Northeast micro-regions of Brazil . Methods: an ecological study was adopted in 2010 and 2015 for 188 micro-regions in the Northeast using structural equation modeling. The data on the population, deaths and indicators on living conditions were extracted from the IBGE, SIM/MS, and SISAP-Idoso (elderly), respectively. The under-registration of death data on breast cancer, badly defined death causes and garbage codes were corrected. The standardized mortality rates were calculated to permit time-space comparison. Results: the recovery of a considerable number of deaths was made possible to obtain a greater accuracy in the mortality rates estimation in micro-regions level. An increase in the mortality rates was observed at the time. The structural equation modeling presented a robust model with significance for some indicators on living conditions. The rates were higher in the micro-regions with lower percentage of illiterate elderly women, lower percentage of elderly women living in poverty, lower dependency ratio, and higher percentage of elderly women living at home with running water. Conclusions: the results showed an increased trend of elderly women dying of breast cancer in the region and with higher levels in the micro-regions with better indicators on living conditions.


Resumo Objetivos: avaliar a relação entre as taxas corrigidas de mortalidade por câncer de mama e indicadores de condições de vida das idosas das microrregiões do Nordeste brasileiro. Métodos: adotou-se um estudo ecológico nos anos de 2010 e 2015 para as 188 microrregiões do Nordeste utilizando a modelagem de equações estruturais. Os dados de população, óbitos e indicadores de condições de vida foram extraídos do IBGE, SIM/MS e SISAP-Idoso, respectivamente. Os dados de óbitos por câncer de mama foram corrigidos para subregistro, óbitos mal definidos e códigos garbage. Calcularam-se taxas padronizadas de mortalidade para permitir a comparação tempo-espacial. Resultados: a recuperação de um número considerável de óbitos possibilitou obter uma maior acurácia na estimação das taxas de mortalidade em nível de microrregiões. Um aumento nas taxas de mortalidade foi observado no período. A modelagem de equações estruturais apresentou um modelo robusto com significância para alguns indicadores de condições de vida. As taxas foram mais elevadas em microrregiões com menor percentual de idosas analfabetas, menor percentual de idosas em situação de pobreza, menor razão de dependência e maior percentual de idosas residentes em domicílios com água encanada. Conclusões: os resultados apontaram uma tendência de aumento das mortes de idosas por câncer de mama na região, com níveis maiores nas microrregiões com melhores indicadores de condições de vida.


Assuntos
Humanos , Feminino , Idoso , Condições Sociais , Sub-Registro , Neoplasias da Mama/epidemiologia , Mortalidade , Fatores Socioeconômicos , Brasil , Atestado de Óbito , Registros de Mortalidade , Indicadores Básicos de Saúde
18.
BMJ ; 365: l1580, 2019 05 29.
Artigo em Inglês | MEDLINE | ID: mdl-31147311

RESUMO

OBJECTIVE: To estimate all cause mortality and cause specific mortality among patients taking proton pump inhibitors (PPIs). DESIGN: Longitudinal observational cohort study. SETTING: US Department of Veterans Affairs. PARTICIPANTS: New users of PPIs (n=157 625) or H2 blockers (n=56 842). MAIN OUTCOME MEASURES: All cause mortality and cause specific mortality associated with taking PPIs (values reported as number of attributable deaths per 1000 patients taking PPIs). RESULTS: There were 45.20 excess deaths (95% confidence interval 28.20 to 61.40) per 1000 patients taking PPIs. Circulatory system diseases (number of attributable deaths per 1000 patients taking PPIs 17.47, 95% confidence interval 5.47 to 28.80), neoplasms (12.94, 1.24 to 24.28), infectious and parasitic diseases (4.20, 1.57 to 7.02), and genitourinary system diseases (6.25, 3.22 to 9.24) were associated with taking PPIs. There was a graded relation between cumulative duration of PPI exposure and the risk of all cause mortality and death due to circulatory system diseases, neoplasms, and genitourinary system diseases. Analyses of subcauses of death suggested that taking PPIs was associated with an excess mortality due to cardiovascular disease (15.48, 5.02 to 25.19) and chronic kidney disease (4.19, 1.56 to 6.58). Among patients without documented indication for acid suppression drugs (n=116 377), taking PPIs was associated with an excess mortality due to cardiovascular disease (22.91, 11.89 to 33.57), chronic kidney disease (4.74, 1.53 to 8.05), and upper gastrointestinal cancer (3.12, 0.91 to 5.44). Formal interaction analyses suggested that the risk of death due to these subcauses was not modified by a history of cardiovascular disease, chronic kidney disease, or upper gastrointestinal cancer. Taking PPIs was not associated with an excess burden of transportation related mortality and death due to peptic ulcer disease (as negative outcome controls). CONCLUSIONS: Taking PPIs is associated with a small excess of cause specific mortality including death due to cardiovascular disease, chronic kidney disease, and upper gastrointestinal cancer. The burden was also observed in patients without an indication for PPI use. Heightened vigilance in the use of PPI may be warranted.


Assuntos
Doenças Cardiovasculares/mortalidade , Neoplasias Gastrointestinais/mortalidade , Úlcera Péptica/prevenção & controle , Inibidores da Bomba de Prótons/uso terapêutico , Insuficiência Renal Crônica/mortalidade , Saúde dos Veteranos/estatística & dados numéricos , Idoso , Causas de Morte , Estudos de Coortes , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Mortalidade , Fatores de Risco , Estados Unidos/epidemiologia
19.
Medicine (Baltimore) ; 98(24): e15662, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31192909

RESUMO

Primary adrenal lymphoma (PAL) is a rare entity of lymphoma with dismal prognosis using systemic chemotherapy. More clinical reports are needed to guide the treatment for PAL.We performed a retrospective analysis of 20 patients diagnosed with PAL who presented to our center between January 2005 and January 2014.Median age at presentation was 48 years (range: 27-73) with a male-to-female ratio of 7:3. Bilateral and right-sided adrenal involvement were seen in 11 of 20 and 7 of 20 patients, respectively. Adrenal insufficiency (AI) was seen in 6 of 10 evaluated patients. Diffuse large B cell lymphoma (DLBCL) was the most common immunophenotype (85.0%). Two patients died due to rapid disease progression before treatment. Two patients received autologous stem cell transplantation as consolidation therapy. All patients received prophylactic intrathecal chemotherapy. The estimated 5-year overall survival (OS) and progression-free survival (PFS) were 52.5% [95% confidence interval (95% CI: 28.2-72.0)] and 53.2% (95% CI: 29.0-72.5), respectively.These findings suggest that PAL should always be considered in differential diagnosis of adrenal mass with AI. Despite the contrasting previous reports, long-term prognosis of PAL is not necessarily inferior to that of non-Hodgkin lymphoma in general.


Assuntos
Neoplasias das Glândulas Suprarrenais/tratamento farmacológico , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Transplante de Células-Tronco Hematopoéticas/métodos , Linfoma Difuso de Grandes Células B/terapia , Neoplasias das Glândulas Suprarrenais/mortalidade , Adulto , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Citarabina/administração & dosagem , Citarabina/uso terapêutico , Dexametasona/administração & dosagem , Dexametasona/uso terapêutico , Progressão da Doença , Esquema de Medicação , Tratamento Farmacológico , Feminino , Humanos , Injeções Espinhais , Linfoma Difuso de Grandes Células B/mortalidade , Masculino , Metotrexato/administração & dosagem , Metotrexato/uso terapêutico , Pessoa de Meia-Idade , Mortalidade , Estudos Retrospectivos , Análise de Sobrevida , Transplante Autólogo , Resultado do Tratamento
20.
BMJ ; 365: l1927, 2019 06 04.
Artigo em Inglês | MEDLINE | ID: mdl-31164326

RESUMO

OBJECTIVE: To evaluate the effect of intensive care unit (ICU) admission on mortality among patients with ST elevation myocardial infarction (STEMI). DESIGN: Retrospective cohort study. SETTING: 1727 acute care hospitals in the United States. PARTICIPANTS: Medicare beneficiaries (aged 65 years or older) admitted with STEMI to either an ICU or a non-ICU unit (general/telemetry ward or intermediate care) between January 2014 and October 2015. MAIN OUTCOME MEASURE: 30 day mortality. An instrumental variable analysis was done to account for confounding, using as an instrument the additional distance that a patient with STEMI would need to travel beyond the closest hospital to arrive at a hospital in the top quarter of ICU admission rates for STEMI. RESULTS: The analysis included 109 375 patients admitted to hospital with STEMI. Hospitals in the top quarter of ICU admission rates admitted 85% or more of STEMI patients to an ICU. Among patients who received ICU care dependent on their proximity to a hospital in the top quarter of ICU admission rates, ICU admission was associated with lower 30 day mortality than non-ICU admission (absolute decrease 6.1 (95% confidence interval -11.9 to -0.3) percentage points). In a separate analysis among patients with non-STEMI, a group for whom evidence suggests that routine ICU care does not improve outcomes, ICU admission was not associated with differences in mortality (absolute increase 1.3 (-0.9 to 3.4) percentage points). CONCLUSIONS: ICU care for STEMI is associated with improved mortality among patients who could be treated in an ICU or non-ICU unit. An urgent need exists to identify which patients with STEMI benefit from ICU admission and what about ICU care is beneficial.


Assuntos
Cuidados Críticos , Mortalidade Hospitalar , Unidades de Terapia Intensiva/estatística & dados numéricos , Infarto do Miocárdio com Supradesnível do Segmento ST , Idoso , Cuidados Críticos/métodos , Cuidados Críticos/organização & administração , Feminino , Acesso aos Serviços de Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Medicare/estatística & dados numéricos , Mortalidade , Determinação de Necessidades de Cuidados de Saúde , Avaliação de Processos e Resultados (Cuidados de Saúde) , Infarto do Miocárdio com Supradesnível do Segmento ST/economia , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Estados Unidos/epidemiologia
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