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3.
Anticancer Res ; 39(11): 6359-6363, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31704868

RESUMO

BACKGROUND/AIM: To analyze whether demographic and facility type characteristics cause inequality in the type of biopsy performed in patients with cutaneous melanoma. PATIENTS AND METHODS: The skin cancer National Cancer Database was assessed. Men and women of all ages with cutaneous melanoma in situ and malignant melanoma at any stage of the disease were included. Patients were selected who underwent one of the following biopsy types: excisional, punch, shave, or incisional. Bivariate and multivariate analyses were performed. RESULTS: We found that the likelihood of undergoing an excisional biopsy decreased in patients who were: Hispanic [odds ratio (OR)=0.63, confidence interval (CI)=0.55-0.71], non-White (OR=0.66, CI=0.58-0.76), older than 80 years (OR=0.77, CI=0.72-0.87), or in Comprehensive Community Cancer Programs (OR=0.33, CI=0.31-0.36), Community Cancer Programs (OR=0.52, CI=0.50-0.54) and Integrated Network Cancer Programs (OR=0.58, CI=0.55-0.61). CONCLUSION: Our study results demonstrate disparities in biopsy type in the treatment of melanoma.


Assuntos
Biópsia/métodos , Disparidades em Assistência à Saúde , Melanoma/patologia , Neoplasias Cutâneas/patologia , Padrão de Cuidado , Fatores Etários , Biópsia/normas , Grupos de Populações Continentais , Grupos Étnicos , Feminino , Disparidades em Assistência à Saúde/etnologia , Hispano-Americanos , Humanos , Cobertura do Seguro/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Análise de Regressão , Características de Residência , Fatores Sexuais , Fatores Socioeconômicos
5.
BMC Infect Dis ; 19(1): 839, 2019 Oct 12.
Artigo em Inglês | MEDLINE | ID: mdl-31606032

RESUMO

BACKGROUND: Household contact tracing of index TB cases has been advocated as a key part of TB control for many years, but has not been widely implemented in many low-resource setting because of the current dearth of high quality evidence for effectiveness. Innovative strategies for earlier, more effective treatment are particularly important in contexts with hyper-endemic levels of HIV, where levels of TB infection remain extremely high. METHODS: We present the design of a household cluster-randomised controlled trial of interventions aimed at improving TB-free survival and reducing childhood prevalence of Mycobacterium tuberculosis infection among household contacts of index TB cases diagnosed in two provinces of South Africa. Households of index TB cases will be randomly allocated in a 1:1 ratio to receive either an intensified home screening and linkage for TB and HIV intervention, or enhanced standard of care. The primary outcome will compare between groups the TB-free survival of household contacts over 15 months. All participants, or their next-of-kin, will provide written informed consent to participate. DISCUSSION: Evidence from randomised trials is required to identify cost-effective approaches to TB case-finding that can be applied at scale in sub-Saharan Africa. TRIAL REGISTRATION: ISRCTN16006202 (01/02/2017: retrospectively registered) and NHREC4399 (11/04/2016: prospectively registered). Protocol version: 4.0 (date: 18th January 2018).


Assuntos
Busca de Comunicante/métodos , Tuberculose/prevenção & controle , Adulto , Criança , Análise Custo-Benefício , Feminino , Infecções por HIV/diagnóstico , Infecções por HIV/epidemiologia , Infecções por HIV/virologia , Humanos , Estudos Retrospectivos , Risco , África do Sul/epidemiologia , Padrão de Cuidado , Resultado do Tratamento , Teste Tuberculínico , Tuberculose/tratamento farmacológico , Tuberculose/epidemiologia , Carga Viral
6.
J Drugs Dermatol ; 18(10): 987-990, 2019 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-31584776

RESUMO

Introduction: Introduction: Although future atopic dermatitis (AD) clinical research is intended to improve standard-of-care treatment, how patients are currently treated is not well characterized. The purpose of this study was to determine the most frequent medications prescribed in all ages of AD. Methods: The National Ambulatory Medical Care Survey (NAMCS) is a nationally representative survey of United States office-based ambulatory visits and records demographics, diagnoses, and treatments. This is a cross-sectional study using the NAMCS of all AD outpatient office visits from 2006 to 2015. Patient visits with an ICD-9-CM code for AD (691.8) were collected and analyzed. Frequency tables were created for age, race, providers managing AD, and treatment. Results: Patient demographics of AD visits included 51% male (95% Confidence Interval [CI]: 44-58%), 71% white (65-77%), 19% African American (14-25%), and 10% Asian (6-14%). About 31% (24-37%) of visits were to pediatricians and 27% (22-33%) to dermatologists whereas per physician, dermatologists managed more AD visits than pediatricians. Topical corticosteroids (59%; 52-66%) were the most common class of medications prescribed followed by antibiotics (11%; 6-16%) and second generation antihistamines (6%; 3-10%). The most common topical corticosteroid prescribed in AD was triamcinolone (25% of office visits; 18-31%). Hydrocortisone was the most common topical corticosteroid prescribed to children <1 year of age and children aged 8 to 18, whereas triamcinolone was more common in children 2 to 7 years and adults >18 years. Discussion: Topical corticosteroids were the most frequent prescriptions provided at office-based ambulatory visits whereas antibiotics and second-generation antihistamines were the second and third most common prescribed medications, respectively. Although pediatricians manage more AD visits than dermatologists in total visits, dermatologists manage more AD visits than pediatricians per physician. Characterizing how AD patients are currently treated may build a reference for future clinical research investigating novel standard-of-care treatment in AD. J Drugs Dermatol. 2019;18(10):987-990.


Assuntos
Dermatite Atópica/tratamento farmacológico , Fármacos Dermatológicos/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Padrão de Cuidado/estatística & dados numéricos , Administração Cutânea , Adolescente , Adulto , Antibacterianos/uso terapêutico , Criança , Pré-Escolar , Estudos Transversais , Dermatologistas/estatística & dados numéricos , Feminino , Glucocorticoides/uso terapêutico , Pesquisas sobre Serviços de Saúde/estatística & dados numéricos , Antagonistas dos Receptores Histamínicos/uso terapêutico , Humanos , Lactente , Recém-Nascido , Masculino , Visita a Consultório Médico/estatística & dados numéricos , Estados Unidos , Adulto Jovem
7.
J Clin Ethics ; 30(3): 223-231, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31573966

RESUMO

While the best interest standard (BIS) enjoys wide endorsement as ethical and decision-making standard in pediatrics, it has been criticized as vague and indeterminate. Alternate decision-making standards have been proposed to replace or augment the BIS, notably the harm principle (HP) and constrained parental autonomy (CPA) model. In this edition of The Journal of Clinical Ethics, Lainie Friedman Ross argues that CPA is a better standard than the BIS or the HP as both guide and limiter in pediatrics. In response, I review the important work done by the BIS in pediatrics, and argue that neither the HP nor the CPA can take over these functions or replace the BIS. Among other things I argue: (1) The BIS provides more robust protections for the moral claims of children. (2) The CPA model and the HP do not resolve the indeterminacy and vagueness present in complex medical situations, and the BIS is better suited to deal with this vagueness and indeterminacy. (3) The BIS is a general principle of medical ethics with special application in pediatrics; it fits seamlessly into the system of medical ethics and fulfills many functions within pediatrics. The HP and the CPA model do not fit in so readily within medical ethics, and are not equipped to take over the functions of the BIS.


Assuntos
Tomada de Decisões , Redução do Dano , Pais , Pediatria , Autonomia Pessoal , Criança , Ética Clínica , Ética Médica , Humanos , Padrão de Cuidado
12.
13.
Metas enferm ; 22(7): 65-71, sept. 2019. tab
Artigo em Espanhol | IBECS | ID: ibc-184101

RESUMO

La función cardiaca y la función renal están íntimamente asociadas, ya que el corazón y los riñones llevan a cabo la regulación hemodinámica del organismo. Cuando se producen alteraciones de forma bidireccional en ambos órganos se activa una serie de mecanismos compensadores que provocan un efecto nocivo de uno de ellos sobre el otro. Es lo que se conoce como síndrome cardiorrenal. Actualmente se dispone de protocolos de Enfermería estandarizados para el manejo de la insuficiencia cardiaca y para la insuficiencia renal; no obstante, es necesario ampliar la información para entender de forma óptima la relación cardiorrenal y aplicar la mejor evidencia científica a los cuidados. Por ello se expone un caso clínico abordado desde Atención Primaria, con el desarrollo de un plan de cuidados elaborado una vez identificados los diagnósticos de Enfermería que se han derivado de la valoración enfermera siguiendo el modelo de las 14 necesidades básicas de Virginia Henderson


Cardiac function and renal function are closely related, because the heart and the kidneys carry out the hemodynamic regulation of the body. When there are bidirectional alterations in both organs, a series of compensating mechanisms are activated, which cause harmful effects of one over the other. This is known as Cardiorenal Syndrome. There are current standard Nursing protocols available for the management of heart failure and renal impairment; however, it is necessary to increase information for an optimal understanding of the cardiorenal interaction, and to apply the best scientific evidence into care. To this aim, we present a case record addressed at Primary Care, with the development of a plan of care prepared after the Nursing diagnoses were identified, derived from nursing assessment following the model of the 14 Basic Needs of Virginia Henderson


Assuntos
Humanos , Feminino , Idoso , Cuidados de Enfermagem , Atenção Primária à Saúde/métodos , Síndrome Cardiorrenal/complicações , Síndrome Cardiorrenal/enfermagem , Transtornos Cerebrovasculares/complicações , Transtornos Cerebrovasculares/enfermagem , Padrão de Cuidado/normas , Nível de Saúde , Atenção Primária à Saúde , Nefropatias/complicações , Cardiopatias/complicações , Implementação de Plano de Saúde/normas , Insuficiência Cardíaca/enfermagem
14.
Lancet ; 394(10198): 604-610, 2019 Aug 17.
Artigo em Inglês | MEDLINE | ID: mdl-31395443

RESUMO

Human genomic sequencing has potential diagnostic, prognostic, and therapeutic value across a wide breadth of clinical disciplines. One barrier to widespread adoption is the paucity of evidence for improved outcomes in patients who do not already have an indication for more focused testing. In this Series paper, we review clinical outcome studies in genomic medicine and discuss the important features and key challenges to building evidence for next generation sequencing in the context of routine patient care.


Assuntos
Genômica/métodos , Medicina de Precisão/métodos , Testes Diagnósticos de Rotina , Genoma Humano , Sequenciamento de Nucleotídeos em Larga Escala , Humanos , Avaliação de Resultados da Assistência ao Paciente , Padrão de Cuidado
15.
Stud Health Technol Inform ; 264: 950-953, 2019 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-31438064

RESUMO

With the novel approach of molecularly stratified therapies based on genetic characteristics of individual tumors, the need for databases providing information on molecular alterations and targeted treatment options is increasing rapidly. In Molecular Tumor Boards (MTB) professionals discuss molecular alterations and provide biological context for therapeutic options using external knowledge databases. The identification of informative databases and the information on their specific contents can greatly facilitate and standardize the functioning of a MTB. In this work we present a list of databases which have been deemed useful and relevant for MTB in a clinical setting. We describe workflows to recommend the use of specific databases at different steps in the clinical curation process. Information obtained from these databases is a necessary prerequisite to evaluate molecular alterations and devise rational targeted therapies in MTB.


Assuntos
Neoplasias , Medicina de Precisão , Humanos , Oncologia , Padrão de Cuidado , Fluxo de Trabalho
19.
J Cancer Res Clin Oncol ; 145(9): 2357-2363, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31273511

RESUMO

BACKGROUND: Hepatic arterial infusion (HAI) of chemotherapy could be used in patients with liver-only metastatic colorectal cancer (mCRC) to fight against chemoresistance. We previously reported the efficacy of raltitrexed plus oxaliplatin (HAI) in a retrospective series. We performed a randomized two-stage phase-II study to evaluate the efficacy of HAI of the combination of raltitrexed and oxaliplatin in refractory mCRC with only liver metastases in comparison with standard of care. PATIENTS AND METHODS: Eligible patients had unresectable mCRC and were refractory or intolerant to fluoropyrimidine, irinotecan, oxaliplatin, anti-VEGF therapy, and anti-EGFR therapy (for tumors with wild-type KRAS). Patients were randomized between HAI raltitrexed (3 mg/m2 over 1 h) followed by oxaliplatin (130 mg/m2 over 2 h) every 3 weeks and standard of care in a 2:1 ratio. A total of 57 patients (38 in the experimental arm and 19 in the standard of care arm) were to be included. The main objective was to demonstrate 6-month PFS of 45% by intention-to-treat analysis in the experimental arm, compared to theoretical PFS of 20%, with a unilateral alpha risk of 5% and beta risk of 10%. RESULTS: After inclusion of 27 patients, the trial was terminated due to insufficient accrual. In the experimental arm, 11 and 4 patients experienced grade 3 and 4 toxicities, respectively. The most frequent grade 3-4 toxicities were neutropenia, liver toxicity, and abdominal pain. Median progression-free survival was 6.7 months (95% Confidence Interval; 3.9-7.2) in the HAI group and 2.2 months (95% CI 1.2-4.3) with standard of care [HR 0.32 (95% CI 0.14-0.76), p = 0.01]. Median overall survival did not differ between the two groups, at 11.2 months (95% CI 4.8-17.6) for the HAI group and 11.9 months (95% CI 2.8-14.3) for standard of care [HR 0.86 (95% CI 0.36-2.04), p = 0.73]. CONCLUSION: Although stopped prematurely, this randomized trial provides evidence for the benefit and safety of HAI of a combination of raltitrexed and oxaliplatin in liver-only mCRC with chemoresistant disease.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Quimioterapia do Câncer por Perfusão Regional , Neoplasias Colorretais/tratamento farmacológico , Neoplasias Colorretais/patologia , Neoplasias Hepáticas/tratamento farmacológico , Neoplasias Hepáticas/secundário , Oxaliplatina/administração & dosagem , Quinazolinas/administração & dosagem , Tiofenos/administração & dosagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Quimioterapia do Câncer por Perfusão Regional/efeitos adversos , Quimioterapia do Câncer por Perfusão Regional/métodos , Resistencia a Medicamentos Antineoplásicos/efeitos dos fármacos , Feminino , França , Artéria Hepática , Humanos , Infusões Intra-Arteriais , Masculino , Pessoa de Meia-Idade , Oxaliplatina/efeitos adversos , Quinazolinas/efeitos adversos , Padrão de Cuidado , Tiofenos/efeitos adversos , Resultado do Tratamento
20.
Minerva Urol Nefrol ; 71(4): 309-323, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31241271

RESUMO

INTRODUCTION: Among the measures taken in the recent years to reduce the morbidity and improve functional recovery after radical cystectomy (RC), the optimization of perioperative care pathways is gaining a prominent role. The aim of this systematic review of the literature with meta-analysis is to assess the impact of enhanced recovery after surgery (ERAS) protocols vs. standard of care on perioperative outcomes of patients undergoing RC. EVIDENCE ACQUISITION: A systematic review with meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. MEDLINE, SCOPUS and Web of Science databases were searched. Only comparative studies evaluating the impact of ERAS protocols vs. standard of care on intraoperative and postoperative outcomes of patients undergoing RC were included. Cumulative analysis was conducted using Review Manager v.5.3 software. Statistical heterogeneity was tested using the χ2 Test, and a P value <0.10 was used to indicate heterogeneity. Random-effects and fixed-effects models were used as appropriate depending on heterogeneity status. EVIDENCE SYNTHESIS: A total of 27 studies were included, namely 3 randomized and 24 non-randomized controlled studies, resulting in 4712 patients, 2690 (57%) participants to some ERAS protocol and 2022 (43%) controls receiving standard of care. A number of primary and secondary outcome measures were assessed in the original studies. Pooled data showed that ERAS protocols were associated with significantly faster recovery of bowel function, faster return to regular diet and shorter hospital stay with no increase in 30-day and 90-day major complication, mortality or readmission rates compared to standard of care. The magnitude of benefit of the various ERAS protocols tested had, however, a non-negligible inter-study variability. CONCLUSIONS: This systematic review with meta-analysis of comparative studies showed that ERAS protocols applied to patients undergoing RC enabled a faster recovery of bowel function, a faster return to regular diet and a shorter hospital stay with no increase in major complication or readmission rate compared to standard perioperative care. RC with ERAS protocols should be considered the new standard of care.


Assuntos
Cistectomia/métodos , Assistência Perioperatória/métodos , Recuperação de Função Fisiológica , Neoplasias da Bexiga Urinária/cirurgia , Procedimentos Cirúrgicos Urológicos/métodos , Humanos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Padrão de Cuidado
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